# Presentation: 771140

## 2005 National Medicare & You Training Program

- 2005 National *Medicare & You* Training Program

**CMS**
**Congressman Bishop**
**Medicare Information Meetings 2005**

- October 2005

**Notes:**
This training module was developed and approved by the Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers Medicare and Medicaid. 
The information in this module was correct at the time of printing (October 2005).
This set of National Medicare & You Training Program materials is not a legal document.  The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.

## What You Need to Know

**General Overview**
**Medicare Prescription Drug Coverage**

- October 2005

**Notes:**
Let’s start with understanding Medicare prescription drug coverage.

## Medicare Prescription Drug Coverage

- Begins January 1, 2006
- Available for all people with Medicare
- Part A, Part B, or both
- Cannot be incarcerated or live outside the U.S.
- Must join a Medicare drug plan to get coverage
- Initial enrollment period November 15, 2005, through May 15, 2006
- Join by December 31, 2005, for coverage beginning January 1, 2006

- October 2005

**Notes:**
All people with Medicare have the option to join a plan that covers prescription drugs, with coverage beginning January 1, 2006.
Anyone who has Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), or both Part A and Part B, is eligible to join a Medicare prescription drug plan and must enroll in a plan to get Medicare prescription drug coverage.  However, people who live outside the U.S. or who are incarcerated may not enroll and are not eligible for coverage.
People must join a Medicare drug plan to get coverage.  They can join beginning November 15, 2005 through May 15, 2006.  If they join by December 31, 2005, coverage begins January 1, 2006.  Later in this module, we’ll talk more about when people can enroll.

## Plan Choices

- Two types of Medicare drug plans
- Medicare Prescription Drug Plans
- Medicare Advantage Plans and other Medicare Health Plans with prescription drug coverage

- October 2005

**Notes:**
Medicare drug plans will be offered by insurance companies and other private companies approved by Medicare.  There are two types of Medicare drug plans.
There will be Medicare Prescription Drug Plans that add coverage to the Original Medicare Plan, to Medicare Private Fee-for Service (PFFS) Plans that don’t offer Medicare prescription drug coverage, and to Medicare Cost Plans.
There will also be prescription drug coverage that is a part of Medicare Advantage Plans (like an HMO, a PPO, or a PFFS Plan) and other Medicare Health Plans.

## Rx Drug Coverage Enrollment

- Coverage is not automatic
- Except people who qualify for extra help
- Initial Enrollment Period (IEP)

| For people entitled to Medicare before February 2006 | November 15, 2005, through
May 15, 2006 |
| --- | --- |
| For people entitled to Medicare on February 1, 2006, or later | 7-month period |

- October 2005

**Notes:**
For most people with Medicare, coverage is not automatic.  They must join a plan to get coverage.  
However, Medicare will enroll people who have qualified for the extra help if they don’t join a plan on their own.  We’ll talk more this enrollment assistance later.
The Initial Enrollment Period is from November 15, 2005, through May 15, 2006, for individuals who
Are currently entitled to Medicare, or
Become entitled in November or December 2005, or January 2006
For people who become entitled to Medicare after January 2006, the Initial Enrollment Period is for 7 months starting 3 months before the month they become entitled to Medicare.

## Annual Coordinated Election Period (AEP)

- November 15 – December 31 every year
- People who don’t have a Medicare drug plan can enroll
- People who currently have a Medicare drug plan can switch
- Change effective January 1
- Special Enrollment Period (SEP) may apply in special circumstances

- October 2005

**Notes:**
There will be an Annual Coordinated Election Period November 15 – December 31 each year starting in 2006.  During the Annual Coordinated Election Period, a person who is not enrolled in Medicare prescription drug coverage can choose to enroll.  Also, a person who has Medicare prescription drug coverage can choose to switch plans at that time.  The change in enrollment or in plan selection will be effective January 1 of the following year.
There are special circumstances when a person with Medicare can join or switch plans at other times, called Special Enrollment Periods.

## Standard Coverage

- Standard coverage in 2006
- Minimum coverage drug plans must provide
- In 2006, person with Medicare pays
- A monthly premium
**$250** deductible
- 25% of yearly drug costs from $250 to $2,250
- Person pays 25% = **$500**; plan pays 75% = $1,500
- 100% of next **$2,850** in drug costs
- 5% of drug costs (or a small copayment) after $3,600 out of pocket
- $250 + $500 + $2,850 = $3,600

- October 2005

**Notes:**
Earlier we mentioned standard coverage (the minimum coverage drug plans must provide)
In 2006, a person enrolled in a plan with standard coverage will pay 
A monthly premium (varies depending on the plan)
The first $250 per year for prescriptions. This is called the “deductible.”
After the $250 yearly deductible, enrollees pay
25% of their yearly drug costs from $250 to $2,250, and the plan pays the other 75% of these costs, then
100% of the next $2,850 in drug costs, often called the “coverage gap,” then
5% of their drug costs (or a small copayment) for the rest of the calendar year after they have spent $3,600 out of pocket.  The plan pays the rest.

## Extra Help With Drug Costs

- Available for many people with limited income and resources
- Those below Federal poverty level save over 95% on average
- People with lowest income and resources
- Pay no premiums or deductibles
- Have small or no copayments
- Those with slightly higher income and resources
- Have a reduced deductible
- Pay a little more out of pocket

- October 2005

**Notes:**
We’ve already discussed that all people with Medicare can get Medicare prescription drug coverage.  In addition, many people with limited income and resources will get extra help paying for prescription drugs.
People with the lowest incomes will pay no premiums, as long as they are enrolled in a plan that costs no more than the standard reimbursement amount in their region.  They will have no deductible and only small or no copayments.
People with slightly higher incomes will have a reduced deductible and pay a little bit more out of pocket.

## Eligibility for Extra Help

- Income
- Below 150% Federal poverty level
- $1,197 per month for an individual* or
- $1,604 per month for a married couple*
- Based on family size
- Resources
- Up to $11,500 (individual)
- Up to $23,000 (married couple)
- Includes $1,500/person funeral or burial expenses
- Counts savings and stocks
- Does not count home the person lives in
- 			*Higher amounts for Alaska and Hawaii

*2005 amounts*

- October 2005

**Notes:**
The extra help is available to people with Medicare with income below 150% of the Federal poverty level and limited resources.  Let’s talk about how income and resources are counted.
As we just mentioned, Medicare counts the income of the applicant and his or her spouse living in the same household, regardless of whether or not the spouse is applying for the extra help.
The income is compared to the Federal poverty level for a single person or a married person.  This takes into consideration whether the applicant and/or his or her spouse have dependent relatives who live with them and who rely on them for at least half of their support.  For example, a grandparent raising grandchildren may qualify, but the same person might not have qualified as an individual living alone.
As we said before, resources also are counted for the applicant and a spouse living with him or her.  Only two types of resources are considered:  
Liquid resources (i.e., savings accounts, stocks, bonds and other assets that could be cashed in within 20 days) and 
Real estate that does not include the applicant’s home or land on which the home is located.
Items such as wedding rings and family heirlooms are not considered resources for the purposes of qualifying for the extra help.
Contact the Social Security Administration or your state Medicaid office for more information on the requirements and how to apply.  I will explain how to apply in just a minute.

## Automatic Eligibility for Extra Help

- Some people may automatically qualify
- People with Medicare who
- Get full Medicaid benefits
- Get Supplemental Security Income (SSI)
- Get help from Medicaid paying their Medicare premiums
- All others must apply

- October 2005

**Notes:**
Certain groups of people automatically qualify for the extra help and do not have to apply.  These include:
People with Medicare and full Medicaid benefits (including prescription drug coverage)
People with Medicare who get Supplemental Security Income (SSI)
People who get help from Medicaid paying their Medicare premiums (Medicare Savings Programs). 
Medicare mailed a notice to these groups in May 2005 letting them know they automatically qualify for the extra help and do not need to apply.
All other people with Medicare must file an application to get the extra help.

## How to Apply for Extra Help

- Social Security Administration (SSA) sent applications to people who may be eligible
- Those who think they may qualify can
- Call the Social Security Administration, 1-800-772-1213
- Visit www.socialsecurity.gov
- Apply at their State Medical Assistance office.
- People who are not sure should still apply
- Even if they did not get an application
- www.socialsecurity.gov can help people decide
- There is no risk or cost to apply

- October 2005

**Notes:**
From May through August 2005, the Social Security Administration (SSA) mailed applications to people who may qualify for the extra help but do not automatically qualify.  SSA began processing applications in July 2005 and is sending decisions to the people who applied.
People who think they may qualify, regardless of whether or not they received an application, can apply in several different ways.  They can
call the Social Security Administration at 1-800-772-1213
visit www.socialsecurity.gov on the web, or
apply at their State Medical Assistance office. 
People who are not sure if they qualify should still apply.  The SSA website has a tool that helps people determine if they are eligible for the extra help and tells them what to expect and what they need to do, if anything.  There is no risk or cost to apply.

## Things to Consider

- What is current health insurance coverage?
- Is there currently prescription drug coverage?
- Even those with current drug coverage should ask
- “Is Medicare prescription drug coverage right for me?”

- October 2005

**Notes:**
All people with Medicare will need to decide whether the new Medicare prescription drug coverage is right for them.  The most important consideration is the type of health insurance coverage people currently have and how that affects their choices.
Even people with current drug coverage at least as good as Medicare’s should look into the new Medicare drug coverage.

## Coverage on Average at Least as Good as Medicare’s

- People with other coverage
- Will not pay a penalty if they wait to enroll
- If coverage is at least as good as Medicare prescription drug coverage
- Possible examples
- Some group health plans (GHP)
- Some Medigap policies
- VA coverage
- Military coverage including TRICARE

- October 2005

**Notes:**
People who do have other drug coverage that, on average, is at least as good as Medicare prescription drug standard coverage may keep that coverage.  They won’t have to pay a penalty if they decide to enroll in a Medicare prescription drug plan at a later date.
 Some examples of coverage that may be at least as good as Medicare prescription drug plan coverage include:
Group health plans (GHP)
Some Medigap policies
VA coverage
Military coverage including TRICARE
People who have other prescription drug coverage will get information from their plan that tells them if the plan is, on average, at least as good as a standard Medicare prescription drug plan.  The plan will also notify them if the coverage changes so that it is no longer as good as Medicare prescription drug coverage.

## Late Enrollment

- Most people will have to pay a penalty if they wait to enroll
- Additional 1% of base premium for every month they were eligible but not enrolled
- For as long as they are enrolled in a Medicare prescription drug plan
- Unless they have other coverage that, on average, is at least as good as Medicare prescription drug coverage

- October 2005

**Notes:**
People who don’t enroll at their first opportunity may have to pay a penalty to enroll later.
People who currently have Medicare and who don’t join a Medicare prescription drug plan by May 15, 2006, will have their premiums go up 1% of the base premium for every month they wait to enroll, unless they have other coverage that, on average, is at least as good as standard Medicare prescription drug coverage, called “creditable coverage.”  These individuals will have to pay this penalty as long as they have Medicare prescription drug coverage.

## Special Enrollment Period

- Change in residence
- Move out of plan’s service area
- Move into or out of a long-term care facility
- People with Medicare and
- Full Medicaid benefits
- Medicare Savings Programs
- People Medicare enrolled in a plan
- Involuntary loss of coverage
- Others

- October 2005

**Notes:**
There are many special circumstances that give a person a special enrollment period (SEP), some of which are listed here.  
Change in residence, including move to/from a long-term care facility
Involuntary loss of coverage
Non-notification of creditable coverage
Violation of contract by plan
Error by Federal employee
One-year trial period for Medicare Advantage
Switch to/from PACE (Programs of All-inclusive Care for the Elderly)
Loss of full Medicaid coverage
 The type of SEP determines its duration and effective date.

## Which Drugs Are Covered?

- Drugs, biologicals, insulin
- Available only by prescription
- Medical supplies associated with injection of insulin
- Syringes, needles, alcohol swabs, gauze
- Brand-name and generic drugs

- October 2005

**Notes:**
To be covered by Medicare, a drug must be available only by prescription, approved by the Food and Drug Administration (FDA), used and sold in the United States, and used for a medically accepted indication.
Covered drugs include prescription drugs, biological products, and insulin.  Medical supplies associated with the injection of insulin, such as syringes, needles, alcohol swabs, and gauze, are also covered.

## Which Drugs Are Not Covered?

- Drugs excluded by MMA law
- But some plans may choose to cover
- Non-prescription drugs
- Drugs that are covered for a person under Medicare Part A or Part B

- October 2005

**Notes:**
Some drugs are excluded by law from Medicare prescription drug coverage.  However, plans may choose to cover them at their own cost or share the cost with enrollees.  These include drugs such as those for anorexia, weight loss, or weight gain; fertility; cosmetic or lifestyle purposes (e.g., hair growth); symptomatic relief of coughs and colds; prescription vitamin and mineral products (except prenatal vitamins and fluoride preparations); non-prescription drugs; barbiturates; and benzodiazepines.
If a drug is covered under Part A or Part B, it can be covered under the Medicare drug coverage if the individual does not meet the coverage requirements for the drug under Medicare Part A or Part B.  Examples may include immunosuppressive drugs after an organ transplant, some oral anti-cancer drugs, hemophilia clotting factors, drugs that are not self-administered, etc.

## Plan Marketing

- Plans began marketing October 1, 2005
- Medicare prescription drug plans may
- Use the Medicare Rx seal
- Send information or call people with Medicare

- October 2005

**Notes:**
All drug plans approved by Medicare may use the Medicare Rx seal in their materials.  People should call 1-800-MEDICARE if they aren’t sure if a plan is approved by Medicare.  
Starting October 1, 2005, Medicare prescription drug plans may send information or make calls to people with Medicare about the Medicare prescription drug coverage they are offering.

## Protecting Against Fraud and Identity Theft

- Medicare prescription drug plans may _not_
- Contact people with Medicare before  October 1, 2005
- Sell door-to-door
- Enroll people by phone
- Unless the person calls them OR
- The person is adding drug coverage to their Medicare Advantage or other Medicare Health Plan

- October 2005

**Notes:**
Medicare plans can’t contact people with Medicare before October 1, 2005.  People should report any plans that send them information about their drug coverage before this date by calling 1-800-MEDICARE.  Starting October 1, 2005, plans are allowed to mail information and to call.  They are not allowed to sell plans door-to-door.  
People with Medicare should only give personal information to plans that are approved by Medicare and to people in the community who work with Medicare like the State Health Insurance Assistance Program or the Social Security Administration.
Medicare prescription drug plans can’t enroll someone into a drug plan over the telephone unless the person has called them, or it is a person adding prescription drug coverage to a Medicare Advantage Plan or other Medicare Health Plan that he or she already has.
Please remind people with Medicare to keep their personal information safe.  They should not give information to anyone who comes to their home or calls them uninvited selling Medicare-related products.

## Protecting Against Fraud and Identity Theft

- Those who think someone is using their personal information should call
- 1-800-MEDICARE (1-800-633-4227)
- TTY users call 1-877-486-2048
- Fraud Hotline at 1-800-447-8477
- TTY users call 1-800-377-4950
- ID Theft Hotline at 1-877-438-4338
- TTY users call 1-866-653-4261

- October 2005

**Notes:**
Identity theft means using, without consent, personal information like a person’s name, Social Security, Medicare, or credit card number, or other personal information to commit fraud or other crimes.
People who think someone is using their personal information should call
• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, or
• the Fraud Hotline of the HHS Office of the Inspector General at 1-800-447-8477. TTY users should call 1-800-377-4950, or
• the Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 to make a report (TTY users should call 1-866-653-4261).
For more information about identity theft, visit www.consumer.gov/idtheft on the web.

## Choosing a Medicare Drug Plan

- Coverage
- Formularies
- Cost
- Premium, deductible, copayments or coinsurance
- Convenience
- Pharmacy networks
- Mail-order

- October 2005

**Notes:**
We’ve already talked about how the Medicare drug plan people choose affects their coverage, cost, convenience, and peace of mind.
Coverage—Plans may have rules about covered drugs and how they provide access to drugs in different categories.  Most plans will have a formulary or list of drugs covered by the plan. 
Cost—Monthly  premiums and the share of the cost people pay for their prescriptions will vary depending on which plan they choose. 
Convenience—Drug  plans must contract with pharmacies in every area, but may have certain pharmacies a person must use.  Some plans also have mail-order options.
Peace of Mind Now and in the Future—Even people who do not take a lot of prescription drugs now should still consider joining a drug plan in 2006.  As we age, most people need prescription drugs to stay healthy.

## Choosing a Plan

**Step 1: Collect information **
- Any current prescription drug coverage
- Prescription drugs and doses
**Step 2: Compare Medicare drug plans**
- Medicare & You 2006
- Medicare Prescription Drug Plan Finder tool at  _[www.medicare.gov](http://www.medicare.gov/)_
- 1-800-MEDICARE
**Step 3: Choose a plan**
- For help, call the State Health Insurance Assistance Program (SHIP) in their state

- October 2005

**Notes:**
There are steps you can take to help people choose a Medicare drug plan. 
Step 1: Collect information about their current prescription drug coverage and needs.  Including information about any prescription drug coverage they may currently have as well as a list of the prescription drugs and doses they currently take.
Step 2: Compare Medicare drug plans.  For lists of the drug plans available in their area, they can 
Read the Medicare & You 2006 handbook.  In October 2005, all households that include people with Medicare are receiving the handbook in the mail, which will include information about Medicare drug plans available in the area.
Use the Medicare Prescription Drug Plan Finder tool at  www.medicare.gov.  People will be able to use the website to get personalized information about plans that meet their needs 
Call 1-800-MEDICARE (1-800-633-4227). (TTY users should call 1-877-486-2048.)
Step 3: Choose the plan they want, and join.  For help choosing a Medicare drug plan, people can call the State Health Insurance Assistance Program (SHIP) in their state.

## Joining a Plan

- Enroll directly with the plan sponsor
- Internet
- Plan website
- _[www.medicare.gov](http://www.medicare.gov/)_
- Telephone
- Paper form
- Mail or fax to plan sponsor

- October 2005

**Notes:**
Anyone who has Medicare is eligible to join a Medicare prescription drug plan, starting November 15, 2005.  A person must live in the plan’s service area to join.
People can enroll directly with the plan.  Enrollment can be done over the internet, either on the plan’s website or on the www.medicare.gov website.  In some cases a person can enroll via the telephone, and plans will also accept paper applications.
Plans must process applications in a timely manner and must notify applicants of acceptance or denial of their enrollment request.

## For More Information

- Websites
- _www.medicare.gov_
- _www.cms.hhs.gov_
- _www.socialsecurity.gov_
- Publications
*Medicare & You* handbook
*Your Guide to Medicare Prescription Drug Coverage*
- 1-800-MEDICARE (1-800-633-4227)
- Social Security Administration
- 1-800-772-1213
- Georgia Cares (1-800-669-8387)

- October 2005

**Notes:**
There are a number of sources for more information about Medicare prescription drug coverage, including:
Medicare’s website for people with Medicare, www.medicare.gov
Medicare’s website for partners, www.cms.hhs.gov
The Social Security Administration’s website, www.socialsecurity.gov
The Medicare & You handbook and Your Guide to Medicare Prescription Drug Coverage brochure.  They can be ordered from the Medicare website or by calling 1-800-MEDICARE
1-800-MEDICARE (1-800-633-4227) or 1-877-486-2048 for TTY users
Social Security, 1-800-772-1213 or 1-800-325-0778 for TTY users