Answers to your Medicare Part D and SeniorCare questions

GOOD TO KNOW
Patricia Hafermann • Benefit Specialist

When does a person on Senior Care Have to be enrolled in a Medicare Part D plan?

Most clients on SeniorCare do not need to be enrolled in a Medicare Part D plan. That is the benefit of SeniorCare – it works as very inexpensive, creditable drug coverage. However, a client who qualified for low-income subsidy (LIS) – also known as extra help benefits – automatically by virtue of their eligibility for a Medicare Savings Program (QMB, SLMB, SLMB+) must be enrolled in a Part D plan to receive SeniorCare benefits. Their Senior- Care drug coverage will not work at the pharmacy unless they are enrolled in a Part D plan. The LIS/extra help benefit will help pay toward the monthly premium for a Part D plan. Coordination of benefits rules require that the Part D plan be billed first and the SeniorCare will pay secondarily. People who applied for full or partial LIS/extra help benefits are not subject to this rule.

Does SeniorCare pay any costs if the client is in a hospital or nursing home? If a client is in the hospital and determined to have inpatient status, the person’s drugs are covered under Medicare Part A. If a person is outpatient or observational status in the hospital, he or she must submit an out-of-pocket reimbursement request to his or her Part D plan to get reimbursed the costs for medications taken while in the hospital. Unfortunately, Senior- Care does not provide coverage for out-of-network claims, so clients with SeniorCare will be fully responsible for the costs of their medications while outpatient or in observational status at a hospital.

Do I need to report a change of circumstances regarding my LIS/extra help benefit if my income changed?

The low-income subsidy (LIS) is run by the Social Security Administration (SSA) and is a very unique program in that it does not have the typical reporting requirements that all our other benefit programs do. Unlike most public benefit programs, LIS eligibility levels are usually determined for the entire calendar year and subsidy beneficiaries are not required to report changes. Subsidy levels will not change during a calendar year unless a beneficiary appeals a subsidy determination, reports a subsidy changing event, or becomes eligible for Medicaid or a Medicare Savings Program. The six subsidy changing events are:

Beneficiary marries,

Beneficiary and living-with spouse divorce,

Beneficiary and living-with spouse dies,

Beneficiary and living-with spouse separate,

Beneficiary and living-with spouse annul marriage, and

Beneficiary and previously separated spouse begin living together again.

Reports of these changes may result in a re-determination that can change benefits the month after the change was reported. However, even when these changes are reported, LIS benefits typically continue through the end of the calendar year. If it is determined that the person is likely not income or asset-eligible for LIS going forward, he or she will receive a notification letter in the fall with the opportunity to provide updated income and asset information.

When nursing home staff runs the plan finder for their residents, what pharmacy choice do the pick if they are using a pharmacy outside the client’s zip code?

Nursing home staff will need to expand the search distance on the screen to include pharmacies further away.

Can you explain if certain outof pocket costs to reach a Part D plan deductible also apply to the SeniorCare deductible?

The enrollee’s out-of-pocket costs count toward the Senior- Care deductible and spend-down amounts. The amount Part D pays toward drugs does not count toward the SeniorCare deductible or spend-down.

Do the SeniorCare deductible/ spend-down amounts count toward Part D TROOP (true out-of-pocket costs)? Level 1 or 2a folks on SeniorCare: Only what you pay toward Senior- Care copays counts toward Part D TROOP. Level 2b or 3: What you pay and what SeniorCare pays counts toward TROOP.

If you have any additional questions, you may call Pat Hafermann, Elderly Benefits Specialist with the Aging and Disability Resource Center at (920) 467-4076.

Resource: Published with permission from the Legal Services Team at the Greater Wisconsin Agency on Aging Resources’ Elder Law & Advocacy Center


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