Medicare D round two: Patients will have questions; here are answers

Washington -- As the Medicare drug benefit approaches the end of its first year, program officials are encouraging beneficiaries and their physicians to gear up for the next one.

Medicare's open enrollment period will start Nov. 15 and continue through Dec. 31. During this time, Medicare beneficiaries who are not receiving the benefit can sign up and those who are already enrolled can change their drug plans.

Consequently, it is likely to be a time when doctors receive more inquiries than usual about plan options, drug formularies and medication choices from Medicare patients. In many cases, the primary care physician is the person who will field these questions first, federal officials said.

Here are some of the general questions physicians may encounter.

What do patients need to do?

Patients confused about whether they need to re-enroll might ask their physicians about it. Beneficiaries who are already in Part D automatically will be signed up for the same plans for 2007 if they do nothing, said Jeffrey Kelman, MD, chief medical officer at Medicare's Center for Beneficiary Choices.

Relatively few seniors will discover that their plans have been discontinued. These beneficiaries will receive notices instructing them to find new plans and sign up before the end of the year to ensure seamless drug coverage. Seniors who were eligible for Part D last year but decided to hold off on joining also must go through the plan selection process if they want to receive the benefit in January 2007.

Beneficiaries who decide they are not happy with their drug coverage or who determine they can get a better deal from another insurer can use the open enrollment period to switch plans, either online or over the phone. New plans cropping up for 2007 mean more options, although this could add to the confusion facing seniors and their doctors, said Ron Pollack, executive director of the consumer group Families USA.

Will needed drugs still be covered?

Whether necessary prescription medications are covered by the insurer could be the single most important determinant of whether a beneficiary should stay in the current plan or sign up for a new one. Plans were required by Medicare to send every enrollee by the end of October an "Annual Notice of Change." This document details any significant formulary additions or deletions for 2007, as well as revisions in how much the patient is expected to pay for medications.

Physicians should ask Medicare patients to bring these notices into the office so doctors or staff can review accompanying revised drug formularies, Dr. Kelman said. By determining if any of the beneficiary's drugs have been dropped from the approved list or moved to a more expensive tier, a physician can help a patient determine if it makes sense to ask for a coverage exception from the plan, find an alternative treatment that will be covered or find a new insurer.

Medicare will monitor plans to make sure that they have an adequate transitional coverage period -- generally a month or more -- in cases in which prescribed drugs are removed from the approved list.

In most cases, plans are adding to their formularies, Dr. Kelman said. But as of January, Medicare no longer will pay for erectile dysfunction drugs when they are used to treat ED, a move that was opposed by urologists and other physicians. The medications still will be subsidized to treat certain cardiac and other conditions on an on-label or off-label basis.

What do doctors need to do?

Some physicians went to bat for their patients in 2006 by requesting prior determinations or coverage exceptions from Medicare drug plans for medications that otherwise would not have been covered. The American Medical Association, along with other groups, earlier this year unveiled a one-page form to simplify this process. For those beneficiaries who remain in the same plans, these determinations and exceptions in the vast majority of cases will still be in effect in 2007, Dr. Kelman said.

Some plans may have limited prior authorizations to only one year or decided that coverage exceptions need to be resubmitted in the new year by physicians. If notices of change sent by the insurer do not specify a policy, Dr. Kelman said, doctors should call the drug plan and file new paperwork well in advance of the Dec. 31 deadline, if such action proves necessary.

How much will this cost patients?

Although they won't be dealing directly with claims for Medicare prescription drugs, physicians still might receive questions on how hard these costs will hit their patients' pocketbooks. Doctors even can help lower the bills by finding less-expensive generics and alternatives, when such a move is medically appropriate.

Medicare officials estimated that beneficiary cost sharing in general will go up only a few percentage points next year. The average monthly premium for Medicare drug plans will be $24 in 2007, the same average as 2006, they said.

Families USA said cost sharing for some patients will go up significantly because many insurers are reducing or dropping their coverage of beneficiary out-of-pocket costs within the "doughnut hole" -- the coverage gap between when initial government subsidies run out and when the catastrophic benefit begins.

Many low-income seniors are eligible for extra government help with their drug bills. In cases in which they also are eligible for Medicaid, federal officials will do the work of picking a drug plan for the seniors and making sure they receive the additional assistance. But other low-income beneficiaries must contact the government to apply for the extra benefits, and many physicians may be in a good position to recognize when this is the case, even if the seniors themselves do not, Dr. Kelman said.