Posts Tagged ‘Donut hole’

Florida ADAP Premium/Plus AIDS Drug Assistance Program
Client’s Frequently Asked Questions -MEDICARE PART D/TrOOP
In order to receive Medicare Part D coverage, persons who are eligible to receive Medicare must sign up for a prescription drug plan (PDP) that is either stand-alone or offered through a Medicare Advantage plan. Part D provides an outpatient prescription drug benefit for anyone
receivine Part A or enrolled in Part B.

1. What is TrOOP?True out-of-pocket (TrOOP) costs are expenses
that count toward your Medicare drug plan out-ofpocket
costs of $4,550 (for 2010 and 2011).
2. What is Low-Income Subsidy (LIS)Low-Income subsidy is also known as “extra help”.
It lowers the costs of your Medicare prescription
drug coverage. If you are eligible to receive
Medicare, you should apply for LIS.
3. How do I qualify for the Low-Income Subsidy
(LIS)? You may be able to get extra help to pay
for your monthly premiums, annual deductibles,
and co-payments related to the Medicare
Prescription Drugs. You must be enrolled in a
Medicare Prescription Drug plan to get this extra
help. For more information call Social Security tollfree
at 1-800-772-1213 (TTY 1-800-325-0778) or
visit: http://www.socialsecurity.gov .
Your case manager or ADAP contact in your area
may be able to assist.
4. When will ADAP dollars be eligible to count
towards TrOOP?
Beginning January 1, 2011.
5. Will I be able to remain in ADAP if I cannot
afford to access (i.e., pay deductibles or
co-pays) my Medicare benefits?
Yes. ADAP will continue to serve you if you cannot
afford to access your Medicare plan.
6. If ADAP count towards TrOOP, will ADAP be
able to help me pay my deductible and/or copayments?

In April 2011, ADAP will contract with a provider to
assist with co-payments and possibly deductibles.
7. What are my responsibilities while enrolled as a
client of the ADAP Premium Plus Program?
You must pay your deductible and maintain your
plan premiums for Medicare Part D. If you are
unable to cover your deductibles, ADAP will serve
you. See Question 5.
You must apply for the Low-Income Subsidy (LIS),
also known as, Extra Help.
8. What is ADAP Premium Plus?ADAP Premium Plus is a new module within
the ADAP database specifically created to manage
clients with private insurance and Medicare Part D.
9. Will I be able to remain in ADAP after I have
gotten through the Donut Hole?
Yes. ADAP will continue to serve as your
medication benefits coordinator.
10. How will I be notified when I reach catastrophic
Your Medicare Prescription Plan keeps track of
your TrOOP costs. Every month that you buy or
receive prescriptions covered by your plan, you will
get an explanation of benefits (EOB) in the mail
showing your TrOOP costs to date.
11. Will I be terminated from ADAP Premium Plus if
I don’t continue my Medicare Part D premiums?
Yes. A client who is eligible must be enrolled in
Medicare Part D in order to continue to receive
ADAP services and assistance with TrOOP.

For more information regarding Medicare Part D call Social Security toll-free at
1-800-772-1213 (TTY 1-800-325-0778) or visit: http://www.socialsecurity.gov .
Your case manager or ADAP contact in your area may also be able to assist you.


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The Health Care Act changes each year
Here are highlights of some changes that may affect group members

-HELP FOR UNINSURED AMERICANS WITH PRE-EXISTING CONDITIONS UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH‐RISK POOL)—Provides access to affordable insurance for Americans who are uninsured because of a pre‐existing condition through a temporary subsidized high‐risk pool. Effective in 2010.

-ENDS RESCISSIONS—Bans insurance companies from dropping people from coverage when they get sick. Effective 6 months after enactment.

-BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on prescription drugs in the donut hole; also completely closes the donut hole by 2020.)

-FREE PREVENTIVE CARE UNDER MEDICARE—Eliminates co‐payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011.

-EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE—Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice. Effective 6 months after enactment.

-HELP FOR EARLY RETIREES—Creates a temporary re‐insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55‐64. Effective in 2010.

-BANS LIFETIME LIMITS ON COVERAGE—Prohibits health insurance companies from placing lifetime caps on coverage. Effective 6 months after enactment.

-BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans. These tight restrictions will be defined by HHS. Effective 6 months after enactment. (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.)

-FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles. Effective 6 months after enactment.

-NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective 6 months after enactment.

-ENSURES VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.

-COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2011.

-INCREASES THE NUMBER OF PRIMARY CARE PRACTITIONERS—Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants. Effective beginning in fiscal year 2011.

-PROHIBITS DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. Effective 6 months after enactment.

-HEALTH INSURANCE CONSUMER INFORMATION—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals. Effective beginning in fiscal year 2010.

-HOLDS INSURANCE COMPANIES ACCOUNTABLE FOR UNREASONABLE RATE HIKES—Creates a grant program to support States in requiring health insurance companies to submit justification for all requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new Health Insurance Exchanges. Starting in plan year 2011

Contributing writer; -RJ

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32 guys showed up to hear Sonia Diaz’s presentation on Positive Healthcare. She brought light snacks and as I was showing people our Christmas Tree downstairs (which is absolutely FABulous), someone offered us the 2 leftover trays of meatballs and meatballs. So we had a full meal.

Sonia gave everyone a package that presented the plans Positive Healthcare offered. They ONLY offer plans to people on Medicare or Medicaid. Positive Healthcare is a non-profit organization designed for people with HIV and as such is the only health care plan designed this way. She explained the the difference between Medicare and Medicaid, the difference between Medicare Part A, B, C and D and HMO, PPO and Point of Sale healthcare plans. She went into detail about the donut hole for prescription drug coverage explaining to us the different level:

1.First $310 is paid by the patient

2.Drug cost up to $2840, the patient pays 25% (2840-310 = 2530 x 25% = 632.50).

3. Donut Hole: Drug cost up to $4550 where the patient pays 100%. (4550 – 2840 = 1710)

4. Catastrophic Coverage; after 4550, the patient pays a flat 5%

Positive Healthcare is an HMO which is a plan where you have a nurse oversee your healthcare and you only see doctors in-network. A plan like this has a lower premium than a PPO.

Medicare only pays 80% of your medical needs. You are responsible for the other 20%. The Positive Healthcare plan covers all 100% being a medicare and supplemental plan.

It was a tough audience and a few people were asking her off-topic questions. The health care system in this country is inadequate and we can’t blame the companies for this situation. The government needs to resolve this issue.

I want to thank Sonia Diaz and Positive Healthcare for this presentation, the food and for being a company that specializes in HIV. We do need you.

After break (the meatballs ran out). We talked about the new drug BIT225 coming out of Australian company Biotron that will allow the Natural Killer T-cells do their job and attack HIV by neutralizes the Vpu protein that now stops this from happening. This is exciting news and ground breaking. This is the first class of drug that moves from just stopping HIV replication to allowing the immune system to attack the virus. The drug is currently in Phase II studies, but we need to keep watch on this.

We also talked about up coming events, Friday Night movie, Saturday night concert at MCC with Gay Men’s chorus, Saturday night LIFE Wonderland party at The Pride Center and Sunday church at MCC. There’s a lot scheduled this weekend, so take advantage of some of these activities and don’t forget to check out our Christmas Tree in the MAIN room (not the Lobby) of The Pride Center ( Look for the sign that says THIS TREE DECORATED BY THE MEN OF POSITE ATTITUDES). So bring your butt over to The Pride Center and hang your balls on the tree as a gesture of group support.


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From Tim:

I have been locked in a fierce battle for the Medicare Part D clients with ADAP regarding coverage once they reach Catastrophic. It seems as if I have lost. The answer I keep getting is that coverage for the “Doughnut Hole” is better than no coverage at all and that people with no other serious illness get assistance with their medication costs so they should be grateful they have not been cut entirely. Please get these clients to attend both the Tuesday SFAN meeting and the Wednesday Town Hall meeting as they really need for their voices to be heard. I have also been hit back with the idea that people chose not to vote on Election Day so we have to deal with the consequences. We desperately need Congress to provide additional funding and need to mobilize as a community.

Unless we can get them to change their mind, the rule is as follows for Medicare + ADAP:
1. Client must carefully pick a plan during the open enrollment plan which began today and runs through December 31, 2010 for plan to start on January 1, 2011.

2. They will be required to go to a retail pharmacy for their medications until they reach the Doughnut Hole. This will happen in January or February for most patients. They need to get the pharmacy to give them a print-out showing they have reached the Doughnut Hole and then they can briefly return to ADAP. ADAP will only assist them with HIV meds and Opportunistic Infection Drugs during this phase until the patient emerges from the Doughnut Hole and hits the “Catastrophic Phase.” Catastrophic occurs when the amount of True Out of Pocket Costs from the patient, ADAP and the 50% discount for Brand Name drugs provided by drug manufacturer’s reaches $4550. They are assuming that ADAP will only be assisting these clients for 2 months at most.

3. At this point, they will have to go back to retail pharmacy for remainder of year for ALL DRUGS and pay $2.50 generic, $6.30 brand, or 5% whichever is greater. For HIV drugs in particular it is going to be the 5% and can get really costly.

4. They need to work with their doctors to lower their costs, perhaps switching to low cost generics in any way possible to use the Walmart/Target $4 list, but ultimately their costs are going to increase A LOT. Some might want to join Medicare Advantage plans so they do not have to pay a premium. I have a feeling that Positive Healthcare Partners will be doing a big sell at the Town Hall meeting.

I know this is awful news, but I have fought this battle extremely hard without being able to win. I have given them specific examples yet I can get no one in power to see the harm this can cause. I have also been unsucessful in getting Ryan White Pharmacy to even consider helping those with Medicare Part D. I plan to keep fighting, but we really need to mobilize like we are back in the 1980’s again.

It is strongly encouraged that those who do not have many assets who may be above the 150% Federal Poverty Level ($16,245) apply for Extra Help at http://www.ssa.gov as they sometimes allow people with higher incomes on.

As far as those who are ADAP without Medicare, the change of reducing eligibility from 400% Poverty ($43,320) to 300% Poverty ($32,490) will not happen until February 1, 2011 instead of the December 1, 2010 we were dreading. If anyone in the group falls into this category, they need to meet with a Patient Assistance Program Navigator or their Case Manager to apply for Patient Assistance Programs as soon as possible. I have been told that these affected people “should” all be able to get all of their HIV medications from the Patient Asssistance Programs.

I hope you will post this or at least pass on to the group. If the SFAN meeting and the Town Hall meeting receive poor attendance, the will of Community Advocates will probably decrease.

I will assist any group member in any way that I can. Just ask.


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South Florida AIDS Network
Community Meeting
Everyone Welcome
ADAP Update (AIDS Drug Assistance Program)
Part D Plan Changes
“Donut Hole De-Mystification”
Opportunity for Questions/Answers
Tuesday, November 16th
5:30 PM Refreshments
6 PM Meeting
Location: Holy Cross Hospital
Sister Innocent Conference Center
Hospital Address: 4725 No. Federal Highway
Ft. Lauderdale, FL 33308
Auditorium is located on the South side of the hospital
map available on website: www.holy-cross.com

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