The Med Diva

An insider's guide to Medicare Part D and more

Archive for the category “Medicare Part D Basics”

Combating fraud and abuse in the Medicare Prescription Drug Program

This is great news from CMS that I wanted to share with my readers.


The Med Diva 2012 in review

The stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 6,200 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 10 years to get that many views.

Click here to see the complete report.

Study suggests most Medicare beneficiaries are paying too much for their Part D coverage

Seniors Pay Too Much for MedicareApproximately 20 percent of Medicare beneficiaries spend at least $500 more than they need to for their Medicare Part D prescription drug coverage, according to a new Health Affairs study released this week. That’s a lot of money being kept out of the piggy bank.

According to University of Pittsburgh researchers Chao Zhou and Yuting Zhang, only 5 percent of Medicare beneficiaries buying a Part D plan choose the plan that’s cheapest for them relative to their prescription drug needs. Based on their analysis of 2009 Part D data, the average beneficiary paid $368 more in premiums and drug costs than they would have if they’d chosen the least expensive plan that was right for them.

Zhou and Zhang attribute most of the overspending to seniors’ inclinations to pick Medicare plans with more generous features and lower deductibles, and thus, higher premiums. For example, they noted that the biggest mistake people make is picking a plan that covers generic drugs in the Coverage Gap (doughnut hole). Many beneficiaries appear to be paying hundreds of dollars more in premiums for this feature than they get back in drug benefits—perhaps because they don’t ask their doctors to prescribe generic drugs or they just never reach the Coverage Gap.

However, the researchers acknowledge there are also a few reasons why Part D beneficiaries may not want to choose the cheapest plan. Some seniors may choose a more expensive plan because it offers better customer service or has a higher Medicare star rating, or because they may be willing to spend a little more for peace of mind in case their medication needs unexpectantly increase.

So how do you find the lowest-cost Part D plan that’s also the best fit for you?

As I’ve said in the past, you should look for a plan that offers the lowest total cost based on the medications you take.  When shopping for a plan, remember to consider the monthly premium and annual deductible as well as the annual costs for all your medications. Fortunately, those good people at Medicare have a great online tool called the Medicare Plan Finder that makes it easy for you to compare costs each year. Here’s what you do:

1. Go to and click on “Find health & drug plans.”  (You’ll see this in a yellow box near the top left of the page.)  

2. Enter your zip code, and then answer the other questions. Make sure you choose one or two pharmacies that are near you, and specify all the drugs you take (and their dosage). You’ll also need to say whether you get your prescriptions filled at a retail or mail-order pharmacy.  Answering these questions is the only way the tool will give you accurate cost information for your personal drug needs.

3. On the search results page, click on “Prescription drug plans (with original Medicare)” to see a complete list of stand-alone Part D plans available in your area. You can also refine your search on this page.

4. The generated list will show the lowest-cost plan first, which includes monthly premiums as well as out-of-pocket costs for the drugs you selected. And because a cheap plan with a low star rating may end up costing you more in the end (more time, more aggravation, more worry, etc.),  you should also sort results by Overall Plan Rating to make sure the lowest-cost choices have a good star rating (3.5 or more stars). 

Remember, Medicare Open Enrollment is October 15 through December 7, 2012.

Medicare rejects claim because man’s name is too long

Not enough spaces on Medicare enrollment form

Looks like they need more spaces on the Medicare enrollment forms.

Here’s another Medicare story from the files called “You Can’t Make This Stuff Up.”

Turns out a retired Spokane man who has been using his Medicare benefit since 2009 no longer exists in the Medicare computer database. Apparently, he simply has too many letters in his last name.

As the story goes, Robert Lautzenheiser recently received a bill from a doctor visit, but it didn’t show a payment by Medicare. The billing office told him his Medicare claim was rejected because his name was incorrect.

Apparently, the “r” at the end of his last name does not appear on his Medicare card, even though his full name is displayed on his driver’s license and Social Security card. So Medicare was not about the pay a claim for a Robert Lautzenheiser who was using Robert Lautzenheise’s Medicare benefit.

According to Robert, the card does not have his entire name because when he originally filed for Medicare in 2009 there weren’t enough spaces on the form to fit it. “Well when someone like Jones makes up the database,” Robert told KHQ News, “they don’t think about how long last names can be.”  

In the past, Robert said he used paper billing, so a human could double-check and correct the error. But with a new electronic filing system, the computer says he doesn’t exist.  Robert says he thinks it should be as easy as adding the letter into a database, but instead he has to go through lots of bureaucratic red tape to convince the government that he really exists and is entitled to his Medicare benefits. 

Hmmmm, I wonder why this doesn’t surprise me. After all, Medicare and red tape go hand in hand!

By the way, I checked the enrollment form for my company’s Medicare Part D plan, and it has 35 spaces for the last name (the online version of the form has unlimited spaces). We’re working on re-designing this enrollment form, so I will make sure that our graphic designer doesn’t take away any spaces!

Five-star special enrollment period for Medicare will help seniors in only 8 states

Although Medicare Open Enrollment officially ended on Wednesday, a new Special Enrollment Period (SEP) has now kicked in for beneficiaries who would like to enroll in a five-star Part D (prescription drug) or Medicare Advantage plan. This SEP theoretically extends the Open Enrollment period for the 2012 plan year to December 31, 2011, which had always been the deadline in the past. The problem is, most seniors will have a hard time finding a five-star plan, since very few plans received this top-quality rating from the Centers for Medicare & Medicaid Services for 2012.

According to an analysis conducted by Allsup, a Medicare plan selection service, as of November 30, there was only one five-star prescription drug plan available in just eight states:  Iowa, Minnesota, Montana, Nebraska, New York, North Dakota, South Dakota and Wyoming.

There were only eight five-star Medicare Advantage contracts (14 total plans) available 10 states, with one available in each of the following seven states: California, Colorado, Hawaii, Illinois, Maine, Massachusetts and Oregon; two available in Iowa and Washington; and three available in Wisconsin.

How the Special Enrollment Period works

Starting December 8, you can make the switch to a five-star Medicare Advantage plan or Part D prescription drug plan that serves your area. You can make this switch only one time through November 30, 2012. 
• If you enroll December 8 – December 31, 2011, your coverage will begin January 1, 2012.
• If you enroll January 1 through November 30, 2012, your coverage will begin on the month following the month in which you submit your enrollment request.

Consider other factors when switching to a five–star plan

If you are fortunate to live in one of the eight states that offer a five-star plan, you may want to consider it if you are not pleased with your current Part D plan. But remember, while the star ratings are important, there are many other factors to think about, such as total plan costs based on all the drugs you are taking and the plan’s formulary (list of covered drugs.) And should you switch to a five-star plan, there’s no turning back: You only get to switch once, so you’ll have to stick with that plan until the next Open Enrollment period in 2012.

Spread the Word: Only 2 Shopping Days Left for Medicare Part D Open Enrollment

There may still be 19 shopping days left until Christmas, but this year the shopping season for Medicare Part D ends on December 7. That means there are only 2 more days (after today) in which you can switch your prescription drug plan for 2012.

You can thank Healthcare Reform for the early deadline this year: The 2010 Patient Protection and Affordable Care Act mandated the earlier enrollment period to give you more time to weigh your plan options and the drug plans more time to complete paperwork and get membership cards and plan materials to beneficiaries by January 1, 2012. The intention was good, but unfortunately, the execution has been poor.

In fact, one recent survey shows that almost 20 percent of seniors are still unaware of the Wednesday deadline.

According to the survey conducted by Opinion Research Corporation and sponsored by PlanPrescriber, one in five seniors 65 years of age and older with Medicare prescription drug coverage were still aware that the Open Enrollment period ends December 7. The national phone survey was conducted between October 28 and October 31, 2011.

Please spread the word

Hopefully, this number has improved during the past month. Ideally, 100 percent of seniors are now aware of the early deadline. However, it’s more likely that a small percentage of beneficiaries are still in the dark about the deadline – which means we must still work hard to get the word out. That’s why I’m asking all of my readers, Facebook friends, and Twitter followers to talk to all the seniors in your lives and remind them that the last day to switch their Medicare Part D plan is Wednesday, December 7.  Thank you everyone!

When to enroll in a Medicare Part D prescription drug plan

Today I spent the day monitoring phone calls from my company’s Medicare Part D plan enrollment call center. Several seniors who called to enroll in our plan said they were very confused about the Open Enrollment deadline, especially those people who are eligible for both Medicare and Medicaid.

To help clear up some of this confusion, here is some basic information about when you can enroll in a Part D plan or switch Part D plans. In a nutshell:

• Most people can enroll in a Part D plan when they first become eligible for Medicare and then once a year after that during Open Enrollment if they want to switch plans.
• People who receive both Medicare and Medicaid can enroll when they first become eligible and then once a month after that if they want to switch plans.

Enrolling for the first time: Turning 65 or new to Medicare

If you are new to Medicare, it’s important to enroll in a Part D plan as soon as you become eligible (during your Initial Enrollment Period) to avoid paying any late-enrollment penalties. When first eligible for Medicare, you have a full 7 months to enroll in a Medicare Part D plan:
• Up to 3 months before you turn 65
• During the month of your 65th birthday
• Up to 3 months after you turn 65

If you join a prescription drug plan during the 3 months before you turn 65, your coverage will start on the first day of your birth month. If you join during or after your birth month, your coverage will begin on the first day of the next month.

Here are 3 examples to show you when your coverage will go into effect:
Let’s assume your 65th birthday is May 3, 2012. That means your Initial Enrollment Period is from February 1 – August 31, 2012 (3 months before to 3 months after your 65th birthday).

1. If you join a Part D plan before your birth month (February 1 – April 30, 2012)
Your coverage will begin the first day of your birth month: May 1, 2012

2. If you join a Part D plan during your birth month (May 1 – May 31, 2012)
Your coverage will begin: June 1, 2012

3. If you join a Part D plan after your birth month (for example, July 1 – July 31, 2012)
Your coverage will begin: August 1, 2012

When you can switch Part D plans

If you are already enrolled in a Part D plan, you can generally switch plans only once a year during Open Enrollment (also called the Annual Election Period). Open Enrollment runs from October 15 through December 7 for the 2012 plan year. Outside this time period, you may make other changes during the year only if you qualify for a Special Enrollment Period (SEP).

For example, you may qualify for an SEP for the following reasons:
• You lose creditable coverage (that is, coverage as good as or better than Medicare) through no fault of your own  (for example, your former employer or union stops providing coverage for retirees)
• You move to a new permanent address that is not in your current plan’s service area
• Your current plan no longer offers Part D coverage
• You receive Medicaid or get Extra Help with Part D costs
• You are enrolled in a State Pharmaceutical Assistance Program (SPAP)

Dual Eligibles can switch plans once a month

If you have both Medicare and Medicaid, you are considered a “dual eligible” individual. “Dual eligibles” may change plans once every thirty days. You can ignore the Open Enrollment dates and the December 7th deadline because they do not apply to you.

Popular brand-drug patent expirations represent $9 billion+ in savings for Medicare beneficiaries

You probably already know that the standard Medicare Part D benefit includes a 50% discount on most brand-name drugs during the Coverage Gap stage.  What you may not know is that even with the discount, lower-cost generic drugs could still help you save more all year long.

Using generic medications instead of brand-name drugs is one of the best ways to lower your overall costs. And here’s even better news: Frequently used brand-name drugs such as Lipitor®, Lexapro®, Seroquel®, and Singulair® are expected to come off patent in 2012. These drugs currently account for more than $31 billion in retail sales. The new generic versions of these drugs could represent more than $9 billion in incremental savings opportunities for Medicare beneficiaries.

Generics are a great choice for savings and quality 

If you’re like me, when you think “generic” you may not always think “quality.” Given the choice of my favorite brand of raisin bran cereal for $3.99 or the generic no-name brand for $2.99, I’ll pay the extra dollar any day. Same goes for brand-name yogurt, shampoo, bread, or body lotion. The brand-name product just seems to taste or work better than the no-name versions.

 But FDA-approved generic drugs have been tested for quality and strength, and are as safe and effective as their brand-name counterparts. Generic drugs look different, but you can expect them to provide the same health benefits as their brand-name counterparts—often at a lower cost to you.

 I always ask my doctor to prescribe the generic drug if it’s available, because I know it will work just as well but cost so much less. In fact, according to the Food and Drug Administration, generic drugs can cost 30 percent to 80 percent less than brand-name drugs.

So if you’re taking a brand-name medication, ask your doctor whether a lower-cost generic drug could work for you. Keep in mind there are two types of generic drugs:

• A generic equivalent contains the same active ingredients as its brand-name counterpart and works the same way in your body.

• A generic alternative may contain different active ingredients, but is used to treat the same condition.

Remember, your doctor wants to help keep your medications affordable, so it’s always okay to ask if the prescription can be written for a generic drug. You deserve to save money, so don’t be afraid to just ask!

28% of #Medicare #partD plans receive poor star ratings from CMS

You probably wouldn’t choose a 2-star restaurant or a resort hotel that has only earned 3 out of 5 stars. You shouldn’t choose a Medicare Part D or Medicare Advantage plan with low star ratings, either. And for pretty much the same reason: Low star ratings mean lower quality and poor customer service.

Each year, the Centers for Medicare & Medicaid Services (CMS) rates how well health plans and prescription drug plans perform in different categories, such as customer service, prescription drug safety, and member satisfaction. The Medicare star ratings are important because they help you compare the overall quality of plans. Star ratings range from 1 star (poor) to 5 stars (excellent), so look for a plan with high ratings (4 or 5) to ensure you get the level of service and safety you deserve.

Now here’s the catch (there’s always a catch with Medicare!). This year, 28 percent of rated prescription drug plans (PDPs) that will be available in 2012 scored poorly (fewer than 3 stars). No national PDPs received a perfect 5-star rating this year, and one only national PDP—Medco Medicare Prescription Plan—received 4 stars. Although a few smaller, regional plans did receive 5 stars, the chance that one of these plans is in your region and meets your needs is very slim. 

The good news for beneficiaries is that CMS is telling these poor-performing plans that unless they take steps to improve their performance over the next few years, they face losing their Medicare sponsor status.

One of the main reasons that many plans’ ratings fell from last year is a shift in the way CMS rates Medicare drug plans. This year, the criteria changed to focus more on clinical outcomes, such as whether patients with diabetes, hypertension and high cholesterol are taking their medications as directed by their doctors.  Although some plans do have very effective medication management tools in place—such as pharmacist outreach calls—it’s not an easy or inexpensive task for plans to ensure their members are following doctor’s orders and taking their drugs as prescribed.

Like last year, the ratings also consider member experience, such as how long a patient is kept on hold when calling the plan, the number of complaints lodged against plans, and the number of people who choose to leave plans.

How does your state rate?

On a national level, 24 percent of the 557 rated drug plans get the top ratings of four or five stars, and about half fall in the middle with three stars. Another 28 percent score below three stars. From Kaiser Health News, here is the percentage of rated Part D plans in each state that get fewer than 3 stars on a scale of 1-5.:

Alabama 50%
Alaska 40%
American Samoa 0%
Arizona 48%
Arkansas 47%
California 42%
Colorado 46%
Connecticut 43%
Delaware 42%
Florida 42%
Georgia 47%
Guam 0%
Hawaii 40%
Idaho 40%
Illinois 44%
Indiana 48%
Iowa 42%
Kansas 39%
Kentucky 48%
Louisiana 50%
Maine 46%
Maryland 42%
Massachusetts 43%
Michigan 44%
Minnesota 42%
Mississippi 47%
Missouri 50%
Montana 42%
Nebraska 42%
Nevada 48%
New Hampshire 46%
New Jersey 43%
New Mexico 43%
New York 31%
North Carolina 43%
North Dakota 42%
Northern Mariana Islands 0%
Ohio 48%
Oklahoma 43%
Oregon 40%
Pennsylvania 39%
Puerto Rico 81%
Rhode Island 43%
South Carolina 53%
South Dakota 42%
Tennessee 50%
Texas 42%
Utah 39%
Vermont 43%
Virgin Islands 0%
Virginia 50%
Washington 40%
Washington D.C. 42%
West Virginia 39%
Wisconsin 45%
Wyoming 42%

How to determine if you have creditable drug coverage

One of my neighbors, a retired school teacher, recently asked me if she should hold onto her prescription drug coverage that she has through her former employer or switch to Medicare Part D when she turns 65. As soon as I started to explain that it all depends on whether or not she has “creditable coverage,” her eyes began to go cross-eyed. So let me see if I can make this easier to understand for you and her.

Creditable coverage is coverage that is considered as good as or better than the standard coverage provided by Medicare Part D. Standard Medicare prescription drug coverage is actually very good, so if your employer’s plan is not that great—for example, if it has a very high deductible, very high co-payments, or a small list of covered drugs (formulary)—it may not be considered creditable coverage. If that’s the case, then you will need to switch to Medicare Part D (or a Medicare Advantage plan with prescription drug coverage, MA-PD) when you become eligible.

On the other hand, if your employer’s prescription drug benefit is considered creditable coverage, it’s wise to stick with that plan. In fact, in some cases you run the risk of losing your employer-group prescription benefit and your employer-group health insurance if you join a Medicare Part D plan!

How do I know if I have creditable coverage or not?

The easiest way to find out if you have creditable coverage is to look through the plan materials provided by your employer-group plan. At least once a year, your employer must send you a letter called a Notice of Creditable Coverage (or Notice of Non-Creditable Coverage). If you cannot find this letter, contact your plan’s benefits advisor and request the document be mailed or e-mailed to you.

If the letter states that the coverage being offered by your employer is “as good or better” than Medicare’s Part D coverage, you have creditable drug coverage. Make sure you keep a copy of this document on file. You should also request a copy of this document every year so you have proof that you have maintained creditable drug coverage. If you ever need to join a Medicare Part D plan in the future, you will need to provide these documents to the plan so you do not incur a late enrollment penalty.

However, if the drug coverage that is being offered through your employer is not as good as Medicare’s standard coverage, you will need to evaluate your options carefully. First, talk with your employer’s benefit advisor to find out if you can keep your group health insurance and enroll in Medicare Part D. If you can, ask for this in writing. As I mentioned before, some employer-group plans will not let you keep your health coverage if you elect Part D rather than sticking with the drug coverage provided in the health plan.

I really can’t stress enough how important it is to talk to your plan’s benefit advisor before making any moves at all. Every employer has different kinds of coverage and different rules pertaining to that coverage. Family and friends can give you some advice, but only your benefit advisor can give you the facts.

Reminder: Medicare Open Enrollment is now through December 7th.

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