Search      Tips on Searching Find Legal Help On Health Care for Elders Related Resources Medicaid Payment for Nursing Home Care By: Legal Hotline for Older Iowans Gifts and Qualifying for Medicaid for Nursing Home Care By: Legal Hotline for Older Iowans Do I Have to Sell or Liquidate All of My Assets to Qualify for Medicaid? By: Legal Hotline for Older Iowans more...

Beginning January 1, 2006, Medicare will provide prescription drug coverage for people with both Medicare and Medicaid. "Dual eligibles" are the group of Medicare eligibles who also qualify for Medicaid. The following information is from Centers for Medicare & Medicaid Services (CMS).

What are the Medicare prescription drug plans?
Beginning January 1, 2006, prescription drug coverage will be available to everyone with Medicare. Every person with Medicare, no matter how they get their health care today (including people with both Medicare and Medicaid), will be eligible for drug coverage under a Medicare prescription drug plan. Insurance companies and other private companies will work with Medicare to offer these drug plans. Medicare prescription drug plans will be available in every part of the country, and all plans will cover both brand name and generic drugs.

Drug plans may vary in which prescription drugs are covered. All drug plans will have to provide at least a minimum standard level of coverage, which Medicare will set.

I am enrolled in both Medicare and my state's Medicaid program. How will these changes affect me?
Your prescription drug coverage is changing. Until December 31, 2005, Medicaid will continue to pay for prescription drugs for you. Beginning January 1, 2006, Medicare will start paying for your prescription drugs. Medicare will enroll you in a Medicare prescription drug plan effective January 1, 2006, to make sure you don't miss a day of coverage. The new plan may charge a small co‑payment for each prescription?between $0 and $5. Medicaid will continue to pay for other health services for you including, at state option, prescription drugs not included in the Medicare program.

When will people with both Medicare and Medicaid join a Medicare prescription drug plan?
In October 2005, Medicare enrolled people with both Medicare and Medicaid in a prescription drug plan so that prescription drug coverage continues without a gap. Medicare will let you know the plan it has chosen for you in October 2005. Beginning November 15, 2005, you can switch to another prescription drug plan and change your plan anytime, for any reason. The change will be effective on the first day of the month following the month you make the change.

Medicaid does not pay for health services for me, but it does pay for my Medicare premiums. How am I affected by the Medicare prescription drug program?
People who get help from their state paying for their Medicare premiums, people in the Medicare Savings Program?CQMB, SLMB, and QIs, will continue to receive assistance with their Medicare premiums and will also receive a low income subsidy and can enroll in a Medicare drug plan beginning November 15, 2005. If you receive help through a Medicare Savings Program and do not choose a plan by May 15, 2006, Medicare will enroll you in a plan to make sure that you do not miss a day of drug coverage.

I have received my plan assignment from Medicare in the mail, what do I do now?
Decide if this plan is the right plan for you. Read the materials your plan sends you about the drug plan Medicare will enroll you in. If you don't like the plan, you can get information about the other Medicare drug plans. For example, find out if the prescription drugs you are currently taking are covered by your assigned plan's list of covered prescription drugs, also called a formulary. Make sure the pharmacy you use works with this plan. If you are happy with the plan that has been assigned to you, you need not do anything. Beginning January 1, 2006, you will receive your drugs through that plan and its pharmacy network. If, after reviewing the plan's information, you find that this plan is not right for you, you can switch to another prescription drug plan and change your plan any time, beginning November 15, 2005.

Can someone who makes health care decisions for me enroll me in a Medicare prescription drug plan?
Yes. If someone has the legal right to make health care decisions on your behalf, (such as through a power of attorney), this person can enroll you in a Medicare prescription drug plan that meets your needs. This person is sometimes called an "authorized representative."

If I want to change plans at some other point in the future, can I?
Yes. A person with Medicare and full Medicaid coverage is entitled to a "Special Enrollment Period." This means you can change your prescription drug plan at any time, and as often as each month if you wish.

What should I do if I am now enrolled in a Medicare Advantage Plan?
If you are already enrolled in a Medicare Advantage (MA) plan you will be enrolled in your MA's prescription drug plan. Check with your MA plan to learn more about its prescription drug coverage.

Will people with both Medicare and Medicaid living in a nursing home be enrolled in a Medicare prescription drug plan or will Medicaid continue to cover their drug costs?
People with both Medicare and Medicaid living in a nursing home will be enrolled in a Medicare prescription drug plan. At state option, Medicaid may pay for some non‑Medicare prescription drugs.

Will I get a new card when I enroll in a plan?
Medicare prescription drug plans will issue new cards to people enrolled in their plan. The cardholder ID will be assigned by the plan. Plans are not to use an enrollee's Social Security Number as the cardholder ID.

How much will I have to pay?
Medicare will help pay the cost of your prescription drugs. Anyone who is enrolled in both Medicare and Medicaid will not pay a monthly premium. You may need to pay a small copayment for each prescription?between $0 and $5. If you join a plan that has a premium higher than a standard plan, you will have to pay the difference. For example, if a standard plan costs $32 per month, and you join a plan that costs $35 per month, you will have to pay the $3 difference each month.

How much will people in institutions, like a nursing home, have to pay for prescription drugs?
If you have both Medicare and Medicaid and live in an institution like a nursing home for at least one month, you will pay nothing for your covered prescription drugs.

Will my pharmacy and/or pharmacist change?
If you want to make sure you stay with the same pharmacy, you need to contact the Medicare prescription drug plans and choose a plan that works with your pharmacy. You may also want to ask your pharmacist which plans she/he works with.

What is a "preferred" pharmacy? Do I have to use one?
Plans may offer "preferred" pharmacies within their pharmacy networks. Plans may offer lower cost sharing for covered drugs purchased by enrollees at certain pharmacies within their networks (the "preferred" pharmacies) compared to other network pharmacies ("non‑preferred" pharmacies).

What happens if I need to go to an out‑of‑network pharmacy?
There may be instances where you may need to purchase your drugs at an out‑of‑network pharmacy, like when you are on vacation. Plans are required to ensure that their enrollees have adequate access to drugs dispensed at an out‑of‑network pharmacy.

Will I pay more to use an out‑of‑network pharmacy?
Ultimately no. Because an out‑of‑network pharmacy, by definition, does not have a contract with your drug plan, you will be charged more than your normal $0-$5 co‑payments when you buy your drugs at an out‑of‑network pharmacy. However, your plan will reimburse you for that cost once it receives your receipt for the prescription drugs. You will still have to pay the normal co‑payment amount for that medicine just as if you had purchased it at your home pharmacy.

Can a plan require me to get my drugs through a mail‑order pharmacy?
No. Plans cannot require enrollees to use a mail‑order pharmacy. However, because many people like the convenience of mail order, many plans will offer mail‑order services.

What will my Medicare drug plan cover?
Each Medicare drug plan will have its own list of covered drugs (or formulary) that will include generic and brand‑name drugs. Plans may have rules about what specific prescription drugs are covered to treat different medical conditions. Every Medicare drug plan must comply with federal rules about the types and number of drugs covered.

How do I know if my prescription drugs will be covered by a particular Medicare prescription drug plan?
Make a list of all of your current prescription drugs including name, dose size (for example: 2 pills, 300mg in each pill), and dosage frequency (for example: 2 times a day). You can use this information to compare the list of drugs that are covered under each plan. You can get the list of drugs a plan covers by calling the plan, visiting the plan's website, visiting www.medicare.gov on the Internet, or by calling 1‑800‑MEDICARE (1‑800‑633‑4227).

Can my plan's formulary change?
Yes. A plan's formulary can change when a plan gets new information. But, the new formulary must meet Medicare's requirements and the plans must tell you about any upcoming changes 60 days in advance.
How will I know if my plan discontinues coverage of my drug?
Your plan must let you know at least 60 days before a drug you use is removed from the formulary.

Will I be able to get my drugs on January 1, 2006?
Medicare prescription drug plans must establish a transition process for all Medicare beneficiaries as they enroll in the new Medicare prescription drug coverage from another drug program. These transition processes must show how they will help people who are on a drug either stay on that drug or safely change to another appropriate drug. You should check with your plan to see what their policy is for continuing a particular drug.

Do I have to change my antidepressants, antipsychotics, anticonvulsants, HIV drugs, cancer medications and immunosuppressants?
No. CMS requires that Medicare prescription drug plan formularies include "all or substantially all" of the drugs in the antidepressant, antipsychotic, anticonvulsant, anticancer, immunosuppressant and HIV/AIDS categories. In addition, plans must give special attention to patients already stabilized on drugs in these classes. If you are already on these drugs when you join the plan, the plan usually cannot require preauthorization or ask you to try other drugs first. For individuals who begin treatment with these drugs after they are in the plan, other than HIV/AIDS drugs, plans may use these techniques to manage therapy. However, for HIV/AIDS drugs, these techniques are not allowed.

I've heard that certain prescription drugs are not covered by the Medicare Prescription Drug Program (i.e. barbiturates, benzodiazepines, or prescription vitamins). Will Medicaid still pay for these drugs?
A state Medicaid agency may choose to continue to pay for some or all non‑Medicare prescription drugs. Contact your State Medicaid Agency to find out what drugs, if any, they have decided to cover.

What if I am taking a drug that is not on my plan's formulary?
Medicare prescription drug plans must have a process for you to get drugs that are not on the formulary when the drug is medically necessary. If your doctor thinks you need a drug that isn't on the formulary, you or your doctor can apply for an exception. If the exception is denied, you can appeal the decision.

How do I apply for an exception if a drug I need is not on my plan's formulary?
First, you should talk to your doctor and make sure no other drug can be used. If your doctor thinks this is the only drug that is appropriate, then you need to file an exception. To file an exception, you should contact your plan. If the plan denies an exception, then you can appeal the plan's decision. To file an appeal, follow the procedure described in the handbook you received from your plan, or talk to your plan to find out how to file an appeal.

Who may help me with my exception and/or appeal?
In addition to allowing you to file an exception and/or appeal, prescribing physicians or your appointed representative can file appeals on your behalf.

Are plans required to cover a temporary/emergency supply of non‑formulary Medicare prescription drugs while an exception request is being processed?
For people living at home and in the community, you should check with your plan to see its policy on covering drugs while an exception request is being processed. Medicare prescription drug plans must cover an emergency supply of non‑formulary drugs for long‑care residents.

Can long term care residents receive an emergency supply of medications?
Yes. Medicare prescription drug plans must cover an emergency supply of non‑formulary drugs for long‑term care residents as part of their transition process.

Where Can I Go for More Information about Medicare Prescription Drug Coverage?
For more information on Medicare prescription drug coverage:

• Visit www.medicare.gov on the web and get personalized information.
• Call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048. When you call, have ready: your Medicare card, a list of drugs you use, and the name of the pharmacy you use.
• Read the "Medicare & You 2006" handbook mailed to you in October 2005.
• Get a free copy of the booklet "Your Guide to Medicare Prescription Drug Coverage," (CMS Pub. No. 11109) on www.medicare.gov or by calling 1‑800‑MEDICARE.
• Check for local events for help joining a plan.
• Contact your local office on aging. For the telephone number, visit www.eldercare.gov on the web or call: 1‑800‑677‑1116.
• Contact your local Iowa Department of Human Services office.
• Contact Iowa Legal Aid's Legal Hotline for Older Iowans at 1-800-992-8161.

Iowa receives a CMS State Health Insurance Assistance Program (SHIP) grant to support local personalized counseling and assistance to people with Medicare and their families. To contact the SHIP in Iowa, call (515) 242‑5190.