Benefits Section

By Danny Dandignac

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How do we decide if you are disabled?

 

SSDI & SSI

 

The process we use to decide if you are disabled involves five steps. They are:

 

1.  Are you working?

If you are working and your average monthly earnings, after considering the effect of work incentives, are at the Substantial Gainful Activity (SGA) level, we generally cannot consider you disabled. If your monthly earnings average less than the SGA level, (in 2006 that level was $860 per month) we look at your medical condition using steps 2 through 5.

 

2.  Is your medical condition "severe"?

For us to consider you disabled, your impairment(s) must significantly limit your ability to do basic work activities, for example walking, sitting, seeing, and remembering. If it does not, we cannot consider you disabled. If it does, we go to the next step.

 

3.  Is your medical condition in the list of disabling impairments?

We maintain a Listing of Impairments for each of the major body systems that are so severe we automatically consider you disabled. If your medical condition(s) is/are not on the list, we have to decide if it is of equal severity to an impairment on the list. If it is, we approve your claim. If it is not, we go to the next step.

 

4.  Can you do the work you did previously?

If your medical condition is severe, but not at the same or equal severity as an impairment on the list, then we must decide if you can do your past relevant work. If you can, we will deny your claim. If you cannot, we go to the next step.

 

5.  Can you do any other type of work?

If you cannot do your past relevant work, we then see if you are able to do any other type of work. We consider your age, education, past work experience, and transferable skills. If you cannot do any other kind of work, we will approve your claim. If you can, we will deny your claim.

 

 

 

Eight Simple Rules

(for getting anything you need)

 

Bob’s friend Jason doesn’t have ALS, but he faced a problem all too familiar to many who do: an insurance company ruled that equipment he needed was “not medically necessary.” Sound familiar?

Jason might have started fighting back by talking to his doctor first. His doctor may be as disagreeable and rushed as Jason pictures him. Moreover, his doctor may work for the very HMO that turned him down. But his doctor has a professional stake in preserving Jason’s shoulders—and in seeing that his prescriptions are filled as written.

When I picked up the phone, Jason sounded desperate. Jason has cerebral palsy and has always walked by leaning heavily on two canes. As a result of decades of wear and tear, he developed severe arthritis and rotator-cuff tears in both shoulders. Most days it’s hard for him to cross the room because of excruciating pain.

His doctor told him the pain and muscle tears were going to get worse—that rotator-cuff and shoulder-replacement surgeries were on the horizon—unless he got a power wheelchair. Although Jason’s doctor had sent the proper paperwork to his insurance company, a Medicare HMO, the wheelchair was denied because it was “not medically necessary.”

“Not medically necessary?” Jason screeched into the phone. “When will it be medically necessary? When I can’t walk at all?”

Sadly, the answer is yes. But I’m getting ahead of the story. Because Jason’s speech is hard to understand, he asked me to call the insurance company. In the process I discovered that there are Eight Simple Rules for getting anything you need from anyone.

 

Rule #1: Get Name, Rank, and Phone Number

 

I called Jason’s insurance company. After spending a turtle’s lifetime on hold, I was connected to a customer representative. I tried to explain my friend’s circumstance, but she said she couldn’t talk to me because I wasn’t “the insured” and hung up.

I was massively ticked! Back on the phone, and after another turtle’s lifetime, I was connected to a different representative. This time I said that I was Jason and wrote down her name, phone number, and title. All she did was repeat what Jason knew—that the wheelchair was denied because it was not medically necessary. With an edge in my voice I asked who made that decision. She told me that she was not allowed to give out that information. I asked who could. She said that I would have to speak to her supervisor, Ms. Lemon, and that she would transfer me. Before she did, I got Ms. Lemon’s phone number—and good thing! I wasn’t transferred; I was disconnected.

 

Rule #2: First Do Your Homework

 

Since it was 5:00 p.m., I decided to do some research first and call Ms. Lemon the next day. On the Internet I found the Medicare regulation for power-wheelchair medical necessity.

It turns out that a power chair is considered medically necessary only if you’re “bed or chair confined,” not Jason’s situation—yet. I then got the name and phone number of the president of Jason’s insurance company and went to the Web sites for the Department of Health and the Insurance Commission in Jason’s state to find out what process insurance companies must follow if they deny medical equipment. I also decided I would keep dated notes of my phone conversations and take exact quotes.

 

Rule #3: An Ally Is Better Than an Adversary

 

At 9:01 the next morning I called Ms. Lemon. Instead of screaming as I wanted to, I decided to take a different tack: I started by saying, “Ms. Lemon, you are the only one who can help me.” I told her that two of her representatives had hung up on me (hoping a little guilt would soften her up) and explained the situation. She apologized. I told her I needed to know who had denied the power chair. Pleasant as you please, she volunteered that she had denied the chair. Aha! I had her! Victory was mine. My homework had uncovered that this state’s law permits only a physician to deny medical equipment.

When I told her this, she stammered and said she was sure that one of the medical directors, a physician, had ultimately signed her denial. When I asked for the medical director’s name and phone number, she said she was not allowed to give out that information. However, she said she’d transfer me and (you know what’s coming) I was disconnected.

 

Rule #4: Go Right to the Top!

 

It was clear I was getting nowhere talking to the hired help. So my next call was to the president of the insurance company—let’s call him “Robert Bucks”. Of course I didn’t get Mr. Bucks on the phone; I got one of his personal assistants. Starting again with “You are the only one who can help me,” I quickly explained the hang-ups, the denial by a clerical worker, and the refusal to let me talk to the medical director.

The assistant sounded both shocked and concerned. He apologized and confirmed that indeed only a medical director can deny a power chair and gave me the name and number of the medical director assigned to the case.

 

Rule #5: Be a Name Dropper

 

I immediately called the medical director’s office and got his secretary. I asked to speak to the doctor and was told that “insureds” were not allowed to speak to medical directors and how had I gotten the number? I said that I had just spoken to “Bob” Bucks, and was told to call the doctor directly. Implying that “my buddy Bob” told me to call got me through to the medical director in a flash.

The doctor explained that he had indeed signed the denial based on the Medicare regulation that required someone to have “severe weakness” in the arms, be unable to push a manual chair, and be “bed or chair confined” before a power chair could be approved.

Still speaking as Jason, I told him that my arms might not yet be severely weak, but that severe shoulder pain prevented me from pushing a manual chair and that shoulder degeneration would soon make me bed- or chair-confined if I kept on as I was. With the Medicare regulation in front of me, I then quoted another paragraph which said that “a patient who uses a power wheelchair is usually totally non-ambulatory.” I suggested that the word “usually” gave him some leeway, since it means not everyone who gets a power chair is totally unable to walk.

To my amazement the doctor listened! He agreed the shoulders would just get worse and that I would eventually be chair or bed confined. “Tell your doctor to write a new prescription and an appeal letter explaining that your shoulders are falling apart, that you can’t push a manual wheelchair and soon won’t be able to walk,” he said. “I can argue that it would be better to give you the power chair sooner rather than later and save your shoulders.”

 

Rule #6: Tell, Don’t Ask

 

Ecstatic, I called Jason. I explained that his doctor only had to send a prescription, write a letter, and the power wheelchair was his. But Jason hemmed and hawed. He said his doctor was very busy and hadn’t liked filling out the insurance forms for the power chair in the first place. I told Jason he needed to advocate for himself. I told him he needed not to ask but to tell his doctor—quietly but firmly—that he “was the only person who could help” and to write that letter. Indeed, Jason’s doctor was not happy, but write a letter he did.

Within two weeks the power wheelchair was approved. I was king of the world ... until Jason called me a month later.

 

Rule #7: Call in the Marines!

 

Jason told me that he was greeted one morning by a truck driver with a huge box. Inside was the promised power chair. Jason’s excitement gave way to confusion and anger when he discovered the wheelchair was twice as wide as he was. I asked him how this could have happened when he had been fitted for the chair. Jason told me the delivery was a total surprise because he had never been fitted.

I immediately called the medical director to find out what had gone wrong. The doctor coolly explained that the insurance company provides only one type of power wheelchair from only one manufacturer. When I told him the chair had never been fitted and was too wide, the doctor’s response was as simple as it was final: “We had a doctor’s prescription.” Click.

The doctor’s answer was not only ridiculous, it smelled way bad. Why would an insurance company provide only one type of power wheelchair that was drop-shipped from another state without being fitted?

I called Jason’s state insurance commissioner and was told that insurance companies cannot provide only one brand of wheelchair, that wheelchairs are indeed custom items that must be fitted. I was referred to the state department of health’s office responsible for overseeing HMOs. And I heard the same thing. For good measure I called the state attorney general’s office. What the insurance company was doing smelled bad to everybody. And, since this was a Medicare issue, I called Jason’s congressman too.

Turned out that the insurance company and the wheelchair manufacturer were under federal investigation for—guess what?—a kickback scheme involving payoffs by the wheelchair maker to the insurance firm.

I once again called my buddy the medical director. I told him about all the offices I had just called and—my voice calm and even—explained that everyone believed that his insurance company was involved in a kickback scheme with the wheelchair manufacturer that broke bushels of state and federal laws. I told him that it wasn’t my idea to testify against him in court or to speak at a television press conference, but that I’d do what the attorney general asked if it would get me a usable power chair.

 

Rule #8: One White Lie May Be Worth a Thousand Truths

 

Of course, no one I talked to had mentioned testifying in court or a TV press conference. But the medical director didn’t know that, and there was no way that he was going to find out. What was he going to do, call the attorney general and ask if he was going to be indicted? Which is why I heard the doctor’s voice raise an octave. “No, no, no! “he said. “You must have misunderstood me.”

He quickly explained that the brand of wheelchair that was shipped was the company’s first choice, not the only choice, and that of course every patient’s wheelchair should be individually fitted. He told me that the insurance company would arrange for the chair to be returned, that a local vendor would be in contact, and that any brand of power chair that met my needs would be provided.

True to his word, within a week the offending wheelchair had been removed and Jason was fitted for a chair that met his needs. Jason and his shoulders are now happily rolling along.

 

God Bless Alexander Graham Bell

 

Since helping Jason, I have told others about “The Eight Simple Rules” and how they have proved helpful in dealing with everything from refusals by employers to provide reasonable accommodations under the ADA to reversing denials for Social Security disability benefits.

The phone can be a powerful weapon. Don’t be afraid to call anyone and everyone who could possibly help you. State officials, congresspersons, and senators. Elected officials love to help their constituents (read: voters).

Sometimes, however, the pen can be mightier than the phone. You can file official complaints under the ADA, state civil rights and consumer laws with your state’s insurance commissioner and with the attorney general. Ultimately, you may need a lawyer specializing in disability or consumer issues if it’s time to lock and load and take the bums to court.

But if you follow “The Eight Simple Rules”, you may get what you need without paperwork or lawsuits by doing your homework, being pleasant but assertive, using your wits, and using Alexander Graham Bell’s marvelous invention.

 

Some useful links are: http://www.congress.org/congressorg/home/

http://www.ssa.gov/

http://www.medicarerights.org/

http://www.nod.org/

http://www.disabilityinfo.gov/

http://www.govbenefits.gov/govbenefits_en.portal

 
 

THE ART OF BEING RESOURCEFUL

 

Being resourceful is an attitude. The following three suggestions that will aid you in becoming your own best advocate while you investigate your insurance policy, as well as while you communicate with health care professionals.

 

1) Ask Questions.

Insurance terms and medical jargon can be like a foreign language. Do not be intimidated by how unfamiliar you are with the health care system or in dealing with insurance matters. The more you ask, the more informed you will be.

 

2) Assume Nothing.

Review your understanding of your insurance policy with the customer service representatives (phone numbers are usually listed on insurance cards). Review how to use your benefits:

 

How do you obtain medical equipment — through your doctor or on your own? Can you take the order to any supplier, or are you directed to use a preferred provider chosen by your insurance plan? Do you need a referral or prescription?

 

3) Don’t Take “NO” for an Answer.

If you are told a piece of equipment or anything you may need, which is ordered by your doctor, is not covered by you insurance, first determine whether the denial is based upon lack of coverage or the insurance company’s belief that the service is not medically necessary. Then ask what the appeal process is and follow it exactly. Many people are surprised when a denial is reversed.

 

Some people do not have coverage for durable medical equipment (DME – medically necessary reusable equipment), but may have coverage for respiratory equipment.

 

Be as specific as possible when talking with your insurer, and also ask for the assistance of the doctor, his/her staff, or a social worker in proceeding with an appeal. Be diligent and persistent.

 

Sometimes an insurance decision maker is not knowledgeable about ALS; you need to educate them about how the service, equipment, or prescription is medically appropriate for this disease. He/she may then authorize the request. Of course, it is not always possible to receive benefits for items not outlined in your plan, but you will never know unless you try.

 

****Remember, insurance policies vary from person to person. If you and your neighbor both have Blue Cross through your employers, he or she may have a very different plan from yours and may include different benefits. Do not assume that specific insurers offer the same coverage. Your plan may cover medical equipment at 100%, while your neighbor’s is at 80%.

 

Refer to the outline of questions in the next section for guidance on what to ask your insurance representative. The areas where you should focus are: DME, home health care, private duty nursing (particularly necessary if considering ventilator support), and prescription benefits.

 

It is helpful to maintain a written “log” or record of the names of the people with whom you speak and correspond. Include their contact information and the agency or organization along with the date of your communication, issues discussed and the outcome of the conversation or written communication.
 

 

Understanding Your Insurance Coverage

 

In order to maximize the benefits of your insurance plan, it is important for you to keep a record of the name, phone number, identification, and group number of your insurance plan. You also should note who the subscriber is (you or your spouse), his/her date of birth, and Social Security number.

 

Identify any other insurance benefits you may have, such as a separate prescription benefit card or a long-term-care policy.

 

If you have more than one insurance plan, determine which policy is primary and which is secondary; confusion with this matter can result in billing errors. Your insurance company customer service representative can be helpful in identifying which plan is to be billed first. Also keep up to date on your insurance; if your coverage changes in any way, notify all your doctors, medical suppliers, and pharmacists immediately, so that the next time you access their services, you will have helped prevent billing errors.

 

Contact your insurance company directly, and ask specific questions about your benefits. Keep a notebook and always note the date and the person who provided the information. Remember, having your benefits described over the phone does not guarantee coverage. Your physician may be asked to write a letter of medical necessity and complete specific forms to verify your medical condition and eligibility for whatever item or service is being requested.

 

Ask if your policy offers case management. Case managers either work for the insurance company, or are contracted by them to monitor and advocate for patients whose costs are high or who have complicated needs. They are often helpful in cutting internal “red tape” (problems), gaining access to little-known insurance benefits, and reducing your overall out-of-pocket expenses. Case management can be activated at various stages of your illness, depending on how your insurance company has defined the benefit.

 

Having direct communication with your insurance carrier will help you gain an overview of your policy and remove the mystery of how your plan works.

 

Use the following guide when contacting your insurance company. Be sure to have all of the specific information about your insurance plan in front of you before calling. Do not hesitate to ask what certain words or terms mean.

 

 

WHAT YOU NEED TO KNOW ABOUT YOUR HEALTH INSURANCE POLICY

 

General Questions

1.    Is there an annual deductible?

2.    Is there an annual out-of-pocket expense limit or maximum? If I meet my limit, does my coverage increase and to what extent?

3.    Do I have a major medical plan? Is there an annual or lifetime maximum?

4.    Do I need to complete any claim forms?

5.    Am I subject to pre-existing condition regulations?

6.    For what services do I need pre-authorization?

 

Durable Medical Equipment (DME) Questions

1.    Does my plan cover DME? What about ventilator and noninvasive ventilator coverage (i.e. BiPAP); are they under respiratory equipment or DME?

2.    What is the percentage of my coverage?

3.    Is there a preferred provider I must see?

4.    Is preauthorization or a medical review required?

 

Prescription Questions

1.    Does my plan cover prescription drugs? What are the terms of this coverage, and is coverage different based on using brand-name versus generic drugs?

2.    Is there a specific pharmacy/supplier network I must use?

3.    Is there a limit on the amount of prescription drugs I can get through this plan?

4.    Is there coverage for all FDA-approved drugs, or is coverage provided only for those listed on your formulary (a list of drugs that an insurance policy covers)?

5.    Does my plan offer a mail-order pharmacy option? Describe this benefit.

 

Home Health Questions

1.    Does my plan have home health coverage? Describe this benefit.

2.    Do I have coverage for a home health aide (for skilled or custodial care)?

3.    Is there a preferred home health care agency I must use? Is there private duty nursing coverage at home? Describe this benefit.

4.    Does my plan offer case management? At what point does case management get involved and for how long?

 

Hospice Questions

1.    Does my plan have hospice coverage? Describe this benefit.

2.    Is there a preferred Hospice agency that I must use?

 

Questions for Health Maintenance Organization/Preferred Provider

Organization (HMO/PPO) Subscribers

1.    Is my ALS neurologist (or other ALS specialist) a member of the network or a participating provider?

2.    Explain the referral process. Do I need a referral from my primary care physician every time I go to the neurologist or other specialist; is there a limit to the number and frequency of referrals?

 

A NOTE ABOUT PRESCRIPTION PLANS

Find out the following details about your prescription benefit: if there is a limit, if injectable medications are covered, what the terms are, and if there is a mail-order option. If you do not have prescription coverage, or if there is a limit on coverage, explore other ways to fund your medications. Some states have pharmaceutical assistance programs or specific programs for the elderly and disabled; however, you may have to meet certain income criteria. There are some drug manufacturers that provide medications free of charge to physicians whose patients may have limited finances. Your doctor or social worker must make the initial contact with the pharmaceutical company. To find out more about these types of programs, please have your health care provider review the Pharmaceutical Manufacturers Association manual, available by calling 1(800) 762-4636, or by going to the Web site at http://www.phrma.org

If you are paying for your medications privately, you may consider national pharmaceutical mail-order houses which order in high volume and pass their savings on to you. Contact your local ALS Association chapter for an updated list.

 

 

 

 

Important Medicare Rx Drug Benefit Resources

 

 

Medicare Prescription Drug Coverage Basics

 

Cost and Coverage Varies by Plan and Region

Beginning on January 1, 2006, Medicare will for the first time provide coverage for prescription drugs, including many of the medications needed by people with ALS (PALS).  Coverage and cost will vary by plan and by region, so it is important for PALS on Medicare to review the options available to them in their particular areas to determine which plans are most appropriate for their needs and whether enrolling in a plan is, in fact, the best choice for them.   This new coverage may provide significant savings to Medicare beneficiaries, especially for those who currently do not have drug coverage.  In addition, those with limited incomes may be eligible for additional assistance, which could enable them to receive their prescription drugs at a very low cost.  Additional information about the low income subsidy is available here:  http://www.ssa.gov/pubs/10128.html.

 

Regardless of a person’s income or whether they currently have drug coverage, all Medicare beneficiaries will be eligible for this coverage with enrollment beginning on November 15, 2005. 

 

Enrollment Not Required

While the new benefit is available to everyone eligible for Medicare, people are not required to enroll.  They may elect to keep their current coverage as it may already meet their needs in terms of coverage, cost and convenience.  However, those who do not enroll during the initial enrollment period (November 15, 2005 to May 15, 2006) may have to pay a penalty (1% premium increase for each month a person waited to enroll), unless their current prescription coverage is deemed to be equal to or better than Medicare’s.  If people currently have coverage, they will receive a notice from their insurer or employer by November 14 indicating whether their coverage is at least as good as Medicare, in which case there will not be a penalty if someone chooses not to enroll in a Medicare prescription drug plan.

 

Options – Stand-Alone PDPs or Medicare Advantage

People who do want to receive Medicare prescription drug coverage will have many different plans available to them in their area.  However, there are two ways to receive coverage.  First, people can add prescription drug coverage to the traditional Medicare plan by enrolling in a stand-alone prescription drug plan (PDP).  Or they can receive drug coverage and the rest of their Medicare coverage by enrolling in a Medicare Advantage plan, like an HMO or PPO.

 

Drug Coverage Not Automatic

It is important to note that Medicare prescription drug coverage is not automatic.  People must choose to enroll if they so desire.  However, those who qualify for extra help receive Supplemental Security Income (SSI), or who receive Medicare and Medicaid will be enrolled in a plan automatically if they do not select one before drug coverage takes effect on January 1, 2006.  We strongly recommend that these individuals enroll in a plan before December 30, 2005. 

 

Medicare Part B Reminder

We also would like to take this opportunity to remind PALS and Chapters that people who do not enroll in Medicare Part B when they first become eligible will face penalties if they enroll at a later date.  Part B provides important coverage for durable medical equipment and supplies, physician services, outpatient services, and other services not covered by Medicare Part A (hospital insurance).  If people do not enroll in Part B when they first become eligible, they will pay increased monthly premiums equal to 10% more for each 12 month period that a person was eligible for Part B, but did not enroll.   This penalty will apply for as long as someone has Part B.

 

Prescription Drug Toolkits Available

 

The Centers for Medicare and Medicaid Services (CMS) has several toolkits available to assist ALSA Chapters and caregivers in educating PALS about the new Medicare drug benefit and help them to make the enrollment decisions that meet their needs.   These include:

 

·        “Outreach Toolkit on Medicare Prescription Drug Coverage.”  The toolkit includes presentation materials and other information available from CMS that will help Chapters and others reach out to their communities and provide information about the Medicare prescription drug benefit.  The Outreach Toolkit is available online at Medicare Outreach Toolkit

 

·        “Help is here Resource Kit: Understanding, Deciding, Choosing, Joining.” This toolkit, which is designed to be included in the Outreach Toolkit, includes information ALSA Chapters and individuals can use to help PALS understand the Medicare prescription drug benefit and choose a plan that meets their needs.  The Kit is available online at "Help is Here" Resource Kit: Understanding, Deciding, Choosing, Joining We strongly recommend that Chapters, family members and caregivers review and retain a copy of this toolkit, as it will help you respond to questions and guide PALS in reviewing the prescription drug options available to them. 

 

This Kit also is available via an online webcast at National Medicare Training Program.  The webcast runs with Windows Media Player and Real Player, and a closed captioned version also is available.

 

If you would like to order hardcopies of the “Outreach Toolkit” or the “Help is Here Resource Kit,” please contact Pat Wildman at pwildman@alsa-national.org or 1-877-444-ALSA.

 

Prescription Drug Plans Available in Your Area

 

Landscape of Local Plans

A listing of the prescription drug plans available in your area can be found online at http://www.medicare.gov/medicarereform/map.asp.   Select your state on the map, and you will be provided links to charts showing the Medicare Advantage Plans (HMOs, PPOs, etc. that offer other benefits in addition to drug coverage) and Stand-Alone Prescription Drug Plans (provide drug coverage only) available in your area.  The charts include information on premiums, deductibles, tiered co-pays, generic/brand name coverage and whether or not mail order is available for prescription drugs. 

 

Medicare & You 2006

Much of the plan information mentioned above also is included in the Medicare & You 2006 handbook, which has been mailed by CMS to Medicare beneficiaries and provides information about the Medicare program as well as the prescription drug benefit.  Handbooks that include state-specific plan information are available online here, , Summary of Medicare benefits, health plan options, rights and protections, and other important resources. Since the information about health and prescription drug plans differs by region, it is important that you select the handbook that covers your particular area. 

 

NOTE:  The Medicare & You 2006 handbooks that were mailed to beneficiaries earlier in October contain an error.  It inaccurately states that low-income beneficiaries who enroll in any Medicare prescription drug plan available in their area will not be required to pay premiums.  That is false.  About 40% of plans will require no premiums.  The error has been corrected in the versions available online.  It is possible that new handbooks will be mailed by CMS.  The “Notice of Errata” is available here: : Notice of Errata

 

The Formulary Finder

The Formulary Finder will allow PALS and Chapters to enter a typical combination of drugs used by PALS to determine which plans in your area have formularies that cover these drugs.  The Formulary Finder is available at

http://plancompare.medicare.gov/formularyfinder/selectstate.asp

NOTE:  Some of these tools may not yet be fully functional as health plan data and the tools themselves have only recently been released. 

 

How to Select a Prescription Drug Plan

 

There are two main ways for Medicare beneficiaries to review their options and select a prescription drug plan, depending on whether an individual has access to the internet.  However, as you use these tools you should also have some key information handy, such as a list of the medications you take, to help you make a decision.  Additional information to have on hand is described in the section below on Information to have and Questions to Ask.

 

Selecting a Plan via the Internet:

For those with access to the internet, we strongly recommend using the online resources that are available to you.  Chapters, caregivers and family members also may use these internet tools to assist PALS in learning more about their prescription drug options.  The internet tools will be the most efficient and easy way to review the options available and select the plan that meets the needs of individual PALS.  There will be several online tools available.  They include:

 

1.    The Prescription Drug Plan Finder

Available on the CMS website, , www.medicare.gov is a Medicare Prescription Drug Plan Finder.  This tool will help Medicare beneficiaries decide whether they want to enroll in a plan that offers Medicare prescription drug coverage.  It is designed to allow individuals to compare the Medicare drug plans in specific geographic areas and select a plan that meets their individual needs.  For example, the tool allows people to enter information about specific drugs they take, the range of monthly premiums and annual deductibles they are willing to pay, as well as their pharmacy preferences and then it will locate available plans that meet the criteria entered and will provide coverage, cost and other important information about those plans.  The tool also allows people to compare between plans that provide prescription drug coverage alone and those Medicare Advantage plans that provide prescription drug coverage as well as coverage for other Medicare services.   Importantly, the tool takes into account how you currently receive your prescription drug coverage and will let you know your options based on your current coverage.

 

The link to the Medicare Prescription Drug Plan Finder is here: Plan Finder Tool

 

NOTE:  Since Medicare prescription drug plan information has only recently been made available and because the Medicare Prescription Drug Plan Finder has just been launched, some of the features may not be fully functioning.  However, the Centers for Medicare and Medicaid Services has stated that the site will be fully functional during the enrollment period.   Once the Plan Finder is fully operational, it will allow people to personalize their search for a drug plan, as noted above, and look at a side-by-side comparison of up to three plans at a time based on cost, coverage and convenience.

 

The Plan Finder also will help people if they are not sure whether they qualify for extra help, whether their employer or union is continuing their current coverage with a Medicare subsidy, or whether they are already enrolled in a Medicare Advantage Health Plan or in a Medicare prescription drug plan.

 

A Webcast describing how to use the Plan Finder Tool is available online at Plan Finder Tool The Webcast runs with Windows Media Player and Real Player.

 

2.    BenefitsCheckUpRx

Another helpful tool that is available to PALS, Chapters, caregivers and family members is BenefitsCheckUpRx  This web-based decision-making tool is provided by the Administration on Aging and the Department of Health and Human Services and can be accessed at www.benefitscheckup.org or through the Access to Benefits Coalition website at, www.accesstobenefits.org.   The tool links to the Medicare Prescription Drug Plan Finder and will help people assess current prescription drug coverage, determine whether they are eligible for additional assistance, inform them of their rights and options based on their situation, and help them take the next step, including enrolling in a Medicare Prescription Drug Plan.  BenefitsCheckUpRx also will help people determine what prescription drug programs they qualify for including:  the Medicare Prescription Drug Benefit (and low income subsidy), State Pharmacy Assistance Programs, Medicare Savings Programs, and Supplemental Security Income (SSI).  The tool also will provide state specific recommendations. 

 

3.    MAPRx

Medicare Access for Patients Rx, MAPRx, is a coalition of patient, family caregiver and health professional organizations committed to safeguarding the well-being of patients with chronic diseases and disabilities under the new Medicare prescription drug benefit.  ALSA is a member of the coalition.   The MAPRx website, www.maprx.info includes helpful information and answers to questions as well as links to tools that allow users to compare prescription drug plans.   The site also is expected to include a step by step guide on how to choose a plan and will include a checklist and comparison chart to assist in the decision-making process.  

 

Selecting a Plan over the Phone:

While we recommend that people utilize online resources whenever possible, we recognize that many people do not have access to the internet.  However, those who do not have internet access do have several options available to turn to for assistance.  They can call the Medicare hotline at 1-800-MEDICARE, their local State Health Insurance Assistance Program or the Area Agency on Aging (contact information is available in the Medicare Training and Assistance Section below).  Representatives at these numbers are available to answer questions and guide PALS, family members and caregivers through the decision-making process, including helping to identify their options and the plans that best meet their needs, if they choose to enroll in the prescription drug benefit.

 

Chapters, family members and caregivers also can be vital resources for PALS to turn to for information about the Medicare prescription drug benefit.  We strongly recommend that Chapters, family members and caregivers use internet resources, such as the Drug Plan Finder, the Landscape of Local Plans, the Formulary Finder and the “Help is Here Resource Kit” to assist PALS in making the choices most appropriate for them. 

 

The “Medicare Rx Help is Here Resource KitMedicare Rx Help is Here Resource Kit” in conjunction with the Drug Plan Finder  are especially valuable tools to use when guiding PALS through the decision-making process.  These tools will help people ask the questions they need to ask when choosing a plan or deciding to enroll in the benefit.   Please note that some of these tools may not yet be fully functional as health plan data and the tools themselves have only recently been released. 

 

Finally, the Medicare & You 2006 handbook also is an important resource to use for those who do not have internet access.  As previously mentioned, the handbook includes information about Medicare and the prescription drug benefit as well as the plans available in your area.   Please note that the Medicare & You 2006 handbooks that were mailed to beneficiaries earlier in October contain an error.  They inaccurately state that low-income beneficiaries who enroll in any Medicare prescription drug plan available in their area will not be required to pay premiums.  That is false.  About 40% of plans will require no premiums.  The error has been corrected in the versions available online.  It is possible that new handbooks will be mailed by CMS. 

 

NOTE:  We again want to note that people are not required to enroll in a Medicare prescription drug plan.  While the drug benefit may bring savings to many PALS, it is important to review the options that are available before deciding whether to enroll in a Medicare prescription drug plan, Medicare Advantage Plan or whether a person should keep their existing coverage.  The tools included here will help PALS, families and caregivers make the choices that are most appropriate for them. 

 

Information to Have and Questions to Ask

 

Regardless of whether people use the internet or more traditional means to identify a prescription drug plan, they should begin the process armed with important information and key questions to ask.  CMS has available two helpful documents that provide suggestions on issues to think about when comparing plans (http://www.medicare.gov/Publications/Pubs/pdf/11163.pdf) as well as tips on how to compare plans http://www.medicare.gov/. In addition, we have included below other information to consider when people review their options.  But please remember that people should compare their current coverage to the new options that are available.

 

ALSA Chapters may want to customize the information below to include any other questions PALS may want to consider as they go through the decision-making process. 

 

General Information to Have On Hand When Choosing a Medicare Drug Plan:

1.    Your Medicare Card, including Medicare number and effective date for Part A or B.

2.    General information on your current prescription drug coverage – whether you receive coverage through an employer, union, Medicare Supplemental, or other retiree drug coverage.

3.    Information on annual income and resources (to determine if you qualify for extra help).

4.    A list of medications you take, including dosage.

5.    The name of pharmacies you use.

 

 

Information to Consider:

§         The amount of the monthly premium

§         Whether the plan formulary includes:

o       The particular drugs needed by PALS

o       The strengths and dosages of the drugs needed

o       The number of days covered in each prescription (Example: 30, 60, 90 days)

§         Whether the pharmacies in the plan’s network include:

o       The pharmacies used by the beneficiary

o       The pharmacy used by the long-term care facility in which the beneficiary resides

§         Whether there are price differentials among pharmacies in the network

§         Whether mail-order is allowed or required

o       The price differential for mail order

o       The number of days covered in each prescription (Example: 30, 60, 90 days)

§         The plan’s utilization management tools

o       The prior authorization requirements

o       Whether the plan requires step therapy (Requirement that certain medication(s) be tried before those prescribed by the PALS’ physician)

o       Whether the plan uses tiered cost sharing (Different co-pays for generics, brands, or for specific drugs)

·        The number of tiers

·        The co-payments/co-insurance per tier

o       Whether the plan offers therapeutic substitutions

o       Whether there are quantity limitations

·        On number of prescriptions in a month

·        On number of pills in a prescription

 

§         Whether the plan offers supplemental benefits

§         How the plan coordinates with the State Pharmaceutical Assistance Program

§         Who is the plan sponsor, has the entity been in the community for a while, is it reliable?

§         The “Transition” process used by the Prescription Drug Plan (Temporary use of a drug not covered by plan)

§         The “Exceptions” process used by the Prescription Drug Plan (Appeal if a person’s drug is not covered by the plan)

§         Whether a PALS has other insurance that covers prescription drugs:

o       Through a Medicare HMO or other Medicare Advantage plan.  If so, the person must keep getting drug coverage through that plan if he wants to stay in that plan.

o       Through a retiree health plan.  If so, has the former employer told the person whether the insurance is as good as or better than Medicare's coverage (i.e., "creditable coverage”)?  If it is creditable coverage, the person may stay in that plan without getting a late penalty on the premium if he later decides to change to a Medicare drug plan.

o       Through a Medigap (Medicare supplemental) policy?  If so, has the insurer told the person whether the insurance is creditable coverage?  If it is not, the person will have to pay a late penalty on the premium if he keeps his Medigap drug coverage and later switches to a Medicare prescription drug plan.

o       Individuals with coverage through the Veteran's Administration, TRICARE, Federal Employee Health Benefit Plan, Railroad Retirement Board, Program of All-Inclusive Care for the Elderly (PACE), or Indian Health Service, may continue receiving prescription drug coverage through one of those plans if that coverage is as good as what is offered from Medicare prescription drug coverage.

 

 

Frequently Asked Question and Answers

 

CMS has a comprehensive list, which is updated regularly, of frequently asked questions and answers about the new drug benefit available here: http://web.archive.org/web/19960101-re_/http://www.cms.hhs.gov/partnerships/news/mma/qsandas.pdf

 Questions and answers include:

§         Basic Information

o       What is Medicare Prescription Drug Coverage?

o       Is Medicare prescription drug coverage better than what I have now?

o       What if I already have prescription drug coverage?

o       How do I join a Medicare Prescription Drug Plan?

o       What happens if I choose not to join a Medicare drug plan by May 15, 2006?

o       Is there information and help available to compare Medicare drug plans?

§         Costs and Coverage

o       What are the out-of-pocket costs for Medicare prescription drug coverage?

o       What does a Medicare drug plan cover?

o       How can I be sure a Medicare drug plan will cover the prescriptions I might need?

o       What is a formulary?

o       What if I need a drug that isn’t on the formulary or is covered at a higher cost?

§         Affect on Current Drug Coverage

o       What do I need to know if I have prescription drug from a former or current employer or union?

o       What do I need to know if I have a Medicare Advantage Plan (like an HMO, PPO or PFFS Plan) or other Medicare Health Plan?

o       What do I need to know if I have a Medigap (Medicare Supplement Insurance) policy that covers prescription drugs and I have the Original Medicare Plan (Medicare Part A and Part B)?

o       What do I need to know if I have drug coverage from TRICARE, the Department of Veterans Affairs, or the Federal Employee Health Benefits Program?

o       What do I need to know if I have full coverage from my state Medicaid program?

§         Information for People with Limited Income and Resources

o       How do I know if I qualify for extra help?

o       How much will my prescriptions cost me if I qualify for extra help?

 

Important Dates and Deadlines

 

A calendar of important dates and deadlines is available by double clicking here: PDF File

The calendar includes enrollment and implementation dates, as well as dates when PALS on Medicare can expect to receive information from CMS.

 

Medicare Training and Education

 

Included in the information that follows is local contact information for the regional CMS offices and State Health Insurance Assistance Program (SHIP) offices in your area.  Local CMS offices can help provide training for ALSA Chapter staff about the prescription drug benefit and can answer questions Chapters may have.  SHIPs are available to provide individual assistance to PALS receiving Medicare and can guide PALS through the decision-making process.  The Medicare Hotline, 1-800-MEDICARE, also is available to provide answers to questions and personalized assistance identifying and reviewing the options available to PALS. 

 

 

Ø      CMS Regional Contacts

CMS regional contacts are available below and by double clicking here: PDF File

 

CMS Regional Contacts

 

Each of the 10 CMS regional offices has designated staff members to lead the education and outreach campaign effort about the prescription drug benefit. They are an invaluable local source of help and information.

 

CMS Regional Offices, States & Territories Covered by Each Region

 

 

 

CMS MMA Education Campaign Regional Contacts

 

 

 

Ø      State Health Insurance Assistance Program Contacts

 

Contact information for local State Health Insurance Assistance Program offices is available below and online here:  Partnerships