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August 2005
1
2005 National Medicare & You Training Program
Speaker Name
Group Name
Date
August 2005 2
Changes in MedicareKeeping up with Today’s Health Care
Promoting a healthy lifestyle Covering preventive services Offering prescription drug coverage Expanding coordinated care options
Including care for chronic conditions
Helping people with Medicare live longer, healthier lives
August 2005 3
What You Need to Know Now
What You Need to Know Now
Medicare Prescription Drug Coverage
August 2005 4
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 5
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 6
Medicare Prescription Drug Coverage
Begins January 1, 2006 Available for all people with Medicare
Part A, Part B, or both For minimum standard coverage in 2006,
enrollees would payAverage monthly premium of about $32First $250 per year for prescriptions
(“deductible”)Part of the cost of prescriptions after $2505% of drug costs (or small copayment) after
paying $3,600 out of pocket
August 2005 7
Savings in 2006
On average, for a person with Medicare and no drug coverage nowTotal drug spending will go down by about 50%Over $1,100 per year saved
People with other drug coverage that, on average, is at least as good as Medicare’s also may save money
These estimates do not include the extra help for people with limited incomes
August 2005 8
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 9
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 resourcesPay no premiums or deductiblesHave small or no copayments
Those with slightly higher income and resourcesHave a reduced deductiblePay a little more out of pocket
August 2005 10
Eligibility for Extra Help
IncomeBelow 150% Federal poverty level
• $1,197 per month for an individual* or• $1,604 per month for a married couple*• Based on family size
ResourcesUp 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
August 2005 11
Automatic Eligibility for Extra Help
Some people may automatically qualify
People with Medicare whoGet full Medicaid benefitsGet Supplemental Security Income (SSI)Get help from Medicaid paying their
Medicare premiums
All others must apply
August 2005 12
How to Apply for Extra Help
Social Security Administration (SSA) is mailing applications to those who may be eligibleThroughout the summer of 2005
Those who think they may qualify shouldComplete this application
• Mail it to the address on the back• Use the enclosed postage-paid envelope• Use original forms only (do not photocopy)
People who are not sure should still applywww.socialsecurity.gov can help people
decide
August 2005 13
Extra Help and Other Drug Coverage
People with other drug coverage Should apply for extra help, even if covered
by• Employer or union group health plan• Indian Health Service• VA health benefits
Should ask how Medicare drug coverage with extra help will work with the current coverage• Could save money with Medicare prescription drug
coverage
August 2005 14
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 15
Which Drugs Are Covered?
Medicare-covered drugsDrugs available only by prescriptionDrugs, biologicals, insulinMedical supplies associated with injection of
insulinBrand-name and generic drugs
Drugs not coveredDrugs excluded by MMA lawNon-prescription drugsDrugs that are covered for a person under
Medicare Part A or Part B
August 2005 16
Coverage Varies by Plan
Plan may not cover all drugsFormularies must include more than one drug in each
classification
Centers for Medicare & Medicaid Services (CMS) will review formularies
Plan must give 60-day notice of many changes Plan must have exception process
Gives enrollees access to medically necessary drugsDecision can be appealed
August 2005 17
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 18
Ways to Get Coverage
Medicare prescription drug coverage is provided throughMedicare Prescription Drug PlansMedicare Advantage and other
Medicare Health PlansSome employers and unions to retirees
Coverage is NOT automatic People need to understand their
options
August 2005 19
Joining a Plan
Enroll directly with the plan sponsor Can get help in enrolling
Legal representativeSpouse, other relative, friend, or advocate
Initial Enrollment PeriodFor 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
August 2005 20
Late Enrollment
Most people will have to pay a penalty if they wait to enrollAdditional 1% of base premium for every
month the person was eligible but not enrolled
For as long as the person is 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
August 2005 21
Coverage on Average at Least as Good as Medicare’s
People with other coverageWill receive information from the other planWill not pay a penalty if they wait to enroll
• If coverage is at least as good as Medicare prescription drug coverage
Possible examplesSome group health plans (GHP)State Pharmacy Assistance Program (SPAP)VA coverageMilitary coverage including TRICARE
August 2005 22
Annual Coordinated Election Period
November 15 – December 31 every year Person who does not have a Medicare
drug plan can enroll Person who currently has a Medicare
drug plan can switch Change effective January 1 Special Enrollment Period may apply at
other times in special circumstances
August 2005 23
Example of Late Enrollment
Mrs. Jones has Medicare Part A and Part B, and she has no prescription drug coverage. She does not enroll in a Medicare prescription drug plan by May 15, 2006, the end of the Initial Enrollment Period.
When will she have another opportunity to enroll in a Medicare prescription drug plan?
What are the consequences of waiting to enroll later?
August 2005 24
Example of Late Enrollment
When will Mrs. Jones have another opportunity to enroll in a Medicare prescription drug plan?
She can enroll during the next Annual Coordinated Election Period, November 15 – December 31, 2006, with coverage effective January 1, 2007.
What are the consequences of waiting to enroll later?
Since Mrs. Jones does not have coverage at least as good as Medicare drug coverage, she will pay a penalty.
August 2005 25
Medicare Advantage Open Enrollment
Person can join a Medicare Advantage Plan or other Medicare Health PlanIn 2006: January 1 – June 30, 2006In 2007 and beyond: January 1 –
March 31, each yearChange effective the first of the month
after the month person joined
August 2005 26
Open Enrollment Limit
During Medicare Advantage Open EnrollmentPerson who has a Medicare plan with
prescription drug coverage• May only switch to another plan with
prescription drug coverage
Person who has a Medicare plan without prescription drug coverage• May only switch to a plan that does not
have drug coverage
August 2005 27
Important Information For All People With Medicare
Medicare prescription drug coverage is available to all people with Medicare
There is additional help for those who need it most
Medicare prescription drug coverage pays for brand-name as well as generic drugs
Look for a Medicare prescription drug plan that meets your needs
Medicare prescription drug coverage helps you pay for the prescriptions you need
August 2005 28
Things to Consider
What is current health insurance coverage?Original Medicare Plan without drug policyOriginal Medicare Plan with Medigap drug policyMedicare and employer/union, including militaryMedicare Advantage and other Medicare Health Plans
• HMO, PPO, PFFS• Medicare Cost Plans
Medicare and Medicaid Is there currently prescription drug coverage? Even those with current drug coverage should
ask“Is Medicare prescription drug coverage right for me?”
August 2005 29
Original Medicare Plan
1) Without Drug Coverage or
2) With Medigap Drug Policy
Medicare and Employer/Union
Coverage, including the
Military
Medicare Advantage and Other Medicare
Health Plans
Medicare and Medicaid or
Other State/Federal
Assistance Programs
Current Insurance Coverage*Current Insurance Coverage*
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
August 2005
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Original Medicare Plan
Without Medigap or
With Medigap Plans A - G
“I have Original Medicare only, or Original Medicare and a Medigap (‘Supplement’) Policy without drug coverage.”
August 2005
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Original Medicare Plan
• What to do– Watch the mail this fall for the Medicare & You
handbook
• Choices to make– Join a Medicare Prescription Drug Plan– Join a Medicare Advantage or other Medicare
Health Plan with prescription drug coverage– Don’t enroll in Medicare prescription drug coverage
• But you may pay a penalty if you join later
August 2005
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Original Medicare Planand Medigap With Drug Coverage
“I have Original Medicare and a Medigap (‘Supplement’) Policy with drug coverage.”
August 2005
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Original MedicareAnd Medigap With Drug Coverage
• What to do– Watch the mail this fall for important information from the
insurance company on Medigap coverage
• Choices to make– Keep coverage through the Medigap policy– Join a Medicare Prescription Drug Plan after you
• Modify the Medigap policy to remove drug coverage, or• Change to a Medigap policy with no drug coverage
– Drop Medigap policy and join a Medicare Advantage or other Medicare Health Plan with prescription drug coverage
August 2005
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Medicare and Employer/Union
Coverage, including the
Military
“I am a retiree and I have drug coverage through my (or my spouse’s) employer or union.”
August 2005
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Employer/Union Coverage
• Medicare is working with employers to help people with Medicare keep their current coverage
• Employer options– Offer coverage in place of Medicare prescription drug
coverage and receive a tax-free subsidy
– Offer or contract with a Medicare drug plan to provide prescription drug coverage
– Provide coverage that supplements the Medicare prescription drug coverage
– Pay all or part of Medicare drug plan premiums
August 2005
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Employer/Union Coverage
• What to do– Watch the mail this fall for important coverage information
from the plan sponsor– Contact the benefits administrator before you make any
changes
• Choices to make– Keep coverage offered by employer/union– Join a Medicare Prescription Drug Plan– Join a Medicare Advantage or other Medicare Health Plan
with prescription drug coverage
CAUTION: If you drop or lose your employer/union coverage, you may not be able to get it back
August 2005
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Medicare Advantage and Other Medicare
Health Plans
“I have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare Health Plan.”
August 2005
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Medicare Advantage Plans(HMO, PPO, and PFFS)
• What to do– Watch for a notice from your plan– Call the plan for details
• Choices to make– If plan will offer drug coverage
• Stay in plan and get Medicare prescription drug coverage
– If plan won’t offer drug coverage• Switch to another Medicare Advantage or other Medicare Health Plan
with prescription drug coverage• Switch to the Original Medicare Plan and join a Medicare Prescription
Drug Plan• Don’t enroll in Medicare prescription drug coverage
– But you may pay a penalty if you join later
August 2005
39
Medicare Cost or PACE Plan
• What to do– Call the plan for details
• Choices to make– If Cost Plan with drug coverage
• Get Medicare prescription drug coverage from the plan or
• Join a Medicare Prescription Drug Plan
– If Cost Plan with no drug coverage• Join a Medicare Prescription Drug Plan
– If PACE plan, will get coverage through that plan
August 2005
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Medicare and Medicaid or
Other State/Federal
Assistance Programs
“I have Medicare and Medicaid, and I get my drug coverage from Medicaid.”
August 2005
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Medicare and Medicaid
• What to do– You automatically qualify for the extra help
– Watch the mail this fall• Letter about choosing a Medicare prescription drug plan
• Medicare & You 2006 handbook
• Choices to make– Compare drug plan options and enroll in a plan
• If not, Medicare will enroll you in one by December 31, 2005
• Starting January 1, 2006, Medicare will pay for your prescription drugs
– Can switch to another plan at any time
August 2005
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Other State/Federal Assistance Programs
• What to do– You automatically qualify for the extra help if you
• Get help from Medicaid paying your Medicare premiums• Get Medicare and Supplemental Security Income (SSI) benefits
– Watch the mail for Medicare & You 2006 handbook
• Choices to make– Compare drug plan options– Find a plan that meets your needs– If no choice made by May 15, 2006, you will be enrolled on
June 1, 2006• Also applies to people who applied and qualify for extra help• Can switch once to another plan (if you get help from Medicaid paying
your Medicare premiums, you can switch at any time)
August 2005 43
Special Populations
State Pharmacy Assistance Program participants
People in long-term care facilities Residents of the U.S. territories
August 2005 44
State Pharmacy Assistance Programs
Provide wraparound coverage Provide same or better coverage
and save money Reduce state costs or expand
population served Costs incurred by SPAP may or may
not be counted toward out-of-pocket limit
August 2005 45
Long-Term Care Facilities
ResidentsUsually obtain drugs from pharmacy
chosen by the facilityCan change plans at any timeWill have convenient access
Those with Medicare and full Medicaid coverage have no premiums, deductibles, or copayments
August 2005 46
U.S. Territories
Each territory has its own prescription drug plan region
Each territory can develop its own extra helpHelp with premiums, coinsurance,
copayments, deductibles or Provide supplemental coverage
August 2005 47
Choosing a Plan
See Medicare & You 2006 handbookTo be mailed October 2005Read about prescription drug plans in the area
For help in choosing a planVisit www.medicare.gov
• To get personalized informationCall 1-800-MEDICARE (1-800-633-4227)
• TTY users call 1-877-486-2048Call the local State Health Insurance Assistance
ProgramAttend local community events
August 2005 48
Important Dates
May 2005Medicare mailed notices to people who
automatically qualify for extra help Summer 2005
Social Security Administration mails applications to people who may be eligible for the extra help
July 1, 2005Social Security application for the extra help
available online
August 2005 49
Important Dates
September 16 – November 15, 2005Medigap plans with drug coverage
mail information to policy holders
October 13, 2005Begin comparing plans
• www.medicare.gov • 1-800-MEDICARE (1-800-633-4227)
August 2005 50
Important Dates
October 2005Medicare & You 2006 handbook mailedMedicare notifies people with Medicare and
Medicaid of the plan they will be automatically enrolled in on January 1, 2006, if they do not enroll on their own
Employer plans send coverage information to enrollees
November 15, 2005Initial Enrollment Period begins
August 2005 51
Important Dates
January 1, 2006Medicare prescription drug plan coverage
begins for those enrolled
May 15, 2006Last day of Initial Enrollment Period
June 1, 2006Facilitated enrollment of people entitled to
extra help who did not enroll by May 15
August 2005 52
For More Information
Websiteswww.medicare.govwww.cms.hhs.govwww.socialsecurity.gov
PublicationsMedicare & You handbookFacts About Medicare Prescription Drug Plans
1-800-MEDICARE (1-800-633-4227) Social Security Administration
1-800-772-1213
