Medicare Plan D FAQ

Q: Who is eligible for the Medicare Drug benefit?

Individuals with Medicare Part A or Medicare Part B, and who live in the service area of a prescription drug plan or MA-PD plan, are eligible to enroll.

Q: How do I join a Medicare Prescription Drug Plan?

Call 203-237-7900 to discuss your PDP options.

Q: Can an individual enrolled in a Medicare HMO join a Medicare D PDP?

If you are enrolled in a Medicare HMO, you can not also enroll in Medicare Part D PDP. Your prescription drug coverage will be covered by the HMO through a Medicare Advantage Prescription Drug Plan.

Q: Is there a penalty for late enrollment?

Yes. If you are currently Medicare eligible and do not join a plan and you do not currently have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage (creditable coverage), your premium cost will increase 1% for every month that you do not join. Similar to Medicare B coverage, this increased premium will have to be paid as long as you utilize Medicare prescription drug coverage. Dual eligibles are not subject to this penalty as they will be auto-enrolled and not subject to paying premiums.

Q: Who can enroll an individual in a Medicare Part D plan or apply for "extra help"? What about individuals who do not have the capacity to make a PDP selection?

 A representative would have to be a parent or guardian in order to select a PDP on behalf of an individual. Representative payees are not considered eligible for this function. The rules for completing the "extra help" application are more relaxed in that anyone can apply for "extra help" on behalf of individuals.

Q: Who is a "dual eligible"?

A "dual eligible" is a person who has both Medicare and full Medicaid coverage. These individuals are also referred to as "full dual eligibles."

Q: How will dual eligibles be assigned to plans?

Dual eligibles will be randomly assigned to plans in their geographic region. A dual eligible individual may change plans on a monthly basis without penalty.

Q: How will dual eligibles be informed of their auto-enrollment assignment?

CMS will mail letters on yellow paper to dual eligibles at the end of October notifying them of the plan that they will be assigned to, if they do not select a plan on their own. Dual eligibles will have a continuous special enrollment period and may therefore change plans on a monthly basis without penalty.

Q: What would happen if a full dual eligible disenrolls from a plan and does not re-enroll in another plan?

The individual would not have access to prescription drug coverage.

Q: Do full dual eligibles have to pay for the gaps in coverage (deductibles, coinsurance)?

No. Full dual eligible individuals will not have any out-of-pocket expenses except for the applicable co-payments.

Q: Will Medicaid pick up the co-payments for the dual eligibles?

No. Medicaid will not cover co-payments.

Q: Are mental health drugs exempt from co-pays?

No. Co-payments are required for all medications. Individual pharmacists have the option to waive co-payments, based on financial need, but this is done solely at their discretion.

Q: Does a pharmacist have to fill a prescription if the person refuses to pay the co-payment?

No. Not collecting a co-payment is solely at the pharmacist's discretion.

Q: When a psychiatrist determines that an individual needs a prescription written in small supplies will the individual have to pay the co-payment each time they pick up medication?

Yes.

Q: What is "extra help?"

Extra help is a subsidy for individuals with low incomes who may not be able to afford the Medicare Part D premiums, deductibles, and co- insurance. For qualified individuals, all or part of the Medicare Part D premiums, deductibles, and co-insurance will be covered by this subsidy. Dual eligibles automatically qualify for extra help and will not have to pay premiums or apply for the "extra help." Other deemed eligibles include Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLIMB) and Qualified Individuals (QI).

Q: What if I have a change in my income?

The "extra help" is available to the individual for one year regardless of changes in income or circumstances.

Q: What if a medication is currently paid for by Medicaid, but is not on any of the formularies for Medicare Part D?

If a plan does not cover a specific drug, it is required to utilize a minimum transition period of 30 days where the current drugs will be covered while the enrollee works with his or her doctor to find an alternative drug that is covered by the plan. If the doctor believes that the enrollee needs to take the current prescription drug and should not switch to another drug, the doctor can initiate an "exception" process to have the drug covered. If the plan refuses to give an exception, the plan's decision can be appealed.
Individuals who are currently stabilized on certain drugs for depression, cancer, or HIV/AIDS will not have to switch to different prescription drugs. Enrollees should consult their doctor or pharmacist to see if specific prescription drugs qualify. When individuals enroll in a PDP, the drug plan will send information about its appeal procedures.

Q: Do the plans have the ability to review drug use patterns?

Yes. Plans may use a medication therapy management program (MTMP) with a goal to optimize therapeutic outcomes and to reduce the risk of adverse effects.

Q: How is Medicare Part D affected for someone in an inpatient facility?

When an individual is in an inpatient facility, medications are covered by Medicare Part A. Upon discharge, Medicare Part D coverage will resume. In State operated psychiatric centers designated as an IMD (Institute for Mental Disease), the psychiatric center is able to bill Medicare Part D for the individual's drugs when their Medicare Part A coverage is exhausted.

Q: What happens to an individual's Medicare Part D coverage when he/she leaves a long-term care facility?

The individual will have a special enrollment period and can change his/her PDPs effective the following month.

Q: What happens when someone is incarcerated?

 While an individual is incarcerated he/she can not enroll in Medicare Part D. Upon release, the individual has 62 days to enroll in a plan without penalty.

  |    |   Share