What is Medicare Part D? (Spanish, Chinese)
Medicare Part D is a prescription drug benefit plan that can pay for both brand-name and generic medications that your doctor prescribes for you. Medicare Part D can help protect people with very high drug costs. Even if you don’t take any medications now, having a Part D plan is a good idea because it can pay for unexpected prescription bills you might have in the future.
Who is eligible?
Everyone who is eligible for Medicare Part A or Part B can enroll in one of the Medicare Part D plans available where you live.
Will it cost me anything?
Yes. Most plans charge monthly premiums, yearly deductibles, and co-pays.
- Premiums are monthly fees that you will pay to the prescription plan.
- Yearly deductibles are the amount you must pay at the beginning of the year before the plan begins to pay. The amount of the deductible is decided on by the plan. While some plans do not charge deductibles, most do.
- Co-pay is the amount you pay for your prescription after you have paid the yearly deductible
What if my income and resources are limited?
There is a program call “Extra Help.” If you are single and your annual income is below $16,245 or married with an annual income below $21,855, you may not have to pay monthly premiums or deductibles. You automatically get Extra Help if you have Medicaid or if Medicaid pays your Medicare Part B premiums. With Extra Help your co-pay for each prescription could be as low as $1.10.
If your annual income is higher, you may still obtain assistance if you or your
- Support other family members who live with you; or
- Have earnings from work.
Your resources must be limited to $12,510 for an individual or $25,010 for a married couple living together. Resources counted by Medicare Part D include savings, investments, and real estate other than the home in which you live.
What documents do I need to apply for Medicare Part D?
Account statements for banks, credit unions or other financial institutions that
- Checking accounts;
- Savings accounts;
- Investment statements;
- Stock certificates;
- Tax returns;
- Pension award letters; and
- Payroll slips.
- Other proof of income such as a letter from your employer.
Are there benefits and other assistance that are not counted as income?
- Food Stamps;
- Help with household repairs;
- Help from a housing agency;
- Disaster assistance;
- Meals on Wheels; and
- Help with medical bills.
Can I be eligible for a full subsidy?
You automatically get the full Extra Help if you:
- have both Medicare and Medicaid;
- Receive Supplemental Security Income (SSI); or
- Are eligible for a Medicare Savings Plan which pays your Medicare Part B premium.
You will be notified if you are automatically eligible for full subsidy and do not need to apply for it. You will be eligible at least until the end of the calendar year.
When can I enroll?
Medicare eligibility starts when you turn 65 or when you have received Social Security Disability Income (SSDI) benefits for two years. You can enroll in a Medicare Part D plan as early as three months before or after you turn 65. Or, if you are under 65 and receiving Social Security Disability Income (SSDI) benefits, you can enroll any time from three months before until three months after your 25th month of your cash disability payment (two years and one month after being considered disabled by the Social Security Administration).
How do I enroll?
You can enroll on line by going to www.medicare.gov (on the left click “Plan Choices” and then scroll down to “Medicare Advantage Plans” or “Medicare Prescription Drug Plans”).
You will have various choices of plans and plan types to choose from. When you are choosing a plan, you will need a list of medications you take, including the name of the drug, dosage strength, and how often you take it.
Each plan has its own list of covered drugs, or formulary. You will want to pick the plan that covers most or all of the drugs you take on its formulary. For further assistance call 1-800-MEDICARE (1-800-633-4227) to find plans in your area. If you are Deaf call 1-877-486-2048. Representatives at these numbers can also help you select the plan that is best for you.
If you do not have access to the internet, or if you need help understanding the forms or the steps to take, contact CIDNY at 646-442-4186 or 646-442-1512 and ask to speak to a benefits counselor.
How long will it take to find out if I am eligible?
A week after you join a plan you should receive a letter letting you know they received your information. Three to five weeks later you should get a welcome package with your membership card.
After I have enrolled, will I ever need to re-enroll or switch plans?
Plan list of covered drugs, deductibles, and copays often change on January 1 each year. You can enroll in a new plan between November 15 and December 31 of the prior year. It is a good idea to look at plan options at this time each year so that you are always sure to be enrolled in the plan that works best for you and covers most or all of your medications. For help choosing a plan, call Medicare at 1-800-633-4227 or go to www.medicare.gov.
Where can I get help?
Contact the plans in which you are interested, visit www.medicare.gov, or call 1-800-633-4227. If you are deaf you can call the TTY at 1-877-486-2048. You can also contact CIDNY and ask to speak to a benefits counselor.
What do I do if something goes wrong?
- If your plan will not pay for a drug you take, the drug may not be on your plan’s list of covered drugs or may require prior approval. If this happens, call your plan and request an explanation in writing (called a “coverage determination”).
- Ask for an exception if you need a particular medication that is not on your plan’s list of covered drugs.
- Ask for an exception if the plan requires prior approval to cover your drug.
- Ask for an exception if you believe you should pay less because your doctor or you believe that you cannot take any of the lower-cost preferred drugs for the same condition.
You or your doctor can request an “expedited” (fast—within 24 hours) decision. If there is no request for an expedited decision, then the plan has 72 hours to respond.
If you are requesting an exception for coverage of your medications, your doctor must provide a statement explaining the medical reason for the request.
What if I am denied?
If the plan denies you or your doctor’s request, you can appeal it. There are 5 levels of appeals.
- You have 60 days from the date of the decision to request an appeal in writing.
- You or your doctor can call or write for an expedited request; the plan has 72 hours to respond. If no expedited request is made, the plan has 7 days to notify you of its decision.
- You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP). For NYC you can contact the Department for the Aging at Two Lafayette Street, 16th Floor, New York, NY 10007-1392 or you can call 212-442-1382.
- If your plan fails to respond to a coverage determination, an exception, or an appeal, you can file a complaint by calling 1-800-633-4227 and if you are deaf call 1-877-486-2048.
- After you appeal through your plan, you will get notice explaining the next level of appeal. If you disagree with the plan’s decision, you have 60 days to ask for an independent review by an agency outside the plan.
For more information about your rights and the appeals process, see pages 34-38 at www.medicare.gov/Publications/Pubs/pdf/10112.pdf, the CIDNY Resource Guide, call 1-800-MEDICARE, or call CIDNY at 646-442-4186 or 646-442-1512 and ask for a benefits counselor.