Medicare Part D

Anyone who has Medicare can participate in the Medicare drug benefit, also known as Medicare Part D. The following is common questions and answers about the program:

Do you need Medicare Part D?

If you have TRICARE for Life, PEEHIP, State Retirement coverage, Civil Service retiree health insurance, or other good coverage because of your or your spouse’s current coverage or because of your or your spouse’s retirement plan, you do NOT need Medicare Part D. You should have received a letter from your current plan explaining whether your drug coverage is at least as good as the coverage available from a Medicare Part D plan.

If you do not have good coverage from such a source, you should strongly consider enrolling in a Medicare Part D plan.

When can I enroll?

Open enrollment for all Medicare beneficiaries occurs from October 15 through December 7 every year. During this period, you can make an initial enrollment or change from one plan to another.

You also have an initial enrollment period when you first become eligible for Medicare, which may be when you turn age 65, when you have been eligible for Social Security disability for 24 months, when you are diagnosed with Lou Gehrig’s disease, or when you need kidney dialysis or a kidney transplant.

If you are eligible for full Medicaid (through SSI or nursing home Medicaid), QMB, SLMB, QI, or the low-income subsidy (LIS) or if you become a nursing home resident, you can change your Part D plan once during each quarter of the year.

Can I receive help with the cost of Part D?

If you are eligible for Medicare, you should be aware of additional programs that may help pay for Medicare premium, deductibles and copayments. These programs apply to persons who have Medicare for whatever reason, including people older than age 65, those who receive Social Security disability and certain renal disease and Lou Gehrig’s disease patients.

If you qualify for full Medicaid (through SSI or nursing home Medicaid) or for QMB, SLMB, or QI, then you are automaticallyeligible for free coverage under Medicare Part D, with no deductible, no coverage gap and only very small copayments. If you qualify for any of these programs, then you do not need to apply separately for help with Part D through the Low-income Subsidy (LIS) program at the Social Security office.

In Alabama, eligibility for QMB, SLMB, and QI is based solely on income and being on Medicare. Alabama does NOT count what a person owns in determining eligibility, so having a bank account or owning a home does not prevent eligibility.

To determine whether your income falls below the income limits: First, if you or your spouse receives any wages or salaries from current employment or self-employment, add together the GROSS amount of earnings for the month (before any deductions or withholding). Then subtract $65.00. Divide the balance by two. This result is the amount of earned income that counts.

Next, add ALL your and your spouse’s gross monthly amount of rent received, Social Security, pension, veterans, and other retirement or disability benefits. Count the amount of these benefits BEFORE any deductions for taxes, insurance, or any other withholding.
Add together the amount of countable earned income, if any, and the total of all rent, retirement and disability income to determine the amount that counts toward the income limits that are printed below. Do not count interest or dividends as income.

Note: The countable income limits for the QI program, which will pay the Medicare Part B premium ($148.50 in 2021) are as follows:

– Married people who reside together: $2,080 gross per month
– Single or married but not residing together: $1,549 gross per month

The countable income limits for the SLMB program, which will pay the Medicare Part B premium ($148.50 in 2021), are as follows:

– Married people who reside together: $1,851 per month (combined income)
– Single or married but not residing together: $1,379 per month.

Being eligible for either QI or SLMB will simply result in an increase in monthly income by the amount of the Part B premium. It does NOT cover any copayments or deductibles, so you should keep your supplemental health insurance unless income is also lower than the QMB limits listed below.

Being approved for SLMB or QI provides automatic eligibility to receive Medicare Part D drug benefits free (no premium for the card of one’s choice) with only the requirement of paying small copayments (roughly $2.95 for generic and $7.40 for brand-name prescriptions).

The countable income limits for the QMB program, which will pay the Medicare Part B premium AND all Medicare deductibles and copayments, are as follows:

– Married people who reside together: $1,546 per month (combined income)
– Single or married but not residing together: $1,153 per month.

Being eligible for this program will not only result in an increase in monthly income by the amount of the Part B premium, but will also cover all copayments and deductibles, so you should drop any supplemental health insurance unless it is free or nearly free to you. For example, those eligible for Tricare for Life, PEEHIP, or coverage that is provided at no cost through a union or retirement plan should keep the coverage even when eligible for QMB. On the other hand, those eligible for QMB who have Blue Cross C+ should drop the C+ coverage because it costs money for coverage that is already provided at no cost by QMB.

Being approved for QMB also provides automatic eligibility to receive Medicare Part D drug benefits free (no premium for the card of one’s choice) with only the requirement of paying small copayments (roughly $3.60 for generic and $8.95 for brand-name prescriptions).

Note: The income limits for QMB, SLMB, and QI will increase in January 2021. The income limits for these programs do NOT increase exactly in line with the cost of living increases in Social Security and other benefits checks. The QMB income limit is equal to 100 percent of the federal poverty level plus $20, the SLMB limit is 120 percent of the poverty level plus $20, and the QI limit is 135 percent of poverty plus $20.

To apply for QMB, SLMB, or QI, contact the Medicaid District office at (334) 702-3101. If you have questions about whether you should apply or need help in applying for any of these programs, contact SARCOA at (334) 793-6843. There is no charge for this assistance.

What if my income is too high to qualify for QMB or SLMB? Can I qualify for help with Part D in any other way?

If you cannot qualify for QMB or SLMB and you are not already eligible for QI, you should check to see whether you can qualify for the Low-Income Subsidy (LIS) through the Social Security office. To apply, telephone 1-800-772-1213 (TTY 1-800-325-0778) or apply online at http://www.ssa.gov/. If you have questions about whether you should apply or need help in applying for LIS, call SARCOA (334) 793-6843 to make an appointment for assistance.

Monthly income limits for help with Medicare Part D when applying through the Social Security Office: Set at 150% of the federal poverty level, in 2020, $1615 for one person, $2170 for two person, and $560 for each additional person.

How to determine household size: Count yourself and your spouse (if he or she lives with you) and also count any other relative who lives with you for whom you provide more than one-half of that person’s support.

How to determine gross income: If any of your or your spouse’s income is income from work ( a job or self-employment), first determine monthly gross earned income (gross pay before deductions or net earnings from self-employment), then subtract $65.00, then divide the remainder by two, then add all other income.

Assets/Resources limits: Your resources (not counting your home and land adjoining it, your vehicles, household personal property, and life insurance) must be less than $14,610 if single or $29,160 if married and living in the same household if you are applying through the social security office for help with Medicare Part D.

These income and resource limits change each year. Unlike the state QMB, SLMB, and QI programs, LIS incomes are based on household size that includes dependents in addition to your spouse and count all income, including interest and dividends, and the LIS program does have asset limits (but does not count your home, vehicle, and life insurance).

How do I choose a Part D plan?

Because dozens of private companies are competing to become your Part D provider, choosing the plan that is best for you may seem overwhelming.

Do not choose a plan based solely on the recommendation of a friend or relative or because you like the sales agent.

Every plan has a different list of drugs that it covers. Different pharmacies accept different plans. Copayments, premiums, deductibles and whether coverage is available in the coverage gap vary widely among plans.

Because the plans change their premiums and coverage each year, you should determine which plan in which to enroll each year during the open enrollment period, October 15 through December 7. Be aware that if you do not do anything during the open enrollment period, you will automatically remain enrolled in the plan you had during the previous year, even if that plan has increased its premium or changed its coverage.

Because everyone takes different medicine and uses different pharmacies, you should make an individual decision about which plan to choose. Even spouses may need to enroll in different plans because they take different prescriptions.

The best way to choose the plan that will save you the most money is to use the Medicare website plan comparison tool by entering all the prescriptions that you take, including how many you take each month and the specific variety of each drug that you have been prescribed (number of milligrams, etc.). This computer program will show you the plans that will save you the most money by taking into account all the costs, including the premium, deductible, cost of each drug (which varies widely among plans), whether coverage is available in the coverage gap, and whether some of your drugs are simply not covered under each plan. The sensible decision would be to enroll in one of the plans that will result in the lowest overall cost out-of-pocket to you each year.

You or a friend or relative can use the Medicare plan comparison tool on the Internet at the Medicare website http://www.medicare.gov/. You can also telephone Medicare at (800) 633-4227. The local SHIP program also provides this service to you at no cost. Call SARCOA (334) 793-6843 to make an appointment for assistance.