Office on Disability

Report on Constituency Expert Input Meeting—May 24, 2005

Department of Health and Human Services
Hubert H. Humphrey Building
Office on Disability  Room, 637D
200 Independence Avenue SW
Washington, DC 20201
www.hhs.gov/od/

INTRODUCTION

The U.S. Department of Health and Human Services Office on Disability (OD) convened a regularly scheduled Quarterly Constituent Input Meeting on May 24, 2005, in the Deputy Secretary’s Conference Room in the Hubert H. Humphrey Building, Washington, D.C. Over 40 constituent organizations and HHS agencies and offices were represented, either in person or by conference call.[1] These quarterly meetings give representatives from the national disability organizations (representing 54 million Americans with disabilities of all kinds) opportunity to be heard by HHS on key topics of concern both to the Federal government and to persons with disabilities.

A recommendation made at the February 22, 2005 Constituent Input meeting – further education about MMA Drug Benefit[2] program – was the springboard for the May 24, 2005 meeting. As a result of that recommendation, the May 2005 constituent input meeting focused on that specific topic, providing participants the knowledge and information they need to help better educate the disability constituencies nationwide about this important program change.

The May 24, 2005, Constituent Input Meeting provided significant exchange among CMS Administrator Dr. Mark McClellan and senior CMS outreach staff, and disability constituency representatives about Medicare prescription drug benefit (also referred to as “Medicare Rx” in this document) outreach campaign plans.

The meeting was designed to provide an important opportunity for representatives of disability constituency organizations to brainstorm, to ask and receive answers to Medicare Rx-related questions, to share recommendations, and to identify opportunities to coordinate Medicare prescription drug outreach plans.

Office on Disability Director Margaret Giannini, MD, FAAP, opened the meeting by welcoming those in attendance. She explained the ground-rules for the meeting. Each participant was given time to raise issues important to their constituencies. They were asked to state at least one issue, and then to provide at least one recommendation that responds to the issue raised. If time permitted, the participant had the option of raising other issues.

During the course of the meeting, participants heard from Secretary Mike Leavitt’s Chief-of-Staff, Richard McKeown. He described the importance of implementation of the Medicare Modernization Act (MMA), including the Medicare Prescription Drug Benefit Program, to the Secretary’s 500-day plan that is guiding the Departments work and priorities. He noted how the Medicare population has been growing as the “baby-boom” generation moves through mid-life. In particular, he observed how the partnerships developed between CMS and the disability community can help achieve the kind of transformation of the healthcare system and the modernization of Medicare and Medicaid envisioned in the 500-day plan. Mr. McKeown stated that Secretary Leavitt has placed an emphasis on promoting high-quality community-based, consumer-centered/self-directed care that is both financially sustainable and flexible enough to meet individual needs.

Mr. McKeown noted that a forum such as the Office on Disability’s quarterly Constituent Input Meetings, provides a wonderful opportunity for exchange and recommendations of an important, often less-heard segment of the population.

MEETING SUMMARY

The following provides a summary of the questions of the disability constituency organization representatives who attended the meeting and shares the observations, comments and suggestions made by CMS Administrator McClellan and his staff as well as constituent responses and recommendations.

A detailed, structured set of questions and answers regarding the Medicare prescription drug benefit (also referred to in this document as “Medicare Rx”), developed by CMS with input from the Office on Disability, in further response to questions posed at the meeting are found at Appendix B and at http://www.cms.hhs.gov/partnerships. [Please note that both sets of questions have been combined into one at this website.]

Constituency/CMS Exchange

Dr. Giannini posed an opening question related to the Medicare prescription drug benefit and then recognized each of the constituency group representatives who posed questions or made suggestions for collaborative work to “help get the word out” about Medicare prescription drug plan registration.

Particular attention was given to the population of “dual eligibles” who are covered by both Medicaid and Medicare. Under MMA, for the purposes of the prescription drug coverage benefit only, persons with dual eligibility will be transferred automatically from Medicaid to a Medicare prescription drug plan effective January 1, 2006. In mid-October 2005, CMS will send a letter to people who are “dual know and let them know into which plan they will be enrolled ifthey do not enroll in one on their own. It would be best if the beneficiary selected one because there is no guarantee that the plan randomly selected by Medicare will meet an individual’s particular needs.

What are “special needs” prescription plans?

Special needs prescription plans are designed to ensure that persons with disabilities – and others – have the health services they need. This extends far beyond prescription needs to help prevent illnesses and secondary conditions. Special needs plans try to prevent the complications of chronic disease and disabilities. In fact, prevention – not just screening, but early intervention that is provided to help reduce the incidence of secondary illnesses – is becoming an increased focus of both Medicare and Medicaid.

While not identical to special need plans, Medicare Advantage Plans, for example, are benefit packages specifically designed for persons with chronic illness who are at highest risk for high need for and use of services (e.g., heard disease, diabetes, HIV/AIDS). Through this program, CMS is able to assess and meet the needs of persons at greatest risk for losing community-based services for institutional care (including persons with dual eligibility). By adopting this approach that focuses on individuals with the highest risk, CMS can help beneficiaries avoid clinically unnecessary institutionalization or acute care hospitalization and receive better care in terms of quality, continuity and coordination, and cost.

Over 60 Medicare Advantage Plans will be in place in FY 2006; CMS hopes to double or triple the number in the next three years. And CMS will be assessing these programs; it wants to know from the disability community how the programs are doing. The intent is to promote high quality care and that means measuring how well the programs are doing what they are intended to do.

What is the geographic distribution of special needs plans? What is being done for rural areas? What is being done to ensure that care for children and youth with disabilities is continued under special needs plans.

Special need plans, effective for 2004 and 2005, exist in at least 21 states, the District of Columbia, and the territory of Puerto Rico. In 2006, at least one special needs plan will be in place in most of the states.

At the present time, special needs plans are primarily found in urban areas, such as in California and Texas. While rural areas have not been as involved in establishing special needs plans, the situation is improving, particularly when PPOs are used. In fact, special needs plans are offered by Medicare Advantage Organizations that cover both rural and urban areas. In 2006, still more coverage for rural areas will be provided.

Special needs plans were enacted by Congress for Medicare Advantage individuals who are institutionalized, entitled to medical assistance under a state plan under Title XIX, or experiencing a severe or disabling condition (or conditions) who would benefit from enrollment in a specialized Medicare Advantage plan. Enactment of special needs plans should not have an adverse impact on children and youth with disabilities. To the extent that children and youth meet the eligibility criteria for the Medicare Advantage plan offering the special needs plan, they could join the Medicare Advantage Plan.

Exactly what will the Medicare prescription drug plans consist of?

Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. Medicare Rx plans will cover both brand name and generic drugs. Plans must cover all types of drugs required by Medicare, but each plan may have rules about what drugs are covered in different drug categories. These are listed on the plan “formulary”.

When will information about specific formularies be made available?

Approval of formularies is being undertaken at this time. CMS has been assessing medications that people are currently are using across six categories – including those for the treatment of mental illnesses and HIV. However, specific formulary information, including pricing and additional information, will be finalized and posted to the CMS website around October 13, 2005. The site will include an interactive program to help beneficiaries choose an individualized Medicare Rx plan based on the medications and pharmacies that beneficiaries already are using.

In the next few weeks, information about the low-income subsidy for Medicare prescription drugs will be sent out by the Social Security Administration (SSA) encouraging the 5-7 million people who SSA believes qualify for this benefit based on their past earning history to sign up for the program. The program is for individuals at 135% of poverty level or lower and will provide medications at a nominal cost.

CMS has over 60,000 local events being undertaken to help promote the low-income assistance program under the Medicare prescription drug benefit; the message is to join a plan now, or be enrolled automatically if one is not chosen by December 31, 2005.

A separate letter will be sent by CMS to all persons who are dually eligible for enrollment in the Medicare prescription drug benefit, a substantial number of these individuals are persons with disabilities. They will not need to do anything to sign up. The letter will alert them that the low income subsidy will become available on January 1, 2006.

CMS appreciates the significant work being done by disability leaders to reach out to disability constituencies to inform beneficiaries. CMS will be making a major push in the fall to bring all persons eligible into the program and welcomes the ongoing collaboration of the disability and provider organizations to achieve broad-based education.

How are CMS and other relevant agencies and informing disability and other affected constituencies and organizations at the state and local level about the Medicare prescription drug benefit?

The Social Security Administration has made funding available to underwrite a broad range of local events. CMS is working to build in a Medicare prescription drug benefit component as a subset of an upcoming National Governors Association meeting on mental health needs. CMS also would be happy to “piggyback” on meetings being convened by disability constituency and provider organizations. CMS is collaborating with Area Agencies on Aging, Housing and Urban Development centers and Department of Transportation grantees for programs for seniors and persons with disabilities as well. Regional CMS offices are prepared to work with organizations at the regional, state, and local levels to “get the word out” through existing resources and planned events and meetings. In fact, to the extent possible, CMS will send representatives to national and regional constituency and provider meetings to speak about the Medicare Rx benefits and the issues of concern to providers and/or beneficiaries. A list of regional contacts was made available (see Appendix B)

A great deal of information has been made available by CMS on the Internet. What steps are being taken to educate those who may not be able to access the internet?

Persons are able to receive information about the Medicare Rx benefit both in face-to-face counseling or by phone. By calling 1-800-Medicare, persons can receive information by phone. Information also is available through State Health Insurance Programs (SHIPs) that can provide personalized counseling both in-person and by phone. Area Agencies on Aging and public libraries also help provide information.

It is equally important that organizations concerned about the issues help in the educational process. In fact, because many beneficiaries have informal caregivers, caregiver organizations, too, should become engaged.

Will states be required to ensure continuity of drug benefits to dual eligible participants? And will the continuity of drug benefits for persons who are dual-eligible be ongoing or time-restricted?

When it comes to persons with dual eligibility, CMS work groups are in place in all states to help persons with dual eligibility make the transition to Medicare Rx plans. Abby Block is the lead for this particular formulary-related transition. Most of the issues related to continuity of medication will be addressed at the state level, since CMS is not making any rulings related specifically to the use of particular medications.

The goal of CMS, however, is to ensure that if persons were covered for treatment with particular medications, they continue to be covered. Clearly, CMS does not want to jeopardize the health of those persons on specific drug regiments (e.g., persons with HIV/AIDS). A letter has been sent to State Medicaid agencies to ask that they make available a 90-day transition supply of medications for dually-eligible persons who will be transitioning to Part D.

All Medicare prescription drug benefit plans must offer a basic or standard package of prescription drugs. A standard plan may not cover benzodiazepines. However, if a plan offers more than standard coverage, it may elect to cover this type of drug. The premium for these plans will most often be higher than for standard plans.

More information about the formularies and the six classes of medications is available for providers at the CMS website <partners.cms.gov>. New information on the drug benefit is available to help train providers on a CD available from CMS as well.

What is CMS’s “Reach” program and how does it work?

The REACH (Regional Education about Choices in Health) program is a national education and publicity campaign implemented at the local level by CMS’s Regional Offices and their partners. The REACH campaign works through partnerships to increase awareness of the Medicare program and resources among hard to reach populations. It provides a list-serv and other information to partner organizations, and provides experts to help educate about the Rx benefit at the community level. Contacts have been identified in every regional office; these individuals can help identify the best local information available. CMS is providing information to the Office on Disability to help disability organizations – including behavioral health care programs – “get the word” out about Medicare prescription drug coverage, particularly for persons who are dually eligible. (See Appendix B for this information)

How is CMS reaching Spanish-speaking communities to educate them about the Medicare prescription drug benefits? What efforts are being made to educate other non-English-speaking populations?

CMS is coordinating outreach programs to Hispanic populations, utilizing persons with specialized expertise. CMS will provide a list of the most relevant “preferred terminology” regarding Medicare Rx coverage in Spanish to the National Alliance for Hispanic Health. CMS is working to undertake special mailings to Asian American and other non-English speaking populations who may be affected by the prescription drug benefit changes, with material in Russian, Korean, and Vietnamese. Materials in other languages also may be developed.

What kinds of outreach, education and assistance in workload management is being undertaken by CMS to help physicians groups work with their patients to help them choose the best plans for them?

Meeting participants suggested it might be of benefit to CMS to drill down to sub-specialty provider groups that have expertise with persons with disabilities. The provision of CME for physician training about the Medicare prescription drug benefits may also be of help. CMS noted that materials are available to providers to help them better educate their patients with disabilities about Medicare prescription drug benefits; the CMS clearinghouse has pamphlets that can be distributed at the local provider level; some materials can made available at the 4^th grade reading level.

If CMS anticipates that 80% of all dual-eligible individuals are to be enrolled in the Medicare prescription drug benefit program in January, how will the remaining 20% be reached to ensure that no one “falls through the cracks”? And what about individuals who are outside the Medicare/Medicaid system today who should not be? How can they be reached?

All dually eligible individuals will be enrolled in the Medicare prescription drug benefit program automatically in a plan selected at random by Medicare unless they select a plan for themselves. However, such individuals would be advised to review the range of drug plan options available to them between now and January 1, 2006, and choose the plan that best meets their needs for such things as continuous coverage of current medications. Further, CMS has sent letters to State Medicaid agencies to encourage states to ensure that dually eligible individuals can receive a 90-day transition supply of their clinically prescribed medications as the changeover to the Medicare prescription drug benefit program takes place.

When it come to the question of persons who are currently outside the Medicare/Medicaid system who should not be, CMS has been working to overcome this problem and will continue to do so.

What is the “prescribing exception” provision of the Medicare Part D prescription drug program?

All Medicare Rx plans must have an exception process for enrollees to request a drug that is not on the covered drug list, or that the enrollee thinks should be covered at a lower co-payment. The enrollee should contact the plan and ask for an exception. Mostly likely, they will have to provide written information from their doctor about why only a specific drug (in a class or category) will benefit them and why others may be harmful to their health. If the plan denies the exception, the enrollee can go through the plan’s appeal process.

What efforts are being made to make information about the Medicare Part D prescription drug program more readily accessible on the CMS website?

In late September 2005, the CMS website [cms.hhs.gov] website will be redesigned. All the current content will be migrated into a management tool called Stellant. Under this new design, there will be a section called “Prescription Drug Plan Center” which will contain all types of information about the MMA, Prescription Drug coverage and preventive benefits. The section will be accessible by every page of the website and should be easy to navigate.

NEXT STEPS

The input provided at this meeting is helping CMS and the Office on Disability better understand the range of questions and issues that need to be addressed in public forums related to the Medicare Rx drug program. It has helped build alliances between CMS and both disability consumer and provider constituencies to help inform the public affected by this significant change in coverage, particularly for persons with dual Medicaid/Medicare eligibility.

The dialogue needs to continue beyond the Office on Disability’s quarterly constituency input meetings. To that end, a range of CMS points of contact for outreach have been identified and will be shared with meeting participants (See Appendix B). The overarching goal is to promote partnerships between CMS and disability constituency organizations at the National, state and local levels to help ensure that everyone who may be affected by the Medicare Rx program’s implementation on January 1, 2006 is well-educated about the program and has the tools and knowledge that will ensure that persons with disabilities have the ability to choose their prescription drug coverage in a way that can foster ongoing self-determination and independence in the community.

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Electronic copies of this report and its appendices as well as reports from other Constituent Input meetings are available on the Office on Disability website at www.hhs.gov/od/

Appendix A

Office on Disability

Department of Health and Human Services

Constituency Expert Input Meeting
Participating Constituent Organizations and Federal Agencies

May 24, 2005

Constituency Organizations

• American Academy of Pediatrics
• American Association of Homes and Services for the Aging
• American Association of People with Disabilities
• American Council of the Blind
• American Health Care Association
• American Physical Therapy Association
• American Speech-Language-Hearing Association
• The ARC and United Cerebral Palsy
• Autism Society of America
• Brain Injury Association of America
• Child Welfare League of America
• Consortium for Citizens with Disabilities
• Epilepsy Foundation
• Family Voices
• Iona Senior Services – Voice of the Retarded
• National Adult Day Services Association
• National Alliance for Caregiving
• National Alliance for Hispanic Health
• National Asian Pacific Center on Aging
• National Association for State Directors of Developmental Disabilities Services
• National Association of Protection and Advocacy Systems
• National Association of State Mental Health Program Directors
• National Center for Assisted Living
• National Council for Independent Living
• National Council on Aging – Access to Benefits Program
• National Council of Community Behavioral Healthcare
• National Mental Health Association
• National Multiple Sclerosis Society

Federal Participants

• Administration on Aging – DHHS
• Administration for Developmental Disabilities, Agency for Children & Families– DHHS
• Centers for Medicare and Medicaid Services – DHHS
• Office on Disability – DHHS
• Office of the Assistant Secretary for Planning and Evaluation -- DHHS
• President’s Committee on Persons with Intellectual Disabilities - DHHS

Appendix B

CENTERS FOR MEDICARE AND MEDICAID SERVICES
QUESTIONS AND ANSWERS ON THE MEDICARE DRUG BENEFIT PROGRAM

Group 1

Basic Information

What is Medicare Prescription Drug Coverage?

Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. This drug coverage may help lower prescription drug costs and help protect against higher costs in the future.

You can get Medicare prescription drug coverage in the following ways:

• Through Medicare Advantage Plans or other Medicare Health Plans that are offering coverage for prescription drugs.
• Through Medicare Prescription Drug Plans, which add coverage to the Original Medicare Plan, and some Medicare Cost Plans and Medicare Private Fee-for-Service Plans.

You can choose and join the Medicare drug plan that works for you. You will have to pay a monthly premium. All drug plans must provide coverage that is at least as good as standard Medicare prescription drug coverage. Some plans might offer more coverage and additional drugs for higher monthly premiums. If you decide not to join a Medicare drug plan when you are first eligible, you may have to pay a penalty if you decide to join later.

If you have limited income and resources, you may qualify for extra help. Most people who qualify for this extra help will pay no premiums, no deductibles, and no more than $5 for each prescription. The amount of extra help depends on your income and resources. If you qualify, you will need to join a plan to get drug coverage. If you apply and qualify, and don’t join a plan, Medicare will enroll you in one by May 15, 2006 to make sure you get this important coverage.

What if I already have prescription drug coverage?

If you already have prescription drug coverage, you should talk to your plan, benefits administrator, or insurer before making any changes. You will be notified about any changes in your current coverage so you can decide if you should join a Medicare drug plan.

Should I join a Medicare drug plan even if I don’t take many prescription drugs?

Where can I get more information about Medicare prescription drug coverage?

For more information on Medicare prescription drug coverage, read the “Medicare & You 2006” handbook mailed to you in October 2005. It will list the specific plans available in your area. After October 2005, if you need help:

• Visit www.medicare.gov on the web and get personalized information.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Have your Medicare card, a list of drugs you use, and the name of the pharmacy you use ready when you call.
• Get a free copy of the booklet “Your Guide to Medicare Prescription Drug Coverage,” (CMS Pub. No. 11109) on www.medicare.gov or by calling 1-800-MEDICARE.
• Call your State Health Insurance Assistance Program for free personalized health insurance counseling.
• Check for local events for help joining. Contact your local office on aging. For the telephone number, visit www.eldercare.gov on the web.

Important Dates

When can I join a Medicare drug plan?

The first time to join is November 15, 2005–May 15, 2006. In most cases, if you don’t join by May 15, 2006, and you don’t currently have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage, you will have to wait until November 15, 2006 to join. When you do join, your premium cost will go up at least 1% per month for every month that you wait to join. Like other insurance, you must pay this penalty as long as you have Medicare prescription drug coverage. If you join by December 31, 2006, your coverage will begin January 1, 2007.

When can I join if I miss the May 15, 2006 deadline?

You will be able to join November 15–December 31 of each year. Your coverage would begin January 1 of the following year. If you choose not to join when you are first eligible and later change your mind, you may pay a penalty.

Costs and Coverage

What are the out-of-pocket costs for Medicare prescription drug coverage?

When you get Medicare prescription drug coverage, you pay part of the costs and Medicare pays part of the costs. You pay a premium each month to join the drug plan. If you have Medicare Part B, you also pay your monthly Part B premium. If you belong to a Medicare Advantage Plan or Medicare Cost Plan, the monthly premium you pay to the plan may increase if you add prescription drug coverage.

Your costs will vary depending on which plan you choose. Your plan must, at a minimum, provide a standard level of coverage as shown below. Some plans offer more coverage or lower premiums.

Standard Coverage (the minimum coverage drug plans must provide):

• A monthly premium (varies depending on the plan you choose, but estimated at about $37 in 2006)
• The first $250 per year for your prescriptions. This is called your deductible.

After you pay the $250 yearly deductible, here’s how the costs work:

• You pay 25% of your yearly drug costs from $250 to $2,250, and your plan pays the other 75% of these costs, then
• You pay 100% of your next $2,850 in drug costs, then
• You pay 5% of your drug costs (or a small copayment) for the rest of the calendar year after you have spent $3,600 out-of-pocket. Your plan pays the rest.

What does a Medicare drug plan cover?

Medicare drug plans will cover generic and brand-name drugs. Plans may have rules about what drugs are covered in different drug categories to be sure people with different medical conditions can get the treatment they need.

Most plans will have a formulary, which is a list of drugs covered by the plan. This list must always meet Medicare’s requirements, but it can change when plans get new information. Your plan must let you know at least 60 days before a drug you use is removed from the list or if the costs are changing. If your doctor thinks you need a drug that isn’t on the list, or if one of your drugs is being removed from the list, you or your doctor can apply for an exception or appeal the decision.

Will my drugs be covered?

Medicare Prescription Drug Plans must include at least two drugs in every drug category. The plans must also do the following:

• Make sure you have convenient access to retail pharmacies;
• Have a process for you to get drugs that are not on the list of covered drugs (formulary) when it is medically necessary; and
• Provide useful information to you, such as how formularies and medication management programs work, information on saving money with generic drugs, and grievance and appeal processes.

Make a list of all the your current medications, including name, dose size (for example- 2 pills, 300mg in each pill), dosage frequency (for example- 2 times a day) and monthly costs of your current prescriptions. You can use this information to compare the list of drugs (also called a formulary) that are covered under each plan. You can get the list of drugs a plan covers by calling the plan, visiting the plan’s website, or visiting www.medicare.gov on the web. This information will be available in October from the plans and on October 13 at medicare.gov on the web.

Effect on Current Drug Coverage

Medicare will help employers or unions continue to provide retiree drug coverage that meets Medicare’s standards. Your (or your spouse’s) former or current employer or union will send you information about how your current coverage compares to the Medicare standard prescription drug coverage by November 14, 2005. This information is important because it can affect the decision you will need to make this fall about if and when you sign up for Medicare prescription drug coverage.

If your (or your spouse’s) employer or union has determined that your current coverage, on average, is at least as good as the Medicare standard prescription drug coverage (called creditable prescription drug coverage):

• You can keep it as long as it is still offered by your employer or union; and
• You won’t have to pay a penalty if your employer or union stops offering prescription drug coverage as long as you join a Medicare drug plan within 63 days after the coverage ends – even if you join after May 15, 2006.

If your (or your spouse’s) employer or union has determined that your current coverage, on average, is not at least as good as standard Medicare prescription drug coverage, if you want to join a drug plan, you must join by May 15, 2006 to avoid a penalty.

Caution: If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health coverage.

If your employer or union plan is not as good as Medicare prescription drug coverage, find out about your options from your benefits administrator. You may be able to

• Keep your current employer or union drug plan and join a Medicare drug plan to give you more complete prescription drug coverage.
• Only keep your current employer or union drug plan. But, if you join a Medicare drug plan after May 15, 2006, you will have to pay a penalty.
• Drop your current coverage and return to the Original Medicare Plan and join a Medicare Prescription Drug Plan, or join a Medicare Advantage Plan or other Medicare Health Plan that covers prescription drugs. See the caution above.

What do I need to know if I have a Medicare Advantage Plan (like an HMO, PPO, or PFFS Plan) or other Medicare Health Plan?

Medicare is working with your Medicare Advantage Plan or other Medicare Health Plan to help them provide even more coverage or lower costs. If you currently have prescription drug coverage from your plan, you will get a notice from your Medicare Advantage Plan or other Medicare Health Plan about your prescription drug choices. Read any materials you get from your plan carefully.

If you don’t have prescription drug coverage, and want to add it, you can

• Check with your current health plan to see if they will offer a prescription drug option in 2006. If they will, you will usually be required to get your drug coverage from your current health plan if you decide to stay in the plan, or
• Switch to another Medicare Advantage Plan or other Medicare Health Plan in your area that offers prescription drug coverage, or
• Switch to the Original Medicare Plan and join a Medicare Prescription Drug Plan.

If you stay in your current plan that isn’t offering drug coverage in 2006, you will have to pay a penalty if you want to switch to a plan that offers prescription drug coverage later.

What do I need to know if I have a Medigap (Medicare Supplement Insurance) policy that covers prescription drugs and I have the Original Medicare Plan (Medicare Part A and Part B)?

Medigap policies are changing. You won’t be able to buy new Medigap policies that cover prescription drugs after January 1, 2006. This fall you will get a detailed notice in the mail from your Medigap insurance company describing your choices for prescription drug coverage. Read the notice carefully before making any decisions.

You must join a new plan that provides Medicare prescription drug coverage to have Medicare help pay for drugs. This will reduce your premium costs because Medicare pays most of the premium for Medicare drug plans. You can first join a Medicare Prescription Drug Plan from November 15, 2005 – May 15, 2006.

Most prescription drug coverage offered by Medigap policies, on average, is not at least as good as Medicare prescription drug coverage. This means, in most cases, if you keep Medigap prescription coverage, and don’t join a Medicare drug plan by May 15, 2006, you will have to pay a penalty if you choose to join later. Your next chance to join will be November 15 – December 31 of each year. Your coverage would begin January 1 of the following year.

Contact your Medigap insurance company before you make any changes to your prescription drug coverage. If you have your Medigap policy from a current or former employer or union, call your benefits administrator.

What do I need to know if I have drug coverage from TRICARE, the Department of Veteran’s Affairs (VA), or the Federal Employee Health Benefits Program (FEHB)?

As long as you still qualify, your TRICARE, VA, or FEHB prescription drug coverage is not changing. You should contact your benefits administrator or FEHB insurer for information about your TRICARE, VA, or FEHB coverage before making any changes. It will almost always be to your advantage to keep your current coverage without any changes. If you lose your TRICARE, VA, or FEHB coverage and you join a Medicare drug plan after May 15, 2006, in most cases, you won’t have to pay a penalty, as long as you join within 63 days of losing TRICARE, VA, or FEHB coverage.

What do I need to know if I have full coverage from my state Medicaid program?

The last day that your state Medicaid program will pay for your prescription drugs is December 31, 2005. You will have continuous Medicare prescription drug coverage and, in most cases, will pay a small amount out of your own pocket. Medicare pays for almost all of the cost of your drugs if you join a Medicare Prescription Drug Plan or a Medicare Advantage Plan or other Medicare Health Plan with Medicare prescription drug coverage.

Compare coverage and choose a plan. You can join a drug plan starting November 15, 2005. Medicare will let you know the plan it has picked for you in October 2005, but you can still compare plans and choose another plan by December 31, 2005. If you have not joined a drug plan by December 31, 2005, Medicare will enroll you in the plan it has picked to make sure you don’t miss a day of coverage. If you decide you want another plan, you can switch to another plan at any time without a penalty.

If you have Medicare and full coverage from Medicaid, and live in an institution (like a nursing home), you will pay nothing for your covered prescription drugs.

What do I need to know if I have the Original Medicare Plan (Medicare Part A and Part B) and I don’t have prescription drug coverage?

To have Medicare help pay for your drugs, you must join a plan that provides Medicare prescription drug coverage. You can choose and join the plan that meets your needs. If you don’t use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you won’t have to pay a penalty if you choose to join later. Your premium will be higher if you wait to join after May 15, 2006 because of the penalty.

You can first join a drug plan from November 15, 2005 – May 15, 2006. In most cases, if you don’t join during this period, your next chance to join will be November 15, 2006 - December 31, 2006 and you will have to pay a penalty. This means you pay a higher monthly premium for as long as you have Medicare prescription drug coverage.

What do I need to know if I have a Medigap (Medicare Supplement Insurance) policy that doesn’t cover prescription drugs and I have the Original Medicare Plan (Medicare Part A and Part B)?

To have Medicare help pay for your drugs, you must join a plan that provides Medicare prescription drug coverage. You can choose and join the plan that meets your needs. If you don’t use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you won’t have to pay a penalty if you choose to join later. Your premium will be higher if you wait to join after May 15, 2006 because of the penalty.

Contact your Medigap insurer for information about your policy. If you have your Medigap policy from a current or former employer or union, call your benefits administrator.

Information for people with limited income and resources

People with limited income and resources may qualify for extra help paying for Medicare prescription drug costs. The amount of extra help you get is based on your income and resources. You may qualify if your income is less than $14,355 or $19,245 for a married couple living together, and your resources are less than $11,500 if you are single or $23,000 if you are married and living with your spouse. [Income levels are for 2005, resource and cost-sharing amounts are for 2006, and will increase each year. The size of your family can also affect whether you qualify based on income. If you live in Alaska or Hawaii, income levels are higher.]

How do I know if I qualify for extra help?

You may automatically qualify for extra help. You may get a letter from Medicare saying that you automatically qualify for extra help and don’t have to fill out the application from the Social Security Administration (SSA).

You automatically qualify for extra help and don’t need to apply if you:

• Have Medicare and full coverage from a state Medicaid program that currently pays for your prescriptions. You should join a plan that meets your needs by December 31, 2005 because Medicaid will no longer pay for prescription drugs. If you don’t, Medicare will enroll you in a plan effective January 1, 2006 so you don’t miss a day of coverage. You can drop the plan or switch to another any time.
• Get help from your state Medicaid program paying your Medicare premiums (belong to a Medicare Savings Program). You should join a plan that meets your needs by December 31, 2005. If you haven’t signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don’t have to pay a penalty. You can drop the plan or switch to another any time.
• Get Supplemental Security Income. You should join a plan that meets your needs by December 31, 2005. If you haven’t signed up by May 15, 2006, Medicare will enroll you in a plan effective June 1, 2006 so you don’t have to pay a penalty. If Medicare enrolled you in a prescription drug plan, you can switch to another plan one time before December 31, 2006.

You may apply and qualify for extra help.