The Medicare Prescription Drug Program, sometimes called Medicare Part D, joins Medicare Part A (hospitalization coverage) and Part B (medical and some kinds of outpatient coverage). Medicare Part C, also known as Medicare Plus Choice or Medicare Advantage, is managed care or HMO coverage. Some Medicare Part C policies already cover prescriptions, and some do not.
Anyone who already has Medicare Part A, or Medicare Part B or Medicare Advantage, will be eligible for Part D prescription coverage. To get prescription coverage, most eligible people will have to apply for it. Although people can apply through their Social Security office for Part A and B coverage, they must apply for prescription coverage directly from an insurance company that offers the coverage.
For people who are becoming eligible for the first time, there is an initial enrollment period during the 2 months before and after the month of their 65th birthday. There are special enrollment periods for people who already have Medicare if they move out of an area that their prescription plan serves. Once a person has Part D coverage, he or she can change the coverage annually during the “open enrollment” period from November 15 through December 31.
Some people may have prescription coverage through employer-sponsored or union-sponsored health insurance, or through the Veterans Administration. If their coverage under these policies is at least as good as that available through a Medicare prescription plan, they do not have to change their plans to Medicare. Nor will they have to pay a monthly penalty if they decide to change to Medicare later on. This exception to the general rule is limited, however. For example, the exception applies only to a worker, but not to the spouse of the worker who is covered by an employer or union plan. The plan administrator of these insurance programs should notify the policyholder whether the coverage is at least as good as the Medicare alternative. People who are uncertain about the scope of their employer- or union-sponsored coverage should contact the plan administrator right away. Mistaken reliance on other coverage can result in costly late enrollment in Medicare prescription coverage later on.
Limited-income people with Medicare, such as those who get Supplemental Security Income (SSI), must also get their prescriptions covered by Medicare Part D. Part D coverage requires payment of premiums, deductibles and co-payments that low-income people cannot afford. These people should be eligible for what the government calls “extra help,” so they will not have to pay these costs. Some low-income people will get the extra-help subsidy without applying for it; it will come automatically. Persons whose incomes are very low who don’t get information about the subsidy should contact their local Area Agency on Aging office or Seniors & People with Disabilities office to get this extra help . The subsidy does not enroll a person in a prescription drug plan, however. It simply helps pay for the coverage, which the person still must choose and apply for.
Other people with slightly higher incomes also may have difficulty paying Medicare prescription deductibles, premiums and copayments. Extra help is available for many of these people, too, although for them it is not automatic — they must apply for it. The application form is available from Social Security offices and from the Social Security website. Generally speaking, an individual whose countable yearly income is less than $16.245 or a couple whose countable income is below $21,805 and whose savings are limited should qualify for this subsidy. Not all income is countable. A person whose application is denied should seek legal advice about whether the law was applied correctly in a particular case. The denial notice will give the person information about the deadline to appeal. Getting legal advice right away is important for those who cannot pay the cost of coverage for needed medicines.
Several insurance companies offer prescription drug plans in Oregon. People should take their time looking at policies and get help evaluating their needs before purchasing coverage. They can get free trained help from Oregon’s Senior Health Insurance Benefits Assistance program, or SHIBA, at (800) 722-4134.
Some people will find that the new prescription plans do not offer to cover the medicines they need. Or, the plan the person chooses may stop covering a drug someone needs. In some cases, it is possible to get an “exception” that will allow coverage. SHIBA, social services staff, doctors and some lawyers may be able to help get an exception. A wrongful denial of coverage for needed medications — or for that matter, needed medical care — may also be grounds for an appeal. A large portion of Medicare claims that are denied are denied in error. Although the SHIBA program can assist people with preliminary parts of appeals, it is important to get legal assistance for help beyond that stage.
Legal editor: Janay Haas, October 2009