MAKING MEDICARE MAKE SENSE

Answers to Some of the Most Commonly Asked Medicare Questions

Q: What if I switched my Medicare Prescription Drug Plan for 2008 and have not received my plan identification card in the mail but need to get my prescriptions; what do I do?

A: The first time you use your new Medicare drug plan, you should come to the pharmacy with as much information as possible, especially if you need to use your new coverage before you receive a plan membership card. Here’s what you need to bring or do:
• Your red, white, and blue Medicare card
• A photo I.D.
• An acknowledgment or confirmation letter from the plan if you have one, or an enrollment confirmation number from the plan.
• Let the pharmacists know the name of the Medicare drug plan you joined. He or she can confirm your plan enrollment and get the information necessary to bill your plan. Since the pharmacist may have to search for your plan information, it could take extra time to fill your prescriptions.
• Also, if you have both Medicare and Medicaid or qualify for extra help with drug plan costs, you should also bring proof of your enrollment in Medicaid or that you qualify for the extra help. Proof of Medicaid or extra help may include the following
• Your Medicaid card
• A copy of your current Medicaid award letter
• A copy of your yellow automatic enrollment letter from Medicare
• A copy of either the green, blue, purple or orange extra help letter from Medicare
• A copy of your extra help, “Notice of Award” letter from Social Security
• A copy of your Supplemental Security Income (SSI) award letter
• Other proof that you qualify for extra help (such as a “Notice of Award” from a state Medicaid program).
• You don’t need to have all of these items, but anything you can bring will help the pharmacist confirm your Medicare drug plan enrollment and /or that you qualify for Medicaid or extra help to make sure you get the prescriptions you need, at the costs for which you are entitled.

Q: What happens if the pharmacist is unable to confirm a beneficiary’s plan enrollment?

A: As a last resort, the beneficiary may have to pay out-of-pocket for the prescription(s) and send receipts to the plan. If the pharmacist can't confirm plan enrollment and a person pays out-of-pocket, they should save the receipts and work with their Medicare drug plan to be reimbursed. However, given that some plans have a deductible that has to be met before the plan begins to pay; beneficiaries may be paying out-of-pocket for their initial prescriptions anyway.

Q: Are there are any transition periods if a new plan does not cover a prescription drug that was covered by a Medicare beneficiary’s former plan?
A: Yes, plans must have the capability to allow enrollees a one-time, temporary supply of non-formulary Part D drugs.
• Non-formulary drugs include:
• Drugs that are not on a plan’s formulary
• Drugs that are on a plan’s formulary but require prior authorization or step therapy
• The new plan must accommodate the immediate needs of an enrollee
• The new plan must allow sufficient time to either have the Medicare beneficiary’s doctor switch them to an equivalent medication or the completion of an exception request through the new plan.
• The Medicare beneficiary enrollee is responsible for normal co-pay or coinsurance that the plan would charge for non-formulary drugs approved under a coverage exception
• For those who qualify for the low-income-subsidy, or what is called the “extra-help”, the co-pay or coinsurance can never exceed the statutory maximum amount
• New plans must provide a 30-day fill when a beneficiary presents a non-formulary prescription within the first 90 days of the coverage under the new plan
• Plans must provide a written notice, via U.S. First Class mail, regarding the transition process to the new Medicare beneficiary enrollee within three business days of a temporary fill
• The notice must include the following elements:
• Explanation of the temporary nature of the transition supply
• Instructions for working with the plan sponsor and prescriber to identify an alternative drug
• Explanation of the enrollee’s right to request a formulary exception
• Description of the procedures for requesting a formulary exception
• Medicare encourages plans to provide additional information: reason for transition fill, alternative formulary drugs etc.
• Pharmacists are encouraged to provide point-of-sale notification about transition fills

Q: What is the special enrollment period for those who lost their “extra-help” (the low-income subsidy) status for 2008?

A: Medicare beneficiaries who lost their low-income subsidy eligibility effective January 1 this year, now have a Special Enrollment Period (SEP) beginning January 1, 2008 through March 31, 2008 allowing them to make one Medicare Prescription drug plan enrollment election so that they are in the best plan for their prescription drug needs, as the beneficiary will now be responsible for all of the out-of-pocket costs incurred through their current plan, instead of having most of it paid for by qualifying the previous year for the extra help. Basically, there may be a more economical plan out there for them and the opportunity to compare and enroll is now.

Q: What about open enrollment that is still on-going until March 31 for choosing a Medicare Advantage health plan; how does that work, and how is that different than the Medicare Prescription Drug plan annual enrollment period that just ended?

A: First here is an explanation of Medicare Advantage Plans:
• Medicare Advantage Plans are health plan options that are approved by Medicare and run by private companies. They are part of the Medicare program and sometimes called, “Part C.” When you join a Medicare Advantage Plan, you are still in Medicare. With some of these plans, you must get a referral before seeing specialists.

• Medicare Advantage Plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services. Basically, Medicare Advantage plans replace your original Medicare, and therefore you would still incur the Medicare Part B premium each month. They generally offer extra benefits, and many include Medicare prescription drug coverage. These plans often have networks which mean you may have to see doctors who belong to the plan or go to certain hospitals to get covered services. Some of these plans coordinate and help manage your overall care and can also result in savings to you.

• Medicare pays an amount of money for your care each month to these private health plans, whether or not you use services. Medicare Advantage Plans also include options that provide specialized care for people who need a lot of health care services. Even if you are out of the service area of the plan, you are still covered for emergency or urgently needed care.

• Types of Medicare Advantage Plans include:
• Preferred Provider Organizations, (PPOs);
• Medicare Health Maintenance Organizations (HMOs);
• Medicare Private Fee-for-Service (PFFS’) Plans;
• Medicare Special Needs Plans and
• Medicare Medical Savings Account (MSA) Plans

• The Medicare Modernization Act (MMA) of 2003 contained legislation that expanded Medicare Advantage Plan options in almost every area of the nation.

• You can join a Medicare Advantage Plan if:
• You live in the service area of the plan you want to join
• You have Medicare Part A and Part B.
• You don’t have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant-which Original Medicare covers).

• You can enroll in a Medicare Advantage Plan when you first become eligible for Medicare. You can switch plans each year between November 15 and December 31, the same time frame for switching your Medicare Prescription Drug Coverage. You can also join or switch plans from January 1, through March 31 of any year, which is called the Medicare Advantage Open Enrollment Period, or (MA OEP) but during this time frame you can’t change whether or not you have Medicare prescription drug coverage. You can only change prescription drug coverage during the annual enrollment period each year, which is November 15 through December 31.

• So now until March 31, if you are in a Medicare Advantage Plan you can switch to a different Medicare Advantage Plan. If your current Medicare Advantage Plan has prescription drug coverage through Medicare Part D and you would like to switch to a different Medicare Advantage Plan you will have to choose another plan with Medicare prescription drug coverage through Part D. Another option would be to switch to the Original Medicare Plan with a stand-alone Medicare Prescription Drug Plan. Again, the MMA legislation of 2003 does not allow joining or dropping Medicare Prescription Drug Coverage anytime other than annual enrollment.

Questions? Contact Julia Allen, Benefits Coordinator at the St. Louis Area Agency at 314-612-5954.

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