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Overview
The State of Connecticut and some drug
manufactures offer programs that help certain persons who need prescription medications.
Medicare now offers a separate, voluntary
drug benefit program called Medicare Part D. Because of this program, Medicaid no
longer pays for most prescription drugs needed by those with Medicaid and Medicare (called
"the dually-eligible"). Medicare Part D is a requirement for the
dually-eligible and for ConnPACE recipients.
Medicaid
(Title 19)
Medicaid covers most prescriptions drugs for
beneficiaries living in the community. For those who are both Medicare and Medicaid
eligible - called "dual-eligibles" - Medicaid will no longer cover most
drugs. Rather, prescription drugs must be obtained through a Medicare Part D drug
plan.
In Connecticut, dual-eligibles cannot be
charged a co-payment for their prescriptions. Those other low income individuals,
such as those persons enrolled in a Medicare Savings Program, can be charged Medicare Part
D co-payments between $2 and $5. For those dual-eligibles in nursing homes and some
other long-term care institutuions, no co-payments will be imposed.
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Volunteers in Health Care has developed RxAssist, an
on-line, searchable database of pharmaceutical company patient assistance programs for
providers. The database includes eligibility requirements, application procedures and
other information for hundreds of medications. www.RxAssist.org
The Pharmaceutical Research and Manufacturers of America
(PhRMA) have brought together public and private patient assistance programs into one
comprehensive resource. Call 1-888-4PPA-NOW or visit the Partnership for Prescription
Assistance web site to find help with drug costs.
The Attorney General of the State of Connecticut has
created a web site that compares pharmacy prescription drug prices throughout the state.
Click here
to view.
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Medicare
Prescription Drug Benefit
With the federal passage of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), Medicare has been
drastically changed to include a voluntary prescription drug benefit.
In Connecticut, the legislature enacted laws covering
ConnPACE and Medicaid to "wrap-around" the Medicare Part D benefit. It is
one of the most comprehensive wrap-around laws in the nation.
Basic benefit
Medicare Part D is the new voluntary prescription drug benefit
that provides Medicare beneficiaries with assistance in paying for their prescriptions.
Private insurance companies offer several different Medicare Part D Prescription
Drug Plans (PDP’s), all of which must include a standard drug benefit package. A
person must be eligible for Medicare Part A or enrolled in Part B to enroll in a Medicare
PDP. There are several costs associated with Medicare PDP’s: deductibles, co-payments
and monthly premiums. For those individuals who need extra help with these costs, Medicare
offers low-income subsidies. Dually-eligible nursing home residents (those with Medicare
and Title 19) do not have co-payments.
If one wants to take part in the Medicare drug benefit, Medicare
beneficiaries must enroll in Medicare Part D and in a Prescription Drug Plan
(PDP). Generally, an individual can only change PDP's once per year,
but those who are eligible for the low income subsidies can change plans every month.
If a person is eligible for Part D, but enrolls after the open
enrollment period, he may be penalized through imposition of a higher monthly
premium. Those with "creditable coverage" for prescription drugs through
employer-based health plans are exempt from this penalty. Click here to
read the CMS explanation of "creditable coverage."
Medicaid (Title 19) no longer pays for prescription drugs covered
under Medicare Part D, but for limited exceptions. The dually-eligible are
automatically enrolled in Medicare Part D and into a PDP if they do not do so
voluntarily. The dually-eligible will also be automatically enrolled in the full
low-income subsidy.
Costs
In a standard PDP, in addition to the monthly premium, there will
be an annual deductible. Once this deductible is met, an individual pays 25% of the
cost of each prescription until he spends an additional out of pocket amount. At
this point, one falls into the doughnut hole -- where there is no Medicare drug coverage
but premium payments are still required. During time in the doughnut hole, one must
pay 100% of prescription drug costs until he spends out of it. Unfortunately, if one
incurs costs for prescriptions not on the PDP's formulary, those expenses do not count
toward the amount needed to escape the hole.
If an individual climbs out of the doughnut hole, he pays only 5%
of prescription costs (or $2.15 co-pay for generic and $5.35 co-pay for non-generic
drugs). This is called "catastrophic coverage." Thus, in addition to
monthly premiums, a person must incur at least $3850 in out of pocket prescription drug
costs before obtaining catastrophic coverage.
The entire scenario occurs every year, with costs increasing due
to inflation.
For a thorough review of Medicare Part D, please visit the
following web sites:
AARP
Center for Medicare Advocacy (CMA)
Families USA
Kaiser Family Foundation
National Senior Citizens' Law Center
Low-income subsidies
Fortunately, for those individuals with low income and assets,
full or partial subsidies are available. ConnPACE now requires one to enroll in a
Medicare PDP if eligible. As a result, income and asset information will be
necessary to complete both ConnPACE and Part D applications.
The dually-eligible, SSI recipients and those persons enrolled in
the Medicare
Savings Programs (MSP) automatically receive a low income subsidy - which is
substantial (see chart below). In Connecticut, the MSP's are the QMB, SLMB and ALMB
(also known as QI) programs.
Click here to
view a Medicare Part D Low Income Subsidy chart for 2007. Please note that the chart
is not specific to Connecticut law.
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