Elderly Confused by Medicare Prescription Plan

ByABC News
November 12, 2005, 5:23 PM

FORT MYERS, Fla., Nov. 13, 2005 — -- Helen Garb is one stressed-out 79-year-old.

A retired business manager for a private school in Queens, Garb wants to spend her time enjoying her golden years -- working as a volunteer usher at a local theater, and visiting her two daughters and her grandchildren in New York and Los Angeles.

Instead, she's spending hours struggling to figure out which Medicare prescription drug plan is best for her.

"This whole program is so complicated that I have stayed awake at night thinking, 'How can a brain come up with anything like this?' " she says. "I am very angry that the government has done this to us."

On Tuesday, senior citizens and the disabled covered by Medicare can begin signing up for the drug benefit -- the biggest expansion of Medicare since the program was created in 1965. It is projected to cost $724 billion over 10 years.

But there is so much confusion surrounding the new program that only about one-fifth of seniors surveyed by the Kaiser Family Foundation and the Harvard School of Public Health said they'd sign up. And a low participation rate could threaten the success of the benefit.

Instead of a single, nationwide program along the lines of Medicare, the prescription drug benefit is market-oriented program. While heavily subsidized by the federal government, the plans are designed, offered and administered by private insurance companies, which are spending tens of millions of dollars to market them.

"Clearly, the people behind the closed doors who were drafting this legislation were mostly paying attention to the interests of the pharmaceutical industry and the insurance companies," says Robert M. Hayes, president of the Medicare Rights Center, an advocacy group. "There was very little thought by the designers of this program about what real people need."

The details of the plans -- premiums, deductibles, co-payments, covered drugs and participating pharmacies -- vary widely. Monthly premiums range from about $2 to $70; the average is $32.

Under the cheapest plans, participants pay the first $250 in prescription costs and $500 of the next $2,000 in costs. Then, a coverage gap -- sometimes called "the doughnut hole" -- kicks in: Participants pay the next $2,850 in drug costs out of their own pocket -- bringing total out-of-pocket expenses to $3,600. After that, you pay only 5 percent of total drug costs for the rest of the year.

More expensive plans have no deductible, no coverage gap and co-payments based on the cost of each drug.

Exactly which plans are available depends on where you live. Garb can choose from 43 plans offered by 18 different companies.

"This is choking me," she says. "I'm just ready to say, 'Forget it.' I'll play for my own medications. I don't want to be bothered by this."

How do you figure out what plan's best for you? The experts say if you're among the 10 million retirees who already have prescription drug coverage from a union or former employer, you should already have gotten a letter from them telling you if it's better or worse than the Medicare plans. If it's better, you probably don't want to do anything at all.

But if you're one of the 40 million who doesn't have drug coverage, you should find out

  • which plans cover your medications
  • what your out-of-pocket costs would be -- including premiums
  • and the pharmacies that participate. If you spend part of the year somewhere else, don't forget to find out if the plan is available at pharmacies there, as well.

Experts add that you shouldn't feel pressured to make a quick decision. Nov. 15 is just the first day you can enroll. As long as you sign up by the end of the year, you'll be covered when the program begins Jan. 1, 2006.

Enrollment for the first year stays open until May 15, although coverage won't begin until the month after you sign up.

If you sign up after May 15 and you are not currently covered by a private prescription drug plan, you will pay higher premiums for as long as you're enrolled in the program. That's because the government and insurance companies want as many people as possible to participate. If only those with high drug costs participate, insurance companies will likely raise their premiums -- which would further discourage participation.

Right now, many seniors say the hardest part is getting information. If you call Medicare's toll-free number, there's an automated menu of options that some seniors say confuses them. And if you want to talk to a live human being, there are long waits.

"I suggest you have a big cup of coffee, or a big cup of tea, or lunch, and be prepared to spend quite a lot of time," says Jo Marshall, a volunteer counselor for the Florida Elder Affairs Department.

Medicare Web sites that were supposed to have had the information starting Oct. 1 are just coming online now. But it's not clear how much help they're going to be, since 76 percent of the seniors questioned by the Kaiser Family Foundation/Harvard School of Public Health survey said they'd never been online.

That includes people like Helen Garb, who retired precisely to avoid the computerization of her work.

"Oh, go on the computer: W-w-w dot-com whatever," she says, mocking the advice she's been getting. "I don't want a computer."

So instead, she's got a lot of booklets, pamphlets and articles to go through.

Does she ever think this is a new government program to keep senior citizens off the streets?

"That isn't fair," Garb says with a mischievous grin and laugh. "I have a lot of fun in the street."