When Part D first started in 2006, EPIC members did not have to join a Part D plan at all -- if they joined one later, they did not have to pay a "late enrollment penalty" for the Part D premium because EPIC was "creditable coverage." After January 1, 2012, if a Medicare beneficiary has a lapse in prescription coverage for more than 63 days before enrolling in a Part D plan, their monthly Part D premium may increase by at least 1% for every month that they don’t have coverage and will remain at that level forever -- even when they do get Part D coverage. (This means Medicare beneficiaries who had drug coverage through their employer health insurance should join a Part D plan within 63 days after they retire and lose that employer drug coverage, or face a penalty.. enrolling in EPIC will no longer save them from that penalty.
Earlier Fact Sheets Issued by EPIC about the changes include:
2011 CHANGES
A. Beginning July 1, 2011, EPIC No Longer Subsidizes the "Deductible" for the Highest Income Deductible Members
Before, for members of the EPIC Deductible program, EPIC reduced its annual deductible by the amount of the benchmark Part D premium x 12 ($38.69 -2011). In effect, this fully subsidized the cost of the Part D premium.
After July 1, 2111, EPIC will no longer subsidize the monthly Part D premium for the highest income EPIC enrollees. After that date, the EPIC deductible credit (up to $464) will be eliminated. Therefore, effective July 1, deductibles will be raised by an additional $464.28 for those EPIC members who have Part D. Members who met their EPIC deductible before July 1, 2011 will be required to meet an additional $464 before they can resume paying only EPIC co-payments
In June 2011, EPIC sent these letters to current EPIC members who have a deductible --
B. EPIC Expands Premium Assistance - it will pay the PART D premium not only for "FEE" program members but some lower-income DEDUCTIBLE members
Until now,, every EPIC member has received help in paying their Part D premiums. 2011 premiums in NYS range from $14.80 (Humana Walmart-Preferred Rx Plan) to $107.80 (Humana Complete), with an average premium of $48/mo for the 33 plans. See plan lists here.
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FEE PLAN MEMBERS -- EPIC will continue to pay the Part D monthly premium for all people in the FEE Plan, up to the benchmark amount ($38.69/mo.). In 2012, the fee will be eliminated altogether, but so will most EPIC benefits. These are:
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SINGLES under $23,000 income/year
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COUPLES under $29,000 income/year
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DEDUCTIBLE PROGRAM - Beginning July 1, 2011, EPIC will now pay for the premium for the lowest people in the current Deductible program -- these people formerly had a credit toward their deductible by the amount of the benchmark premium ($38.69/mo x 12 months = $464.28/year - 2011) but now EPIC will pay it and they will no longer have any deductible.
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SINGLES $20,000 - $23,000 income/year
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COUPLES $26,000 - $29,000 income/year
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ALERT - MEMBERS MUST TAKE ACTION -- EPIC recently announced, "If an EPIC member’s Part D premiums currently are being deducted from their Social Security check, the member will need to call their Part D plan as soon as possible to cancel these deductions if their income falls within these limits."
NOTE: The change is a wash for the approximately 20,000 people in this income tier. EPIC deductibles for singles in this tier ranged from $530-$580/year. Credit for the cost of a benchmark premium ($38.69 x 12= $464.28) reduced their EPIC deductible to between $65 - $116/year. So.. they save that small amount of money, but probably will lose it with the other cuts in EPIC's subsidies in 2012.
A. Beginning January 1, 2012, EPIC will no longer cover anyone without Part D.
Of the current 307,500 EPIC enrollees, about 12% -- or 36,904 people -- are not in Part D plans - (10/2010 figures). They will no longer be eligible for EPIC at all. Most of them do not have Part D because they are in a Medicare Advantage plan that does not include prescription drug coverage -- they can choose to switch to an "MA-PD" - a Medicare Advantage plan that includes Part D prescription drug coverage. But.. others may not have joined Part D because they it would jeopardize their retiree health coverage. Still others are not eligible for Medicare at all.. and would have NO drug coverage unless they spend down to qualify for Medicaid (many are immigrants who have not had green cards for 5 years).
In June, 2011, EPIC sent these form letters to the "Deductible" plan EPIC members informing them of the changes:
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Letter 3 - Deductible members with no Part D -- Note that this letter only suggests that "this may be a good time" to enroll in Part D. It does not state that EPIC eligibility will end if the member does not join Part D, or when it will end. This is apparently because they will not be cut off until January 2012 -- even though the State could have cut them off EPIC as early as July 2011.
B. Beginning January 1, 2012 -- EPIC will cover drugs only during the "Doughnut Hole" or Coverage Gap of Medicare Part D
1. EPIC will no longer cover drugs during the annual Part D deductible period
21 out of 33 Part D plans in NYS in 2011 have an annual deductible - which in 2011 is up to $310/month. It will become more important for seniors to choose plans with no deductible. IF the plan has a deductible, the EPIC member will now have to pay the full cost of the drug -- (the only reduction is to the extent that the Part D plan negotiated a discount with the pharmaceutical company. But if that discounted price is $150 for the prescription, then the member must pay it all. EPIC pays nothing).
2. EPIC will no longer subsidize the Part D costs during the "Initial Coverage Period."
This is the period after the beneficiary met their Part D deductible, when the Part D plan pays for part of the cost of the drug, and the member pays the Part D co-insurance, which varies depending on whether the drug is GENERIC or BRAND NAME, and for Brand name drugs, which "Tier" the drug is on in the Part D plan.
EXAMPLE: The drug is a Tier 3 drug with a Part D co-insurance of $70.
Now and through the end of 2011 --
EPIC pays $50
EPIC member pays $20
Beginning January 1, 2012 --
EPIC pays $-0-
EPIC member pays the full $70
3. EPIC wil no longer pay for drugs that are not on the Part D plan's formulary.
Now, and until January 1, 2012, EPIC pays for a drug that is not on the Part D plan's formulary, if the treating physician has requested an "exception" for the plan to cover the drug. See more in this article.
After January 1, 2012, this coverage will end.
4. EPIC will still cover drugs in the Doughnut Hole (Coverage Gap) -- but more limited than now.
a. EPIC will pay for drugs covered by the Part D plan, with the EPIC member paying the EPIC copayments up to $20/prescription, as before.
b. EPIC will pay for drugs excluded entirely form the Part D program -- benzodiazapenes (ativan, valium) and barbiturates, but ONLY while the client is in the doughnut hole/coverage gap -- not during the rest of the year!
c. EPIC will no longer pay for drugs generally covered by Part D, but that are not on the particular Part D plan's formulary. The enrollee will have to switch to a different drug or switch to a different Part D plan-- but they may only do this once a year outside of the annual enrollment period (this is a special privilege for people in EPIC that allows them to switch once a year)
5. EPIC will no longer subsidize Part D costs during "Catastrophic Coverage" --
Catastrophic Coverage applies to a limited number of people with the highest drug costs. They are people who fall into the doughnut hole, spend so much on drugs that they climb out of the doughnut hole before the end of the calendar year. This means that the beneficiary’s drug costs for the year (including the amount paid by the plan AND by EPIC) reach $6,447.50 (2011) Then they enter catastrophic coverage. From this point onward (until the next January), the beneficiary is responsible for only about 5% of the cost of their drugs, and the Part D plan pays the rest.
Even though the Part D subsidy increases during this period, the out-of-pocket costs can still be high. Until now, EPIC continues to subsidize those costs so that the EPIC member pays a maximum of $20 for a prescription. That will end as of 12/31/11. Selfhelp has a client who will have to pay over $300/month for 11 months from Feb. 2012 - Dec. 2012 because she will be in Catastrophic Coverage during that period, and her drug costs are so high. As it is now, before those changes go into effect, EPIC would cut her costs by over two-thirds.
Who will be most affected -- and How To Help Them ?
See this article for Strategies to Help Clients Qualify for "Extra Help" -- Even though their income is too high -- by Using Costs Paid by EPIC to Qualify for Medicaid Temporarily, and other ways to qualify for Medicaid or the Medicare Savings Programs, which are "back doors to "Extra Help."
This article written by Selfhelp Community Services, Inc.
