Clinical Geriatrics

May 15, the end of the initial open enrollment period for Medicare Part D, is quickly approaching and, despite all the talk about the dangers of not making a decision, some 20 million Medicare beneficiaries have yet to enroll in a prescription plan. But how do people evaluate, select, and enroll in a prescription plan? The fact is that it is a complex process, but in most cases well worth it because the costs involved in not making a decision are high, and the benefits of joining are much greater. Those costs include a late enrollment penalty, being locked out until January 1, 2007 from any coverage, and the lost opportunity for significantly reduced out-of-pocket expenditures, especially for those eligible for the low-income subsidy. But how exactly should individuals go through this process, and what can busy practices do to assist them?

ASSESSING THE OPTIONS
To start the enrollment assessing process, people need to first ask themselves if they have creditable coverage. Creditable coverage is prescription drug coverage that is just as good as Medicare Part D. This coverage can come from current or previous employers, the federal government through a military benefit such as the Veterans Administration, or certain State Pharmacy Assistance Programs. These providers are supposed to provide a letter stating whether their coverage is creditable, and if that is the case, to also inform the Centers for Medicare & Medicaid Services (CMS). This notification is to assure that if these individuals switched from this creditable coverage to a Medicare Part D prescription plan they would not be subject to a late enrollment penalty. If individuals are not covered by a creditable plan, in almost all cases they should enroll in a Medicare Part D prescription plan.

Others who should definitely enroll in a Medicare Part D prescription plan are those who are eligible for the “extra help.” Some 9 million Americans qualify for this extra help through the low-income subsidy; the enrollment for this program is managed by the Social Security Administration and state Medicaid program. Unfortunately, less than 1 million Medicare beneficiaries have taken advantage of this significant benefit. If you have patients who are having a difficult time paying for their medications because of limited income and assets, they should be encouraged to apply for the low-income subsidy, and then enroll in a prescription plan.

Now to the question of what type of plan. There are basically two types of prescription plans: those covering just prescription drugs known as prescription drug plans (PDPs), and those from Medicare Advantage Prescription Drug (MA-PD) plans that cover not only the prescription drugs but also benefits offered under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). The benefit of one over the other must take into account personal preference with regard to access and conveniences. While the MA-PDs are able to offer greater benefits, they do so within a network of providers.

Within the options for MA-PDs are traditional health maintenance organizations (HMOs), preferred provider organizations (PPOs), and a new entity called special needs plans (SNPs). The SNPs become possible as a result of a provision within the Medicare Modernization Act; these plans can choose to treat one of three unique groups: institutionalized Medicare beneficiaries, those suffering from chronic illnesses, or the dually eligible (those having both Medicare and Medicaid). Those individuals who fit into one of these three groups should look into the availability of a SNP in their area, and decide whether this specialized program that covers all of their Medicare services would be most beneficial for them.

Once it has been decided whether to enroll in a PDP or a MA-PD, the process moves to assessing the different companies and their plan offerings.