Answers to Your Questions About Medicare
How to Decide Which Prescription Drug Program Is Best For You
Thank you for submitting so many questions about the new Medicare prescription drug plan. Here is a selection of answers to your queries, with responses provided by consumer health experts.
Rachel Chang in Brooklyn asks: My grandmother is covered by Medicare and Medicaid. I believe her medication is covered by Medicaid. Does she have to enroll in Medicare Prescription Plan? Can she stay with her Medicaid for her prescription drug coverage? If she has to convert to Medicare, which plan covers the most number of prescription drugs that's accepted in New York City? I assume she's exempt from paying co-pay and deductible because she also has Medicaid. Thank you.
Answer: Under the new law, Medicaid will no longer provide prescription coverage for people with Medicare, like your grandmother. She will have to sign up for one of the new Prescription Drug Plans, and Medicare will pay her premiums and co-payments. If she does not sign up herself, Medicare will automatically enroll your grandmother in a plan available in her area. However, plans vary in terms of the drugs they cover and the pharmacies that are available. So it is very important that your grandmother find and select a plan that fits her medical needs and is convenient for her, so she doesn't get auto-enrolled in a plan that doesn't cover her medications.
The Medicare program has developed a computerized tool to help select a plan. The tool helps you identify (1) which plans are available, by zip code; (2) which drugs are covered by each plan; and (3) which pharmacies are affiliated with each plan. If you are Web savvy you can help your grandmother by checking out this tool, which is at www.medicare.gov If you need further assistance (and you may!), your best bet is to call New York's Health Insurance Information and Counseling Assistance Program (HIICAP). Their toll free number is 1-800-333-4114; the local number is (212) 869-3850. Be patient, these phone systems will surely be "experiencing high call volume!"
Source: School of Public Affairs, Baruch College, City University of New York
Nancy McConnell in New York asks: Do we have to pick a plan if we don't want to?
Answer: No, you don't have to pick a plan if you don't want to. However, if you don't have similar coverage from another source and decide you want coverage sometime in the future, you will pay a penalty. You have until May 15, 2006 to make this decision and you should check your options before you make up your mind.
Most people use prescription drugs as they age and prescription drugs can be expensive. Some plans have a very low monthly premium or even a zero premium but you need to see if they cover the drugs you take. You may choose a different plan next November if your needs change. The best way to see what your options are is either to call 1-800-MEDICARE and speak to someone about the plans available in your area and what if any drugs you use or to go on-line at www.medicare.gov and click on Basic Information or "Things to Consider." There are many volunteers able and ready to help you. Be sure and get more information before you make a final decision. You have six months to make this decision. Don't feel you need to do it immediately.
Source: Project HOPE
Rita asks: I don't know what to do … I was told to stay away from part D … and I get very little money … I don't even want this, what should I do?
Answer: While joining is your choice, it is important to understand your options. If you have very little money (and not very many assets) Medicare will provide you with extra help and pay almost all of your prescription drug costs. Almost 1 in 3 people with Medicare will qualify for extra help. Most people use some prescription drugs and will therefore want this new benefit. Even if you don't need it now because you don't use many drugs, it is likely that you will want the coverage as you age. If you don't choose drug coverage by May 15 of next year and don't already have coverage like what is being offered, you will face a penalty if you decide to join after May 15, 2006.
The best step to do now is to find out the choices in your area. Many plans have a low monthly premium or no premium even, but they may or may not cover the drugs you take. You can call at 1-800-MEDICARE and tell someone where you live, what drugs you take and also ask them how to find out if you are eligible for special assistance. Alternatively, since you e-mailed your question, you can go to www.medicare.gov and click on Prescription Drug Coverage: Basic Information or Important Links.
If that makes you uneasy, ask someone who is comfortable with the Internet to help you -- like a friend, son/daughter or grandchild. Also, you can change your choice next November if you want. So, don't worry about needing to make a "perfect choice," just a "good" one.
Source: Project HOPE
Erin Spear in Oklahoma asks: How do I choose a Medicare prescription drug plan that will work best for me?
Answer: No one can give a general answer to your question because the variety of plans is so great and you have not provided details of your circumstances that might push you in one or another direction.
If you have coverage with employment right now, you might be better off sticking with that coverage. (That is the case with my coverage at Yale University, for example, even though there are frightening statements about how waiting will cost one more later on.)
No one should suppose the present program -- and the confusing variety of insurance plans offered -- will remain the same in the next few years. The anger, confusion, and simply dismay at the complexity will not diminish. So, sticking with the simplest version you can find may make sense if you need some coverage because of chronic illness and substantial use of drugs. Where the offer is of a plan with a $250 deductible, a 25 percent co-insurance rate from $251 to $2250, a so-called donut hole of no coverage from $2251 to $5000, and a 5 percent co-insurance after that, you have the basic Bush Administration idea. That is better than no coverage if you now use substantial medications (or will), but it is, as noted above, unlikely to stay the same. All the other options are directed at somewhat different mixes of healthy, less healthy, and much less healthy Americans whose drug use will be expected to be not much, a bit, or a lot. Sadly, this is all one can say in general.
Source: Yale School of Management
Ana Maria Osberger in Florida asks: I am 66 years old and do have Medicare, but I still work and have health insurance through my employer. Do I need to sign up for the Medicare Drug Program? If I do not sign up now, how much of a penalty will I have to pay when I sign up in 18 months when I do retire?
Answer: If you are Medicare-eligible, working and your primary source of health insurance is your employer plan, you probably do not need to sign up for a Medicare drug plan at this time. Under the law, Medicare pays employers who continue to provide prescription drug benefits to Medicare-eligible individuals -- as long as the drug coverage under the employer plan is at least as good as the standard Medicare drug benefit.
In general, benefits offered by employers are more generous than the standard Medicare drug benefit, but there are exceptions, so it is important to determine whether your employer's plan is at least as generous in value as the new Medicare drug benefit. Fortunately, you don't need to answer this yourself. Employers are required to send letters with this information to their employees and retirees. If your employer says your plan meets this test, you have the option of keeping your employer health plan next year (without incurring a penalty for late enrollment in a Medicare prescription drug plan) or enrolling in one of the new Medicare prescription drug plans. If you do not receive this letter, you may want to contact your employer's human resources department to get clarification. If your employer plan is not as generous as the standard Medicare prescription drug plan, then you could face a penalty for late enrollment if you do not sign up for coverage in 2006.
According to the Medicare and You 2006 handbook, you can keep your employer plan instead of signing up with a Medicare drug plan as long as it remains at least as good as the Medicare standard prescription drug benefit. And, you won't have to pay a penalty if your employer or union stops offering prescription drug coverage, as long as you join a Medicare plan within 63 days after the employer plan ends.
Source: Kaiser Family Foundation
Audrey Liba in Michigan asks: We have Blue Cross & Blue Shield HMO without prescription coverage. Can we get Medicare part D to go with this at a reasonable rate? So far all I've seen is so expensive. It would cost my husband and me close to $1,000 a year more.
Answer: If you are currently enrolled in a Medicare HMO without prescription drugs, you may not be able to enroll in a drug-only plan without giving up your existing coverage for other medical services. Your current plan may add prescription drugs to its package. Contact your plan administrator to find out if it will. If it does not, you may want to consider switching to a plan in your area that covers drugs.
Source: Leif Wellington Haase, Econ Century Foundation
Louise Maxwell in Texas asks: How much will be deducted monthly from my present social security check to pay for this "coverage" that we are being presented?
Answer: If you sign up for a Prescription Drug Plan, you will pay the premium to the plan. You can choose one of several ways to pay; the plan will tell you the options. If you don't sign up for a plan, you don't pay anything for the coverage. There are dozens of plans to choose from, and their premiums and the details of what they cover vary. So take your time deciding whether to sign up for a plan and which plan to choose.
Source: School of Public Affairs, Baruch College, City University of New York
Gini Habayeb in Ohio asks: I am trying to find the best plan for my mother based on the medication she now takes (and might need in the future). I called Medicare and they suggested a plan, but how do I know it is the best one?
Answer: Which plan is best will depend on both financial and medical factors.
One good way to find out which plan is best financially would be to list the individual medications that your mother now takes and measure how much she would have to pay for these, in total, under each of several of the plans available in your area. What matters is your mother's total cash outlay each year. The total cash outlay is the sum of: premium payments; deductibles -- how much she must pay with her own money each year before the insurance kicks in; dollar co-payments of each prescription -- $5 for generics and $10 for brand name drugs, for example; co-insurance -- the percentage of drug costs that your mother would have to pay, even after paying deductibles and co-payments; and no-coverage zone -- the payments that your mother would have to make entirely on her own. Congress based its estimates of the cost of Part D on a no-coverage zone from $2,250 to $5,100 yearly.
Each plan will have different premiums, deductibles, dollar co-payments, co-insurance, and no-coverage zones.
Medically, it's important to learn whether a plan covers your mother's current medications (or medications that are at least as good and that she tolerates at least as well), and whether it works with her pharmacy.
Depending on your mother's income, she may qualify for special assistance that would greatly cut her total cash outlay. If she's eligible for this assistance, a plan with more benefits might be better for your mother, especially if she has high drug costs now or might have them in the future.
Source: Health Reform Program, Boston University School of Public Health
Joan Taylor in North Carolina asks: I don't think you can make a decision until you can compare prices of the drugs you are taking with what it will cost with the new plans. I would like to know if the cost of the medicines will be the same no matter what plan you use?
Answer: The short answer is no. There are significant differences among the new Medicare prescription drug plans that could have a big impact on the amount seniors will pay out-of-pocket for their prescriptions. Plans vary in terms of the specific list of drugs that are covered (known as the formulary). Clearly, enrollees will pay a lot more if they sign up for a plan that does not cover their drug than they would pay in a plan that does cover it. In addition, plans vary in terms of the amount enrollees pay for their medications when they go to fill their prescription, the amount enrollees pay when they go to preferred in-network pharmacy instead of an out-of-network pharmacy, and the prices for filling prescriptions at retail pharmacies versus mail order.
In addition, many plans have a coverage gap which means after the enrollee incurs $2,250 in total drug costs, the enrollee is responsible for 100 percent of costs until they qualify for catastrophic coverage.
Each of these differences is important to consider when thinking about which plan might be best for any given individual. Medicare.gov has two new online resources to help people compare plans. The first is called the Medicare Prescription Drug Plan Finder which allows individuals to compare out-of-pocket costs across plans, based on the specific drugs they take. The second online tool is the Formulary Finder which is designed to help consumers review plans to see if their specific drugs are covered, the cost-sharing requirements for each prescription, and any restrictions and/or limitations that the plan may impose, such as quantity limits. Those who do not use the Internet might try calling 1-800-MEDICARE.
Source: Kaiser Family Foundation
Paul Silicato in Boca Raton asks: My mother has Medicare and Medicaid. She currently pays zero for prescriptions using both coverage plans. Will Medicaid's involvement continue giving her free prescriptions? If not, what program do you suggest? She has very limited funds.
Answer: Your mother appears to be one of those with "very limited funds" who may be eligible for substantial subsidies under the current legislation. She is what the officials call a "dual eligible."
No one can predict for sure what would be best, but my advice is two-fold. Look up the Web site of The Center for Medicare Advocacy, which has offices in Washington, D.C., and search for information about the options for dual eligibles. And contact either the Medicaid office in her community or an advocacy group for low-income citizens. They will be able to advise you better about what will apply in your mother's state. But do not expect that she will be any better off than she has been under Medicaid and Medicare. Her drug bills will not be zero until and unless this plan changes.
Source: Ted Marmor, Yale School of Management
Pawel Borek asks: Can I get any comparison of plans in Illinois or address of advising station or any information?
Answer: The Center for Medicare and Medicaid Services -- the government agency that oversees the new Prescription Drug Program -- has a Web site that you can use to compare plans servicing your zip code. Here is the link: https://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/Questions.asp. Be patient -- a lot of people are using the Web site and it could be rather slow for the first day or two.
Kellogg School of Management Northwestern University
Ann Nuccio asks: My mother (90) is quite content with Illinois' Circuit Breaker plan and Medicare denied her. Will she now lose out on the plan she has used since its inception?
Answer: Your mother will definitely want to sign up for one of the new Medicare drug plans. However, she should also consider the Illinois Cares Rx plan. This is sponsored by the Illinois Department on Aging, the same agency that administers the Circuit Breaker Pharmaceutical Assistance plan. Illinois Cares Rx helps people in need cover costs that are not included under the Medicare Prescription Drug program. Here is a link to their website: http://www.state.il.us/aging/3hot/pharm-assist.htm
Source: Kellogg School of Management Northwestern University
Linwood Grant asks: I am a retired federal employee with full Medicare coverage (Parts A and B), as well as Blue Cross/Blue Shield federal health insurance that provides prescription drugs. There is a co-pay for each prescription $15 for generic and $25 for brand name. Between my wife and I, we pay about $200 a year in these co-payments.
Should I sign up for Medicare prescription coverage?
Answer: It's great that you already have solid coverage. You may be better off financially and medically in staying where you are.
First, and from the financial side, we should consider your total cash outlays for premiums, co-payments with each prescription, and annual deductibles (the amount you must pay before the insurance kicks in). Your current cash outlays are $200 for co-payments plus your Blue Cross/Blue Shield premiums. If those are for medications only, you should add the premium total to the $200 to see your current annual cash outlays. If your Blue Cross/Blue Shield federal health insurance covers more than medications, you'd need to estimate the share of your premiums going to medications. Maybe someone at Blue Cross/Blue Shield could give you an idea about that.
If you signed up for a new Medicare Part D plan, you and your wife might face cash outlays -- annual premiums, deductibles, co-insurance, and co-payments -- that are lower or higher than your current cash outlays. Also, some Medicare Part D plans will have zones of no coverage. Congress described a Part D plan with a no-coverage zone ranging from about $2,250 to $5,100 annually. That's a gap, a black hole, where there would be no insurance coverage at all, where you'd be on your own. Actual Part D plans can vary from this. To make the comparison, you could try to take your current medications and learn your cash outlays under a few of the new Part D plans available in your area.
Source: Health Reform Program, Boston University School of Public Health
