PART D ENROLLMENT & BENEFIT INFORMATION COMING YOUR WAY


Introduction

As the November 15th start of the annual coordinated (open) enrollment period for Medicare Part D prescription drug plans (PDPs) and Medicare Part C Medicare Advantage plans approaches, Medicare beneficiaries can expect to receive important information about their health care coverage.  All beneficiaries will get mailings from the Centers for Medicare & Medicaid Services (CMS) and from the health plans in which they are enrolled. Some beneficiaries may also get information from the Social Security Administration (SSA) and/or their retiree or employer-sponsored health insurance.

All Medicare beneficiaries should carefully read through the information they receive to make sure they understand their health benefits for 2007 and to determine whether they need to change to a different drug plan.

Information from CMS

·    Medicare & You 2007 Handbook:  Every Medicare beneficiary will receive a copy of the Medicare & You 2007 Handbook during the end of October or the beginning of November.[1]  The Handbook provides general information about Medicare, including services covered by Medicare and the rights of Medicare beneficiaries.  The Handbook also contains detailed information about Part D plans and Medicare Advantage plans available in the beneficiary’s geographic area.  Specifically the beneficiary will find information about the name of the sponsoring organization, the plan name, the monthly premium, doctor co-payments for Medicare Advantage plans, the Part D deductible, Part D co-payment and/or cost-sharing amounts, and whether the plan provides any drug coverage in the “donut hole” coverage gap.[2] 

Note: The page called “How to read the local prescription drug plan charts…” explains that individuals who qualify for the full “extra help pay $0 premium for PDPs whose premium amount is in blue.”

·    Notice of change in low-income subsidy (LIS):  CMS sent letters to two different groups of beneficiaries concerning their low-income subsidy:

o       Change in LIS-eligibility status:  CMS sent a letter on white paper to about 632,500 Medicare beneficiaries in late September informing them that in 2007 they would not be “deemed” or automatically eligible for the low-income subsidy (also called extra help).  The letter informed beneficiaries they could apply for LIS.  Beneficiaries who believe they should still qualify for LIS automatically because they qualify for Medicaid, receive one of the Medicare Savings Programs (MSPs) [QMB, SLMB, QI], or receive SSI but not Medicaid should contact their state Medicaid office.

o       Change in co-payment level:  CMS sent a letter in early-to-mid October to LIS-eligible individuals who will still be deemed LIS-eligible for 2007, but whose co-payment levels will change in 2007.  A change may occur, for example, because a person with both Medicare and Medicaid moved from a nursing home and is no longer entitled to $0 co-payments.

·    Notice of reassignment of some LIS-eligible individuals:  CMS will send letters at the end of October to some LIS-eligible individuals to notify them that they have been reassigned to a different prescription drug plan.  The LIS-eligibles will be reassigned because the drug plan in which they are currently enrolled will have premiums that are more than $2 above the benchmark amount for their region in 2007 and therefore will not qualify for the subsidy.  Only those LIS-eligible individuals who are in non-benchmark plans to which they were assigned by CMS in 2006 will be reassigned for 2007.  LIS-eligible individuals who are in a non-benchmark plan that they chose for themselves or that a State Pharmacy Assistance Program (SPAP) chose for them will not be reassigned to a new plan by CMS. 

Information from SSA

·    Notice of LIS redetermination:  At the end of August and beginning of September, SSA mailed notices to all beneficiaries who applied and were found eligible for LIS in 2006.  The notice informed beneficiaries that if their situation (e.g. income, assets, family size) has not changed they would continue to be eligible for LIS in 2007, and that they did not have to take any action.  Those whose situation had changed were required to notify SSA within 15 days.  Individuals who reported changes then received a redetermination statement from SSA to explain their change in circumstances. Beneficiaries who requested and received the redetermination statement from SSA must return it within 30 days even if, upon review, they realize that their circumstances have not changed, they are still eligible for LIS, and they did not need to contact SSA.

Information from drug plans

·    Notice of plan termination:  Beneficiaries whose prescription drug plan or Medicare Advantage plan will be terminating its contract with Medicare for 2007 should have received a notice from their plan in early October.  Beneficiaries whose plans are terminating can change to a new plan during the annual enrollment period.  They also may be entitled to a special enrollment period.

·    Annual Notice of Change (ANOC):  Each prescription drug plan must send an annual notice of change to all of its current enrollees by the end of October.  The ANOC includes information about changes to premiums, formularies, cost-sharing, low-income subsidy, and exceptions for coverage of non-formulary drugs.

o       Beneficiaries who are LIS-eligible need to review their ANOC to make sure that their plan still qualifies for the full-LIS premium subsidy.  They also need to review the information about new co-payments for their drugs.

o       All beneficiaries need to review their ANOC for:

§         Changes in premium amounts

§         Changes in deductible amounts

§         Changes in coverage for drugs in the donut hole

§         Changes in cost-sharing, including changes in tiered co-payment amounts and placement of their medicines

§         Changes in the formulary, including addition of utilization management tools such as quantity limits, step therapy, and prior authorization

§         Information about whether exceptions that were granted in 2006 to cover non-formulary drugs, to waive utilization management requirements, or to change cost-sharing amounts will continue in 2007

§         Information about transition coverage and the right to request an exception

·    Notice about formulary exceptions:  Each Part D plan has the option of continuing into 2007 an exception granted in 2006 to cover non-formulary drugs, to waive utilization management requirements, or to change cost-sharing amounts.  Some plans included information in their coverage determination decisions that the exception was only good through 2006.  If the coverage determination did not include that information, and the plan decides it will not continue the exception, the plan must inform the beneficiary that further action is needed.  Some plans will include such information in their ANOC.  Plans that do not intend to continue exceptions and that did not provide the information either in the coverage determination or in the ANOC must send a notice to beneficiaries who received favorable exception decisions by the end of October.  Note:  All beneficiaries who need to request an exception for 2007 are encouraged to file their exception request before January.

Notice for Employers/Unions

·    Creditable coverage notice:  Employers and unions that provide health benefits to current employees, retirees, and their dependents must provide notice, before November 15, of whether the prescription drug coverage they offer is creditable, i.e., as good as Medicare coverage.  Note that the information may be provided in a summary plan description or other writing about the health insurance that is routinely provided to employees/retirees/dependents, and may have been sent as part of the employer plan’s open enrollment period.  All beneficiaries who had creditable drug coverage in 2006 need to make sure that their drug coverage remains creditable in 2007.

Conclusion

Medicare beneficiaries can expect multiple mailings from a number of sources in advance of the November 15 date.  These mailings will be in addition to marketing materials distributed by drug plans.  Beneficiaries should review the mailings very carefully to determine if their drug plan is still available, how the coverage and payment responsibilities will change,  and whether they are enrolled in the plan that will provide them with the most drug coverage in 2007.

Beneficiaries who have questions about the letters they receive can call their state health insurance assistance program (SHIP).  To find out their SHIP’s telephone number, beneficiaries can call the Eldercare Locater, 1-800-677-1116.


[1] The Medicare & You 2007 Handbook is also available at www.medicare.gov.

[2] Some advocates have determined that information about coverage of brand name drugs in the donut hole or coverage gap may be inaccurate or misleading.  Beneficiaries are advised to check directly with the drug plans to determine whether the specific drugs they take will be covered in the gap.


Copyright © Center for Medicare Advocacy, Inc.