41. How will I find out if I qualify for the extra help paying for my Medicare drug costs?
You will receive a notice from either the state Medicaid office or the Social Security Administration (depending on which agency you applied through) telling you whether you qualify for extra help, which level of extra help you qualify for (see chart in question 23), your appeal rights if you did not qualify, and what to do if your situation changes.
In addition, if you applied through Social Security, you will get a worksheet with your verified financial information. You can take this to your local Medicaid office to apply for a Medicare Savings Program, which helps pay your Part B premium.
42. What do I do if my application for extra help is denied?
If you believe you do qualify for the extra help, follow the instructions on how to appeal that will be included in the notice you receive.
43. What if I become eligible for the extra help after I have already enrolled in a Medicare private drug plan?
You can apply for the extra help at any time. If you qualify for the extra help, Medicare will notify your drug plan and the plan will change your premium, deductible and copayment requirements to the appropriate level. The plan must reimburse you for any additional payments you may have made.
44. What if I get some extra help but later qualify for Medicaid, a Medicare Savings Program or Supplemental Security Income (SSI)?
You will then qualify for full extra help and have lower out-of-pocket costs. That means you pay no monthly premium (unless you join a plan that has a higher premium than the extra help premium amount for your area), no deductible, and copays of no more than $0–2 for generics and $0–5 for brand-name drugs (see question 23). If your plan charges you additional costs after you qualify for Medicaid, a Medicare Savings Program or SSI, it must reimburse you for those costs. Since you automatically qualify for the extra help, you will not have to recertify as long as you continue to be enrolled in any of these programs.
45. Will I lose my subsidized housing or Food Stamps if I get the extra help paying for my Medicare drug costs?
The extra help you get paying for your Medicare drug costs does not count as income. But if you have been deducting your drug costs from your income when calculating your income for housing assistance or Food Stamps, you would no longer be able to do so. Your rent may go up and your Food Stamp allowance may go down or be eliminated if you get the $10 minimum allotment. However, Medicare estimates that what you gain in coverage of your drug costs will more than offset whatever you may lose in rent or Food Stamps.
Talk to your state social service agency to learn how the extra help with your Medicare drug costs might affect your other benefits.
46. I live in Puerto Rico. Can I get the extra help?
If you live in a U.S. territory (Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands), you may qualify for other special programs that help reduce the cost of the Medicare drug benefit. These programs vary by region. To find out more about the programs, call your Medicaid office or 800 MEDICARE.
47. When can I first enroll in the Medicare drug benefit?
You can enroll in the Medicare drug benefit (Part D) during your Initial Enrollment Period (IEP).
- If you currently have Medicare or will be eligible for Medicare in January 2006, your IEP will be between November 15, 2005, and May 15, 2006.
- If you will become eligible for Medicare during February 2006, your IEP will be between November 15, 2005, and May 31, 2006.
- If you will become eligible for Medicare during or after March 2006, your IEP will be the same as for Part B. It will be a seven-month period that includes the three months before the month you become eligible, the month you are eligible and three months after the month you become eligible.
48. When can I enroll if I delayed enrolling in the Medicare drug benefit or want to change my Medicare private drug plan?
You will be able to enroll in the Medicare drug benefit (Part D) or change your Medicare private drug plan once a year during the Annual Coordinated Election Period, which will be between November 15 and December 31. You may have to pay a premium penalty unless you had drug coverage from another source that is at least as good as Medicare’s (see question 13).
You will also be able to join or change plans during a Special Enrollment Period (SEP). Medicare has not yet specified how long all the various SEPs will be or when your coverage will start if you enroll during an SEP. Stay tuned for upcoming information. You qualify for an SEP when you:
- Move out of your plan’s service area.
- Lose your prescription drug coverage (such as retiree insurance) through no fault of your own.
- Enroll in a Medicare private health plan (Medicare Advantage) during your first year of Medicare eligibility and return to Original Medicare.
- Enroll in a Medicare private health plan for the first time.
- Your Medicare private drug plan stops offering coverage, fails to provide benefits on a timely basis, or misled you about what benefits you would get.
- Receive inadequate information about whether your existing prescription drug coverage is comparable to Medicare’s. (You can apply to Medicare to have your premium penalty waived in this situation.)
- Enroll or fail to enroll in a Medicare private drug plan because of a federal employee’s error. (Your premium penalty may also be waived in this situation.)
- Enroll in a Program of All-Inclusive Care for the Elderly (PACE).
- Enter, reside in, or leave a long-term care facility.
Notes:
- If you have Medicaid or a Medicare Savings Program, you can change your Medicare private drug plan once a month.
- If you have a Supplemental Security Income (SSI), or if you applied for extra help and Medicare randomly assigned you to a Medicare private drug plan, you can change plans once before the next Annual Coordinated Election Period.
- The Open Enrollment Period offers another opportunity to change your Medicare drug coverage if you receive it through a Medicare private health plan (see question 49).
49. What is the Open Enrollment Period?
Starting in 2006 you will only be able to change your Medicare health plan (Original Medicare or Medicare private health plan), two times a year (this is known as the “lock-in”):
1. During the Annual Coordinated Election Period (November 15 through December 31), when you can also change whether you elect Medicare drug coverage at all and your new coverage is effective January 1.
2. During the Open Enrollment Period (OEP), when you cannot also change your choice of enrolling in the Medicare drug benefit. Your new coverage will be effective the first day of the month after the month the plan receives a completed enrollment form.
During the open enrollment period, which will be January through June in 2006, and January through March in 2007 and beyond, you can:
- Switch from a Medicare private health plan with drug coverage to another Medicare private health plan with drug coverage.
- Switch from a Medicare private health plan with drug coverage to Original Medicare plus a stand-alone drug plan.
- Switch from Original Medicare plus a stand-alone drug plan to a Medicare private health plan with drug coverage.
- Switch from a Medicare private health plan without drug coverage to another Medicare private health plan without drug coverage.
- Switch from a Medicare private health plan without drug coverage to Original Medicare without a stand-alone drug plan.
- Switch from Original Medicare without a stand-alone drug plan to a Medicare private health plan without drug coverage.
You cannot:
- Switch from a Medicare private health plan with drug coverage to join a Medicare private health plan without drug coverage (unless you drop the Medicare drug benefit altogether).
- Switch from a Medicare private health plan without drug coverage to join a Medicare private health plan with drug coverage.
- Switch from a Medicare private health plan with drug coverage to join Original Medicare without joining a stand-alone drug plan (unless you drop the Medicare drug benefit altogether).
- Switch from Original Medicare without a stand-alone drug plan to a Medicare private health plan with drug coverage.
Note:
- If you are in a stand-alone drug plan, you can only switch to another stand-alone drug plan during the Annual Coordinated Election Period (see question 48).
- Institutionalized individuals can change plans once a month. Leaving an institution allows you change plans for two months after you leave. Medicare has not released final details on how the open enrollment period will work for these persons. Stay tuned.
50. Can I change plans if my Medicare private drug plan stops covering the drug I need?
Not until the next Annual Coordinated Election Period. While a Medicare private drug plan can change the drugs it covers (its formulary) at any time, you do not have the right to a Special Enrollment Period if your plan stops covering a drug you need.
Note: If you have Medicaid or a Medicare Savings Program, you can change your Medicare private drug plan once a month. If you are living in a nursing home (institutionalized), you can change plans once a month. Leaving an institution allows you change plans for two months after you leave. Stay tuned for more information on this.
51. How can I compare Medicare private drug plans?
Starting in October, Medicare will have a comparison tool on its www.medicare.gov web site that will allow you to search for Medicare private drug plans in your area and compare their costs, covered drugs and pharmacy networks. It should be available starting in October 2005. You can also call 800-MEDICARE.
In addition, information about Medicare private drug plans in your area will be mailed to you in the Medicare & You 2006 handbook, which you should receive in the fall of 2005.
Some community-based tools may be available to help you compare your choices in the future. Stay tuned for more information about these tools.
52. Will there be a tool to help me compare the Medicare private drug plans with my existing drug coverage?
No. You will have to pick the Medicare private drug plan that best meets your current needs and then see how that plan’s coverage compares to your existing drug coverage.
53. How do I join a Medicare private drug plan?
You can join a Medicare private drug plan by:
- Completing an online application on the Medicare’s www.medicare.gov website. You can join a plan through Medicare’s online enrollment center.
- Calling 800-Medicare. Medicare representatives will enroll you over the phone.
- Completing a paper application. Contact the company offering the drug plan to ask for an application. Once you complete it, mail or fax it back to the company.
- Completing an online application on the plan’s website. Visit the plan’s website to see if it allows you to apply online.
You or a representative who is authorized under state law can enroll you. A representative authorized under state law could include a health care or general Power of Attorney or a surrogate decision maker as defined by state law.
54. What if I accidentally sign up for more than one Medicare private drug plan?
During an enrollment period, if you have a Medicare private drug plan already and enroll in a new one, you will be automatically disenrolled from your previous plan. Additionally, if you make multiple plan selections during a month, the last one you make will become effective on the first of the following month. Note: you must be in an enrollment period to join a plan.
If you try to join a plan outside of an enrollment period you will be denied.
55. After I join a Medicare private drug plan, can the deductibles, premiums and coinsurance change?
The deductibles and premiums cannot change until the following calendar year. However, your coinsurance and overall out-of-pocket costs may change if the drug you need is moved to a different cost tier or is removed from the plan’s list of covered drugs (see questions 64 and 65).
56. Will I need to reapply every year?
No. If you do nothing your current plan will continue, but you should reevaluate your Medicare private drug plan every year to make sure you are getting the best coverage for your needs.
57. Once I enroll in a Medicare private drug plan, when does the coverage begin?
If you join in 2005 (between November 15, 2005, and December 31, 2005), your drug coverage will begin on January 1, 2006. If you enroll in 2006 (from January 1, 2006, to May 15, 2006), your coverage will start the first day of the month after the month in which you signed up.
If you become eligible for Medicare drug coverage any time after that, your coverage will start on the month you become eligible if you joined in the first three months of your Initial Enrollment Period, or the month after the month in which you joined if you sign up during the last four months of your Initial Enrollment Period (see question 47).
Plan changes made during the Annual Coordinated Enrollment Period (November 15 to December 31 of every year) will become effective on January 1 of the following year.
Medicare has not yet specified when your coverage will start if you enroll or change plans during a Special Enrollment Period.
58. What should I do if I enroll in a Medicare private drug plan but don’t receive a card or any information from it and I need my drugs now?
You should contact the plan immediately. If you do not get a timely response from the plan, you should contact Medicare at 800-MEDICARE.
59. Can my application to enroll in a Medicare private drug plan be rejected?
Yes, your application can be denied in the following situations:
- You are not eligible for Medicare drug coverage.
- You are not in the plan’s coverage area.
- You are not eligible to enroll in a Medicare private health plan (Medicare Advantage) with drug coverage because you have End-State Renal Disease (ESRD) or do not have both Medicare Parts A and B.
- You try to apply for a Medicare private drug plan outside the Annual Coordinated Enrollment Period or a Special Enrollment Period.
- The plan is not accepting new members.
- You apply for a stand-alone drug plan but you are enrolled in a Medicare private health plan (such as an HMO, PPO or PFFS). (Note: if you are in a PFFS plan that does not offer drug coverage, you can enroll in a stand-alone drug plan.)
60. What can I do if my application is denied?
If a Medicare private drug plan denies your application to join and you believe you qualify for the Medicare drug coverage, you should call the plan and ask it to clarify the reason it did not approve your application. You can also contact Medicare if you believe the Medicare private drug plan is not addressing your concerns. (There is no formal appeals process for enrollment denials at this time.)
© 2005 Medicare Rights Center
