5-23-05 Chatroom Log From Virgil: What are the eligibility requirements for Medicare savings groups? Individuals who are Qualified Medicare Beneficiaries (QMB) must have income below 100% of the federal poverty level (FPL) ($818/individual) and assets under $4000 for individual and $6000 for couple. Individuals who are specified low-income Medicare beneficiaries must have income above 120% of FPL. and assets under $4000 for individual/$6000 couple. Qualified Individuals (QI-1) must have income between 120% and 135% of FPL and assets of $4000 for an individual and $6000 for a couple. QI-1 From Guest65909: Did I understand correctly that the "income" which places you in a particular eligibility group will actually be the countable income determined by an-SSI type calculation? Yes, eligibility for the low-income subsidy will be based on an SSI- type calculation. From Guest15793: how will this affect the medicaid buy in program? The eligibility rules for the Medicaid buy-in program will not change as a result of the Medicare drug benefit. However, individuals who are enrolled in the Medicaid buy-in program will not be able to get prescription drugs through Medicaid and will have to enroll in Medicare for drug coverage. From Guest12385: when you started talking about formulary, i got lost, what does that mean? The formulary is a listing of the drugs that the private drug plan will cover. The formularies are set by the drug plans and approved by the Centers for Medicare and Medicaid Services (CMS). From Guest65909: But this is only true for the low income subsidy, not for determining whether you are in group one through 5? No, the low-income subsidy applies to groups 2 through 5 (Group 1 is the standard coverage). The eligibility for these groups are based on the person's "countable" income. From Guest28163: Is there a link to the SHIP offices from the CMS website? I'll have to double-check this. If there is a link or other contact information, we will post it on the web board. From Guest62540: Where can consumers get an exception form and how long will it take? The exception forms will be handled by the private drug plan as a first step. Other levels of appealing coverage of a certain drug may also be available. The drug plans must respond to an exception request within 72 hours for a standard request or 24 hours for an expedited request. From Guest24607: For the consumers who has no family members or support system to assist them with sorting or understanding this information, has SSA or CMS developed a system so that these people will not have to go without their medications? CMS and SSA have taken several steps to try to help individuals get information. Some of these steps have been to do grassroots outreach, the automatic enrollment and facilitated enrollment for beneficiaries, and grants to the State Health Insurance Partnerships. CMS is also requiring the drug plans to have transition plans for individuals who are enrolling in their plan and who may be switching from other types of drug coverage. From Guest28163: Will the next level of appeals be at the state or CMS? The levels of appeal follow the Medicare managed care process. The next step after the exceptions request will be an independent medical review. We can get more information about the exceptions and appeals process and post it on the web board. From Guest25791: Who will help beneficiaries choose the correct medication if their medication is not on the list? I expect that a number of individuals will be helping beneficiaries in this area. Prior to enrolling in the drug plan, a beneficiary may get help from a number of the sources I mentioned in the webcast so they can choose and enroll in a drug plan that best fits his or her needs. Once the individual is enrolled, I would expect that the person's physician would help the beneficiary if an exception is needed. From Guest65909: Following up on a question by another user, if individuals who have difficulty understanding this information are automatically enrolled, how will they know they've been enrolled in the most appropriate plan? How is the automatic enrollment decided? The automatic enrollment will be handled through random assignment. It would not be made by the types of drugs the person takes or whether there is a pharmacy in their area. It is very important for individuals to understand the types of drugs covered by the plan they are assigned to and switch plans if necessary. From Guest65909: what qualified a request to be expedited? I will have to delve into the exact criteria and can post a response. However, the information I've seen indicates that it will be partially based on the medical necessity of the request. From Guest28163: Is it only group 4 & 5 the Dual eligible that will automatically be enrolled in a plan if they don't enroll? Only the dual eligibles will be automatically enrolled. This includes some individuals in Group 3 and all of Groups 4 and 5. From Guest65909: if a person chooses to purchase a prescription that is not on the formulary, because is recommended by their physician, and they can't get an exception, does the entire cost count as part of the out-of- pocket cost to the beneficiary? If the drug is not covered by the drug plan and the individual can not get an exception, the cost does not count towards the person's out-of-pocket costs. From Guest28163: So , eligible folks that are not automatically enrolled will not be enrolled unless they initiate the enrollment? Correct. From Guest25791: Will VCU put out a white paper? Possibly. It sounds like their might be interest, the staff will discuss it. If a white paper is done, it would be distributed through the list serve and posted on the website. From Guest25791: What about access to Pharmacists to discuss pros and cons of drugs? Not the program but the medications. There is not a separate pool of pharmacists for consultation by enrollees through this program, but Individuals will be able to talk with their local pharmacists, as they can now. From Guest25791: When can we expect the new Medicare handbooks to be published? I'm not sure when the new Medicare handbooks are published. We can post this on the web board. However, the CMS website has a significant amount of information about this new benefit, and I would encourage you all to take a look at it. They also have a frequently asked questions section which can be very useful. From Guest28163: Will CMS anything to distribute to beneficaries? CMS will have general information for beneficiaries through the Medicare and You Handbook and other fact sheets, but other than the letters regarding eligibility for the low-income subsidy and the auto enrollment for dual eligibles. I am not aware individualized information for beneficiaries. The drug plans will also be developing their own marketing materials for beneficiaries. Thank you for your questions. Please visit the webboard throughout the week to post questions.