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UNDERSTANDING THE ROLE OF THE MEDICARE

PRESCRIPTION DRUG BENEFITS

BY

KYLA GROFF KELIM1

Understanding the Role of the Medicare Prescription Drug

Program:

1. Who is Eligible for Benefits?

Medicare at a glance.

Medicare is national health insurance program that provides

coverage for:

People 65 or older

People under 65 who have been disabled for more

than 24 months (except for the two following conditions)

People of any age with end stage renal disease

(ESRD)(permanent kidney failure requiring dialysis or a kidney

transplant)

People with amyotrophic lateral sclerosis (ALS), or Lou

Gehrig disease. 2

1 Kyla Groff Kelim is an elder law attorney and principal of the firm Aging in Alabama located in Fairhope,

Alabama and has been practicing in Florida and Alabama for nearly 20 years. A prolific national speaker and advocate of senior issues, her firm provides consultation and representation to seniors, their families, caretakers and professionals to protect their life’s work from the devastating costs of long term care. 2 Source: http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/medicare-benefits-overview.aspx,

accessed December 2, 2012.

Introductory note:

Practicing in the area of elder law or

health care law, requires an advanced

knowledge of a number of different

regulatory schemes and programs,

such as Medicare, Medicaid and Social

Security, as well as a thorough

understanding of estate and tax

implications. The key is to provide

options for your client that will offer

him or her a clear roadmap of the

obstables that these regulatory

schemes present, and how their

particular situation may be affected.

Often, I compare this area to learning

several difficult foreign languages at

once, such as Mandarin Chinese and

Sanskrit.

The practitioner should be aware that

planning in this area often comes with

a price tag in copays and deductibles

that run into thousands of dollars per

year. Clients often want increased

benefits for no cost, or are willing to

sacrifice necessary benefits due to

decreased income upon retirement.

That being said, if you do not fully

understand the Medicare Prescription

Drug Program, you could be in the

unenviable position of explaining to

the client that you did not intend to

DISENROLL them from their

supplemental insurance just in time for

their major heart surgery or stroke

because you were not permitted to

have both…

2

Medicare has 4 parts or components, parts A through

D.

a. Medicare Part A is usually considered the

“hospital” portion of Medicare, and most do not pay a

monthly premium but some may not qualify for part A

without a very large premium, notably if the beneficiary

or spouse had less than the requisite 40 quarters of

work (see sidebar for 2013 premium information). To

offset hardship, a number of states will also permit a

“buy-in” during the year for low income individuals

suffering a catastrophic illness.3 As shown in the

sidebar, Medicare part A provides very basic coverage

with large copays and deductibles for many services.

Given the large out of pocket expense, it is desirable for

any beneficiary to maintain a “Medigap” policy that will

provide coverage for the “gaps” in Medicare A and B

coverage. See more below. Medicare part A also

covers skilled nursing home care, and hospice care, as

well as other types of care that would be typically

associated with an inpatient or institutional setting.

3 Those states not offering a “buy-in” for Medicare part A during times of the year not usually subject to open enrollment

are: Alabama, Arizona, California, Colorado, Illinois, Kansas, Kentucky, Missouri, Nebraska, New Jersey, New Mexico, South Carolina, Utah and Virginia. Center for Medicare Advocacy. “Medicare General Enrollment begins January 2

nd: An

Opportunity for Some Individuals and States to Expand QMB Coverage,” http://www.medicareadvocacy.org/2011/12/medicare-general-enrollment-begins-january-1st-liminted-opportunity-for-some-states-to-expang-cmb-coverage/, accessed January 9, 2012.

COPAYS*PREMIUMS*DEDUCTIBLES*

COINSURANCE*COST-SHARING

2013 Medicare Part A numbers:

· $ 1,184 per hospital stay, 1-60

· $ 296 per day 61-90

· $ 592 per day 91-150

· SNF DAYS 21-100, $ 148.00 per day

· 20% durable medical equipment

· most Americans have a zero premium for Part

A so long as they or their spouse worked at

least 40 quarters.

· For the rest, 2013 premium is $ 441.00 per

month for those with less than 30 quarters or

otherwise not eligible or a lesser amount per

month for those who worked between 30 and 39

quarters. (figures not available)

2013 Medicare Part B numbers:

· $ 147 deductible

· a coinsurance, generally 20% of physician,

lab, outpatient and related care but this amount

varies according to a formula

· premium for most is $ 104.90, an increase for

many by $5.00 over 2012 premium rates.

· premium is adjusted on a sliding scale for

those with income over $ 85,000.00 or couples

with more than $ 170,000 annually, up to a

maximum premium of $ 230.80, a substantial

decrease over 2012, for those making more

than $214,000 annually (couple - $428,000

annually.

·

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Penalties. For those who do not enroll on time

for Medicare Part A, there is a 10% penalty

imposed upon those who are subject to a

premium. This penalty will be in place for twice

the number of years that Medicare enrollment

was delayed.

b. Medicare Part B is usually considered the

“medical” or “doctor” portion of Medicare as it

covers outpatient medical care, and generally is

associated with a monthly premium similar to

privately owned health insurance. As with Part A, Part B, is subject to an annual

deductible and then some significant coinsurance and flat copays will apply to various

services. Part B will cover medically necessary physician services, outpatient services

such as physical therapy and diagnostic tests, home

health care, and durable medical equipment, as well as

some preventative therapies. While the coverage is

thought to be a general 20% of the covered service, this is

not precisely correct. The coinsurance is tied to a

complex formula that, in some cases, may leave the

beneficiary with a much larger than 20% liability. The beneficiary should have some kind

of “Medigap” coverage in order to pay for some or all of these costs.4

Penalties. For those beneficiaries who wish to avoid the payment of premiums and “wing

it” by not signing up for Medicare, a significant penalty of 10% per year will apply for each

12 month period the beneficiary has been eligible – but not enrolled – in a Medicare

4 See below.

QUICK FACTS:

Nearly 50 Million beneficiaries in 2012 (statehealthfacts.org)

25% are in Medicare Advantage (part C) plans (medicare.gov).

In effect since 1965

For major medical, physician and prescription drug coverage

Appointments with dentists, chiropractors, opticians not covered

Generally, only covers beneficiary while in the United States

DID YOU KNOW? Medicare is available

to all, otherwise qualified beneficiaries

(so long as they pay for the premiums)

and no one can turned down for

preexisting conditions or refused for

any health care related reason. The

same is NOT true of Medigap plans.

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program. Thus, if the beneficiary were first

eligible in May of 2006, and enrolls right now,

the monthly premium for the majority of

Medicare beneficiaries for 2013 of $104.90

will not apply; instead, he will pay more than $

178.00 per month, each month until his

death.5

c. Medicare Part C is really a misnomer.

Part C is the name for a number of “Medicare

Advantage programs” operated by private insurance companies that completely replace

Part A and Part B, and in most cases, Part D as well.6 Those beneficiaries who choose a

Medicare Advantage plan are no longer Medicare recipients. Part C plans include Health

Maintenance Organizations (HMOs) as well as Preferred Provider Organizations (PPOs)

and Private Fee for Service (PFFS) organizations. Special Needs Plans (SNPs) are also

included, but are subject not only to the specific coverage area available, but also have to

be prequalified by being either 1) chronically ill with one or more conditions such as

diabetes, congestive heart failure or

other debilitating chronic illness or

2) be dual eligible or 3) be in a

nursing home. It is extremely

important to understand the

limitations as well as the benefits of

5 Those beneficiaries who are eligible for a savings program or another Medicaid program that will impact the premiums will

benefit by losing the penalty. 6 It is rare that a client recognizes that he is no longer in the Medicare system and when he does, he is very upset. This will

be important for appeal purposes where the client is not giving his provider the correct card. Just keep reminding him that he did not have to pay nearly $4,000.00 for a supplement last year, his memory may return.

Client interviewing tips:

1. The client can opt to have Medicare premiums

deducted from client’s Social Security check or can

be billed quarterly for premiums.

2. Most clients will tell you how much Social Security is

deposited in the bank when you ask how much the

client receives in Social Security funds. Since most

beneficiaries have the premium for Part B and/or

other parts taken out, this can lead the practitioner to

believe the income is much lower than it is.

3. For purposes of screening clients to determine if they

may qualify for a Medicare Savings Program or other

government discount program, add back into the

monthly Social Security check the amounts deducted

for health insurance premiums.

TIP: For those clients who are retiring at 65, and

in very good health, having a zero premium HMO

may be a very good idea. Also, some HMOs in

large, urban areas with a multitude of providers

may certainly offer an attractive alternative to a

high cost Medigap policy (see below), as the

health care premiums eat away at a retiree’s

limited fixed income.

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enrollment in one of the Part C plans, as it can wreak havoc on the access to the

beneficiary’s health care if the wrong plan is selected. For example, there are some plans

available that not only provide no prescription drug coverage under Part D, the beneficiary

cannot get a stand alone plan either! In this case, if the beneficiary takes a number of

high cost medications, it could be a mistake in the tens of thousands of dollars. In cases

where the beneficiary has a number of chronic illnesses and long term care nursing home

admission is a subject of planning, whether imminent or near future, or the beneficiary is

on hospice care or of very advanced age, and the Medicare C program does not offer

skilled nursing benefits consistent with original Medicare or the nursing home is out of

network, then at least a month will not be paid. That can lead to a $ 5,000.00 or more

error that the client will not appreciate.7 Special needs plans can provide great coverage

for those persons who qualify for help, but not for QMB as it can provide great

supplemental coverage without premium.

d. Medicare Part D, our subject today, is the prescription drug coverage plan, and is

generally divided between those plans that are part of a Part C plan, or those plans that

are “stand-alone” plans (PDP). The part D plan does not provide coverage for every

event, it contains a basic benefit, which might or might not be subject to a premium. If so,

then the premium is paid each month or deducted from the beneficiary’s monthly income.

The plans vary and contain variable amounts of deductibles. The coverage continues on

its terms until the company has provided the initial coverage limit of $ 2,970. Then, the

client is in the “gap” or “donut hole” until the client’s out of pocket costs exceed $

4,750.00. When the total drug cost reaches $ 6,733.75, then the client is on “catastrophic

coverage” or paying $ 2.650 to $ 6.60 for prescription drugs. These amounts will change

7 Be sure to confirm that the client is actually switched to Original Medicare or another plan that will cover the facility

before the end of the month, or else this is a $ 5,000.00 per month mistake that keeps on going.

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every year. See more detail in Part V, Medicare Part D Prescription Drug Program

Updates.

New provisions to Medicare D are added this year though the implementation of parts of

the Affordable Care Act. See below for more, the meat of our talk.

Penalties. As of May 2006, Medicare beneficiaries must select a plan and pay a monthly

premium for a part D plan, unless their existing health insurance provides certification that

the prescription drug portion is equivalent or better than the Part D program or the

beneficiary will be subject to a penalty of 1% per month in additional premiums when she

does finally enroll. Thus, if a beneficiary chooses a plan right now that is at the average

cost of $ 30.00 per month, with the penalty it would cost a beneficiary over $ 50.00 per

month for life.8

e. Medigap coverage. Medigap coverage is the private health insurance plan that is

also referred to as a Medicare supplement plan. These plans are also referred to by

letter, Plans A through N. Each Plan type has a set of specific coverage parameters, and

were updated in 2010. A chart summarizing the types of Medigap plans is attached

below.

f. Special help is available to help low income beneficiaries pay for their insurance

and lower the overall out of pocket cost. LIS or Low-Income Subsidy can provide extra

help for paying for Medicare part D premiums and copays, as well as traditional Medicaid

provisions, and Medicare Savings Programs, below.

8 Right now is misleading, as the open enrollment period is over and the late enrollee must still wait until October to sign up

for a plan that will not start until January, generating a larger penalty still. As with Medicare part B, if the beneficiary is eligible for a savings program or LIS, then the penalty can be forgiven. But see Chart, Medicare Enrollment Dates (Secondary).

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g. Medicare Savings Plans (MSP): For beneficiaries with low income, there are a

number of “Medicare Savings Programs” (not to be confused with Medicare Advantage

Programs), that will pay for up to 100% of the shortfall or “gaps” in Medicare, depending

upon income. Those qualifying for one of these programs or for full Medicaid benefits are

often referred to as “Dual Eligibles.” Medicare Savings Plans are administerered

through Social Security and the local Medicaid agency and generally offer 3 programs,

although other state specific programs may be available as well. They are:

An alarming number of clients get upset that we cannot predict the future with more

precision. ---Kyla Kelim, Aging in Alabama (not related to famous seer)

Guitar music is on the way out. ---Decca Recording Co. in rejecting the Beatles, 1962 (Source: Matthew Perpetua, “Paul McCartney Signs to Label

That Rejected the Beatles”, Rolling Stone Magazine, August 23, 2011, accessed online at

1/19/2012.http://www.rollingstone.com/music/news/paul-mccartney-signs-to-decca-20110823.

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1. QMB: Qualified Medicare

Beneficiary program.9 This is a

great program that gives a person who

is making below 100% of the Federal

Poverty Limit (FPL) several important

benefits. First, the program pays the

Medicare premium, so this year, the

annual savings of having QMB, just for

that portion, is a few dollars more than

$ 1,200.00. Next, the program gives

Medicaid health coverage as a

supplement to the Medicare, meaning

that the low income beneficiary does

not have to participate in cost-sharing

and will only have to contribute very

nominal amounts for services or

drugs. Third, the prescription drug

card is free, so long as it is one of the

cards that is at or below the average

cost of $ 31.17 per month. There are

no premiums, copays, coinsurance, deductibles and prescriptions will be $ 2.50 to $ 6.50.

To qualify, the beneficiary must have income of less than $ 951.00 if single and $

9 Not included in this discussion is the QDWI or Qualified Disabled Working Individual program that pays for premiums if the

disabled beneficiary loses benefits due to one or more periods of SGA or Substantial Gainful Activity.

PRACTICE TIP:

It is always a good idea to have your clients come

in for a consultation after the death of a spouse.

One of the primary advantages is to see if the

spouse now qualifies for benefits such as the

Medicare Savings Program. Many middle income

workers will have no idea they are eligible for any

benefits, particularly if they have significant

assets and have no familiarity with government

benefit programs in general. You can save your

client tens of thousands of dollars per year by

simply screening and advising. Some states will

limit the savings programs to those who have

limited assets as well. This is one of the areas

of great confusion because of the low income

subsidy on Part D (LIS). The rules for the LIS

only permit a small amount of assets, other than

the home and vehicle. See Part D, infra, Section

V. for more detail and comparison. It is

important that the attorney either become very

familiar with the Medicare program and its

various savings plans and the LIS, or refer the

client to the local Area Agency on Aging or SHIP

counselor for the most up to date Medicare

advice.

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1,281.00 if married10, and some states also limit the assets of the recipient.11 Those limits

are $ 6,940.00 if single, $ 10,410.00 if married. When calculating income for these

programs, be sure to disregard the first twenty dollars of income for everyone and the first

$ 65.00 and half of all remaining earned income.12

2. SLMB: Special Medicare Low Income Beneficiary program. Qualification for

those who make a bit to much to qualify for QMB but still make less than 120% of the

FPL. The main benefits of this program are the payment of the Medicare premium and

the free drug card13, both the same terms as described above for QMB. What SLMB

does not provide is additional help with health care costs. Those users need either a

Medigap policy or a Medicare Advantage plan under Part C to assist with the costs of

healthcare. For 2013, the monthly income limits are $ 1,137.00 for an individual and $

1,533.00 for a married couple. As with QMB, the resource limits may apply, as well as

the income disregards. (See above).

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Several states have raised or otherwise altered the income limits. Connecticut has aligned its income threshold to correspond with its State Pharmaceutical Assistance Program to nearly 200% of FPL for QMB. The District of Columbia has raised their limit to 300% of FPL, eliminating QI-1 completely and SLMB except for the first month and the three retroactive months of application. Maine adds a $75 income disregard in addition to the others, and effectively has raised the limits to 150% for QMB, 170% for SLMB and 185% for QI-1. See analysis: Kaiser Family State Health Facts, based on data submitted to CMS February 18, 2010, and other private analysis, located online at http://www.statehealthfacts.org/comparereport.jsp?rep=61&cat=6&gsa=2, , accessed on January 7, 2012. 11

37 states do not have the precise asset limit in place. 9 states, Alabama, Arizona, Connecticut, Delaware, District of Columbia, Maine, Mississippi, New York and Vermont have eliminated the asset test. Minnesota raised the asset limit to $ 10,000 and $ 18,000. See analysis, Kaiser Family State Health Facts, as set out in n.10. 12

Federal Poverty Limit or FPL is actually $ 20.00 more for an individual as the first $ 20.00 is disregarded for the entitlement calculations. These numbers are also different for Alaska and Hawaii. 13

Program will at least cover Medicare part B premiums. Other benefits for SLMB and QI-1 may vary with state Medicaid coverage. See your state for specifics.

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3. QI-1 is the Qualified Individual

Program. This program is similar to the

benefits of SLMB, but permit income up to

135% of FPL. The QMB and SLMB

programs are available anytime, but the QI-

1 program is not an entitlement, and is

periodically extended by Congress, the latest extension expires on Feburary 29, 2012.

Income limits for 2013 are $ 1,277.00 for an individual and $ 1723.00 for a married

couple. Those who will qualify, particularly if the COLA for 2013 will jeopardize QMB or

SLMB, should apply RIGHT NOW.

See also, a list of resources at the end of the material.

It is important to educate your

clients that their insurance will

not pay for long term nursing

home care as most believe that

they will never have to apply for

Medicare.

FIND HELP! The SHIP program provides free Medicare counseling to all beneficiaries through the Center for Medicare and Medicaid Services (CMS). That person can knowledgeably determine coverage and let the lawyer know what options are available for all types of Medicare coverage. To get more information, go to the SHIP website and make an appointment with your counselor https://www.shiptalk.org/About/CounselLocSearchForm.aspx?mf=Display

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Blue Cross C+, the most

popular / recognizable

Medicare supplement,

is not a C plan, it is a B

plan, and thus does not

cover the skilled nursing

coinsurance

To get more information, go to

http://www.ssa.gov

Medigap

In contrast to the various plans under Medicare plan C,

the Medigap plan fits on top of Medicare A and B and

covers some of the costs that Medicare assigns as a

deductible, copay or coinsurance. The Medigap plans

have been standardized since 1990, with the latest revision in

2010. As a result, there are now 10 standards plans, identified by letter, which is

very confusing since the Parts are identified by letter as well. Keep in mind that Medigap

plan A for example, does not correlate with Medicare part A, anymore than the new

Medicare plan N corresponds to the Medicare part N (there is no such thing).

One of the many pieces of legislation that implicates Medicare seeks to abolish

Medicare coverage for the 9 million disabled recipients of SSDI currently receiving it

after 24 months of disability.

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2. Best Practices in Seeking Prescription Drug Assistance

There are thousands of stand-alone drug plans under Medicare being offered in

2013, along with a projected 2600 Medicare part C or Medicare Advantage plans,

the vast majority of which carry drug coverage. Without becoming an expert, the

practitioner can and should do 2 things:

A. Become familiar with the drug plan finder. The drug plan finder at

http://www.medicare.gov is an excellent tool. Go to the site and launch the plan

finder tool, and either search generally (NOT RECOMMENDED) by zip code, or

enter your client’s data, including prescription drugs (dosage and quantity) in the

tool, which has a saving feature, to be given a ranked list of plans that will reveal

the exact cost of each plan. Remember that a client that is newly eligible for “extra

help” through the LIS program, or through the Medicare Savings programs, may

pay even less than what is listed.

B. Become familiar with your SHIP counselor. The State Health Insurance Program is

sponsored by the Department of Health and Human Services and provides free

counseling to Medicare beneficiaries. These trained counselors and volunteers will

know more than you do about new developments, so I would make friends with

your local counselor and keep abreast of late breaking news by cultivating that

relationship. Your counselor has government grant money available to hold free

outreach and enrollment events and you can direct your client to that resource.

When I counseled my brother last year on enrolling for Medicare for the first time, I

spent 14 HOURS reviewing plans by hand and presenting them to him in a short

memo so that he could easily decide what to do.

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Keep in mind that clients on a budget may prefer to pay $20 more per year to

avoid a large deductible.

3. Comtemplating Recent Changes to the Program.

The Patient Protection and Affordable Care Act (PPACA, Public Law 111-148),

enacted March 23, 2010, as amended by the Health Care and Education

Reconciliation Act of 2010 (HCERA, Public Law 111-152), enacted March 30, 2010 is

the major federal health care reform legislation that impacts the agencies affecting

seniors as well as most everyone else. References will be made to the “Affordable

Care Act” for convenience. Of the hundreds of provisions that this law governs, many

affect the Medicare program primarily. Notably, the U.S. Supreme Court has upheld

challenges to the law, but struck passages mandating expansion of state Medicaid

programs. Although characterized as a “tax”, as provisions of the Affordable Care Act

mandate individual health coverage, the White House retained stewardship, at least

stabilizing the Act for the next several years.

A. Prescription drugs savings.

Seniors welcomed the addition of Medicare Part D, or the prescription drug plan, in

2006, however, it contains large “gaps” in coverage, that have translated into many

thousands of dollars in out of pocket costs for seniors who must take expensive

medication. For many on a fixed income, this has been a “Hobson’s choice” of

selecting medicine or food during any given month in the “gap” or “donut hole” of

coverage. Recall that after the initial $2,970 (2013 numbers) coverage limit is reached,

often within the first few months of the year, then the senior must pay a total of $ 4,750

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out of pocket before “catastrophic” coverage would provide relief. This resets itself

each year, so the senior on a fixed income who did not quite qualify for relief is really in

trouble.

Implementation of the Affordable Care Act provides savings to Medicare enrollees who

enter the gap or “donut hole” in their prescription drug coverage. Beneficiaries

received a $ 250 check initially and in 2013, will receive a 52.5% discount from the cost

of premium drugs. The gap is gradually phased out in the year 2020 to provide for a

25% copay in the gap, rather than 100%. A discount continues for generic prescription

drugs this year, raised 7% from 2011 to 14% and from 2012 to 21% for 2013.

A. Preventive services.

Prescribed mammograms and cancer screenings are now available with no out of

pocket cost for Medicare beneficiaries.

B. Free annual checkup.

Seniors may have a free annual wellness visit with no out of pocket cost.

C. Community coordination of health care needs.

The senior may have more coordinated care, helpful for those with complex health care

needs requiring multiple providers. Pilot programs are underway throughout the

country.

D. Medicaid may not reduce eligibility.

Under the Affordable Care Act, the state Medicaid agencies may not reduce eligibility.

Many states have sought a waiver of this provision.

E. Increased resources for community care.

For those on Medicaid, more community choices will be available, avoiding nursing

home admissions in those cases. The PACE program provides for additional options

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in the community for those who would have been institutionalized with no choice

previously.

F. Changes in payment structure to Medicare Advantage plans

Medicare C plans have been traditionally paid a premium of 10% or more over what

the same care would cost under Medicare A or B, and that payment is now being

eliminated and a bonus payment system is put into place where quality plans may earn

additional payment through a star rating system. Overpayments to Medicare

Advantage plans resulted in the average costs at 114% of the costs of care through

traditional Medicare. One of the cost cutting measures in the Affordable Care Act was

to reduce those overpayments and replace the system with a “star rating” that rewards

plans with bonuses based on quality benchmarks. Those with the highest number of

“stars” reap the largest rewards. These measures are projected to realign the costs of

care to about 102% of the costs of traditional Medicare, saving billions of dollars.

Certainly, the incentive program has worked to keep many Medicare Advantage plans

from jumping ship as they have done in previous years when presented with budget

cuts. B. Biles, G. Casillas, G. Arnold, and S. Guterman, The Impact of Health Reform

on the Medicare Advantage Program: Realigning Payment with Performance, The

Commonwealth Fund, October 2012.

H. Star Rating.

As the charts herein show, there are a number of advantages to having a 5 star quality

rating, including the largest financial bonuses, and a nearly yearlong open enrollment

period. See Chart, Medicare Enrollment Dates (secondary). The criteria for the star

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rating is set out in the attachment below. The public wins too, as consistently low

performers may be deleted from the system.

I. Five Star Plans.

Current 5 star MA plans nationwide for 2013 are below, and join more than 100 5 star

stand alone drug plans (PDP):

Location Plan Name

FL Capital Health Plan

WI Dean Health Plan, Inc.

WI Gunderson-Lutheran Health Plan, Inc.

MN Health Partners

FL HealthSpring of FL

MA HNE Medicare Advantage

WI Humana WisconsinHealth Organization, Inc.

CA Kaiser Permanente Medicare Cost

CA Kaiser Permanente

CO Kaiser Permanente

HI Kaiser Permanente

VA-DC-MD Kaiser Permanente

MN-SD-ND Medica Insurance Company

WI Medical Associates Clinic Health plan of WI

IA Medical Associates Health Plan

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19

Source: Center for Medicare and Medicaid Services Training documents, accessed online on December 2, 2012,

https://www.cms.gov/Outreach-and-Education/Training/NationalMedicareTrainingProgram/Downloads/2013-5-

Star-Enrollment-Period-Job-Aid.pdf

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21

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OTHER PART D SPECIFICS:

All Medicare beneficiaries are generally eligible for Part D

Specific eligibilty in a Part D plan may require enhanced training and specialized knowledge to determine,

for example, if the plan that covers the beneficiary’s medical insurance also provides prescription drugs

as part of the benefit. If so, enrollment in Part D may DISENROLL them from their health insurance with

distrastrous consequences.

Some medications are covered through Medicare part B, such as IV drugs or chemotherapy

Part C offers some benefits Medicare does not offer, for example, some will offer routine dental care,

discounts on hearing aids, and more, so if a client can benefit from some of those perks, then they may

want to consider a Part C plan with prescription drug coverage.

Most Part C plans will continue to have Part D benefits tied in, but be sure you have one that does

See charts above for general enrollment information

A special enrollment period exists to switch back to Medicare A, B and D from a Part C plan 1/1 – 2/14

each year

A special enrollment period will start if you qualify for extra help, or if you go into an institution, or move

to an area not serviced by your plan

Many Part C plans will have a “gatekeeper” or referral requirement for specialist treatment

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Where you can find more information:

Medicare - 1-800-MEDICARE http://www.medicare.gov/

Center for Medicare and Medicaid Services (CMS): http://www.cms.gov

State Health Insurance Program (SHIP): Free counseling for seniors (and their lawyers):

https://www.shiptalk.org/About/CounselLocSearchForm.aspx?mf=Display

Aging in Alabama – http://www.elderconsults.com