Kansas City Star

MEDICARE DRUG PROGRAM | Second Time Around

It's Time To Cram For 'Part D' Exam

Better make your decisions by Dec. 8, but take a good look at some new options for 2007

The Kansas City Star — Sunday, October 29, 2006

By JULIUS A. KARASH
The Kansas City Star

There's nothing like autumn: watching football, raking leaves, carving jack-o'-lanterns and, if you're on Medicare, hunkering down for your annual Part D exam.

Part D is Medicare's gigantic prescription drug program that came on line this year. It represented the biggest benefit expansion in Medicare's 41-year history, and one of the most controversial.

Part D has been criticized for being too stingy and too complex for consumers, while being too advantageous for drug firms and insurance companies. The program early on was fraught with glitches, such as computers not keeping accurate records of those who had signed up.

But government officials say most of the kinks have been worked out, and about 33 million Americans now receive their drugs through the program. Approximately 650,000 more will become eligible in 2007, according to the government.

"There were problems with computer systems from different entities not communicating well with each other," said Julie Brookhart, a spokeswoman for the U.S. Centers for Medicare & Medicaid Services in Kansas City.

More confusion ensued when some low-income Medicare beneficiaries chose their own plans after Medicare had automatically enrolled them.

But Brookhart said Medicare has improved its computer systems and gotten them more in sync with those of drug plans and Medicaid, the state-federal health insurance program for the indigent.

Whether you're already in the program or looking at it for the first time, you need to roll up your sleeves and do some homework. First-timers need to check out the available plans, compare costs and see which drugs are covered. If you're already in the program – even if you're satisfied – you should still check out what's new.

"Even if people have been happy, we are encouraging them to compare the options for 2007," said Nancy Schmidt, a Medicare outreach campaign manager in Kansas City.

Experts say you should take your time with this exercise and make thorough comparisons, just as you would if you were buying a house or shopping for a car. Attention to details could save you money and help you obtain the medications you need.

But don't delay making decisions for too long. You technically have until Dec. 31, but it's best to make your decision by Dec. 8 to avoid any administrative problems.

Look beyond premiums

Before you start this exam, you may want to put on a pot of coffee to go with your "doughnut holes." (More on those later.)

"Don't just look at one factor, like premiums," said Ron Pollack, executive director of Families USA, a national health-care consumer advocacy organization. "Look at other out-of-pocket costs. Look at the (drug) formulary. Look at which pharmacies you can go to. There are so many things that will determine whether a particular plan is the right one for you."

More than 80 percent of those enrolled in Part D drug plans were satisfied with their choice, though less than half of the beneficiaries said they had saved money, according to a survey released in July by the Kaiser Family Foundation. Eighteen percent said they had major problems with their drug plans.

You don't have to sign up for Medicare Part D if you don't want to. If you take few or no drugs, that's a judgment call.

For example, 67-year-old Roy Harman is trying to get off medications he's been taking for a back injury he suffered at work in 2000. Nonetheless, he recently signed up for a Medicare HMO that includes drug coverage through Part D.

"Even though I'm healthy now, I don't know what I'm going to need in five years," said Harman, a Kansas City, Kan., resident who attended a Humana presentation in Merriam last week.

Some seniors are fine-tuning their coverage to get the most bang for their buck. Herrick and Jean Kesler of Overland Park said they're switching from a Humana Medicare PPO to a Humana Medicare HMO to save money on premiums  $19 per person per month versus $52.

Anyone who joins a Medicare HMO or Medicare PPO that includes drug coverage is automatically enrolled in the Part D program. Herrick Kesler said the Humana HMO and PPO both offered good coverage, and he and Jean expect to save about $5,000 on medications this year.

"It gives us more money for other necessities, like gasoline," Herrick said.

Simplified information

One of your best sources for help is the drug plan finder tool on Medicare's Web site at www.medicare.gov.

The tool lets you enter the names of drugs you take, and the dosages, and figure your potential out-of-pocket costs for the plans you're considering.

Many consumers complained last year and this year that the Medicare Web site was complex and cumbersome, particularly for seniors who had little or no experience with Internet navigation.

"We really did listen to what consumers said about our plan finder tool," Schmidt said. "We've made a number of enhancements this year that will make key information very straightforward, available right up front and simplified."

Consumers also complained that there were too many plans to choose from. But there will be 53 stand-alone drug plans available in Kansas and Missouri next year, compared with 41 in Missouri and 40 in Kansas this year.

So what kind of help is that?

Schmidt said the U.S. Centers for Medicare & Medicaid Services asked drug plans to consolidate options that were too much alike, because consumers had a tough time differentiating between them. And if companies do offer more than one plan, the agency has asked that one offer a significantly richer benefit package than the other.

"People won't see plans offered by the same company where there seems to be very little difference," Schmidt promised.

'Doughnut hole' issues

Also on tap for next year are more plans offering full or partial coverage through the notorious "doughnut hole."

The doughnut hole is the coverage gap through which beneficiaries are held responsible for 100 percent of their drug costs in a standard drug plan.

Next year the government will cover total prescription spending – by the patient and Medicare combined – of up to $2,400 before the gap is reached. Then, after the patient reaches $3,850 in out-of-pocket spending, government coverage will resume.

The concept is that the government will pay for most of your drug costs up to a certain amount, after which you have to spend your own money until you reach a level considered "catastrophic." At that point, the government takes over and pays 95 percent of your drug costs.

The current doughnut hole – $2,250 to $3,600 – left a sour taste in many mouths.

PricewaterhouseCoopers has estimated that 3.4 million people will fall into the gap this year. The advocacy groups Institute for America's Future and New Jersey Citizen Action have estimated the number at 7 million.

Debbie Richmond, the pharmacy manager at Bruce Smith Drugs in Prairie Village, said some of her customers reacted with surprise and anger when they hit the coverage gap.

"It wasn't quite what people were expecting," Richmond said. "It was publicized, but it's a very complicated program. Some people felt they were deceived."

John O. Stanley, a Northland family practice physician, said several of his Medicare patients experienced problems after falling into the doughnut hole.

"When they hit the gap, they stop taking their medications or they start rationing them, taking them every other day, doing whatever they can to stretch them out," said Stanley, a former president of the Metropolitan Medical Society of Greater Kansas City. "Their blood pressure goes up, their cholesterol goes up, their diabetes gets out of control."

Brookhart, with the U.S. Centers for Medicare & Medicaid Services in Kansas City, said the Medicare Web site now includes a monthly cost estimator so beneficiaries can see what their drug costs are expected to be every month next year.

That will help people determine which month they can expect to hit the doughnut hole, if at all.

"That's a great enhancement," Brookhart said. "That information was in there (before), but it wasn't broken down on a month-to-month basis, so beneficiaries had to do some calculating themselves to figure it out."

Even with all the improvements, Medicare Part D isn't going to please everyone or completely fill everyone's needs. The program continues to draw objections.

But Stanley, the Northland physician, sounded a conciliatory note in spite of his criticism of the program.

"People need to think in retrospect," Stanley said. "Before Medicare Part D, many had no coverage. It has helped many, but it's still a work in progress."

Part D planning

Key dates for Medicare sign-up

Week of Oct. 30: The Centers for Medicare & Medicaid Services will notify Part D participants who receive government subsidies for the program if they need to be reassigned to a different plan in order to keep paying zero or minimal premiums. This group includes beneficiaries who are on Medicaid and others who qualify for government assistance for Part D.

Oct. 31: All participants should receive notice from their plan by this date of any changes that will occur in their coverage next year.

Also, all Medicare beneficiaries by this date should receive the 2007 "Medicare & You" handbook that includes detailed information about prescription drug plans available to them. The handbook also will include information about Medicare Advantage Plans that offer prescription drug coverage.

Nov. 15: Enrollment period begins.

Dec. 8: If you are enrolling for the first time or choosing a new plan, Medicare recommends that you decide and sign up by this date in order to make sure your new prescription plan card is mailed to you by Jan. 1.

Dec. 31: Annual enrollment period ends.

Where to obtain help/information

Medicare: (800) 633-4227 or www.medicare.gov

Senior Health Insurance Counseling for Kansas (SHICK): (800) 860-5260.

Community Leaders Assisting the Insured of Missouri (CLAIM): (800) 390-3330.

Westport Cooperative Services: (816) 753-7039.

"Medicare Prescription Drug Plan Guide: How to Choose Your 2007 Plan," offered by America's Health Insurance Plans, the National Association of Chain Drug Stores and the National Community Pharmacists Association. View at www.healthdecisions.org/guide.

MORE ON MEDICARE

For additional resources compiled by the Johnson County Library, go to JoCoBusiness.net.

Consider your choices under Medicare Part D

Q. Do Medicare beneficiaries have to sign up for the Part D prescription drug program?

A. No. But if you don't sign up within three months after the month of your 65th birthday, you will pay a penalty if you sign up later unless you already have coverage that's at least as good.

Q. Do I have to make any changes if I'm already covered by Part D and I'm satisfied?

A. No. But Medicare recommends that you look at the plan offerings available to you to make sure you're getting the best deal.

Q. What are the three main methods for paying Part D premiums?

A. Automatic electronic monthly withdrawal from your checking or savings account, through monthly billing from the plan, or through automatic deduction from your monthly Social Security benefit.

Q. What can I do to try to lower my prescription drug spending if I hit the "doughnut hole" coverage gap?

A. You may consider asking your doctor about the advisability of switching to generic or less-expensive brand-name drugs.

Q. How can I obtain financial help to participate?

A. If you're on Medicare and have limited income and resources, you may qualify for assistance to help you pay for your drugs. Information may be obtained by calling Social Security at (800) 772-1213 or by going to www.socialsecurity.gov.

Q. Could the program be changed someday?

A. Yes. For example, some politicians would like to change the program to allow the federal government to negotiate directly with pharmaceutical companies for discounts on medications. But that may never happen, so those who wish to participate have to work with the program as it exists now.

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