Low-Income Subsidy Designed to Help Qualifying Seniors Pay for Prescription Drugs

If you qualify for Medicare and have limited resources, you may also qualify for the low-income subsidy available to people who need extra help. This subsidy is intended to help individuals pay for their Medicare drug plan’s monthly premium, yearly deductible, and coinsurance/copayments.  It can also limit any coverage gaps.

 To qualify for extra help, you need to have limited income and limited resources available to you.   This year, you might qualify if you alone make below $15,315 and have resources under $11,710.  If you are married and living with your spouse (with no other dependents), you must make below $20,353 per year and have resources under $23,410. 

A number of people automatically qualify for this extra help. For instance, if you have full Medicaid benefits, are receiving help from your State Medicaid program, or are receiving SSI without Medicaid, you will most likely automatically qualify for the low-income subsidy.  If you do, you will receive a letter from Medicare to inform you of your status.  After qualifying, you need to choose a Medicare drug plan in order to reap the benefits of your extra help. Research your available plans and select one that covers the medication you require.  If you don’t select a plan, Medicare will select one for you.

Even if you don’t automatically qualify for extra help, you may be able qualify by applying.  To apply, contact Social Security at 1-800-772-1213 or visit them online at www.socialsecurity.gov. 

Enrolling in a Medigap Policy

Medigap policies, sold by various private insurance companies, are intended to supplement your Original Medicare Plan and help pay for a number of services not otherwise covered. Although they don’t cover all gaps, they can ultimately save you a number of out-of-pocket expenses, such as copayments, coinsurance, deductibles, and, in some cases, extra benefits (for an additional cost).

Depending on the policy you chose, and sometimes, your age as well, the price of a Medigap policy can vary. . All Medigap policies do follow state and federal laws, and all companies must sell specific standardized policies, but companies will charge different amounts and some will charge more as you get older. Also, some States sell Medigap Select policies which require you to use specific doctors and/or hospitals in order to get full benefits.

In order to enroll in a Medigap policy, you need to be enrolled in the Original Medicare plan, and you usually need to have Medicare Parts A and B. Your Medigap policy will only cover your own Medicare (spouses cannot be included), and you will also need to pay a Medigap premium. Like most Medicare plans, you should enroll in your Medigap policy during your open enrollment period. This period begins when you are enrolled in Part B and it is six months before to six months after the month you turn 65.

Medicare policies can be highly advantageous when facing medical expenses. However, to ensure you get the coverage you need at the price you can afford, spend some time researching policy providers and weighing your options.

Costs Involved in Medicare Part B

Depending on the plan you choose and the type of care you require, the costs involved in your Medicare Part B coverage can vary significantly. However, there are a few general cost categories to consider when planning for your expenses.

One of the first things to keep in mind are the premiums you will be required to pay.  While Part A in the Original Medicare doesn’t typically require a montly premium, Part B does.  This year, the standard premium is $96.40, although it may be higher if you make more than $82,000 per year individually or $164,000 together with your spouse. Your premium may also be 10% higher if you did not enroll in Part B when you were first eligible.  In order to collect Part B benefits, you will usually also need to pay a yearly deductible before receiving any coverage.  This year, the deductible is $135.

The care you require will also have an effect on your costs.  Some services are denoted as “no cost” services; these are free for you.  For many other services, you need to pay a coinsurance.  Usually, this coinsurance is 20% of the approved Medicare amount.  Sometimes, you may be required to pay a copayment, which is a set fee for a service, such as a doctor’s visit.

If you qualify for extra help, your costs may be much lower. Research your options carefully, and don’t hesitate to ask your State Health Insurance Assistance Program for help.

Enrolling in Medicare Part B

Medicare Part B refers to the component of Medicare that covers your medical insurance.  It consists of medically-necessary services not included in your hospital insurance (Part A), like doctor’s services, outpatient care, and some preventive services.  Enrolling in Part B is an important aspect of maintaining continued health and ensuring adequate coverage for a number of your health needs.

Unlike Medicare Part A, however, Part B will cost most beneficiaries a monthly premium, as well as the annual deductible.  In addition to these fees, if you don’t sign up for Medicare Part B when you are first eligible, you may be required to pay a late enrollment penalty, depending on the circumstances surrounding your delayed enrollment.  The late penalty is typically 10% for each year you could have been enrolled, and can be required as long as you are enrolled in Part B.

The best time to sign up for Medicare Part B is, like most parts of a Medicare plan, when you’re first eligible.  If you are receiving Social Security or RRB benefits, you will automatically be enrolled the month you turn 65.  If you choose not to receive Part B, you can opt out.  If you don’t qualify for automatic enrollment and want to receive Part B, you will need to sign up when you are nearing your 65th birthday.

If you previously chose not to sign up (or decided to opt out) but now think you may like to enroll, you will need to take advantage of the general enrollment period.  This period is from January 1 to March 31 of each year, and coverage begins on July 1.  Keep in mind, however, that even if you enroll during this period, you may have to pay the late enrollment fee, unless you qualify for a special enrollment period.

In order to be exempt from this late enrollment penalty, you must qualify for the special enrollment period. If you or your spouse have a group health plan through work, you can sign up for Part B any time during that employment plan or eight months after the month the employment - or the group health plan coverage - ends. You also qualify if you didn’t enroll during your initial eligibility due to health insurance you had when volunteering in a foreign country.  In most cases, if you do qualify for a special enrollment period, you will not have to pay your late enrollment penalty.

The easiest way to receive complete coverage through Medicare is to sign up as soon as you can.  For more information, visit www.medicare.gov, or call Social Security at 1-800-662-1213.

Facing a Coverage Gap: How to Reduce Expenses

Enrolling in a Medicare Prescription Drug Plan is an excellent way to ensure your continued health, and is often essential in providing a way for you to receive the medication you require.  However, there are times when you may experience a gap in your Medicare drug coverage. In fact, most drug plans have some type of coverage gap.  For instance, sometimes the gap is in the form of a financial limit.  Other times, the gap is due to a lack of coverage for a specific type or brand of medication.  Whatever the cause, finding yourself in a coverage gap can be costly.  There are, however, a number of things you can do to reduce this financial burden.

One way to reduce your expenses is to switch to a generic version of your required medication.  You may also be able to find brand name which is less-expensive than the one you currently use or use an over-the-counter variety.  To explore your options, visit the Prescription Drug Plan Finder section at www.medicare.gov, or talk to your health care provider.

Another way to reduce costs is to look at programs offering financial assistance.  There are a number of community based and national charitable programs that are designed to help people cover the cost of medication.  You may also want to explore whether there are any State Pharmaceutical Assistance programs available in your area.  Many drug manufacturers also offer assistance programs worth looking at. If you’d like additional information about assistance programs, there are a number of helpful online resources available.  Visit http://www.benefitscheckup.org for a “Benefit Checkup” website, http://www.medicare.gov/pap/index.asp for “Pharmaceutical Assistance Programs”, and http://www.medicare.gov/spap.asp for the “State Pharmaceutical Assistance Program” site.

Finally, if you have limited income and are a Medicare recipient, you may be able to receive extra help covering your costs.  To find out if you qualify, visit www.socialsecurity.gov, call them at 1-800-772-1213, or contact your State Health Insurance Assistance Program.

Recent Harvard Study Examines Medicare Part D

According to a recent study by Harvard Medical School in Boston, Medicare prescription drug plans have yielded mixed results for enrolled seniors. While there have been significant gains in coverage due to Medicare Part D, many people are still struggling to meet the high costs of their medication.

The survey, addressing 24234 Medicare beneficiaries, involved questions regarding medication expenses and the personal changes necessary to meet those costs. The survey showed that although Medicare prescription drug plans do offer some substantial coverage to recipients, there are a number of individuals who are negatively affected due to the high financial impact of meeting remaining medication costs.

Before the new Medicare Part D plan was available, in order to meet drug costs, approximately 15.2% of Medicare beneficiaries chose not to fill prescriptions and/or switched to less expensive types, and 10.5% skipped basic needs to pay for necessary medications. In 2004, about 14.1% and 11.1%, respectively, chose to take these measures.

The good news? When Medicare Part D was instated, only 11.5% of recipients reported having to skip or switch medications, and only 7.6% said they were unable to meet needs in order to pay for their medications.

Unfortunately, although there have been substantial improvement in Medicare coverage due to Medicare Part D, the study also showed that not all needs are being met. It seems that in this case, the plans fall short where the financial need is the greatest. The most significant difficulty is for seniors requiring the most expensive drugs, falling between $2250 to $5100.

According to the study, Medicare Part D is, for most seniors enrolled in a plan, helpful in elevating prescription drug costs. However, it also illustrates the fact that there are still gains to be made in creating a system where even the neediest of beneficiaries are able to afford their expensive but ultimately life-saving medications.

CMS Adds SFF Information to Nursing Home Compare Site

The Centers for Medicare & Medicaid Services has added important new information to their Nursing Home Compare Website.  The site, which is designed to assist families in finding quality nursing homes in their area, includes information about nursing homes in terms of quality, staffing, and health, safety, and fire inspection reports. Now, due to the inclusion of further data, beneficiaries will have a more complete picture of the quality of care nursing homes have to offer.

CMS is now including information about CMS’ special focus facility (SFF) list.  A nursing home appearing on the SFF list means it has, at one point, had a history of poor performance or recurring infringements of state and federal health and safety rules.  

The SFF list was created due to the fact that nursing homes with poorer quality of care were often able to pass a survey by simply making slight improvements.  However, because they were not adequately attending to the issues causing the problems, they would fail the next.   The SFF list identifies the nursing homes that have serious quality of care problems and are not making any real improvements. It also includes the category they are in, like “new additions”, “not improved”, “improving”, “recently graduated”, or “no longer in the Medicare and Medicaid programs”.  When a nursing home becomes an SFF, twice the number of standard surveys is given to it, and the state survey agency will increase enforcement until the home improves and graduates, is given more time due to some improvements, or is terminated from Medicare and Medicaid. Currently, there are 16,000 active nursing homes, 134 of which are on the SFF list.  The hope is that as nursing homes improve, they can graduate from the program.

The SFF information can now be found on the Nursing Home Compare site, at www.medicare.gov.

CMS Releases Plan to Improve Nursing Home Quality of Care

The “2008 Action Plan for Further Improvement of Nursing Home Quality” is designed to improve the quality of nursing homes, along with the access to information about long-term care.

One improvement CMS intends to make involves “consumer awareness and assistance.” Providing relevant, easy-to-read information to individuals requiring care, as well as to their family or other caregivers, will allow them to be informed members of their own health care decisions. It will also allow them to make educated choices to ensure a higher quality of care. These new informational documents will be available at www.medicare.gov. The “Guide to Nursing Homes” and “Compare” data have already been posted, and can provide valuable information about the Medicare nursing home benefits, as well as about specific nursing homes, to beneficiaries and their families.

A second focus of CMS is “survey, standards, and enforcement improvement.” According to CMS, they intend to improve the effectiveness of nursing home surveys as well as the investigation of complaints. Additionally, they are striving to improve enforcement methods.
CMS is also looking at “quality improvement.” By focusing on several specific areas, they intend to improve the quality of care in nursing homes across the country. Two significant areas of concerns include reducing the occurrences of preventable pressure ulcers and reducing the use of unnecessary physical restraints. Although CMS has already been working towards improvements in these areas, there are a number of States in which nursing homes exceed the national average in pressure sore occurrences and uses of physical restraints. By addressing these concerns, as well as others (such as developing individualized care plans), the quality of care afforded to individuals in nursing homes should be significantly improved.

Finally, CMS is working towards “quality through partnership.” They believe that in order to ensure wide-spread quality of care in nursing homes, they need to coordinate the efforts of a number of principals, including beneficiaries and their families, health care providers, purchasers (such as CMS, States, Private/public health care plans, and individual purchasers), quality improvement organizations, educational organizations, legal rights organizations, and law enforcement. When all members are working towards a common goal, quality will improve. There are a number of ways a variety of individuals, organizations, and institutions can be involved. For instance, CMS will be collaborating with over 20 national organizations in order to run a national nursing home campaign entitled “Advancing Excellence in America’s Nursing Homes.” This campaign is intended to improve both the measurement of quality of care, as well as the quality of care itself. Specifically, it will focus on a number of goals, like reducing high risk pressure sores and physical restraints, improving pain management, setting individualized quality improvement targets, assessing satisfaction of residents and/or families, measuring staff turnover (and working to reduce this), and making it possible for residents to be regularly cared for by the same caregiver.

Through these measures, CMS expects to see a notable improvement in quality of care across the country. To find out more, the official document containing the “2008 Action Plan for Further Improvement of Nursing Home Quality” can be downloaded from http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp#TopOfPage

Medicare Hospice Care Coverage

For terminally ill patients, Medicare’s hospice benefit can provide support, care, and rest. Hospice Care primarily includes medical and nursing care, therapy, medication for the terminal and related conditions, and durable medical equipment. Designed to allow quality-of-life for these patients, it doesn’t cover treatment to cure the terminal illness. However, regular Medicare benefits will continue to cover treatments unrelated to the disease.

A number of services are covered by Original Medicare’s Hospice Care coverage. The medical and support care include doctor’s services, skilled nursing, home health aide, and respite care. Medicare Hospice Care also covers physical therapy, speech-language therapy, occupational therapy, dietary counseling, and patient/family counseling. Drugs to control symptoms and provide pain relief are also included, as are wheelchairs, walkers, and wound dressings.

In order to be eligible for Medicare’s hospice benefit, recipients must have Medicare part A. Their doctor and a hospice medical director must certify that the recipient likely has six months or less to live and is, indeed, terminally ill. The recipient must also sign a statement choosing Hospice Care rather than routine Medicare covered benefits. This is important, since Hospice Care does not cover any curative treatments. Finally, the recipient must receive care from a Medicare-approved hospice program.

To find out more, call your State Hospice Organization, your Regional Home Health Intermediary, or 1-800-MEDICARE. If you or someone you love is terminally ill, sometimes Hospice Care is the best option. Although it doesn’t attempt to cure the illness, it can offer comfort and peace.

An Introduction to Medicare Preferred Provider Organization Plans

A Medicare Preferred Provider Organization (PPO) Plan is a type of Medicare Advantage Plan, offered by a Medicare-approved private insurance company.  A PPO plan will cover your Medicare Part A and Part B, as well as usually offering additional coverage and, in some cases, drug coverage. However, PPO plans do differ from Original Medicare in function and cost.

PPO plans have a specific network of approved health care providers.  While you may go to other doctors and hospitals not on the list, doing so will usually cost you more.  Choosing a doctor from your PPO plan’s list allows you, then, to save money.  You can also receive care from specialists without a referral, but like choosing your regular doctor, it’s advisable to select one from your plan’s network in order to reduce costs.  Some plans may give you a discount if you give notice when you’re getting service outside of the network. 

PPO plans cover all services offered by Medicare Parts A and B, although the costs differ. In addition to the monthly Medicare Part B premium, you will usually also pay a monthly premium for Part A and Part B coverage, as well as prescription drug coverage and/or extra benefits, if offered by your plan.  Your PPO plan will likely charge additional deductibles, coinsurances, or copayments according to the services you receive.  In a Regional PPO plan, there is an annual out-of-pocket cost maximum.  Local PPO plans may not have a cap.

When choosing your plan, keep in mind that all PPO companies must offer a plan with prescription drug coverage.  If you choose a plan without this coverage, you can’t enroll in a Medicare Prescription Drug Plan.  If you need – or think you may one day need – prescription drug coverage, choose a plan that includes this benefit. 

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