PART D - PRESCRIPTION DRUG COVERAGE Flashcards
in the context of Medicare Plans, what is the difference between SPAP and LIS-Extra help/ What does each apply to, what does each do for the beneficiary?
State Pharmaceutical Assistance Programs (SPAPs) and Low Income Subsidy (LIS)/Extra Help are both programs designed to help eligible individuals with their prescription drug costs, but they operate differently and have different eligibility requirements
SPAPs:
SPAPs are state-run programs that assist low-income seniors and adults with disabilities in paying for their prescription drugs.
SPAP coverage varies by state, but the programs generally provide Part D “wraparound” coverage, meaning that they pay costs that Medicare Part D does not pay.
Most SPAPs have income guidelines. Many also require you to enroll in a Medicare Part D plan and to apply for Extra Help.
LIS/Extra Help:
The Extra Help program is also known as the Part D Low Income Subsidy (LIS).
It’s a federal program that helps people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
Some people get Part D Extra Help automatically, including those who are enrolled in both Medicaid and Medicare (“dual eligible”), those receiving Supplemental Security Income (SSI), and those who qualify for a Medicare Savings Program.
If you are not already enrolled in the benefits programs noted above, you must apply to Social Security to receive Extra Help.
Starting in 2024, eligibility for the full Extra Help benefit will be expanded to people with up to 150% of the Federal Poverty Level (FPL).
Most people who qualify for Extra Help will pay no premiums for their drug plan, no deductibles, and no more than $11.20 in 2024 for each brand-name drug the plan covers ($4.50 for generic).
Is there any occasion when both SPAP and LIS/Extra Help can be used together?
Yes, there are situations where State Pharmaceutical Assistance Programs (SPAPs) and Low Income Subsidy (LIS)/Extra Help can be used together, but it depends on the specific rules of the SPAP and the level of LIS/Extra Help for which an individual qualifies.
For example, if an individual qualifies for the full LIS/Extra Help (Level 1 or 100%), they will be able to get medication assistance directly from Social Security and will not be eligible for help from the SPAP1. However, if an individual is denied the LIS or is approved for the partial LIS, they will be eligible for the SPAP as long as they continue to meet the other SPAP eligibility requirements.
Some states require applicants to be enrolled in Medicare and unable to qualify for the Part D Low Income Subsidy (LIS/Extra Help). Other states may only offer SPAPs to individuals with certain chronic conditions.
It’s important to note that the specifics can vary by state and program, so it’s recommended to check with your state’s SPAP and the Social Security Administration for the most accurate information.
So a Beneficiary would apply first for LIS-Extra Help first to determine how much benefits they would receive; and then apply for additional assistance from SPAP, secondly?
Yes, that’s generally the recommended approach. A beneficiary would first apply for the Low Income Subsidy (LIS)/Extra Help program to see how much assistance they can receive for their Medicare prescription drug costs. If they are denied the LIS or only approved for partial LIS, and they meet the other eligibility requirements, they can then apply for additional assistance from their State Pharmaceutical Assistance Program (SPAP).
However, the specifics can vary by state and program, so it’s always a good idea to check with the Social Security Administration and your state’s SPAP for the most accurate and up-to-date information.
In the context of Medicare, what is the PACE program?
The Program of All-Inclusive Care for the Elderly (PACE) is a joint Medicare and Medicaid program that helps people meet their healthcare needs in the community instead of going to a nursing home or other care facility.
Here are some key points about the PACE program:
Eligibility: To join PACE, you must be at least 55 years old, live in the service area of a PACE organization, need a nursing home-level of care (as certified by your state), and be able to live safely in the community with help from PACE1.
Services: PACE covers all Medicare- and Medicaid-covered care and services, and anything else the healthcare professionals in your PACE team decide you need to improve and maintain your health. This includes prescription drugs, adult day primary care, dentistry, emergency services, home care, hospital care, laboratory/x-ray services, meals, nursing home care, nutritional counseling, occupational therapy, physical therapy, preventive care, social work counseling, and transportation to the PACE center for activities or medical appointments.
Cost: If you have Medicaid, you won’t pay a monthly premium for the long-term care portion of the PACE benefit. If you don’t qualify for Medicaid but you have Medicare, you’ll pay a monthly premium to cover the long-term care portion of the PACE benefit and a premium for Medicare Part D drugs. There’s no deductible or copayment for any drug, service, or care your healthcare team approves.
Application: To find out if you’re eligible and if there’s a PACE program near you, you can search for PACE plans in your area, or call your Medicaid office
Does PACE have anything to do with Prescriptions drugs or their costs, or Part D in any way?
Yes, the Program of All-Inclusive Care for the Elderly (PACE) does have a relationship with prescription drugs and Medicare Part D.
Here are some key points:
Prescription Drugs: PACE covers all Medicare- and Medicaid-covered care and services, including prescription drugs. The PACE program provides any prescription medications you need.
Part D: PACE organizations offer Medicare drug coverage (Part D). If you join PACE, you’ll get your Part D-covered drugs and all other necessary medication from the program.
You can’t have a separate Part D prescription drug plan beyond what’s provided by PACE.
Interaction with Part D: The PACE Program works with Medicare Part D plans to lower out-of-pocket costs for medications. Many PACE or PACENET cardholders will save money by being enrolled in both Part D and PACE or PACENET at the same time. If PACE/PACENET enrolls you in a Part D plan, you will receive a letter from the program telling you the Part D plan and the effective date of enrollment. All PACE/PACENET cardholders get help with their Part D deductibles, co-pays, and costs during the coverage gap.
Please note that this information is current as of the time of this conversation and may change over time. Always check with the appropriate regulatory body for the most current information.
Are there any other programs that can reduce a Beneficiary’s Part D prescription drug costs?
Yes, there are several programs and strategies that can help reduce a beneficiary’s Part D prescription drug costs:
Switching to Generics or Lower-Cost Drugs: There may be generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now.
Choosing a Medicare Drug Plan with Additional Coverage: There are plans that offer additional coverage during the Medicare drug coverage gap, like for generic drugs.
Pharmaceutical Assistance Programs: Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare drug coverage (Part D).
State Pharmaceutical Assistance Programs (SPAPs): Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs.
Extra Help: Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs.
Changes to Medicare Part D in 2024 and 2025: The Inflation Reduction Act of 2022 includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government2.
Please note that this information is current as of the time of this conversation and may change over time. Always check with the appropriate regulatory body for the most current information
In the context of Medicare Part D, what is IRMAA, and how does it relate to Part D, if at all?
The Income-Related Monthly Adjustment Amount (IRMAA) is a surcharge that you may have to pay in addition to your Medicare Part B and Part D premiums if your income is above a certain level.
In the context of Medicare Part D (prescription drug coverage), if your income is above a certain limit ($97,000 if you file individually or $194,000 if you’re married and file jointly in 2023, and $103,000 if you file individually or $206,000 if you’re married and file jointly in 2024), you’ll pay an extra amount in addition to your plan premium. This extra amount is sometimes called “Part D-IRMAA”.
The extra amount you have to pay isn’t part of your plan premium. You don’t pay the extra amount to your plan. Most people have the extra amount taken from their Social Security check. If the amount isn’t taken from your check, you’ll get a bill from Medicare or the Railroad Retirement Board5. You must pay this amount to keep your Part D coverage.
If Social Security notifies you about paying a higher amount for your Part D coverage, you’re required by law to pay the Part D-Income Related Monthly Adjustment Amount (Part D IRMAA)5. If you disagree with the amount (for example, if your income goes down), you can use a specific form to contact Social Security.
Please note that the amount you pay can change each year. If you have questions about your Medicare drug coverage, you should contact your plan.
What is the Penalty for having a break in creditable drug coverage?
The penalty for having a break in creditable drug coverage, also known as the Part D late enrollment penalty, is an amount that can be added to your Medicare drug coverage (Part D) premium.
You may have to pay a late enrollment penalty if, at any time after your Initial Enrollment Period is over, there’s a period of 63 or more days in a row when you don’t have Medicare drug coverage or other creditable prescription drug coverage. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.
The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” (which is $32.74 in 2023 and $34.70 in 2024) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $0.10 and added to your monthly Part D premium. The national base beneficiary premium may increase or decrease each year, so your penalty amount may also increase or decrease each year.
For example, if you were without creditable prescription drug coverage from August 2019–December 2021, your penalty in 2023 is 29% (1% for each of the 29 months) of $32.74 (the national base beneficiary premium for 2023) or $9.68 each month. Since the monthly penalty is always rounded to the nearest $0.10, you will pay $9.70 each month in addition to your plan’s monthly premium.
After you join a Medicare drug plan, the plan will tell you if you have to pay a penalty and what your premium will be. In general, you’ll have to pay this penalty for as long as you have a Medicare drug plan. If you disagree with the late enrollment penalty, you can appeal.
