MEDICARE

Even though the Medicare Prescription Drug Coverage, also known as Part D, went into effect 1/1/2006, people are still experiencing a number of problems.  People are still very confused as to what and how the coverage works.  Wrong information is given out by the insurance companies, pharmacies and Medicare.  The Medicare web site changes regularly.  It is not easy to navigate for someone who is very familiar with computers and must be a nightmare for any of the seniors who are not computer literate.

It is still to your benefit to enroll in any Medicare Savings Programs (QMB, SLMB, and Q1) and any state pharmaceutical assistance programs available.  The state programs that are available usually have been changed to wrap around Part D benefits.  See Illinois below and check with your own state. 

The new law affects nearly everyone who has Medicare coverage.  There are a few exceptions, but most people will have to sign up for a Drug Card from a private company.  Some of the exceptions will be retirees from companies who have great insurance and drug coverage, government employees and folks who are still working and veterans who use the VA prescription coverage.  Your company, union or insurance company should have notified you about whether or not they meet the Medicare Drug standard by now.  If you have not heard from them, contact your Benefits Administrator and ask about your plan and whether or not it is creditable.

The companies that have been accepted by CMS to participate do a lot of marketing so don't be surprised if you get promotional literature through the mail.  Investigate the various plans carefully and be sure to check out their formularies (lists of drugs covered).  Each company will have their own list of drugs that are covered.  The law states that the companies only have to have one generic and one brand drug in each category, with very few exceptions, so it is vital that you make sure your drugs are on the formulary of the insurance plan you join.  If you have a drug that is not on your plan's formulary, you will have to pay full price for it and the cost will not be applied to your deductible or your out-of-pocket expenses.  This is an extremely unfair part of the plan.

The monthly cost of a prescription card goes from $17+ to over $86, which the consumer will pay directly to the company they choose or they can have the premium deducted from their Social Security.  We are recommending to our seniors that they should not have the premium deducted from their Social Security as there have been a great many problems over the past year. There is a standard plan and then the various companies have the option to offer one or more enhanced versions or so at a higher cost.  Our experience has been that there are way too many plans within each company and this adds to the confusion.

THE MOST IMPORTANT PART -- IF YOU HAVE MEDICARE AND HAVE TO SIGN UP FOR A CARD - THE NEXT ENROLLMENT PERIOD STARTS NOVEMBER 15, 2007 AND GOES TO DECEMBER 31, 2007.  THIS YEAR, WE WERE TOLD BY CMS THAT YOU HAD TO HAVE JOINED A PLAN BY 12/8 TO BE SURE OF COVERAGE STARTING JANUARY 1.  IF YOU MISSED THE ORIGINAL ENROLLMENT DEADLINE, YOU WILL BE PENALIZED AT THE RATE OF 1% PER MONTH FOR EACH MONTH YOU HAVE GONE PAST 5/15/2006 ON THE CURRENT PREMIUM AND THAT COST WILL BE  FOR THE REST OF THE TIME YOU ARE COVERED.  PEOPLE ON MEDICARE AND WHO HAVEN'T SIGNED UP YET NOW FACE A 19% PENALTY IF THEY SIGN UP IN NOVEMBER, 2007.  THIS IS OBSCENE!!!!

Check with CMS, your state Dept. of Aging, your local S.H.I.P. Counselors or your senior center to see if you qualify for a Special Enrollment Period so that you don't have to wait for coverage until 11/15/07.

Below is a little history of what happened last year.  Check out the following to see what group you fall into and what action you may need to take (or not):

Medicare and Medicaid enrollees - got extra help automatically and were  automatically assigned - no premiums, deductibles or gaps - will pay $1 or $3.10 for each prescription filled and no premiums or deductible or $2.15 for generics or $5.35 for Brand names.  This is dependent upon income.

Medicare Savings Programs (QMB, SLMB, QI) enrollees - got extra help automatically - most were automatically assigned.

Limited income and assets and qualifies for LIS (low income subsidy) - have to apply for extra help - different levels of help based on income and assets - you will have a co-pay for each prescription and need to pick a plan.   You will pay $1 or $3.10 for each prescription filled and no premiums or deductible or $2.15 for generics or $5.35 for Brand names.  This is dependent upon income.

IL Cares Rx Basic and Plus (Circuit Breaker/SeniorCare) - had to apply for extra help by the Social Security Administration form and many were automatically  assigned to one of the two plans - state will pay premiums, deductibles and there will be no gaps - you will pay $2.15 for generic,$5.35 for brand name and $15 for tier 3 drugs, up to $2,400 worth of covered drugs, then you pay the co-pay shown and 20%.  After $5,451.25 total drug costs, you pay 5% of your drugs and the insurance company pays 95%.  NOTE:  check the sreligibility page for the new increased limits for IL state help effective 3/2007.

This year it is not certain whether or not there will be any automatic enrollments so you will need to check it out and if not, enroll yourself when the enrollment period opens up again.

IMPORTANT - YOU MUST APPLY FOR EXTRA HELP THROUGH SOCIAL SECURITY TO ACCESS HELP FROM THE STATE OF ILLINOIS...........  For other states, you need to check locally to see what you may need to do.

Over Income & Asset Limits/no current creditable prescription coverage - not eligible for extra help -- you need to pick a plan.

Have current creditable coverage (retirees, state employees, VA, etc.) - can stay with current plan if it is offered and will not incur a penalty if they change later if the coverage is dropped.  It will be important to keep all paperwork that shows they have creditable prescription coverage at this time.

A brief outline of the basic plan of Medicare Part D:

Monthly premium of $27 (more or less)

$265 deductible (you pay or some of the plans will cover)

Between $265 and $2,400 in drug costs - the plan pays 75% and you pay 25%

Between $2,401 and $5,451.25 you pay ALL - no benefit - this is what is referred to as the doughnut hole you may have heard about.  Check out the plans you are looking at to see if they are offering any coverage through the doughnut hole - there are a few plans that offer some limited coverage.

After $5,451.25, the plan will pay 95% and you will only pay 5% of your drug costs.  You will have paid $3,051 out of your pocket (plus the premiums, maybe a deductible and the 25%).

IT IS IMPORTANT THAT YOU make your feelings known to your local, state and federal politicians.  Seniors are voters and our elected officials need to know that they need to do a better job on medication assistance than what they have done so far.  The pharmaceutical houses are big contributors and lobbyists -- so speak up.  SO ARE THE INSURANCE COMPANIES AND THIS IS A BIG WINDFALL FOR THEM.  Make your voice heard.  Be sure your vote counts.

For Illinois, the Circuit Breaker/Senior Care program has changed.  The new plan is IL Cares Rx Basic or Plus.  The state no longer pays for a person's drugs.  Instead, it wraps around the insurance plans by paying the premiums, deductibles and establishing co-pays shown above.  To date, Illinois is working with two companies and three plans:  United Healthcare's AARP MedicareRx Plan (S5820-016) and United Health Care Basic Rx Plan (S5921-082) and Wellcare's Signature Plan (S5967-051).  If an IL resident had Circuit Breaker or SeniorCare in 2006, that prescription coverage will be extended through 2007 if they have also returned the 7-page form sent out from the Social Security Administration in 2005.  If you did not receive such a form or threw it out, please contact either your local senior center, Area Agency on Aging, Senior Health Insurance Program (S.H.I.P.) counselor or Social Security and request another one.  Then, complete it and send it in.  This is mandatory to get state assistance in 2007.  If your assets are over $11,710 for one person or $23,410 for a couple, just check "Yes" and then go to the last page, complete that page and sign it.  If your assets are under those figures, you will have to complete the other pages.  IL does not have an asset test although they will be asking about assets when IL residents apply for IL Cares Rx in 2007.  When Social Security gets your form, it will generate a letter that will tell you whether or not you receive Federal financial help.  If you qualify, great.  If not, don't panic as Social Security will kick your information over to the state and you will then receive state help under the new program IL CaresRX Basic or Plus (which is the new name for what used to be Circuit Breaker/Senior Care). 

Another way we are helping our clients and something you may want to do is to check out the www.medicare.gov web site and use the tool shown to check out the formularies and compare the plans.  We are telling our clients to bring in their medication lists, the dosages and what drug store they use and we will look up that information for them.  You might want to check with your local senior center or social service agency and see if you can get that type of help from them.  The bottom line is we can only guide people but the bottom line is everyone will have to make their own decision.  You really have to dig into each plan to find any restrictions or what drugs are not in formularies.  Don't just decide by looking at the first list that is ranked by Medicare.  They rank the plans by estimated annual cost and not whether or not your drugs are actually on the company's formulary.

WARNING:  BEWARE OF THE SCAM ARTISTS.  They know this is very confusing so they are jumping in to try and fleece seniors.  Don't give out personal information on the phone and don't enroll in any plan over the phone -- get it in writing before you sign up.  Don't sign up with anyone going door-to-door.  Legitimate companies will not solicit that way.  If you have any questions about whether you should sign up with a plan, don't -- give yourself time to check it out further.  Call your local senior center and check it out.    

Basic MEDICARE

Below is a brief and hopefully simple explanation of what Medicare is and what it does and does not cover.  Basically, Medicare is an insurance plan that has 4 parts: 

Part A which is hospital insurance and helps pay

the cost of in-patient hospital care

certain kinds of follow-up care (inclusive medical services

minus any deductibles and co-insurances) and

Part B which helps pay for physician

outpatient hospital and other medical services

An annual deductible must be met.

Seniors and their dependents are eligible because the individual has paid into social security for 40 calendar quarters.  Eligibility usually is at age 65.

Most seniors are familiar with the Part B monthly premium ($93.50 starting 1/1/07), which is deducted from their social security payments.  They may not be aware of state programs for low-income seniors that cover the monthly premium for Part B, co-payments and deductibles.  In IL, the programs are called QMB (qualified medical beneficiary) and SLMB (specified low-income Medicare beneficiaries) and QI.

Besides regular Medicare where you choose your own doctor, there are a number of Medicare HMO/PPO/PFFS  organizations.  This whole area is very confusing with a lot of the HMOs dropping out of the program these days so check with your local social security office, area agency on aging or senior center to find specific information for your area.  The S.H.I.P. counselors are also a good resource.

Medicare has added benefits over the years and now covers yearly mammograms for women, Pap Smears (including pelvic and breast examinations).  For people with diabetes, glucose monitoring and education are covered.  Other coverage includes colorectal cancer screening, bone mass measurement and Flu and Pneumococcal Pneumonia Shots.

Medicare does not cover custodial care and often people are confused because doctors and nurses will tell them they have 100 days coverage in a nursing home.  Their coverage is dependent on the level of care they are receiving and the progress they are making in their recovery.  Check with a local nursing home to find out exactly what Medicare will cover if your senior needs to go into a nursing home for skilled care or rehabilitation.  Medicare will usually cover if the patient receives one skilled service per day.  Skilled services include daily IVs, daily therapies, feeding tubes, stage 3+ decubs – wound care (bedsores).  

Medicare Part D