An Interview with Beth Witten, MSW, ACSW, LSCSW, Medicare Modernization Programs Manager, National Kidney Foundation, Inc.

On November 15, 2005, anyone who has Medicare Part A or Part B can choose a plan that should help save money on prescription drugs. Unless you have coverage that is as good as Part D, you must choose a plan by May 15, 2006, or you may have to pay higher premiums.

What is Medicare Part D and why should people on dialysis care?

Medicare is changing starting Jan. 1, 2006, to offer help to pay for prescription drugs that haven’t been covered by Medicare before. You need to have either Medicare Part A or Part B to get a Medicare Part D plan. The plans are not free; they are sold through insurance companies, but if you have limited income, you may qualify for extra help to pay the premiums and most other costs.

Typically people who are on dialysis take 10-15 prescription drugs, and often must spend a lot of money on them. If they don’t have other coverage for drugs, they must pay these costs out-of-pocket each month. Medicare Advocacy, a consumer advocacy group, says if you spend more than $70 per month on drugs, Part D should help you.

How is the situation different for home dialysis?

When you do home dialysis (PD or home hemo), you are not going into a clinic, where you would typically be getting Part B covered drugs during your treatment. At home, you may be able to take some of the same drugs by mouth and get help to pay for them through Part D. (Intravenous or injected drugs that Medicare Part B pays for now will stay under Part B.)

What is a Part D plan and what’s the best way to choose one?

There is a standard Part D plan that has a premium. The national average premium is about $32.20/month. Each plan has a deductible—$250 year—then for the next $2,000 it pays 75% of your drug costs. After that, it goes into a “doughnut hole” or coverage gap. Some plans don’t cover any of the next $2,850, while some enhanced plans cover generic drugs in the doughnut hole or have higher benefits (with higher premiums). Once you spend $3,600 out-of-pocket ($250 deductible + $500 + $2,850), you’d only pay 5% or a small co-pay for any remaining drug costs. You may even get help from family, friends, state pharmacy assistance programs, or charities to pay the $3,600.

The plans are going to vary, so you’ll need to really review the plans. The Centers for Medicare & Medicaid Services (CMS) is using what I call the “3 C’s”:

• Coverage: Which drugs are covered by the plan’s formulary?
• Cost: How much are premiums, deductibles, co-pays?
• Convenience: Is the pharmacy nearby or does it offer mail order? Mail order pharmacies often provide more drugs (e.g., a 90-day supply) for less money.

How do I find a plan that will suit me?

Insurance companies are sending out information right now, advertising through the media, and even calling people on the phone. You can also learn about plans in your area in Medicare and You, 2012 [Ed. note: this link has been updated from the 2006 edition]. Also on the Medicare website, you can compare Medicare prescription drug plans. There is a database of all of the plans, their formularies, prices, pharmacies, and any rules that apply.

What should kidney patients watch out for?

If you have an employer group health plan, talk to your benefits advisor before you choose a Part D plan. You’ll want to ask how having Part D could affect your other health coverage. If your employer is encouraging you to drop your health plan, this could be a violation of the Americans with Disabilities Act. Contact the Equal Employment Opportunities Commission to file a complaint.

If your kidneys have failed, you can’t buy a Medicare Advantage plan right now unless it is one of the new “special needs plans.” But if you already had a Medicare Advantage plan and then your kidneys failed, you can keep it. Companies that sell those plans will include drug coverage in at least one plan in your area, and some plans are not even charging higher premiums to add drug coverage. But, if you have a Medicare Advantage plan don’t sign up for a stand-alone prescription drug plan: you will lose your Medicare Advantage health coverage.

If you have a COBRA plan and not Medicare, and are looking to sign up for Medicare now to get drug coverage, you need to know that you will lose your COBRA coverage when you sign up for Medicare. This means you may have to pay more of your healthcare costs.

What happens if my plan drops a drug I need?

Medicare has to approve all of the formularies—and any changes to those formularies. So if a plan wants to drop a drug that you take, Medicare would have to approve it first, and the plan would have to give you 60 days notice.

The first thing for you to do if this happens is talk to your plan about what other drugs can be used instead. Then, ask your doctor which one would be the best for you. There is also a process where doctors can request an exception to the formulary—they would send in a letter telling the plan medical reasons why you need this drug.

Can I switch plans for any reason?

Yes. Everyone will have a chance to join or switch plans from November 15 to December 31 each year; the new plan would start on January 1. Some people who have limited income can switch plans more often.

Where can I learn more?

About 40 different kidney organizations have come together to “provide timely, consistent, reliable, and up-to-date information about Medicare and Medicare prescription drug coverage.”

• Right now, there is the Kidney Drug Coverage website. Free 30-minute teleconferences are being held each month where you can send questions. There are also links, resources, tools, and much more.
• There is information for patients, including posters, fact sheets, and articles.
• Professionals can find a resource kit that includes fact sheets, newsletter articles, tools, resources, links, and more.
• Read frequently-asked questions about Part D.
• For other questions about Part D, .(JavaScript must be enabled to view this email address) and put “Questions” in the subject.

Note: If you have both Medicare & Medicaid, the deadlines for signing up are different; learn more.

Copyright © 2005 Medical Education Institute, Inc. All rights reserved.