Medicine Dish: Medicare Part D and Program Updates

Uploaded by CMSHHSgov on 27.10.2011

Kitty Marx:
Welcome to Medicine Dish. I'm Kitty Marx, Director of the CMS Tribal Affairs
Group and your host of today's Medicine Dish. This broadcast will feature CMS
and IHS experts providing an overview of Medicare Part D and the recent changes
in the Medicare program. All this and more on today's installment of Medicine
[music playing]
Again, welcome to Medicine Dish. As I mentioned earlier, today's topic is
Medicare Part D. But first, let's take just a minute to review what the Medicine
Dish is and how you can use the information.
The Medicine Dish was developed by the Centers for Medicare and Medicaid
Services for health care programs operated by the Indian Health Service, Tribes,
Tribal Organizations, and Urban Indian Health Programs. Our shows are archived
at so you can watch them at your convenience. Look for
previous shows under "Past Events," select "Training" and "Meetings," and then
select "CMS: Centers for Medicare and Medicaid Services." You'll also find
Medicine Dish on YouTube. Just go to and search on the words
"Medicine Dish."
And now let's turn to the topic for today's Medicine Dish broadcast: the
Medicare Prescription Drug Plan, or Part D.
Today we'll also have a demonstration of the Medicare Plan Finder, a tool you
can use today. I'm going to turn the show over to David Nolley, our moderator
for today's show, to introduce our experts. David?
Dave Nolley:
Thanks, Kitty. As you know, this is the time of year that CMS encourages all
Medicare beneficiaries to review their Medicare prescription drug and health
plan coverage to make sure they're getting the best coverage for their needs. If
not, it's time to make changes for the year ahead. We know that Medicare
Beneficiaries turn to IHS Tribal and Urban Indian Health Programs for assistance
in enrolling in their Medicare prescription drug and health plans, so we've
brought together a panel of experts to share their insights with you. I am
pleased to welcome Captain Pam Schweitzer from the Indian Health Service, Kay
Pokrzywa, and Roslyn Thomas from the Centers for Medicare at CMS. Thank you all
for joining us today.
Now, we have a lot of information to cover, so let's get started quickly. And
Roslyn, I'm going to start with you first. Can you tell us more about when
individuals can make those changes to their Medicare coverage?
Roslyn Thomas:
Yes. I want to share some new information about Medicare's annual election
period, called the Fall Open Enrollment period. They can enroll in a Medicare
Advantage plan or opt to return to Original Medicare for their health coverage.
They can also pick up or drop Medicare prescription drug coverage during this
time. The big, new news for this year is that the Open Enrollment period is
October 15 through December 7. This is very different from years past, which
used to allow for people to make changes all the way up the end of December.
This timing change came from new legislation, specifically the Affordable Care
Act, which requires the open enrollment period to be these new dates moving
Dave Nolley:
When would their coverage begin?
Roslyn Thomas:
Anyone making a change during the Fall Open Enrollment period will have their
new coverage begin on January 1, 2012. Those who do not make any changes will
remain in whatever health plan coverage they currently have. However, costs may
be different as plans change each year. This is why it's important for
individuals to review the Annual Notice of Change mailed to them by their health
plans. Individuals should have received this information by October 1.
Dave Nolley:
What if someone is currently in a plan that isn't offered next year?
Roslyn Thomas:
Some individuals may have to select a new plan because their current plan will
no longer be offered in their area. For those individuals, they can enroll in
another plan during the Fall Open Enrollment period. Their new plan coverage
will begin on January 1. For those who don't enroll in another plan, they will
have Original Medicare starting January 1.
Those individuals who did not enroll in a different plan during the Fall Open
Enrollment period, which is October 15 through December 7, do have some
additional time to enroll in Medicare Advantage or Medicare Prescription Drug
Plan. These individuals have a special election period and may select a plan up
from December 8 through the end of February.
Dave Nolley:
Okay, well, what other times -- or I guess I should say, are there other times
individuals can make changes to their Medicare coverage?
Roslyn Thomas:
Yes. While the primary time an individual can make changes is during the Fall
Open Enrollment period, there is also another opportunity to make changes to
coverage. People with Medicare can disenroll from their Medicare Advantage plan
and go back to Original Medicare if they aren't happy with their new coverage.
This opportunity is called the Medicare Advantage Disenrollment Period, and it
occurs from January 1 through February 14 each year. During this time, an
individual may disenroll from their Medicare Advantage plan and go back to
Original Medicare. They then can also pick up a standalone Part D plan to
continue or add Medicare prescription drug coverage.
Dave Nolley:
Okay. Well, it looked like you have something you might want to add here, Pam?
Pam Schweitzer:
Yeah, I just wanted to add, and Kay's going to address this in a little bit,
that patients or beneficiaries that have both Medicare Part D or Medicare and
Medicaid, or dual eligible patients, they can enroll anytime during the year.
Dave Nolley:
Oh, okay. Okay. So what else is new this year?
Roslyn Thomas:
Well, also new this year is a special enrollment period for individuals who want
to join a Medicare Advantage or prescription drug plan in their area with a
5-star rating. These are the overall ratings that Medicare assigns and you can
see on while comparing plans. A plan can get a rating of one to
five stars. A 5-star rating means the plan has received high marks from members,
health care providers, and other information provided by the plan. A 5-star
rating is considered excellent. An individual can use this special enrollment
period one time each year to make a change outside of the normal open enrollment
Just like any other enrollment opportunity, prior to any enrollment into a
different plan, individuals should check the plan's coverage and costs to make
sure they're making an informed decision. Finally, I'd like to add that Cost
Plans are now able to accept telephonic and online enrollments.
As a reminder, Medicare provides information to help individuals see and compare
coverage options so they can make an informed decision. First, we have, including the Plan Finder tool where individuals can see the plans
in their area and receive plan information based on their needs. Individuals can
also get information to enroll in most plans on their website.
Second, we have 1-800-MEDICARE if you want to talk to a live individual. We have
customer service representatives available 24 hours a day, seven days a week, to
assist people in making plan choices and enrollments.
Third, individuals can also use their State Health Insurance Assistance Program,
also known as SHIP, to provide individual counseling regarding health care
decisions. To find your local SHIP providers, you can contact 1-800-MEDICARE to
obtain the phone number of your local SHIP. Also, American Indian and Alaska
Native beneficiaries may prefer to get assistance from their local Tribal, IHS,
or Urban Indian Health clinic staff.
And fourth, each person with Medicare receives a Medicare and You handbook. It
was mailed to you early this year to assure that Medicare beneficiaries had the
information they needed to start the beginning of open enrollment, which began
on October 15.
David Nolley:
Okay. Wow. So, if someone decides to change plans, how do they get enrolled in
the new plan?
Roslyn Thomas:
Well, if they want help, they can call 1-800-MEDICARE or work with the staff at
the SHIP or their local IHS, Tribal, or Urban Indian clinic to complete the
enrollment online at Or they can go to the website of the plan
they choose and enroll on their own.
Dave Nolley:
Okay. It sounds like the plan finder on will be used by most of the
IHS, Tribal, and Urban Indian clinics, as well as our partners, to help with
plan comparison and enrollment assistance. So let's take some time to walk
through the process. Stacey Platte will demonstrate the plan finder on
Stacey Platte
Today I'm going to show you how you can use the Medicare Plan Finder to learn
about health and drug insurance options, compare plans, and enroll in one that
best meets your needs. We'll take a look at the Online Enrollment Center and
also highlight a few important dates to keep in mind this fall.
We'll start the demonstration from the homepage. From this homepage
there are two ways you can get to the Medicare Plan Finder. You can use the
"Resource Locator" tab and select "Medicare Plan Finder," or you can click on
the link from the homepage that says, "Compare Drug and Health Plans". This will
bring you to the Medicare Plan Finder homepage.
As of October 1, the Medicare Plan Finder will automatically show you 2012 plan
information. You'll be able to enroll in 2012 plans during the Open Enrollment
period, which is earlier this year, from October 15 through December 7. You'll
also be able to view 2011 plan information from the Medicare Plan Finder, if you
choose to do so.
From the Medicare Plan Finder homepage you have the option to complete a general
search or a personalized plan search. A personalized search may provide you with
more accurate cost estimates and coverage information. To complete a general
search you only need to enter your zip code whereas a personalized plan search
requires your zip code and complete Medicare information. For this
demonstration, we're going to do a general search, and I'm going to start by
entering a zip code.
When doing a general search, the Medicare Plan Finder requires a bit more
about a person's coverage and also whether or not they receive extra help to pay
for their prescription drugs. For this demonstration, I'm going to select that
our current coverage is Original Medicare, and also say that we don't get any
extra help to pay for our prescription drugs.
This brings us to the "Enter Your Drugs" page. Please enter your prescription
drugs, if at all possible. This will help us estimate your costs and allow you
to see which plans cover your drugs. Please note that the Plan Finder doesn't
show pricing for over the counter drugs or diabetic supplies. For more
information about those items, you want to contact your plan directly.
To enter a drug, I'm going to click in the name of the drug field and type the
name of the drug I would like to enter. You can either click on the name of the
drug below where you're typing or you can click on "Find My Drug" to add that
drug to your drug list. As you'll see, the drug that I'm looking for is the
first drug in this list, so I can click on the "Add Drug" button to select the
dosage, frequency, and quantity of that drug. Once I'm finished, I can click on
"Add drug and dosage." The Medicare Plan Finder adds that drug to my drug list
at the bottom of the page and it also saves my drug list with a "Drug List ID"
and a "Password Date" that I can use and enter into the Plan Finder at a later
time to bring up my drug list again.
There are two additional options on this page. If you do not wish to enter
you can click on the button that says, "I don't take any drugs," or "I don't
want to add drugs now," if you don't have your prescriptions with you. However,
for the most accurate cost estimates, we do recommend that you enter drugs when
at all possible.
For this demonstration, I'm just going to add this one drug, so I'm finished
with my drug list and I'm going to click on "My Drug List is Complete" to
continue to the pharmacy page. From this page you can select up to two
pharmacies. And if your pharmacy isn't in a plans network, the cost you will see
is the full cost of the drug with no insurance. Please note that some plans may
charge lower drug prices at preferred pharmacies and higher prices at
non-preferred pharmacies.
For this example, I'm going to add one pharmacy by clicking the "Add Pharmacy"
button under this first pharmacy here. Once I'm finished, I can click "continue
to plan results" to proceed with the search.
This next page is a summary of the types of plans available in your area. Use
the checkboxes to select the types of plans you'd like to view. You may also use
the filters on the left to narrow your search. Please note that using filters
may eliminate some options, including plans with the lowest estimated annual
costs. For this example, I'm going to select that we'd like to look at all plan
types by clicking on the button that says, "All," and then I'll continue to plan
Now we've come to the "Plan Results" page. Your plan results are organized by
plan type and are in order of lowest estimated costs. To view more plans, you
can click on the buttons that say, "View 20" or "View 50." You can click on any
plan name for more details about that plan or you can compare up to three plans
by using the checkboxes and clicking on "Compare Plans." Please note that the
costs displayed here are estimates and that your actual costs may vary.
As we take a look at this page, there are a few things I'd like to point out to
you. The first thing is this link at the top of the page that lets us know that
we're viewing 2012 plan information. If you would like to view 2011 plan
information, you can click on the link that says, "View 2011 Plan Data."
Underneath that we have a new section, which is a symbol section. This section
will display icons to let you know which plans offer additional coverage such as
some dental coverage, some vision coverage, some hearing coverage, or also
nationwide coverage. These symbols will be displayed next to plan information
for those plans that do offer these additional benefits.
As we look further down the page, the first section will show us our current
plan information, which in this case is Original Medicare. The rest of the page
is organized by plan type and starts by showing you prescription drug plans,
followed by Medicare Health Plans with prescription drug coverage and Medicare
health plans without prescription drug coverage.
For this demonstration, we're going to look at the prescription drug plan
section. In the left-most column, you'll see the estimated annual drug cost
column. The first field in this column lets us know whether the pharmacy that we
selected on the "Select Your Pharmacy" page is a network pharmacy, a preferred
network pharmacy, or an added network pharmacy for this plan. The rest of the
column lets you know what the estimated annual retail cost would be for your
drugs at both a retail and mail order pharmacy. The remaining columns show you
information about monthly premiums, deductibles, coverage information, and also
plan ratings.
Right now you'll see that the plan ratings say, "Coming Soon," and we will be
adding updated plan ratings to the Medicare Plan Finder on October 12.
In the last column, you'll see a message that lets you know that, for 2012
plans, enrollment begins on October 15. So, beginning on October 15, you'll see
an "Enroll" button in this column that you would be able to click on to enroll
into a 2012 plan.
For this example we're going to compare three plans, so I'm going to select the
first three plans in the "Prescription Drug Plan" section and click on the
"Compare Plans" button. This will bring us to the "Plan Comparison" page. Since
we are looking at Medicare Prescription Drug Plans, we're automatically going to
default to see the drug cost and coverage tab information first.
As you'll notice there are also a few other tabs we can click on to view
additional information about these plans. For instance, we could click on the
"Health Plan Benefits" tab, to view the health plan information about the plans
we selected. Since we are looking at prescription drug plans, please note that
the health plan benefits and also the cost sharing information that you see on
this tab will refer to Original Medicare. If you were looking at a Medicare
Health Plan, the information on this page would refer specifically to that
health plan and its benefits and cost sharing.
We could also click on the "Plan Ratings" tab to view much more detailed
information about how plans are rated on a variety of different measures by
Medicare. Beneficiaries may find this information helpful when they're comparing
plans and making a decision about which plan they'd like to enroll in.
Also, please note that, starting on October 1, the Plan Finder started
displaying 2012 plan information. So when you come to the Plan Finder, you will
automatically be viewing the 2012 plans. If you would like to view 2011 plan
data, you can click on this link that appears at the top of all of the pages,
which says "View 2011 plan data." Now I'm going to click on that link now, so
that I can show you how we would enroll in one of these drug plans. Okay.
So, now we're viewing the 2011 information. Once I've decided which plan I'd
like to enroll in, I can either click on the name of that plan to get more
detailed information about that plan, or I can go ahead and click on the
"Enroll" button that appears under the plan information. Clicking on that button
will take us to the Online Enrollment Center on, where we can
enroll in Medicare Prescription Drug Plans, and also Medicare Health Plans.
At the top of the page, the Online Enrollment Center lets me know that we are
trying to enroll in a 2011 plan and also lets us know when the effective date
for that coverage would be. Since I am enrolling in a 2011 plan, I do need to be
eligible for a special enrollment period, which is listed at the bottom of the
page. As I click "Continue to Enrollment," it's going to ask me on the next page
which special enrollment period I'm eligible for. In this case I'm going to say
that I'm new to Medicare, and select that option, and continue on through the
Online Enrollment Center.
The next page asks us to fill out some information about the beneficiary who's
being enrolled into this plan. For this demonstration, I'm just going to enter
"Test Information." The next page of the Online Enrollment Center asks for the
person's Medicare number, their Medicare effective date, and also asks you to
select how the person would like to be billed for their Medicare Prescription
Drug Plan or Health Plan premium.
This next step in the Online Enrollment Center asks you whether the person has
any additional prescription drug coverage and whether they live in a long-term
care facility such as a nursing home. Once you select the answers to those
questions, you can continue with the enrollment.
Now we come to a page which asks us to verify this beneficiary's personal
information before we proceed with the enrollment. So, once you verify that
information, you can click on "Agree Submit Enrollment." Once you've read this
important information, you can continue and also read through this important
information to be sure that you and the beneficiary understand the plan that
they are enrolling in.
The next page asks you to please read and sign below, and once you've done that
you'll come to a confirmation page, which is the last step in the enrollment
process. This page lets you know that your enrollment request was received and
also lets you know what the effective date of that enrollment may be. It
includes an online confirmation number for that enrollment, and also the contact
information and additional information about contacting the plan, if you need to
do so.
I've just demonstrated how to enroll someone who is new to Medicare into a 2011
plan. You can also enroll people into 2012 plans using the Online Enrollment
Center. Again, you can do that during the Open Enrollment period, which runs
from October 15 until December 7. If you enrolled someone into a 2012 plan
during the Open Enrollment period, their effective date for that plan would be
January 1.
That concludes my presentation. I hope you found this demonstration helpful.
Thank you very much for your time.
David Nolley:
Now that we had the overview of the plan finder, Pam, what do ITU sites need to
do to prepare for 2012?
Pam Schweitzer:
Good question, Dave. We have a few reminders for providers and staff as they get
ready for this year. First, we have a Fraud, Waste, and Abuse Training. And it's
just a reminder to have all the staff involved in Medicare Part D billing
complete the Fraud, Waste, and Abuse training. Several of the plans and pharmacy
benefit management companies have trainings that are available for use. Indian
Health also has a training on the FTP site that you can download and use. On the
last page, there is a place to enter your name and print it off so you can keep
that on file. This training needs to be completed every year. The prescription
drug plan will request that you complete an attestation stating your staff has
completed the training. Be sure to review, sign, and return that to them. For
Indian Health Service sites, we're trying to complete these at a national level
as we receive them.
Next, there's an OIG Exclusion List, and this is the Office of Inspector General
exclusion list, to not hire providers that are on this list. CMS requires that
all staff, which includes employees, providers, contractors, and any
subcontractors performing any activity related to Medicare Part D to review the
exclusion list upon employment and annually thereafter. So you may want to
coordinate this process with your quality assurance department or human resource
And then, next we have the Creditable Coverage Letters. Some of you have called
already on this, and we have a few questions on if we're supposed to send out
the creditable coverage letters. Last year the process was changed and rather
than mailing creditable coverage letters to all eligible Part D beneficiaries,
facilities now will provide a creditable coverage notice to all new and existing
members upon enrollment at an ITU facility. Creditable coverage notices are to
be displayed in public areas and a personalized creditable coverage letter or
notice can be provided promptly upon a request of the beneficiary.
And then next, as Roslyn already mentioned, reviewing the handbook, 2012
handbook, the Medicare and You handbook: you can download this from the CMS
website, and we also included it on the FTP site. It has a lot of really
current, useful information, and if you're a patient benefit coordinator, this
is a great resource for you, so we encourage you to download that.
And then, those of you that are involved in doing the pharmacy network
agreement, there have been several mergers and plan changes, and you might be
seeing some more agreements being sent to your pharmacy. For tribal and urban
facilities, make sure you have a good process to collect, review, and return the
agreements so your reimbursement is not affected.
David Nolley:
Besides the plan updates, which we will get back to in a moment, what changes do
we need to know about this year?
Pam Schweitzer:
Okay, for those involved in prescription processing, there is something that's
real important to be able to utilize for their -- to get your claims to go
through. And you'll need to view the beneficiaries' membership or use the
eligibility transaction to obtain the four key elements for the claim to process
successfully. And those are: the BIN, the PCN, the Cardholder ID, and the Group
And then, for sites using the RPMS system, Emdeon is the switch company used to
route prescriptions. They've had a change in their different network and there
is now a new website to look up the formats and information like the BIN and
PCN. And I've included the instructions on how to access that website on the FTP
site that we'll talk about in a little bit.
And then there's been a change also for those using RPMS, for the benchmark drug
pricing. At the end of September, First Data Bank, the company we use to do our
pricing, discontinued publication of the AWP, which is the average wholesale
price. We now use a different published price that we call, "Consolidated Price
Number 1." You may notice differences in what the billing package uses to
calculate the price.
And then there's a new version of NCPDP standards for pharmacy transactions that
will be effective January 1, 2012. These are the HIPAA compliance standards that
the new version -- and it's called D.0, and this replaces the current pharmacy
claims standard, which is NCPDP 5.1. If you are involved in claims processing,
you have probably already noticed that many of the payers have already starting
using D.0 standards. If you use RPMS, the Office of Information Technology, or
OIT, is currently testing and will be releasing a patch that will comply with
the new standards. For pharmacies that use a commercial software vendor, check
with them to make sure you're using D.0.
And then, closing the donut hole or the coverage gap, we'll be -- last January,
we started and we made some changes. And for those individuals that have
Medicare Part D drug coverage that reaches the coverage gap, they can use an
Indian Health, Tribal, or Urban facility to help them get through the donut
hole. So, if a beneficiary uses the IHS, then what they do is the spending will
count toward the annual out-of-pocket threshold in the donut hole. So if the
spending reaches $4,700 out-of-pocket for the year, the coverage gap ends and
the beneficiary is now in catastrophic coverage. By 2020, this coverage gap will
be closed.
And then, last year, the ITU addendum that is used for the network agreements,
was updated, and the changes from the Affordable Care Act were incorporated. The
plans including -- are including this new wording, and several updates and
addendums in agreements. So, be watching for them and get them reviewed, signed,
and returned.
David Nolley:
All right. Oh, tell us now, though, about the plan changes for 2012.
Pam Schweitzer:
And this is the part that everybody's sort of been waiting for, because every
year we get a lot of requests for this. And I wanted to provide an overview of
the Medicare Part D Prescription Plans for 2012. There are two types of Medicare
Part D plans. The Medicare Advantage Plan, MA-PD, and that's kind of like an
HMO, where the beneficiary may have Part A, B, and D all through the same plan.
A small of percentage of our beneficiaries that we see are in these plans. Then
we have Medicare Prescription Drug Plan, which is also called PDP. Sometimes you
hear it called the standalone prescription drug plan. These are the plans that
the majority of beneficiaries are enrolled in.
Now I am going to show you the Medicare Part D landscape standalone prescription
drug plans. This is a summary of the plans that we have available, and it's
organized by state. And this is a document used extensively by the patient
benefit coordinators, because it shows them the plans that the patients are
eligible for.
Okay, so, in reviewing the document, and I'll go through the columns, you'll see
a column with the state, with the company name, and the plan name. And then
there's a column marked in yellow, it's the zero dollar premium with the full
low subsidy; that's the same with our dual eligible, and that's marked in
yellow. And you'll see in there, there's a dot that marks -- all of them that
are marked and they're colored in yellow, they're all marked in the dot, those
are the dual eligible plans.
And then you'll see a column for the deductible. There are a few plans that
don't have a deductible, but for the most part the deductible this year is $320.
And what that means for us, processing the claims, is that the patient is seen
in our clinics, and until the deductible is met, we won't be receiving any
payments. And then you'll see another column for the contract ID, and that's
used to help you find the BIN and PCN on another spreadsheet.
And then, finally, in the far right-hand side, you'll see a blue column that's a
star rating. And that's what Roslyn was talking about earlier. And the -- if you
don't see a plan on this list when you're looking at it, it's because the plan
may not be here this year. And specifically, I want to make sure you notice that
the plans that are marked in red, these are plans that are now above the LIS,
and so the premium will now have to be paid by the beneficiary if they don't
change plans. So the patient benefit coordinators will need to make sure they
look at those red plans, and then make sure that they assist this group of
patients to enroll in a different plan if they do not want to pay the premium.
The Limited Income NET Program is a program that allows low income subsidy --
LIS -- to receive immediate needed coverage at the point of sale if they are not
already enrolled in a plan. So we see that plan; when people are in the process
of changing plans, they'll be able to be in this plan. And I -- make note of
that, because there are some new BIN changes that need to be made, and the
format needs to be changed, for those that are using the RPMS system.
And then, lastly, I wanted to mention a little bit about the new star rating
column. This is really a great program that CMS has implemented and has
available for us this year, because this is like restaurants, hotels, and
movies, who all have a star rating, and now CMS has it. And this is going to
make it a lot easier for beneficiaries to be able to find a good drug plan. And
the star ratings are actually based, for the prescription drug plans, are based
on 19 independent criteria, and they're focused on performance and quality. So
this is really going to help them select a good plan.
In looking at the range for the year, I took a look at it and looked at all of
the plans that were available for our patient population, and the rating range
was anywhere between two and four. I did not see any ones. I didn't see any
fives, but for the dual eligible patients, the rating range is from two to four.
The other thing I wanted to mention was that, for medication therapy management,
for the pharmacists, it's a great opportunity to get involved this year. You'll
be seeing further training on how to bill for the MTM services that you are
providing to your patients with chronic diseases. This is mentioned in the
handbook this year, too.
And the other -- last thing I wanted to mention was the vaccine reimbursement.
I'm not sure how many sites are billing for vaccines, but if you do bill via the
point of sale system, note that there are instructions on which codes to include
in the DUR segment. They vary a little bit by payer, and those instructions are
also included on the FTP site.
David Nolley:
How can people get more information, including the plan list you just told us
Pam Schweitzer:
The best way to stay current is -- a couple ways. One, to join the point of sale
listserv, and this is for tribes, urban, and IHS staff, because there's messages
going out on that almost daily. And then the medication -- the Medicare Part D
information for 2012 -- there's a whole folder on there, and it's going to be
placed on an FTP site, and folks can download that -- basically that whole
folder, and have everything that's from this presentation.
Dave Nolley:
Great bits of information there. Whoever would have guessed that, you know,
health care would have a Zagat rating, you know?
Pam Schweitzer:
I know.
Dave Nolley:
That's for, like, hotels and restaurants.
Pam Schweitzer:
Dave Nolley:
That's pretty cool. Are there any other issues or changes that might be of
Pam Schweitzer:
Well, I've included several other additional handouts on the FTP site, because
we weren't able to have time to cover everything. So what they should do is go
and download that whole folder, and there is information on end-stage renal
disease, there's information on the differences between Part D plans and Part B
drugs. So there's a lot of really good handouts on there. I encourage people to
download that whole folder.
Dave Nolley:
Thank you, Pam. Great, great job. Okay. Now that we've covered Medicare plans
and enrollment, it's time to talk with you, Kay. So, what activities are
occurring this fall for individuals who are eligible for extra help? You know,
the individuals with limited income and resources?
Kay Pokrzywa:
Thanks, Dave. There are two key activities that are occurring this fall:
redeeming and reassignment
Redeeming is CMS' process to determine if beneficiaries who automatically
qualified for extra help this year will continue to qualify next year. CMS uses
state data and SSI data from Social Security to decide who continues to qualify
next year.
Reassignment is CMS' process for protecting beneficiaries from plan
disenrollment or premium liability in the coming year. If an individual's plan
will have a premium next year that is above the regional low income premium
subsidy amount, also known as the benchmark, that individual would be
responsible for paying a portion of the plan's premium even if he or she has 100
percent premium subsidy. To prevent the individual from having this premium
liability, CMS will move him or her to a plan where the premium will be covered
in full by the subsidy.
If an individual's plan is terminating, CMS will reassign subsidy-eligible
individuals to ensure that they have prescription drug coverage in the coming
Dave Nolley:
Can you describe what individuals can expect from the redeeming process?
Kay Pokrzywa:
The redeeming process has already begun with the mailing of notices in
September, on grey paper, to individuals who will not automatically qualify for
LIS next year. Included in this mailing was a Social Security LIS application
and prepaid return envelope. Individuals were encouraged to complete and return
the Social Security application in order to requalify for LIS for the coming
year. CMS has already mailed notices on orange paper to individuals who will
continue to qualify for LIS next year, but whose copay level will change.
Individuals who will experience no change will not receive a notice.
Dave Nolley:
Great. Can you also describe what individuals can expect from the reassignment
Kay Pokrzywa:
Individuals who will be reassigned by CMS to new plans will receive notices on
blue paper in late October. Individuals whose plans have an increasing premium
may choose to remain in that plan. The notice describes their premium liability
if they remain and gives them directions for continuing their enrollment in
their current plan, if they wish. Individuals whose plans are terminating are
free to choose a plan other than the plan into which CMS has enrolled them. In
all cases, CMS encourages beneficiaries to make sure that the plans in which
they are enrolled meet their prescription drug needs and offer convenient
Dave Nolley:
Have changes taken place in the redeeming and reassignment processes?
Kay Pokrzywa:
No changes have taken place in the reassignment process in 2011. CMS will
continue to reassign LIS-eligible beneficiaries in Medicare Advantage plans that
are terminating or reducing their service area, resulting in non-coverage in the
beneficiary's area. These beneficiaries will be assigned to prescription drug
plans effective January 1, 2012, ensuring their access to prescription drug
CMS will also continue to mail notices to reassigned beneficiaries with
formulary differences between their former drug plan and the plan into which CMS
has assigned them. Each drug the individual has used in 2011 will be listed with
the status of that drug in the 2012 plan; that is, is it covered, not covered,
covered as generic only, or covered with special rules such as step therapy or
The notice will also provide a description of the beneficiary's right to request
a coverage determination, exception, or reconsideration, or to file a grievance.
The notices with formularies will be sent to beneficiaries in December 2011.
Dave Nolley:
Oh, okay. Well, now that the Open Enrollment period is already upon us, can you
tell us more about when individuals can make changes to their plans?
Kay Pokrzywa:
Pam did mention that individuals with LIS can make changes to their enrollment
at any time. This means that, when they make a change to their enrollment, the
change is actually effected the beginning of the following month. They can do
that every month in the year, if they wish. Individuals who don't have LIS may
still have opportunities throughout the year to make changes in their
enrollment, if their circumstances change. For instance, if they move out of the
service area of their plan, or they enter a long-term care facility such as a
nursing home, or leave such a facility. They have an opportunity to choose a new
plan, even if they don't have LIS.
Dave Nolley:
Okay, great. What about individuals who want to disenroll? I mean, can an
individual disenroll from a Medicare drug plan at any time?
Kay Pokrzywa:
Actually, disenrolling is really very similar to the enrollment process, and it
depends on the individual having the same sort of enrollment period opportunity.
In other words, if a person doesn't have LIS, they may be limited as to when
they can disenroll. But, in general, if they have an enrollment period
opportunity and they enroll in a new plan, that automatically disenrolls them
from their old plan. They don't have to take a separate step of disenrolling
from their old plan.
Dave Nolley:
Okay. So you've talked about when someone can make changes; can you describe how
that's done? I mean, do they just call in? Do they send in a paper application?
What's done?
Kay Pokrzywa:
Merely enrolling with a new plan will accomplish a disenrollment and
reenrollment, or they can use 1-800-MEDICARE.
Dave Nolley:
Okay. Thank you very much. And I want to say thank you to all of our experts:
Pam, Roslyn, and Kay. And thank you to our viewers for watching. We hope you can
use all the resources we've talked about today. Remember, you can view this
Medicine Dish show at: or on
Kitty Marx:
We've covered a lot of information today. I'd like to thank Stacy Platte, Pam
Schweitzer, Kay Pokrzywa, and Roslyn Thomas for sharing their insights on the
Medicare program and its impact on Indian country.
There's never been a better time to check out Medicare coverage. New benefits
are available for all people with Medicare: lower prescription costs, wellness
visits, and preventive care. Encourage Medicare beneficiaries in your tribal
communities to take advantage of the Open Enrollment season.
CMS needs your help in getting the word out about the new Open Enrollment
period, October 15 through December 7. We're counting on you to help our
Medicare beneficiaries in Indian country to get the best coverage for their
needs. Please encourage and assist the Medicare beneficiaries in your community
to visit: to compare current coverage with all of the
options that are available. Call 1-800-MEDICARE 24 hours a day, seven days a
week to find out more about coverage options. Review the Medicare & You 2012
handbook that was mailed in September and get one-on-one help from the IHS,
Tribal, or Urban Indian Health programs in your community.
We're at the end of our Medicine Dish show, and I want to thank you for your
participation in our broadcast. I'm Kitty Marx, host of Medicine Dish, wishing
you a very productive day.
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