CASE FLASH: ENROLLING IN A STAND-ALONE PDP

Mrs. D was enrolled in a Medicare private health plan with drug coverage (MA-PD), but she was responsible for the full cost of some of her prescription drugs because they were not included in her plan's list of covered drugs (formulary). She decided that she needed additional coverage for her prescription drugs.

During the Annual Coordinated Election Period (November 15 to December 31 of every year), Mrs. D decided to enroll in a stand-alone Prescription Drug Plan (PDP) that covered all of the drugs she was taking.

She called the PDP to enroll in the plan, and her new drug coverage began in January. Because Mrs. D showed her new drug plan card the next time she went to the pharmacy and got all of her drugs without a problem, she assumed she was enrolled in her Medicare private health plan with the stand-alone PDP coverage.

In February, however, Mrs. D had an appointment with her radiologist. Soon after, she received a letter from the radiologist's office, saying that her Medicare private health plan denied payment for the appointment. A few days after she spoke with the radiologist's office, she received a letter from her Medicare private health plan, stating that she was no longer enrolled in the plan.

Mrs. D called the Medicare Rights Center to ask why she was no longer covered by her Medicare private health plan. A hotline counselor explained to Mrs. D that you can never be enrolled in a Medicare private health plan with drug coverage and a stand-alone drug plan at the same time, unless your Medicare private health plan is a private-fee-for-service plan or a Medicare Medical Savings Account plan that does not offer drug coverage.

When Mrs. D enrolled in the new stand-alone PDP, she was also automatically disenrolled from her Medicare private health plan and was switched back into Original Medicare. Together, the counselor and Mrs. D called 800-Medicare and confirmed that Mrs. D now was covered for Part A (hospital insurance) and Part B (medical insurance) under Original Medicare, and she had prescription drug coverage through her PDP.

The counselor at 800-Medicare suggested that Mrs. D ask the radiologist's office to submit the bill to Medicare, rather than to the Medicare private health plan. Mrs. D brought a copy of the letter from her Medicare private health plan explaining her disenrollment to her radiologist's office and asked them to send the bill to Medicare. Medicare covered the visit, and Mrs. D only had to pay the approved coinsurance.

-Adapted from Medicare Watch, Vol. 10, No. 23, From the Medicare Rights Center, November 13, 2007.

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