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Medicare Part D
 

 

 

Overall/Quick Reference: Kaiser Family Foundation Medicare Consumer Guide Talking About Medicare: Your Guide to Understanding the Program, 2012

 

SECTIONS

Medicare D

Medicare D Transition Assistance and Advocacy
Includes tips sheets, appeal rights, etc.

Other Sections:

I. Background and Basics
II. Benefits
III. Extra Help
IV. Choosing a Plan & How to Join a Plan
V. Rights and Responsibilities   
VI. To Join or Not to Join? (Late enrollment penalty)
VII. Special Situations

VII. More Information for Consumers and Providers

VIII. More Information for Providers, Advocates and Policy Wonks

Transition Assistance and Advocacy

Handout/Fact Sheet: 2017 Transition Rights to Medications Under Medicare Part D, Justice in Aging (Formerly the National Senior Citizens Law Center)

The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Part D prescription drug plans provide beneficiaries with access to transition supplies of needed medications to protect them from disruption and give adequate time to switch to a drug that is on a plan’s formulary, file a formulary exception request or, particularly for Low Income Subsidy (LIS) recipients, enroll in a different plan.

In the early months of the year, transition rules will be particularly important for low income beneficiaries who were automatically reassigned to new plans, which may or may not cover their medications. All plans change their formularies each year, however, so even people who remain in the same plan may find that their plan no longer covers their medications or has newly imposed utilization management requirements.

CMS Minimum Transition Requirements

CMS requires Part D plans to establish transition policies that cover beneficiaries when they:

  • first enroll in a Part D plan.
  • are moving to a new plan that does not cover their current drug, including when that move is mid-year.
  • experience a change in level of care (e.g., from hospital to a nursing facility, from a nursing facility to home, or out of hospice status to standard Medicare, etc.).
    Or
  • When, at the start of a new plan year, the plan in which they currently are enrolled drops coverage of a drug they are taking or imposes new utilization management restrictions on that drug.

For all enrollees:

Plans must provide a one time fill–30 day supply (unless a lesser amount is prescribed) — of an ongoing medication within the first 90 days of plan membership.

  • Applies both to drugs not on formulary and to those subject to utilization management controls.
  • Applies to the first 90 days in the plan, even if not at the beginning of the plan year and even if the 90 day period extends over two plan years (e.g., a November enrollment).
  • Applies both to new members and to continuing members when a plan has changed formulary.
  • Does not cover non-Part D drugs.
  • Does not cover multiple fills.  For example, if a doctor only prescribes a pain medicine in 14 day batches, the transition will only cover one batch.

Plans must mail a written notice explaining that the transition supply is temporary, including instructions for identifying appropriate substitutes; notice of the right to request a formulary exception; and instructions on how to file an exception request.  The notice must be mailed within 3 business days of the temporary fill. Transition fills are temporary. Clients should take action immediately and have the doctor change the prescription to a covered drug or ask the plan for an exception.

If, at the point of sale, a plan cannot determine whether a newly written prescription is for ongoing drug therapy or not, the plan must assume that the prescription is ongoing and apply transition policies.

Note: The pharmacist may need to ask the plan for its override code to bill correctly.

Residents in a long-term care (LTC) facility or other institution get further protections.

For CMS Guidance on transition drug supplies, go to Medicare Prescription Drug Benefit Manual, Chapter 6 at 30.4 et seq.

-See the Justice In Aging fact sheet: 2017 Transition Rights to Medications Under Medicare Part D or see summary/excerpts: Medicare D Plan Transition Coverage Rights Fact Sheet, MGH Community News, January 2016.

Learn more: Transition Drug Refills  

Problems Getting Scripts Filled?

I. Background and Basics

Beginning in January 1, 2006, Medicare began covering most outpatient prescription drugs through Medicare Part D. Medicare contracts with private companies to provide this drug coverage. Medicare D is a voluntary program.

Members will need to chose from a number of privately-managed programs in their area. Medicare encourages applicants to consider the three “Cs” in choosing a plan: Cost, Coverage, and Convenience.

    • Cost- plans have to operate within certain limits, but will vary.
    • Coverage- the drugs each plan covers is called the “formulary”. The companies or “plans” must offer two medications in each category, but plans will differ in the specific drugs they cover. More information is available on the Medicare website and from the specific plans. See www.medicare.gov for more information, including formulary guidance - an interactive program to help you choose the best plan for you. For more information about what is and isn't covered, see Medicare Reminder – Medicare Drug Coverage- MGH Community News, April 2019. Also see "Benefits" below.
    • Convenience- does the applicant’s pharmacy participate in that plan?

Medicare Part D Basics- MGH Community News, August 2018

Watch for Scams!  The Massachusetts Executive Office of Elder Affairs issued these scam prevention tips.

II. Benefits

    • Medicare.gov- Medicare D Page
    • "How new Medicare drug plans will provide you with high-quality, lower-cost drug coverage" - From CMS. Includes information on network pharmacies, lists of covered drugs (Formulary), prior authorization, and quantity limits.

      • There are four different phases—or periods—of Medicare Part D prescription drug coverage:

      1. Deductible period: Until you meet your Part D deductible, you will pay the full negotiated price for your covered prescription drugs. Once you have met the deductible, the plan will begin to cover the cost of your drugs. While deductibles can vary from plan to plan, no plan’s deductible can be higher than $545 in 2024, and some plans have no deductible.
      2. Initial coverage period: After you meet your deductible, your plan will help pay for your covered prescription drugs. Your plan will pay some of the cost, and you will pay a copayment or coinsurance. How long you stay in the initial coverage period depends on your drug costs and your plan’s benefit structure. For most plans in 2024, the initial coverage period ends after you have accumulated $5,030 in total drug costs.
        • Note: Total drug costs include the amount you and your plan have paid for your covered drugs.
      3. Coverage gap: After your total drug costs reach a certain amount ($5,030 for most plans), you enter the coverage gap, also known as the donut hole. The donut hole closed for all drugs in 2020, meaning that when you enter the coverage gap you will be responsible for 25% of the cost of your drugs. For example, if a drug’s total cost is $100 and you pay your plan’s $20 copay during the initial coverage period, you will be responsible for paying $25 (25% of $100) during the coverage gap. Prior to the closure of the donut hole, you were responsible for a higher percentage of the cost of your drugs.
      4. Catastrophic coverage: In all Part D plans, you enter catastrophic coverage after you reach $8,000 in out-of-pocket costs for covered drugs. This amount is made up of what you pay for covered drugs and some costs that others pay. During this period, you owe no cost-sharing for the cost of your covered drugs for the remainder of the year. The out-of-pocket costs that help you reach catastrophic coverage include:
        • Your deductible 
        • What you paid during the initial coverage period 
        • Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap 
        • Amounts paid by others, including family members, most charities, and other persons on your behalf 
        • Amounts paid by State Pharmaceutical Assistance Programs (SPAPs) (such as Prescription Advantage in MA), AIDS Drug Assistance Programs (such as HDAP in MA), and the Indian Health Service 

    Note: If you have Extra Help, you do not have a coverage gap. You will pay different drug costs during the year. Your drug costs may also be different if you are enrolled in an SPAP.

    Learn More.

    Note: Medicare B covers drug costs in certain situations. Medicare Drug Coverage: Part D vs. Part B, Medicare Rights Center (updated January 2019).

    NOTE: Dual-eligibles receiving Medicaid Home and Community Based Waivers should have no co-pay for Part D drugs. Justice in Aging created an FAQ, Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, to give advocates working with dual eligibles the tools they need to prevent these co-pays. (Also see MGH Community News, September 2019) 

III. “Extra Help”

Extra Help, also called the Medicare Low-Income Subsidy (LIS), is offered to those with a low income and assets. This will cover some or all of the patient costs under the Medicare D.

Individuals AUTOMATICALLY qualify for Extra Help (and should not need to apply) if they

  • Are eligible for both Medicare and Medicaid (full dual-eligibles),
  • Get help from their State Medicaid Programs to pay their Medicare premiums, or
  • Get Supplemental Security Income (SSI) benefits

Others Can Apply

Individuals with income up to 150% FPL $1,903 monthly for an individual, $2,575for couples in 2024*) and have limited resources ( $17,220 for individual; $34,360 for a couple*- more detail at Extra Help Program Income and Asset Limits), but who do not automatically qualify for “Extra Help” can apply through Social Security, by calling 1-800-772-1213 or by visiting https://secure.ssa.gov/i1020/start. *Note: those with income/assets above these limits may still qualify because certain types of income and assets may not be counted. For example, part of earned income and the value of the house will not be counted;

    • The amount of extra help you get depends on your income and resources (The Medicare Rights Center's Extra Help Program Income and Asset Limits factsheet includes corresponding assistance level details.)
    • You still need to join a Medicare prescription drug plan for Medicare to pay for your drug costs.
    • See What help can I recieve?, or you can call the Social Security Administration toll-free, 1-800-772-1213 for a paper application or to make an appointment.  If you are deaf or hard of hearing, call the toll-free TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.  Tell the representative that you want to apply for the Help with Medicare Prescription Drug Costs. 
Mediare Interactive's Extra Help Page

Loss of Deemed Low Income Subsidy (Extra Help) Status Notice
Each year in September, some individuals with the LIS will receive notices that they no longer automatically qualify for Extra Help for the following year, and to encourage them to apply for Extra Help to see if they’ll continue to qualify. These notices are specific to individuals who were deemed eligible for LIS because they were eligible for Medicaid or a Medicare Savings Program (MSP). When these individuals lose their Medicaid or MSP eligibility they also lose their automatic LIS eligibility. A person typically loses LIS many months after they lose Medicaid or MSP.  The financial eligibility criteria for LIS are broader than those for Medicaid. Accordingly, even if someone is no longer eligible for Medicaid, they may still qualify for LIS. They are encouraged to reapply for LIS coverage as soon as possible to ensure they continue to receive assistance with Part D drug costs. Individuals not eligible for LIS may want to consider choosing a different Part D plan that is more affordable. (More information: Newsletter article, 9/24)

Extra Help Redeterminations
How to keep Extra Help from Year to Year - Medicare Rights Center

If one receives a recertification letter, it must be returned, even if there are no significant changes or one will lose Extra Help. If this does happen, one can reapply. See an Extra Help Redetermination case example- MGH Community News, December 2008

For more information about Extra Help, see Are Your Clients Missing Out on Enrollment in the Medicare Low-Income Subsidy? from MGH Community News, January 2018

Special Enrollment Period
Those receiving Extra Help are limited to changing their Part D plan once per calendar quarter in the first three quarters of each year. Any changes made during this special enrollment period are effective on the first of the following month. People with LIS may use the Fall Open Enrollment period during fourth quarter to make changes to their coverage, with changes effective January 1.

For more information, see the Medicare Rights Center Open Enrollment guide. 

Co-Pays
New in 2024, everyone with Extra Help will pay a $0 premium, $0 deductible, and a reduced amount for both generic and brand-name drugs. (Prior to 1/24 there were two levels of Extra Help - those with "Partial"l had premiums and deductibles. More information.)

Those receiving Extra Help will pay either the Extra Help copayment or their plan’s copay for their prescription drugs. They always pay the lower cost between the two. Note that plan copays for prescriptions may change during the year, meaning at times the price for prescription drugs may differ. For more information, including catastrophic coverage, see Medicare Reminder: Copays if You Have Medicare D “Extra Help”- MGH Community News, September 2018.

Top of Page

IV. Choosing and Joining a Plan:

V. Rights and Responsibilities under the plans- (83 page booklet – overall overview) Your Guide to Medicare Prescription Drug Coverage

VI. To Join or Not to Join?  

    • Late enrollment penalty
      If you do not enroll in the Medicare drug benefit (Part D) when you first become eligible and you choose to enroll at a later date, you may have to pay a premium penalty. The late enrollment penalty does NOT apply to those with low-income (more).

      • The premium penalty will be 1 percent for every month you delay enrollment (1 percent of the average national premium). For example, the average national premium in 2018 is $35.02 a month. If you delayed enrollment for 31 months, your monthly premium penalty would be 31% of $35.02, or $10.86, which will be added to your plan’s monthly premium.

      If you have to pay the premium penalty, and you do not qualify for full Extra Help, you will have to do so for as long as you are enrolled in the Medicare drug benefit. This penalty will increase every year, as the national average premium increases. In some specific circumstances you will not have to pay the premium penalty.

      You will NOT have to pay a premium penalty for late enrollment if:

      • you already have prescription drug coverage at least as good as Medicare's ("creditable"). In order to avoid a premium penalty, you cannot have been without creditable drug coverage for more than 63 days. Speak with your insurer or your company's human resources department to find out if your current drug coverage is as good as Medicare's or better. For more information, see Medicare Reminder: Part D and Retiree Insurance Plans- MGH Community News, August 2018.
      • you qualify for Extra Help and enroll in a Medicare private drug plan.
      • you show that you received inadequate information about whether your drug coverage was creditable.
      -Above from Part D Late Enrollment Penalties

      • Note: The late application penalty does not apply to those with low-income; it was eliminated as part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Every year, since Part D began in 2006, to encourage enrollment, Medicare has waived the late enrollment penalties for low-income beneficiaries. To ensure that this policy continues in the future, MIPPA permanently eliminates the Part D late enrollment penalty for low-income beneficiaries. Learn more about MIPPA
      • Late Enrollment Penalty Tips
        • When you become eligible for Medicare, you should enroll in a Part D plan unless you have other creditable prescription drug coverage. Creditable prescription drug coverage is coverage that is considered to be as good as or better than Part D. Your employer (or other entity providing prescription drug coverage) should inform you whether or not your coverage is creditable. If you do not receive this information, you should ask for it.
        • Hold onto any notice of creditable coverage that you may receive. Keep this in a safe place just in case you have to prove your creditable coverage.
        • If you have been without creditable drug coverage for more than 63 days while eligible for Medicare, you may face a lifetime Part D late enrollment penalty that must be paid or you will likely lose your coverage.
        • Everyone has the right to appeal their penalty.

      A Medicare Rights Center “Ask Marci” column also addressed this topic and included this additional advice:

      • If you drop or lose your creditable prescription drug coverage through no fault of your own, you will have a Special Enrollment Period (SEP) to sign up for Part D for up to 63 days after your coverage ends. If you drop or lose your current or former employer-based prescription drug coverage, regardless of whether it is creditable, you will also have an SEP to sign up for Part D for up to 63 days after coverage ends. In order to avoid a late enrollment penalty, this employer-based coverage must have been creditable.
      • Those with Employer Plans- There may be consequences if you sign up for Part D in addition to your current drug coverage. You should ask your employer or retirement benefits administrator if you can keep their coverage and have Part D at the same time. You could lose your employer, retiree, or other benefits if you sign up for a Part D plan. It is important to keep this in mind if your plan covers a spouse or dependents because if you lose coverage, they will too, and it is unlikely you will be able to get the coverage back.

      The Five-Star Special Enrollment Period: Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans. For more information, see 5-star special enrollment period.

      More Information on Medicare Interactive

      -See the original Medicare Rights Center blog post (October 2016)

    • Joining (how & when): Signing Up For A Plan- AARP

VII. Special Situations

VII. For more Information for consumers and providers:

    • 2006 Fact Sheet:  “Introducing Medicare's New Coverage for Prescription Drugs” Source: CMS
    • AARP:
    • “Medicare & You” – To get a free copy of a state-specific book, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Also see:
    • Medicare Interactive (from the Medicare Rights Center) Part D Coverage Overview
    • “Your Guide to Medicare Prescription Drug Coverage”, from the Centers for Medicare and Medicaid Services (CMS)- 88 pages, best single source for detailed information.
    • Medicare Advocacy Project (MAP) helps Massachusetts residents’ secure Medicare coverage. MAP provides free legal services to individuals in a Medicare plan or individuals having problems with Medicare enrollment.

      Contact MAP:

      Greater Boston Legal Services

      Essex, Middlesex, Norfolk, and Suffolk counties
      197 Friend St.
      Boston, MA 02114
      617-603-1700; 800-323-3205

      South Coastal County Legal Services

      Bristol and Plymouth counties
      231 Main St., Suite 201
      Brockton, MA 02302
      800-244-8393; 508-586-2110

      Fall River
      22 Bedford St., 1st Floor
      Fall River, MA 02720
      800-287-3777; 508-676-3777

      Barnstable, Dukes, Nantucket, and Plymouth counties
      460 West Main St.
      Hyannis, MA 02601
      800-742-4107; 508-776-7020

      Community Legal Aid

      Berkshire, Franklin, Hampden, Plymouth, and Worcester counties
      405 Main St., 4th Floor
      Worcester, MA 01608

      1 Monarch Pl., Suite 400
      Springfield, MA 01144

      20 Hampton Ave., Suite 100
      Northampton, MA 01060

      152 North St., Suite E-155
      Pittsfield, MA 01201

      All offices: 855-252-5342

VIII. Detailed Information for providers: