If you think you and your patients had trouble understanding Medicare coverage before, it's going to get a little more complicated
in the coming months, when the prescription drug benefit (often referred to as Part D) is introduced. No one says you have
to be an expert on the new program, but it would help to know a few basics, since patients are bound to come to you with their
questions.
Beneficiaries will have a choice of at least two prescription drug plans, and possibly many more depending on where they live.
Those who currently have prescription drug coverage through a Medicare Advantage plan or other Medicare health plan will get
a notice from the plan about their choices. If a patient doesn't have prescription drug coverage and wants to add it, he can:
- check with his current health plan to see if they'll offer a prescription drug option in 2006. If they will, the patient will
usually be required to get his drug coverage from his current health plan if he decides to stay in the plan, or
- switch to another Medicare Advantage plan or other Medicare health plan in his area that offers prescription drug coverage,
or
- change to the original Medicare plan and join a Medicare prescription drug plan.
Patients who are dually eligible for both Medicare and Medicaid will be automatically enrolled in a plan at the end of 2005
if they haven't chosen one.
Power Points
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Because companies that will offer Medicare prescription drug coverage plans have flexibility in designing the benefits they'll
provide—including the formulary, costs, and which pharmacies may be used—your patients shouldn't act hastily in choosing one.
Covered drugs, for instance, will be either "preferred" or "non-preferred," and copayments will be based on these categories.
If a patient needs a drug that isn't on a particular plan's formulary, she can appeal to have the drug covered, or pay for
the drug herself. However, that out-of-pocket payment doesn't count toward the cost-sharing amounts, which we'll discuss later.
Thankfully, there's some protection against your patient making a "wrong" choice, as all of the plans must provide a Medicare-set
standard level of coverage. And, of course, patients have the option to sign up with a different plan during their next open
enrollment.
The enrollment timetable is fast approaching
On Jan. 1, the new Medicare prescription drug plans (PDPs) will be available to anyone who has Medicare Part A or Part B.
Those who want it—and want coverage to begin on Jan. 1—will have to enroll between Nov. 15 and Dec. 31. For the first year
of the program, patients can enroll until May 15, 2006. Thereafter, decisions on enrolling or changing plans will generally
have to wait until the next November-December enrollment period.
One thing worth reminding patients about: those who don't enroll when they're first eligible may have to pay a penalty if
they decide to join later on, unless they have coverage that's at least as good as standard Medicare prescription drug coverage
(such as from a former employer or union). The Medicare participant will receive a notice from the entity providing the coverage,
telling him if the plan he's got will provide as much or more than a Medicare prescription drug plan.
It's also important to note that the Medicare prescription drug benefit, which will be managed by private companies in conjunction
with Medicare, is a separate program from the one that introduced Medicare-approved drug discount cards in June 2004. Patients
who have drug discount cards may use them until May 15, 2006—or until they begin receiving coverage under a Medicare prescription
drug plan, whichever is earlier.
CMS has prepared materials to help physicians, healthcare professionals, and their staffs explain the new benefit to their
patients. These materials, such as "The Toolkit for Healthcare Professionals: Medicare Prescription Drug Coverage," are available
at www.cms.hhs.gov/medlearn/provtoolkit.pdf.
Cost will be a concern for many patients
Patients' costs will vary depending on the prescription drug plan they choose. Some may offer more coverage and additional
drugs for a higher monthly premium.
Here's how the standard plans work: In 2006, participants will pay a monthly premium (at press time) of $32.20—although CMS
says many plans will offer premiums far lower than that—and a yearly deductible of $250. After the deductible has been met,
the plan pays 75 percent of the next $2,000. After that, there's a gap in coverage (known as the "doughnut hole") for drug
costs between $2,251 and $5,100, during which a beneficiary must pay all costs. After $5,100, "catastrophic" prescription
coverage will kick in, with the plan absorbing about 95 percent of the cost until the end of the calendar year.
Patients who are eligible for both Medicare and Medicaid won't pay a prescription drug benefit premium or a deductible, and
they won't be subject to the gap in coverage. However, these patients will have copayments for generic or preferred drugs
and for nonpreferred drugs. This may confuse your Medicaid patients because they may not have had copayments before. (There's
no copay for dually eligible patients who reside in nursing homes.)
Low-income patients may also be eligible for assistance from the Social Security Administration. The SSA has begun mailing
details about this extra help to people who are likely to qualify. Deane Beebe, communications director of the Medicare Rights
Center in New York City, recommends that patients who haven't received the mailing apply to the SSA anyway if they think they're
eligible. The application's available online at www.socialsecurity.gov/prescriptionhelp, or patients can call 800-772-1213 for assistance.
The net effect on you and your staff
Given the complexity of the prescription drug benefit, you can expect that your eligible patients will pepper you and your
staff with questions. Some will even ask you to pick a prescription drug plan for them. Don't.
Aside from the fact that the patient may ultimately be dissatisfied with your recommendation, "Stark is a consideration since
prescription drugs are a designated health service, and some doctors own interests in dispensaries for outpatient prescription
drugs," says attorney Geoffrey T. Anders of The Health Care Group in Plymouth Meeting, PA. "Even without such a financial
interest, though, why would you want to direct a patient to a particular plan without a comprehensive assessment of his needs?
At a minimum, you risk damaging the doctor-patient relationship."
Deb Allison, office manager for Rafael R. Soria, a family physician in Turlock, CA, is taking a proactive approach to patients'
prescription drug coverage questions, offering seminars to give them basic information about selecting (or choosing not to
select) a prescription plan. "By meeting in groups with our patients," she says, "we hope to avoid the health visit being
taken up with questions regarding prescription drug coverage."
Anders suggests directing patients to the Medicare Web site (www.medicare.gov), where there's abundant general information and, sometime this month, patients will be able to get personalized information
to help compare plans in the Search Tools section on the home page. The same comprehensive information will be available through
a toll-free customer service line, 800-MEDICARE (633-4227).
You might also consider providing a computer in your reception area for those patients who don't have Internet access. And
keep an eye out, too, for community groups (a local industry healthcare coalition, Chamber of Commerce, or hospital system)
that may analyze the prescription plan offerings available to your patients.
