Transcript Deciphering Medicare Part D

Deciphering Medicare Part D
Susan Miller, Patient Education
Douglas A. Magenheim, MD, MBA, FACP
Medicare D Is Important for
Your Health Care
How many of you pay for most of
your prescription medicines?
Will Seniors Enroll?
Cost of Prescriptions Will Go Up
• The cost you pay today is much higher
than what you paid just 5 years ago.
• Medicare D insurance will help you with
the cost of your medicine.
• Yes, it is confusing to understand, but
Medicare estimates the average senior will
save a minimum of 30-40% on their drug
costs
Senior Spending on Prescription
Medications
$2,763*
Average annual out-of-pocket drug
costs among the Medicare population:
Projected:
$1,457*
$999
$644
2000
2003
2006
2013
Percentage of Seniors Not Taking All
Prescribed Medication
Seniors with coverage
33%
16%
Heart Failure
Seniors without coverage
31%
30%
17%
Diabetes
14%
Hypertension
SOURCE: Kaiser/Commonwealth/New England Medical Center 2001 Survey of Seniors in Eight States.
Understanding Medicare D
How does the plan work?
Overview of Plan
• Medicare Part A and B – now Part D for
prescription drug coverage
• 16 insurance companies are selling 57 plans
from which to choose
– Snowbirds must choose national plan
• You must enroll in a plan – you are not
automatically going to get prescription drug
coverage
• You must pay a monthly premium for this
ranging from $14 to $68 a month
• It is optional – you don’t have to buy it
Overview of Plan -- Enrollment
• You must enroll by Dec. 31, 2005 to have
coverage Jan. 1, 2006
– can change your mind before 12/31/05
• Must enroll by May 15, 2006 to avoid premium
penalty
– can change your mind 1 time before 5/15/06
• Each year, annual open enrollment will be held
in November for a January 1 effective date
– This will be the only time you can change your mind
each year.
Current Insurance Coverage*
Medicare and
Employer/Union
Coverage,
including the
Military
Original
Medicare Plan
with or without
supplemental/
secondary plan
Medicare
Advantage and
Other Medicare
Health Plans
Medicare and
Medicaid or
Other
State/Federal
Assistance
Programs
Which box describes the health insurance you have now?
*Does NOT include doctor samples, discount cards,
Medicare-approved drug discount cards with or without the
$600 credit, free clinics, or drug discount websites
Current Insurance Coverage*
Medicare and
Employer/Union
Coverage,
including the
Military?
Check your
company’s plan –
Most Employer
Coverage is
BETTER than
Medicare D Plans
Original
Medicare Plan
Medicare only –
Enroll in Part D to
save money on
your medicine
Medicare with
supplemental
plan – check your
supplemental plan
for drug coverage
Medicare
Advantage and
Other Medicare
Health Plans
New plans will
include drug
coverage. If you like
it – stay with it or
evaluate other
options from
Anthem, United, etc.
Medicare and
Medicaid or
Other
State/Federal
Assistance
Programs
No drugs through
Ohio Medicaid
effective 1/1/06.
Must choose
Medicare D Plan.
Extra Help with
benefits and costs
How does Insurance Work?
• Take your prescription to a Network pharmacy
• You will get an immediate discount on prescriptions
• If your plan has a deductible, you must pay for this out of
your pocket
– Deductibles are $0 -- $100 -- $250
• After deductible, you pay a percentage of the discounted
price OR a flat dollar amount
– Co-insurance percentage -- 25-75%
– Flat dollar copayments -- $0 to $60 per prescription
• Most plans have a coverage gap or “donut hole”
– After spending $2,250 (you and insurance company), you pay
100% of the cost up to $5,100 – or $2,850 out of your pocket
– Some plans offer limited coverage for generic drugs during this
gap.
• Catastrophic Coverage - You pay only 5% of the cost of
your drugs
What Else Should You Know?
• Insurance companies are selling both drug plans
and “Advantage Plans” – know the difference
and what they are selling
• You must use a network pharmacy – ask who is
in the network
• All plans have drug lists or formularies. If your
drug is not on the list, it may not be covered.
– What you pay for your medicine will depend on
“where” it falls on the insurance company’s list
• Some companies are partnering to sell their
plans through specific organizations
– AARP and Walgreens = United HealthCare
– Walmart and State Farm = Humana
Extra Help Is Available
• Financial help is available if:
– Your income is less than $11,500 (single)
– Your income is less than $23,000 (married)
• Apply for help with the Social Security
office
– If approved:
•
•
•
•
Little or no premium to pay
Little or no deductible
Copayments for drugs are $1 to $5
No coverage gap
– Still must enroll in a plan
To Apply For Financial Help
• For financial help: Social Security
Office
– Call 1-800-772-1213 to apply for help
– www.socialsecurity.gov
Premium Penalties
• Insurance companies want you to enroll
– They will try to talk you into the basic plan at $14 per mo.
• What if you don’t enroll?
– Cost to enroll for 1 year: $14.43/mo = $173.16/yr
– Cost to enroll 1 year later – 1% per month penalty = 12%
• $14.43 x 12% = $1.73
• $14.43 + $1.73 = $16.16/mo or = $193.92/per year
• Will cost you $20.76 to wait versus paying $173.16
to pay for something you may not use.
• No penalty if you are covered by employer or retiree
plan that ends
Cost of Medicare D Insurance
Sum of Expenses
2000
Cost of Plan
1500
1000
Cost of Plan
Starting After
One Year
500
0
1
3
5
7
Years
9
11
How do I Choose A Plan?
• Medicare.gov is most comprehensive
source of information
• How to use this tool and enroll in the plan
that is right for you!
• Have friend/family member help you
review the website
• Or Call 1-800-MEDICARE
Talking with Your Doctor
Understand the Plan You Choose
• Look at the list of your medications and
their costs
• Ask for a copy of the company’s formulary
drug list
• Bring your insurance formulary list to your
doctor’s appointment
– Will help the doctor understand the options
you have and help make decisions about
changing your medications
Talking with Your Doctor
• Don’t be afraid to ask the doctor what the
medicine is for and what other alternatives
there are (i.e. Can I safely switch to a less
expensive medication?)
• Ask your pharmacist and doctor about
generic alternatives
• Understand how often you must take your
medication and when
Talk with Your Doctor
• Most insurance plans will only give you a
30 day supply of medicine at a time
– Plan for this when you call the office for refills
or follow-up appointments
– Some offer 90 day mail in
• If you have to change your pharmacy, let
your doctor’s office know so your
information can be updated.
The Medicare Part D Plans
Questions?