Beginning January 1, 2006, Medicare will provide insurance coverage for prescription drugs under Part D. As a family physician, many of your patients may come to you with questions. We have provided basic details about the new coverage.

As a family doctor, what will my role be in helping my patients?
Who is eligible and how do they enroll?
When does enrollment begin?
What happens if my patient doesn't enroll by the May 15, 2006 deadline?
What are the co-pays and deductibles for the new coverage?
Will this insurance cover all of my patients' drug costs each year?
What about my low-income patients who may not be able to afford the new coverage?
What's covered?
If my patient already has prescription drug coverage through Medi-Gap or a Medicare HMO, should they enroll in the new plan?
If my patient already has prescription drug coverage through a union or as part of retiree coverage, should they enroll in the new plan?
Where can I find information targeted to doctors and other providers?
What information is Medicare providing to beneficiaries?
What are the enrollment dates and other important deadlines?
Are there phone numbers I can give patients who need more information?

As a family doctor, what will my role be in helping my patients?

While you will likely be getting many questions from patients, CMS does not expect you to take time away from your clinical responsibilities to help your patients decide which plan to select. This is a complicated program and it would be difficult for you to determine which plan works best for each of your patients.And patients have many plans to choose from. As you may know, in California there are 47 stand-alone prescription drug plans and 85 offered through managed care companies, known as Medicare Advantage plans. Some companies may offer multiple plans with different costs and coverage. One-on-one counseling will be important, which is why CMS is encouraging doctors to tell patients and families to call Medicare (1-800-MEDICARE or 1-800-633-4227) with questions. Medicare has posted detailed plan information, including a prescription drug plan finder, to their Web site so patients and their families can make more informed decisions.

Who is eligible and how do they enroll?

This optional drug benefit will be open to all Medicare beneficiaries, no matter their income, illnesses, or current drug costs. To enroll, your patients must either call the plan in which they would like to enroll or call Medicare.

When does enrollment begin?

Part D enrollment began November 15, 2005; beneficiaries who enroll by December 31, 2005 will receive coverage on the January 1 starting date. Enrollment ends May 15, 2006.

What happens if my patient doesn’t enroll by the May 15, 2006 deadline?

Beneficiaries who decide to decline Part D now but change their minds after May 15, 2006 will pay more than if they had enrolled prior to that date. They may also have to wait to enroll for the annual open enrollment period. Medicare officials recommend that ALL Medicare patients enroll in a plan now -- even if it is in a plan with extremely limited benefits. They are able to change plans during the open enrollment period in the future, in the event their situations change and they need better coverage.

What are the co-pays and deductibles for the new coverage?

Monthly co-pays and deductibles for beneficiaries who enroll in Part D vary by plan; in California the average co-pay is $23, and may have up to a $250 deductible. Some plans in California may not charge a co-pay or have a deductible. The place where drugs are purchased can also affect costs because each plan can have its own network of participating pharmacies. Coverage is complicated; urge your patients to speak with counselors at the Medicare call-in number.

Will this insurance cover all of my patients’ drug costs each year?

No. Once the deductible has been met, Medicare will pay 75% of prescription drug costs, capped at $2,250. Beneficiaries are then responsible for the next $2,850 in costs unless they choose a plan that provides additional coverage; once these costs exceed $3,600, Medicare will then pay 95% of the costs. The coverage above the $3,600 threshold is known as the “catastrophic benefit.”

What about my low-income patients who may not be able to afford the new coverage?

According to CMS, low-income beneficiaries are those whose annual income is below $14,400 for a single person, $19,250 for married couples living together who have limited resources. Low-income beneficiaries are eligible for additional assistance to manage co-pays and deductibles, and should be receiving letters about the new coverage from the Social Security Administration. Dual eligibles (those enrolled in both Medicare and Medicaid) will be automatically enrolled in Part D. You should know that the “Medicare and You 2006” handbook INCORRECTLY indicates that low-income beneficiaries will pay no monthly premium no matter which plan they choose. Some plans may require low-income beneficiaries to contribute.

What’s covered?

The new coverage is not directly provided by CMS; rather, it is through private companies. Medicare sets minimum coverage levels. Once these levels have been met, plans have significant flexibility in developing their formularies so patients should choose carefully. Some plans may only cover certain drugs or allow beneficiaries to use certain pharmacies. The co-pay may also vary by plan. Plans will cover both generic and brand name drugs, however.

If my patient already has prescription drug coverage through Medi-Gap or a Medicare HMO, should they enroll in the new plan?

Some of your patients may already have prescription drug coverage and it is important for these patients to investigate whether or not their coverage will change, and if Part D provides better coverage than their current policies. This is particularly important because beneficiaries cannot enroll in both a Medi-Gap plan that covers prescriptions and Part D. We have heard from Medicare officials that it is likely that many Medi-Gap plans will stop providing prescription coverage in favor of offering Part D products.

If my patient already has prescription drug coverage through a union or as part of retiree coverage, should they enroll in the new plan?

Patients who have prescription coverage through a union or as part of their retiree health benefits should be receiving information on how this coverage compares to Medicare Part D, so they may make an informed decision. In general, if their current coverage is less than Medicare, they may want to keep their current plan AND join a Medicare plan for complete coverage. They could elect not to enroll in the new plan and rely solely on their current coverage, but if they eventually enrolls in Medicare (after the May 15, 2006 deadline), they will pay more. They could also drop their current plan and join a Medicare plan, however, they may not be able to get their current plan back.
If their current plan covers the same or more than Medicare drug insurance, patients can keep their current plan and will not pay more if they choose to enroll in a Medicare plan at a later date. Patients can also drop their current plan and join a Medicare plan, however.

Where can I find information targeted to doctors and other providers?

CMS has developed a provider Web site which includes more detailed information on Part D. For example, some physicians who provide biologics/drugs (e.g., oral immuno-suppresive drugs) under Part B may have questions about whether or not they can bill for prescription drugs under Part D. The short answer is no; however, more detail on this and other topics can be found here. AAFP has developed Frequently Asked Questions and other resources to respond to your concerns, available here.

CMS has also made available a range of downloadable brochures and a toolkit (.pdf) to help you and your patients understand the basics of Part D. The toolkit includes reproducible artwork (e.g., patient brochures, memo pads for patients to list medicines/dosages), and has some materials in Spanish.

What information is Medicare providing to beneficiaries?

In October 2005 Medicare beneficiaries should have received a Medicare & You 2006 (.pdf) handbook in the mail with information on Part D. A regional (California) specific handbook, also available in Spanish, can be accessed here. Information is also available on the Medicare Web site and on California’s State Health Insurance Program (SHIP) Web site. Information on the specific plans offered in California is available here; formulary information is available on the Medicare Web site and should be updated monthly.

If your patients have questions, they may call Medicare (1-800-MEDICARE) or a county-based SHIP (in California, your patients may call 1-800-434-0222 to get the number for a local SHIP). If you think patients may qualify for low-income subsidies for Part D, they may call the Social Security Administration for information on financial assistance (1-800-772-1213).

What are the enrollment dates and other important deadlines?

December 31, 2005: Deadline for enrollment to begin coverage January 1, 2006
January 1, 2006: Part D coverage begins
May 15, 2006: Enrollment deadline to receive lower premiums

Are there phone numbers I can give patients who need more information?

California State Health Insurance Program: 1-800-434-0222
Medicare: 1-800-MEDICARE (1-800-633-4227)
Social Security Administration: 1-800-772-1213