Блог Анкара

In This Chapter

^ Checking out your membership card and other important info from your plan

^ Determining when your coverage begins

^ Getting organized — why keeping records pays off

■ XOu’re in. Medicare has confirmed your enrollment, and you’re going to Jt Get drug coverage under Part D. Whether that makes you feel elated, relieved, or wary, you’ve overcome the hurdle of making several important, and perhaps difficult, decisions. Congratulate yourself!

So what happens next? This chapter explains what to expect from your drug plan the first time out. I begin with the question of when your drug coverage actually starts, according to your circumstances. Then I describe what you’ll receive from your plan — namely, your membership card and a lot of important documents to read. I also explain what to do if you’re told you need to pay a late penalty. Finally, I clue you in on why keeping good records pays off in tracking your coverage and expenses, and in protecting yourself in case of disputes. Even if this isn’t your first time in a Medicare prescription drug plan, you may find some of this information helpful.

Knowing When Your Coverage Will Start

Can’t wait to get that drug coverage? It’s what you’ve signed up for, after all. You won’t have to wait long — less than one month in most cases. But your coverage doesn’t start until the date it becomes Effective, Meaning the very first day you can fill a prescription under your Part D plan, even if you receive your membership card in the mail before then.

When you’re joining a Part D plan for the first time, the date your coverage begins depends on the following circumstances:

You’re just coming into the Medicare program because you’re turning 65 or qualifying through disability.

You’re just coming into the Medicare program after a delay due to turning 65 while living abroad or in prison

You’ve received a special enrollment period because you lost your creditable drug coverage from an employer or some other plan, or because you recently came out of prison or have returned to the U. S. after a period living abroad.

You failed to join Part D when you were first eligible and now need to enroll in a drug plan during the annual enrollment period at the end of the year.

You qualify for Part D’s Extra Help because your income is limited. Table 13-1 shows when your coverage begins in all of these situations.

If you sign up for a plan during your initial Medicare enrollment period upon turning 65

On the first day of the month in which you turn 65, if you enrolled in the plan during the previous three months. Or on the first day of the month after enrollment if you signed up in the month of your birthday, or during the following three months.

If you sign up for a plan because of disability during your initial Medicare enrollment period

On the first day of the month in which you receive your 25th disability payment, if you enrolled in the plan during the previous three months. Or on the first day of the month after enrollment if you signed up in the month you received your 25th check, or during the following three months.

If you sign up for a plan during a special initial enrollment period due to turning 65 while abroad or in prison

Immediately after your return to the U. S. or your release from prison, if you enrolled in the plan during the previous three months. Or on the first day of the month after enrollment if you signed up in the month of your return or release, or during the following three months.

As you can see in Table 13-1, the longest you can wait to start coverage after enrollment is six weeks. And that’s only in one particular situation: if you delay joining Part D beyond when you were first eligible and need to wait for open enrollment at the end of the year. If you sign up on the first day of that period, November 15, your coverage starts six weeks later on January 1.

The shortest wait can be as little as one day. If you enroll in a plan on the last day of a month, your coverage becomes effective the first day of the following month — in other words, the next day. (However, I don’t advise cutting it that fine. Loading your coverage info into Medicare’s computer system takes a while, so enrolling at the last minute can cause delays when filling your first prescriptions, as explained in Chapter 14.)

Of course, if you’re already in Part D, your current coverage lasts until the end of the calendar year — midnight on December 31. If you decide to switch plans and sign up for another during open enrollment (November 15 through December 31), coverage in your new plan starts January 1. (See Chapter 17 for details about switching plans.) If you stay in the same plan, your coverage just rolls on through the following year.

Receiving Your Plan’s Card and Other Important Stuff You Need to Read

Soon after you enroll, your plan will send you a bunch of stuff through the mail. So watch for its arrival and get out your glasses! This is important information you must read — even if you’ve been in a Medicare drug or private health plan before. In the next several sections, I show you what to expect and check up on when you receive your plan’s membership card, its Evidence of Coverage document, and other information. I also touch on the form you should send back to the plan showing what other types of coverage you may have for prescription drugs or medical care. And I explain what to do if you’re told you need to pay a late penalty on your Medicare prescription drug coverage.

JfitBER You receive a membership card and information about coverage regardless ^ of whether you’re joining Part D for the first time, have just switched from

Jjljjl J one drug plan to another, or are remaining in the same plan you had last year. In this last situation, even though you don’t need to re-enroll, you still get a new card and Evidence of Coverage (EOC) document for the new year. That’s because some details of your coverage have likely changed since the previous year. (Your plan sends advance warning of any changes in its Annual Notice of Change [ANOC], mailed in the fall, and incorporates them in your new EOC document. So if you didn’t read the ANOC, be sure to read the EOC.)

The membership ID card: Your key to coverage

The very first mailing you receive from your new Part D plan is an acknowledgment of your enrollment request, which the plan must send you within ten calendar days of receiving it. This mailing also tells you when you can expect your coverage to become effective, as explained in the previous section. The plan sends your membership ID card either with this mailing or soon afterward, and you can start using it at the pharmacy as soon as your coverage begins.

BER If you don’t receive your card by the time your coverage starts, you can use what your plan calls its Proof of coverage To fill your prescriptions until your card arrives. This proof may be a copy of your enrollment form, the plan’s acknowledgment of your enrollment request, or a letter from the plan stating that you’re entitled to coverage, starting on the effective date. (See Chapter 14 on what to do if you encounter problems obtaining your prescriptions the first time out.) Note that Proof of coverage Isn’t the same as the Evidence of Coverage document, which may arrive either with your membership card or several weeks later.

When you receive your plan’s membership card, keep it safe. The card is your key to getting prescription drugs and letting your pharmacist know what you should pay, as I explain in Chapter 14. You need to present it at the pharmacy each time you fill a prescription. So keep it in your wallet. (If you were in a different Part D plan previously, destroy your old card — but be sure to do so only after your new coverage begins.)

In the following sections, I explain the details you need to check when you receive your card and give you pointers on how to keep track of different Medicare cards you may have.

Double-checking the details

HHJ ) Verify that the information on your card is correct. It should include W The plan’s name

W Your name and membership ID number W The plan’s customer service phone number(s) W The plan’s mailing address

Make sure this plan is the one you signed up for. If you’re not certain, take a look at your plan’s info packet (which it must send you soon after it receives your enrollment request, ideally before your coverage begins). You can also check the plan’s name and identification number that appears on your membership card against information in your Medicare & You Handbook or on Medicare’s online plan finder tool. Or you can call Medicare’s help line to check what kind of plan it is. If it turns out you’re enrolled in the wrong plan — for example, this plan’s a private Medicare health plan rather than the drugs-only plan you wanted — flip to Chapter 17 to find out what to do.

Playing your cards right

You may find yourself with several cards entitling you to different Medicare services. And sometimes it isn’t easy to see at a glance which card is which, or to remember what each is used for. It can be especially confusing if, for example, you have a prescription plan and a Medigap policy that are provided by the same insurance company, and its name appears on both cards.

Presenting the correct card when you show up at a doctor’s office or hospital, or use any other medical service, is critically important. That’s because the card tells your provider whom to bill. For example, if you’re in a Medicare private health plan, you must show the plan’s card and not your Medicare ID card. If by mistake you show your Medicare card instead, the provider will bill Medicare and not the plan. Medicare will then deny your claim, and you or the provider will have a lot of hassle sorting it all out. So it pays to know your cards and use them appropriately.

Here’s how to identify and use each of the Medicare cards you may have:

W Your red-white-and-blue Medicare ID card: Use this card to obtain medical services if you receive your health benefits through traditional Medicare. The card shows your name and Medicare ID number. It says whether you’re entitled to Medicare Part A, (hospital services) or Part B (doctor visits and other outpatient care), or both, as well as the date(s) on which your coverage became effective. The card also provides the phone number of the Medicare help line.

W Your Medicare private health plan card: Use this card (not Your Medicare ID card) to get medical services if you’re enrolled in a Medicare private health plan (such as an HMO, PPO, Special Needs Plan, Private Fee-for-Service plan, a Medicare Cost plan, or a Medicare Medical Savings Account; see Chapter 9 for details on these plans). If your plan includes drug coverage, you may be able to use the same card at the pharmacy when filling your prescriptions, or you may be given a separate card to use at the pharmacy, depending on the plan. Either way, the plan’s name, its identification number, and contact information appears on the card. So does your name and membership number.

W Your Medicare stand-alone prescription drug plan card: Use this card to get your prescriptions filled under Part D if you receive your medical benefits from traditional Medicare or a Medicare private health plan that doesn’t cover drugs (Medicare Medical Savings Accounts, as well as some Private Fee-for-Service plans and Medicare Cost plans). The card shows your name, your plan membership number, the plan’s name, its identification number, and its contact information. Your card likely has wording that indicates you’re entitled to Medicare prescription drug coverage. It may simply say PDP — initials that stand for Prescription Drug Plan, the phrase Medicare uses for stand-alone Part D plans.

W Your Medigap supplementary insurance card: Use this card to prove that you have separate insurance to help cover your co-pays for medical services when you’re enrolled in traditional Medicare. Show it every time you receive services from a doctor, hospital, or other provider. (Medigap insurance can’t be used to cover out-of-pocket costs in Medicare private health plans, as explained in Chapter 9. Nor can it be used for prescription drug expenses, as explained in Chapter 15.) The card shows your name and membership number, the name of the insurance company, its contact information, and the type of Medigap plan you have (marked with a letter of the alphabet, A Through L) — for example, MEDIGAP F.

Information about your plan: Your new bedtime reading material

Sooner or later (either together with your plan’s membership ID card or separately) you’ll receive a sizeable information packet that should include the following documents about your new plan:

W Evidence of Coverage: This booklet is your legal contract with the plan, so be sure to keep it in a safe place. It contains masses of stuff you can use for reference when you first join the plan and throughout the year. Here are some examples:

• Phone numbers: Call if you have any questions or problems.

• An explanation of how the plan works, its conditions, and its rules: This part lays out the plan’s responsibilities in giving you coverage and the rules you must accept. It shows the plan’s costs and benefits for this year, which may be different from those the same plan provided last year.

• Details of the plan’s benefits and costs: If this is a drugs-only plan, the Evidence of Coverage explains what the plan charges for different kinds of covered drugs. If it’s a Medicare private health plan, you’ll find this info, plus details of how much you’ll pay for every covered medical service, like doctor visits, hospital stays, and many more.

• An explanation of your legal rights if you have a complaint against the plan or disagree with a decision it makes: This section includes detailed instructions on how to file a complaint or make an appeal. (I cover the general process of doing both in

Chapter 19.)

W The plan’s drug formulary: The Formulary Is a list of all the medications the plan covers. It shows which drugs come with restrictions such as prior authorization, quantity limits, and step therapy. (I explain what these restrictions mean, and what you can do about them, in Chapter 4.)

W The plan’s pharmacy network: The Pharmacy network Is a list of all the pharmacies in your area that accept your plan’s card. This list shows which ones are Preferred Pharmacies (where your drugs may cost less) or Specialist Pharmacies (which stock special drugs, like those that are injected or require careful handling), as explained in Chapter 14.

W The plan’s provider directory: If your plan is a Medicare managed care plan (HMO, PPO, Special Needs Plan, or Medicare Cost plan), this Provider directory Is a list of doctors, hospitals, and other facilities in your area that are in the plan’s network and have agreed to treat its members.

W The plan’s service area: The service area is a list of all the zip codes that your plan (if it’s a Medicare managed care plan) covers.

Everything in your plan’s info packet is critical. If any of the items listed here are missing, call the plan and ask for them, according to your type of plan:

W If you’re in a Medicare managed care plan that covers prescription drugs, you need all these items. (Private Fee-for-Service plans and Medicare Medical Savings Accounts don’t have limited service areas or provider directories.)

W If you’re in a stand-alone plan that covers only prescription drugs, you just need the first three items on the preceding list.

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A form for disclosing other coverage: Your chance to put it all out there

Your plan’s packet includes a form asking whether you have other coverage for prescription drugs and/or medical care. The plan may have already requested this information on your enrollment form, as explained in Chapter 12, but the separate form in your info packet probably requires more details. Filling out this form and returning it to the plan as instructed are in your best interests.

The plan needs to know of other coverage so all of your benefits can be coordinated properly. This Coordination of benefits Means you don’t pay more than you should, and, in most cases, you don’t have to make separate claims, as explained in Chapter 14. So if you’re entitled to drug and/or medical coverage from any of the following, enter that on the form:

W A current or former employer or union (or COBRA insurance)

W The Veterans Affairs (VA or CHAMPVA) health program

W The Department of Defense (TRICARE)

W The Federal Employees Health Benefits program (FEHB)

W The Indian Health Service, a Tribal Health organization, or the Urban Indian Health Program

W A qualified State Pharmacy Assistance Program (SPAP)

W An individual health insurance policy

I explain each of these programs, and how they fit in with Medicare prescription drug coverage, in Chapter 6.

A late penalty assessment: Your price for missing your enrollment deadline

Not long after you enroll in Part D for the first time, you may receive a letter from your plan saying you need to pay a late penalty. This scenario should happen Only If you miss your deadline for joining Part D and go for more than 63 days without Creditable coverage — drug coverage that’s at least as good as Part D, such as you may have had from an employer or union. (If you haven’t the faintest idea what I’m talking about here, you need to read Chapter 6 to get familiar with creditable coverage and Chapter 8 to find out about the late penalty — and fast!)

How your plan decides whether you should be penalized

Every plan is responsible for finding out whether any new enrollees should have a late penalty. Plans can do so by obtaining the information from Medicare, making their own inquiries, or sending an Attestation form To new enrollees. If you receive this form, you have up to 30 days to respond and indicate whether you’ve had creditable coverage for drugs and, if so, where you got it from.

This is the time when any notices you’ve kept about former creditable coverage come in very handy, as covered in Chapter 6. However, if you’ve lost this proof, be aware that Medicare requires your plan to accept letters from any former employer or union confirming the creditable coverage you once had. So when you return your attestation form, be sure to add the name of and contact info for your former employer or union and, if possible, the dates when your creditable coverage began and ended so your plan can verify them. Or, if you prefer, you can ask the benefits department of your former employer or union to send you a similar letter, and you can attach a copy to your attestation form. (But be careful not to miss that important 30-day deadline for returning the form. Send it in on time, even if the requested letter hasn’t arrived.)

If the plan decides you have an unexplained gap in your drug coverage, it informs Medicare, and someone there does the math to work out the amount of your late penalty. The plan then notifies you of this amount and tells you how it was calculated (according to a formula I explain in Chapter 8).

How your plan may be wrong

What if your plan slaps you with a late penalty you don’t think you deserve? That’s a real curve ball. But your plan may have gotten it wrong. Here are some of the ways mistakes can happen:

W Your record of coverage hasn’t been verified due to computer glitches or other screw-ups in the system. People have occasionally received these letters after being in Part D ever since it began — and therefore couldn’t possibly deserve a late penalty! Gotta love technology.

W You had drug coverage but didn’t know it wasn’t creditable because the plan that provided it didn’t clearly inform you of this fact.

W During the time in question, you were living abroad or in prison and therefore couldn’t sign up for Part D. Provided you started receiving Part D coverage within one of the special enrollment periods granted after your return or release, as explained in Chapter 12, you shouldn’t face a late penalty.

W You went without creditable coverage for a certain length of time, but not for as many months as the letter claims. The length of time without coverage determines the amount of your late penalty, as explained in

Chapter 8.

W You qualified for Extra Help (see Chapter 5) and joined a Part D plan

Between May 15, 2006, and December 31, 2008. The late penalty was waived during this period for people eligible for Extra Help and without creditable coverage. Congress has now made this waiver permanent, so starting on January 1, 2009, nobody eligible for Extra Help faces a late penalty.

W During the time in question, you were living in an area affected by Hurricane Katrina. Medicare allowed a special enrollment period extending from May 15 to December 31, 2006, and waived the late penalty for this six-month period for people living in certain parishes on the Gulf Coast when the hurricane hit in August 2005.

What your rights are if you think your plan is Wrong

When your plan sends you a letter regarding your late penalty amount, it encloses a notice headed "Your Right to Ask Medicare to Review Your Part D Late Enrollment Penalty," which explains your right to challenge the ruling. It also encloses a form you can use to request a Reconsideration — in other words, an independent review of the decision. You have 60 days from the date on the letter to complete and return the form to the address provided. (You can authorize someone else to fill out the form on your behalf if you want; follow the instructions on the form.) If you choose to request a reconsideration, you must still pay the late penalty throughout the process until a decision is made.

On the form, check off any circumstances that apply to you or write other reasons on a separate sheet. Add copies (not The originals) of any documents that support your case, which may include proof of creditable coverage from a former employer or union, or a previous plan’s benefits summary that didn’t explain whether the plan’s drug coverage was creditable, for example.

Be sure to meet all deadlines or, if you have a good reason why you can’t, request an extension by following the instructions on the form. Otherwise, your case will be dismissed, and you’ll have no further opportunity to argue it.

You should receive a decision from the Independent Review Entity (IRE), the official panel that conducts the reconsideration, within 90 days of the IRE receiving your request. (The decision may come a lot sooner, but it depends on how many similar cases the IRE is dealing with.) The IRE can extend the reconsideration process for up to 14 days for good reason, such as to examine more evidence. Here’s what happens next, based on the IRE’s decision:

W If the decision goes in your favor: You no longer face a late penalty. Your plan must then refund any late penalty fees you’ve already paid during the reconsideration process. Or, if the penalty is reduced, the plan must refund any overpayments you’ve made.

W If the decision goes against you: You’re stuck with the late penalty amount. You can’t appeal against a negative decision.

How to pay the late penalty

If your plan premiums are deducted from your monthly Social Security check, then the late penalty is automatically taken out of it, too. If the plan sends you a monthly bill for premiums, the late penalty is added to the bill. If you prefer, you can choose to pay the penalty on a quarterly or annual basis.

Nice ‘n’ Neat: Starting and Keeping Careful Records

People tend to be pretty slapdash about keeping records. Overwhelmed by junk mail, sometimes you toss the lot and lose something important. You put a vital document in a folder and then forget where you put the folder. Or you start off with the best intentions to sort and keep records in a file cabinet or computer file, and then — just like New Year resolutions that evaporate come February — you somehow fail to update them.

But if there’s one set of records you should keep safe, accessible, complete, and up-to-date, it’s all the accumulated bits of paper relating to your medical and prescription drug insurance. Doing so helps you keep track of your expenses and see how your drug coverage is panning out through the year (how close you’re coming to the doughnut hole, for example; see Chapter 15 for more on this topic). It also serves as a protection in case you get into any disputes with your plan and need hard facts to argue your case. In the following sections, I share how to tidy up your medical and drug insurance records, including how to store them online (if you’re so inclined).

Keeping hard-copy records you can rely on

If you hit a pothole while cruising down the Part D highway, you don’t want to have to scramble for your paperwork only to find it’s missing or unreadable because Fido used it as a new chew toy. In the next several sections, I present some suggestions for keeping records in such a way that you can actually find them when you need them.

Filing each type of insurance separately

Depending on how many different kinds of insurance you have — traditional Medicare, a stand-alone Part D plan, a Medigap supplemental insurance policy, a Medicare private health plan that includes drug coverage, or any other insurance (such as retiree or veterans health benefits) — keep records for each one in a separate file. Even if you have only one plan, creating one file for its medical benefits and another for its drug coverage is practical. Label each folder with the name of the plan and the type of insurance.

Keeping your Evidence of Coverage and other plan information

Your Evidence of Coverage booklet is a legal document that contains details of your legal rights and how to exercise them if you need to, as explained in the earlier section, "Information about your plan: Your new bedtime reading material." If you have more than one plan, file each EOC and other documents in the appropriate folder for each plan so you can access them easily.

Tracking your expenses and level of coverage

Your plan must send a regular statement, called the Explanation of Benefits, About the treatment you’ve received and what you’ve paid. In the case of Part D, every EOB is worth keeping because together they show you

W How much you and your plan are paying for your drugs as the months go by. (The total amount paid by you and your plan affects your coverage level.)

W How close you are to the doughnut hole and, if your costs are high enough to land you in it, how much more you need to spend out of pocket before you qualify for the low costs of catastrophic coverage. (I explain the doughnut hole, catastrophic coverage, and other coverage levels in Chapter 15.)

W How much you’ve spent out of pocket on drugs during the year to date in this plan — in case you need to switch to another plan partway through the year (as explained in Chapter 17) and want to ensure that all of your payments under the old plan will count toward your out-of-pocket limit in the new one.

Hanging on to documents that may help you resolve problems

Medicare has a system consumers can use to resolve disputes with their plans — whether they involve complaints against traditional Medicare, private Medicare health plans, or Part D plans — at several levels of appeal. (I explain the procedures for filing grievances and appeals in Chapter 19.) In Part D, you may need to ask the plan to cover a nonformulary drug or waive a restriction.

Keeping records of any interaction with your plan — including notes from phone conversations — helps your case if you need to file an appeal.

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Opening and reading your mail

When an envelope marked with your plan’s name shows up in your mail box, open it! This advice may sound obvious, but plans too often send unwanted marketing materials to their members (sometimes unrelated to the health or prescription drug plan they’re on), and it’s easy to get into the habit of disregarding everything. But some plan mailings are important and may require timely action on your part. Here are some examples:

W The plan notifies you that it’s going to stop covering one of the drugs you’re taking and gives you 60 days’ warning. Or it informs you that one of your drugs has been taken off the market for safety reasons, and the plan will no longer cover it.

W The plan alerts you that it’s disenrolling you and terminating your coverage for some reason (as explained in Chapter 17) and gives you a certain amount of time to respond.

W The plan has decided you should pay a late penalty (as explained earlier in this chapter) and gives you 60 days to respond.

W The plan sends you its Annual Notice of Change (ANOC) — as all plans must do in October — which shows how its costs and benefits, and maybe its whole design, will change for the following year. (I explain more in Chapter 17 about the critical importance of reading the ANOC Every year.)

W The plan informs you that it’s withdrawing service from your area, not renewing its contract with Medicare, or going out of business entirely. (See Chapter 17 for more on these possibilities.)

Tracking information online

Everything’s going electronic, and Medicare’s no exception. Following are two ways you may be able to keep track of your medical information online, up to a point, if that’s your preference:

W On Medicare’s Web site: Medicare offers a free way of accessing some of your personal medical information through its MyMedicare Web portal. Among other tasks, you can use this tool to

• Track your health claims in traditional Medicare

• See which preventive tests and screenings you’re entitled to

• Order a replacement for a lost Medicare card

• Keep a list of your medications

To create a personal account, go to Www. MyMedicare. gov, click "Need to Register?," and enter your Medicare ID number. About two weeks later, Medicare will send you the password you need to access your account. Oddly, the password is sent via regular mail!

W In a personal health record: An increasing number of Medicare drug and private health plans are offering personal health records (PHRs) to their members for free. A PHR Is an online tool that allows you to enter and keep any information you choose about

• Your medical history

• The visits you make to doctors and other medical services

• The dates of tests and screenings you need for your health condition

Call your plan or visit its Web site to see whether it offers a PHR. You can also download a PHR that’s not connected to any health plan for free from the Internet.

These personal accounts may be a convenient way of storing files that are of interest to you — information downloaded from the Internet about your health condition, for example — or keeping a record of your treatments and setting up a calendar for your medical appointments. In some cases, you may be able to arrange for e-mails alerting you to tests, screenings, and checkups that are due. As more doctors transfer to electronic recordkeeping, you may be able to arrange to have their records of your visits, diagnoses, and tests transferred to your account. In this way, you choose what information you want to put into your account.

On the flip side, neither the MyMedicare site nor PHRs provide a way of tracking all your medical records and expenses as comprehensively as you can do the old-fashioned way — by filing paper. At least not yet. Also, many people remain uncomfortable with committing sensitive health information to a Web site. Both the operators of the MyMedicare portal and the suppliers of PHRs (including some of those private Medicare health plans) maintain that the accounts are secure and can be accessed only with your permission. But look carefully at the contract agreement (which you must sign) to see whether they retain the right to share your information with other parties.

Chapter 14