Enrollment Deadline for Medicare Part D Is Monday, May 15, 2006

The Impact of Medicare's New Prescription Drug Program on AIDS Care
Medicare’s new prescription drug program offers millions of Medicare beneficiaries a dizzying array of new choices and rules to closely evaluate and monitor against their own needs and financial circumstances.

The AIDS Foundation of Chicago (AFC) has developed a detailed set of Frequently Asked Questions as a reference for HIV-positive Medicare beneficiaries and their service providers. Highlights from the FAQs are described in this article.

Medicare, the nation’s health insurance program for nearly 42 million disabled workers and retirees, accounts for 25% of all federal spending on HIV/AIDS care. Until this month, the basic Medicare benefit did not offer outpatient prescription drug coverage, leaving its millions of beneficiaries with significant and unmet medication needs. For the estimated 100,000 people with HIV on Medicare, the new program offers real benefits but, in some cases, imposes steep out-of-pocket costs.

Approximately 600 clients currently enrolled in the Illinois AIDS Drug Assistance Program (ADAP) are eligible for the new prescription drug program offered through Medicare, known as “Part D.” Officials at the Illinois Department of Public Health, which administers ADAP, recently set policies regarding ADAP services for Medicare-eligible clients. For Illinois ADAP, the HIV-positive Medicare-eligible population breaks into two groups: those with annual incomes below 135% of Federal Poverty (Very Low-Income Clients); and those with annual incomes above 135% of Federal Poverty (Low-Income Clients).

At the end of January, Illinois will no longer provide ADAP services to Medicare-eligible clients with annual incomes below 135% of Federal Poverty (approximately $13,000 per year, i.e., the Very Low-Income group). These clients will need to utilize Medicare Part D instead of ADAP to obtain their prescription drugs, including their antiretroviral medications. In order to make the program less costly, people in the Very Low-Income group should apply for Medicare’s Extra Help, a federal subsidy provided under Part D for low-income beneficiaries. With Extra Help, clients will have access to the medications offered by the plan of their choice for $1 to $5 co-pays per prescription. People in this Very Low-Income group may be reconsidered for ADAP on a case-by-case basis if (1) they are deemed ineligible for Extra Help; or (2) pick a plan that does not cover an ADAP formulary medication they are prescribed.

People in this Very Low-Income group will need to carefully plan their switch to Part D to ensure they experience no interruption in medication access. A significant change for these individuals will be required co-payments of $1 to $5 per prescriptions. To minimize this cost, clients should immediately ask their physicians to write them new prescriptions for 90-day or 100-day supplies of the medications they take regularly as co-payment amounts are charged every time a medication is dispensed. The same price ($1 or $2 for generics and $3 or $5 for brand-name drugs) is charged for a 30-day supply as for a 90- or 100-day supply. AFC also encourages individuals to carefully review the FAQs and consult with a benefits specialist for individual assistance.

HIV-positive Medicare-eligible clients with annual incomes above 135% of Federal Poverty (the Low-Income group making over $13,000 per year) will continue to receive ADAP services uninterrupted as long as they select and enroll in a Part D private plan. To do so, they may need to pay a monthly premium ranging between $13 and $66 depending on the plan they choose. ADAP will require proof of Part D enrollment as part of its annual re-application process beginning in June 2006. Clients with annual incomes below $22,000 may quality for assistance paying premiums through a state-funded program known as Illinois Cares Rx. See the FAQs for details about how to apply for Extra Help and Illinois Cares Rx. Clients in the Low-Income group will generally be using the Part D plan only for prescribed medications not available through ADAP.

Medicare Part D and Medicaid
People who are dually eligible for Medicaid and Medicare should have already received a letter in the mail notifying them that beginning January 2006 they will no longer receive prescription drug coverage through Medicaid but need to rely on the new Medicare program to fill their prescriptions. Medicare clients can verify dual-eligible status online at www.medicare.gov or consult with a benefits counselor for individual assistance (see FAQs for additional resources and recommended benefit counselors).

To ensure uninterrupted pharmacy coverage, all dual-eligible beneficiaries should have been auto-enrolled in one of the Part D plans and should have already received another letter notifying them of the private plan to which they have been assigned. All dual-eligible beneficiaries should go online to www.medicare.gov and carefully evaluate whether their assigned plan covers all the medications they need and their cost. Dual-eligibles should also review the pharmacies coordinating with their assigned plan to ensure they are conveniently located. All Part D plans are required to include all anti-retroviral medications in their formularies, so individuals should pay special attention to ensuring the non-HIV medications they require are on the plan they choose. Most medications will cost dual-eligibles $1 to $5 per prescription, however, some medications not in the plan may be listed at their retail price. Dual-eligibles should consider switching plans to obtain better coverage for the medications they need.

AFC and Test Positive Aware Network (TPAN) will host a community forum on Thursday, January 19 on Medicare and ADAP at 6:00 p.m. at TPAN, 5537 N. Broadway. Staff from Health & Disability Advocates, the AIDS Legal Council of Chicago, and Progress Center for Independent Living will provide individual benefits counseling at TPAN by appointment on Friday, January 20 from 10:00 a.m. to 4:00 p.m. Call TPAN at 773-989-9400 to schedule an appointment.

AFC will continue to work closely with ADAP officials, state and federal lawmakers, and others to advocates for changes to make Part D a better benefit for people living with HIV/AIDS.

MEDICARE RESOURCES

Illinois letter to ADAP recipients on Medicare Part D (PDF)

HIV Medicine Association

Medicare Rights Center

Center for Medicare Advocacy