What You Should Know About Part D

Subsidy Eligibility: Beneficiaries with incomes up to 135 percent of the federal poverty level and limited assets are eligible for a full subsidy of premiums and deductibles with low copays. Beneficiaries with incomes up to 150 percent of the federal poverty level and limited assets are eligible for a partial subsidy of premiums, deductibles, and copays. Individuals who automatically qualify for subsidies include those who have both Medicare and Medicaid (full-benefit dual eligibles), belong to Medicare savings programs (partial dual eligibles), or get Supplemental Security Income benefits. Individuals who no longer qualify automatically for assistance in 2007 should have received a personalized letter from Centers for Medicare and Medicaid Services (CMS) explaining the loss and an SSA application for other assistance.

Low-Income Subsidy (LIS) Enrollees Whose Plans Terminate on December 31, 2006: Some time in early November, LIS beneficiaries enrolled in plans that are terminating December 31 will be informed by CMS about the new plan to which they've been assigned, effective January 1, 2007. This is how CMS will proceed:

LIS Enrollees Whose Premiums Are Increasing Above Subsidized Amount: The premium for some plans in which low-income beneficiaries are enrolled will increase above the low-income subsidy amount for 2007. Beneficiaries in these plans should receive a notice from the government and be auto-enrolled into a new low-premium plan—providing they have stayed in the low-premium plan to which they were auto-enrolled in 2006. If they switched out of the assigned plan, and the 2007 premium of the plan into which they switched exceeds the subsidy amount, they will not learn of this until they receive their Annual Notice of Coverage or their first bill in 2007.

Non-LIS Enrollees Whose Plans Terminate on December 31, 2006: Plans that are not participating in Part D in 2007 were required to have sent a notice of termination to enrollees by October 1. Affected beneficiaries must enroll in a new plan during the open-enrollment period. After the open-enrollment period, beneficiaries may have to pay a penalty to join if they don't have other credible drug coverage.

Favorable Decisions Granted in 2006: Favorable decisions about drug prescriptions are not likely to extend into 2007. Thus, patients and their psychiatrists should review all letters of approval (prior authorizations, favorable coverage determinations, favorable redeterminations, favorable ALJ rulings) received in 2006 to determine the exact date that coverage will end. They also should contact the plans to determine whether they must file anew so that they can continue to get their currently approved drugs in the new plan year beginning January 1, 2007.

Formulary Changes: Patients should review their plan's complete 2007 formulary for their currently prescribed medications. If the plan has dropped needed medications from its formulary or changed the utilization-management requirements for 2007, patients have the option of filing a request for an exception or switching to a plan that does cover the medications. Note: The “Annual Notice of Coverage” mailed to beneficiaries at the end of October is not beneficiary specific, and so patients are advised to contact their plan directly to inquire about formulary information that may affect them.

Plan Enrollment or Changes: CMS recommends that beneficiaries enroll in or change plans by December 8. This can be accomplished online at<www.medicare.gov>, by phone at (800) MEDICARE, or in person at various locations. Plans can be compared by using the improved Medicare Prescription Drug Plan Finder at<www.medicare.gov>.