Published: November 19, 2006 01:15 am            

Medicare ‘donut hole’ not so sweet

There are steps to help bridge gap in coverage

FAIRMONT — Wading through all the rules and options for the Medicare Prescription Drug Benefit Program, or Medicare Part D, can be time-consuming and downright confusing.

From now until Dec. 31, West Virginia’s approximately 360,000 Medicare beneficiaries are either re-enrolling in the program or signing up for the first time.

For a lot of seniors, the most confounding part is the so-called “donut hole,” the not-so-sweet empty gap between prescription coverages.

This is how it works:

Each year, Medicare D will pay 75 percent of initial drug costs up to $2,250 after a $250 deductible for most seniors. But then the program pays nothing and the beneficiary must pay 100 percent for prescriptions while still paying Medicare D premiums — that’s the hole — until drug expenses reach a “catastrophic amount,” which is $5,100 for 2006.

“The government will pay 95 percent after this,” said David Summers, social services coordinator, Marion County Senior Center.

“Once you get beyond this donut hole, you have more coverage. It’s just the way the government set it up. That’s simply the way the law is.

“There are some policies without the donut hole, but they’re more expensive per month.

“A lot of people found in the middle of this year that their coverage had stopped. They were confused and naturally upset.”

“This (gap) is for the remainder of the plan year,” said Jim Smallridge, director of WV SHIP (State Health Insurance Assistance Program).

“Then it starts over Jan. 1. All those numbers will change annually, as well, and will probably go up slightly each year.

“There are also plans that offer coverage through the gap, which will continue to pay at the same rate for the entire year. They offer more coverage, so the premiums will be higher.

“Persons with Medicare and Medicaid are not affected by this gap,” he added.

Some suggestions to help bridge this gap:

• Call Medicare at 1-800-633-4227 for information and help.

• Apply for state, community and private prescription-assistance programs.

• Seniors approaching the gap can delay it by more than two months by switching to generic drugs and using mail-order pharmacies.

• For low-income beneficiaries, there is help ... Extra Help.

Administered by the Social Security Agency, this program, also called a “low-income subsidy,” aids persons with limited income and resources in paying for many of the costs of the Part D program, including premiums, deductibles and copayments. The amount of extra help is based on income and resources.

To determine eligibility and to apply online for Extra Help, visit www.benefitscheckup.org. To apply by phone, to request a paper application or to make an appointment at your local Social Security office, call 800-772-1213 or visit www.socialsecurity.gov.

Some things to know about Extra Help:

• It’s not the same as Medicare Part D.

“A lot of people, when told they didn’t qualify for Extra Help, thought they weren’t getting Medicare D,” Summers said. “They confused Extra Help with the program itself. Extra Help is just that ... extra help.”

• You have to sign up for each separately.

“If you sign up for Extra Help, you’re not automatically signed up for Medicare D.”

• You have to sign up for Extra Help by Dec. 31 of each year to get it for the following year.

“For example, if you don’t sign up by Dec. 31, 2006, you’ll have wait to Dec. 31, 2007,” Summers said.

• Social Security is not e-mailing people about Extra Help. Beware of an Internet identity theft scam in which impostors claiming to be from SSA are asking for personal information for Extra Help, he said.

“So anything you get about Extra Help by e-mail is not from Social Security. If you have any doubts, contact them or call us, and we’ll check for you.”

To protect yourself from other Medicare-related scams:

• Register for the national Do-Not-Call registry at 1 (888) 382-1222. Medicare D plans cannot call you if your home telephone and cell phones are on this registry.

• Do not give out any personal information, particularly your bank account or Social Security number, over the telephone.

• Demand written materials from telephone solicitors.

• Remember, you can hang up on telemarketers.

• Do not allow anyone you do not know and have not invited into your home.

• Do not allow yourself to be pressured into a quick decision.

• Check out Medicare D companies with Medicare at 1 (800) 633-4227 or at www.medicare.gov.

• Do not pay any money to apply for a plan. Medicare D plans may not require an application fee.

• If you become apprehensive about a caller or telephone solicitor, call your local police.

For more information about Medicare Part D:

• Visit www.medicare.gov; www.healthdecisions.org/guide; www.AccessToBenefits.org; www.maprx.info; or nationalhealthcouncil.org/help

• Call the Medicare Hot Line (1-800-633-4117).

• Call the West Virginia Bureau of Senior Services Medicare Call Center (1-877-987-4463, 8:30 a.m.-5 p.m. Monday through Friday).

• Call or visit the local SHIP counselor at the Marion County Senior Center (366-8779).

Experts say it is best to enroll in any new plan by Dec. 8 to get a prescription drug card and get the prescriptions you need on Jan. 1.

E-mail Debra Minor Wilson at dwilson@timeswv.com.

        

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