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Gearing up for Open Enrollment: An Online Chat on Medicare Part D

MedicationOctober 10, 2012, Online Q&A Chat

Amy Jackson of the Caring Voice Coalition and Doug Taylor, a PHA support group leader, discuss tips on preparing for the Medicare open enrollment period — from what to look for in a Part D plan to how to navigate the online plan finder.

Chat Transcript

Moderator
Daniela Maristany, PHA Insurance Program Associate

Panelists
Amy Jackson, Caring Voice Coalition
Doug Taylor, PHA Support Group Leader

moderator_daniela_maristany_pha: Good afternoon and welcome to “Gearing up for Open Enrollment: An Online Chat on Medicare Part D.” My name is Daniela Maristany and I am the Insurance Program Associate at the Pulmonary Hypertension Association.

Today we will start with some basic information about Medicare and then move on to answering questions that were submitted beforehand and any new questions that you submit today. If you have a question, simply type it into the yellow chat box below the chat room. Don’t be concerned if the chat doesn’t appear immediately in the chat room, as it must be filtered through the moderators first.

We will try to answer all questions during the chat, but any unanswered questions should be redirected to the Caring Voice Coalition at 1-888-267-1440 or to the Medicare Rights Center’s hotline at 1-800-333-4114.

Before we start, I want to thank our panelists who took the time to chat with us today and give them a chance to introduce themselves.

panelist_doug_taylor: Hi, Chatroom. I lead a support group in Lexington, SC and have gone through several reviews of my personal Medicare coverage. It can be important to do an annual review of your coverage to be sure you have adequate insurance. Hope this chat helps you all.

panelist_amy_jackson_caringvoice: Hi, My name is Amy Jackson and I am a Trainer/Case Manager Specialist at the Caring Voice Coalition. I have been working with Medicare patients for 7 years and look forward to answering your questions!

moderator_daniela_maristany_pha: Great! Thank you Doug and Amy. The chat is open for your questions! Just enter them into the yellow box. As you are thinking of your questions, Amy is going to give an overview of Medicare Part D.

panelist_amy_jackson_caringvoice:

Medicare Part D is Prescription Drug Coverage available to everyone with Medicare. You must select and enroll into a plan during specified enrollment periods. Medicare Part D coverage is included with most Medicare Advantage plans but there are Advantage plans that do not offer drug coverage.

The initial enrollment into Part D coverage is available during a 7 month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

Example: Your birthday is October 9, 1947 – You can enroll into a Part D plan during the months of July, August, and September; the month of October; OR the months of November, December, and January.

If you are new to Medicare because you’ve been found disabled by the Social Security Administration for 24 months, the same rule above applies except the initial enrollment is available during a 7 month period that starts 3 months before your 25th month of receiving Social Security or Railroad benefits, includes the 25th month, and ends 3 months after your 25th month of receiving disability benefits.

Example: Your 25th month of receiving disability benefits is October 2012 – You can enroll into a Part D plan during the months of July, August, and September; the month of October; OR the months of November, December, and January.

Effective Date: The effective date of your plan depends on when you enroll. If you enroll within the three month before you turn 65 or before your 25th month of receiving disability benefits, your effective date will be on the 1st day of the month you are eligible.

Example: You turn 65 on October 9, 1947 and enroll into a Part D plan in the month of August. Your plan effective date will be October 1, 2012.

If you enroll during or within the three months after the month you turn 65 or after your 25th month of receiving disability benefits, your effective date will be on the 1st day of the following month you enroll.

Example: Your 25th month of receiving disability benefits is October 2012 and you enroll into a Part D plan in the month of January 2013, your effective date will be February 2013.

The Annual Election Period (AEP), also called the Open Enrollment Period, is the time of year in which anyone with Medicare can join, drop, or switch Part D plans. Each year, the Annual Election Period begins on October 15 and ends on December 7. The effective date of your plan if you enroll during the open enrollment period will be January 1st of the following year. ** Enrollment into a Part D plan is not required when you are first eligible but it is important. If you don't join a Medicare Part D plan when you are first eligible for Medicare, and you don't have other creditable prescription drug coverage, you may have to pay a late enrollment penalty with your monthly premium if you decide to enroll later. You may also have to pay a late enrollment penalty if you go without Medicare Part D coverage or other creditable prescription drug coverage for 63 days or more in a row. The penalty is 1 percent for every month that you didn't have creditable coverage.

Special Enrollment Periods (SEPs) are special circumstances that allow you to make changes outside the specified enrollment period above. Rules about when you can make changes and
the type of changes you can make are different for each SEP.

panelist_amy_jackson_caringvoice: I will now answer one of the questions previously received during the chat registration:

Q: Please explain the difference between a Medicare D program, some of the other insurance out there, and Advantage plans.

A: Medicare Part D covers prescription drugs only! Most Medicare Advantage plans combine Medicare Part A, Part B, and Part D. Some Advantage plans do not over drug coverage but most do. A Medicare Advantage plan is offered by a private company and contracts with Medicare to provide you with all of your Part A and Part B benefits. If enrolling in a Medicare Advantage plan, you are still responsible for the Part B premium (standard part B premium is $99.90).

panelist_doug_taylor: My plan happens to be a Medicare Advantage Plan with drug coverage. It is a PPO and I have been happy with it.

karen_o: Will the part b premium be increasing?

moderator_daniela_maristany_pha: No, the Part B premium will be staying constant at $99.90.

panelist_amy_jackson_caringvoice: Hi Merle. Plans may have outlined in the benefits a cap on costs per year. However, you should never be refused care. It is important to read through all of the plans benefits (especially caps) before enrolling.

panelist_amy_jackson_caringvoice: To review what the different parts of Medicare do:

Medicare A covers Hospital benefits Medicare B covers doctors, part B drugs, and other benefits. A Medicare Advantage plan is also known as Part C and, as mentioned above, combines A, B, & D. Medigap plans, also known as supplemental plans, supplement what A & B do not cover. Part D covers medications

Cmorres: Do you have to pay more for an Advantage Plan?

panelist_doug_taylor: This year I paid the $99.90 plus a monthly premium about $70. In 2013, there will be no monthly premium on my plan. Both years there is a maximum out of pocket that I meet, but after that, everything is covered. For me, on Remodulin, this has been the best plan available in South Carolina.

panelist_amy_jackson_caringvoice: There are many Advantage plans and some do not have a premium. However, you are still responsible for the part B premium. If you’re Advantage plan does not have a premium, you will only pay the part B premium. If the Advantage plan has a premium, you will pay both.

Merle: But is there a limit to stays in the hospital -- many of us make frequent visits :(

moderator_daniela_maristany_pha: Hi Merle, are you referring to the recent change in Medicare reimbursements, where hospitals that have excessive readmission rates will receive up to a 1% reduction in their reimbursements from the government? This fine on hospitals for readmissions will not affect you getting care in the hospital; it only means that the hospitals receive less money.

panelist_amy_jackson_caringvoice: Please keep in mind also that availability of plans varies by the area in which you reside. This includes Advantage plans and part D plans.

LaDona_Walters: When I had private insurance, which covered Rx Drugs, I never had a problem with being covered. Unfortunately I was kicked off the private insurance and don't understand how some drugs under the Medicare part D are not covered.

panelist_doug_taylor: LaDona, you aren't the only one! But, the coverage is based on the plan you choose. Some plans have broader coverage than others -- more drugs are covered. That is why it is important to try to find a plan that covers the drugs that you have been prescribed.

LaDona_Walters: What is the name of your plan in South Carolina? Is it a Medicate Part D plan?

panelist_doug_taylor: My plan is a Medicare Advantage Plan that includes Medicare Part A, B, & Part D. It is offered by Care Improvement Plus.

moderator_daniela_maristany_pha: Hi LaDona, this website has a very helpful plan finder: https://www.medicare.gov/find-a-plan/. You enter all of your medications and your zip code and the site shows you available plans in your area

panelist_doug_taylor: The website is VERY helpful in finding the best coverage for YOU that is available in your area.

Cmorres: What about the Medicare Part D “donut hole?” Has it been closed?

panelist_amy_jackson_caringvoice: Hi cmorres! Unfortunately it has not been closed. However, it is being reduced each year. If the healthcare reform continues as scheduled, it is projected to be closed by 2020.

moderator_daniela_maristany_pha: To follow up on the question about the "donut hole," the Affordable Care Act (ACA), also known as healthcare reform, gradually closes the Medicare Part D coverage gap or “donut hole.” Previously the donut hole required patients to pay 100 percent of medication costs out-of-pocket after their and their insurers’ contributions reached a pre-determined amount (usually $2,930) and before catastrophic coverage began, costing patients an average of $3,600 out-of-pocket. Starting in 2012 these out-of-pocket costs will be reduced, and by 2020 patients will only be responsible for 25 percent of brand name and generic drugs.

karen_o: What is an initial coverage limit?

panelist_amy_jackson_caringvoice: This is the total amount you must pay for prescription drugs before you reach the donut hole. The initial coverage limit for 2012 is $2,980.

Cmorres: once you have reached the limit... what is the normal cost for drugs? Or does it depend on the type of coverage you get?

moderator_daniela_maristany_pha: Hi Chris. Once you reach the limit, then you are unfortunately in the "donut hole" and you have to pay for 50 percent of the cost of brand name drugs and 86 percent of the cost of generic drugs until you reach an out-of-pocket limit. This reduction in payment to 50 and 86 percent of drug costs from 100 percent is due to the Affordable Care Act. After you reach the out-of-pocket limit (meaning you've paid a certain amount of money out of your own pocket), then you move into the catastrophic phase, where 95% of your costs are covered. This coverage gap or "donut hole" can be incredibly straining on people, which is why the ACA works to close the donut hole by 2020.

moderator_daniela_maristany_pha: Hi Chris, to follow up on the donut hole question, here is a handy chart that explains the donut hole: http://www.phassociation.org/page.aspx?pid=2110

Merle: What suggestions do you have for those on Medicaid and Medicare who don't have choices

panelist_doug_taylor: Pray! You kind of answer your own question. If you don't have a choice you go with what you have. Merle, you are a terrific self-advocate, and that is especially important if you are on a predetermined plan with Medicaid and Medicare. You might see if your plan offers 'patient advocates' or 'case managers' to help you get the treatments you need. If you can hook up with a care manager and educate them about PH, they can go to bat for you. I have taken advantage of care managers myself.

panelist_amy_jackson_caringvoice: Now I will answer some more questions asked before the chat:

Q: I start Medicare in January and just need to know what to look for in a plan.

A: The type of plan you want to look for depends on your individual situation. Some of the questions I would ask include:

Are you looking for a Part D plan only or an Adv. Plan? What medications are you taking and how do you receive those medications (Specialty Pharmacy, Local Pharmacy, or Mail Order)? If you are looking for a Med. Adv. plan, do you have specific doctors you’d like to see? How much can you afford to spend on a premium?

Q: How can denial of a new medication (ie brand name such as Ilopost, Tracleer, or Flolan) by Medicare Part D be appealed?

A: Some of the medications listed are usually covered under part B and one is covered under part D. If covered under part B, you can appeal Medicare’s decision through the Medicare appeal process. A good resource, if you have internet access, is http://www.medicarerights.org/. If your medication is covered under part D, you must follow the appeal process for the part D plan in which you are enrolled.

panelist_doug_taylor: I've had good luck appealing Part D drug coverage -- with my doctors going to bat and explaining why I needed a particular medication. I have even gotten coverage for drugs not on the plan. As long as they are within Medicare's approved drugs.

panelist_amy_jackson_caringvoice: Another previous question:

Q: Are Tyvaso, Tracleer, and Tevatio covered by Medicare Part D?

A: Tyvaso is usually covered under part B with a 20% coinsurance. If you join a Medicare Advantage plan, it will usually limit your cost with an annual out of pocket max. If you are already enrolled in a medigap plan, you will not need a Medicare Advantage plan and most Medigap plans will pick up that 20%. Tracleer and Revatio are covered under Prescription benefits and would be included in part D coverage. However, be sure to check the plan’s formulary.

Merle: When insurance companies don’t want to pay for your medications, ask your doctor to continue to fill out those forms and all the red tape that is involved. It seems persistence is the key to this horrendous issue that many of us face. I have been known to contact my politicians whether it is at the local level or the federal level. They have aides who specifically work with this problem – insurance issues.

You could also be denied coverage if the proper paper work is not included such as a copy of a right heart catherization which shows a mean pap (pulmonary arterial pressure) greater than 25 and a wedge of less than 15 or if there is an improper diagnosis. Medicare uses a set of service codes and sometimes providers accidentally use the wrong codes when filling out paperwork, which can result in denial. Denial claims can sometimes be easily resolved by checking with your doctor that it was submitted with the correct codes. If it was submitted with the wrong code, ask your doctor to resubmit the claim with the correct code.

moderator_daniela_maristany_pha: Merle has a good tip about being persistent in the face of a lot of red tape. Thanks Merle!

moderator_daniela_maristany_pha: The State Health Insurance Assistance Program (SHIP) is a great resources for one-on-one counseling on Medicare questions. You can learn more here: https://shiptalk.org/public/home.aspx?ReturnUrl=%2f

LaDona_Walters: Will the medicare web site previously suggested, find a plan, list all of Medicare's approved drugs?

panelist_amy_jackson_caringvoice: The Medicare website will bring up a list of all the plans available in your area. It will show you if the medications are covered, if they have restrictions, and will even show you how much they will cost in the initial coverage limit, donut hole, and catastrophic levels of coverage. For Medicare Advantage plans, it will detail both prescriptions benefits and health benefits. Caring Voice Coalition Case Managers can also assist with navigating through the process.

panelist_doug_taylor: Insurance is very confusing. But, there are two places you can go to get some help with your shopping. The first is the State Health Insurance Information Program (SHIIP) -- I think that is the name of it -- in SC it is in the Lt. Gov. Office on Aging. They have counselors that can help you. The second one is to ask Caring Voice Coalition to help you.

panelist_doug_taylor: That link is posted above. Scroll up to find it.

moderator_daniela_maristany_pha: Going back to the SHIP question, here is a site that has a SHIP office locator, as the name for the program in each state can vary slightly. http://www.hapnetwork.org/ship-locator/ Hope this helps!

panelist_doug_taylor: Another question I hear a lot is “Do I really need to shop for a Part D plan again, my medications are not changing??” It is always good practice to review both your Medi-Gap or Medicare Advantage plans and your Part D plan. Your medications may not be changing, but sometimes the plan's coverage changes. Also, other plans become available and you might be able to get better coverage or save money with a different plan. So, in my humble opinion, yes you should shop around each year.

Cmorres: I am still on my husband’s insurance, who would be my primary if I choose to go on Medicare A/B/D and would this help to bring my cost down? I have 10,000 out of pocket now and am on a lot of the most expensive PH drugs now.

panelist_amy_jackson_caringvoice: Who pays first depends on several things. If you are 65 or older and your husband's employer has 20 or more employees, the group would pay first. If 65 or older and the employer has less than 20 employees, Medicare pays first. Regarding your concerns about bringing the cost down would depend on the medications you are taking.

Cmorres: I am not 65, got a ways to go.

panelist_amy_jackson_caringvoice: That's a good thing :) If you are under 65 and covered by a group, the group coverage would pay first.

panelist_doug_taylor: Since we are talking about Part D, which is drug coverage, let me remind everyone to look into Patient Assistance Programs for assistance with drug coverage. Caring Voice Coalition also has grants for some meds for qualified patients. Accredo also has grants for qualified patients (for Remodulin, Veletri, Tyvaso… prostacyclins). Daniela has a great link to PAPs on PHA's website.

moderator_daniela_maristany_pha: Here you go Doug! http://www.phassociation.org/page.aspx?pid=2034

StephMN: If I were to change insurance companies, would they tell me up front if I could still be denied because of my pre-existing diseases? And would they tell me if my med's would be covered?

moderator_daniela_maristany_pha: Hi Steph, The Affordable Care Act prevents insurance companies from denying coverage due to pre-existing conditions for children under 18 years old. Starting in 2014, insurance companies will also be prohibited from denying coverage to adults with pre-existing conditions. However, if there has not been a gap in your coverage for more than 63 days then the new insurance company is required to cover you, regardless of your pre-existing conditions. The key is not having gaps longer than 63 days.

panelist_amy_jackson_caringvoice: Caring Voice Coalition looks forward to speaking to PH patients who have questions or concerns regarding coverage. It is our mission to serve you!

moderator_daniela_maristany_pha: At this time we have to end the chat, but if you have any unanswered questions please direct them to the Caring Voice Coalition at 1-888-267-1440 or to the Medicare Rights Center’s hotline at 1-800-333-4114. I would also direct you to Medicare Rights’ site www.medicareinteractive.org. It has an extensive set of information about Medicare, including a search function so you can search for topics like “oxygen” that pertain to PH patients. Another great resource, mentioned earlier, is www.medicare.gov/find-a-plan. This will allow you to customize your search to find the best plan for you.

panelist_doug_taylor: Thank you all for coming to the chat room.

moderator_daniela_maristany_pha: Thank you so much to Amy and Doug for giving us their expert advice! And thanks to all who participated in this chat!

Caring Voice Coalition’s patient line is 888-267-1440.

You can also contact PHA's insurance program at Insurance@PHAssociation.org.

 

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