Medicare and Rx Plans for Diabetics Tips

Getting Information About Medicare and Medicare Part D

With all the press about the new Medicare Prescription Drug Benefit program, which started January 2006, it is no wonder that many people are confused about where to go, to get the answers to their questions.

Some great resources for answers to the most common questions, you can contact:

* The Medicare Hotline - 1-800-MEDICARE
* Social Security - 1-800-772-1213

Or you can get information online:

* Medicare.Gov
* CMS.HHS.Gov

Your local Social Security Office will also have information on Medicare and Medicare Part D, and how you can get enrolled.

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Diabetic Supplies Covered Under Medicare

The Balanced Budget Act, passed by Congress in 1997, provides coverage for diabetic services, which reduces many of the out-of-pocket expenses for diabetics.

Effective January 1, 1998, some Medicare diabetic supplies were covered for Type I and Type II diabetics, whether or not the person was using insulin.

To be eligible for benefits, the individual needs:

*a prescription from their physician on

file with their pharmacy

*to meet the annual Medicare Part B

deductible, which is usually $100

The pharmacy can file a claim for the individual and, if the pharmacy accepts the assignment, Medicare will pay the pharmacy for the diabetic supplies. These supplies can include:

* blood glucose monitor

* testing strips

* lancets

* lancet devices

* control solution to check that your

glucose meter is working properly

If the pharmacy does not accept the assignment, the individual will need to pay the pharmacy, and then submit a copy of the receipt along with the Medicare claim form, to the Medicare Government Benefits Office, to receive a check for 80% of the approved amount, for their Medicare-approved diabetic supplies.

If the individual has a Medicare supplement, their 20% responsibility may also be covered.

The most important thing is to be informed about how the Balanced Budget Act effects you. Contact your local Medicare office, or talk to your pharmacy about how you can take advantage of the Act to ease the costs associated with diabetes.

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Eligiblity for Medicare

In order to be eligible for a Medicare Prescription Drug Benefit, you must first be eligible for Medicare.

Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are a younger person with a disability or with chronic kidney disease.

Here are some guidelines:

You can get Part A at age 65 without having to pay premiums if:

* You are already receiving retirement
benefits from Social Security or the
Railroad Retirement Board.
* You are eligible to receive Social
Security or Railroad benefits but
have not yet filed for them.
* You or your spouse had Medicare-
covered government employment.

If you are under 65, you can get Part A without having to pay premiums if:

* You have received Social Security or
Railroad Retirement Board disability
benefits for 24 months.
* You are a kidney dialysis or kidney
transplant patient.

General enrollment for medicare is January 1 through March 31. You may be auto-enrolled approximately 3 months before your 65th birthday, or you may need to apply.

Since Medicare plays such an important roll in your diabetes management supplies, it is vital that you do not delay in getting registered. Contact your local Social Security Office for more information.

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Considerations When Choosing a Medicare D Plan

When selecting a Medicare Prescription Drug Benefit plan, you need to consider several important things, including:

1. Deductible - many plans require that you pay a "deductible" - a specified amount out of your own pocket before Medicare D kicks in. This amount varies depending on your plan.

2. Monthly Premium - each Plan has a standard monthly premium, and the premiums vary from Plan to Plan. Remember to consider the overall cost of your medications PLUS the monthly premium, when calculating your annual drug costs.

3. Co-Pays - you will pay a minimum amount for each of your prescription medications. This amount is based on "tiers," numbered from 1 to 5. Drugs are placed on these tiers generally according to their relative cost. New medications cost more than older drugs, so some Plans will pay a higher percentage of costs for older medications than for the new ones. In some cases, the insurance provider will not cover (pay for) a medication on its drug formulary, so you are responsible for 100% of the cost of that medication.

4. Formulary - the drug formulary is the list of medications that the Part D Plan agrees to provide coverage for. Newer drugs tend to be on fewer formularies, due to cost and availability. It is vital that you look at the formulary of any Plan that you are considering, to ensure that your medications are included.

5. Available pharmacies - some Medicare Part D Plans are only available at certain pharmacies. While the majority of pharmacies are contracting with a large number of the Plans, some may not have a contract with the Part D Plan that you are going to select. Contact your pharmacy to see which Plans they contract with, so that you can keep both your regular pharmacy and the Plan of your choice.

Remember to consider all 6 key factors when making the decision about a Medicare Part D Plan, to ensure that you find the best Plan to meet your needs.

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Medication Coverage Under Medicare Part D

Medicare Part D outlines the minimum requirements for prescription drug coverage plan, provided by private insurance companies.

If you have prior prescription drug coverage, your providing company is required to notify you whether their coverage is equal to or better than Medicare D. If their coverage does not meet the minimum standard you may need to sign up for Part D drug plan.

Here are key considerations when choosing a Medicare Part D Prescription Drug Plan:

1. Does the plan cover the prescription

medications that you take?

Each Plan has a formulary - a list of

medications that they will cover, at

varying costs. Before you sign up for a

Part D plan, you need to check your

medications against the formulary, to

ensure that your medications are covered.

2. How much will the Part D cover?

All of the Part D plans use a tiering

system to determine how much of each

medication that they will pay for.

Generally, the older less costly

medications are covered more than the

newer more expensive medications. Check

out what your out-of-pocket expense is

going to be, for each of your

medications, before you sign up for Plan.

3. What is the cost of a Part D Plan?

Since the companies providing the Part D

Drug plans are private insurance

companies, the costs will vary from

company to company, and can include a

deductible. In general, the Plans

charging a deductive tend to have a

lower monthly premium, so you need to

add up the annual cost of your

medications, including the premiums and

deductible to find the most cost-

effective Plan for you. The Government

website "Medicare.Gov" has a program to

help you compare Prescription Drug Plans.

4. What about people who cannot afford to

pay for a Part D plan?

There is assistance available for low-

income persons with little savings or

assets. They may qualify for reduced or

eliminated premiums based on their

income. You will need to apply for this

assistance, and the form is available

through your local Social Security

Administration office.

5. When do I have to sign up for a Plan?

You have until May 15, 2006 to sign up

for plan. After that date, if you

choose to sign up, you will be charged

an additional penalty of 1% for every

month that you delay. This is a

lifetime penalty that you will pay, on

top of your usual monthly premium.

The exception to this: If you do have a

Prescription Drug Plan that is equal to

or better than Medicare Part D, and they

have sent you a letter to this effect,

KEEP THE LETTER! If at some point, in

the future, your current coverage lapses

or changes, this letter will save you

from paying the penalty as long as there

is no gap in your transition for your

private insurance carrier to Medicare D.

Confusing? It can be, but your local Social Security Office, the Medicare.Gov website, an Elder Law Attorney or other professional versed in Medicare D can help you make the right choice in a Medicare D Prescription Drug Plan.

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Medicare Advantage Plans

A Medicare Advantage Plan has the benefits of Medicare - coverage for doctor's visits, hospital stays and Hospice care - with the benefits of a prescription drug plan.

Currently, if you are eligible for Medicare, you are eligible to apply for a wide range of plans, from Medigap to Medicare Prescription Drug Benefit Plan (Part D). If you already have a good healthcare insurance plan, you may want to consider whether changing to a Medicare Advantage plan is right for you.

Weigh the risks and benefits:

1. Will you lose coverage with your

original Medicare or insurance plan?

2. Will your premiums or drug costs

increase?

3. Will your prescription drug co-pays be

more expensive?

4. Will choosing the Medicare Advantage

plan negatively impact your ability to

get your medicare diabetic supplies?

If the answers to these questions is a resounding "no," then perhaps a Medicare Advantage Plan is for you.

Contact your local Social Security Office, the Medicare hotline at 1-800 MEDICARE, or log onto the Medicare website at: MEDICARE.GOV, to get more information on Medicare Advantage Plans.

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"Welcome to Medicare" Physical Exam

Medicare Prescription Drug Benefit Improvement and Modernization Act of 2003 has expanded Medicare's covered services in the prevention of chronic disease

This benefit, also referred to as the "Welcome to Medicare" visit, is an excellent way for new Medicare beneficiaries to get information on health screenings and vaccinations, as well as to talk with their health care provider about their medical history and how to stay healthy.

All beneficiaries enrolled in Medicare Part B with effective dates that begin on or after January 1, 2005, will be covered for this benefit.

You can only take advantage of this one-time visit within your first six months of Medicare Part B coverage, so it is important that you make an appointment with a health care provider right away.

The "Welcome to Medicare" visit enables your health care provider to comprehensively review your health, to identify risk factors that may be associated with various diseases, such as diabetes, and to detect diseases early, when outcomes are best.

Contact your healthcare provider within 6 months of receiving your enrollment confirmation for Medicare B, and plan for a healthier future.

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DSHS and Medicare: Dual Enrollment

When the government initiated Medicare Part D, they included Medicare prescription drug benefit for eligible persons receiving their medical healthcare coverage through DSHS - Medicaid. Persons receiving Medicaid for healthcare benefits were automatically enrolled in a Medicare Part D Prescription Drug plan.

The government allows Medicaid residents to choose a different plan, if the one they receive is not adequate, by May 15, 2006. After that date, the auto-enrolled plan must stay in effect until the next enrollment date in 2007.

Persons who are dual-enrolled - using DSHS Benefits with Medicare D coverage - are required to pay the premium associated with their chosen prescription drug plan, and may also have to pay co-pays for their medications.

Persons may have the premiums automatically deducted from their monthly state checks, or may use automatic withdrawal from their checking accounts. Other payment options may be available on a state by state basis.

For persons with diabetes, the registration and dual-enrollment process is the same, and it is important that you research and register for a plan that will provide the maximum coverage your diabetic medications and supplies.

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Medicare D: The Standard Plan

Medicare Part D allows a number of private insurance carriers to provide prescription drug coverage for persons who qualify for Medicare. Part D is optional, however if your current prescription drug coverage does not meet the minimum standards set by the Government, you may want to consider selecting a Medicare Part D Prescription Drug Plan.

What is the Government's Standard Plan?

1. If your total annual drug cost is less

than $250, you must 100% of the cost.

2. If your total annual drug cost is

between $251 and $2250, the Plan will

pay 75% of the cost, while you pay the

remaining 25%.

3. If your annual drug cost is between

$2251 and $5100, you pay 100% of the

cost of your medications.

4. If your annual drug cost exceed $5100,

the Plan will pay 95% of the costs,

while you cover the last 5%.

Each insurance carrier offers a different plan. The above figures are the "minimum" required by the government, however most plans offer coverage that exceeds this standard.

Each carrier and Plan has different costs and deductibles. It is vital that you research the Plans based on the medications that you take, rather than simply on the recommendation of a friend, insurance representative or pharmacy. Compare the Part D Plans to see how well they meet your individual needs, and then make your decision.

To help you in this process, Medicare should have mailed you the 2006 "Medicare and You" booklet. If you did not receive the booklet or if you need further information, contact Medicare at: 1-800-MEDICARE, or access the Web site at MEDICARE.GOV.

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Medigap Coverage

Medicare Parts A and B pay for a lot of medical supplies and healthcare services, however they don't pay for everything. Traditionally, the patient still needs to pay 20% of the costs for covered services. To this end, some people choose to purchase supplemental insurance to pay the cost share not covered by Parts A and B, such as copays, coinsurange and deductibles.

In order to get Medigap coverage, you need to be already enrolled in Medicare A and B. Medigap plans are standardized. The Government has established different types of plans, lettered A through J. Most States can sell any, all or none of these plans, so it is important to shop around for a Medigap policy, since the premiums will vary from Plan to Plan, and State to State.

It is illegal for a company to sell you a Medigap plan if:

* you are on Medicaid
* you are in a Medicare Advantage or
Medicare + Choice Plan
* you already have a Medigap plan
(unless you are cancelling your old
one)

On the plus side, all Medigap plans purchased after 1990 are guaranteed renewable, so as long as you keep paying the premium, you cannot be cancelled because your get sick and make alot of claims!

Medicare Part D does impact Medigap plans in that no insurance carrier may sell you a plan that includes prescription drug coverage, because of the coverage offered through the Medicare D Plans.

Remember, your Medigap carries needs to send you a letter stating whether or not its drug coverage is equal to or better than Medicare Part D. If you did not receive such a letter, contact your Medigap provider and request one.

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Medicare Part D: Who's on the Playing Field?

There are over 50 different plans available for those interested in Medicare Part D, however the number of insurance companies administering those plans is significantly smaller.

Some of the primary players in the Medicare Prescription Drug Benefit program for Medicare Part D are:

1. Asuris
2. Humana (Wal-Mart)
3. AARP
4. Pacificare
5. Community Care (specific to your
community)
6. HealthNetOrange
7. Regents Blue Shield
8. SierraRx
9. Wellcare

This list is not all-inclusive, as the providers for the plans vary from state to state. You will need to check which plans are available in your specific area to find one that best fits your Medicare diabetic supplies needs.

Choosing the right plan for you is important, because it will determine not only your insurance premiums for the coming year, but also your co-pays for your diabetic supplies and medications, and the availability of your prescribed medications.

Each plan has a different formulary, which covers medications at different rates, may not include some of your medications or which have restrictions on how much it will cover for your medications and/or under what conditions.

Contact the Medicare hotline, at 1-800-MEDICARE, or access their website at: MEDICARE.GOV for more information about the individual plans and plan providers.

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Formulary Comparison with Medicare D

When most people start looking at Medicare Part D Prescription Drug Plans, they focus on the premium and the deductible.

However, when researching prescription plans it's essential to take into consideration the formulary tables for the Plans you are comparing.

To see the formulary specifics of a plan on the Medicare Web site, click in an individual Plan. After entering all of your medications, the Plan details the costs of your medications. Next to some of your medications you may see an asterisk (*) or double asterisk (**). These marks refer to limitations in the formulary. For example:

* a single asterisk indicates that there may be restrictions to the medication, in terms of how many pills you can have each month, other medications that you may need to try first, or other restrictions. These medications may not be available to you, if you don't meet the criteria, or you may not be able to get the prescribed dose, due to the pill count restriction. This can apply to diabetic medications, too.

** a double asterisk indicates medications that are not on that particular Plan's formulary. You will pay 100% of the cost for these medications, which can be substantial, depending on the medication. Currently, all diabetic medications have some level of coverage, but you need to check the individual formularies to see which one covers the most.

You may wish to look at another Plan, if you find that the Plan you are considering looks good in terms of premiums and deductibles, but has a lot of * or ** in the fine print.

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Medicare Part B and Diabetic Supplies

If you receive Medicare A benefits, you are eligible for Medicare Part B, however, Part B is not free. All Medicare enrollees who elect Part B coverage pay a monthly premium. The 2006 monthly cost is approximately $88.50, though the Social Security Administration can verify your exact premium.

There is also a deductible of $110, prior to Medicare B jumping in to pay. After that, Medicare Part B will pay 80% of the Medicare-approved cost of your medically necessary supplies and services.

You are not required to enroll in Medicare B, however if you decline to do so, when you first become eligible, you will pay a 10% penalty for each year that you delay, and this is a lifetime penalty.

Medicare B provides coverage for:

* Doctor's services
* Outpatient hospital care
* Some medically necessary services not
covered by Medicare Part A, like
physical/occupational therapy and
some home health care
* Diabetic supplies and services
- glucose monitors
- testing strips
- lancets
- lancet devices
- glucose control solutions
* Preventative care services
- "Welcome to Medicare" physical
for new enrollees
- screening for cardiovascular
disease
- diabetes screening
- glaucoma tests

If you are diabetic it is vital that you have cost-effective access to necessary diabetic supplies, health care and preventative care services. This can be accomplished by taking advantage of your Medicare Government benefits.

Call your Social Security Office for more information on Medicare B.

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Medicare and Self-Management Training

Proper self-care for diabetes is the key in preventing complications, and obtaining prompt and appropriate treatment.

The Balanced Budget Act of 1997 provided for coverage of some diabetic-related supplies and self-management services, to decrease the risk factors associated with having diabetes.

In order to qualify for payment of self-management services, your physician must certify that the services are provided to you under a comprehensive plan of care.

The physician or other individuals that provide other Medicare and Medicare Part D services, can provide self-management training services. They can then bill Medicare for the services. If they accept the assignment, Medicare will reimburse the physician or individual for 80% of the cost of the training. This does not include the services of a Registered Dietitian, who is reimbursed at 85% of the costs of nutrition therapy.

If the provider does not accept the assignment, the individual is responsible to seek reimbursement and also to cover the 20% co-pay.

Note that if the individual is covered by an HMO (Health Maintenance Organization), the self-management services are a covered benefit, but a co-payment may apply.

Learning how to manage your disease is an important part of treatment, and Medicare is prepared to help you become skilled and knowledgeable in staying as healthy as possible with your diabetes.

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Introduction to Medicare Part D

On January 1, 2006, the new Medicare Prescription Drug Benefit - Medicare Part D - went into effect and provided financial assistance for diabetics.

However, diabetics are not required to choose a Part D plan. You will need to look at your current prescription drug plan to see if you have viable options. Your current insurance carrier is required to send you a letter stating whether their coverage is equal to or better than the minimum coverage required by Medicare Part D. If the coverage does not meet the minimum requirement, you should sign up for a Part D plan, to get the most benefit from your drug coverage.

Medicare Part D plans are actually prescription drug plans sold by insurance companies. There are over 50 different plans to choose from, each offering different levels of coverage for medications and covered medical supplies, like syringes and lancets.

Medicare requires that each insurance company provide benefits as good as the government's "standard plan." This is a set of guidelines to ensure that each person receiving Medicare Part D benefits receives at least the same minimum level of care. Most offer coverage that exceeds the minimum standard, however the Plans have alot of leeway in designing their benefits, so costs and coverage will vary from plan to plan.

This is important in terms of diabetic medications, because they may pay 75% for Glucophage, but only 25% for Avandia. Diabetic medications are not inexpensive, so it is vital that you choose a plan that provides the most comprehensive coverage based on the medications that you take.

Talk to your pharmacy, Elder Law Attorney or contact our local Social Security Office to get more information about Medicare Part D and how to get signed up.

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Medicare and Diabetes Screening

What makes you at risk for developing diabetes?

Some of the key risk factors include:

* obesity

* high blood pressure (hypertension)

* high cholesterol

* history of high blood sugars

In an effort to detect diabetes early, and to reduce the potention complications of this serious disease, Medicare government now covers services that include supplies, self-management and diabetic screening.

Effective January 1, 2005, individuals at increased risk for diabetes that have any of the above risk factors may be eligible for up to 2 screenings each year, to detect diabetes.

There is no cost to this screening for individuals who already qualify for Medicare coverage, and it includes a Fasting Plasma Glucose Test - to check the amount of sugar in your blood, first thing in the morning. Elevated fasting levels can indicate diabetes and a need for more further testing and treatment.

Contact your healthcare provider and take the time to check out the Medicare-covered Diabetic Screening - it could make a lifetime of difference in your health.

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Medicare Health Support Programs and Diabetes

Section 721 of the Medicare Modernization Act of 2003 authorized development and testing of a chronic care improvement program called Medicare Health Support.

The goal is to improve the quality of care and quality of life for people living with multiple chronic illnesses, including persons with diabetes. The program helps participants follow their physicians' treatment plans and get the medical care necessary to reduce health risks, since chronic health conditions are a leading cause of illness, disability and death among those receiving Medicare benefits.

Medicare Health Support will help diabetics keep track of your medical treatments, and will provide you with education and materials to help follow your doctor's plan of care to aid you in staying healthy.

Currently, the participating states include: Oklahoma (LifeMasters Support SelfCare, Inc), Pennsylvania (Health Dialog Services Corp), Washington, DC (American Healthways, Inc), Michigan (McKesson Health Solutions,LLC), Georgia (CIGNA HealthCare) and Florida (Green Ribbon Health).

If you are interested in participating in Phase I studies of the Chronic Care Improvement Program, talk to your provider or contact one of the agencies listed above.

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Veterans and Medicare

Persons who are eligible for Medicare, who are receiving veteran assistance benefits for prescription drugs, do not generally need to register for a Medicare Part D Prescription Drug Plan (PDP). Veteran's benefits typically include medications and medical treatment, including diabetic supplies.

Persons eligible for VA benefits should request a letter from Tri-Care - the primary VA medical insurance carrier - similar to the letter that non-Veterans received, indicating whether or not VA Prescription Drug Benefits are equal to, or better, than the Government Medicare Standard Plan.

The Veteran should then retain this letter, in the event that they are no longer covered under VA benefits program - for example if the coverage exists because of a spouse, and the marriage ends - so that they will not have to pay a late-registration penalty, should they later need to register for a Part D drug plan.

Contact your local VA Office for more information about the impact of Medicare Part D on your prescription drug coverage.

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Medicare A Services for Persons with Diabetes.

To be eligible for Medicare Part A services, you must be:

* 65 years old
* worked paying into Medicare for at
least 10 years or had a spouse that
paid in

You may also qualify if you are a younger person and are disabled, or have chronic kidney disease - a serious complication of diabetes.

So, you have Medicare Part A services - what do they cover?

Medicare Part A will cover:

* in-patient hospital stays
* critical care access hospitals -
rural areas
* skilled nursing facilities for up to
100 days per calendar year for
qualifying conditions and treatments
* Hospice Care for end-of-life
* Some limited Home Health Services,
usually following a qualifying
hospital stay of at least 3 days for
an approved condition

Medicare Part A does not cover:
* Medicare Part D
* Home care supplies, including
diabetic supplies
* Outpatient physical and occupational
therapy
* Medications to be taken at home

To see if you have Medicare Part A coverage, look on your red, white and blue Medicare Card. If you have Part A, you will see "Hospital (Part A)" printed on the lower left corner of the card.

If you don't have Medicare Part A, you may be able to purchase it by calling your Social Security Office at 1-800-772-1213.

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