Understanding the basics will help you field patients' questions about the new prescription drug benefit.
When
a recent poll asked seniors where they would turn for help with
Medicare's Part D prescription drug benefit, their No. 1 answer was
their doctor. Patients expect us to have answers to their questions
about the new drug benefit, which was created by the Medicare
Prescription Drug, Improvement and Modernization Act (MMA) of 2003.
While
the Centers for Medicare & Medicaid Services (CMS) does not expect
doctors to have all the answers, it is our professional responsibility
to understand the basics of the benefit so we can help our patients get
the medications they need.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp.
A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE.
Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp.
A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE.
Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
How does it work?
Starting in January 2006, private
organizations contracting with CMS will begin to offer Medicare
beneficiaries a number of prescription drug plans. These plans will
include some stand-alone, prescription-drug-only plans and some
Medicare Advantage plans that will include prescription drug coverage
along with Part A and Part B coverage. Details of the plans in your
area can be found at http://www.medicare.gov/medicarereform/map.asp. A
standard prescription drug plan is structured as follows: Patients can
buy prescription drug coverage for a monthly premium of about $37.
After paying a $250 out-of-pocket deductible, participants must pay 25
percent of the cost of each medication until drug costs reach $2,250.
Under the standard benefit, the individual then pays 100 percent of
drug costs over $2,250 until the costs reach $5,100. At that point,
patients begin paying 5 percent of drug costs (or $2 for generics and
$5 for brand-name drugs) until the end of the year, when the cycle
starts over. Premiums, deductibles and cost-sharing may all vary from
plan to plan, but many follow this standard structure.
For
a plan with a monthly premium of $37.50 to pay for itself, a patient's
annual drug costs would need to be greater than $850. For example, the
beneficiary will pay approximately $450 in premiums plus the $250
deductible and then $150 of the next $600 worth of medications over the
deductible. At this point, the individual has paid $850 out-of-pocket
for $850 worth of medications.
Who should enroll?
2. Once approved to receive extra help,
enroll in a Part D prescription drug plan. This can be done by
contacting the drug plan, visiting Medicare's Web site at http://www.medicare.gov or calling 1-800-MEDICARE. Patients
with low incomes will need to complete both steps listed above with the
SSA and CMS to take advantage of all of their options.
Medicaid
eligible beneficiaries. Beginning Jan. 1, Medicaid ceased paying for
prescription drugs for those also enrolled in Medicare, and coverage by
the new Medicare plan began. Individuals enrolled in both Medicare and
Medicaid (dual beneficiaries) have been automatically assigned a
prescription drug plan, though they may change plans if they choose.
Dual beneficiaries are the only people with the freedom to change plans
outside of the "open enrollment" periods each year.
Beneficiaries
with current drug coverage. A recent nationwide survey of
employer-based prescription drug plans found that most were more
generous than the plans offered by Medicare.For this reason,
individuals with drug plans offered by an employer, the state or the
military should not switch to a Medicare plan unless they receive a
letter stating that their current coverage is "not creditable" (i.e.,
not as actuarially sound as a Medicare-sponsored plan). Those whose
current plan is deemed not creditable will likely benefit from changing
to a plan that meets Medicare's standards. Patients with coverage
deemed not creditable who do not change their plan by the end of the
open enrollment period on May 15, 2006, will be subject to the
financial penalty described earlier.
Beneficiaries in
long-term-care facilities. About three-fourths (77.6 percent) of
Medicare beneficiaries in long-term-care facilities have a documented
cognitive impairment and will need assistance deciding whether to
enroll in a Part D plan and in which plan to enroll.They will also need
to select plans using specialized dispensing pharmacies that serve
their facility.
Beneficiaries without drug coverage.
Medicare beneficiaries without current drug coverage who do not qualify
for extra help will need to decide if a Medicare drug plan will be
worthwhile to them in the foreseeable future. As mentioned earlier, if
patients plan on spending at least $850 out-of-pocket each year on
prescription drugs, enrollment probably will be worth it. Because of
the financial penalty for signing up late, it is advisable to enroll as
soon as possible.
How will this affect your practice?
Preparing for Part D
If
they haven't already, your Medicare patients soon will be coming to you
with questions about Medicare Part D. For the questions you can't
answer, it is your job to point patients in the right direction. These
new plans can provide them with much-needed prescription drug coverage.
By learning as much as you can about Part D now, you will help your
patients make the transition to the new coverage more effectively and
efficiently.
About the Author
Written
by Holly Biola, MD. Dr. Biola is a National Research Service Award
Primary Care Research Fellow working at the University of North
Carolina at Chapel Hill Department of Family Medicine. Conflicts of
interest: none reported. Copyright American Academy of Family
Physicians, www.aafp.org.
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