Eligible for Medicare?
Coverage, telehealth and more during the COVID-19 crisis
What should I do and how do I sign up?
Managing Prescription Costs with Medicare
For most people on Medicare, coverage of prescriptions works very differently than coverage they had prior to enrolling in Medicare. Prescription medications can be an expensive, but important part of your overall healthcare. Here is some important information for you whether you need some financial assistance or just want to spend wisely for your prescription medications.
Help with Prescription Costs
If you need financial assistance to afford your prescriptions, there are several programs available to help you pay for the medications that maintain your health and manage your conditions. Medicare Part D is the insurance program that offers generally affordable prescription coverage, though for some the costs are still an issue. That is where the first of these programs, Social Security Administration’s (SSA) Extra Help program, comes in. For those who qualify, Extra Help may reduce your Medicare Part D premiums and deductibles and, depending on your income, even eliminate them. Additionally, Extra Help can reduce what enrollees pay when filling a prescription (no more than $3.70 for generic drugs and $9.20 for Brand name drugs in 2021).
Extra Help was created to assist those with limited income and financial resources. To qualify to enroll in Extra Help, you:
must be enrolled in Medicare Part A and/or Part B,
live in one of the 50 States or the District of Columbia, and
the value of your resources (combined savings, investments and real estate, excluding the value of your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts, back payments from Social Security or Supplemental Security Income (SSI)) cannot exceed $14,790 for a single person or $29,520 for a married couple.
A second alternative to assist with your costs is a state pharmaceutical assistance program. In Pennsylvania, those programs are PACE and PACENET. These programs are based on income rather than financial resources. To qualify you must be age 65 or older, a resident of Pennsylvania for at least 90 consecutive days and meet the income requirements:
PACE: total income last year less than $14,500 for single person and $17,700 for a married couple. Helps with premium and limits copay for 30-day supply to $6 generic/$9 brand.
PACENET: total income last year between $14,501 and $27,500 for a single person and between $17,701 and $35,500 for a married couple. Limits copay to $8 generic/$15 brand.
Managing Prescription Costs Under Medicare Part D
The single most important thing Medicare beneficiaries can do to control their expense for required medications is to select a plan based on the specific prescriptions used. Whether you shop for Medicare Part D coverage on your own or use a broker, start with your medication list. While many plans may have your medication on their formulary (the list of drugs they cover) what you pay under different plans may vary substantially. Also, its usually wise to consider to total cost of your premiums and cost sharing combined when picking a plan. Brokers are used to doing this and can be of great assistance. Also, be aware that your plan may cover similar drugs at higher or lower cost. If you have a higher cost prescription, consider discussing it with the prescribing provider. If the lower cost alternative is medically acceptable and likely to be as effective the provider may agree to change the prescription. In most cases your plans will offer lower rates when filling prescriptions at preferred pharmacies or though mail order so be sure to check you plan materials to get the best rates.
Finally, remember that your health changes and your prescription needs are likely to change with them.
At the same time the Medicare Part D plans are updated annually. Since you are entitled to change plans each year During the Medicare Annual Enrollment Period (AEP) it is worthwhile to consider a periodic review of your prescription coverage to ensure you plan is still a good fit.
If you have questions or would like to discuss the topic, please contact Tri-State Senior Consultants at (610) 399-1917.
Free Medicare Consultation Services Now Available for CMMD and Associates Patients
Sorting through Medicare options and information can be overwhelming and complicated. We think no patient—or caregiver—should have to navigate Medicare options alone, uncertain of how to enroll, what costs they may encounter, or what programs can help them fill in the gaps.
As a patient of Christine Meyer, MD and Associates, you have free access to an independent broker who will personally assist you in understanding Medicare options, so you can select a plan with confidence. Whether you are a Medicare enrollee or a caregiver, a one-on-one meeting or phone call with our broker can help you understand eligibility, the differences between each Medicare plan, and prescription coverage (including minimizing your out-of-pocket costs). Call today to schedule your free consultation!
Did You Know?
Medicare Part D Prescription Drug Plans include five tiers of prescriptions drugs. The lower the tier, the lower your co-pay for that drug. Each insurer decides the tier a specific drug will be categorized into. There are also formulary exceptions, quantity limits, prior authorization requirements and step therapies.
This is just one of the many topics our broker, Tina Garrity at Tri-State Senior Consultants, can explain at your Medicare consultation meeting. Call (610) 399-1917 to schedule yours today.
Topics to explore:
Medicare and COVID-19
Medicare covers related needs:
Medicare covers the lab tests for COVID-19. You pay no out-of-pocket costs.
Medicare covers all medically necessary hospitalizations. This includes if you're diagnosed with COVID-19 and might otherwise have been discharged from the hospital after an inpatient stay, but instead you need to stay in the hospital under quarantine.
At this time, there's no vaccine for COVID-19. However, if one becomes available, it will be covered by all Medicare Prescription Drug Plans (Part D).
If you have a Medicare Advantage Plan, you have access to these same benefits. Medicare allows these plans to waive cost-sharing for COVID-19 lab tests. Many plans offer additional telehealth benefits beyond the ones described below. Check with your plan about your coverage and costs.
Scammers may use the coronavirus national emergency to take advantage of people while they’re distracted. As always, guard your Medicare card like a credit card, check Medicare claims summary forms for errors, and if someone calls asking for your Medicare Number, hang up!
Telehealth & related services
Medicare has temporarily expanded its coverage of telehealth services to respond to the current Public Health Emergency. These services expand the current telehealth covered services, to help you have access from more places (including your home), with a wider range of communication tools (including smartphones), to interact with a range of providers (such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social worker). During this time, you will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure you are able to visit with your doctor from your home, without having to go to a doctor’s office or hospital, which puts you and others at risk of exposure to COVID-19.
You may be able to communicate with your doctors or certain other practitioners without necessarily going to the doctor’s office in person for a full visit. Medicare pays for “virtual check-ins”—brief, virtual services with your established physician or certain practitioners where the communication isn't related to a medical visit within the previous 7 days and doesn’t lead to a medical visit within the next 24 hours (or soonest appointment available).
You need to consent verbally to using virtual check-ins and your doctor must document that consent in your medical record before you use this service. You pay your usual Medicare coinsurance and deductible for these services.
Medicare also pays for you to communicate with your doctors using online patient portals without going to the doctor’s office. Like the virtual check-ins, you must initiate these individual communications.
If you live in a rural area, you may use communication technology to have full visits with your doctors. Our patients are using a real-time audio and video communication system to communicate with a remotely-located practitioner. Medicare pays for many medical visits through this telehealth benefit.
Our Medicare broker is able to do Medicare consultations remotely, over the phone or through Zoom, and can also do applications for all carriers remotely so that we can maintain appropriate social distancing. Contact Tri-State Senior Consultants at (610) 399-1917 to set up your free, remote Medicare consultation.
I've lost my job and need to sign up for Medicare. What should I do?
People who work past age 65 and have health insurance through their employers can delay Medicare enrollment without incurring steep penalties for late enrollment in Part B (10 percent lifetime for each 12-month period past the otherwise-mandatory sign-up age of 65).
If you were in this situation and need to sign up for Medicare now because of a job loss, you can take advantage of a special enrollment period that is available to you up to eight months after you lose coverage from employment.
A broker is available to guide you through the process of getting started with Medicare. Feel free to call (610) 399-1917 to reach Tina Garrity and the Tri-State Senior Consultants team for any questions you have.
The Medicare application is processed through local Social Security. During the COVID-19 response, local offices are closed to protect the public and employees. However, some field office staff are still reporting for work, and others are working virtually. Offices are offering in-person assistance for a short list of crucial services. These include reinstatement of benefits in dire circumstances; assistance to people with severe disabilities, blindness or terminal illnesses; and people in dire need of eligibility decisions for Supplemental Security Income or Medicaid eligibility related to work status. Those seeking these services must call in advance.
You may also need to interact with a local field office is if you are filing for Medicare benefits for the first time and are past the initial filing age of 65. In that situation, call your local office to get the application started, because you will need to file some forms.
If you need to visit a local Social Security office for in-person services, call the office to request an appointment. You can find the closest office using an office locator tool on the Social Security website, where the agency is also providing updates and information on services.
Start the process by calling your local office to get the application started — you can find it using this local office directory. The field agent there can advise you on which forms and supporting documents (also provided below), you will need to submit, and where to mail them. Request a “protected filing date” and proof of receipt from the office. This will create a record that you applied for benefits on that date, which could affect the date your coverage begins.
If you have not previously enrolled in Part A, you’ll need to do that along with Part B. This is also the time to enroll in a Part D prescription drug plan and a Medigap supplemental policy. Or, select a Medicare Advantage plan that includes drug coverage.
If your job loss happens to occur around the time you turn 65, the process will be less complex. This is called your Initial Enrollment Period — the three months before, the month of, and the three months after your 65th birthday.
If you already are receiving Social Security, you will receive your Medicare card automatically for Part A and Part B. If you are not on Social Security (this is more likely, since you’ve been working), you’ll need to sign up. Call Social Security at (800-772-1213) or sign up online. The temporary hours of operation are 8:00 a.m. to 5:30 p.m. EST. Please keep in mind that wait times may exceed two or more hours when waiting to speak to a Social Security Administration representative.
There can be a gap of one to three months before Part A and Part B coverage starts, depending on when you sign up during the initial enrollment period. However, Part A coverage is retroactive up to six months, back to the first month that you were eligible for Medicare.