October 2017 Center for Health Care Rights 2018
October 2017© Center for Health Care Rights 2018 Medicare Prescription Drug Benefit
Part A Hospital Insurance Part B Medical Insurance October 2017© Center for Health Care Rights Original Medicare 2
o Prescription Drug Plan (PDP) o Medicare Advantage Plan (MAPD) October 2017© Center for Health Care Rights Medicare Part D Drug Plan Choices 3
o Obtain Medicare Part D coverage by enrolling in a PDP o Continue to use original Medicare to obtain Part A and B services October 2017© Center for Health Care Rights Prescription Drug Plan (PDP) 4
o Obtain Medicare Part D coverage by enrolling in a MAPD o When you enroll into a MAPD plan, you must receive all Medicare Parts A, B and D services from the plan October 2017© Center for Health Care Rights Medicare Advantage Plan (MAPD) 5
o Enrollment is voluntary o There is a penalty for late Part D enrollment if you do not have drug coverage and delay your enrollment into a Part D drug plan. o The penalty is 1% of the base premium for each uncovered month. The 2018 national base premium is $33. 50 October 2017© Center for Health Care Rights Do I Have to Enroll in a Part D Drug Plan? 6
o Initial Enrollment Period Ø New Medicare beneficiaries have a 7 month enrollment period. It starts 3 months before the month of eligibility and ends 3 months later. Ø Example: month of Medicare eligibility is February; enrollment period starts November 1 st and ends May 31 st. October 2017© Center for Health Care Rights When Can You Enroll in a Part D Drug Plan? 7
o Annual Election Period “Open Enrollment” Ø October 15 th through December 7 th you can enroll in a Part D drug plan or change to another plan Ø Part D plan benefits are effective January 1 st. October 2017© Center for Health Care Rights When Can You Enroll in a Part D Drug Plan? 8
Medicare Advantage Prescription Drug Plan members are able to disenroll from their MAPD plan between October 2017© Center for Health Care Rights Medicare Advantage Prescription Drug Plan Disenrollment Period January 1 – February 14 of each year. 9
+ MAPD or (NO) Medicare Part D drug coverage Original Medicare + MAPD Original Medicare (YES) Medicare Part D drug coverage October 2017© Center for Health Care Rights During this time, they can make the following changes: 10
October 2017© Center for Health Care Rights o After this enrollment period, you must remain in the Part D plan until the next enrollment period, unless you qualify for a special enrollment period. 11
o You can change your Part D drug plan outside of an enrollment period in certain situations. Examples: Ø Lose your employer based drug coverage Ø Move out of your Part D service area Ø Enter or leave a nursing home October 2017© Center for Health Care Rights Special Enrollment Periods 12
o Persons who are eligible for the Part D Low-Income Subsidy “Extra Help” Program can also change their Part D plan monthly. October 2017© Center for Health Care Rights o Persons who have Medicare and full Medi-Cal can change their Part D plan monthly. 13
o 2018 California Part D drug plan monthly premiums range from $0 to $169. 80. o The Part D drug plan annual deductible ranges from $0 to $405. Initial Coverage Period o After the deductible, you pay 25% of the total retail cost of your drugs when costs are between $405 to $3, 750. October 2017© Center for Health Care Rights 2018 Standard Part D Plan Costs and Benefits 14
o When your total drug costs reach $3, 750, you are in the coverage gap or doughnut hole -- You pay: 35% of the cost for brand name drugs 44% of the cost for generic drugs Catastrophic Coverage o You get out of the coverage gap when your total drug expenses reach $7, 508. 75. Your out of pocket costs are then reduced to a 5% co-insurance or $3. 35/generics and $8. 35/brand name drugs. October 2017© Center for Health Care Rights Coverage Gap 15
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o Between 2011 -2020, the ACA reduces the amount that Medicare Part D enrollees pay when they are in the coverage gap. o By 2020, persons in the doughnut hole will pay only a 25% copayment for their prescription drugs. October 2017© Center for Health Care Rights The Affordable Care Act (ACA) and the Part D Coverage Gap (Doughnut Hole) 17
o Shop for the lowest cost plan that covers all your prescription drugs. o Each drug plan has their own list of covered drugs (formulary) and co-payments. o Use the Medicare Part D Drug Plan Search Tool on the Medicare. gov website to help you choose the plan that is right for you. October 2017© Center for Health Care Rights How to Select a Medicare Part D Drug Plan 18
o The enrollment period to change your Part D drug plan for the following year is October 15 th through December 7 th. o It is always a good idea to check your drug plan coverage for the new year. o Compare your drug plan coverage and costs to other plans to make sure you are getting good coverage at the lowest cost. October 2017© Center for Health Care Rights Do I need to change my Part D drug plan each year? 19
o Persons who have drug coverage through an employer health plan do not have to join a Medicare Part D drug plan, if the employer sponsored drug plan is as good as a standard Medicare Part D plan. This is called the “creditable coverage” standard. o If you lose your employer/retiree drug coverage, you will have a special enrollment period to enroll in a Part D plan with no Part D penalty for late enrollment October 2017© Center for Health Care Rights Medicare Part D and Employer/Retiree Drug Coverage 20
o Persons with TRICARE For Life or VA benefits do not need to enroll in Part D. o They have drug coverage that meets the Part D “creditable coverage” standard. October 2017© Center for Health Care Rights Part D Coordination with TRICARE For Life and Veterans Administration (VA) Benefits 21
o Medicare beneficiaries with incomes greater than $85, 000/year (single person) or $170, 000/year (married couple) pay an additional Medicare Part D income related premium. o The Part D income related premium is based on income reported on the IRS tax return from two years prior. October 2017© Center for Health Care Rights Income-Related Part D Premiums for Higher Income Beneficiaries 22
Transition Fills If you recently enrolled into a Part D drug plan, you may be entitled to a “transition fill” of the drug if: o The medication is not a new prescription, o You are in the first 90 days of being in a new Part D drug plan. If you meet these requirements, in most cases, the Part D plan must provide you with a 30 day supply of the drug. October 2017© Center for Health Care Rights What Can I Do If My Prescription Is Not Covered by My Part D Plan? 23
Exception Request o If you are not entitled to a transition fill of the medication, ask your doctor if you should switch to a formulary drug covered by your plan. o If the formulary drugs are not appropriate for your medical condition, you have the right to file an “exception request”. o Your doctor must explain your medical need for the requested drug and explain why other covered drugs are not appropriate for you. October 2017© Center for Health Care Rights What Can I Do If My Prescription Is Not Covered by My Part D Plan? 24
o An expedited review will take 24 hours if you suffer from serious health conditions. o A standard review will take 72 hours. October 2017© Center for Health Care Rights How Long Will it Take to Process My Exception Request? 25
o You have the right to appeal. o The first level of the appeal process provides for a standard and expedited time frame. Ø Expedited – 72 hours Ø Standard – 7 days October 2017© Center for Health Care Rights What Can I Do if My Exception Request is Denied? 26
o Redetermination by the Plan o Reconsideration by the Independent Medical Review o Administrative Hearing October 2017© Center for Health Care Rights Part D Appeals Process o Federal Court 27
o You may qualify for help with Part D expenses even if you are not eligible for Medi-Cal. o The program is called the Low-Income Subsidy Program or Extra Help Program. October 2017© Center for Health Care Rights Financial Help with Medicare Part D Costs 28
Income Limits (135% of poverty level) Ø Equal to or less than $1, 357/month (individual) Ø Equal to or less than $1, 827/month (married couple) (In-kind support is not counted. ) Asset Limits * Ø Less than $8, 890 (individual) Ø Less than $14, 090 (married couple) (Your home, cars, and life insurance policies are not counted. ) * Asset limits include $1500 burial allowance person. October 2017© Center for Health Care Rights Low Income Subsidy Program Full Subsidy 29
o No premium o No annual deductible o $3. 35 to $8. 35 co-payments until costs equal $7, 508. 75. o Medicare pays 100% of covered costs when total costs are greater than $7, 508. 75. October 2017© Center for Health Care Rights With Full Subsidy You pay: 30
Income Limits (150% of poverty level) Ø Equal to or less than $1, 508/month (individual) Ø Equal to or less than $2, 030/month (married couple) (In-kind support is not counted. ) Asset Limits* October 2017© Center for Health Care Rights Low Income Subsidy Program Partial Subsidy Ø Less than $13, 820 (individual) Ø Less than $27, 600 (married couple) (Your home, cars, and life insurance policies are not counted. ) *Asset limits include $1500 burial allowance person. 31
o Monthly premium (sliding scale) o $83 annual deductible o 15% of drug costs (until total costs reach $7, 508. 75) October 2017© Center for Health Care Rights With Partial Subsidy You pay: o $3. 35 to $8. 35 co-payments (after total costs are greater than $7, 508. 75) 32
These Part D drug plans have no monthly premium if you qualify for Medicare Part D Extra Help. Ø Aetna Medicare Rx Saver Ø Humana Preferred Rx Plan Ø Silver. Script Choice Ø Symphonix Value Rx Ø Well. Care Classic October 2017© Center for Health Care Rights 2018 California Part D Prescription Drug Plans that are Extra Help Qualified 33
o Medicare’s Limited Income Newly Eligible Transition (NET) Program provides temporary drug coverage for persons who are eligible for the Low Income Subsidy Program but are temporarily not in a Part D plan. o This program provides immediate prescription drug coverage for any Part D covered drug with no network pharmacy restrictions. o The LIS eligible person should be charged the copayment appropriate for their level of LIS assistance. October 2017© Center for Health Care Rights Medicare’s Limited Income NET Program – LI NET 34
How to use the Plan Search Tool October 2017© Center for Health Care Rights Visit www. Medicare. gov 35
October 2017© Center for Health Care Rights Click on Find health and drug plans. The following screen appears. 36
October 2017© Center for Health Care Rights Type in your zip code. Click Find Plans. The following screen appears. 37
October 2017© Center for Health Care Rights Type the name of your drugs. Click Find My Drug. See screen below. 38
October 2017© Center for Health Care Rights The screen below appears. Select the option that applies to you. 39
October 2017© Center for Health Care Rights Pick your pharmacy. Click Add Pharmacy. See screen below. 40
October 2017© Center for Health Care Rights Select the type of plan you are searching for. Click Continue to Plan Results. 41
Medicare Website www. Medicare. gov Medicare Telephone Hotline 1 -800 -633 -4227 Medicare Part D Plans Center for Health Care Rights 1 -800 -824 -0780 October 2017© Center for Health Care Rights Where to get information on Medicare Drug Plans 42
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