Marilyn Stebbins,
Tim Cutler
by
Jeff Miller
In
our
last story
about Medicare Part D, Marilyn Stebbins, clinical professor in the UCSF School
of Pharmacy, offered an independent, frontline perspective on how the new drug
insurance plan was then unfolding. With less than 30 days before the May 15,
2006 sign up deadline, Stebbins, who has been busy conducting education and
enrollment sessions with seniors all over northern California, and her colleague
Tim Cutler, assistant clinical professor in the UCSF School of Pharmacy, answer
this latest round of Medicare Part D questions.
Have most eligible seniors now signed up with a drug insurance plan?
And among those who haven't, are there any population groups that seem more
reluctant or unable to do so? Why?
Of the 43 million Medicare-eligible patients, the US Department of Health
and Human Services estimates that 39.1 million will have creditable drug
coverage in 2006. It is estimated that 29.3 million of these enrollees would
be enrolled in a Part D plan, and that 10 million of these enrollees would
have creditable coverage through an employer or union. As of March 1, 2006,
17.9 million of the 29.3 million have enrolled in a Part D plan. The majority
of those that have enrolled have had facilitated enrollment. Only 6.4 million
beneficiaries have actually signed up for a Part D plan on their own. This
leaves another 11.9 million who have not enrolled, but are eligible.
For the March 2006 Medicare Prescription Drug Coverage Enrollment Update,
go
here (pdf).
Of these 11.9 million beneficiaries who have not yet enrolled, cultural
barriers, where there is a lack of trust in government, and language barriers
may play a role. The majority of outreach programs and materials produced
have been in English. There are also those who are just too confused by
the enrollment process (Internet or 800 telephone numbers) and the large
numbers of plan choices and options.
What is the best way to reach the unregistered before the May 15
deadline? Is the UCSF School of Pharmacy making any special effort to do
so?
Pharmacies are making a huge effort to reach Medicare beneficiaries before
May 15 with mailings and incentives to come in and talk to the pharmacist
about a Part D plan. The UCSF School of Pharmacy, in particular, has been
conducting Medicare outreach programs to assist patients in the decision
and enrollment process. Many of the areas that have been targeted include
underserved, low-income communities. An upcoming outreach program will be
offered in five languages - Mandarin, Cantonese, Russian, Spanish
and English - with one-on-one sessions to assist these individuals
with their plan choices and to ensure that they are getting any extra help
for which they may be eligible.
What are the penalties if someone misses the May 15 deadline, and
how are the penalties calculated?
If you are told that you are eligible for Medicare Part D and you do not
join by May 15, you will be assessed a penalty AND you may not join a plan
until the annual open enrollment period the next year (November 15-December
31). If you join at a later date than when you were eligible, you will be
assessed a penalty of 1% per month of missed enrollment. The penalty is
based upon the national average premium in the year the patient signs up.
Here is an example:
You decide 4 years after you become eligible for Medicare to join a Part
D plan. That year, the national average premium is $50.
-
• 4 years of missed enrollment adds up to 48 months x 1% = 48%.
-
• 48% of $50 (the national average premium that year) = $24.
-
• $24 is added to the premium that the patient chooses that year.
-
• If the plan the patient chooses has a $15 premium, the patient will
pay $39 each month that year, instead of $15, due to the penalty.
-
• This penalty is recalculated every year, based on that year's
national average premium, and added to the premium of the plan that the
patient chooses that year.
Is it true that the drug insurance plans can change their coverage
almost daily? If true, are the plans required to inform their members in
some way? And if prescription drug coverage changes and a drug suddenly
is not covered, can members appeal the decision or seek after-the-fact reimbursement?
Yes, drug plans can change their formularies at any time during the year.
However, the provision is that the plan must inform the patient, the prescriber
and the pharmacy 60 days prior to the change. Each plan must also have an
appeal process in place, and a member may appeal to get the drug covered
after the change. Usually, the plan will contact the prescriber to determine
whether another agent in the formulary would be appropriate. If not, the
prescriber can fill out a prior authorization to continue to have the drug
covered for the patient. Because of the 60-day prior notification, after-the-fact
reimbursement may not be possible. If patients know that a drug they are
taking is being removed from the formulary, they need to contact the plan
immediately to discuss the appeal process.
Can people who have already signed up with a plan change their
mind? What should govern that decision?
This year - and this year only - people who have chosen a plan have one
chance to change their mind before May 15, and switch into another plan.
If you are in a plan and discover that there may be plan that covers your
medications and is less expensive, this may be a good reason to consider
changing plans. If you are not sure whether you are in the most economical
plan, you may call 1-800-Medicare or go to the
website
to see whether the plan you are in is the best plan for you, based on the
medication that you take. You can also visit your local pharmacy and ask
them to help you with the Medicare website, if you are unfamiliar with the
Internet. After this year, once you enroll in a plan, that will be your
plan for the entire year, and you will not have the option to switch until
the next year.
Does the drug insurance coverage extend to other states, so that
you don't have to worry while traveling?
In general, the answer is no. Each Medicare region in the country has its
own set of plans that are offered. If you travel outside of your region
and the region that you visit does not have that plan, you may be unable
to get your prescription filled. There are several plans, however, that
are nationwide. To be safe, people should travel with enough medication
to cover them while traveling. All plans offer 90-day prescription fills,
either at local pharmacies or through mail order, so there should not be
a problem getting enough medication to cover you while traveling. If you
live a portion of the year outside of your home region, you may want to
choose a national plan or be sure that the plan that you have can mail your
medication refills to you when you are away.
Do you expect a shakeout of the many different insurance plans
after the May 15 enrollee numbers are known? What will happen to those who
joined a plan that decides not to participate next year in Medicare Part
D?
I think we will see some changes in plans in
the next open enrollment period. I think we will see fewer plans and changes
in premiums, copayment structures and formularies. Each year, Medicare patients
will have to reevaluate their plan choice, even if the plan remains a Medicare
Part D plan. This is because the plan can change its structure each year,
as well as its formulary, so it may no longer be the best choice for you.
If the plan you are in this year chooses not to participate next year, you
will receive notification of this, and you will need to choose a new plan
during open enrollment.
