By LEE BOWMAN
Scripps Howard News Service
October 01, 2005
Between 11 and 20 organizations are offering prescription drug plans in each region - a state or part of a state - and in many areas, drug coverage is also offered as part of membership in Medicare-approved HMOs. That can mean 40 or more plans to consider for people who live in some urban areas.
Premiums are ranging from $20 to $70 a month for the freestanding drug benefit. The drug coverage may cost nothing through some managed care plans. But no matter what the up-front costs, Medicare patients need to know that not all drugs they take will necessarily be covered, and most people will face out-of-pocket costs that will vary depending on how much they spend on drugs each year.
Critics of the program say the array of choices may prove so daunting to many seniors that they'll make poor choices or simply skip signing up for the coverage.
"Seniors across the country will be absolutely bewildered by the choices they are confronted with, and they are going to have a very difficult time navigating those choices," said Ron Pollack, executive director of the health care advocacy group Families USA.
But advocates insist the coverage is worthwhile for most people on Medicare who don't already have good drug benefits through a current or former employer.
"We really believe this coverage is going to save lives," said John Rother, policy director for the senior advocacy group AARP, which is marketing its own plan and is also part of an alliance promoting the coverage through grassroots organizations around the country.
"There's no need to rush in, but most people will probably be better off getting the coverage than not joining up. Still, it's important to keep in mind that there is no 'typical Medicare beneficiary' when it comes to drug coverage," Rother said.
Virtually everyone involved in the drug program, officially known as Medicare Part D, stresses that seniors and disabled people should do their homework and talk over choices with someone they trust during the next few months.
Here are questions and answers that may make the shopping experience a bit easier:
Q: What kind of marketing pitches should I expect to see?
A: Companies and organizations sponsoring plans can contact you by mail, by phone or by e-mail, and will offer promotional materials at places like pharmacies, senior centers and churches. They are not supposed to sell coverage door-to-door. Be wary of any such salesperson; don't give them personal information or money.
Never give out a Medicare ID number, credit card number or other personal or financial information over the phone or Internet without being sure who you're dealing with. You can call Medicare at 1-800-633-4227 to confirm if a company is legit.
Q: What do I need to do to prepare to shop for a drug plan?
A: Make a list of the drugs you're taking now and what you're paying for them. Find out what plans your pharmacy will be part of and consider whether you're willing to switch or use a mail-order pharmacy. If you have supplemental insurance coverage for expenses Medicare doesn't pay that includes drugs, you can keep it, but you can't add the Medicare benefit, too. No new enrollments in Medigap drug plans will be allowed after Jan. 1, and your Medigap insurer must let you know by mid-November how your coverage compares with the Medicare plan. If you keep Medigap coverage beyond next May, you'll probably pay a penalty if you move to Medicare D coverage later.
Q: What should the plan cover?
A: Each plan has to cover at least one type of drug in almost all therapeutic categories. But the plan can drop coverage of specific drugs during the year with 60-days notice. Financially, the plan has to have an overall value that's at least as good as the Medicare basic plan. You would have to meet a $250 deductible, then pay 25 percent of the cost of the next $251 to $2,250 of prescriptions. You would pay 100 percent of the cost for the next $2,251 to $5,100 in prescriptions (the so-called donut hole in the coverage), then you'd be responsible for 5 percent of all drug expenses above $5,100 - the catastrophic coverage threshold.
Q: What if I already have drug coverage through a current or former employer?
A: The company should tell you if your present coverage will change. If they continue to cover you as well or better than Part D, Medicare will pay them a credit each year, or they may ask to enroll in a new Medicare plan for their retirees. They may also offer supplemental coverage to a Medicare plan, or they may choose to stop providing retiree coverage. If they do this after next year, you can still sign up for the Medicare coverage with no penalty, as long as the coverage you lost was equivalent to the Medicare basic plan.
Q: Am I eligible for extra help if I'm low income?
A: Yes. There's a $600 a year subsidy if your annual income is below 150 percent of the poverty level ($14,355 a year for individuals and $19,245 a year for couples in 2005) and if you have assets of less than $11,500 for individuals and $23,000 for a couple. The Social Security Administration has mailed applications for this assistance to beneficiaries who may be eligible. But you may be eligible even if you didn't get one of the forms.
Q: What if I have drug coverage through Medicaid or VA or TriCare?
A: Vets and military retirees can keep the coverage they have now and enroll in a Medicare plan later with no penalty. Medicare-eligible people enrolled in Medicaid will be automatically eligible to move to a plan that's part of the new program.
Q: I'm pretty healthy right now and take only one prescription regularly. Do I have to enroll now?
A: Medicare Part D is a voluntary insurance program. No one is being forced to sign up. If you sign up later than May 15, 2006, and haven't had equivalent coverage from another government or private program, you'll pay a higher premium. The penalty is 1 percent of the national average premium for each month you delay. This is being done because the government wants to encourage more people to join to spread out the costs - or risks, in insurance terms. If only people who use a lot of drugs sign up, the premiums will be a lot higher.
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