Medicare Part D prescription drug coverage provides assistance with prescription drug expenses. However, for Medicare beneficiaries who have been getting their prescriptions through Medicaid or for those who have been receiving other financial assistance from the State of Texas for their health care or drug assistance, the change to Medicare Part D presents some challenges.

Click on the question below to get further information or just scroll down and read.

Who are these clients and how are they affected?

What does that mean to your patients?

The challenge

Specific issues related to full dual eligible clients

Specific issues related to Kidney Health Care clients

What is covered under Medicare Part D?

Costs of this coverage plan

How do people apply for extra help?

How can I get more information?

Who are these clients and how are they affected?
The State of Texas is particularly concerned with several groups of Medicare beneficiaries who have been receiving prescription drug assistance through the state Medicaid program or through programs under the Texas Department of State Health Services (DSHS), including the Kidney Health Care Program, Mental Health Services Program, and the Texas HIV Medication Program. The groups are:

Medicare Part D offers beneficiaries several plans that they can choose from. To guarantee these clients have coverage once they lose Medicaid prescription drug coverage, Medicare will select a Part D prescription drug plan for these clients if they have not chosen a plan for themselves. However, the plan that Medicare selects may not be the plan that works best for that individual. These beneficiaries will have the option to enroll in a plan that better meets their needs. For more information about Medicare Part D and these clients, click here.

For information on ways to assist those in this group who have neither chosen a Medicare Part D prescription drug plan or were not automatically enrolled in a Part D plan, click here.

Medicare Part D will offer beneficiaries several plans that they can choose from. The annual enrollment period begins November 15 each year for coverage effective the following January 1 but each month, hundreds of these Medicaid clients become eligible for Medicare, including the Part D benefit. If these beneficiaries do not voluntarily enroll in a plan, Medicare assigns them to one. For more information about Medicare Part D and these clients, click here.

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What does this mean to your patients?
There may be some confusion on the part of those clients whose drug coverage shifts from Medicaid or the state health programs, to Medicare Part D. As a trusted source, your patients may turn to you for information about Medicare Part D prescription drug coverage. Help can be as simple as referring them to this Web site or federal sources such as www.medicare.gov or 1-800-MEDICARE. It is important to encourage your patients to learn more about Medicare Part D since their access to certain prescription drugs will depend on whether those drugs are covered by their Medicare Part D prescription drug plan. If any of your patients rely on caregivers, you can help by getting this information into their hands as well.

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The challenge
A smooth transition to Medicare Part D will require most beneficiaries to make a decision once they become eligible for Medicare. Beneficiaries will have a choice of two or more plans. The formularies for each Medicare Part D prescription drug plan must cover each therapeutic category and class of prescription drugs but the formularies do not have to cover every drug in every class. Again, this situation makes it important for beneficiaries to make sure they choose, or are placed in a Medicare Part D drug plan that covers the prescription drugs they need.

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Specific issues related to full dual eligible clients
Each of the Medicare beneficiaries who receive drug coverage through Medicaid (dual eligible clients) will be served by a Medicare Part D prescription drug plan once they become eligible for Medicare. If the client doesn’t choose a plan, Medicare will assign the client to one of the drug plans available under Medicare Part D. Due to different formularies, that assigned plan may not cover the prescription drugs the client needs. It’s important full dual eligible clients review their Medicare Part D prescription drug plan options and make sure the one they choose covers the prescription drugs they need.

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Specific issues related to Kidney Health Care Program clients
Kidney Health Care Program recipients who become eligible for Medicare need to select and enroll in a Medicare Part D prescription drug plan. The Kidney Health Care Program will assist with Medicare Part D premiums up to $35.00 per month minus any subsidized amount. The Kidney Health Care Program will only assist with coordination of benefits for drugs and for premiums when recipients are enrolled in a stand-alone Medicare prescription drug plan and not with a Medicare Advantage prescription drug plan.

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What is covered under Medicare Part D?
Medicare Part D will cover most necessary prescriptions. Specific information on the prescription medicines each drug plan covers is available from each individual plan. While Medicare Part D will not cover certain categories of drugs including over-the-counter medications, barbiturates (sedatives), and benzodiazepines (anti-anxiety agents), Medicaid will continue to pay for these drugs for those who have been getting those medications from Medicaid.

Another significant change for clients who have been getting their prescriptions through Medicaid: The three-prescription drug limit imposed by Medicaid will not be in effect once these clients shift coverage to Medicare Part D.

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Costs of this coverage plan
Medicare beneficiaries who are currently receiving prescription drugs or Medicare cost-sharing assistance from Medicaid will automatically receive extra financial help that will cover monthly premiums, annual deductible, and coinsurance costs for Medicare Part D prescription drug plans. These beneficiaries will pay a per-prescription co-payment of between $1 and $5.35.

Medicare beneficiaries whose income is less than 150% of the federal poverty level and have assets up to $11,710 (or $23,410 if married) may qualify for financial help through the Social Security Administration. Beneficiaries who receive this help can expect to pay an annual Medicare Rx deductible of $50, a coinsurance rate of 15%, and a monthly premium adjusted according the beneficiary's income. According to Medicare, with this extra help, Medicare Rx will cover an average of 85% of the beneficiary's prescription drug costs.

The standard Medicare Rx prescription drug plan benefit will carry a $265 annual deductible. After that, the plan will cover 75% of drug costs up to $2,400. Once that level of spending is reached, the beneficiary will pay 100% of the cost of prescription drugs between $2,400 and $5,451.25 while continuing to pay monthly premiums. After reaching $5,451.25 in spending, the beneficiary will pay 5% of drug costs for the rest of the year while Medicare Rx pays the other 95% of those costs. This graphic illustrates how the standard Medicare Rx benefit would impact prescription drug spending for a beneficiary who spends $250 a month in drug costs. This graphic reflects how the standard benefit would impact prescription drug spending for a beneficiary with greater drug expenses, in this case $500 per month.

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How do people apply for extra help?
Social Security has an online tool to help determine if a beneficiary qualifies for additional help with prescription drug costs. A beneficiary can also apply for extra help online. Go to www.socialsecurity.gov and click on the "Medicare Prescription Drug Plan" link.

It’s important to remember that for most clients currently relying on the State of Texas for financial assistance with health care or prescription drugs, accessing Medicare Part D will be a two step process. Many of these beneficiaries will first need to apply for extra help from Social Security and, second, enroll in a Medicare Part D prescription drug plan. Even those who apply but don't qualify for extra help may still be eligible for extra help for costs associated with Medicare Part D from their state or community health program.

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How can I get more information?
For consumer information, call 1-800-MEDICARE. For more detailed information, please visit www.medicare.gov.

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