"Medicare Prescription Drug Benefit: What You Need to Know" FAQs

How often can a person change his or her Medicare private drug plan?

Most people can only change their Medicare plans once before May 15th. After May 15th, those people are unable to change their health plans until the following year. This is often referred to as the “lock-in.” If you have Medicaid, a Medicare savings program, or live in a nursing home, then you are able to switch your plan once every month.

Can you have both EPIC and Part D of Medicare? Would you want to?

You can have both EPIC and Part D, but you don’t have to. EPIC is considered creditable coverage. This means that if you have it and you like it, you can keep it. If you later decide to enroll in a Medicare private drug plan, you can do so without penalty as long as you have not been without EPIC for more than 63 days.

Whether you should have both EPIC and Part D depends on your circumstances. EPIC will cover any drugs not covered by your Medicare drug plan. If you qualify for Extra Help (see below) or have very high drug costs, EPIC can lower your drug costs.

EPIC works with almost all types of insurance except Medicaid. You can have Original Medicare, a Medicare Advantage Plan (HMO, PPO, PFFS), a stand-alone drug plan, or a Medigap, and use EPIC (see next question about how to qualify for EPIC).

How do you get EPIC, and how does it work?

To qualify for EPIC, you must be a New York State resident 65 or older, and your annual income must be less than $35,000 ($50,000 a year for couples). You cannot get EPIC if you have full Medicaid benefits or if you are under 65 and enrolled in Medicare because of a disability.

If you qualify, you will only pay $3 - $20 per prescription. There are two types of plans under EPIC; the Fee Plan and the Deductible Plan, and which one you will have depends on your annual income. The Fee Plan is available to seniors with an annual income of less than $20,000 ($26,000 for couples). You will have to pay a fee, but EPIC will start paying for your prescription medications right away. If your annual income is between $20,001 and $35,000 (between $26,001 and $50,000 for couples), you would apply for EPIC’s Deductible Plan. If enrolled in this plan, you would pay full price for your prescriptions until you have met an annual deductible, based on your income. Deductibles range from $530-$1,230 ($650–$1,715 for couples). Once you reach the deductible, you will pay EPIC co-payments. If you sign up for the Deductible plan and your drug costs are low, you may never reach your deductible, but it will not cost you anything just to have EPIC. If your drug costs are high, EPIC will help you once you have reached your deductible.

What are the qualifications for Extra Help?

If your monthly income is below $1,226 ($1,651 for couples) and your assets are below $11,500 ($23,000 for couples), you may be eligible for Extra Help, a federal program that helps you pay for some or most of the costs of Medicare prescription drug coverage. Even if your income or assets are above the limit, you may still qualify for Extra Help, because certain types of income and assets may not be counted.

If you are eligible for a Medicare Savings Program, you will automatically qualify for Extra Help Medicare Savings Programs and pay the $88.50 Medicare Part B premium that is usually deducted from your Social Security check. In New York State, you can apply for a Medicare Savings Program even if your assets are above $11,500 ($23,000 for couples).

How can a person apply for Extra Help?

If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program, you automatically qualify for Extra Help, and you do not have to apply. If you are not enrolled in one of these programs that automatically qualify you for Extra Help, there are several ways to apply. You can call 888-RX-LINCS to have a counselor screen you for Extra Help eligibility. If you are eligible, the counselor can complete the application with you over the phone. You can also apply online, call the Social Security Administration (800-772-1213) to request a paper application, or go to your local Social Security office to complete an application. 

How can you choose a Medicare drug plan?

Medicare’s prescription drug benefit is a type of insurance, so you have to think about whether you feel it is important to pay money each month for drug coverage. You should choose a plan based on what you know about your health and the drugs you take now, and also talk to your doctor about what you may need in the near future.

Before you sign up, make sure the plan works with your current health coverage and covers the drugs you need at a price that you can afford. If you have Original Medicare and want to stay with it, you need to choose a stand-alone drug plan. If you are in an HMO or PPO, you will have to get drug coverage from the same company that provides your health coverage as part of your full benefits package.

If you want to sign up for a Medicare private prescription drug plan, you can either call the plan directly or sign up by calling 800-MEDICARE.

If you have a Medicare private drug plan and it changes so that your drug is no longer covered, what can you do?

Each Medicare prescription drug plan will have its own list of covered drugs. Plans can change their formularies at any time as long as they give you a 60-day notice of the change. During those 60 days, you should talk to your doctor about switching to a covered drug or requesting an exception from your drug plan that would allow your drug to continue to be covered for you. If you want to switch to a different plan that covers all of your drugs, you can generally only do so during specified enrollment periods.

How do providers decide which plan will cover which drugs?

Medicare drug plans must offer at least two drugs under each type of drug class. All drug plans are required to cover most drugs in these drug categories:

• Antidepressants
• Anticonvulsants
• Antipsychotics
• Antiretrovirals (AIDS medications)
• Immunosuppressants
• Anticancer

Some drugs are specifically excluded from Medicare coverage by law, including some anti-anxiety drugs, weight-loss and weight-gain drugs, and over-the-counter drugs. “Enhanced” plans may choose to cover these types of medications.

What is a Medigap?

If you do not have insurance from a former employer that fills gaps in Medicare, you might consider your options for how to supplement your Medicare coverage. Medigaps help cover Medicare deductibles, coinsurance, and some additional benefits. There are 12 different standardized Medigap plans, labeled A-L, with Plan A offering the fewest benefits. All Medigap plans must include 365 additional days of full hospital coverage and full or partial coverage of the 20 percent coinsurance for doctor charges and other Part B services.

Medigap is a type of insurance used to supplement Medicare, so you pay a fee every month to buy this insurance to receive extra coverage.

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 have historically offered limited drug coverage, are no longer sold as of January 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 and get your drugs covered another way. You are probably better off with EPIC and/or the new Medicare prescription drug coverage than with the limited coverage offered by these plans. If you enroll in the Medicare drug benefit between November 15, 2005 and May 15, 2006, you have a guaranteed right to switch to another Medigap policy offered by the same insurance company. To receive this protection, you must switch your Medigap policy within 63 days of the beginning of your Medicare Part D drug coverage.

posted 4/24/2006

Transcribed by Rebecca Cohen, Health and Wellness Coordinator, Public and Patient Education