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2007 Open Enrollment for Medicare Drug Benefit Ends on December 31 – Efforts in Place to Avoid Problems at the Pharmacy Counter Next Week

December 27, 2006

The current "Open Enrollment" process for the coming 2007 plan year for the Medicare Part D prescription drug benefit ends on December 31.  Many Medicare beneficiaries now have until midnight on Sunday to make a decision about whether or not switch plans – or be forced to wait until the next open enrollment period in November 2007. 

The Centers for Medicare and Medicaid Services (CMS) is keeping 1-800-MEDICARE open 24/7 through midnight on Sunday.  Beneficiaries can also enroll through

Anticipating Problems at the Pharmacy Counter on January 1

On Monday morning, the new 2007 plan year for the Medicare drug benefit will begin.  NAMI met with senior officials at CMS earlier this week to discuss plans to avoid the problems that occurred last year at the pharmacy counter verifying coverage and ensuring that the proper cost sharing occurs.  Of particular concern this year will be:

  1. Individuals who in 2006 were automatically deemed eligible for zero-premium, zero-deductible coverage with limited cost sharing – i.e., those who automatically got the Low-Income Subsidy (LIS) – and are not automatically receiving LIS in 2007.  These individuals (estimated at 588,000 Medicare low-income beneficiaries) must now re-qualify for LIS in 2007 to avoid higher costs.  Most drug plans are providing beneficiaries who lost automatic LIS a 90-day grace period into 2007 to get their LIS status restored (additional details below).
  2. Dual eligible (those eligible for both Medicare and Medicaid) that were automatically reassigned to a different plan for 2007 because they are no longer eligible to stay in the plan they were enrolled in during 2006.  These dual eligibles are entitled to an automatic refill of all their medications during January (additional details below).

For vulnerable low-income beneficiaries in these categories, CMS, Medicare drug plans and pharmacies have put in place systems to ensure that no one leaves the pharmacy counter in early January without their medications.  This includes both the grace period for individuals losing LIS status and the required transition refill policy.     

Who Needs to Contact Medicare Before Midnight December 31?

The short answer is anyone who wants to switch their drug coverage for the coming year, or who did not enroll in 2006.  In addition, Medicare beneficiaries who are happy with their prescription coverage also need to carefully check into changes in coverage for 2007 including: 

  • Changes in premiums and cost sharing,
  • Adjustments to formularies (the list of covered drugs),
  • Movement of specific drugs to different cost sharing tiers, or
  • Imposition of new or different utilization management policies on specific medications (prior authorization, step therapy, quantity limits, etc.).

If a Medicare drug plan made any of these adjustments to their coverage policies for 2007, then they were required to notify all enrollees in writing by October 31 through an "Annual Notice of Change" or ANOC letter.  In addition, Medicare has also been sending notices of changes in coverage in recent, especially for dual eligibles whose status as "Low Income Subsidy" is changing (see details below). 

"Re-Deeming" of Certain Dual Eligibles

Of particular concern to NAMI in the transition to the new plan year on January 1 are low-income Medicare beneficiaries who had dual eligible or "Low Income Subsidy" (LIS) status in 2006, who will not in 2007.  These are individuals that prior to 2006 qualified for Medicaid in their state as a result high medical expenses and "spend-down" eligibility.  Most of these dual eligibles were automatically enrolled in a Part D plan for 2006. 

For 2007 however, many will not have dual eligible status because they never reached the Medicaid "spend-down" level in 2006.  Others have experienced some other "change in status" that has prevented CMS from "deeming" them (making them automatically) eligible for LIS or dual status in 2007. 

These individuals will need to send in a new application for the Medicare Part D "Low Income Subsidy" (LIS) in order to access affordable drug coverage for 2007 (in most cases, coverage with no monthly premium, no deductible, no gap in coverage and as little as $3 for a generic, and $5 for a brand name prescription).  A number of Part D drug plan sponsors have already announced their intentions to provide a 90-day grace period in which higher cost sharing and deductibles will NOT be assessed against anyone losing "deemed" dual eligible or LIS status.  Further, CMS is providing a special 90-day open enrollment period (through March 31, 2007) under which low-income beneficiaries losing automatic dual eligible for LIS can select a different drug plan if they wish. 

Notices from CMS to these "deemed" individuals were sent in September (a letter printed on blue paper), with an LIS application and postage paid envelope.  For more information on this important issue, click here:

Drug Plan Choices for Dual Eligibles and Low-Income Subsidy (LIS)

A key priority population for NAMI in the drug benefit in 2007 remains the 6.2 million extremely low-income Medicare beneficiaries simultaneously eligible for Medicaid in their state (also known as dual eligibles) and the nearly 2.8 million Medicare beneficiaries receiving "extra help" or the Low-Income Subsidy (LIS). 

In most states, as many of 40% of dual eligibles have a serious mental illness.  These dual eligible individuals will continue to participate in the Medicare drug benefit on a mandatory basis.  LIS recipients applied for (or were deemed eligible for) a deep subsidy that makes coverage affordable.  So long as dual eligibles selected a drug plan that is "at or below benchmark," they are able to access coverage with no monthly premium, no annual deductible and no gap in coverage (the so-called "doughnut hole" gap), with their only costs being $1.10 for a generic and $3.15 for a brand name prescription (this is a slight increase over 2006 as a result of an inflationary increase).  Likewise, LIS recipients that select a plan "at or below benchmark" access drug coverage with no monthly premium (or in some cases, discounted premiums), no deductible, no "doughnut hole" gap in coverage and cost sharing limited to $3 for a generic and $5 for a brand name.  

Because of the lower than projected premiums, in some states the cost of the average "benchmark" plan has gone down for 2007.  As a result, some dual eligibles and LIS are in drug plans for 2006 that will not be "at or below the benchmark" for 2007, i.e. they will not be able to re-enroll in these plans in 2007 at the $0 premium level.  There is also a $2 de minimus threshold whereby if a plan is $2 or less above the new 2007 benchmark, the higher $2 premium is waived. 

For those dual eligibles in plans shifting above the benchmark (for which dual eligibles can no longer enroll with a $0 monthly premium), CMS is planning to automatically re-assign them to a new drug plan with the same sponsoring organization or with an identical formulary list in an attempt to avoid disruption.  It is important to note that if a dual eligible switched to different plan in 2006, CMS will NOT disenroll them from that plan. 

Data released last week by CMS indicates that only a few prescription drug plans are losing dual eligible and LIS beneficiaries and are restricted to the following plans and states:

  • Medco YOUR Rx Plan in ME, NH, DE, DC, MD, PA, WV, VA, NC, AL, TN, LA, IN, KY, IA, MN, MT, NE, ND, WY, WI and HI,
  • Silverscript in NY, LA and TX,
  • WPS Medicare Drug Plan in WI,
  • Universal Health Masterpiece Rx in FL,
  • Sierra Rx in TX,
  • First Health Premier in NV,
  • Asurius Medicare in OR and WA, and
  • Regence Medicare Script in ID and UT.

CMS has already sent out written notices to all dual eligibles that may be subject to this re-assignment for 2007 – these re-assignment letters were all mailed by October 30 and were printed on blue paper.  In other words, if you (or a family member) are a dual eligible or LIS recipient and you have not received this blue letter from CMS, then you will continue in the same drug plan for 2007.  Finally, all dual eligibles who switch plans for 2007 will get an automatic 30-day initial transition period during which their new plan must automatically refill all of their prescriptions.  

How to Find Out if Your Rx Coverage is Changing?

Most Medicare beneficiaries who are happy with their prescription coverage will not have to switch plans in 2007.  As noted above, any change in premiums, cost sharing or coverage of specific drugs required notice in writing by October 31.  In addition, all Medicare beneficiaries can explore different coverage options for 2007 through several web-based search tools offered by CMS (the Centers on Medicare and Medicaid Services, the federal agency that administers Medicare).

View the plan "landscape" that lists available drug plans by state.

The Medicare personal plan finder allows a beneficiary, family member, case manager or counselor to compare available plans on the basis of cost and coverage of specific medications.

Finally, the CMS "formulary finder" allows a beneficiary, family member, case manager or counselor to search plans on the basis of placement of specific medications on a formulary.

More Web-Based Tools Available

In addition to the resources listed above, more web-based information about the Medicare prescription drug benefit is available through the following links.  The new "My Health/My Medicare" Campaign designed to promote on-line personalized information: