Блог Анкара

Mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm

In This Chapter

► Thinking with your skin

► Looking at your multidimensional skin (► Recognizing that your skin is on guard

► Understanding how massage affects the skin

Mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm

"We touch heaven when we lay our hands on a human body." — Novalis (pen name of Frederich von Hardenberg)

Kin is the essence of what makes humans human. How do I know, you

Ask? I saw it in a Star Trek Movie, so it must be true. In the movie, a wily alien treated Data, the android, to a taste of being human by grafting a swatch of flesh to his mechanicaLarm. He already had a brain and a fully functioning body, but the one thing he lacked was sensation. He was just a machine until he had this little patch of skin attached to him, and with it, he became

The essence of being human is the ability to feel. "But," you might respond, "I feel things in my mind and with my nerves, too, not just my skin. And besides, can I really trust Star Trek As a source of anatomical knowledge?" Well, guess what? In this case, the writers of Star Trek Happened to be right on the money. Your skin, your nerves, and your mind are really just different layers of the same thing.

Human.

Thinking tfith \lour Skin

In his book, Job’s Body, Deane Juhan, a researcher into the effectiveness of massage and other touch therapies, says, "Depending upon how you look at it, the skin is the outer surface of the brain, or the brain is the deepest layer of the skin."

This assertion, though it may seem absurd initially, can be proven quite easily if you look closely at the development of the embryo. As you know, you start out as a little clump of cells deep in your mother’s womb. In the very first days after conception, these cells begin to divide into three distinct layers that will later become your body. The Endoderm Layer of cells eventually forms your internal organs, the Mesoderm Forms the muscles and connective tissues, and the Ectoderm Forms the nervous system and the skin.

As the Ectoderm Cells develop, they gradually turn into your brain, spinal cord, nerves, and skin, which are really all one unit. "Nowhere along the line can I draw a sharp distinction between a periphery which purely responds as opposed to a central nervous system which purely thinks"(Juhan p. 36). In other words, your skin "thinks" as well as feels, and your brain "feels" as well as thinks. It’s all one thing. And it starts at a very early age. In fact, at six weeks and less than an inch long, the little embryo can already "feel" light stroking on its upper lip, which causes a withdrawal reaction.

Feeling = thinking

Imagine the following sequence:

1. Imagine a pinprick at a certain point on the skin (Point A).

2. Imagine the sensation that travels up from the sensory receptor near the skin’s surface, to the nerve, and then on toward the spine, which it enters at Point B. From there it continues up to the brain.

3. Imagine your brain processing this impulse somewhere around Point C, sending a further impulse to your mouth, which then says "ouch."

So the question is, at what point does the sensation of the pinprick cause you to pull your skin away from the sharp object?

A. At point A, the exact moment the pin pricks the skin.

B. At point B, a nanosecond later, when the sensation enters the spine.

C. At point C, inside the brain itself.

D. None of the above.

This question is tricky. Most people assume that the answer is C, inside the brain, because that’s where they think they have the thought, "That hurts." But in actuality the answer is B, when entering the spine, for the following reason:

You pull yourself away from the pinprick as a result of a Reflex arc At point B, which is an impulse that enters the spine and then shoots right back out again in the form of a reaction. You actually experience the pulling away before your brain catches up to what’s happening and you say the word "ouch." Ever notice that? For the same reason, your knee jerks when tapped with a little rubber hammer, without your having time to think about it. So, in this sense, your skin and nerves do the "thinking" for you.

Note: Do not try this pinprick experiment at home on friends or family. I guarantee that they won’t appreciate it.

Im’estimating Hour Multidimensional Skin

In his book, Touching: The Human Significance of the Skin, Ashley Montagu offers many pearls of wisdom, such as: "To shut off any one of the senses is to reduce the dimensions of our reality, and to the extent that that occurs we lose touch with it; we become imprisoned in a world of impersonal words, sans touch, sans taste, sans flavor. The one-dimensionality of the word becomes a substitute for the richness of the multi-dimensionality of the senses, and our world grows crass, flat, and arid in consequence."

Sadly, he’s right. People end up ignoring most of what they feel, and as they get less and less in touch with themselves, they become more and more hectic, filling their days with frantic activity rather than just enjoying the sensation-filled miracle of being alive. Instead of hectic, I think people should become more Haptic. A Haptic Person is especially in tune with her sense of touch, or, as Ashley Montagu would say, has a "mentally extended sense of touch which comes about through the total experience of living and acting in space."

Haptic comes from the Greek word, Haptesthai, To touch. To start yourself in a haptic direction, you need to know a few details about the skin:

11^ You have more than 3 million cells in a patch of skin about the size of a bottle cap. Your skin contains 2 to 5 million sweat glands and about 2 million pores.

^ Your skin is your largest organ system:

• 2,500 square centimeters in newborns and approximately 19,000 square centimeters (19 square feet) in an adult male.

• An adult male’s skin weighs approximately 8 pounds.

Your skin gets strength and form from collagen, which comprises 70 percent of your skin’s dry weight.

You have approximately 640,000 sensory receptors embedded in your skin.

Your skin ranges in thickness from Xo Of a millimeter on the eyelids to 3 or 4 millimeters on the soles and palms.

\S Your skin becomes softer in summer and more dense in winter.

Because you have so many sensory receptors in your skin (pain cells are the most plentiful, followed by a variety of pressure sensors, cold sensors, and warmth sensors), it’s no wonder you can be so "touchy" if you’re "rubbed the wrong way." And no wonder that a caring, calming massage can be so soothing.

All you really have to do to get back "in touch" with your true, haptic self is to tune in to your senses, your skin, and your environment, like you did when you were six years old and mud puddles were sources of unending pleasure. To help you get back to that sacred sensory space, you can try the sensitivity exercises that follow.

Sensitivity exercise #1:

The Zen cantaloupe ceremony

Consider, for a moment, the word "cantaloupe." Nice, round word that evokes the picture of the fruit itself in your mind. Perhaps the word even summons up a sweet cantaloupe memory or two. But too often the word itself is a substitute for the fullness of the thing, a crutch people use to classify this or that specific bit of reality, filing it away for easy reference.

If you want to move yourself beyond your mind’s habitual categorizing mechanisms, try the Zen cantaloupe ceremony:

1. Buy or borrow a fresh, ripe, high-quality cantaloupe.

2. Find a quiet, private place (where no one can see you and make fun of you) and sit with your cantaloupe placed on a plate within reach.

Have a knife handy. Then close your eyes.

3. Spend five minutes or so just calmly breathing and slowing your mind.

4. Slowly, with your eyes still closed, reach your fingertips out until you make contact with the cantaloupe.

Do not attempt to pick it up. Just feel the surface in extremely minute detail, as though you’re trying to decipher a message encoded in the fruit’s convoluted furrows. Pay attention to your fingertips.

5. Begin to lift the melon up, using your fingertips alone.

Spend a minute feeling the weight, shifting it from hand to hand. Then slowly bring the fruit up to your face, rubbing the rough texture against your cheek.

6. After this thorough tactile encounter with the melon, place it on the plate again, and then slowly and ritualistically lift the knife and begin your incision, slicing out just one sliver, cleaning off the seeds.

Open your eyes while slicing but then close them again.

7. Lift the slice to your nose and take three long inhalations.

8. Open your mouth and place the cool orange flesh inside your lips, but don’t bite down at first.

Let the juices gather on your tongue and savor the sensation.

9. Let your teeth literally sink down into the fruit, and then let the piece melt in your mouth for a minute before chewing.

10. Repeat the biting and chewing until you eat the whole sliver.

Breathe deeply for a few minutes again. Then, finally, open your eyes.

If you pay attention to the feelings that you have at each step of the ceremony, you’ll discover that cantaloupes have much more depth than just the word "cantaloupe."

Just as the original Zen tea ceremony was used by Samurai warriors in Japan to calm their minds and bring them into the present moment, the cantaloupe ceremony can help focus you on the tactile reality underlying your ongoing reinterpretation of the world through thoughts and words. You can repeat the experience with other fruits, vegetables, and just about any safe, non-toxic foodstuff.

This exercise is a great way to help yourself get into the right frame of mind for giving a good massage. You don’t have to think so much. Don’t speak. Just touch. Feel. Be with the world you come into contact with, including other people. Performing the Zen Cantaloupe Ceremony is a great way to sensitize your fingers and your mind immediately prior to giving a massage.

Sensitivity exercise #2: The texture of the utorld

Your fingertips have the largest concentration of sensory receptors of any part of your body. This feature is quite convenient for giving massages, which requires a real sensitivity to the person you’re touching.

With their unique sensitivity, your fingers can actually "see" objects, a fact you confirm every time you fish through a purse or pocket, searching for keys. You can develop and fine-tune this capability through a simple attune-ment exercise called the "texture of the world." The exercise helps you gain a certain sensibility that is crucial for getting and giving good massages.

You need a partner for this experience — someone you trust.

1. Have your partner gather four or five objects and arrange them on a table, without showing you what they are.

See why you have to trust your partner? You don’t want someone who may choose bird droppings, tar, rotten dairy products, and so on.

2. Have your partner blindfold you and sit you in front of the table, within arms’ reach of the objects.

If you haven’t been blindfolded since playing Pin the Tail on the Donkey as a child, be prepared for a startling and powerful experience.

3. Reach out and touch one object at a time, picking it up and using your fingertips to try to determine what it is.

If your partner has been creative in choosing the objects, you should have an interesting experience. Use just your fingertips for this exercise and resist thetemptation to get your nose or other senses involved in the process.

4. Override your mind’s tendency to identify the object and then create a visual picture of it, categorize it, and dismiss it.

Your mind goes into its automatic pattern the moment you realize what the object is. Instead of giving in to that tendency, continue to explore the object, discovering properties you overlooked before. If you can’t guess what the object "really" is, that’s okay. In fact, that’s good. Just continue to feel it. When your mind can’t categorize something, you’re forced to perceive it in a new way.

5. Based on your present tactile encounter alone, rename the objects.

A golf ball, for example, may become a dimple-nut. Have your partner write the new names down on pieces of paper and place them next to the objects.

Little skin, lotta feeling

Do you know why little tots seem so extraordinarily sensitive when it comes to touch? Children up to three years old have a total of 80 Specialized sensory receptors called Meissner’s corpuscles Per square millimeter of skin, as

Opposed to 20 In a young adult, and 4 In old age (Montagu, p. 7). That’s why babies are so overwhelmed by tickles and touches. They feel more than we do.

6. Remove the blindfold and check out your work.

Just being blindfolded greatly alters your perception of the objects. Unable to take them for granted, labeling one a "golf ball" and another a "yellow stick-on note," you will quite likely discover something about your ability to feel, and in the process increase your touch-ability (see Chapter 5 for more on touch-ability).

Layering It On

Your skin, like every other part of your body, is a living, growing, changing thing. In fact, you have an entirely new outer layer of skin every 27 Days, which means you’re an awful lot like snakes, lizards, and other animals who leave their skins behind periodically. You just shed your skin one skin cell at a time, so it’s not so obvious.

The Epidermis, The outer portion of your skin that keeps replenishing itself and flaking off, is made up of several layers. The bottommost layer keeps reproducing new skin cells, which are then pushed toward the upper layers, collectively known as the Horny zone. It is called the horny zone because the cells there are hardened, like horns.

So, what you’re really seeing when you look at somebody’s skin is a whole bunch of dead, hardened cells that are about to fall off. In fact, Exfoliation, A particular type of spa treatment that I explain further in Chapter 15, assists the skin in this process.

Keep in mind that certain skin conditions make performing a massage inadvisable (see Chapter 10). For now, I’m talking about basic, healthy skin in an average person.

The hazards of breathing

The "dust" particles that you see floating in a shaft of sunlight are mostly dead skin cells from the epidermis that have recently been shed by you and any other people who have inhabited the room. As you breathe, you can’t help but inhale some of these flaky cells, thus sucking cousin Bob, Aunt Julia, the refrigerator repair

Man, and even your own self into your lungs. This situation presents no biological hazard and is usually not a cause for concern because most people don’t know about it and therefore don’t get grossed out.

Whoops.

^tMty/ Beneath the epidermis lies the Dermis, Which is filled with fat cells, blood and c" " " lymph vessels, oil glands, sweat glands, nerve endings, and hair follicles. The dermis also helps to bind the outer layers of the skin to the subcutaneous (which means "beneath the skin") tissues below. In this area, you find some very important cells called Fibroblasts, Which are responsible for producing connective tissues. You owe a great debt of gratitude to your fibroblasts, especially after you break your skin in some way, because these specialized cells are responsible for rushing to the area and filling it with connective fibers, mending you back together. Massage can also affect these fibroblasts to enhance the appearance of your skin.

Getting the Skinny an Hour Personal Border Guard

Throughout your life, your skin defines the intimate boundaries of your existence. Skin is the millimeters-thin line that separates you from the rest of reality and allows you to perceive that reality. Here are the six major functions of your own personal border guard, the skin:

P0 Protection I** Absorption

Secretion and excretion

Heat regulation

Respiration J> Sensation

The importance of getting licked

Have you ever watched a cat give birth? Directly afterwards, mamma cat begins licking her babies all over, with a special concentration in the genital area. The same is true for dogs. And horses. And cows. And aardvarks and antelopes and giraffes. In fact, every species of mammal with the exception of man lick their young immediately after birth.

At first, you may assume that this licking is to clean off the gooey stuff plastered all over the newborn’s body. That’s partially true, but far more important than the cleaning is the licking itself, the touch of tongue to flesh or fur.

I was in my first massage therapy class, in California, when the instructor stated that massaging a newborn baby’s Perineum (the area between the genitals and anus) with a warm moist cloth was a good idea to simulate the

Action of licking engaged in by other animals. In other words, he was advising us to metaphorically lick the baby’s butt.

At the moment, and for several years afterwards, I thought this California massage instructor was a little too "out there" for his own good. But now, after discovering the importance of this type of stimulation in every other species of mammal, it makes perfect sense. This critical form of early contact jump-starts the newborn’s gastrointestinal tract and is perhaps the most primal type of "massage" that we can offer our

You can recreate the natural sensations of lick* ing for your newborn by taking a baby-wipe or moist towel and rubbing it gently over the skin in this important area a couple times a day for the first few months of life, starting on day one.

Protection

Whenever anyone tries to pass over the border from Spain to France, say, he or she is stopped by the border guard (usually men in sadly decorative hats, with sour expressions on their faces). The same basic thing happens with your body. Your skin says "Stop and present your papers" to anything big and obvious trying to get inside of it, such as steak knives, harmful bacteria, #2 pencils, and so on. Having the men in the sad little hats there to protect us is a very good thing, as I’m sure you can appreciate when you think about what kind of chaos would ensue were millions of Spaniards to suddenly turn up in your pancreas.

Absorption

Once in a while, you want to allow some people across the border to spend those tourist dollars and improve the economy, right? Your skin can do the same thing through a process called absorption. Your skin can absorb certain cosmetic products, chemicals, drugs, and water in small amounts. Unfortunately, certain items are not beneficial to your body, such as toxins

And pesticides. Your skin is equally capable of allowing these terrorists to cross the border, which means you should stay on guard regarding the products you come into contact with.

Excretion and secretion

Your skin can also get rid of toxic elements, like exiling unwanted characters from the country. This process is called Excretion, And it’s handled by those ruffians, the sweat glands. You have several million of these glands, and they eliminate waste products via perspiration.

In addition to excreting, your skin secretes as well, issuing forth an oily substance called Sebum That coats the skin and helps preserve moisture. Secretion is a good thing, because the skin is about 50 – 70 percent moisture, and you don’t want it to dry out.

Heat regulation

Your skin is constantly monitoring the temperature in the environment and helping to maintain your body’s internal temperature at an even 98.6T (37°C) through adjustments of blood vessels and sweat glands, which dilate or contract in response to heat and cold.

If you don’t touch mer Til die

Touch is literally a matter of life and death. The philosopher Bertrand Russell noted the importance of touch, saying, "Not only our geometry and our physics, but our whole conception of what exists outside us, is based on the sense of touch." For this reason, it’s urgently important that infants and small children receive an abundant supply of human contact.

In the early 1900s, Dr. Henry Dwight Chapin reported that when orphaned babies were routinely put in homes and left to wither away with

Essentially zero human contact, a startling 99 percent of them died within one year of admission (Juhan p.43). Those who survived suffered signs of retardation and maladjustment

To say that the world would truly be a better place if more people received massage — especially as part of their developmental years — is not an exaggeration. Touch is a vital part of human growth, for individuals and for the entire community.

Respiration

Oxygen comes in through the pores of the skin, and carbon dioxide goes out, just like in the lungs, but on a smaller scale. If you’re a James Bond fan and saw the classic movie, Gold Finger, You may remember the famous opening scene, which featured a woman painted completely gold and then left on a hotel room bed in Miami Beach. In the movie, she died because her skin couldn’t "breathe," and a similar fate could happen to you in real life if all of your pores were suddenly blocked.

Sensation

If skin were basically just nature’s way of keeping what’s inside of our bodies in and what’s outside out, life wouldn’t be nearly as much fun as it is, and, as it turns out, those guards at the border have a sensitive side beneath their hats after all.

Providing you with a rich, complex variety of sensations is by far the most personally gratifying of the skin’s functions, which is something you’ll develop an even greater appreciation for as you practice the techniques in the other chapters of this book.

Touching the Skin through Massage

Recently, even the U. S. Food and Drug Administration (FDA) has become convinced that massage offers undeniable results. My co-author, Michel Van Welden, has worked with the FDA extensively and has substantiated some claims for the effectiveness of massage. Following are some of his findings:

Scientific evidence points to the fact that massage can positively impact skin tone.

Pigs love massage.

It’s true. In a series of experiments at Vanderbilt University and UCLA, Michel worked with a team of ace physicians administering a series of massage experiments on some very special subjects: Flopsy, Zeus, and Peewee, three Yorkshire pigs.

The three pigs were chosen for their high moral character and love of luxurious spa treatments. No, actually they were chosen because pigs (even though you may not like to admit it) have remarkably similar skin to humans. Twice a week for 13 weeks the three brave little oinkers received deeply stimulating

Massages with a device that strongly affects circulation. The FDA eventually approved this device as an effective way to tone the skin and improve the appearance of cellulite. Here are some of the findings of these experiments, as reported in Newsweek Magazine, November 1998:

U* This type of massage, called Endermologie®, stimulates fibroblasts, which produce collagen.

V0 An increase in collagen fibers can improve the elasticity and youthful appearance of the skin.

Michel should know. He’s been a physical therapist in France for almost 30 years, and in that country the physical therapists do an awful lot of massage. In fact, each of the 35,000 practicing physical therapists in that country gives an average of 4,374 massages a year, most of them paid for by national insurance. Perhaps that’s why the French have a saying, Bien dans son peau, For someone who is happy and content; the phrase means "good in his skin."

Chapter 4

In This Chapter

^ Knowing what you pay and what you get in Extra Help

^ Qualifying automatically or applying for Extra Help

^ Seeing whether Extra Help affects other assistance you may receive

^ Selecting a drug plan, enrolling, and switching

^ Finding out whether you’ll still qualify for Extra Help all year and next year ^ Figuring out what to do if you’re denied or lose eligibility for Extra Help

#«^remiums, deductibles, co-pays, and that huge chunk of change that is V The doughnut hole — yes, a lot of consumer costs go along with Part D. And for many people, they’re just not affordable. That’s where Extra Help comes in. This is the name of the program-within-a-program that’s specifically designed for people with limited incomes and savings and has the most generous benefits that Part D provides. If you qualify, you’ll receive drug coverage throughout the year, and your out-of-pocket expenses will be much smaller than in the regular Part D program.

Millions of older Americans and those with disabilities are thought to qualify for Extra Help but, for one reason or another, they aren’t receiving it. Could you be one of them? It may be worth applying even if you’re not sure you’d qualify. Or do you think that someone you know — a relative, a friend, a neighbor — could use some Extra Help? If so, you may want to encourage or help that person to apply.

In this chapter, I explain how Extra Help works, depending on whether you qualify for it automatically or need to apply, and how it could affect other government assistance you may receive. I also explain Extra Help in the context of choosing and enrolling in a Part D plan or switching to another, the all-important question of continuing to receive Extra Help from year to year, and what to do if you’re denied or lose eligibility for Extra Help.

This chapter explains the Extra Help program as it works in the 50 states and the District of Columbia. Similar but different assistance is available in Puerto Rico, the U. S. Virgin Islands, and other American territories.

For information and help in Puerto Rico, call the Medicare Platino program at 866-596-4747.

In the U. S. Virgin Islands, call the Department of Human Services at 340-774-5265 (St. Thomas/St. John) or 340-773-2323 (St. Croix).

For contact information for other U. S. territories, call Medicare at

800-633-4227.

Understanding the Value of Extra Help

Millions of people in Medicare have been able to save many hundreds or even thousands of dollars a year on their drug bills under the Extra Help program. Even more crucially, Extra Help has allowed many folks who didn’t previously have any drug coverage to fill all the prescriptions they need for the first time. For them, Extra Help has been a godsend.

At the same time, there are many who aren’t much better off with Extra Help than they were before — and a few who may be worse off. People enrolled in Medicaid are automatically transferred to Part D for their drug coverage when they join Medicare. Those in states that require Medicaid recipients to pay small co-pays for their prescriptions won’t see much difference in their out-of-pocket expenses under Part D. However, people who are used to getting their meds completely free from their state’s Medicaid program should expect to have small co-pays for the first time.

Is there much red tape to go through? Compared to many assistance programs, Extra Help is easy to get into. Some people qualify automatically and don’t have to apply. Others must apply, but navigating the application is fairly straightforward. On the other hand, after you’re in the program, you may have some hoops to jump through in choosing and joining a drug plan and, when you’re in a plan, getting all the meds you need. Also, no question, people who receive Extra Help one year but don’t qualify the next face big disruptions. I cover these specific topics later in this chapter.

But first, you need to know how you can qualify for Extra Help and, if you do, how it can help pay for your medications. Extra Help benefits are available at five levels, mainly according to income. Table 5-1 explains these levels at a glance.

Table 5-1 The Different Levels of Benefits in Extra Help

(Based on Income and Savings in 2008; Costs for 2009)

Medicaid benefits and live in an institution,

Such as a

Nursing home

2 Full $0 $0 $1.10 for $0 Automatic

Medicaid generics;

Benefits $3.20 for

And a brand -

Yearly name

Income drugs

No higher

Than

$10,400

(single) or

$14,000

(married couple)

3 Full $0 $0 $2.40 $0 Automatic

Medicaid generics;

Benefits $6.00

And brand -

Income name

Higher drugs

Than in level 2; Or Supplementary Security Income; Or Your state

Pays your Medicare premiums

(continued)

Table 5-1 (continued)

Level If You Monthly Annual Co-Pay Cata- Eligibility

Have Premium Deductible per Pre – strophic Medicare scripttion Coverage

And also: Co-Pay

4 Yearly $0 $0 $2.40 $0 Must

Income generics; apply

No higher $6.00 than brand -

$14,040 name

(single) or drugs

$18,900 (married couple) and value of assets no higher than $7,790 (single) or

$12,440

(married couple)

5 Yearly Percentage $60 Up to 15% No more Must

Income of plan’s of the cost than $2.40 apply

No higher premium of each for generics

Than according prescrip- or $6.00

$15,600 to income tion after for brand -

(single) or meet- name

$21,000 ing the drugs or

(married deductible 5% of the

Couple) cost

And value of assets no higher than

$11,990

(single) or

$23,970

(married couple)

Source: Centers for Medicare & Medicaid Services.

Checking out examples of Extra Help at work

Here are some examples of how Extra Help works in practice (at 2009 rates):

Louisa is very frail and lives in a nursing home. The little income she has from Social Security goes to Medicaid, which pays her costs in the home, leaving her a small allowance for personal needs. The full price of her medicines runs to $370 a month. But because she gets Medicaid and lives in an institution, she automatically qualifies for maximum Extra Help (Level 1) and pays nothing for her prescription drugs.

Edward and Sue’s combined income is $12,750 a year, and they get medical benefits from their state Medicaid program, so they qualify automatically for full Extra Help under Level 2. The total, joint cost of their drugs is $550 a month. Under Extra Help, Edward’s four brand-name drugs and two generics cost him $15 a month ($3.20 x 4 = $12.80; $1.10 x 2 = $2.20). Sue’s one brand-name med and six generics cost her $9.80 a month ($3.20 x 1 = $3.20; $1.10 x 6 = $6.60). Together, their monthly out-of-pocket expense is $24.80, saving them $525.20 each month, or $6,302.40 over the year.

Cora has many health problems, and the meds her doctor prescribes add up to $1,220 a month, or $14,640 over the year — unafford-able for her without Extra Help. Because her state pays her Medicare Part B premiums, she qualifies automatically for full Extra Help at Level 3. She uses four brand-name drugs (including an expensive one for cancer) and four generics regularly. Her out-of-pocket

Cost is $33.60 a month ($6.00 x 4 = $24.00; $2.40 x 4 = $9.60) for the first five months of the year. But then, because her drug costs are high, catastrophic coverage kicks in, and from June through December, she pays nothing. Over the whole year, her total expense is $168 ($33.60 x 5), and she saves $14,472.

Carlton is a widower with an income that entitles him to partial Extra Help (Level 5). He pays half ($14) of his Part D plan’s regular monthly premium, a $60 annual deductible, and 15 percent of the cost of his drugs. At full price, his drugs would cost $350 a month, or $4,200 over 12 months. Under Extra Help, they cost $52.50 a month (15 percent of $350). His total out-of-pocket expense over the year is $858 ($14 x 12 = $168 in premiums + $60 deductible + $630 share of drug costs). He saves $3,342 over the year.

These examples reflect the 2009 maximum co-pays set in law. People receiving Extra Help can’t pay more than these amounts. But in some Part D plans, they may pay less. For example, if a plan normally charges nothing for certain generic drugs, Extra Help enrollees in that plan don’t pay anything for them either. (So if Cora were in a plan like this, she’d get her four generics free and save $48 more over the year.) And if a plan has no deductible, people receiving partial Extra Help receive coverage right away and don’t have to pay their reduced deductible. (So Carlton would save a further $60 in a no-deductible plan.)

From Table 5-1, you see that

People who receive full Medicaid benefits And Live in nursing homes or other types of institutionalized long-term care (Level 1) automatically qualify for full Extra Help and pay nothing for their medications.

People who receive benefits from Medicaid or some other government programs that pay their Medicare premiums or provide supplemental income (Levels 2 and 3) automatically qualify for full Extra Help and pay a small amount for prescriptions.

Others who aren’t enrolled in any of these programs but whose monthly incomes are still below certain dollar amounts (Levels 4 and 5) must apply for Extra Help.

People in Levels 4 and 5 have their assets (mainly savings), as well as their incomes, taken into account to qualify for Extra Help.

People in Level 4 receive full Extra Help benefits and pay the same co-pays as those in Level 3, but don’t qualify automatically. They must apply for Extra Help.

People in the highest qualifying income group (Level 5) receive "partial" Extra Help. They pay a share of their plan’s premium on a sliding scale according to income, a reduced annual deductible (about one-fifth of the regular Part D deductible), and up to 15 percent of the cost of each prescription.

People in Levels 1, 2, 3, and 4 pay nothing for catastrophic coverage, which kicks in after their drug costs reach a certain level in the year ($4,050 in 2008; $4,350 in 2009). People in Level 5 have small co-pays after getting to that level. Everything the government contributes toward prescription costs through Extra Help counts toward the spending limit that triggers catastrophic coverage.

Everybody, at all five levels, gets full drug coverage throughout the year. Nobody receiving Extra Help has to face the dreaded doughnut hole.

Income and asset limits increase every year. The Social Security Administration announces the new amounts in February or March, and they become effective immediately. These limits are higher in some circumstances — if you live in Alaska or Hawaii, have dependent relatives living with you, or have some earnings from work that aren’t counted. Any of these situations may give you a better chance to qualify for Extra Help than the income and asset limits in Table 5-1 suggest.

Extra Help co-payments (and the amount of the deductible for people in Level 5 who receive the partial benefit) increase at the beginning of each calendar year and remain the same for that whole year.

Qualifying Automatically for Extra Help

—35x You qualify automatically for Extra Help — without having to go through the process Llll 1 Of applying for it or answering any questions about your income and savings — if " you’re in Medicare and also receiving any of the following government benefits:

Medicaid: This is the program in your state that provides healthcare benefits for people whose incomes are below a certain level. The program is generally known as Medicaid but may have other names in different states — for example, MediCal in California, MassHealth in Massachusetts, and TennCare in Tennessee. If you’re in Medicaid, you get Extra Help as soon as you become eligible for Medicare (Chapter 1 explains the eligibility rules). Or, if you’re already in Medicare, you’d get it if and when you qualify for Medicaid.

Supplementary Security Income: SSI is a federal program that provides monthly payments to people in certain categories (blind, disabled, or 65 and older) whose incomes are very low.

Medicare savings program: Three Medicare savings programs (officially designated QI, SLMB, or QMB) give varying help to people with low incomes and few resources to pay for the out-of-pocket costs of Medicare. If you’re in any of these programs, your state pays your Medicare Part B premiums (see Chapter 1 for Part B information).

Medicaid medical spend-down programs: Some states have a system that allows people whose incomes are above the state limit for Medicaid to become eligible for it when their out-of-pocket medical expenses reach a certain level in a calendar year. If you’re receiving Medicaid in one of these medical Spend-down Programs, you automatically start getting Extra Help for drug coverage as soon as you become eligible for Medicare. Or, if you’re already in Medicare, you qualify for Extra Help as soon as your medical spend-down reaches the point of putting you in Medicaid. After you’re in the Extra Help program, you’ll continue to receive its benefits until the end of the calendar year. (See the later section "Determining Whether You’ll Qualify for Extra Help All Year and Next Year" for more about these programs.)

Jargon alert: People in any of these programs are known as Dual eligibles In Medicare lingo, because they qualify for help from both Medicare and Medicaid.

If you automatically qualify for full Extra Help, Medicare should send you a letter telling you so. If you don’t receive this notice but are in one of the previously listed programs, call Medicare at 800-633-4227 to find out why.

Be aware that qualifying for Extra Help, even automatically, is only one step in the process. You still have to join a Part D private plan to get prescription drug coverage. You can sign up for a plan of your own choosing — but if you don’t do so, Medicare will pick one and enroll you in it, even though that plan

May not be ideal for you. You’ll find more details about this in the section on choosing a plan later in this chapter.

It could happen that you qualify for Extra Help only after you’ve been in the regular Part D drug program for some time — for example, if your situation changes and you suddenly become eligible for Medicaid, Supplementary Security Income (SSI), or your state’s Medicare savings program. But be aware that it can often take months before the various government agencies get their paperwork sorted out and confirm your eligibility.

You have the right to be reimbursed for the money you spent on drugs dating back to the day you applied for Medicaid, SSI, or the Medicare savings program. Your Medicare drug plan must return the difference between what you would’ve paid under Extra Help rules during this period and what you actually paid. But you can’t rely on your plan to automatically refund that money to you. Instead, you should contact the plan and ask for the appropriate refund, explaining the circumstances. If you still don’t get the money, call Medicare at 800-633-4227 and report it. Or, if necessary, file a grievance against the plan, as covered in Chapter 19.

Applying for Extra Help

Perhaps your income and resources are limited but you’re not enrolled in one of the programs that qualify you for Extra Help automatically, as I explain in the previous section. In this case, you need to Apply For Extra Help. You can apply at any time — when you first join Medicare; when you lose a job, become widowed or divorced, or experience any other change that lowers your income; or if you’re already in Part D and have only just realized that you may qualify for Extra Help.

Applying involves filling out a form and sending it to the Social Security Administration (not Medicare), which will then decide whether you qualify. I walk you through the process in the following sections.

Obtaining an application form

You must apply for Extra Help in writing on the official printed form or online on the Social Security Web site. Don’t use a photocopy or a form printed from the Web site — these can’t be scanned by computers, so they’ll just delay your application.

You can obtain a form in any of the following ways:

F By mail (without requesting it): You’re likely to receive an Extra Help application in the mail soon after you sign up for Medicare. Social Security seems

To send them out to virtually all new beneficiaries, even people who are still working and earning far more than the Extra Help income limits.

F By phone: Call Social Security toll-free at 800-772-1213. (If you’re hard of hearing, call the TDD number at 800-325-0778.) Tell the representative that you want to apply for Extra Help to pay for Medicare prescription drug costs. You can ask for the form (in English or Spanish) to be sent to your home, or you can arrange to pick one up at your nearest Social Security office.

F Online: Go to Www. ssa. gov and click "Medicare" on the top panel, then click "Apply for help with prescription drug costs." You can use this form to apply directly online, but only in English. Before downloading the application form, it’s helpful to click the link headed "How the Online Application Works." This page explains the process, including instructions on how you can save your work so you can leave the form partially completed and return again later.

You Can’t Print out the form and mail it in — but a printout may be useful for a practice run before you make the proper application. (For more information about applying online, see the later section "Signing and sending in the application.")

F In person: You can obtain a form (and help filling it out, if you need it) at your local Social Security office or State Health Insurance Assistance Program (SHIP) office. (To make an appointment at a Social Security office, call 800-772-1213. To call your SHIP, see the contact info in Appendix B at the end of this book.) Forms are also sometimes available in pharmacies, doctors’ offices, and senior centers.

Helpful tips for filling out the application

The Extra Help application contains four pages of questions, mainly about your income and savings. I provide tips for answering them in the following sections.

Don’t panic if you can’t answer all the questions! Answer as many as you can and send in the form. Someone from Social Security will be in touch to help you complete it. However, if you apply online, you must answer every question before you can submit the form.

Getting instructions

You can get detailed instructions in English and 15 other languages (Arabic, Armenian, Chinese, Farsi, French, Greek, Haitian-Creole, Italian, Korean, Polish, Portuguese, Russian, Spanish, Tagalog, and Vietnamese) by calling Social Security or by visiting its Web site. If you want these instructions mailed to you, ask for form SSA-1020B-INST plus the language you need. But you must fill out the actual application in English or Spanish only.

Gathering information you need

^lM3Eft Before you start, pulling together some information is useful. This info

Includes your Social Security number and recent financial records relating to any earnings, pensions, savings, life insurance, and investments you may have. You need to refer to these records to answer questions about your income and savings. You do Not Have to send in any documents to support what you say about your finances, but that doesn’t mean you can be untruthful! Social Security will likely compare what you say with information from tax records and other government sources.

Single or married status

Income levels are for either single people or married couples "who are living together." If you’re married and living with your spouse, you can both apply on the same form. If only one of you is applying, you still have to provide your spouse’s income and resources. You count as single if

F You’re married but living apart.

F Your spouse is living permanently in a nursing home or another type of long-term care.

F You have a domestic partner or are in a common-law or same-sex marriage.

If you’re not sure whether you count as single or married for this purpose — for example, if it isn’t clear that your spouse will be in a nursing home permanently — call Social Security for clarification.

Income

The income limits for qualifying for Extra Help go up slightly each year and are announced in February or March. The application form doesn’t actually say what these dollar limits are, mainly because they’re somewhat flexible. For example, the limits are higher if you

F Have relatives living with you who depend on you for at least half of their support

F Live in Alaska or Hawaii (where the cost of living is higher than in other states)

F Have some earnings that aren’t counted as income

F Have certain expenses related to disability that allow you to work

Otherwise, if none of these circumstances are applicable, the upper income limits in 2008 and the early part of 2009 are $15,600 a year for a single person and $21,000 a year for a married couple living together.

You should include the following as income:

F Pretax wages or earnings from self-employment

F Social Security or Railroad Retirement benefits, Before Deductions

F Veterans benefits

F Pensions and annuities

F Workers’ compensation

F Net income from rental property

F Alimony

F Payments from anyone (other than a government agency) to help pay for certain household expenses, as explained later in this chapter

You can leave out the following:

F Cash or credit acquired from a loan or through a reverse mortgage

F Federal income tax refunds and earned income tax credit payments

F Victim’s compensation

F Education grants and scholarships

F Help from food stamps or Meals on Wheels

F Help from a housing agency, energy assistance program, or public relocation program

F Help paying for medical treatment and drugs

F Disaster assistance

If you’re not sure whether you qualify for Extra Help because your income may be a bit over the top, it’s still worth applying. Social Security doesn’t count every dollar of income toward the limits, so you may find that you qualify after all. Also, remember that the income limits increase a little each year in February or March. You can find updated levels by calling Social Security or Medicare or by going to the chart in Section 3 of "Your Guide to Medicare Prescription Drug Coverage," available online at Www. medicare. gov/ Publications/Pubs/pdf/1110 9.pdf. You can apply for Extra Help at any time, so if a new level suddenly brings your income within the limits, you can apply at once.

Assets

Assets (also called "resources") are the value of certain things you may own, mainly savings. The upper limit of this value increases from time to time. In 2008 and early 2009, it’s $11,990 for a single person and $23,970 for a married couple living together.

You should include the following as assets:

F Bank accounts, including checking, savings, and certificates of deposit F Proceeds of a loan if saved beyond the month they are received F Cash kept at home or anywhere else F Individual retirement accounts (IRAs) and 401(k)s F Stocks and bonds F Mutual funds

F Real estate (other than your primary home)

You can leave out the following:

F Your primary home and the land it stands on F Your vehicle(s)

F Personal possessions, including jewelry and furnishings F Property you need for self-support, such as land used to grow your own food F Burial plots

F Up to $1,500 (or $3,000 for a married couple living together) of the cash value of life insurance policies

Social Security rules for Extra Help don’t prevent you from spending down or giving away some of your savings to reduce them below the asset limit. Only what you have during the month you apply is counted. However, bear in mind that spending down may affect your eligibility for other assistance programs — especially Medicaid, which has strict rules about this — if you should need them within a few years.

Life insurance

The Cash value Of a life insurance policy means the amount you’d receive if you cashed it in right now. This is less than the Face value Of the policy, which is what you’d receive if it went to term. Most people have no idea what their policies’ cash value is, you’ll probably need to call your insurer to find out. Some types of life insurance — such as policies that can’t be cashed in before they come to term, or burial insurance where the benefit can be used only for funeral expenses — don’t count as assets. Note: Starting in 2010, life insurance will no longer count as an asset under Extra Help.

Funeral expenses

The application asks whether you expect to use money from your savings or investments to pay for funeral or burial expenses. Answering "yes" simply means you expect to do so, not that you have some amount ready and waiting for that purpose. Answering "no" will reduce your asset limit for qualifying for Extra Help by $1,500 if you’re single or $3,000 if you’re married and living together.

Dependent relatives

If you have any relatives — related to you by blood, marriage, or adoption — who live with you and depend on you (or your spouse) for at least half of their financial support, be sure to answer the question on household size. Every extra person raises the income limits and increases your chances of qualifying for Extra Help.

Help toward household expenses

The application asks whether anyone else (other than a government agency) helps you pay for food, mortgage, rent, heating fuel or gas, electricity, water, and property taxes. If you answer "yes," a part of the amount you specify will count as income. For example, if you live with someone who pays all these expenses each month, you’d add the amounts together and divide by the number of people in the household — then subtract from the total any contribution you normally make. The result is the amount you report on the application. Social Security will decide what portion of that amount would count toward your income. You don’t have to show proof of such help. Note: Starting in 2010, this assistance will no longer count as an asset under Extra Help.

Getting a hand with applying

Many circumstances — like being sick or recently widowed, to name just two — may make you feel that dealing with this application on your own is beyond you at this time. In that case, don’t hesitate to get help. All sorts of people can lend you a hand in applying:

F Someone you know: Anybody can help you fill out the application, or even apply on your behalf — a family member, a friend, a legal representative, a social worker, or anyone you choose to act for you.

F Free, expert personal help: Counselors at State Health Insurance Assistance Programs (SHIPs) are specially trained to personally assist people in sorting through their Part D options, including helping them apply for Extra Help or applying on their behalf. For the number of your local SHIP, see Appendix B at the end of this book.

F Help from Social Security: If you’re filling out the application on your own and need help on how to answer specific questions, you can call Social Security at 800-772-1213 (or the TDD number at 800-325-0778 if you’re hard of hearing) or visit your local Social Security office.

F Community groups: You may be a member of a church, senior center, or other community group that can assist you in filling out the form. If English isn’t your first language, an organization or group for people of your own nationality may be especially helpful in this regard. (Also, see Appendix B for sources of help in other languages.)

Signing and sending in your application

Signing the form means you’re legally declaring that all the information you’ve given is true to the best of your knowledge. If you’re married and living together, your spouse must also sign the application, even if he or she isn’t applying for Extra Help at this time. If someone else signs on your behalf, that person should complete the section provided on the form for his or her name, address, and personal or professional relationship to you. Then you can submit the form by

F Using the printed application form: After you’ve completed and signed the form, just put it in the preaddressed envelope and mail it in. If the envelope is missing, send the form to the Social Security Administration, Wilkes-Barre Data Operations Center, P. O. Box 1020, Wilkes-Barre, PA 18767-9910.

F Applying to Social Security online: Go to Www. ssa. gov and click "Medicare" on the top panel. Then click "Apply for help with prescription drug costs." Remember to look at the instructions, as explained in the previous section "Getting an application form," before filling out the form. You must answer all the questions before signing the form electronically and submitting it.

F Applying on the BenefitsCheckUp Web site: You can apply for Extra Help at Www. benefitscheckup. org using the same Social Security online form. The advantage of going this route is that the site automatically screens your information and lets you know whether you qualify for other benefits to help pay for prescription drugs and other living expenses. (I give more information about this Web site in the later section "Looking for help to pay other expenses.")

Knowing what happens next

So you’ve sent in your application and crossed your fingers, waiting for a decision. What happens next?

F Social Security should send you a notice saying it has received your application and is processing it. If you don’t receive this notice within a couple weeks of applying, call Social Security to let it know you sent in an application for Extra Help, just in case your form has gone missing.

F You may hear from Social Security by phone or mail if it has additional questions. The agency will contact you if your application is incomplete or if some of your financial information doesn’t match other government records, for example.

How do you know that the person on the end of the line is actually from Social Security and not just some scam artist trying to steal your Social Security number and financial data? If the call is legitimate, the person

Won’t normally ask for your Social Security number — unless the one you’ve given on your application appears incorrect — or for your credit card or bank account numbers. If you have any suspicions, hang up and call Social Security right away to check that the call was really from someone in that agency. (For more tips on avoiding scams, see Chapter 11.)

F You may receive what’s called a "Pre-Decisional Notice" saying that your application is likely to be turned down. This document specifies what information on your application will cause you to be denied — for example, that your income is too high or that your assets are above the limit. If this information is wrong, receiving the notice allows you time to correct it. You must do so within ten days of the date of the notice, by calling or visiting your local Social Security office at the number or address given on the notice.

F Social Security will decide whether you’re eligible for Extra Help. You

Should hear within 60 days of Social Security receiving your application, maybe sooner. You’ll receive either a "Notice of Award" saying that you qualify for either full or partial Extra Help (see the earlier section "Understanding the Value of Extra Help" to find out how to tell the difference) or a "Notice of Denial" saying that you don’t qualify.

If you’re told you don’t qualify, you can appeal the decision, as explained in the later section "Taking Action if You’re Denied or Lose Your Eligibility for Extra Help." That section also looks at alternative ways of reducing costs outside of Extra Help.

Figuring Out Whether Extra Help Affects Other Assistance

You may hesitate about Extra Help if you think it may cause you to lose or reduce other benefits you’re receiving. Sometimes it can, but maybe not to your disadvantage. The money you save through Extra Help should far outweigh reductions in other benefits. In other words, you end up better off and with more cash in hand, even if you receive less in other assistance. Take a look at these situations:

F Food stamps and housing assistance: Medical expenses are taken into account in receiving food stamps and government housing subsidies. So if you pay less for your drugs under Extra Help, your food stamps will be reduced, and you’ll pay a larger share of your subsidized rent. But you’re still likely to be better off.

Here’s an example: Sarah was paying $400 a month out of pocket for her prescription drugs before joining Medicare. But when she began receiving Extra Help, her monthly drug expenses dropped to $40. This meant losing $40 in food stamps. And under the formula used by her housing

Assistance program to calculate her new benefit — Not A dollar-for-dollar reduction — she paid $108 more in rent. But what she saved on medicines ($360) was more than her extra expenses for food and rent ($148). Overall she saved $212 a month, making her $2,544 better off over the year.

F Home heating/cooling assistance: Eligibility for the Low-Income Home Energy Assistance Program is based on income, without regard to medical expenses. So Extra Help does Not Affect it.

F Supplementary Security Income (SSI): Medical expenses aren’t taken into account in calculating eligibility for SSI. So even though Extra Help reduces what you spend in drugs (effectively giving you more cash in hand), you’ll continue to qualify for SSI.

Choosing a Drug Plan, Signing Up, and Switching Plans

Qualifying for Extra Help is just one step in the process. You still have to be in a Medicare drug plan to get coverage for your drugs. If you qualify for Extra Help Automatically And don’t immediately sign up for a Medicare drug plan on your own, Medicare enrolls you in one. Medicare does this to make sure you continue to get your medications, especially if you’re being moved from Medicaid to Medicare for your drug coverage. Medicare may sign you up with a plan a month or two before you’re switched from Medicaid to Medicare — a move that’s intended to ensure your details are entered into the computer system and that everything will go smoothly at the pharmacy. (If it doesn’t go smoothly, you have a right to a 30-day supply of drugs to tide you over, as explained in Chapter 14.)

However, Medicare enrolls Extra Help people in plans at Random. This is the computerized version of taking your name out of a hat and matching it to the name of a plan taken out of another hat. In other words, there’s no effort to put you into a plan that suits your needs, or even to ensure that the plan you’re assigned to actually covers your drugs. So you may find yourself in a plan that’s not ideal for you — unless you take action and choose a plan for yourself. You can switch to another plan immediately or whenever you want to, as explained in the next section.

You have the right to enroll in a Medicare drug plan of your own choosing — and you should do so by comparing plans carefully according to the drugs you take — just like anyone else (see Chapter 10 for details). But you should know about some details specific to Extra Help. I give you the nitty-gritty in the following sections.

What were they thinking. . . when they created the asset test?

Well over 2.5 million people on Medicare have incomes limited enough to qualify for Extra Help — yet fail because of the asset test. Not surprisingly, many feel the test is deeply unfair because it penalizes those who, despite limited incomes, have managed to save a small nest egg toward their retirement.

Medicare never had any type of asset test before Part D began in 2006. But Congress created the test for Extra Help as a cost trade-off — without it, the program would’ve cost $35 billion more.

Lawmakers in favor of the test pointed out that other assistance programs, such as Medicaid, have long taken people’s assets into account when deciding eligibility. Nonetheless, consumer advocates have consistently lobbied against the Extra Help asset test from the beginning, and some members of Congress are working to eliminate it or raise its limits so that more people with low incomes can qualify.

Before you choose: Realizing that some plans may cost you more than others

In the earlier section "Understanding the Value of Extra Help," I point out that full Extra Help entitles you to a zero premium. But there’s a catch. You can get that benefit Only If you join a plan with premiums below a certain dollar amount.

JrtNG/ Under Medicare rules, you don’t pay a premium if you’re in a plan with a premium that’s generally below the average of all plan premiums in your region in any given year (see Chapter 3 for an explanation of premiums). But if you join a more expensive plan — one with a premium above that regional average — you have to pay the difference between the average premium and the full premium. For example, if the average premium in your region is $30, and the premium in the plan you join is $37, you’d pay $7 each month for your drug coverage. (This rule doesn’t affect your low-cost Extra Help co-pays for prescriptions — they remain the same.)

This regional average (which bureaucrats call the Benchmark) Changes every year. That’s why, each fall, Medicare sends letters to some Extra Help beneficiaries, warning them that if they stay in the plan they’re in for the following year, they’ll no longer be able to claim zero premiums, or in some cases, the letter tells them they’ve been automatically switched to a new plan that has zero premiums. So be sure to read any letters that come from Medicare or your plan during the fall (September to November) so you’re not caught off-guard in January having to pay a premium you didn’t expect.

Finding a plan with the premium you want and the drugs you need

In general, the process of comparing plans to find the least expensive one that covers all or most of your drugs is the same in Extra Help as it is for folks in the regular Part D program, as explained in detail in Chapter 10. But there are some differences, depending on whether you’re receiving full or partial Extra Help.

Using an online comparison tool if you’re getting full Extra Help

Under full Extra Help, your co-pays (being set in law) are the same under any Part D plan. But the premium you pay depends on whether you choose a plan with a premium above or below the regional average, as explained in the preceding section. How can you tell which plans have these higher or lower premiums?

Fortunately, you can see this information at a glance on Medicare’s online Prescription Drug Plan Finder. (If you don’t have access to the Internet, you can get the same info in other ways, which I explain later in this chapter.) Before using the plan finder, you may want to look at the step-by-step instructions given in Chapter 10 on how to navigate it. Here are the variations if you’re on full Extra Help:

1. Go to Www. medicare. gov and click "Medicare Prescription Drug Plans." Then click "Find and Compare Plans," and then "Begin General Search."

2. Type in your zip code and answer the questions — in particular, the ones at the bottom of the page that establish what kind of Extra Help you qualify for.

3. Enter the names of all of your drugs, plus their dosages and how often you take them.

You’ll then see a list of drug plans, starting with the least expensive.

4. Look under the Monthly Premium column to the right of each plan’s name.

A zero dollar amount means you won’t have to pay a premium under that plan. A dollar amount shows what part of the premium you’ll pay if that plan’s premium is above the regional average. Click the name of any plan to see its details — in particular, whether it covers all of your drugs.

Using an online comparison tool if you’re receiving partial Extra Help

If you receive partial Extra Help, you pay 15 percent of your drugs’ full price under any plan. And your premium is a percentage of the plan’s regular premium — such as 25, 50, or 75 percent — calculated on a sliding scale according to your income. How can you tell what you’ll pay for drugs and premiums under any given plan?

Again, you can use Medicare’s online plan finder to see instantly how much you’ll pay for your drugs. (You may want to look at the step-by-step instructions in Chapter 10 on how to navigate it though.) Go to Www. medicare. gov and follow the steps outlined in the preceding section. But when you’re asked in Step 2 whether you receive full or partial Extra Help, click "Partial." After you’ve entered the names of your drugs (plus their dosages and how often you take them — this is important in determining the price), you’ll see the list of plans in descending order of out-of-pocket expense. The premium you see given for any plan is what you pay, according to what percentage of the regular premium your partial Extra Help entitles you to. Click a plan’s name to bring up its details, and you’ll see what you’d pay for each of your drugs under that plan. This price is 15 percent of the plan’s full price. In other words, your premium and co-pays for drugs are automatically calculated for you.

Comparing plans if you don’t have Internet access

Comparing plans carefully is so important that this would be a good time to ask a relative or friend who’s savvy about computers to search the Medicare plan finder for you. Or you can get the same info in the following ways:

F By phone: Call the Medicare help line toll-free at 800-633-4227. Tell the customer representative that you’re qualified for full or partial Extra Help and give the names of your drugs, plus their dosages and how often you take them. (If you’re on full Extra Help, say whether you want only plans that will accept you for a zero premium or whether you’re willing to consider paying your share of a premium for more expensive plans. You can also ask for a full list of plans that won’t charge you a premium.) Ask for printouts of the most suitable three or four plans to be sent to you.

F In person: Counselors at your local State Health Insurance Assistance Program (SHIP) can help you find the plan that suits you best. To find your SHIP phone number, see Appendix B at the end of this book.

Moving forward if no affordable plan covers all of your drugs

Medicare doesn’t cover all medications. Some Part D plans cover most drugs that Medicare has approved and even some that Medicare doesn’t pay for, as explained in Chapter 4. But these are mostly "enhanced" plans that have higher premiums. In general, the lower-premium plans cover fewer drugs — and some of these plans cover brand-name drugs Only If they have no lower-cost, generic equivalents. So some people on Extra Help who are seeking less expensive plans — especially those needing a zero premium — may find themselves without access to some of the drugs they need.

This won’t necessarily happen to you — it all depends on the drugs you take. But if you do find yourself in this situation, what can you do? Consider these options:

If you’re receiving Medicaid, your state may pay for the drugs your Part D plan doesn’t cover, or even those that Medicare doesn’t cover. To find out, and to get help applying, call your State Heath Insurance Assistance Program (SHIP). (See Appendix B for contact numbers.)

If you’re in a State Pharmacy Assistance Program (SPAP), it may pay for drugs your Part D plan doesn’t cover. Contact the program to find out. (I cover these programs in more detail later in this chapter.)

Ask your doctor whether switching to a similar drug (or drugs) that your plan Does Cover would be just as effective for you. This may lower your co-pays as well as give you coverage, as explained in Chapter 16.

You have the right to ask the plan to cover a particular drug — by requesting an exception to the plan’s rules — if your doctor considers it necessary for your medical condition, as described in Chapter 4.

You can choose to pay an extra share of the premium of an "enhanced" Part D plan that does cover all of your drugs.

You can switch to another plan that does cover all of your drugs. In Extra Help, you have the right to switch plans at any time of the year, as explained in the next section.

Joining and switching plans

Joining a plan is easy. After you’ve picked the plan of your choice, you can

Sign up by calling the Medicare help line at 800-633-4227 (877-486-2048 for

TDD users) or by visiting Www. medicare. gov, as described in Chapter 12.

But there are some things to keep in mind about switching plans. Unlike most folks in the regular Part D program, you won’t be limited to enrollment periods or locked into a Medicare drug plan for a whole year. Extra Help gives you the flexibility to join or switch to another plan at any time of the year. Table 5-2 shows when you can switch from one Part D plan to another, and when your coverage begins in different circumstances.

You need to compare plans carefully to find one that suits you to begin with so that you won’t want to change, unless it becomes necessary. Why? Because it’s possible that switching (and especially switching often) could cause any of these problems:

F It may take time for your new plan to be entered in Medicare’s computerized record system, which could cause delays in getting your meds at the pharmacy. (But see Chapter 14 for ways to avoid delays.)

F If you’ve requested and received from your present plan an exception that allows you to use a drug not on its formulary — or a prior authorization before the plan agreed to cover a drug — you may have to go through the same process again in the new plan.

F If you’re paying any premiums at all, and these are being taken out of your Social Security check, you may find yourself paying two premiums for a while — for both the old plan and the new one. Why? Because communication between Medicare (which knows you’ve changed plans) and the Social Security Administration (which cuts your checks) doesn’t always work as rapidly as it should. If this situation happens to you, call Medicare at 800-633-4227 immediately to complain.

An option to consider: Participating in a State Pharmacy Assistance Program

About 30 states have State Pharmacy Assistance Programs (SPAPs) in 2008, though over time new ones are introduced and others disappear. All help people whose incomes are limited (but too high to qualify for Medicaid) pay for prescription drugs. Some SPAPs have income limits above Part D’s Extra Help maximums and/or no asset tests.

Benefits vary a great deal among these programs. Some — including the long-established and excellent programs in New York (EPIC) and Pennsylvania (PACE and PACENET) — provide comprehensive services that wrap around Extra Help and offer additional benefits, as well as assisting many Part D

Enrollees who don’t qualify for Extra Help. Other SPAPs focus on drug assistance for patients with a particular medical condition (such as HIV-AIDS or cancer) or offer discount cards to use at pharmacies.

For details on SPAPs, go to Www. medicarerights. org/searchframeset. htm or Www. medicare. gov/spap. asp. You also can call 800-633-4227 and ask for a brochure to be mailed to you, or you can call your State Health Insurance Assistance Program (SHIP) for this information. (See SHIP phone numbers in Appendix B.)

Determining Whether You’ll Qualify for Extra Help All Year and Next Year

I’m going to assume that you didn’t just win the lottery or suddenly inherit great riches from some distant relative you’ve never heard of. So you’re hoping you’ll continue to get Extra Help throughout this year and next year too. The following sections explain the circumstances that can cause you to lose Extra Help (or get a lesser benefit) and how you’ll know where you stand for next year.

How you could lose Extra Help

In most cases, you’ll still receive Extra Help until the end of the year — once qualified, you’re likely to receive the benefit until midnight December 31 of the same year, regardless of whether your financial circumstances changed during the previous 12 months. But there are some exceptions. If any of the following marital events happen during the year, you’re expected to report them immediately so your eligibility for Extra Help can be reviewed:

F Your spouse dies.

F You and the spouse you’ve been living with start living apart, divorce, or have your marriage annulled.

F You and your spouse start living together again after being apart.

F You get married.

These events wouldn’t necessarily result in losing Extra Help during the year. In fact, they could mean that you qualify for More Extra Help than you received before, if your income reduces. Any benefit changes — whether a decrease, increase, or loss of Extra Help — take place the month after you report your new circumstances.

Continuing to get Extra Help Next Year, starting January 1, depends on whether you’ve become financially better off this year. You can lose Extra Help (or receive less benefit) next year if

F Your income rises above the limits for Extra Help

F The value of your savings and other countable resources rises above the asset limits for Extra Help

F You cease to qualify for one of the programs that makes you Automatically Eligible for Extra Help — Medicaid, SSI, having your Medicare premium paid by your state, or being in a state Medicaid spend-down program

Finding out where you stand

What will happen next year, and how you’ll find out, depends on how you qualified for Extra Help in the first place, as follows:

F If you qualified for Extra Help automatically: If nothing has changed — that is, if you continue to receive Medicaid or SSI benefits, or are still having your Medicare Part B premiums paid by your state — you don’t need to do anything. You’ll continue to receive Extra Help. If you no longer get help from any of these programs, Medicare will send you a notice (headed "Loss of Extra Help") saying that you no longer Automatically Qualify for Extra Help next year but that you can still Apply For it. An Extra Help application should be enclosed with this notice.

F If you qualified for Extra Help through a Medicaid medical spend-down program: As long as you continue to qualify for Medicaid benefits, you’ll still receive Extra Help. So if your medical expenses this year — for example, being in the hospital, going to the doctor, having lab tests, and so on — have been high enough to keep you on Medicaid at the end of the year, you’ll still get Extra Help next year. But if those medical expenses are no longer high enough to qualify you for Medicaid, then you’ll probably get a letter from Medicare saying you’ll no longer receive Extra Help starting January 1. However, even if you lose your Medicaid spend-down, you may still receive Extra Help automatically next year, depending on the timing of when you met your spend-down this year. If your name is in the system in July, when Medicare compiles its list of people automatically eligible for Extra Help next year, you’ll continue to receive Extra Help for all of next year.

F If you qualified for Extra Help by applying: In August or September, you may receive a letter and a form from Social Security asking whether your financial circumstances have changed. Not everybody receives this letter (which is headed "Review of Your Eligibility for Extra Help"), but if you do, you must fill out the form and return it to Social Security within 30 days. If you don’t return it, your Extra Help will end on December 31. Social Security reviews your information and will notify you, saying whether you’ll still qualify for Extra Help next year and, if so, whether your benefits will change. For example, if your income has gone down, you may get lower co-pays next year — or, if it has risen above a certain level, you may get "partial" instead of "full" Extra Help. Any changes will begin on January 1.

Taking Action if You’re Denied or Lose Your Eligibility for Extra Help

Being told "No — you don’t qualify" is a bummer. And it’s even more of a blow to lose Extra Help at the end of the year after you’ve already been receiving it. But in either event, you may still want to persist in getting Extra Help or exploring other ways to ease your expenses. The following sections explain some options.

Appealing a "no" decision

You can always appeal Social Security’s decision if you don’t agree with it. Here’s what to do, depending on whether you’ve been denied Extra Help or been told you’ll no longer be eligible next year.

If you’re denied Extra Help

You must appeal within 60 days of receiving a decision. (This deadline may be extended if you have good reason to miss it, such as being too sick to deal with it on time.) You can appeal in one of two ways:

F Request a telephone hearing. Call your local Social Security office or the SSA national help line (800-772-1213); or print an appeal request form from its Web site (Www. ssa. gov), fill it out, and mail it in. You’ll receive a letter confirming the date of your hearing and the number to call. (You can ask for a conference call if you want someone who’s helping you to be on the phone at the same time.) The letter also explains how to send in documents showing evidence that supports your case.

F Request a "case review." This means having a Social Security agent review your application and any additional information or evidence you’ve sent in, but without being able to present your case in person.

After Social Security has reviewed your appeal, you’ll receive a letter notifying you of the decision. If you win, you’ll receive Extra Help backdated to the first day of the month in which you originally applied for the benefit. If you lose, but still disagree with the decision, you can file a further appeal in a federal district court within 60 days of receiving the decision.

If you’re told that you’ll lose eligibility

Mistakes are often made in vast bureaucracies. So if you think you’ve lost eligibility by error or an unfair judgment, don’t hesitate to speak out. For example, if you’ve been told that you’ve lost your automatic right to Extra Help next year when you know you’re still enrolled in one of the programs that give you that right (Medicaid, SSI, having your Medicare premiums paid

0

BE*

By your state, or being in a Medicaid spend-down program), call Medicare at 800-633-4227 immediately. If you got Extra Help by applying and are now told — wrongly, in your view — that your income or assets are too high to continue receiving the benefit next year, you can appeal to Social Security by the procedures explained in the previous section. The notification letter you receive from Social Security should also explain the process.

In general, if you received Extra Help Automatically, You should contact Medicare to resolve problems. If you Applied For Extra Help, you should contact Social Security.

Getting Extra Help another Way

Even if you’re denied Extra Help or lose eligibility, you may still be able to get benefits in another way. Take a look at your options.

F If you lose your Automatic Right to Extra Help: You may still qualify by applying for it. The income and asset limits for Extra Help are higher than the qualification limits for Medicaid or SSI. You should apply as soon as possible after being notified that you won’t qualify automatically next year, following the procedures explained in the earlier section "Applying for Extra Help."

F If you applied for Extra Help but are denied or lose eligibility: One

Of the ways to qualify for Extra Help automatically is by having your Medicare Part B premiums paid by your state under one of the Medicare savings programs. The income and asset limits for eligibility vary state by state. But some may be a little higher than the limits for Extra Help, and some states don’t require an asset test at all. So if you’re denied Extra Help (or lose eligibility) because your income or assets are a bit over the top, you might consider applying for this assistance. There’s no guarantee that you’ll get it, because enrollment for these programs is often limited to the funds a state has available. But it may be worth trying — and if you get this state assistance, you’ll get full Extra Help automatically. Contact your State Health Insurance Assistance Program (SHIP) for information and help in applying.

F If you lose Extra Help but qualify again in the future: It may happen that you lose Extra Help on January 1, but become eligible again later in the year or in a future year. That’s possible if your income or assets once again dip below the limits, or if the new limits (which Social Security announces in February or March of each year) make you eligible again. As soon as this situation happens, you can again apply for Extra Help. Or, if you’re in a Medicaid medical spend-down program and lose both your Medicaid and Extra Help benefits on January 1, you may qualify for both programs again later in the year as soon as your expenses once again rise to the required level.

Seeking other help to pay for drugs

If none of the options in the preceding section work out, you may be able to get other kinds of help to pay for your medications.

F A State Pharmacy Assistance Program (SPAP): If your state has an SPAP, contacting it to find out whether you qualify is well worth it. These programs vary, but some of them give additional help to people of limited means who are enrolled in the Medicare Part D program — sometimes with income limits that are much higher than those required in Extra Help and with no asset tests. (For more details, see "An option to consider: Participating in a State Pharmacy Assistance Program" earlier in this chapter.)

F Private and local pharmacy assistance programs: Some companies that manufacture drugs, some national organizations for patients with certain medical conditions, some charities, and some local assistance groups offer help paying for drugs. For details on these, as well as other ways of reducing prescription costs, check out Chapter 16.

F Falling back on the regular Part D program: The costs are higher and the benefits aren’t nearly as generous as under Extra Help, but you’ll still have insurance and pay less for your drugs than being outside of Part D.

Looking for help to pay other expenses

If you can’t obtain help paying for drugs, consider other federal, state, and local or private programs that might lower your other daily living expenses. Many people with low incomes are entitled to help in paying for food, housing, utility bills, and taxes, and they often don’t even realize they’re eligible.

The best and quickest way to figure out whether you qualify for any of these programs is to go to Www. benefitscheckup. org. You don’t have to give your name. Just enter your zip code and answer questions about your income and circumstances. Details of all programs that you may be eligible for, and how to contact them, appear on the screen. These may include the Medicare savings programs and State Pharmacy Assistance Programs mentioned earlier in this chapter, among many more. If you don’t have computer access, you can get similar details from your State Health Insurance Assistance Program (SHIP; for contact info, see Appendix B).

Part II