50. What if I have Medicare and Medicaid?

You automatically qualify for the low-income subsidy known as Extra Help. If you received Extra Help in 2012, you should automatically receive it again in 2013 without having to fill out any additional paperwork. If for some reason you are not deemed automatically eligible for Extra Help in 2013, you will receive a letter from Medicare informing you of this fact. If you get this letter, you should still apply for Extra Help at the Social Security Administration because you may still be eligible for some Extra Help even if you were not granted eligibility automatically (see question #56).

You may be able to stay in the Part D plan you had in 2012. However, many plans that qualified for the low-income subsidy in 2012 will no longer qualify in 2013.

OVERVIEW OF EXTRA HELP IN PART D

Notes: Dual eligible individuals are Medicare beneficiaries who also receive full Medicaid benefits.

*“FPL” is the federal poverty level which is used to determine the annual income limits for the low-income subsidy. FPL numbers are those applicable from August 2012 through January 2013. We will publish new FPL guidelines when they are updated in 2013.

Also, those who become eligible for Medicare for the first time in 2013 will be subject to slightly higher allowable resource dollar limits. We will publish the new thresholds as an addendum to this booklet following their release. Asset limits include $1,500 per person for burial expenses.

Review your plan materials to be sure it still qualifies as a low-income subsidy plan.

If you chose your Extra Help plan, and your plan no longer qualifies, you will face monthly premium costs for your coverage unless you choose to change plans for 2013.

If you did not choose your plan, but were assigned one, you will be automatically reassigned to a new prescription drug plan in 2013 if one of the following events has occurred: your plan is terminating, your plan’s monthly premium is increasing above the regional threshold for Extra Help plans or your plan is switching from a standard to an enhanced plan. You will not be reassigned to a new plan if you select your own plan voluntarily or if you are currently enrolled in a plan with monthly premiums that are at or below the regional threshold for Extra Help plans. If you are assigned to a new plan by Medicare, you will be randomly assigned to a plan that qualifies as an Extra Help plan so that you do not have to pay a monthly premium.

This random assignment means the plan you are assigned to may not cover all the drugs you need. If none of the basic plans cover your medications, you may decide to sign up for a more expensive plan (plans with premiums higher than the regional threshold for Extra Help or those that offer enhanced coverage) which does cover your medications. If you sign up for an enhanced plan, you will have to pay a monthly premium equal to the difference between the regional threshold and the enhanced plan premium.

If you don’t like the plan that you chose or that was chosen for you by CMS, you can switch to another plan. You have the ability to switch plans as often as you like, with the new plan becoming effective the first day of the following month.

If you are enrolled in a plan that qualifies for Extra Help, you will pay no monthly premium, no annual deductible and experience no gap in prescription drug coverage. If you have income at or below 100 percent of the federal poverty level ($11,170/individual and $15,130/couple in 2012), you will be responsible for a $1.15 copay for generic drugs and a $3.50 copay for brand-name drugs. If you have income above 100 percent of the federal poverty level, you will be responsible for a $2.65 copay for generic drugs and a $6.60 copay for brand-name drugs. Once you have over $6,733.75 in covered drug costs (the total of what you and the plan have spent), you will no longer have any copays for prescription drugs for the rest of 2013.

If you have both Medicare and Medicaid and are also living in a nursing home or other long-term care facility, you will pay no monthly premium, will have no annual deductible and will experience no gap in prescription drug coverage. Further, you will never have a copayment on any of your prescription drugs. You are also able to switch drug plans at any time. A drug plan must accept a wide range of documents as proof that you are eligible for Extra Help because of your Medicaid eligibility. Any official letter from CMS indicating that you qualify for Extra Help will be adequate, as will a copy of your Medicaid card, a copy of a state document that shows you have Medicaid, a printout from a state Medicaid system computer or a bill from your nursing home that shows Medicaid has been paying for your care.