Oh, The Plans They-Are-A-Changin’
Medicare Part D
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Staff Attorney

Staff Attorney

Medicare Part D “Open Season” Begins – Challenges Remain as Many Recipients Face Possibility of Increased Costs and Less Coverage in 2010.

This past Sunday, November 15th, marked the first day of the Medicare Part D “open season,” the time when Medicare enrollees attempt to navigate the maze of prescription drug plans to find the one that will best meets their needs in 2010.  For the fourth year, Legal Aid in partnership with the Whitman Walker Clinic Legal Program, will host free walk-in clinics and conduct extensive outreach among our current and former clients, as well as the greater DC community, to assist enrollees with the selection process.  These clinics are staffed by our lawyers as well as generous volunteers from area law firms.  Since the fall of 2005, Legal Aid staff and pro bono volunteers have helped hundreds of low-income Medicare beneficiaries avoid health crises by ensuring that they are in appropriate prescription drug plans. 

Medicare Part D is a dizzying array of private drug plans – each of which has its own drug formulary (list of covered medications), monthly premium, and set of restrictions.  Low-income Medicare beneficiaries in the District – those with income below 300 percent of poverty (or about $2,700 per month for a household of one in 2009) – can receive the Low-Income Subsidy to pay most of their portion of the drug costs.  Beneficiaries who receive this subsidy have limited co-pays for their drugs, and many do not have to pay a monthly premium.  But the number of plans that do not charge a premium for low-income beneficiaries continues to shrink.  As recently as 2007, for example, low-income enrollees could choose from over twenty five zero-premium drug plans in the District.  For 2010, that number has dropped to eleven.  As such, it has become increasingly difficult for low-income Medicare enrollees in the District to find a zero-premium plan that meets their prescription drug needs.

Moreover, most of the various drug plans change their formularies, add or eliminate restrictions, and vary their premiums on an annual basis.  These changes go into effect each January, and can take enrollees by surprise.  For instance, some low-income enrollees learn that their plan has begun to charge a monthly premium only when they start receiving bills in January.  Others learn that one of their medications is no longer covered when they go to their pharmacy and are told they must pay full price.  Still other enrollees find that, although a medication is still covered, their plan has imposed a new restriction on the drug, such as a quantity limit or prior authorization.  Such barriers can delay enrollees’ access to critically important medication.

The story of two Legal Aid clients, Mr. and Mrs. S, illustrates why an individualized analysis is important for every enrollee.  When Mr. and Mrs. S came to Legal Aid, they were covered by drug plans that did not adequately meet their medical needs.  Both clients needed several medications that were not covered by their plans, and so were forced to pay out of pocket.  Furthermore, even though they qualified for the Low-Income Subsidy, neither client was enrolled in the program.  This meant they were being charged a monthly premium, and were responsible for higher co-pays for their drugs.  Legal Aid was able to help Mr. and Mrs. S enroll in the Low-Income Subsidy.  Legal Aid also helped them each identify a zero-premium drug plan that covered all their medications with no restrictions.  As a result, Mr. and Mrs. S no longer pay a monthly premium for their drug coverage, and pay only limited co-payments for their medications.

However, the story of another Legal Aid client, Ms. D, illustrates how the dwindling number of zero-premium plans can greatly reduce options for low-income enrollees.  When Ms. D came to one of Legal Aid’s walk-in clinics last year, we discovered that every zero-premium plan in the District applied significant restrictions to many of her medications.  Only one drug plan did cover all of Ms. D’s medications without any restrictions, a plan that included a monthly premium of more than $40.00.  Despite Legal Aid’s efforts to help Ms. D avoid these restrictions, it became clear that all of the zero-premium plans would greatly restrict her access to important medications.  Ms. D, therefore was forced to choose between an affordable plan that did not best meet her medical needs, or a plan that would further strain her already limited income.  Ultimately, because she did not want lose access to important medications, Ms. D chose to pay the high monthly premium.  Because this plan’s premium is likely to rise even more next year, Ms. D will likely face another difficult decision in the coming weeks. 

Medicare Part D, along with the Low-Income Subsidy, helps many seniors and people with disabilities access drugs that would otherwise be prohibitively expensive.  But another reality of Part D is that many Medicare enrollees need a great deal of assistance to identify and enroll in the most appropriate drug plan.  As the health care debate continues to rage at the national level, Medicare Part D illustrates how a complex and confusing program can often prevent those most in need of fully realizing the program’s benefits. 

So if you or someone you know is a low-income Medicare beneficiary with income below $2,700 per month for a household of one, please come to one our free walk-in clinics.  The remaining dates, times and locations are listed below.  If those dates and times don’t work, please call 202-628-1161 to get a phone or in-person appointment for help.



Date & Time

Advocates for Justice & Education

The “Big Chair” Building:

2041 Martin Luther King Jr. Ave. SE, Office #400

Friday December 4 from 9:00a to 12:00p 

Bread for the City

Northwest Office

1525 Seventh St., NW

Tuesday December 8

from 5:00p to 8:00p 

The Legal Aid Society

Main Office

1331 H St. NW, Suite 350

Near Metro Center

Weds. December 9

From 9:00a to 12:00p

Bread for the City

Southeast Office

1640 Good Hope Road, SE 

Tuesday December 15

from 9:30a to 1:00p 

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