Rx for Confusion

Rx for confusion
Baffled by Medicare's new prescription-drug program? Here's a guide to sorting out its major details.


By DEBORAH HARKINS
Medicare Rights Center staff and volunteers can answer queries on benefits.

It's almost upon us — Jan. 1, 2006. That's when the 42 million seniors enrolled in Medicare will qualify for benefits under a controversial law, passed by Congress in 2003, that aims to help Medicare recipients pay for their prescription drugs.

The new benefits will be offered through scores of private Medicare prescription-drug plans. These plans — available to the 87% of beneficiaries who receive Original Medicare — will be provided under a new section of Medicare called Part D.

(Note: This article covers only the plans available to recipients of Original Medicare. The 13% of Medicare beneficiaries who are not enrolled in Original Medicare belong to Medicare Part C, which covers "Medicare Advantage" private health plans like HMOs, PPOs and PPFs. The rules are different for Part C enrollees; they can learn about their coverage by calling the hot lines listed in the box at right.)

The new Part D coverage is available to any Original Medicare recipient who wishes to enroll. However, "dual eligibles" — people who get benefits under both Medicaid and Medicare — are required to enroll in one of the Part D plans.

And so, seniors will soon be hit by a tsunami of sales pitches by private companies extolling the virtues of their particular plans. The profusion of plans (in New York State, 20 companies are offering 46 plans!) promises to make the selection process mystifying, if not maddening.

The benefits
The savings on drugs will vary from plan to plan. But at a certain point each year — after you have gone through a "coverage gap" in which you must pay all of your drug costs — you will have paid enough out of pocket to qualify for "catastrophic coverage." With catastrophic coverage, you will pay only 5% of the cost of each drug.

If your income is low, Part D plans promise to bring substantial savings. How good will the savings be if you're middle class? Right now, it's impossible to tell, because the plans vary so greatly. But the Centers for Medicare and Medicaid Services, the federal agency that runs Medicare, estimates that the average beneficiary could save up to $2,260 a year.

Choosing unwisely will have consequences. Picking the wrong plan could mean that you can no longer use a drugstore nearby. Or that you're locked until the end of the calendar year into a plan whose coverage does not include the particular drugs your doctor has prescribed. Delaying the choice of plan beyond the signup period can permanently drive the monthly premium higher.

The costs
1. What will I pay for the monthly premium and the annual deductible if I join a Part D plan?

The premium and the deductible will vary from plan to plan.
(In New York State, premiums currently range from $4.10 to $85.02 a month.)
The 2006 Part D deductible can be no more than $250. Those whose income and assets are low will pay no (or a low) monthly premium.

2. When can I sign up?

Between Nov. 15 and May 15, 2006. If you wait until after May 15, 2006, the next open enrollment period is Nov. 15-Dec. 31, 2006.

3. Can I wait to see how this program pans out before signing up?

That might seem prudent. But if you're not now covered by another drug plan (say, from your current or former employer or union) that's as good as, or better than, the model Part D plan, be careful: Your premium will go up by at least 1% per month for every month after May 15, 2006, that you wait to enroll.

4. Can I get my drugs at any pharmacy?

No. You can use only the pharmacies in your plan's network. So make sure that whatever plan you choose includes a drugstore that's convenient to you.

5. Can I change plans if I don't like the one I've chosen?

No. After May 15, you will have to keep your plan through Dec. 31, 2006, unless you're a Medicaid or Medicare Savings Program recipient; in that case, you can change once a month.

6. Will the plan I choose guarantee coverage of the drugs I need?

No. You should choose a plan whose formulary (list of covered drugs) includes the brand-name medications your doctor has prescribed. But even if it covers those drugs when you enroll, the company can drop or add any drug after it makes 60 days' supply available to you or gives you at least 60 days' notice. (That time period might change.) And you are locked into your plan for the calendar year.

7. What good is 60 days' notice?

It's supposed to give you time to ask your doctor to switch you to a similar drug that the plan does cover.

Every Part D plan must cover at least two drugs in all but a very few categories (weight-loss drugs, barbiturates and tranquilizers are among those excluded from Part D). Fortunately, most drugs in six crucial categories — antidepressants, antipsychotics, anticonvulsants, antiretrovirals (AIDS treatment), immunosuppressants and cancer drugs — are required to be covered.

Suppose your plan's formulary offers the brand-name drug you take, but then, with 60 days' notice, withdraws coverage for it. If your doctor believes that using a different drug in the same category (a generic or a different brand-name medicine) would harm you, he or she can help you request an "exception." An independent committee will then con-sider your appeal (your plan must respond within 72 hours). If this panel rules that your current drug is medically necessary, the exception will be granted and your plan will be required to ­cover that drug.

8. Right now I receive both Medicare and Medicaid benefits. Can I keep my Medicaid prescription-drug coverage, which is quite good?

No. On Jan. 1, 2006, those who get both Medicare and Medicaid will lose their Medicaid drug coverage and start receiving drug coverage from one of the new Medicare Part D private prescription-drug plans.

If you are one of these "dual eligibles," you can choose the plan you want to join — but you must make your choice by Dec. 31, or a computer will assign you a plan at random. (You can, however, switch out of that plan and into another.) If you're a dual eligible who is currently stabilized on prescription drugs that Part D doesn't cover, the Part D plan you select (or get assigned to) must provide for you to receive a transitional supply. After that, you must appeal your right to coverage for that medication under your new plan, and prove that it is medically necessary.

9. If I don't enroll in Part D, can I find other ways to save on drugs?

Yes. EPIC, New York State's popular prescription-drug assistance program, will still be available (1-800-332-3742). And the Medicare Rights Center (see box) can tell you about other non-Medicare programs offering discounts on drugs.

Help for the bewildered
Most seniors will need translations of the rules. (There are many complexities, not discussed in this article, involving catastrophic coverage, creditable coverage, cost tiers, the coverage gap and more.) Low-income seniors in particular will want to call a hot line or visit a trained counselor to find out about the extra benefits available to them.

• For free counseling, get in touch with:
  The Medicare Rights Center, a nonprofit group that provides free counseling to people with Medicare questions and problems. Its phone number, 1-800-333-4114, open weekdays from 9 a.m. to 3 p.m., is the official New York State hot line for those with questions about Medicare. The counselors can help low-income Medicare recipients apply for extra help to pay for their drugs. There's also a wealth of information on the MRC's Web site, www.medicarerights.org.
• The federal Centers for Medicare and Medicaid Services offers help over the telephone and on the Web. In mid-October, after the specifics of all the private plans have been released, you can use the "Search Tools" option on the agency's Web site, http://www.medicare.gov/, to compare the plans available in your area. You can also call 1-800-MEDICARE to have comparisons mailed to you.

For original article in the New York Daily News, view @:

http://www.nydailynews.com/city_life/health/story/356970p-304232c.html