Health Under Medicare

May 6, 2010    Volume 1, Issue 10

People with Medicare who hit the coverage gap or “doughnut hole” in the Medicare drug benefit next year will receive a 50 percent discount at the pharmacy—without having to send in receipts or request a refund—according to draft guidance implementing the recently passed health reform law.

The guidelines from the Centers for Medicare and Medicaid Services (CMS) also state that the insurance companies offering Part D plans will inform pharmacies through their electronic claims systems when consumers are eligible for the discount, although the discounts will come from drug manufacturers.

State pharmaceutical assistance programs (SPAP) that provide coverage through the doughnut hole will also benefit from the discounts, while consumers enrolled in these programs will continue to pay the copays charged by their SPAP. Consumers enrolled in Part D plans offered by their employers, which often provide coverage through the doughnut hole, will not be eligible for the discount, according to CMS’s proposed guidance. The guidance is open for public comment until May 14, 2010.

Read the CMS draft guidance.       

Under current law, the Medicare Part D coverage gap, or “doughnut hole,” is projected to double
in size by 2021, exposing seniors to drastically increased liability for the costs of their
medications. This characteristic of the coverage gap makes it exceedingly expensive to correct –
Congress must dedicate significant resources simply to keep the gap from becoming larger every
year; reversing the momentum takes an even greater commitment of funds. The House of
Representatives has proposed to provide additional protection to seniors from the cost of
prescription drugs by closing the doughnut hole completely, though the high cost requires this
closure to be phased- in over time. According to a recent analysis by the National Committee to
Preserve Social Security and Medicare, the provisions to close the coverage gap in the House’s
America’s Affordable Health Choices Act (H.R. 3200) would close the gap by 2023. The
financial protection afforded by the bill becomes progressively stronger beginning in 2011,
providing increasing relief to seniors experiencing the coverage gap throughout the phase-out
period.
 from: National Committee to Preserve Social Security and Medicare

On January 12, the Centers for Medicare & Medicaid Services (CMS) suspended enrollment in WellPoint’s Medicare private drug and health plans and suspended all marketing activity for those plans because of the Indiana insurer’s persistent failure to ensure that its enrollees have access to the drugs they need. CMS issued the sanctions after a marked increase in complaints by people enrolled in a WellPoint plan.

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Medicare Part D Update: Premium Hikes and Drug Plan Changes Mean Seniors Should Consider Options for 2009

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In January 2009, Medicare Part D premiums will increase by the
largest amount since the program was implemented, according to data
from the Medicare Trustees and the Centers for Medicare and Medicaid
Services (CMS). ¹
Alarmingly, for the 10 most popular prescription drug plans, premiums
will jump by 30 percent, according to an analysis by the Avalere Health
data group. This premium spike highlights the need for seniors to take
a second look at their Part D coverage to make sure they are getting
the best value from their drug plan and will not be surprised by
increasing costs.

During the annual open enrollment period for the program – which
runs from November 15 th to December 31 st 2008 – seniors should be
aware that drug plans can change the drugs they cover, the co-payments
charged, and the coverage rules they use. In choosing a plan for 2009,
it is important to examine these changes in coverage in addition to the
cost of premiums and deductibles.

Low-income beneficiaries who participate in the Part D “extra help”
program have a particular concern during open enrollment. More than 1.6
million of these beneficiaries will be automatically reassigned to new
drug plans by CMS ²
unless they choose one themselves by December 31. This reassignment
will be random as CMS will not try to match beneficiaries with the
plans that best meet their needs. In addition, many of these
beneficiaries will have fewer options available to them. It is
important that these seniors consider their options carefully.

All beneficiaries should be aware of new federal marketing rules
that have been put in place to curb recent abuses in sales practices by
agents working with private Medicare Advantage managed care plans and
stand-alone prescription drug plans in a number of states. A list of
banned practices is provided below. In general, in evaluating
information about the plans, beneficiaries should be wary of any sales
solicitation that they did not request.

Under the current Part D program, however, seniors
are given only six weeks each year to make difficult decisions about
their prescription drug coverage, and they are then locked into the
plans they select for an entire year. This year’s Annual Coordinated
Election Period (ACEP) begins on November 15, 2008 and lasts until
December 31, 2008 . It is only d uring this open enrollment period that
most seniors are permitted to enroll in a Part D plan, drop Part D
coverage, or switch to a different plan. While most seniors will be
locked into the plans they select for all of 2009, plans are allowed to
make significant changes to their prices, formulary, and benefits
throughout the year. In addition, many plans have already announced
significant changes to their coverage for next year. We strongly
encourage you to closely examine how your current coverage will change
in 2009. It might be to your advantage to choose another plan that
better matches your prescription needs and your cost expectations.

Check the new handbook

2. LOW-INCOME PEOPLE WITH MEDICARE FACE REASSIGNMENT AS DRUG PREMIUMS RISE

At least 1.3 million low-income people with Medicare will be reassigned to a new prescription drug plan in 2009, as the number of drug plans that qualify for a full premium subsidy dropped from 495 in 2008 to 308 in 2009, according to Avalere, a health consultancy firm.

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Much has been written about the offer by Walmart and Target to fill generic prescriptions for $4 for 30 days supply and $10 for 90 days supply. However be informed and aware before transfering prescriptions there.  They publish a list of the medications covered under the plan - and you can check to see that your medications are on the list by going to their web page or calling them in advance.  But also check carefully the dosage and size of the prescription. If you have a 180 MG prescription and they only list a 50 MG prescription you will be charged the regular cost of the drug. Also for some prescriptions they will charge more because of “extra import taxes” or  other expense they have to pay.  Consider that  if your medication is not listed in the exact dosage that you are prescribed you will be charged the regular market rate - in which case you need to determine if you are better off staying with your original pharmacy and plan.

June 19, 2008 • Volume 8, Issue 25

People who hit the doughnut hole aka the gap in coverage built in to the Medicare drug benefit, are painfully aware of the high prices Part D drug plans charge for brand-name drugs.

What many people do nott know, however, is that a number of Part D plans, as well as Medicare private health plans, charge inflated prices for generic drugs. These prices are far higher than either widely available retail prices or the reimbursement rate that the plans pay drugstores for the very same drugs.

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For all the complexity of health insurance, the idea behind it is pretty simple. You and millions of other people pay premiums so that those who get sick will be protected, particularly if the illness is severe or debilitating. But increasingly — and to policyholders’ surprise — that’s not the case when someone needs the most expensive drugs.

Policyholders might find out only when they or a family member suffer a serious illness — such as multiple sclerosis, rheumatoid arthritis or many types of cancer. Then they are faced with a financial catastrophe on top of a health crisis: Costs can run as high as $100,000 a year for some medicine needed to cope with a serious disease.

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Mrs. L was enrolled in a Medicare private health plan, an HMO, with prescription drug coverage (Part D). Even with that coverage, she was having trouble paying for her medications because the copayments were very expensive. In January, she decided to enroll in a stand-alone prescription drug plan that offered lower copayments for her medications. Mrs. L assumed that she would be able to keep her health coverage through the Medicare private health plan, but would just get her prescription drug coverage through the stand-alone drug plan. But then she got a letter from the HMO stating that she had been disenrolled. Realizing that she must have made a mistake, Mrs. L called 800-MEDICARE to say that she wanted to re-enroll in the HMO. However, the Medicare representative told her she would have to wait until the next enrollment period—in November—to make another change and her new coverage would not start until January.

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