The Part D Low Income Subsidy (“Extra Help”) in 2015

 

Requirements to Become Eligible for Extra Help

This reviews the two main requirements for the Part D low income subsidy (LIS), that is, “Extra Help,” and also indicates what the basic structure of the Part D benefit looks like for those who qualify for it during 2015.  The two main requirements are, of course, low income and few resources.

At this point in time (October 2014) you can qualify for Extra Help if your income is at or below $17,505 AND your resources are at or below $13,440 for an individual; or if your income is at or below $23,595 AND your resources are at or below $26,860 for a couple.  Remember that neither your home nor your car or vehicle count as resources.  And it has been said a thousand times before, but bears repeating, if your income or resources are ANYWHERE near these limits, apply, because there are many, complex rules as to what counts as income and what counts as resources, and as to how these are calculated if additional people live in your household.  (And note that all the income levels are higher in the states of Hawaii and Alaska than we show here.)

All this is fully explained in Chapter 7 (which begins on page 99) of Managing Your Medicare.

Be aware that as we move forward, new limits for 2015 will be announced for both the resource levels and the income levels.  The new resource levels are typically announced in the Fall, and the new income levels, in late January.  I will update this text as these new amounts are issued by the government.

The income and resources levels shown below are the ones which are currently being used to determine eligibility, but the amounts for what Extra Help will cover are those which will go into effect on January 1, 2015.  And to summarize before we get into the details, if you do qualify for Extra Help, it will pay all or part of your Part D monthly premium, all or part of your annual deductible, and will eliminate or reduce your 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.  The benchmark premiums for each state for 2015 are shown the end of this text.)  The specifics are as follows:


Basic Structure of the Extra Help Benefit in 2015

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 or are in a community-based waiver program:
You pay nothing.

Your income is at or below $11,670 (individual) or $15,730 (couple):
You pay $1.20 for a generic or preferred brand, and $3.60 for a non-preferred brand.*

Your income is above $11,670 (individual) or $15,730 (couple):
You pay $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand.*


If 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 $2.60 for a generic or preferred brand, and $6.60 for a non-preferred brand.*

If you are not in the categories above, but you qualify for Extra Help because your income and resources levels are as shown below, the cost of your drugs will be as follows, and you will be subject to an annual deductible and monthly premium payments as follows:

If your income is below $15,755 (individual) or $21,236 (couple) & resources are at or below $8,660 (individual) or $13,750 (couple):
You pay $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand.* You pay neither a premium nor a deductible.

If your income is below $15,755 (individual) or $21,236 (couple) & resources are at or below $13,440 (individual) or $26,860 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible.** You pay no premium.

If your income is at or below $16,338 (individual) or $22,022 (couple) & resources are at or below $13,440 (individual) or $26,860 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 25% of your premium.**

If your income is below $16,922 (individual) or $22,809 (couple) & resources are at or below $13,440 (individual) or $26,860 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 50% of your premium.**

If your income is below $17,505 (individual) or $23,595 (couple) & resources are at or below $13,440 (individual) or $26,860 (couple):
You pay 15% of the cost of your drugs, plus you are subject to a $66 annual deductible, and you must pay 75% of your premium.**


*If your “drug expenses” ever exceed $4,700 in 2015, you will pay nothing for any prescription. (These are “Full Subsidy” beneficiaries.)

**If your “drug expenses” in the year ever exceed $4,700 in 2015, you will pay not more than $2.65 for a generic or preferred brand, and $6.60 for a non-preferred brand. (These are “Partial Subsidy” beneficiaries.)

Note on resource limits: Technically, the resource limits are $7,160 for an individual and for $10,750 a couple for “Full Subsidy” beneficiaries, and $11,940 for an individual and $23,860 for a couple for “Partial Subsidy” beneficiaries.  However, in practice, when determining resources for Extra Help, the Social Security Administration allows a burial expense allowance of $1,500 for an individual or $3,000 for a couple, so these resource limits are almost always shown as $8,660 for an individual and $13,750 for a couple for “Full Subsidy” beneficiaries, and $13,440 for an individual and $26,860 for a couple for “Partial Subsidy” beneficiaries, and these are the limits shown above.


Benchmark Premiums for 2015

This is the most that Extra Help will pay for a premium in each state.  If you choose a Part D drug plan with a monthly premium higher than this, you will have to pay all of the difference between these amounts and the premium.  (Note that, depending on a plan’s formulary and pricing structure, this might possibly be cheaper for an Extra Help beneficiary than choosing a plan whose premium is below the benchmark.)

Alabama $30.20; Alaska $32.90; Arizona $32.90; Arkansas $24.80; California $28.80; Colorado $28.90; Connecticut $29.60; Delaware $30.60; District of Columbia $30.60; Florida $25.80; Georgia $26.50; Hawaii $27.90; Idaho $39.70; Illinois $28.20; Indiana $31.80; Iowa $30.00; Kansas $30.30; Kentucky $31.80; Louisiana $31.30; Maine $29.60; Maryland $30.60; Massachusetts $29.60; Michigan $31.50; Minnesota $30.00; Mississippi $29.30; Missouri $28.30; Montana $30.00; Nebraska $30.00; Nevada $24.20; New Hampshire $29.60; New Jersey $37.60; New Mexico $21.20; New York $36.90; North Carolina $29.30; North Dakota $30.00; Ohio $28.60; Oklahoma $30.00; Oregon $33.80; Pennsylvania $33.90; Rhode Island $29.60; South Carolina $28.80; South Dakota $30.00; Tennessee $30.20; Texas $27.30; Utah $39.70; Vermont $29.60; Virginia $29.50; Washington $33.80; West Virginia $33.90; Wisconsin $35.30; Wyoming $30.00.

(Note: In 2015 a Prescription Drug Plan may voluntarily elect to waive up to $2.00 over on the premium of a “Full Subsidy” Extra Help beneficiary as long as this is done for all such beneficiaries.  This is why you may see a plan charge a $0 premium for an LIS beneficiary but it has a standard premium slightly above the LIS benchmark premiums shown above.  This is the so called “de minimis rule.”  Plans may not waive this for “Partial Subsidy” beneficiaries, that is, Extra Help beneficiaries who have to pay part of their Part D premiums.)

 

PART D FOR 2015

Get Ready Now for Medicare Open Enrollment - Part D Changes for 2015

It’s less than two weeks to Medicare Open Enrollment, so it’s time for you to get familiar with what will change in 2015 and what you need to do now to prepare for it.

Of extreme importance is that the Annual Election Period (the open enrollment period) will begin on Wednesday, October 15 and will run only until Sunday, December 7 of 2014.  So if you want to change your plan, do so in this time frame.  If you do change, it will be effective on Thursday, January 1, 2015.

 

Preparing to Review Your Part D Coverage

One thing that you ought to do now to prepare for this is to make sure that to the extent possible you are on the right drugs and dosages.  So, for example, if you were planning to visit your physician to check on a condition you have, or if you are scheduled for a lab test to determine if a drug you are taking is working properly, you should be sure to do these now, so if you have to change your prescriptions in any way, you will know this before you go to determine which Part D plan is best for you in the coming year.  Or, if you are eligible for the annual wellness visit, do that now, so if anything comes up, and you are put on a new medicine, you will know what it is, and take it into account when selecting a Part D plan.

And be sure to update your personal list of drugs you take so it’s completely up-to-date.  While this list is critical in using Medicare’s plan finder to get you the best drug plan, you should always have such a list with you so you can show it to any health professional when you visit them, or if you have a medical emergency, your caregivers can quickly learn what drugs you are on.

Part D Premiums

The actuaries at the Centers for Medicare & Medicaid Services (CMS) recently released information about some of the costs that beneficiaries will experience in Part D of the Medicare program in 2015.  This indicates that the monthly premiums for Part D plans will increase slightly in 2015.  And so if your plan’s premium does increase, and especially if it goes up significantly, you may be able to find a drug plan for 2015 that will cost about what you are now paying in premiums.  Just remember that every year you should take advantage of the annual open enrollment period to search for the best Part D deal you can get – taking into consideration not only your monthly premiums, but also deductibles, co-payments, the plan’s formulary, the restrictions it places on individual drugs in its formulary, preferred pharmacies, mail order options, etc.

Discounts in the “Donut Hole”

In 2015 the discounts you will get if you go into the “donut hole” will increase both for brand name and for generic drugs.  Specifically, the discount on brand name drugs will increase to 55% (from 52.5% in 2014), and that for generic drugs will increase to 35% (from 28% in 2014).  So, in effect, the donut hole will close a little bit more in 2015.

The 2015 Part D Benefit Structure – Some Helpful Changes from 2014

And although the changes are not large, for 2015 there are increases in the annual deductible, the initial coverage limit, etc., which will increase costs for many beneficiaries.  But, as detailed above, if you do go into the donut hole, in 2015 Part D will pay a bit more for your brand name drugs and somewhat more for your generic drugs than in 2014.  So my guess is, even though premiums will average a tad higher than they were in 2015, most beneficiaries will be paying, for their overall Part D benefit, just a bit more in 2015 than in 2014.

In 2015 the four bands of the recommended benefit structure are as follows: (Remember that your plan’s structure, or that of any plan that you are considering, may look very close to this or not at all like it, because plans are allowed to vary from this as long as their structure is “actuarially equivalent” to it.)

Annual Deductible Band: From $0 to $320

The recommended deductible is $320, up $10 from 2014.  The beneficiary is responsible to pay all of this out-of-pocket.  Of course, many plans will have a smaller or no deductible.

25% Coinsurance Band: From $320 to $2,640

After the deductible is satisfied, the next $2,640 of drug costs falls into this band.  The plan will pay 75% of the cost of a drug, and the beneficiary, 25%.  The beneficiary will remain in this band until the plan has paid a total of a $1,980 and the beneficiary, $660.

At this point, the beneficiary has spent $980 ($320 plus $660) and the plan, $1,980, for a total of $2,960.  (You may see this figure referred to as the “initial coverage limit;” it is up by $110 compared to the 2014 limit of $2,850.) The beneficiary now goes into the “donut hole.”

Donut Hole Band: From $2,960 to “Drug Expenses” of $4,700

Once in the donut hole, also known as the “coverage gap:”

For brand name drugs, the plan will pay 55% of the cost of a drug, and the beneficiary, 45%. (These figures were 52.5% and 47.5% in 2014, so the beneficiary gets a slightly better deal.)

For generic drugs, the government will pay 35% and the beneficiary, 65%. (In 2014 the government paid 28% and the beneficiary, 72%, so the beneficiary gets a better deal.)

The beneficiary will remain in the donut hole until their “drug expenses” total $4,700 (this is up by $150 compared to $4,550 in 2014).  That is, the beneficiary will have to incur an additional $3,720 in “drug expenses” while in the donut hole.  But by “drug expenses” we mean anything the beneficiary spends to meet the deductible, anything they spend in the 25% band, and whatever the beneficiary spends in the donut hole, plus 50% of the 55% their plan “pays” for their brand name drugs in the donut hole – technically, the plan doesn’t “pay” this 50% – it’s a discount given by the manufacturer – and this discount counts toward “drug expenses.”  (The extra 5%, which the plan actually pays, does not count, nor does the 35% which is paid by the government for generics.)

 
And while it will be different for each beneficiary, I estimate that in general you will actually pay somewhat over $2,000 of your own money on your Part D drugs before you get out of the donut hole and into the next band.

Catastrophic Band: From $4,700 Up

And once a beneficiary’s “drug expenses” reach $4,700, the beneficiary goes into the Catastrophic Band, where the beneficiary pays 5% of the cost of a drug, and the plan, 95%. This is sometimes called the “5% Band” for obvious reasons.  There are no upper limits to this band.  (This band started at $4,550 in 2014.)

And be advised that there have been tiny changes made to the minimum amount you must pay in this Catastrophic Band.  The minimum you must pay on a generic or preferred multi-source drug is $2.65 (up a dime from 2014), and, for other drugs (typically a brand-name) is $6.60 (up a quarter from 2014).

 

Late Enrollment Penalty (LEP)

 

Some other information the actuaries released include what the monthly premium late enrollment penalty will be.  This changes each year, and generally applies to those beneficiaries who did not sign up at their first opportunity to get Part D.  (If they had “credible coverage” it does not apply, nor does it apply to those beneficiaries who get “Extra Help.”)  The penalty in 2015 will be $0.3313 for each month that you could have had Part D coverage but did not.  This is slightly higher than the current 2014 penalty of $0.3242.  These penalties are added to your plan’s monthly premium amount and are collected with your plan’s premium.
High-Income Surcharge

The number-crunchers also have calculated the so-called high “income related Medicare adjustment amounts,” also known by their acronym “IRMAA,” and which I have always called the Part D premium surcharges.  If you are subject to this, the amounts will increase modestly in 2015.  More specifically, you will be subject to this if your 2013 adjusted gross income plus your tax-free interest exceeds $170,000 for a couple filing jointly or $85,000 for an individual or a married person filing separately.  (Your adjusted gross income plus your tax-free interest is called your “Modified Adjusted Gross Income,” or MAGI.)  Be aware that the health care reform legislation de-indexed these amounts (They used to rise with inflation.), so it’s possible that if your income in 2013 was higher than in 2012, you may first be subject to this in 2015.  (And remember that if you are subject to these for Part D, you will also be subject to the much higher Part B premium surcharge, if you have Part B.  The Part B premium amounts and surcharges have not yet been announced for 2015.)

The actual amounts that will be in effect for 2015 are:

FOR COUPLES FILING JOINTLY:

If your 2013 joint income was over $170,000 and less than or equal to $214,000, your monthly surcharge is $12.30, up $0.20 from 2014.

If your 2013 joint income was over $214,000 and less than or equal to $320,000, your monthly surcharge is $31.80, up $0.70 from 2014.

If your 2013 joint income was over $320,000 and less than or equal to $428,000, your monthly surcharge is $51.30, up $1.10 from 2014.

If your 2013 joint income was over $428,000, your monthly surcharge is $70.80, up $1.50 from 2014.

(Remember that these are the rates for each beneficiary with Part D, so if you and your spouse are both enrolled in it, you each have to pay this monthly surcharge.)

FOR MARRIED PERSONS FILING SEPARATELY:

If your 2013 income was over $85,000 and less than or equal to $129,000, your monthly surcharge is $51.30, up $1.10 from 2014.

If your 2013 income was over $129,000, your monthly surcharge is $70.80, up $1.50 from 2014.

FOR INDIVIDUALS:

If your 2013 income was over $85,000 and less than or equal to $107,000, your monthly surcharge is $12.30, up $0.20 from 2014.

If your 2013 income was over $107,000 and less than or equal to $160,000, your monthly surcharge is $31.80, up $0.70 from 2014.

If your 2013 income was over $160,000 and less than or equal to $214,000, your monthly surcharge is $51.30, up $1.10 from 2014.

If your 2013 income was over $214,000, your monthly surcharge is $70.80, up $1.50 from 2014.

These surcharges are not collected by your drug plan, but by the government, and you get them deducted from your Social Security, Railroad Retirement, or Federal Civil Service monthly payment; otherwise Medicare will bill you quarterly for them.

Enrollment Periods

Medicare beneficiaries will shortly begin receiving their Medicare & You 2015 booklets in the mail, or electronically if they signed up for this option.  Again, this signals that the open enrollment period will soon begin, on October 15, and will end with December 7.

And, as happens each year, a 5-Star Special Enrollment Period (SEP) will open on Monday, December 8 and will be continuously open from then and throughout 2015.  This will allow a Medicare beneficiary to sign up for a 5-Star Medicare Advantage and / or a 5-Star Part D drug plan.  A beneficiary can enroll in a 5-Star Medicare Advantage and / or a 5-Star Part D drug plan whether they are in Original Medicare or are already in a Medicare Advantage and / or a Part D drug plan.  A beneficiary can enroll beginning on December 8, 2014 and any day thereafter, and their enrollment will be effective with the first day of the month following their enrollment.  Also, a beneficiary enrolled in a plan with a 5-Star overall rating may also switch to a different plan with a 5-Star overall rating.  A beneficiary can use this Special Enrollment Period only once for an enrollment effective in 2015.  Note that achieving this rating is difficult, so it likely that you won’t have a 5-Star option available to you in your area.

Warning: A beneficiary in an Medicare Advantage only plan or in a Medicare Advantage plan with Part D coverage who switches to a stand-alone Part D prescription drug plan (PDP) with a 5-Star overall rating will lose Medicare Advantage coverage and will revert to Original Medicare for basic hospital and medical coverage.

 

Changes in Medicare Deductibles, Premiums, etc. for 2014 - Parts B, A, C, D

Part B

Most of the Medicare annual change amounts have been released for 2014, and the good news is that the Part B premium and deductible will not change.  That is, the Part B monthly premium will stay at $140.90, and the annual deductible at $147.  This is particularly nice for beneficiaries as your Social Security cost-of-living increase will only be 1.5%, but none of this rather modest increase will be eaten up by any rise in your Part B premium.

For those of you who have to pay a High Income Part B Premium Surcharge, your monthly surcharge will not change.  And while only about 5% of beneficiaries must pay these surcharges, remember that the base income amounts (the so-called modified adjusted gross income, or MAGI) which determine if you are subject to this stay the same from year to year, so some few of you who don’t pay this in 2013 may have to in 2014.  (If so, you should have been informed of this by the Social Security Administration by now.)  And also remember that your 2014 surcharge will be based on your 2012 income, and this may put you in a higher or lower surcharge bracket, or may put you into or out of having to pay a surcharge at all.  (Again, you should have been informed of this by Social Security by now.)

And the Part B coinsurance rate for outpatient mental health services will decrease to 20% in 2014.  That is, the coinsurance for these services will, beginning in 2014, be the same as for the other Part B services subject to coinsurance.  So in this respect will now be parity between all Part B services – mental or physical – for the first time since the program began.

Part A

The Part A inpatient hospital deductible goes up by $32 in 2014 to $1,216. This is the amount you are responsible for the first 60 days of an inpatient stay.  And, of course, the various other Part A co-pays have modest increases.  For longer hospital stays (from 61 to 90 days), the daily co-pay will be $304 (up $8); for even longer hospital stays (over 90 days), the daily co-pay will be $608 (up $16); and the daily co-pay for long skilled nursing facility (SNF) stays (from 21 to 100 days) will be $152 (up $4).

Those relatively very few of beneficiaries who pay for their Part A will welcome the news that their monthly premiums will again decrease in 2014.  The Part A premium for those currently paying $441 a month will decrease $15 a month to $426, and for those paying $243, it will go down $9 to $234 a month.

Part C

The Centers for Medicare & Medicaid Services reports that in Part C – Medicare Advantage or Medicare managed care – the premiums have gone up, on average, about 5% for 2014, or about $1.60 a month, quite modest.  But your current plan’s may have changed more, and always remember that you need to do your homework every year to see if you are in the best plan for you.  Or, if you are in Original Medicare, you may wish to consider joining a Medicare Advantage plan.  (For example, a lot of work has been done to improve Special Needs Plans, and to develop plans that work for dual Medicare-Medicaid beneficiaries.)  Remember that you mostly have only until Saturday, December 7, 2013 to join or change plans, that is, the Annual Election Period or Open Enrollment lasts only until that date.

Several exceptions exist to this deadline. One is that if your plan is leaving the Medicare program; if so, this will occur effective with Wednesday, January 1, 2014.  In addition to the Annual Open Enrollment Period, you also have from the day after it ends, that is, Sunday, December 8, until Friday, February 28, 2014 to change.  But don’t wait; if you change during the Annual Open Enrollment, or after it ends but in December 2013, you will be in your new plan January 1, 2014, and so will not have a gap in Medicare Advantage coverage.  (Recall that if your plan leaves, you will be put into Original Medicare January 1, 2014 if you don’t opt for a Medicare Advantage plan.)  But if you enroll in a plan in January, you will be put into it effective February 1, 2014; if you enroll in February, you will be enrolled effective March 1, 2014.)

Another is that, if there is a plan with a five-star quality rating where you live (and there may not be one where you are), you can switch to it after Open Enrollment in 2013 and in any month in 2014 (except December). You will be enrolled in your new plan on the first of the month following the month in which you enroll.  But, if you have your Part D drug coverage with your current Medicare Advantage plan, and switch to a 5-star one which does not have Part D drug coverage, you will lose your drug coverage, and will not be able to get it back until January 1, 2015.

Finally, and Medicare doesn’t generally “advertise” this (for example, it’s not explained in the Medicare and You booklet), but beneficiaries who are enrolled in “low performing” Medicare Advantage plans will be given the opportunity to enroll in higher quality plans.  By “low performing” is meant any plan which has had an overall star rating of less than three stars for three years in a row.  The Centers for Medicare & Medicaid Services (CMS) sent notices in October to individuals enrolled in these plans informing them of their plan’s low rating and offering them an opportunity to request a special enrollment period (SEP) to move into a higher quality plan for 2014.  They can do this any time after the Open Enrollment and in any month in 2014 (except December).  And they can only make this enrollment by calling the 1-800-MEDICARE number.  But, if you have your Part D drug coverage with your current Medicare Advantage plan, and switch to a better one which does not have Part D drug coverage, you will lose your drug coverage, and will not be able to get it back until January 1, 2015.

And for those of you who want to disenroll from a Medicare Advantage plan, you may drop your plan and go back to Original Medicare anytime between Wednesday, January 1 and Tuesday, February 14, 2014.  If you do this, you can also join a Part D standalone plan if you had your Part D drug coverage with your Medicare Advantage plan, or if you had no Part D coverage at all.  (If you have your drug coverage with a Part D standalone plan instead of your Medicare Advantage plan, you cannot change your Part D plan.)

Part D

For Part D in 2014, again changes are minimal from 2013.  On the whole Part D premiums have increased by only a hair from 2013 (although your current plan may be increasing its significantly). And, in general, beneficiaries will pay less for their drugs in 2014.  As usual, the overall recommended structure has changed somewhat. The recommended deductible is $310, but remember that many plans have none or a smaller deductible than this. The next payment band, the 25% Coinsurance Band, covers the next $2,540 of your drugs, and you pay 25% of this, or $635, while your plan covers $1,905.  Your plan may structure this differently.  In the “donut hole,” also known as the “coverage gap,” in 2014 for brand name drugs, the plan will pay 52.5% of the cost of a drug, and you, the beneficiary, 47.5%. (These figures were the same in 2013.)  And for generic drugs, the government will pay 28% and, you, the beneficiary, 72%. (In 2013 the government paid 21% and the beneficiary, 79%, so you get a better deal.)  The beneficiary will remain in the donut hole until their “drug expenses” total $4,550.  And, finally, in the Catastrophic (or 5% Insurance) Band, which starts when your drug “expenses” reach $4,550, you will pay a minimum of $2.55 for a generic or $6.35 for a brand name drug, but no more that 5% of its cost, if that is greater than these amounts. (And by “expenses” is meant your deductible, anything you spent in the 25% band and in the donut hole, AND the 52.5% that manufacturers discount on your brand name drugs in the donut hole (but not the 28% the government pays on your generics).  Unless otherwise noted, all the amounts for 2014 are lower than the 3013 amounts; this is laid out in greater detail in my posting of October 3.

The structure for “Extra Help” or “Low Income Subsidy” beneficiaries is, of course, different, but these beneficiaries will experience slight decreases in their liabilities.

But the admonition above with regard to Medicare Advantage plans applies here also – do your homework to make sure you are in the best Part D prescription drug plan for 2014.  A recent Kaiser Family Foundation study showed that beneficiaries are reluctant to change their Part D plans and, as a result, the vast majority of them pay more for their drugs that they could.  And the special enrollment periods discussed above (Non-Renewing plans, the 5-Star Quality Rating, and Low-Performing plans) all apply to Part D plans also; the special disenrollment period does not.

And for those of you who have to pay the High Income Part D Premium Surcharge, your monthly surcharge will increase, but quite modestly, ranging from 20 cents a month to $2.70 a month.  The details are in my post of October 3.  But remember, as with the High Income Part B Premium Surcharge discussed above, your surcharge will be based on your 2012 income, and this may put you into a higher or lower bracket, or may put you into or out of having to pay a Part D premium surcharge.