01/29/06 — Doctor: Patients still confused by drug plan

View Archive

Doctor: Patients still confused by drug plan

By Phyllis Moore
Published in News on January 29, 2006 2:08 AM

Changes in prescription drug plans offered through Medicare have got many scampering to untangle the information in time to take advantage.

WAGES, Wayne County Services on Aging, and the Social Security Administration are several agencies that have been holding seminars and information sessions for Wayne County seniors since August. There have also been sign-ups held, with WAGES and Services on Aging having trained counselors on staff and volunteers assisting where needed.

A local physician, Dr. Muin Dugom, has taken his own professional interest a step further, by working to educate his patients about the inner workings of the plan. He has been a frequent guest on local radio and PACC 10, trying to simplify the complicated plan as much as possible.

He said it has always been a problem that Medicare did not pay for prescription drugs, which he said left a "vacuum" for those who signed up for insurance plans. Yet when the Medicare Modernization Act was signed into law in 2003, he said it "seemed like nobody was ready for it or prepared."

Rather than have the vast majority of seniors be left in the dark, he said he started talking with patients about their options.

"Most of them had no clue that it existed, no idea about the deadlines. Some of them did not have any relatives to help them," he said.

His decision to reach more people, encourage and inform them has been rewarding, he said, even though he still finds that "the average patient out there doesn't have it."

It is still a work in progress, he said, having been introduced for patients to sign up by Dec. 31, 2005, with slight penalties imposed each month the beneficiary does not sign up by this year's deadline of May 15.

Dr. Dugom spoke about the most commonly posed questions about the new prescription plan.

What is Medicare Part D? In December 2003, the Medicare Modernization Act was signed into law. Under that, all Medicare beneficiaries are offered outpatient drug benefits under the new Part D.

Medicaid Part D will join the traditional parts A, B and C.

D actually covers inpatient hospital care, skilled nursing facilities, health and hospice care, and outpatient prescription drugs.

Set up like an insurance plan, patients will have to sign up for the prescription drug plan.

Who is eligible? Seniors, certain disabled persons and those with in-stage renal disease, for the voluntary Medicare drug prescription plan. A few exceptions must actively select and enroll in the plan.

For 2006, beneficiaries can sign up between Nov. 15, 2005 and May 15, 2006. For every month that the beneficiary does not sign up, the premium rate increases.

In general, will pay a monthly premium plan deductible, co-pay and insurance. Qualifying beneficiaries will receive substantial financial help with drug costs.

What is the cost to the patient?

Costs will vary depending on which medical prescription drug plan beneficiary chooses. In general, will have to pay the following costs in 2006: Monthly premium to participate (usually about $32 a month), yearly deductible before prescription drugs are paid ($250).

How does the plan work with the co-pay for insurance and deductible?

In general, after meeting the yearly deductible, the beneficiary will pay the share of his or her drug cots and the plan will pay a bigger share.

The beneficiary will pay 25 percent of the drug costs known as the co-insurance until the total cost of the drugs reaches $2,500.

After that, the beneficiary will pay 100 percent of the next $2,850 in drug costs.

For the total drug costs of $5,100, the beneficiary would have paid $3,600 out of pocket. In a year, the plan pays most of any additional drug costs for the rest of the year.

How do you get extra help with medical prescription premiums, deductibles, and co-payments?

The amount a beneficiary pays depends on his income and resources, such as savings accounts, stocks, bonds, real estate, etc. the beneficiaries own.

Beneficiaries can contact the Social Security Administration or the state Medicaid office to find out if they qualify.

Explain more about the process of enrollment for people with Medicare and Medicaid.

In October 2005, beneficiaries received a handbook for 2006, which included a list of all the drug plans available. Drug plans have also been releasing details about the plan since last fall. This information is still available on the Medicare Website, www.medicare.gov or by calling 1-800-Medicare.

As far as the penalties are concerned, if eligible beneficiaries do not sign up for a drug plan by May 15, the monthly premium may cost them more. The late enrollment fee is about 1 percent for each month before the beneficiary enrolls in the plan.

If the beneficiary is late joining the drug plan because of other qualifying drug coverage such as a plan with a former employer, the late fee may not apply.

People with both Medicare and Medicaid will be able to choose a Medicare drug plan or sign up for a plan beginning Nov. 15, 2005.

If the person does not choose a plan by Dec. 31, 2005, Medicare will enroll that beneficiary into a plan on Jan. 1, 2006. People with both Medicare and Medicaid can change plans at any time. Also Medicare will pay the full amount for the plan premium if those beneficiaries with both Medicare and Medicaid.

To find out more about eligibility through Social Security for lower income subsidy, call 1-800-772-1213 or go to www.ssa.gov.

If a beneficiary has applied for and been determined to be eligible for low-income subsidy but has not signed up or a plan by May 15, Centers for Medicare-Medicaid will help enroll the beneficiary into a plan.

Under certain circumstances, beneficiaries will be able to enroll in a different prescription plan or disenroll from a plan and enroll in another one under the special enrollment period.

What drugs are not covered? There are several classes of medications that are not covered under this plan, including barbiturates, non-prescription vitamins (except prenatal vitamins and fluoride preparations), agents used for cosmetic purposes or hair growth, to promote fertility, agents used for anorexia, weight loss or weight gain.

What if the patient, family or physician wants a drug that's not available or a co-payment reduction?

This is another hot topic area. The answer is that for years, the drug benefit contains an exception or appeals process, which is intended to ensure the beneficiaries have access to prescription drugs they need.

By providing a straightforward process for them to obtain a covered drug that's not on the plan, must provide information about the exception and appeals process to beneficiaries to sign up for the plan. The physician can do that on behalf of the enrollee.

What about the time frame for the exceptions and appeals?

Plans must make their determinations regarding exception requests as expeditiously as possible, but no later than 24 hours for an expedited decision on serious health conditions, and 72 hours regarding a standard decision.

If a plan does not make a coverage determination within the appropriate time frames, a decision is automatically forwarded to the independent review entity for consideration.

There are several levels of appeals and this process will obviously vary from plan to plan.

Do beneficiaries have to drop their drug coverage if they are receiving it from a former employer? No. The patient should be notified of any changes to existing drug coverage and information regarding available options.

What if beneficiaries can't pay the co-payment?

Under the prescription drug benefits, pharmacists are permitted to waive the cost sharing on case by case noon-routine and unadvertised basis if the pharmacist determines that the beneficiary is financially needed.

From your standpoint, what steps should patients who have not enrolled yet in a drug plan take before the May 15 deadline?

I recommend a five-step plan for patients who do not have Medicare and Medicaid. They actually have to enroll themselves in Medicare Part D.

First, prepare the information needed, which includes a list of medications being taken.

Second, contact Medicare by calling 1-800-Medicare (633-4227) or go on-line to www.medicare.gov and ask for the prescription drug plans in that area. We currently have about 38 plans in North Carolina. Those who might qualify for low-income subsidies can contact the Social Security Administration for an application.

Third, contact the preferred plan directly and request application information.

Fourth, since all the plans are not the same, obtain specifics to determine out of pocket costs, premiums, deductibles, and co-payments. Also, the pharmacy network to make sure they're included and signed up with that plan.

Fifth, complete an application and return it to the plan to get enrolled.

Summarize all the resources that patients can use to get additional information.

*1-800-Medicare (633-4227)

*Web site: ww.medicare.gov

*Social Security Administration - 1-800-772-1213 or www.ssa.gov

There is also plenty of information available on Centers for Medicaid at www.cms.gov, and a Website to educate patients at www. Medicare.rxeducation.org and on the AARP Web site at www.AARP.org.