A number of Medicare beneficiaries have received a notice from their Medicare Advantage Plan that their current Plan is leaving the Medicare program on January 1, or that it will no longer serve the area the beneficiary lives in, effective with that date. (These are called, respectively, a “nonrenewal” and a “service area reduction.”)
As I point out on page 126 (“Nonrenewals”) of Managing Your Medicare, a special election period (these are also called “special enrollment periods” and are often abbreviated SEP) exists for members of Medicare Advantage (MA) plans that are affected by a nonrenewal or service area reduction effective January 1.
For beneficiaries currently affected by this, your special election period began October 1, 2010, and ends next year, on January 31, 2011.
As noted in the book, your current Medicare Advantage Plan must send you a detailed notice about what your options are, and the deadlines imposed on you. The Centers for Medicare & Medicaid Services (CMS) supervises these notices quite closely, and they are fairly comprehensible, but it’s important to clearly understand them and to know what your several options are.
These are your options:
You may choose to go into another Medicare Advantage Plan with Part D drug coverage. Or you may join one without drug coverage AND also join a stand-alone Part D drug plan. Or you may join one without drug coverage and NOT join a stand-alone Part D drug plan.
You may take any of the three options above whether or not you currently have any Part D drug coverage.
OR
You can go into Original (fee-for-service) Medicare, and, if you wish, join a stand-alone Part D drug plan. And you can do this whether or not you were ever in Original Medicare, or whether you do or don’t currently have Part D drug coverage.
The effective date will depend on what choice you make. If you enroll in another Medicare Advantage Plan, your enrollment will be effective January 1 if the Plan you choose receives your request before that date. If it receives your request in January, it will be effective February 1, 2011.
The same is true if you enroll in a stand-alone Part D drug plan. If you enroll in one of these, your enrollment will be effective January 1 if they receive the request before that date. If they receive your request in January, it will be effective February 1, 2011.
If you do not sign up for another Medicare Advantage Plan, you will automatically be put in Original Medicare effective January 1. If you had drug coverage with your Medicare Advantage Plan, you will no longer have drug coverage unless you sign up for a stand-alone Part D plan. The exception to this is that if you have extra help (the low income subsidy, sometimes abbreviated LIS), and you don’t sign up with a drug plan, Medicare will automatically enroll you in one.
For those beneficiaries who are 65 years of age or older, and decide to go back to Original Medicare, you will get a special federal right to buy a Medigap policy. These special rights are sometimes called “Medigap protections” or “guarantee issue rights.” (And for those of you who are not 65 years of age or older, your state may require Medigap insurers to sell you a policy; check with your state insurance commissioner.)
Beneficiaries who are 65 years of age or older and go back to Original Medicare have only until March 4, 2011, to purchase a Medigap policy using their guarantee issue rights. (This is the standard 63 days from when you loose your coverage from your Medicare Advantage Plan) Specifically, any company that offers a Medigap policy of type A, B, C, F-High, F-Low, K or L in your area has to sell you one. That is, the company (1) must sell you a policy, (2) it must cover your pre-existing conditions, and (3) it cannot charge you more because any past or current health problems you may have had or have.
And remember that if you go into Original Medicare effective January 1, your SEP continues until the end of that month. You still have the option of signing up with a Medicare Advantage Plan with or without drug coverage. And if you decide to stay in Original Medicare, or if you sign you with a Medicare Advantage Plan that does NOT have drug coverage, you may still use your SEP to join a stand-alone Part D drug plan. The effective dates for these actions will be February 1, 2011. And remember that, if you decide to stay in Original Medicare, your deadline to get a Medigap policy continues to be March 4.
You notice from your Plan will also tell you that there are some other special Medigap protections which apply to you (1) if you are age 65 or older and got Part B within the last six months, or (2) if in the last 12 months (sometimes up to 24 months) you dropped a Medigap policy to join a Medicare Advantage Plan for the very first time; or, (3) if in the last 12 months (sometimes up to 24 months) you joined a Plan when you were first eligible for Part A at age 65. (These are covered in detail in items 8.1, 8.2.4 and 8.2.5 of the book.) These may permit you to buy a policy other than type A, B, C, F-High, F-Low, K or L, that is, type D, M or N.
There is also one other special right that comes if you are affected by your Medicare Advantage Plan’s nonrenewal or service area reduction. If you are one of the few beneficiaries who have End Stage Renal Disease and are in one of these Medicare Advantage Plans, you get a one-time right to join a Medicare Advantage Plan. You may exercise this right at this point in time, or you may hold it and use it in the future. But you have only a ONE-time right, and remember that otherwise, in general, beneficiaries of any age with this disease cannot join a Medicare Advantage Plan, so use this special right carefully.
By the way, there is some confusion as to the proper effective date. This is simply because in the past CMS has allowed the effective date, at the beneficiary’s choice, to be the first of the month immediately following the month the beneficiary files their enrollment request. (So, for example, if you filed it in November, you could choose December 1.) This, however, has changed for this year; the effective date can only be January 1 or February 1, depending only on when the request is received by the Medicare Advantage Plan and/or stand-alone drug plan you are joining. This probably makes more sense as if you went into Original Medicare or a new Plan on December 1, you would again have to meet all the applicable deductibles for calendar year 2010, and then have to do this all over again beginning in 2011.
Tuesday, October 26, 2010
Saturday, October 16, 2010
Clinical Trials and Medicare Advantage Beneficiaries – New Rules in 2011
Not too long ago, Medicare began covering certain of the costs of those clinical trials which meet very specific approval requirements. Prior to that time, clinical trials were considered to be “experimental,” and nothing was covered under Medicare. The information on this is in section 2.13 of Managing Your Medicare, on page 57.
This section of the book also mentions that even beneficiaries in Medicare Advantage must have these costs covered, and that this is true even if they use out-of-network services, which is normally the case with clinical trials. For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on this issue, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. What this means is that if you get a clinical trial service that is Medicare covered, let’s say a specialist’s consultation, and that Original Medicare would approve $100 for the consult, and pay $80, and you are billed for the 20 percent coinsurance, or $20, but for this same type of consult your Plan’s in-network rule is that you are responsible for a co-payment of $15, then you are responsible for only this $15, and your Plan is responsible for the remaining $5.
What is basically going on here is that the clinical trial people are charging you as if you were in fee-for-service Medicare, but you are responsible only for what you would pay under the terms of your Plan’s benefit structure. One of the issues here is that because the clinical trial people have no contractual relationship with your Plan, they may bill you the standard Medicare coinsurance. If this happens, you may submit the bill to your Plan, and it must pay the provider any difference between what you owe under their rules and the Medicare fee-for-service amount.
(And it’s quite possible that the clinical trial people may send you a bill for the whole service because they don’t understand that you are in a Plan. If this happens, send the whole bill to your Plan, and make sure, when they process it, that they pay everything except what you would owe for an in-network service.)
So you get the nice benefit of getting a covered clinical trial service out-of-network, but you pay only what you pay if you had gone in-network. Not bad. But it gets better!
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule just discussed. So in the example given, your Plan has to count toward your yearly maximum not only the $15 you were responsible for, but also the $5 it had to pay. That is, $20 will go to count for your annual out-of-pocket maximum, not just $15.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial, or even advise them that you are in such a trial. However, best advice seems to be that, if you are in a coordinated care Plan of any type, letting your Plan’s health care providers know what is going on with all of your health care is very important. And, as it has no other way of knowing, your Plan may ask you for information it needs to properly process claims relating to the clinical trial.
This section of the book also mentions that even beneficiaries in Medicare Advantage must have these costs covered, and that this is true even if they use out-of-network services, which is normally the case with clinical trials. For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on this issue, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. What this means is that if you get a clinical trial service that is Medicare covered, let’s say a specialist’s consultation, and that Original Medicare would approve $100 for the consult, and pay $80, and you are billed for the 20 percent coinsurance, or $20, but for this same type of consult your Plan’s in-network rule is that you are responsible for a co-payment of $15, then you are responsible for only this $15, and your Plan is responsible for the remaining $5.
What is basically going on here is that the clinical trial people are charging you as if you were in fee-for-service Medicare, but you are responsible only for what you would pay under the terms of your Plan’s benefit structure. One of the issues here is that because the clinical trial people have no contractual relationship with your Plan, they may bill you the standard Medicare coinsurance. If this happens, you may submit the bill to your Plan, and it must pay the provider any difference between what you owe under their rules and the Medicare fee-for-service amount.
(And it’s quite possible that the clinical trial people may send you a bill for the whole service because they don’t understand that you are in a Plan. If this happens, send the whole bill to your Plan, and make sure, when they process it, that they pay everything except what you would owe for an in-network service.)
So you get the nice benefit of getting a covered clinical trial service out-of-network, but you pay only what you pay if you had gone in-network. Not bad. But it gets better!
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule just discussed. So in the example given, your Plan has to count toward your yearly maximum not only the $15 you were responsible for, but also the $5 it had to pay. That is, $20 will go to count for your annual out-of-pocket maximum, not just $15.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial, or even advise them that you are in such a trial. However, best advice seems to be that, if you are in a coordinated care Plan of any type, letting your Plan’s health care providers know what is going on with all of your health care is very important. And, as it has no other way of knowing, your Plan may ask you for information it needs to properly process claims relating to the clinical trial.
Friday, October 15, 2010
The Limited Income Newly Eligible Transition Program
Starting January 1, 2010, a special program began to make sure that those newly eligible for Part D because they become eligible for extra help would get their prescription medicines. These persons are automatically enrolled in the Limited Income Newly Eligible Transition Program, also called the Limited Income NET Program, and sometimes known as LI NET or LI-NET. They are immediately permitted to use this special Part D drug plan to get their prescriptions at their pharmacy. After they are in the program for two months, they are automatically enrolled in a regular Part D drug plan; in this way, beneficiaries will typically get advance notice of what their regular Part D plan will be. And beneficiaries in this new program can also use it to get retroactive reimbursement for drugs they already paid for if they were entitled to Part D in certain past periods.
The program is a little difficult to explain, but if you keep in mind that it has these diverse aims, you can see how it really eases a beneficiary’s transition into extra help status and Part D.
Smooth Bumps in the Enrollment Process - If there is delay or confusion in the extra help enrollment process, or if the beneficiary has not received timely notice of their enrollment, these beneficiaries can still get their prescriptions filled as pharmacists (and others, such as SHIP counselors) can deal directly with the program to have this happen.
Facilitate Transition into Part D and Extra Help - These beneficiaries are initially and temporarily put in drug plan which will, almost without exception, cover whatever prescription medicines they are taking. This will give these beneficiaries a little time, as they transition to a regular drug plan, to have their prescriptions adjusted or use the exceptions process to help ensure their prescriptions will continue to be covered to the maximum extent possible.
Ease Retroactive Reimbursement - Beneficiaries who qualify for extra help because of Medicaid or SSI are sometimes retroactively entitled to extra help, and thus eligible for reimbursement for prescriptions they already paid for. This program is designed to facilitate compensating them for drugs they paid for out-of-pocket during the period of their retroactive entitlement.
Notify Beneficiaries of Ineligibility - Some beneficiaries who believe they may be entitled to Part D or extra help may be told by their pharmacy that they are not. This program will notify beneficiaries in writing of this result and indicate what they may do to overcome it.
Some special features should be noted about this program. One rationale for the program is to overcome the problem of making sure that beneficiaries can get their prescriptions while the various eligibility systems at both state and federal levels process the many data streams to show that these beneficiaries are indeed eligible for Part D and extra help. In effect, they become eligible for Part D before they get notification or proper proof of this. For this reason a beneficiary can bring documentation of their dual eligible or extra help (low income subsidy) status to a drug store, have the pharmacist enter certain information into their systems, and get an immediate OK to dispense medicine. These are sometimes called “point-of-service” or “POS” beneficiaries. The Centers for Medicare & Medicaid Services believes that about 60,000 beneficiaries fall into this category each year.
And if it later turns out that the individual was not in fact eligible, the Medicare program holds that person, and not the pharmacy, liable for the cost of prescriptions. Also, if it later turns out that the beneficiary’s co-payment level changes up or down, any refund, or any bill for additional charges, will go directly to the beneficiary, and not to the pharmacy. This feature helps to insure that pharmacies will cooperate with the program.
While in this transition program, beneficiaries will not have to pay any monthly premium, nor meet any deductible, but they will be responsible for any applicable co-payment. There is no specific formulary, so any drug which can properly be dispensed under Medicare Part D will qualify. Presumably, the eligible beneficiary, when actually enrolling in a regular Part D plan, will get into one which is best suited for their particular prescriptions. But in the interim while the beneficiary is in the Limited Income NET program, this “no formulary” approach allows them to get whatever specific drug has been prescribed for them. In addition, other than some safely limits, there are no prior authorization requirements or other similar utilization controls. Nor are there any restrictions on what pharmacy they can use.
The program also has generous dispensing rules. When a beneficiary goes to fill a prescription, and they are shown as eligible by the Limited Income NET system, the pharmacist may dispense up to a 90-day supply. If they are not in the system but it appears they are eligible for the program, the pharmacist may dispense up to a 34-day supply.
It should be clearly understood that, under Medicare’s general policy of beneficiary choice, if a beneficiary proactively enrolls in a regular Part D drug plan (or a Medicare Advantage Plan with Part D drug benefit) before or in their very first month of their coverage in the Limited Income NET program, then their enrollment choice will trump the Limited Income NET program’s POS option. That is, on the first day of the month following their enrollment, they will be switched to the regular Part D plan they chose. Because of the liberality of the Limited Income NET program’s rules, they should avoid this.
When a beneficiary is enrolled in this Limited Income NET program, they are automatically and prospectively enrolled in a regular Part D plan. The effective date of this will be the second month after being enrolled in the Limited Income NET program. For example, if a beneficiary is enrolled in the Limited Income NET program on April 20, he or she will be enrolled in a regular Part D plan effective on June 1. These automatic enrollments will always be into a plan with a monthly premium at or below the “benchmark.” But, as indicated above, a beneficiary has the right to choose any regular Part D plan.
One of the special features of this program is to simplify retroactive reimbursement to beneficiaries who have already paid for prescription drugs. When a decision is made that an individual is a full dually-entitled Medicare and Medicaid beneficiary, or entitled to both Medicare and SSI, it is also often determined that a period of retroactive entitlement exists. The Limited Income NET program will enroll these beneficiaries retroactively, with certain limits. This retroactivity will go back to either the start of their dual Medicare and Medicaid eligibility or, if later, their last enrollment in a Part D plan. If they have SSI and then get Medicare, it will go back to the start of their Medicare eligibility. Other beneficiaries will be limited to 30 days or even shorter periods of retroactivity.
This is particularly important to beneficiaries because it enables them to more easily get reimbursement for prescription drugs they purchased with their own, often very limited, funds during this retroactive period.
Beneficiaries who are enrolled in this program will get the YELLOW letter from the Centers for Medicare & Medicaid Services. There are two versions. Version one, “CMS Product No. 11429,” will indicate that the beneficiary has retroactive enrollment, and will state how far back it goes. Version two, “CMS Product No. 11154,” will be sent to those without any retroactive enrollment. Both will also show which regular Part D drug plan the beneficiary has been automatically enrolled into, and the effective date of that enrollment.
Those who receive version one will also get a letter from the Limited Income NET program, run by Humana, explaining how to get reimbursement for retroactive prescriptions. Beneficiaries should be certain to make these requests timely, as they cannot do so after they have been disenrolled from this program for over 180 days. But they should also clearly understand that even if they are currently enrolled in a regular Part D plan, this reimbursement feature is available to them for those 180 days. And this is true even if they never actually got a prescription dispensed by the Limited Income NET program before they went into their regular Part D plan.
Beneficiaries who believe they have become eligible for extra help but don’t get either of these YELLOW letters can take any of the following documents to their pharmacy and ask the pharmacist to verify their eligibility:
Any of these letters issued by the Social Security Administration:
“Notice of Award”
“Notice of Change” indicating an award increase
“Notice of Planned Action” indicating an award reduction
“Notice of Important Information” indicating no change to an award
a letter showing the beneficiary receives SSI
Any of the following state issued documentation that shows any Medicaid eligibility or enrollment after June of the previous calendar year:
a Medicaid card
any state document confirming active Medicaid status
a printout from the state Medicaid enrollment or eligibility file
any other appropriate documentation from the state Medicaid office
Beneficiaries who try to use this program but cannot be confirmed as eligible (this typically happens when a pharmacist tries to get the program to OK the dispensing of a prescription) will be sent a special letter the “Beneficiary Evidence of Eligibility Letter” – indicating what proof the can submit if they believe they are eligible. Humana has a help line, 1-800-783-1307, which is open 8 AM to 8 PM in each time zone. While this is a general help line for the program, beneficiaries, Medicaid staff, SHIP counselors and so forth may call it for help with eligibility issues.
Humana also has a web site www.humana.com/pharmacists/pharmacy_resources/information.aspx which is of particular help to pharmacists.
The web site also has a “Prescription Drug Claim Form” which can be used to make a claim for retroactive reimbursement for a prescription drug from the Limited Income NET program. However, the program has noted that many such requests are invalid because (1) the claim is for a drug dispensed when the beneficiary was not both Medicare AND Medicaid or SSI eligible; (2) the beneficiary was actually enrolled in another Part D plan when the drug was dispensed; or (3) the drug is not covered by the Part D program (such as an over-the-counter (OTC) drug or vitamin.
The program is a little difficult to explain, but if you keep in mind that it has these diverse aims, you can see how it really eases a beneficiary’s transition into extra help status and Part D.
Smooth Bumps in the Enrollment Process - If there is delay or confusion in the extra help enrollment process, or if the beneficiary has not received timely notice of their enrollment, these beneficiaries can still get their prescriptions filled as pharmacists (and others, such as SHIP counselors) can deal directly with the program to have this happen.
Facilitate Transition into Part D and Extra Help - These beneficiaries are initially and temporarily put in drug plan which will, almost without exception, cover whatever prescription medicines they are taking. This will give these beneficiaries a little time, as they transition to a regular drug plan, to have their prescriptions adjusted or use the exceptions process to help ensure their prescriptions will continue to be covered to the maximum extent possible.
Ease Retroactive Reimbursement - Beneficiaries who qualify for extra help because of Medicaid or SSI are sometimes retroactively entitled to extra help, and thus eligible for reimbursement for prescriptions they already paid for. This program is designed to facilitate compensating them for drugs they paid for out-of-pocket during the period of their retroactive entitlement.
Notify Beneficiaries of Ineligibility - Some beneficiaries who believe they may be entitled to Part D or extra help may be told by their pharmacy that they are not. This program will notify beneficiaries in writing of this result and indicate what they may do to overcome it.
Some special features should be noted about this program. One rationale for the program is to overcome the problem of making sure that beneficiaries can get their prescriptions while the various eligibility systems at both state and federal levels process the many data streams to show that these beneficiaries are indeed eligible for Part D and extra help. In effect, they become eligible for Part D before they get notification or proper proof of this. For this reason a beneficiary can bring documentation of their dual eligible or extra help (low income subsidy) status to a drug store, have the pharmacist enter certain information into their systems, and get an immediate OK to dispense medicine. These are sometimes called “point-of-service” or “POS” beneficiaries. The Centers for Medicare & Medicaid Services believes that about 60,000 beneficiaries fall into this category each year.
And if it later turns out that the individual was not in fact eligible, the Medicare program holds that person, and not the pharmacy, liable for the cost of prescriptions. Also, if it later turns out that the beneficiary’s co-payment level changes up or down, any refund, or any bill for additional charges, will go directly to the beneficiary, and not to the pharmacy. This feature helps to insure that pharmacies will cooperate with the program.
While in this transition program, beneficiaries will not have to pay any monthly premium, nor meet any deductible, but they will be responsible for any applicable co-payment. There is no specific formulary, so any drug which can properly be dispensed under Medicare Part D will qualify. Presumably, the eligible beneficiary, when actually enrolling in a regular Part D plan, will get into one which is best suited for their particular prescriptions. But in the interim while the beneficiary is in the Limited Income NET program, this “no formulary” approach allows them to get whatever specific drug has been prescribed for them. In addition, other than some safely limits, there are no prior authorization requirements or other similar utilization controls. Nor are there any restrictions on what pharmacy they can use.
The program also has generous dispensing rules. When a beneficiary goes to fill a prescription, and they are shown as eligible by the Limited Income NET system, the pharmacist may dispense up to a 90-day supply. If they are not in the system but it appears they are eligible for the program, the pharmacist may dispense up to a 34-day supply.
It should be clearly understood that, under Medicare’s general policy of beneficiary choice, if a beneficiary proactively enrolls in a regular Part D drug plan (or a Medicare Advantage Plan with Part D drug benefit) before or in their very first month of their coverage in the Limited Income NET program, then their enrollment choice will trump the Limited Income NET program’s POS option. That is, on the first day of the month following their enrollment, they will be switched to the regular Part D plan they chose. Because of the liberality of the Limited Income NET program’s rules, they should avoid this.
When a beneficiary is enrolled in this Limited Income NET program, they are automatically and prospectively enrolled in a regular Part D plan. The effective date of this will be the second month after being enrolled in the Limited Income NET program. For example, if a beneficiary is enrolled in the Limited Income NET program on April 20, he or she will be enrolled in a regular Part D plan effective on June 1. These automatic enrollments will always be into a plan with a monthly premium at or below the “benchmark.” But, as indicated above, a beneficiary has the right to choose any regular Part D plan.
One of the special features of this program is to simplify retroactive reimbursement to beneficiaries who have already paid for prescription drugs. When a decision is made that an individual is a full dually-entitled Medicare and Medicaid beneficiary, or entitled to both Medicare and SSI, it is also often determined that a period of retroactive entitlement exists. The Limited Income NET program will enroll these beneficiaries retroactively, with certain limits. This retroactivity will go back to either the start of their dual Medicare and Medicaid eligibility or, if later, their last enrollment in a Part D plan. If they have SSI and then get Medicare, it will go back to the start of their Medicare eligibility. Other beneficiaries will be limited to 30 days or even shorter periods of retroactivity.
This is particularly important to beneficiaries because it enables them to more easily get reimbursement for prescription drugs they purchased with their own, often very limited, funds during this retroactive period.
Beneficiaries who are enrolled in this program will get the YELLOW letter from the Centers for Medicare & Medicaid Services. There are two versions. Version one, “CMS Product No. 11429,” will indicate that the beneficiary has retroactive enrollment, and will state how far back it goes. Version two, “CMS Product No. 11154,” will be sent to those without any retroactive enrollment. Both will also show which regular Part D drug plan the beneficiary has been automatically enrolled into, and the effective date of that enrollment.
Those who receive version one will also get a letter from the Limited Income NET program, run by Humana, explaining how to get reimbursement for retroactive prescriptions. Beneficiaries should be certain to make these requests timely, as they cannot do so after they have been disenrolled from this program for over 180 days. But they should also clearly understand that even if they are currently enrolled in a regular Part D plan, this reimbursement feature is available to them for those 180 days. And this is true even if they never actually got a prescription dispensed by the Limited Income NET program before they went into their regular Part D plan.
Beneficiaries who believe they have become eligible for extra help but don’t get either of these YELLOW letters can take any of the following documents to their pharmacy and ask the pharmacist to verify their eligibility:
Any of these letters issued by the Social Security Administration:
“Notice of Award”
“Notice of Change” indicating an award increase
“Notice of Planned Action” indicating an award reduction
“Notice of Important Information” indicating no change to an award
a letter showing the beneficiary receives SSI
Any of the following state issued documentation that shows any Medicaid eligibility or enrollment after June of the previous calendar year:
a Medicaid card
any state document confirming active Medicaid status
a printout from the state Medicaid enrollment or eligibility file
any other appropriate documentation from the state Medicaid office
Beneficiaries who try to use this program but cannot be confirmed as eligible (this typically happens when a pharmacist tries to get the program to OK the dispensing of a prescription) will be sent a special letter the “Beneficiary Evidence of Eligibility Letter” – indicating what proof the can submit if they believe they are eligible. Humana has a help line, 1-800-783-1307, which is open 8 AM to 8 PM in each time zone. While this is a general help line for the program, beneficiaries, Medicaid staff, SHIP counselors and so forth may call it for help with eligibility issues.
Humana also has a web site www.humana.com/pharmacists/pharmacy_resources/information.aspx which is of particular help to pharmacists.
The web site also has a “Prescription Drug Claim Form” which can be used to make a claim for retroactive reimbursement for a prescription drug from the Limited Income NET program. However, the program has noted that many such requests are invalid because (1) the claim is for a drug dispensed when the beneficiary was not both Medicare AND Medicaid or SSI eligible; (2) the beneficiary was actually enrolled in another Part D plan when the drug was dispensed; or (3) the drug is not covered by the Part D program (such as an over-the-counter (OTC) drug or vitamin.
Monday, October 11, 2010
Medicare Competitive Bidding Program on Durable Medical Equipment
The Medicare program is continuing an effort to get better prices on Durable Medical Equipment and allied supplies through a bidding process that competes the prices that Medicare pays for these rather than establishing the prices by the current method of using a fee schedule set by the program. Medicare tried this on a pilot basis in Florida and Texas a number of years ago and it appeared to be successful in helping beneficiaries by lowering prices and improving customer service. The entire issue of using competition or direct federal negotiation rather than the current regulatory processes to lower health care costs for Medicare beneficiaries is a hugely controversial and rather politicized issue, but my guess is that in the future we will see these new processes used to deal with the relentless rise in health care costs.
Note that this competitive bidding program is will go into effect on January 1, 2011, but only in selected areas of the nation, and it will apply only to certain , items of equipment and supplies. (And while this technically only involves those of you in Original Medicare, those of you in Medicare Advantage may be affected and you need to carefully check with your Plan before you purchase or rent any of the involved items, but, of course, it’s always wise to do that when you are in Medicare Advantage.)
These are the metropolitan areas it will apply to; note that some cover more than one state. If you live in these areas, or if you visit one and get one of the involved items while you are there, you need to get them from a “contract” supplier. And all contract suppliers must take assignment, an important protection for beneficiaries. Medicare is publicizing its competitive activities in these areas as they proceed, and this will help let you know if you are affected and how.
California: Riverside – San Bernadino – Ontario
Florida: Miami – Fort Lauderdale – Pompano Beach
Florida: Orlando Kissimmee
Missouri and Kansas: Kansas City
North and South Carolina: Charlotte – Gastonia – Concord
Ohio, Kentucky and Indiana: Cincinnati – Middletown
Ohio: Cleveland – Elyria – Mentor
Pennsylvania: Pittsburgh
Texas: Dallas – Fort Worth – Arlington
You can find a contract supplier by calling 1-800-MEDICARE or by going to www.Medicare.gov, clicking on “Resource Locator,” and then on “Medical Equipment Suppliers,” and entering your zip.
These are the items, that is, the equipment and supplies which will be included in the competition:
Oxygen, oxygen equipment and supplies
Standard power wheelchairs and scooters
Certain complex rehabilitative wheelchairs
Mail-order diabetic supplies
Enteral nutrients, equipment and supplies
Certain respiratory devices, specifically:
Continuous positive airway pressure devices
Respiratory assist devices
Hospital beds and related accessories
Walkers and related accessories
Certain support surfaces (mattresses, overlays), but only in the
Florida: Miami – Fort Lauderdale – Pompano Beach area
Basically, beginning on January 1, 2011, anytime you rent or purchase an item or supply on this list while you reside in or visit the areas mentioned, you will have to get it from a supplier which has a contract with Medicare under the competitive bidding program. If you do not, Medicare will not pay anything. As with any Medicare activity, exceptions to this rule can apply. Note that doctors, treating practitioners (such as physical therapists) and hospitals may supply certain items. A skilled nursing facility or nursing home can’t, however, unless it becomes a contract supplier. And if you are renting one of the affected pieces of equipment from a supplier when the program goes into effect on January 1, 2011, and that supplier elects to be “grandfathered in,” you can continue to rent that item from your supplier. But if they are not, you need to change suppliers as Medicare will not pay anything on your equipment.
Note that this competitive bidding program is will go into effect on January 1, 2011, but only in selected areas of the nation, and it will apply only to certain , items of equipment and supplies. (And while this technically only involves those of you in Original Medicare, those of you in Medicare Advantage may be affected and you need to carefully check with your Plan before you purchase or rent any of the involved items, but, of course, it’s always wise to do that when you are in Medicare Advantage.)
These are the metropolitan areas it will apply to; note that some cover more than one state. If you live in these areas, or if you visit one and get one of the involved items while you are there, you need to get them from a “contract” supplier. And all contract suppliers must take assignment, an important protection for beneficiaries. Medicare is publicizing its competitive activities in these areas as they proceed, and this will help let you know if you are affected and how.
California: Riverside – San Bernadino – Ontario
Florida: Miami – Fort Lauderdale – Pompano Beach
Florida: Orlando Kissimmee
Missouri and Kansas: Kansas City
North and South Carolina: Charlotte – Gastonia – Concord
Ohio, Kentucky and Indiana: Cincinnati – Middletown
Ohio: Cleveland – Elyria – Mentor
Pennsylvania: Pittsburgh
Texas: Dallas – Fort Worth – Arlington
You can find a contract supplier by calling 1-800-MEDICARE or by going to www.Medicare.gov, clicking on “Resource Locator,” and then on “Medical Equipment Suppliers,” and entering your zip.
These are the items, that is, the equipment and supplies which will be included in the competition:
Oxygen, oxygen equipment and supplies
Standard power wheelchairs and scooters
Certain complex rehabilitative wheelchairs
Mail-order diabetic supplies
Enteral nutrients, equipment and supplies
Certain respiratory devices, specifically:
Continuous positive airway pressure devices
Respiratory assist devices
Hospital beds and related accessories
Walkers and related accessories
Certain support surfaces (mattresses, overlays), but only in the
Florida: Miami – Fort Lauderdale – Pompano Beach area
Basically, beginning on January 1, 2011, anytime you rent or purchase an item or supply on this list while you reside in or visit the areas mentioned, you will have to get it from a supplier which has a contract with Medicare under the competitive bidding program. If you do not, Medicare will not pay anything. As with any Medicare activity, exceptions to this rule can apply. Note that doctors, treating practitioners (such as physical therapists) and hospitals may supply certain items. A skilled nursing facility or nursing home can’t, however, unless it becomes a contract supplier. And if you are renting one of the affected pieces of equipment from a supplier when the program goes into effect on January 1, 2011, and that supplier elects to be “grandfathered in,” you can continue to rent that item from your supplier. But if they are not, you need to change suppliers as Medicare will not pay anything on your equipment.
Thursday, October 7, 2010
Kidney Disease Patient Education Services
Kidney Disease Patient Education (KDE) Services
In Managing Your Medicare we mentioned earlier that Medicare has a special relationship with those with severe kidney disease as it covers over 90 percent of people with end stage renal disease. I want to make sure that everyone knows that Medicare has further extended this relationship, as it provides for an entirely new service called “Kidney Disease Patient Education Services.” The basic aim of this service is to intervene with those beneficiaries who have severe but not yet end stage kidney disease with the hope of either preventing or delaying the onset of end stage renal disease (which will require dialysis or a transplant) and of preparing beneficiaries for that eventuality. The benefit specifically takes into account that many beneficiaries with chronic kidney disease or CKD are elderly and have other chronic diseases, especially hypertension, diabetes and cardiovascular disease.
It is available to those with stage 4 chronic kidney disease (stage 5 is end stage renal disease), which is technically defined as a specific glomerular filtration rate (or GFR, a measure of how quickly blood is filtered through the kidney). The beneficiary’s physician that is managing the kidney disease must make a referral for this service.
Generally, this service is available only from a physician, nurse practitioner, clinical nurse specialist or a physician assistant, except in rural areas, where a variety of institutional providers, including hospitals, may also give it. However, note that renal dialysis facilities may not provide this service.
The service is limited to face-to-face sessions, of one hour duration, and these may be either individual or group sessions, or a combination. No more than six sessions are covered.
The sessions, which must be tailored to meet the needs of the beneficiary, must cover these general areas:
managing comorbidities and delaying the need for dialysis;
prevention of uremic consequences;
options for renal replacement (the various types and locales of dialysis, as well as transplants); and,
ensuring beneficiary participation in their choice of therapy.
A wide variety of specific topics should be covered, including conveying information about these items:
overview of kidney functions and disease,
prolonging kidney function,
survival rates, quality of life,
comorbidity treatment and management,
psychosocial arrangements,
renal replacement treatments and options, including transplantation,
vocational rehabilitation,
diet and exercise,
sexuality and fertility issues,
financial support and insurance, and
medication management.
The sessions should be patient-centered, encourage collaboration, and offer support to the patient.
In addition, it is expected that the beneficiary be assessed during one of the sessions for their understanding of CKD and its treatment, and their understanding of and the ability to make informed decisions about their healthcare and treatment options.
This is a Part B service; after you meet the Part B deductible, Medicare pays 80% of the cost, and the beneficiary is responsible for 20%. (For those few of you who get this in a hospital setting, you will have a copayment.)
In Managing Your Medicare we mentioned earlier that Medicare has a special relationship with those with severe kidney disease as it covers over 90 percent of people with end stage renal disease. I want to make sure that everyone knows that Medicare has further extended this relationship, as it provides for an entirely new service called “Kidney Disease Patient Education Services.” The basic aim of this service is to intervene with those beneficiaries who have severe but not yet end stage kidney disease with the hope of either preventing or delaying the onset of end stage renal disease (which will require dialysis or a transplant) and of preparing beneficiaries for that eventuality. The benefit specifically takes into account that many beneficiaries with chronic kidney disease or CKD are elderly and have other chronic diseases, especially hypertension, diabetes and cardiovascular disease.
It is available to those with stage 4 chronic kidney disease (stage 5 is end stage renal disease), which is technically defined as a specific glomerular filtration rate (or GFR, a measure of how quickly blood is filtered through the kidney). The beneficiary’s physician that is managing the kidney disease must make a referral for this service.
Generally, this service is available only from a physician, nurse practitioner, clinical nurse specialist or a physician assistant, except in rural areas, where a variety of institutional providers, including hospitals, may also give it. However, note that renal dialysis facilities may not provide this service.
The service is limited to face-to-face sessions, of one hour duration, and these may be either individual or group sessions, or a combination. No more than six sessions are covered.
The sessions, which must be tailored to meet the needs of the beneficiary, must cover these general areas:
managing comorbidities and delaying the need for dialysis;
prevention of uremic consequences;
options for renal replacement (the various types and locales of dialysis, as well as transplants); and,
ensuring beneficiary participation in their choice of therapy.
A wide variety of specific topics should be covered, including conveying information about these items:
overview of kidney functions and disease,
prolonging kidney function,
survival rates, quality of life,
comorbidity treatment and management,
psychosocial arrangements,
renal replacement treatments and options, including transplantation,
vocational rehabilitation,
diet and exercise,
sexuality and fertility issues,
financial support and insurance, and
medication management.
The sessions should be patient-centered, encourage collaboration, and offer support to the patient.
In addition, it is expected that the beneficiary be assessed during one of the sessions for their understanding of CKD and its treatment, and their understanding of and the ability to make informed decisions about their healthcare and treatment options.
This is a Part B service; after you meet the Part B deductible, Medicare pays 80% of the cost, and the beneficiary is responsible for 20%. (For those few of you who get this in a hospital setting, you will have a copayment.)
New Cardiac and Pulmonary Rehabilitation Programs
Cardiac and Pulmonary Rehabilitation Programs
The Medicare Program has just issued final instructions on these two types of programs, although they technically have been in effect for some time.
While Medicare has long covered cardiac rehabilitation services, the MIPPA law established two types of cardiac rehabilitation services programs, a “regular” cardiac rehabilitation services program, and a brand new intensive cardiac rehabilitation services program. In addition, it called for an also brand new program of pulmonary rehabilitation services; all of these are effective with January 1, 2010. These are all outpatient services, and, as such, are covered under Part B. These programs have somewhat similar requirements, but are different enough so it helps to discuss them separately.
The cardiac rehabilitation programs must be:
1. physician supervised;
2. delivered only in hospitals and doctors’ offices and always with a physician immediately available;
3. given under a physician’s plan individualized for the beneficiary and specifying the “type, amount, frequency, and duration” of the services to be rendered to or performed by the beneficiary. This plan must be renewed every 30 days.
The programs’ specific services must consist of exercise(including aerobic exercise), both psychosocial and outcomes assessments, and a “cardiac risk factor modification” component, which includes education, counseling, and behavior intervention. Depending on the individual, these may include smoking cessation counseling, nutritional education, meal planning, stress management, drug education, and so forth.
To qualify for cardiac rehabilitation, the beneficiary must have or have had a specific coronary-related diagnosis or procedure. These are (1) an acute myocardial infarction (AMI) within the last 12 months, (2) coronary by-pass surgery, (3) stable angina pectoris, (4) a heart valve repair or replacement, (5) a percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, or (6) a heart or heart lung-transplant.
One way the two cardiac rehabilitation programs differ is that the “regular” program must conform to standards of frequency and duration of services that are prescribed in regulation, while this has been done in the statue for the “intensive“ program. Specifically, beneficiaries in the regular program are limited to a total of 36 sessions, each one hour in duration, over a period of 36 weeks. Because of the severity of the qualifying conditions, the sessions are limited to two per day. Under some conditions the program may be expanded up to an additional 36 sessions over an extended period of time.
The intensive program calls for up to 72 one-hour sessions, not exceeding six per day, and not exceeding 18 weeks in length. Finally, any intensive program has to be specifically qualified as such by the Centers for Medicare & Medicaid Services through its national coverage determination process. To date, both the Ornish and the Pritkin programs have been so approved.
The pulmonary rehabilitation program for beneficiaries must meet the same requirements (1) through (3) shown above.
Its specific services must comprise exercise (including aerobic exercise), both psychosocial and outcomes assessments, and an educational component. This latter must be designed to enable beneficiaries to adapt to their limitations and improve the quality of their life. It may include instruction in the use of home respiratory equipment, prevention and treatment of exacerbating conditions, respiratory techniques for physical energy conservation, work simplification, relaxation techniques, medication training, nutrition counseling, and smoking cessation.
To qualify, beneficiaries must have “moderate to very severe” chronic obstructive pulmonary disease or COPD. (These are technically defined in terms of a GOLD classification of II, III, and IV; GOLD, in turn, is a standardized measure of airflow limitation.) COPD is typically associated with chronic bronchitis, emphysema, persistent asthma, bronchiectasis, primary pulmonary hypertension, obesity-related respiratory disease and ventilator dependency.
As established in regulations, the program is limited to a total of 36 sessions, each one hour in duration. Because of the severity of the qualifying conditions, the sessions are limited to two per day. If medically necessary, the program may be extended up to an additional 36 sessions.
These are all Part B services; after you meet the Part B deductible, Medicare pays 80% of the cost, and the beneficiary is responsible for 20%. If you get them in a hospital, you will have a copayment.
The Medicare Program has just issued final instructions on these two types of programs, although they technically have been in effect for some time.
While Medicare has long covered cardiac rehabilitation services, the MIPPA law established two types of cardiac rehabilitation services programs, a “regular” cardiac rehabilitation services program, and a brand new intensive cardiac rehabilitation services program. In addition, it called for an also brand new program of pulmonary rehabilitation services; all of these are effective with January 1, 2010. These are all outpatient services, and, as such, are covered under Part B. These programs have somewhat similar requirements, but are different enough so it helps to discuss them separately.
The cardiac rehabilitation programs must be:
1. physician supervised;
2. delivered only in hospitals and doctors’ offices and always with a physician immediately available;
3. given under a physician’s plan individualized for the beneficiary and specifying the “type, amount, frequency, and duration” of the services to be rendered to or performed by the beneficiary. This plan must be renewed every 30 days.
The programs’ specific services must consist of exercise(including aerobic exercise), both psychosocial and outcomes assessments, and a “cardiac risk factor modification” component, which includes education, counseling, and behavior intervention. Depending on the individual, these may include smoking cessation counseling, nutritional education, meal planning, stress management, drug education, and so forth.
To qualify for cardiac rehabilitation, the beneficiary must have or have had a specific coronary-related diagnosis or procedure. These are (1) an acute myocardial infarction (AMI) within the last 12 months, (2) coronary by-pass surgery, (3) stable angina pectoris, (4) a heart valve repair or replacement, (5) a percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, or (6) a heart or heart lung-transplant.
One way the two cardiac rehabilitation programs differ is that the “regular” program must conform to standards of frequency and duration of services that are prescribed in regulation, while this has been done in the statue for the “intensive“ program. Specifically, beneficiaries in the regular program are limited to a total of 36 sessions, each one hour in duration, over a period of 36 weeks. Because of the severity of the qualifying conditions, the sessions are limited to two per day. Under some conditions the program may be expanded up to an additional 36 sessions over an extended period of time.
The intensive program calls for up to 72 one-hour sessions, not exceeding six per day, and not exceeding 18 weeks in length. Finally, any intensive program has to be specifically qualified as such by the Centers for Medicare & Medicaid Services through its national coverage determination process. To date, both the Ornish and the Pritkin programs have been so approved.
The pulmonary rehabilitation program for beneficiaries must meet the same requirements (1) through (3) shown above.
Its specific services must comprise exercise (including aerobic exercise), both psychosocial and outcomes assessments, and an educational component. This latter must be designed to enable beneficiaries to adapt to their limitations and improve the quality of their life. It may include instruction in the use of home respiratory equipment, prevention and treatment of exacerbating conditions, respiratory techniques for physical energy conservation, work simplification, relaxation techniques, medication training, nutrition counseling, and smoking cessation.
To qualify, beneficiaries must have “moderate to very severe” chronic obstructive pulmonary disease or COPD. (These are technically defined in terms of a GOLD classification of II, III, and IV; GOLD, in turn, is a standardized measure of airflow limitation.) COPD is typically associated with chronic bronchitis, emphysema, persistent asthma, bronchiectasis, primary pulmonary hypertension, obesity-related respiratory disease and ventilator dependency.
As established in regulations, the program is limited to a total of 36 sessions, each one hour in duration. Because of the severity of the qualifying conditions, the sessions are limited to two per day. If medically necessary, the program may be extended up to an additional 36 sessions.
These are all Part B services; after you meet the Part B deductible, Medicare pays 80% of the cost, and the beneficiary is responsible for 20%. If you get them in a hospital, you will have a copayment.
Medicare Compare 2011 Up and Running
Medicare's Compare for 2011 Medicare Advantage Plans and stand-alone drug plans is up and running today, October 7, thus beating their advertised deadline of October 8.
Beneficiaries should go ahead and start studying what is available for them now, although actual changes to their plans can't be made until beginning November 15. The program appears significantly improved from the previous versions, and more user-friendly.
Also available is a new facility which allows beneficiaries to download their "My Medicare" information to a file on their home computer. Previously the only way to "save" it was to print it out. When you have signed into your "My Medicare" account, look for the Blue Button "Download My Data" logo to download your informtion. You get choices of what types of information you want to download (eg, claims data, drug data, etc.) And there is an important warning there about downloading only to a personal, not a public (eg library), computer.
Beneficiaries should go ahead and start studying what is available for them now, although actual changes to their plans can't be made until beginning November 15. The program appears significantly improved from the previous versions, and more user-friendly.
Also available is a new facility which allows beneficiaries to download their "My Medicare" information to a file on their home computer. Previously the only way to "save" it was to print it out. When you have signed into your "My Medicare" account, look for the Blue Button "Download My Data" logo to download your informtion. You get choices of what types of information you want to download (eg, claims data, drug data, etc.) And there is an important warning there about downloading only to a personal, not a public (eg library), computer.
Monday, October 4, 2010
2011 High Income Part D Premium Surcharges
Section 3308 of the Health Care Reform Bill extended high income premium surcharges to Part D, parallel to those in Part B. So basically, those of you who are paying a surcharge on your Part B premium will now, if you have Part D, will pay a surcharge on your premium there as well, beginning in 2011. (For those few of you who do not have Part B, you are subject to this if you have Part D and exceed the income limits we discuss.) Another section of the statute froze the income levels which determine if you are subject to the surcharge, and if so, how much it is. Basically, an individual with a “modified adjusted gross income” (MAGI) of over $85,000 in 2009, or a couple filing jointly with such an income of over $170,000 in 2009, will be subject to these. (Page 20 of Managing Your Medicare explains how your MAGI is calculated; basically it is your Federal adjusted gross income plus any tax-exempt interest you earned.)
Perhaps because this will be the first tax imposed as a result of the new legislation, little information seems to be available about it yet, and so far nothing is on the government websites. But I have used the statue to figure out what the surcharges will be. And remember that your 2009 income and marital status is the determiner. And if both of a couple have Part D, each has to pay this.
If you were single and had a MAGI over $85,000 but less than $107,000, or if you were a couple filing jointly with an MAGI of over $170,000 but less than $214,000, your monthly premium surcharge will be $12.00 a month, or $144.00 a year.
If you were single and had a MAGI over $107,000 but less than $160,000, or if you were a couple filing jointly with an MAGI of over $214,000 but less than $320,000, your monthly premium surcharge will be $31.10 a month, or $373.20 a year.
If you were single and had a MAGI over $160,000 but less than $214,000, or if you were a couple filing jointly with an MAGI of over $320,000 but less than $428,000, your monthly premium surcharge will be $50.10 a month, or $601.20 a year.
If you were single and had a MAGI over $214,000, or if you were a couple filing jointly with an MAGI of over $428,000, your monthly premium surcharge will be $69.10 a month, or $829.20 a year.
If you were married and living together, but file separately, and had a MAGI of over $85,000 but less than 129,000, your monthly premium surcharge will be $50.10 a month, or $601.20 a year.
If you were married and living together, but file separately, and had a MAGI of over $129,000, your monthly premium surcharge will be $69.10 a month, or $829.20 a year.
You will not be paying these surcharges to your drug plan (or Medicare Advantage Plan, if you get your Part D from them) with your monthly Part D premium. Rather, for those of you on Social Security, they will be deducted from your monthly payment. Rather, for those of you on Social Security or Railroad Retirement, or who receive a federal pension from the Office of Personnel Management, they will be deducted from your monthly payment; all others will be billed directly by Medicare, just like they are for Part B. Note that the amount of your surcharge does not vary by the size of your plan’s premium; and, for those of you who do not pay any Part D premium (because your Medicare Advantage plan does not charge one) will still have to pay this surcharge.
Pages 20-21 of Managing Your Medicare explains how to appeal to Social Security if they use the wrong income, or if your circumstances have changed significantly since you filed your 2009 income tax (perhaps you retired, your business burned down, you divorced, or your spouse died, etc.).
Finally, I have learned that the Medicare website’s Compare function, which allows you to find the best drug plan or Medicare Advantage Plan, does not take this surcharge into account, so you will not get the full story on how much you will pay, as the surcharge you are responbible for won't be included. But at least it will still be able to help you pick out the best plan for you. And for those of you who are thinking that you might wish to forego Part D if you are subject to a surcharge, especially a high one, remember, that if you don’t have other creditable coverage, and you do not take Part D, if you latter sign up, you will be penalized $0.32 per month for each month that you could have had Part D but did not. (This amount may change each year.)
Perhaps because this will be the first tax imposed as a result of the new legislation, little information seems to be available about it yet, and so far nothing is on the government websites. But I have used the statue to figure out what the surcharges will be. And remember that your 2009 income and marital status is the determiner. And if both of a couple have Part D, each has to pay this.
If you were single and had a MAGI over $85,000 but less than $107,000, or if you were a couple filing jointly with an MAGI of over $170,000 but less than $214,000, your monthly premium surcharge will be $12.00 a month, or $144.00 a year.
If you were single and had a MAGI over $107,000 but less than $160,000, or if you were a couple filing jointly with an MAGI of over $214,000 but less than $320,000, your monthly premium surcharge will be $31.10 a month, or $373.20 a year.
If you were single and had a MAGI over $160,000 but less than $214,000, or if you were a couple filing jointly with an MAGI of over $320,000 but less than $428,000, your monthly premium surcharge will be $50.10 a month, or $601.20 a year.
If you were single and had a MAGI over $214,000, or if you were a couple filing jointly with an MAGI of over $428,000, your monthly premium surcharge will be $69.10 a month, or $829.20 a year.
If you were married and living together, but file separately, and had a MAGI of over $85,000 but less than 129,000, your monthly premium surcharge will be $50.10 a month, or $601.20 a year.
If you were married and living together, but file separately, and had a MAGI of over $129,000, your monthly premium surcharge will be $69.10 a month, or $829.20 a year.
You will not be paying these surcharges to your drug plan (or Medicare Advantage Plan, if you get your Part D from them) with your monthly Part D premium. Rather, for those of you on Social Security, they will be deducted from your monthly payment. Rather, for those of you on Social Security or Railroad Retirement, or who receive a federal pension from the Office of Personnel Management, they will be deducted from your monthly payment; all others will be billed directly by Medicare, just like they are for Part B. Note that the amount of your surcharge does not vary by the size of your plan’s premium; and, for those of you who do not pay any Part D premium (because your Medicare Advantage plan does not charge one) will still have to pay this surcharge.
Pages 20-21 of Managing Your Medicare explains how to appeal to Social Security if they use the wrong income, or if your circumstances have changed significantly since you filed your 2009 income tax (perhaps you retired, your business burned down, you divorced, or your spouse died, etc.).
Finally, I have learned that the Medicare website’s Compare function, which allows you to find the best drug plan or Medicare Advantage Plan, does not take this surcharge into account, so you will not get the full story on how much you will pay, as the surcharge you are responbible for won't be included. But at least it will still be able to help you pick out the best plan for you. And for those of you who are thinking that you might wish to forego Part D if you are subject to a surcharge, especially a high one, remember, that if you don’t have other creditable coverage, and you do not take Part D, if you latter sign up, you will be penalized $0.32 per month for each month that you could have had Part D but did not. (This amount may change each year.)
Saturday, October 2, 2010
Medicare Part D in 2011
In “Managing Your Medicare” beneficiaries are urged to review their options every year to make sure that they have the best Medicare deal going for them.
But this is especially true as we transition into 2011.
In Part D, we know that the number of available Medicare Prescription Drug plans has been cut back drastically; there will be about a third fewer plans available in 2011 as opposed to 2010. Some see this as good as a deliberate effort was made to not allow any plans that differed only little bit from each other, thus simplifying things for beneficiaries. Others are not so sure, as the decrease is also due to some companies dropping out of Part D, and thus fewer competitive consumer choices are available to beneficiaries. But it’s done.
And you are likely to see a premium increase for 2011 over 2010. There are many different ways to calculate this, and, depending on how it is done, it’s an average of 10% or 15%. But a beneficiary should be more concerned with what particular situation they as an individual are facing. It’s entirely possible that your current plan’s premium will go down.
And finally, as already blogged here, beginning in 2011 there is a big change to how much you have to pay when you are in the “donut hole.” Basically, in 2011, for everyone of you who do NOT get “extra help,” when you hit the donut hole you will get a 50% discount on your name brand drugs, and a 7% discount on your generics. Plus, in addition to this, a number of plans, in fact, more plans in 2011 than 2010, will be offering additional benefits in the donut hole.
What all this says is that you really need to go ahead and make sure you get into the right Part D drug plan for 2011. As we point out in the book (on pages 88-89), this can be done by going on the Medicare website, www.Medicare.gov, and by clicking on “Health Plans” and then “Compare Drug and Health Plans.” You can do this beginning in mid-October, and actually enroll in a different plan beginning November 15 through December 31, effective with January 1, 2011.
And some of you will be automatically switched from your current plan to a different one offered by the same drug plan sponsor. (A “sponsor” is the actual company that offers a plan, but the same company or sponsor may offer several different plans in the same state.) This is because with the cutback in plans, yours will no longer be available, but there is a similar one offered by your sponsor. You should clearly understand that the government has NOT made the best choice for you; it’s merely put you in the closest thing that you had. You definitely need to take action to make sure you get the best deal available to you.
And there is one fly in this ointment. Based on a provision in the Health Care Reform bill, for those of you who are already paying a high income premium surcharge for your Part B benefits, you will also in 2011 be hit with a high income premium surcharge for your Part D benefits. This will increase the cost of your Part D plan by, for a married couple earning more than $170,000 and a single person earning more than $85,000, anywhere from about $150 to $1,000 more per year. I will blog the details of this shortly.
And, for those of you who are in a Medicare Advantage Plan (Part C of Medicare), or are thinking of going into one, I'll blog about what you should be doing as we transition into 2011.
But this is especially true as we transition into 2011.
In Part D, we know that the number of available Medicare Prescription Drug plans has been cut back drastically; there will be about a third fewer plans available in 2011 as opposed to 2010. Some see this as good as a deliberate effort was made to not allow any plans that differed only little bit from each other, thus simplifying things for beneficiaries. Others are not so sure, as the decrease is also due to some companies dropping out of Part D, and thus fewer competitive consumer choices are available to beneficiaries. But it’s done.
And you are likely to see a premium increase for 2011 over 2010. There are many different ways to calculate this, and, depending on how it is done, it’s an average of 10% or 15%. But a beneficiary should be more concerned with what particular situation they as an individual are facing. It’s entirely possible that your current plan’s premium will go down.
And finally, as already blogged here, beginning in 2011 there is a big change to how much you have to pay when you are in the “donut hole.” Basically, in 2011, for everyone of you who do NOT get “extra help,” when you hit the donut hole you will get a 50% discount on your name brand drugs, and a 7% discount on your generics. Plus, in addition to this, a number of plans, in fact, more plans in 2011 than 2010, will be offering additional benefits in the donut hole.
What all this says is that you really need to go ahead and make sure you get into the right Part D drug plan for 2011. As we point out in the book (on pages 88-89), this can be done by going on the Medicare website, www.Medicare.gov, and by clicking on “Health Plans” and then “Compare Drug and Health Plans.” You can do this beginning in mid-October, and actually enroll in a different plan beginning November 15 through December 31, effective with January 1, 2011.
And some of you will be automatically switched from your current plan to a different one offered by the same drug plan sponsor. (A “sponsor” is the actual company that offers a plan, but the same company or sponsor may offer several different plans in the same state.) This is because with the cutback in plans, yours will no longer be available, but there is a similar one offered by your sponsor. You should clearly understand that the government has NOT made the best choice for you; it’s merely put you in the closest thing that you had. You definitely need to take action to make sure you get the best deal available to you.
And there is one fly in this ointment. Based on a provision in the Health Care Reform bill, for those of you who are already paying a high income premium surcharge for your Part B benefits, you will also in 2011 be hit with a high income premium surcharge for your Part D benefits. This will increase the cost of your Part D plan by, for a married couple earning more than $170,000 and a single person earning more than $85,000, anywhere from about $150 to $1,000 more per year. I will blog the details of this shortly.
And, for those of you who are in a Medicare Advantage Plan (Part C of Medicare), or are thinking of going into one, I'll blog about what you should be doing as we transition into 2011.
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