Medicare

Prescription Drug Coverage

Robert Hayes, president of the Medicare Rights Center, was online Tuesday, Nov. 15, at 2:30 p.m. ET to examine Medicare's New Drug Plan.

From The Post:

Press 'D' for Details (Post, Nov. 15)

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Full Coverage: Medicare and You

Interactive Map: State by State Data

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Robert Hayes: Thank you for the opportunity to chat with you today. At the Medicare Rights Center - a national, nonprofit consumer organization which is the largest independent source of health care information and assistance in the United States for people with Medicare - we are being inundated with questions as people try to understand what this new benefit means to them. There are a couple of things you should know up front about this new drug benefit. The first is that it works nothing like traditional Medicare. This coverage is offered only through private companies. To get the benefit you have to choose a private drug plan and enroll. The second is that whether you should take the drug benefit depends entirely on your circumstances. If you are one of the 14 million or so people with Medicare who have drug coverage already, you probably do not need to worry about it at all. You can stay with what you have as long as it is at as good or better than Medicare's drug coverage. Most employer and retiree insurance is since the new drug benefit does not offer comprehensive coverage-it is estimated to only cover about 50 percent of your drug costs. If you have no drug coverage and your income is low, you will probably benefit from the drug benefit if you enroll in the Extra Help program, which pays most of the costs of Medicare drug coverage. If your income is not low enough to qualify for Extra Help, whether or not to enroll in the benefit depends on your current drug costs and your risk tolerance. Do you want to pay a premium now for coverage you do not need or face a penalty later if your drug needs increase in the future? Keep in mind that you have until May 15, 2006 to make that decision without penalty.

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Stamford, Conn.: I spent a good many years, before I received my PhD. Now, in my "elder" years, The government offers me a prescription drug plan(s)/Please find me ONE person who can explain it to me, in plain and simple English!

Robert Hayes: This drug benefit does not work at all like Medicare, which is why people are so confused about it. Congress designed the benefit to rely entirely on private insurers to provide coverage. If you want it, you must choose from among dozens of different plans that are very hard to compare. In addition, it is a limited benefit that only covers about 50% of your drug costs. We recently compared the costs under Part D plans and buying drugs from Canada, and found that it may still save more buying from Canada.

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Greenwich, N.Y.: Where can people find an online chart of all choices for their state of residence with the added ability to visit each company's plan/s? Right now I believe I have located all my state's choices but would have to call or write (!) more than 40 companies if I wished to make an informed choice! Also, are these plans in flux right now, due to competition between companies, meaning any investigation now by the consumer is a waste of time?

Robert Hayes: www.medicare.gov is in the process of finalizing its drug plan comparison tool that helps you compare drug plans in your area. It allows you to enter the drugs you currently take and the pharmacies you use and gives you an estimate of how much you would pay for those drugs under various plans. The tool is not finished yet, so you are best advised to take your time. Remember, unless you have Medicaid and Medicare, you have until May 15, 2006 to make a decision.

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Carolina, Puerto Rico: I have not seen the following issue addressed anywhere, not even in the Medicare online site:

Does a beneficiary have to have Medicare's part B in order to get into part D, or is Part A sufficient?

Robert Hayes: To be eligible for Part D, you can have either Part A and/or Part B. Having just Part A is sufficient.

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San Rafael, Calif.: Which Medicare plan would provide me with the most broad-ranging and cost effective medicine plan? Please base your answer on the following: Due to age and brain injury, and loss of earned income and savings, my blessed secondary insurance is Medi-Cal.

Robert Hayes: If you have both Medicare and Medicaid you will have to get your drug coverage through Medicare starting January 1, 2006. You will be automatically enrolled in Extra Help, the federal program that helps pay for your Medicare drug costs. Your only costs will be a small copay of $1 to $5 for every prescription you fill. I can't tell you which plan is best for you. You need to choose a plan based on the drugs it covers and the pharmacies in its network. If you take a drug not on the plan's formulary (list of covered drugs), you will have to pay the full cost yourself.

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Ormond Beach, Fla.: After comparing the list of medications covered by various Medicare D plans, it seems to me that what the insurers have omitted many of the more expensive medications to protect their profits. I thought this plan was supposed to relieve our senior citizens of the heavy cost of meds. But with the high premiums, deductibles, and the infamous "doughnut hole," it seems to be designed more for the drug companies and the health insurers. Am I reading this all wrong?

Robert Hayes: This is a limited benefit. It works nothing like the traditional Medicare program and was designed by a Congress that believes private companies can do better than government programs. Since you have until May 15th to decide what you want to do, it is best to take your time and see how these private plans do over the next few months. However, plans are supposed to, by law, cover at least two drugs in every drug class.

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Buffalo, NY: I am retired age 77 and my wife is 73 we have full prescription coverage with a co-pay of one dollar per prescription.

At my death my wife will cease to be covered. Must she join the program at this time or could she wait until she required new coverage.

What advantage in waiting and what disadvantage is there? We see only the extra cost per month for coverage we don't need.

Robert Hayes: You should have gotten a letter or notice telling you if your drug coverage is as good or better than Medicare's. Sounds like it is. Since Medicare's drug coverage is a limited benefit that only covers about 50% of your drug costs, most employer and retiree insurance is better. If your current drug coverage is, you do not have to take Part D. Your wife can join Part D when she loses her current drug coverage with no penalty, as long as she is not without drug coverage for more than 63 days.

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Washington, D.C.: My father is 91, lives in Florida and has prescription drug coverage as part of his HMO medical insurance with Humana. The plan covers almost all of his prescription drug costs. My sense is that he should not enroll in a Medicare D plan, and simply continue his current plan. Do you agree?

Robert Hayes: If the plan your father is in is a Medicare HMO, he should be getting a letter from the plan telling him how his coverage will change in 2006. Most likely the plan will be offering drug coverage through Part D and your father will have to take Part D if he wants to stay in the plan. However, he should know that starting in 2006, he will be locked into his plan for the year, even his doctors leave the plan. He can change to traditional Medicare, which allows access to virtually any doctor or hospital in the country, and sign up for a drug-only plan.

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Asking for mother in nursing home: She has Blue Cross Blue Shield (my late father was a Federal worker). She also has Medicare Part B. That's it.

Currently her prescriptions cost her about $250 per month.

I don't know what to recommend for her. Any suggestions? She's 85 years old and in reasonably good health for her age. Thanks.

Robert Hayes: People with low drugs whose income is not low enough to get Extra Help (less than $13,000 a year), have the hardest decision to make. If you have low drug costs, having Medicare drug coverage could cost you more now, but could protect you from high drug costs in the future. There may be a Medicare drug plan in your area with a low monthly premium you can afford. If you do not enroll when you are first eligible, you will pay a penalty if you enroll later. The penalty may be small (1% of the average national premium-$32.20 in 2006-for every month you do not enroll). But you will not be able to enroll until the next enrollment period (Nov. 15 - Dec. 31 each year), so you will have no coverage if your drug needs change in the course of a year. Still, there may be other low-cost ways to get the drugs you need. To find out, call your State Health Insurance Assistance Program (call 800-MEDICARE for phone number).

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Glen Burnie, Md.: My mom is currently getting her drugs from Medicaid. She got a letter in the mail saying that starting Jan. 1, Medicaid will no longer cover her drugs and she will be "assigned" to a new drug plan if she does not choose one - I was surprised to find out that these drug plans are not really regular Medicare at all, but private insurance. I'm really worried that a new plan will not be as good as the coverage my mom currently gets under Medicaid. I want to help her pick the best plan, but I looked on the Medicare Web site (it is very complicated- how do they expect older people to figure this out?!) and I have not been able to find a plan in Maryland that covers all of her drugs. What do you suggest? I'm worried that I'm going to wind up paying for all the drugs my mom needs that aren't paid for by the drug plan.

Robert Hayes: People with Medicaid will see the biggest change to their drug coverage. There is no easy solution to the problem you are describing because this benefit was designed by Congress to be very different from the guaranteed reliable coverage people have been used to with the traditional Medicare program. You should ask your mother's doctor if any of the drugs not covered by the Medicare plans can be changed to covered drugs. If the doctor feels her current drugs are the only ones that will work for her, the doctor can help her file an exception request with the plan. The plan should then cover the drugs she needs. You should also call the Maryland Medicaid program to ask if they will cover drugs not covered by the Medicare drug plan.

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Phoenix, Ariz.: When is the maximum income amount to qualify for financial assistance with pharmaceutical medications going to change in 2006, and what will that amount be raised to? If they know it is going to be changed this year why didn't they just change it now?

Robert Hayes: The income limits for getting Extra Help are based on the Federal Poverty Level, which is updated around February or March of every year.

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Springfield, Va.: Hello. I am 64 years old, ready to turn 65 in May when I will be eligible for Medicare. HOW DOES ONE ENROLL IN MEDICARE? Will Medicare contact me or do I need to go forward to enroll?? No one seems to know here (my friends are younger!) Pleeeeeeze respond. Thank you a lot.

Robert Hayes: If you have applied for Social Security retirement benefits, you will be automatically enrolled in Medicare and should receive a mailing about your Medicare benefits about three months before your 65th birthday. If you have not applied for Social Security benefits, you can enroll in Medicare in the seven months surrounding the month you turn 65 at your local Social Security office.

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Bremerton, Wash.: During open enrollment periods at the end of each year, can we switch plans or upgrade our plans as our prescription needs change? And, if we can, are we then subjected to rejection by insurance companies because of pre-existing conditions or because our prescription needs have increased and make us an undesirable risk or do they have to accept our applications without conditions because they are submitted within the bounds of the rules?

Robert Hayes: Yes, you can change your drug plan during the Annual Coordinated Election Period, which is November 15 through December 31 of every year. You cannot be rejected from joining a a Medicare drug plan because of your age, health or because you take a lot of drugs.

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Arlington, Va.: I was watching a special report last night on the new Medicare changes, and one of the predicted problems was that seniors who do not have access to the computer, or who do not possess the skills to sign up for these new benefits. Are there programs in which volunteers can assist isolated or homebound seniors after being trained? I would be interested in signing up.

Robert Hayes: People without Internet access can call 800-MEDICARE or their local State Health Insurance Assistance Program for help (800-MEDICARE can give you the number). Various groups do have volunteer programs that will assist people as well. We at the Medicare Rights Center have started one program that trains volunteers to help people from their homes or offices by phone. If you are interested in volunteering you can contact us at 212-869-3850 ext. 82 or lincs@medicarerights.org.

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Atlanta, Ga.: I currently have medigap coverage J. Where can I find out how the Medicare advantage plans will compare?

Thanks

Robert Hayes: If you have a Medigap, you probably do not want a Medicare Advantage plan, which are plans that restrict your choice of doctors and hospitals. You can look at stand-alone drug plans (plans that offer only drug coverage and work with the transitional Medicare program).

If you enroll in the Medicare drug benefit (Part D), you cannot also have a Medicare supplemental insurance policy (Medigap) that offers drug coverage. Medigap plans H, I and J, which currently offer limited drug coverage, will no longer be sold once the Medicare drug benefit begins in 2006.

If you had one of these plans before January 1, 2006, you can:

Keep it and choose not to enroll in the Medicare drug benefit. If later you want to drop the Medigap drug coverage and buy the Medicare drug benefit, you may have to pay a premium penalty.

Switch to another Medigap policy that does not offer drug coverage and enroll in the Medicare drug benefit. You are probably better off with the new Medicare prescription drug coverage than with the limited coverage offered by these plans.

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Burke, Va.: Most information I have seen concerns seniors. I have a question about Part D regarding a disabled 32 year old.

Our adult son receives Social Security disability payment and is covered under Medicare Part A and B and Medicade for prescription drugs. He also has secondary health insurance coverage under my Blue Cross Blue Shield with the federal government. It is my understanding that the the Medicade prescription drug coverage will go away under the new Medicare Plan and we will have to choose another provider for drug coverage, could this also be Blue Cross Blue Shield?

Robert Hayes: The new Medicare drug benefit will work the same way regardless of whether you are eligible for Medicare based on age or disability. People with Medicaid and Medicare will have to get their drug coverage from Medicare starting January 1, 2006 and should look for a Medicare drug plan that will cover the drugs they need. People with Medicaid should generally not be in a Medicare HMO, so they should look for a drug-only plan, which work with Original Medicare and Medicaid.

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Warren, Mich.: Can I get prescription drugs only from medicare?

Robert Hayes: No, Medicare drug coverage is only available through private plans. However, you can keep traditional Medicare for your doctor and hospital benefits and join a drug-only plan if you want the Medicare drug benefit.

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Washington, D.C.: You say it only covers half of drug costs. What's wrong with that? especially for folks who no help right now. You make it sound like cutting their cost in half is a bad thing. Plus, doesn't the benefit give more help to seniors with really high drug costs or little income.

Robert Hayes: Medicare was originally designed to be a comprehensive benefit, meaning that it covered at least 75% of your costs. That is why I say that a benefit that only covers 50% of your costs is limited. Particularly since people can save 50% or more simply by buying their drugs from Canada.

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Washington, D.C.: My parents are 80 and 81 years old. They are confused and scared by the information they've received from the government about the new drug benefit. HHS blithely says, "Call the toll free number, or go online." But the toll free number is always busy, and if someone answers they refer you somewhere else, and my parents don't have a computer. Fortunately, I've offered to sort this out for them, and I'm not only confused, I'm spitting mad. This is FAR more complicated than it should be. And what about the millions of seniors who don't have children who are willing and able to help? I'm hearing this whole fiasco described as "elder abuse," and I agree. Will public outcry cause change or repeal, similar to what happened with catastrophic health care several years ago?

Robert Hayes: The Medicare Rights Center believes that the best way to offer drug coverage for people with Medicare would be to offer it under Medicare Part B, which currently covers some outpatient drugs, and work like the rest of Medicare. We certainly encourage everyone to call their representatives and demand the option of getting this Medicare benefit through Medicare and not only through private plans.

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Empire, Mich.: The Medicare Formulary Finder and Plan Finder are returning incorrect results. They are showing false negatives; ie: stating that a plan does not cover a drug when, according to the plan's formulary, it does cover the drug.

The results I obtained from the Formulary Finder where 75 percent incorrect as it claimed that 3 plans did not cover all the drugs submitted when they actually did cover. The Plan Finder reiterated the same results and within the specific plans incorrectly shown to not cover all drugs submitted, the finder was in error 40-80% of time about coverage of a specific drug.

Is any action being taken to correct the errors in the Medicare Web programs? Has any warning been issued about relying upon the Medicare Web site?

Robert Hayes: We have found the same problems, which is why we have been encouraging people to take their time. And we will let people know when we feel the tool is ready to be used. If you are interested in getting out updates, you can subscribe to Dear Marci, our free weekly e-mail newsletter. You can subscribe by going to www.medicarerights.org/dearmarci.html.

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Reno, NV: I receive virtually all my prescription drugs from the VA. I'm not eligible for TriCare. Do I need to sign up for Part D?

Robert Hayes: If you get your drugs through the VA you do not need to enroll in the Medicare drug benefit. VA benefits are considered better than the Medicare drug benefit. If at a later date you move and are no longer near a VA facility where you can get your medications, you can join the Medicare drug benefit without penalty.

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Phoenix, AZ: I'm 68, but use no prescription medicines (only vitamins and Polycosinol) so I don't want to pay in to a prescription plan. I understand that may cost me a penalty in the future, as I expect to live into mid-80s. How much is the penalty?

Robert Hayes: The penalty is 1% of the average national premium ($32.20 in 2006) for every month you do not enroll, starting with June 2006. This amount will be added to the monthly premium of the plan you join. The average national premium s expected to go up every year.

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Berkeley, Calif.: Thanks for this great information. You told one person earlier who is eligible for both Medicare and Medicaid that they'll get be signed up for Medicare drug coverage, but that if a drug they take isn't on the formulary of the plan they sign up with that they'll have to pay for the drug. Isn't it true that all Part D plans have to cover medically necessary nonformulary drugs by an exception process? Will Medicare Rights Center help people figure out how to use plans' exception processes? Thanks again for your important work.

Robert Hayes: Yes, if your doctor believes that the drug prescribed is the only drug that will work for you or that any other drug would be harmful, the doctor can file an exception request with your drug plan. The plan should then cover the drug you need. If the plan still says no, there are several more appeals you can make. MRC will be helping people appeal drug coverage denials. However, this is completely new territory so we have no way of knowing how often plans will deny exception requests yet.

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Ellicott City, Md.: There is a lot of discussion about the pros and cons of Part D. But, at the end of the day, are you telling beneficiaries to join, which would likely promote the longevity of this poorly designed program, or are you recommending that people stay out of the program, which would speed up the likelihood of designing a better system?

Robert Hayes: At MRC we wear several hats. We help individuals make the most of the current benefits and we advocate for better benefits. In one-to-one counseling we are trying to help people decide whether they will be helped by this new benefit. In our advocacy work, we are pushing for changes that will make this drug benefit work like the rest of Medicare.

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Bethesda, Md.: Do you think seniors will be inundated by marketing efforts by the private insurance companies (e.g. phone calls, direct mail) to encourage seniors to join their plans? How much competition for subscribers is permitted. Is CMS doing anything to control or limit direct marketing?

Robert Hayes: Yes, MRC believes CMS has allowed the plans too much leeway in their marketing, even allowing plans to cold call people. That is why we are advising people not to base their decision on any marketing materials.

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Seminole, Fla.: My drug costs are $1300 per month. My SS benefits are $1275 per month. Why do I not qualify for extra help???????

Robert Hayes: To qualify for Extra Help your income must be less than about $1,200 a month for individuals ( $1,600 for couples) and your assets (savings, stocks, etc.) must be less than $11,500 for individuals ($23,000 for couples). Your current drug costs are not taken into account.

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Silver Spring, Md.: Are US Permanent Residents eligible for Medicare/Medicaid, or do you have to be a US Citizen to qualify?

Robert Hayes: Legal residents who have lived in the US for 5 years or more are eligible for Medicare.

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Wheeling, W.Va.: BACKGROUND: Some Medicare drug plans have a formulary which excludes certain prescription drugs. The patient therefore would have to pay 100% of the costs of the EXCLUDED drugs.

QUESTION: Do the costs of the drugs EXCLUDED from the formulary count toward the "Total Drug Costs" in reaching the $2,250 milestone at which point all patients start paying 100 percent.

- This question is important because if the patient's drugs that are excluded from the formulary are included in the "Total Cost" calculation, the patient could reach the $2,250 milestone without any - or very few ]payments from the plan. Thus the patient would be paying up to 100 percent of the drug costs up to the limit of $2,250 as well as 100 percent after $2,250 until the next milestone, merely because the plan decided to exclude drugs from the formulary.]

Need answer to this question in order to make economic decision when shopping for plans with different formularies.

THANKS.

Robert Hayes: No, the cost of a drug not covered by the plan wither because it is not on the plan's formulary, it is excluded from Medicare coverage or you bought it at a pharmacy outside the plan's network, will not count towards meeting your out-of-pocket cost limit.

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Laurel, Md.: Mr Hayes, Some of the Medicare Advantage plans seem to let you choose your Doctors and Hospitals. Am I reading this incorrectly?

Robert Hayes: Yes, you can choose the doctor and hospital you want as long as it is part of the plan's network. PPOs allow you to go outside the plan's network, but then you have to pay a higher copayment.

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Robert Hayes: Thank you all for your great questions. I'm sorry I couldn't get to all of them. However, you can read all the materials about the drug benefit MRC has created at www.medicarerights.org/drughelp.html. They can answer most of your questions, including what happens if you are in a nursing home, in a private health plan, or in Medicaid. In addition, you can sign up for our free weekly consumer and advocacy e-newsletters at www.medicarerights.org/subscribe.html.

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