Appendix G: IMA Procedures for Resolving Medicare Part D Concerns
Many DC Medicaid and QMB recipients have questions about the new Medicare Part D program. The questions and answers below should help you provide assistance to these customers. To search for a particular word or phrase (for example, “Veteran” or “Kaiser”) just hit CTRL-F and search for that term.
IMA’s most important role: reassure customers with Medicare that they will still be able to get their prescriptions under the new program. These customers just need to pick a Part D drug plan. To get help choosing a plan, customers can call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
For customers in distress: please write down the customer’s information and email it to medicaid@dc.gov. We will reach out to the customer and try to help.
Frequently Asked Questions
Also, here are some additional references that may be helpful:
Questions and Answers
Q1: Should you enroll in Part D if you have DC Medicaid?
"Should I enroll in Part D if I have a blue or white DC Medicaid card?"
A1: YES! Starting January 1, 2006, you must get your drugs through a Part D drug plan if you have Medicare. Even if you have both DC Medicaid and Medicare, you will have to use your red, white, and blue Medicare card to get most of your drugs.
You can pick a plan by calling (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227). If you pick a plan before New Year's, then you will get your drugs from this new plan. You will still have drug coverage after January 1, 2006.
A2: Medicare recently sent letters to customers who also have DC Medicaid. These letters explain the “automatic enrollment” process. If you do not pick a Part D drug plan before January 1, 2006, then Medicare will randomly assign you to a drug plan. However, you can change your plan. To find out whether you should keep this plan or switch to another plan, call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A3: Each drug plan covers different drugs. You need to pick a plan that covers the drugs that you take. To find out which drug plan is right for you, call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
There are 15 special drug plans for people who have DC Medicaid or who get extra help for Part D. (See Question #5 below.) If you pick one of these 15 special plans, then you will not have to pay a monthly premium for Part D. Also, these special plans will have no deductibles. The IMA Fact Sheet on Part D lists these 15 plans and their contact information.
Note: IMA staff should (a) offer to transfer the call and (b) counsel customer to call back to IMA if he or she does not get any assistance.
A4: You should pick a Part D plan between November 15 and December 31, 2005. If you pick a plan before New Year's, then you will be able to get your drugs starting on January 1, 2006.
A5: If you have DC Medicaid, then you can choose a plan with no monthly premium. If you choose one of these special plans, then your prescriptions will cost $1 (or $3 for some drugs). Also, these special plans have no deductibles.
If you do not have DC Medicaid, then you can get for "extra help" to pay for Part D. You can get this help if your income is less than $1,200 ($1,600 if you are married). The income limit is higher if you are working.
If you get the extra help, then you can choose a plan with no monthly premium. If you choose one of these special plans, then your prescriptions will cost $2 (or $5 for some drugs). Also, these special plans have no deductibles.
You need to apply for this extra help if Social Security takes money out of your check now for insurance. To apply, please fill out our Combined Application form. We can mail you a form if you need one. If you are already eligible as a QMB, then you do not need to apply.
Please Ask:
"Does Social Security take out money from your check for insurance?"
If YES, IMA staff should fix any existing problems with the Medicare Buy-In (see Buy-In Procedures below). If the customer is new (or inactive), explain that he or she can apply for "extra help" to pay their Medicare costs. Please offer to mail the customer a Combined Application form. Customers can apply by mail, or if they prefer, they can come to IMA to apply. Also, remind them about the need to pick a Part D plan.
If the customer already participates in the Buy-In, then just remind them that they need to pick a Part D plan between November 15 and December 31, 2005. They can pick a plan by calling (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
Note: Social Security deducts overpayments from some checks; many customers think that these overpayments are actually for Medicare. If they say that they pay $50 each month for Medicare, then this is likely an overpayment. You may need to check BENDEX and clarify this for them.
"Should I enroll in Part D if I have Aetna, Kaiser, or Blue Cross/Blue Shield?”
A6: Some customers get their drugs through the Veterans Administration, Federal Employees’ Health Benefits Plan (FEHBP), TriCare, or through retiree benefit programs. If this is true for you, then you may want to keep this insurance. In that case, you may not need to sign up for Part D. To talk to a counselor about this decision, call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
Note: Customers may confuse private retiree plans with the Medicare “Advantage” plans discussed in Question #11 below. For example, Kaiser offers both retiree plans and Medicare “Advantage” plans. However, this distinction between retiree plans and Advantage plans is very important. Please refer customers with these concerns to (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A7: You can change your mind and change plans. To talk to a counselor about this decision, call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A8: The District offers more generous help than Social Security does. If DC is not paying your Medicare premium already, you should apply through IMA. [Follow script for Question #1 above.]
A9: Many of these drug discount cards will end in early 2006. These drug discount cards are not the same as Part D. You still need to sign up for Part D. To pick a Part D drug plan, call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A10: If you live in a nursing facility and have DC Medicaid, you will not have to pay for your drugs. If you have other questions, please talk to the social worker at your nursing home. You can also call (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A11: No. The other parts or Medicare (Parts A and B) are not changing. You can keep your same doctor unless you sign up for a Medicare “Advantage” plan (such as Aetna, Elder Health, Kaiser, SecureHorizons, or United). If you are in “regular” Medicare (instead of an “Advantage” plan), you can keep your same doctor no matter which Part D drug plan you choose. To find out more, call (202) 739-0668 or 1(800) MEDICARE.
Q12: What is a Medicare "Advantage" plan"
A12: Medicare has several "Advantage" health plans that are different than regular Medicare. These “Advantage” plans include Aetna, Elder Health, Kaiser, SecureHorizons, and United. These health plans manage your doctor's visits and other care. You may also get some extra benefits. However, you may have to pay a monthly premium for an "Advantage" plan. You can choose an "Advantage" plan, or you can stay with regular Medicare Part A and B. In either case, you may still need to sign up for a Part D drug plan. To find out more, call (202) 739-0668 or 1(800) MEDICARE.
Note: Customers may confuse private retiree plans discussed in Question #6 above with the Medicare “Advantage” plans. For example, Kaiser offers both retiree plans and Medicare “Advantage” plans. However, this distinction between retiree plans and Advantage plans is very important. Please refer customers with these concerns to (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A13: Yes. If you are already in an “Advantage” plan (such as Aetna, Elder Health, Kaiser, SecureHorizons, or United), you can still sign up for Part D drug coverage. However, you must choose the Part D drug plan offered by your “Advantage” plan. You cannot choose a different Part D drug plan. To find out more, call (202) 739-0668 or 1(800) MEDICARE.
Note: Customers may confuse private retiree plans discussed in Question #6 above with the Medicare “Advantage” plans. For example, Kaiser offers both retiree plans and Medicare “Advantage” plans. However, this distinction between retiree plans and Advantage plans is very important. Please refer customers with these concerns to (202) 739-0668 or 1(800) MEDICARE (1(800) 633-4227).
A14: Yes. You will get the “extra help” for Part D as long as you recertify for Medicaid or QMB. If you do not recertify, you may lose the extra help for Part D. Remember: you can now call (202) 727-5355 to recertify by phone. You must recertify for Medicaid or QMB each year.
Procedures for Buy-In Queries
Step 1: Verify that the QM, SR, or AZ program type is open.
If there is not current case open, then the customer may need to re-apply. Note: a very, very small number of customers have AR/AX programs.
Step 2: Verify that an active Medicaid program code appears on MEAE for the customer for the period in question.
Step 3: Verify that the customer has Medicare Part B by checking the Option Code (under "Supplemental Medical Insurance" on the right of the BENDEX screen) is Y.
(a) If the Premium Payer is 090, then the District is paying the premium or will shortly begin paying the premium.
(b) If the Premium Payer is a number other than 090, then SSA is reporting that another state is paying the Part B premium; refer these cases to me.
(c) If the Premium Payer is SELF, then continue with procedures below.
Step 4: Verify that the following in BENDEX matches exactly the customer information on CAP2:
(a) Date of birth
(b) Sex
(c) Spelling of last name (use spaces instead of hyphens)
(d) Spelling of first name
If necessary, please correct any customer information on CLIM.
Step 5: Verify that the correct claim number (as it appears on BENDEX) has been entered on MEAE (or VIRE).
Notes: Some customers have more than one claim number (e.g., widows/widowers, adult disabled children, Railroad beneficiaries, etc.), Forward these queries to Chris Proctor.
Make sure that you are looking at the most current data, which you can verify by making sure that there is an entry on the CURRENT line. If not, just hit ENTER until you are back at the main menu, at which point you will enter "8" as the function.
Codes: If a 1728 code appears on the BUY-IN screen, then another state may be paying the Part B premium.
If a 16 code appears on the Buy-In screen, then SSA believes the customer to be deceased. Please refer both types of cases to Chris Proctor.
Other codes that may be helpful:
1751: ACEDS-initiated termination
2961: Accretion by ACEDS attempted after date of death
2161: Accretion attempted by ACEDS but rejected because of data mismatch.
Starting in January 2006, Medicare will cover prescription drugs. This new program is called Part D. Part D will help many people get their prescriptions. If you have Medicare Part A or B, then you can get Part D.
Customers must choose a Part D drug plan. The Part D drug plans will cover many if not most drugs. However, each Part D drug plan covers different medications. Customers need to pick the right plan for their needs. Customers may pick a drug plan starting November 15, 2005.
Part D is not free, but customers can get “extra help.” This extra help pays for the Part D deductible and monthly premiums. It also reduces the co-payments for each prescription.
IMA determines eligibility for this extra help. The Medicare Modernization Act of 2003 requires that District and other states determine the eligibility for Part D’s low income subsidy. Customers may apply through IMA to get this extra help with Part D.
The District has minimized these costs by automating this process. Specifically, the District aligned the income limit of the “Qualified Medicare Beneficiary” (QMB) program with that of the new Part D subsidy. Thus, persons eligible for the Part D low-income subsidy would also be eligible as QMBs. As required by law, the federal government then “deems” all QMB enrollees as automatically eligible for the full Part D subsidy. By merging these eligibility processes, the District eliminated the need for duplicative, stand-alone eligibility determinations for the Part D subsidies.
This automated process vastly streamlines the eligibility process. District residents need to complete only one form (IMA’s new Combined Application) to apply for the Part D subsidy, the QMB program, Medicaid, Food Stamps, and cash assistance. Thus, the District’s process is both fiscally attractive and customer-friendly.
Moreover, this process maximizes the number of District residents who will get the full Part D subsidy. By enrolling all eligible persons under 150 percent Federal Poverty Level (FPL) as QMBs, the District ensures that these customers will not have to pay a Part D monthly premium and will not have to pay a deductible. Further, all customers will pay the lowest possible cost-sharing amounts ($1 and $3 per prescription) under Part D. If this were not done, those customers with incomes between 135 percent and 150 percent FPL would be responsible for monthly premium payments of approximately $37 and an annual deductible of $50. Additionally, all persons above 100 percent FPL would face higher cost-sharing under Part D.
The costs of this streamlined approach are nominal. To align the eligibility criteria of the QMB and new Part D subsidy programs, the District simply increased the income eligibility limit for the QMB population from 100 percent to 150 percent of the FPL.
To explain these changes, the District developed a simple, one-page fact sheet. This flyer, which is available in both Spanish and English, is easy to read and understand. Customers can request this flyer from their IMA worker or by calling (202) 724-5506.
Privacy Note: As with all Medical Assistance programs, IMA staff member are bound by the confidentiality provisions of 42 CFR 431 Subpart F and other District and federal statutes and regulations. These provisions are detailed in Part II, Chapter 3 of the IMA Policy Manual. To safeguard the confidentiality of customer data, it is essential to fully comply with these confidentiality procedures.
