Late last year Susan Jaffe of the Kaiser Health News wrote an excellent article in The Washington Post (September 7, 2010) concerning a significant increase in the use of “observation services” by hospitals for Medicare beneficiaries. Of course, many patients who show up or who are brought to hospitals are treated and then held for observation, not only because the hospital physicians and staff need to be sure their diagnoses are correct and that the treatments are working, but also because they often know absolutely nothing about the patient when they arrive in the emergency room or at an outpatient clinic. So their being cautious is quite understandable. But, as Ms. Jaffe so clearly points out, this appears to have gotten out of hand; indeed, she cites the case of an 85-year old beneficiary who broke a number of ribs and was held in observation for six days! This was in spite of the fact that Medicare says observations stays should be limited to 24 hours, and, with rare exceptions, to 48 hours. And, as her article further points out, beneficiaries who are put in this limbo often do not understand that they have not been admitted as an inpatient, as they are assigned a bed and get one of those plastic bracelets and are fed their meals and seem to be regarded as any other inmate.
But from the beneficiary point-of-view, there are two big downsides to this whole trend. One of them is not what you will directly owe the hospital for your observation care. This is because although you are responsible for a Part B co-payment for your observation care, this is limited to the amount of the Part A inpatient deductible, that is, what you would have owed the hospital for your inpatient care if you had been admitted. So you are protected on your hospital bill whether or not you are admitted as an inpatient. [Well, mostly protected; see the note at the end of this posting.*]
But you will be liable for two other expenses, which can be huge. In Medicare, recall that your Skilled Nursing Facility (SNF) care is covered only if you were admitted to a hospital as an inpatient for at least three days. So if you get put in “observation care,” no matter how long you are there, you will NOT qualify for Medicare to cover your Skilled Nursing Facility care if you go to one of these facilities after your hospital treatment. (While some of your care there may be covered, that is, your Part B will have to pay for “ancillary services” such as physical or occupational therapy, your basic room and board charges, which are the big part of the bill, will not be covered at all.) In Ms. Jaffe’s article, she points out that the beneficiary ended up owing well over $10,000 out-of-pocket to a Skilled Nursing Facility.
The Centers for Medicare & Medicaid Services has begun to realize that this is quite a problem, and is working on it. Perhaps they will issue a requirement that hospitals give beneficiaries in observation status an “Advanced Beneficiary Notice” clearly telling them that their care is covered under Part B and not Part A and what the implications of this are. But unless there is a way to instantly appeal this, I’m not sure where it leaves the beneficiary. Probably still in limbo.
My only suggestion at this point is that if your are put into a protracted observation status at a hospital, and you think you should be admitted, immediately call, or have a family member or caregiver call, your Quality Improvement Organization (QIO) and formally complain to them about the quality of care you are receiving. Perhaps they can intervene. These outfits are discussed on page 215 of Managing Your Medicare; you can get your organization’s number by calling the 1-800-MEDICARE number or by going on www.medicare.gov.
And while this will not help you while you are in the hospital, you can always appeal your Medicare Summary Notice about the hospital observation services, and insist that you should have been admitted as an inpatient. If you are successful, you can demand that any subsequent Skilled Nursing Facility also be covered by Medicare. The Center for Medicare Advocacy, a strong proponent of beneficiary rights, has excellent suggestions on its website www.medicareadvocacy.org on how to do this. It advises that you may need help from an organziation such as itself or from your State Health Insurance Counseling Program (SHIP).
The other liability arises when, while you are in observation status, you have to take prescription drugs you take everyday, and which may have nothing to do with your being at the hospital. You may have neglected to take your drugs with you, or perhaps the hospital wouldn’t let you take what you did bring. Or perhaps you have to take a prescription that you have but which you don’t usually take everyday. In cases where the hospital gives you these drugs, you will be in a bind as generally Part B will not pay for self-administered drugs in a hospital outpatient setting unless they are part of the hospital’s therapy. And so the hospital will bill you, and not Medicare, for these drugs.
If you have Part D, your drug plan MAY pay for what the hospital billed you. Particularly because most hospital pharmacies do NOT participate in Part D, the hospital will likely bill you for these drugs, you will have to pay them, and you should submit the bills to your Part D plan. You can call them to find out how to do this. Your plan may inquire about the reasons for your hospital visit, or if you could have gotten the medicine in another way, or from an in-network pharmacy. If your drug plan does reimburse you, it will probably be only at the level that it would have paid if you got the medicine at a network pharmacy, taking Part D deductibles, coinsurance and co-payments into account. The amount it establishes will count toward your Part D true out-of-pocket costs (TrOOP).
This issue has become such a problem that the Centers for Medicare & Medicaid Services had a “tip sheet” about it. You can download it, “How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings,” CMS Product No. 11333 (January. 2010), from their website, www.medicare.gov.
Perhaps the “moral of this story” is that you should always try to have a small supply of your prescription drugs with you, and your schedule for taking them, with you. And while this perhaps this can’t be done in all emergencies, it is just a good habit. For example, recently I was unexpectedly stranded overnight in an airport due to a flight cancellation; I was not happy that I did not have my meds with me.
I would be interested in any experiences you may have had with this issue. Please email me at managingyourmedicare@gmail.com.
[*Well, you are mostly protected. But you should also be aware that if you are not admitted, your Part A “benefit period” or “spell of illness” will not begin. Recall that once that happens, that is, you are admitted as an inpatient, you are liable for the Part A deductible of $1,132 (in 2011). And that’s all you pay for your first 60 days of hospital inpatient care. So, for example, if you are admitted as an inpatient, and then discharged, let’s say five days later, and you are readmitted four weeks later, your benefit period (spell of illness) is still in effect and you do NOT have to pay the inpatient deductible again. (Your benefit period or spell generally does not expire until you have been out of a hospital or a Skilled Nursing Facility for 60 days.) But, if you were held in observation status for four days and then released, and then readmitted four weeks later, but now as an inpatient, you would be liable not only for the Part B copayment for the observation stay, but also for the Part A deductible for the new, inpatient stay.]
Thursday, March 31, 2011
Tuesday, March 29, 2011
2011 Medicare Cheat Sheet
2011 Medicare Cheat Sheet
Years ago, when I worked for the Social Security Administration, and it ran the whole Medicare program, we would go out and give talks about Medicare. For ready reference, we would always keep a 3x5 index card in one hand, and on it we wrote all the numerical information that changed from year to year. It wasn’t much, usually the Part A inpatient hospital deductible would change, and the other Part A deductibles, and also the Part B premium, and rarely, the Part B deductible. But the point being, every variable could fit on one side of one little index card.
No more! Not only are there more Parts to Medicare now, but the program has become very, very complex. And with this, there are many, many variables which typically change from year to year, and which no one, and certainly not me, can easily remember. To help me, especially when I do counseling, I keep a “cheat sheet” which I update each year. And, to warn you, it’s six pages in an Excel spreadsheet! Goodbye index card!
You can access this by going to the CD that comes with Managing Your Medicare, clicking on the check for any updated forms and instructions link, and printing it out. I keep it color-coded not only to highlight the changes from last year to the current year, but also to help separate the many different topics it covers, and so I strongly recommend that you print it out in color. And note that the last two pages cover only Alaska and Hawaii, respectively, so you probably don’t need to print those pages unless you live in one of those two states. Helpful printing instructions are at the very end of the sheet.
Finally, you should be aware that the information for the next year starts coming out early in the current year, and various items for the next continue to be released as the current year goes along, and even into the next year. So I will begin posting the next year’s cheat sheet late in the current year, but it won’t be fully complete until early in the year it covers. At that point it will be named “Final Cheat Sheet for 2012,” or whatever the year is.
Years ago, when I worked for the Social Security Administration, and it ran the whole Medicare program, we would go out and give talks about Medicare. For ready reference, we would always keep a 3x5 index card in one hand, and on it we wrote all the numerical information that changed from year to year. It wasn’t much, usually the Part A inpatient hospital deductible would change, and the other Part A deductibles, and also the Part B premium, and rarely, the Part B deductible. But the point being, every variable could fit on one side of one little index card.
No more! Not only are there more Parts to Medicare now, but the program has become very, very complex. And with this, there are many, many variables which typically change from year to year, and which no one, and certainly not me, can easily remember. To help me, especially when I do counseling, I keep a “cheat sheet” which I update each year. And, to warn you, it’s six pages in an Excel spreadsheet! Goodbye index card!
You can access this by going to the CD that comes with Managing Your Medicare, clicking on the check for any updated forms and instructions link, and printing it out. I keep it color-coded not only to highlight the changes from last year to the current year, but also to help separate the many different topics it covers, and so I strongly recommend that you print it out in color. And note that the last two pages cover only Alaska and Hawaii, respectively, so you probably don’t need to print those pages unless you live in one of those two states. Helpful printing instructions are at the very end of the sheet.
Finally, you should be aware that the information for the next year starts coming out early in the current year, and various items for the next continue to be released as the current year goes along, and even into the next year. So I will begin posting the next year’s cheat sheet late in the current year, but it won’t be fully complete until early in the year it covers. At that point it will be named “Final Cheat Sheet for 2012,” or whatever the year is.
Thursday, March 24, 2011
Hurry, the 2011 General Enrollment Period Ends March 31
As we come upon March 31, beneficiaries without Part B who wish to get it must enroll by that date. You can do this by calling the Social Security Administration (1-800-772-1213). Your enrollment will not be effective until July 1, 2011. Your base premium will be $115.40 per month; if you get Social Security, this will automatically be deducted from your monthly payment. But remember that you are, as a late enrollee, subject to a penalty; it is 10% (or $11.50 a month) of the base premium for each 12 months you could have been enrolled but were not. (And, if you have a high income, generally $170,000 for a couple or $85,000 for an individual, you will also be subject to the high income surcharge. But the penalty applies only to the base premium, not to any surcharge.)
(For those very few of you who do not have Part A but can qualify for “Premium Part A”, you can also sign up now, with the same effective date. Your monthly premium will probably be $495.00, if you have fewer than 30 “quarters of coverage,” or $272.80, if you have at least 30.
If you do sign up for Part B and you also have had or get Part A, two important events occur:
If you are 65 or older, and this is the very first time you have Part B, you will have a guaranteed issue right to any Medigap policy sold in your area beginning July 1st. This is true no matter how much older than 65 you are, although there may be some temporary preexisting condition exclusions. This is the federal law; your state may have additional protections. This right exists for only six months, so act before December 31.
For a beneficiary of any age (but not if you have End Stage Renal Disease), you also may, effective with July 1st, join a Medicare Advantage Plan as you now have both Part A and Part B, a requirement to join such a Plan. You must sign up within three months of July 1, that is, by September 30. You may not, in doing this, change your Part D status. If you don’t have Part D, you must sign up for a Plan which does not offer it; if you do have Part D, you can either do that and keep your current Part D stand-alone plan, or you can join any Plan which does include Part D coverage.
So act quickly if you want to enroll in more of Medicare! Call Social Security by Friday, March 31 and don’t wait ‘til the last minute. More detailed information on all these topics is available in Managing Your Medicare.
And, as I blogged on January 9, when enroll in Part B you know you will get it on July 1, so aggressively begin to schedule all applicable preventive and educational services beginning with that date, as these are all Part B services. It may take you months to schedule your “Welcome to Medicare” exam with your physician, so begin lining it up as soon as you enroll. Same for all the other preventive and educational services. My blog of November 29, 2010 explains everything available in 2011. And go over chapter 4 of Managing Your Medicare to see what else Part B covers. Perhaps you have put off some physical therapy that you really need, or some mental health services; line these up, too.
(For those very few of you who do not have Part A but can qualify for “Premium Part A”, you can also sign up now, with the same effective date. Your monthly premium will probably be $495.00, if you have fewer than 30 “quarters of coverage,” or $272.80, if you have at least 30.
If you do sign up for Part B and you also have had or get Part A, two important events occur:
If you are 65 or older, and this is the very first time you have Part B, you will have a guaranteed issue right to any Medigap policy sold in your area beginning July 1st. This is true no matter how much older than 65 you are, although there may be some temporary preexisting condition exclusions. This is the federal law; your state may have additional protections. This right exists for only six months, so act before December 31.
For a beneficiary of any age (but not if you have End Stage Renal Disease), you also may, effective with July 1st, join a Medicare Advantage Plan as you now have both Part A and Part B, a requirement to join such a Plan. You must sign up within three months of July 1, that is, by September 30. You may not, in doing this, change your Part D status. If you don’t have Part D, you must sign up for a Plan which does not offer it; if you do have Part D, you can either do that and keep your current Part D stand-alone plan, or you can join any Plan which does include Part D coverage.
So act quickly if you want to enroll in more of Medicare! Call Social Security by Friday, March 31 and don’t wait ‘til the last minute. More detailed information on all these topics is available in Managing Your Medicare.
And, as I blogged on January 9, when enroll in Part B you know you will get it on July 1, so aggressively begin to schedule all applicable preventive and educational services beginning with that date, as these are all Part B services. It may take you months to schedule your “Welcome to Medicare” exam with your physician, so begin lining it up as soon as you enroll. Same for all the other preventive and educational services. My blog of November 29, 2010 explains everything available in 2011. And go over chapter 4 of Managing Your Medicare to see what else Part B covers. Perhaps you have put off some physical therapy that you really need, or some mental health services; line these up, too.
Tuesday, March 1, 2011
Part D Formulary Changes after March 1
After March 1, 2011, drug plans can make “negative” changes to their formularies during most of the remainder of the year. By negative changes we mean they can remove a drug from their formulary, that is, no longer cover it; or remove a particular dosage of a drug from their formulary; or they can change a drug from one price tier to another tier where a beneficiary has to pay more; or they can impose utilization controls (such as step therapy) which had not previously been in place. In other words, “negative” changes are those which either restrict a beneficiary from getting a drug, or which cause a drug to be more costly to a beneficiary. (Part D drug plans are always able to add drugs to their formulary, or put a drug in a lower cost tier, or remove utilization controls.)
And there is a general rule that a plan cannot actually make these negative changes until 60 days after giving notice of the change. The exceptions are that an immediate change can be made if the FDA issues a warning about a drug or if a manufacturer stops making a drug.
Some Medicare guidance talks about what a beneficiary’s rights are when these changes are made (“maintenance” vs. “non-maintenance” changes), but a beneficiary has no real way of knowing what kind of change has been made other than that their plan has to notify them of it if they are affected by it, and tell them what their rights are.
What is important is that some changes (the so-called “non-maintenance” changes) are not supposed to directly affect a beneficiary for the remainder of the calendar year in which they are made. So, for example, if you are taking a drug and your plan now decides (for its own reasons, and not, for example, because of an FDA warning) that it will require step therapy for it, you will not be affected as for the remainder of the year as this new requirement won’t apply to you. Nor will it apply to a beneficiary who first presents a prescription for the drug in the 60 days between when the plan announces the change and the change actually goes into effect. It will apply to a beneficiary in the plan that subsequently starts taking that drug after the change goes into effect.
(Importantly, if you stick with this plan for the next calendar year, you will then be subject to the change, but you, of course, will have to the opportunity, from October 15 to December 7, 2011 Note the new dates, the Annual Coordinated Election Period, which is sometimes called Fall Open Enrollment, is different this year. to switch plans in 2012. But what is a little tricky here is that your plan doesn’t have to notify you of the specific change if you are not affected by it, and so you may stick with your plan into the new year, when it will affect you. Again, this just reinforces the need for you to check your plan’s Annual Notice of Change you get in the fall to make sure that all your drugs will continue to be covered, or, even better, to go on Medicare’s Plan Compare feature and shop, each and every year, for the very best plan for you.)
The other changes (the so-called “maintenance” changes) will apply to you, but your plan has to give you a 60-day notice of what the change is before it goes into effect, and it has to allow you to have at least a 60-day supply of your drug. But from then on, you are subject to the change. So, for example, if a generic drug begins to be marketed, and your plan removes its brand name equivalent from its formulary, you have to get the notice 60 days before it actually does so, and your plan has to make sure you can get a 60-day supply of the brand name drug. The idea here is that the 60 days gives you time to check with your prescribing physician or health care provider about the change. And, if it is not suitable, the important paragraph below applies.
In these cases, because you are affected, your plan must tell you your rights. So in these cases you may ask for exception, which is really just another way of saying you can appeal. And this applies to any action which is negative to you: removal of a drug (or particular dosage of it) from their formulary; a change a drug from one price tier to another, higher tier; or the imposition of utilization controls. And the first appeals step is a “request for a drug coverage determination” in which you ask your plan for a formal decision on your request, in this case, for an exception.
Most beneficiary advocates prefer that you make your “request for a drug coverage determination” in writing; this is especially so because your prescribing physician or health care provider will have to endorse your exception request. You can easily download a form to so this on by searching for “Request for Medicare Prescription Drug Coverage Determination” on the net. Print this out and fill out all of it that you possibly can, and then take it to your prescriber to have them finalize it. They usually will fax it to the plan for you. Alternatively, you can ask your State Health Insurance Counseling Program (SHIP) to help you with this process. Their toll free phone number is on the back of your Medicare and You booklet.
If your plan’s decision is not acceptable to you, follow the rest of the appeals process as set out in Chapter 14 of “Managing Your Medicare.”
And there is a general rule that a plan cannot actually make these negative changes until 60 days after giving notice of the change. The exceptions are that an immediate change can be made if the FDA issues a warning about a drug or if a manufacturer stops making a drug.
Some Medicare guidance talks about what a beneficiary’s rights are when these changes are made (“maintenance” vs. “non-maintenance” changes), but a beneficiary has no real way of knowing what kind of change has been made other than that their plan has to notify them of it if they are affected by it, and tell them what their rights are.
What is important is that some changes (the so-called “non-maintenance” changes) are not supposed to directly affect a beneficiary for the remainder of the calendar year in which they are made. So, for example, if you are taking a drug and your plan now decides (for its own reasons, and not, for example, because of an FDA warning) that it will require step therapy for it, you will not be affected as for the remainder of the year as this new requirement won’t apply to you. Nor will it apply to a beneficiary who first presents a prescription for the drug in the 60 days between when the plan announces the change and the change actually goes into effect. It will apply to a beneficiary in the plan that subsequently starts taking that drug after the change goes into effect.
(Importantly, if you stick with this plan for the next calendar year, you will then be subject to the change, but you, of course, will have to the opportunity, from October 15 to December 7, 2011 Note the new dates, the Annual Coordinated Election Period, which is sometimes called Fall Open Enrollment, is different this year. to switch plans in 2012. But what is a little tricky here is that your plan doesn’t have to notify you of the specific change if you are not affected by it, and so you may stick with your plan into the new year, when it will affect you. Again, this just reinforces the need for you to check your plan’s Annual Notice of Change you get in the fall to make sure that all your drugs will continue to be covered, or, even better, to go on Medicare’s Plan Compare feature and shop, each and every year, for the very best plan for you.)
The other changes (the so-called “maintenance” changes) will apply to you, but your plan has to give you a 60-day notice of what the change is before it goes into effect, and it has to allow you to have at least a 60-day supply of your drug. But from then on, you are subject to the change. So, for example, if a generic drug begins to be marketed, and your plan removes its brand name equivalent from its formulary, you have to get the notice 60 days before it actually does so, and your plan has to make sure you can get a 60-day supply of the brand name drug. The idea here is that the 60 days gives you time to check with your prescribing physician or health care provider about the change. And, if it is not suitable, the important paragraph below applies.
In these cases, because you are affected, your plan must tell you your rights. So in these cases you may ask for exception, which is really just another way of saying you can appeal. And this applies to any action which is negative to you: removal of a drug (or particular dosage of it) from their formulary; a change a drug from one price tier to another, higher tier; or the imposition of utilization controls. And the first appeals step is a “request for a drug coverage determination” in which you ask your plan for a formal decision on your request, in this case, for an exception.
Most beneficiary advocates prefer that you make your “request for a drug coverage determination” in writing; this is especially so because your prescribing physician or health care provider will have to endorse your exception request. You can easily download a form to so this on by searching for “Request for Medicare Prescription Drug Coverage Determination” on the net. Print this out and fill out all of it that you possibly can, and then take it to your prescriber to have them finalize it. They usually will fax it to the plan for you. Alternatively, you can ask your State Health Insurance Counseling Program (SHIP) to help you with this process. Their toll free phone number is on the back of your Medicare and You booklet.
If your plan’s decision is not acceptable to you, follow the rest of the appeals process as set out in Chapter 14 of “Managing Your Medicare.”
2011 Income Amounts for the Part D Prescription Drug Low Income Subsidy or “Extra Help”
The federal government recently released the federal poverty income levels (FPLs) for 2011, and they have increased slightly over 2010 levels, which will probably enable some beneficiaries to qualify for “Extra Help,“ particularly because Social Security payments did not automatically increase for 2011. The Low Income Subsidy or Extra Help allows Medicare beneficiaries with low incomes and resources who enroll in Part D to qualify for full or partial payment of their premiums, deductibles and reduces their co-payments on drugs. Full payment of the premium is restricted to plan premiums which are at or below the “benchmark” premium for your state.) This is fully explained in Chapter 7 (which begins on page 99) of Managing Your Medicare. (Finally, these income amounts apply to the contiguous 48 states and the District of Columbia, the income levels (but not the resources levels) are higher for Alaska and Hawaii.)
Those who qualify for Extra Help at these levels will pay no premium, and will not be subject to the deductible, and the cost of their drugs will be as follows:
If you have Medicaid AND:
You live in a nursing home:
You pay nothing.
Your income is at or below $10,890 (individual) or $14,710 (couple):
You pay $1.10 for a generic or preferred brand, and $3.30 for a non- preferred brand.*
Your income is above $10,890 (individual) or $14,710 (couple)
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
You don't have Medicaid but your state helps you pay your Medicare premiums (that is, you are in the “Medicare Savings Program”) OR you get supplemental security income (SSI):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
You are not as above but qualify for Extra Help because of your income and resources levels as follows:
If your income is below $14,702 (individual) or $19,859 (couple) & resources are at or below $8,180 (individual) & $13,020 (couple):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
If your income is below $14,702 (individual) or $19,859 (couple) & resources are
at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible.**
If your income is at or below $15,246 (individual) or $20,594 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 25% of your premium.**
If your income is below $15,791 (individual) or $21,330 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 50% of your premium.**
If your income is below $16,335 (individual) or $22,065 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 75% of your premium.**
*If your “drug expenses” ever exceed $4,550 in 2011, you will pay nothing for any prescription.
**If your “drug expenses” in the year ever exceed $4,550 in 2011, you will pay not more than $2.50 for a generic or preferred brand, and $6.30 for a non-preferred brand.
Those who qualify for Extra Help at these levels will pay no premium, and will not be subject to the deductible, and the cost of their drugs will be as follows:
If you have Medicaid AND:
You live in a nursing home:
You pay nothing.
Your income is at or below $10,890 (individual) or $14,710 (couple):
You pay $1.10 for a generic or preferred brand, and $3.30 for a non- preferred brand.*
Your income is above $10,890 (individual) or $14,710 (couple)
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
You don't have Medicaid but your state helps you pay your Medicare premiums (that is, you are in the “Medicare Savings Program”) OR you get supplemental security income (SSI):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
You are not as above but qualify for Extra Help because of your income and resources levels as follows:
If your income is below $14,702 (individual) or $19,859 (couple) & resources are at or below $8,180 (individual) & $13,020 (couple):
You pay $2.50 for a generic or preferred brand, and $6.30 for a non- preferred brand.*
If your income is below $14,702 (individual) or $19,859 (couple) & resources are
at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible.**
If your income is at or below $15,246 (individual) or $20,594 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 25% of your premium.**
If your income is below $15,791 (individual) or $21,330 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 50% of your premium.**
If your income is below $16,335 (individual) or $22,065 (couple) & resources are at or below $12,640 (individual) & $25,260 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $63 annual deductible, and you must pay 75% of your premium.**
*If your “drug expenses” ever exceed $4,550 in 2011, you will pay nothing for any prescription.
**If your “drug expenses” in the year ever exceed $4,550 in 2011, you will pay not more than $2.50 for a generic or preferred brand, and $6.30 for a non-preferred brand.
2011 Income Levels for Medicare Savings Programs
The federal government recently released the official federal poverty levels or “FPLs” for 2011. These income levels are key in two areas of Medicare. Here we discuss their effect on the Medicare Savings Programs, sometimes abbreviated as “MSP.” These are discussed in full beginning on page 16 of Managing Your Medicare. A separate posting will be made of the other key area, the Low Income Subsidy for Part D, also known as “Extra Help.”
Remember that you apply for the Medicare Savings Programs with your state’s Medicaid program, and that the resources you are permitted to have and still qualify have not changed in many years and are usually shown as $6,600 for an individual and $9,910 for a couple, but there are many exceptions and disregards both for resources, and for the income limits given below.
As the new income limits are different in both Alaska and Hawaii from the rest of the United States, in makes sense to give the 2011 income limits in three separate segments, as follows:
For the lower 48 states and the District of Columbia:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $10,890 annually, or $908 monthly.
For a couple, $14,710 annually, or $1,226 monthly.
For each additional person in a family, add $3,820 annually, or $318 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $13,068 annually, or $1,089 monthly.
For a couple, $17,652 annually, or $1,471 monthly.
For each additional person in a family, add $4,584 annually, or $382 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $14,702 annually, or $1,225 monthly.
For a couple, $19,859 annually, or $1,665 monthly.
For each additional person in a family, add $5,157 annually, or $430 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $21,780 annually, or $1,815 monthly.
For a couple, $29,420 annually, or $2,452 monthly.
For each additional person in a family, add $7,640 annually, or $637 monthly.
For Alaska:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $13,600 annually, or $1,133 monthly.
For a couple, $18,380 annually, or $1,532 monthly.
For each additional person in a family, add $4,780 annually, or $398 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $16,320 annually, or $1,360 monthly.
For a couple, $22,056 annually, or $1,838 monthly.
For each additional person in a family, add $5,736 annually, or $478 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $18,360 annually, or $1,530 monthly.
For a couple, $24,813 annually, or $2,068 monthly.
For each additional person in a family, add $6,453 annually, or $538 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $27,200 annually, or $2,267 monthly.
For a couple, $36,760 annually, or $3,063 monthly.
For each additional person in a family, add $9,560 annually, or $797 monthly.
For Hawaii:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $12,540 annually, or $1,045 monthly.
For a couple, $16,930 annually, or $1,411 monthly.
For each additional person in a family, add $4,390 annually, or $366 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $15,048 annually, or $1,254 monthly.
For a couple, $20,316 annually, or $1,693 monthly.
For each additional person in a family, add $5,268 annually, or $439 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $16,929 annually, or $1,411 monthly.
For a couple, $22,856 annually, or $1,905 monthly.
For each additional person in a family, add $5,927 annually, or $494 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $25,080 annually, or $2,090 monthly.
For a couple, $33,860 annually, or $2,822 monthly.
For each additional person in a family, add $8,780 annually, or $732 monthly.
Note on resources: Technically, the resource limits for these programs are $4,000 for an individual and $6,000 for a couple, but because of disregards and exceptions, they are usually shown as $6,600 and $9,910, respectively. Again, the best advice is, because of disregards and exceptions, not to speak of differing states’ interpretations and waivers, if a beneficiary is ANYWHERE near the income and resource limits, they should apply for these programs.
Remember that you apply for the Medicare Savings Programs with your state’s Medicaid program, and that the resources you are permitted to have and still qualify have not changed in many years and are usually shown as $6,600 for an individual and $9,910 for a couple, but there are many exceptions and disregards both for resources, and for the income limits given below.
As the new income limits are different in both Alaska and Hawaii from the rest of the United States, in makes sense to give the 2011 income limits in three separate segments, as follows:
For the lower 48 states and the District of Columbia:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $10,890 annually, or $908 monthly.
For a couple, $14,710 annually, or $1,226 monthly.
For each additional person in a family, add $3,820 annually, or $318 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $13,068 annually, or $1,089 monthly.
For a couple, $17,652 annually, or $1,471 monthly.
For each additional person in a family, add $4,584 annually, or $382 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $14,702 annually, or $1,225 monthly.
For a couple, $19,859 annually, or $1,665 monthly.
For each additional person in a family, add $5,157 annually, or $430 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $21,780 annually, or $1,815 monthly.
For a couple, $29,420 annually, or $2,452 monthly.
For each additional person in a family, add $7,640 annually, or $637 monthly.
For Alaska:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $13,600 annually, or $1,133 monthly.
For a couple, $18,380 annually, or $1,532 monthly.
For each additional person in a family, add $4,780 annually, or $398 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $16,320 annually, or $1,360 monthly.
For a couple, $22,056 annually, or $1,838 monthly.
For each additional person in a family, add $5,736 annually, or $478 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $18,360 annually, or $1,530 monthly.
For a couple, $24,813 annually, or $2,068 monthly.
For each additional person in a family, add $6,453 annually, or $538 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $27,200 annually, or $2,267 monthly.
For a couple, $36,760 annually, or $3,063 monthly.
For each additional person in a family, add $9,560 annually, or $797 monthly.
For Hawaii:
For the Qualified Medicare Beneficiary (QMB) program (which pays your Part B monthly premium, your annual deductibles and your Part B coinsurances), your income must be at or below 100 percent of the federal poverty level, which is now:
For an individual, $12,540 annually, or $1,045 monthly.
For a couple, $16,930 annually, or $1,411 monthly.
For each additional person in a family, add $4,390 annually, or $366 monthly.
For the Specified Low-Income Medicare Beneficiary (SLMB) program (which pays your Part B monthly premium), your income must be at or below 120 percent of the federal poverty level, which is now:
For an individual, $15,048 annually, or $1,254 monthly.
For a couple, $20,316 annually, or $1,693 monthly.
For each additional person in a family, add $5,268 annually, or $439 monthly.
For the Qualified Individual (QI) program (which pays your Part B monthly premium), your income must be at or below 135 percent of the federal poverty level, which is now:
For an individual, $16,929 annually, or $1,411 monthly.
For a couple, $22,856 annually, or $1,905 monthly.
For each additional person in a family, add $5,927 annually, or $494 monthly.
For the Qualified Disabled & Working Individuals (QDWI) program (which pays your Part A monthly premium), your income must be at or below 200 percent of the federal poverty level, which is now:
For an individual, $25,080 annually, or $2,090 monthly.
For a couple, $33,860 annually, or $2,822 monthly.
For each additional person in a family, add $8,780 annually, or $732 monthly.
Note on resources: Technically, the resource limits for these programs are $4,000 for an individual and $6,000 for a couple, but because of disregards and exceptions, they are usually shown as $6,600 and $9,910, respectively. Again, the best advice is, because of disregards and exceptions, not to speak of differing states’ interpretations and waivers, if a beneficiary is ANYWHERE near the income and resource limits, they should apply for these programs.
Special Election Period for Beneficiaries Who Lost Part D Prescription Drug Coverage on January 1, 2011 Because their Plan Left the Medicare Program
The Centers for Medicare & Medicaid Services has extended a special election period for Medicare beneficiaries whose Part D prescription drug coverage ended with December 31, 2010, either because their stand-alone prescription drug plan (PDP) or their Medicare Advantage Plan with prescription drug coverage (MA-PD) left the Medicare program on January 1, 2011. These beneficiaries now have until February 28, 2011 to sign up for either a Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MA-PD). Beneficiaries who do this will be enrolled effective with March 1, 2011. You can call 1-800-MEDICARE to do this.
Special Election Period Prescription Drug Coverage Part D
Special Election Period Prescription Drug Coverage Part D
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