Community Mental Health Centers should be able to help pay for co-payments, deductibles and premiums.  However, Medicaid cannot pay for these wraparound payments and these payments would probably not count towards an individual's True Out of Pocket Costs (TROOP).

Here is the CMS response to questions about what organizations can pay for out of pocket costs:

Out-of-pocket spending consists of costs related to the $250 deductible, the 25 percent beneficiary co-insurance (or equivalent co-pays) up to the initial coverage limit, 100 percent co-insurance during the coverage gap, and the roughly 5 percent co-insurance paid in the catastrophic coverage. By law, only cost-sharing paid by certain sources counts toward the drug benefit’s out-of-pocket limit, which defines the start of the catastrophic coverage. These sources include:

• The enrollee (or another person on behalf of the enrollee)
• CMS (on behalf of a low-income enrollee who qualifies for low-income subsidies), and
• A State Pharmaceutical Assistance Program (SPAP)

In the final rule, we define “person” (first bullet, above) in the legal sense of the word, to include unrelated corporations, so charities that are not connected to insurers or the beneficiary’s employer could have a role in helping beneficiaries with their out-of-pocket costs. Therefore, our broad definition of the term “person” captures not only “bona fide” charities, but other charitable organizations as well. Thus, even if a charity is not a bona fide charity for purposes of Federal fraud and abuse law, any drug payments it makes on behalf of Part D enrollees would count toward True out-of-pocket costs (TrOOP) unless otherwise excluded as payments by a group health plan, insurance or otherwise, or similar third party payment arrangement. Charities that are established, maintained, or otherwise controlled by an employer or union will likely fall under our definition of “group health plan” and will therefore be excluded from TrOOP on this basis.

The rule also outlines specific insurance and government programs that will not count toward the out-of-pocket limit. These include cost-sharing obligations subsidized in whole or in part by employers, other insurers, and government programs (for example, the Indian Health Service (IHS), Department of Veterans Affairs (VA), Department of Labor Federal Workers’ Compensation Program, Federally Qualified Health Centers (FQHCs); Medicaid; the State Children’s Health Insurance Program (SCHIP); black lung benefits; Ryan White CARE Act funds; and State special funds that assist certain individuals with their medical costs). Congress chose to distinguish between payers of out-of-pocket costs in order to encourage current employers, other insurers, and government programs to continue offering prescription drug coverage when the Medicare drug benefit begins.

The poverty level guidelines change by the number of people in your household, including dependents such as spouse, children, and elderly parents.  Here are the 2005 federal poverty income levels:

2005 HHS Poverty Guidelines

Persons in Family Unit	48 Contiguous States and D.C.	Alaska	Hawaii
1	$ 9,570	$11,950	$11,010
2	12,830	16,030	14,760
3	16,090	20,110	18,510
4	19,350	24,190	22,260
5	22,610	28,270	26,010
6	25,870	32,350	29,760
7	29,130	36,430	33,510
8	32,390	40,510	37,260
For each additional person, add	3,260	4,080	3,750

SOURCE:  Federal Register, Vol. 70, No. 33, February 18, 2005, pp. 8373-8375.

For the Medicare prescription drug benefit, you will qualify for extra help at 150% of the federal poverty level and for additional help at 135% of the federal poverty level.  Do remember that the Medicare prescription drug benefit also has an asset test, which significantly limits the number of people who can qualify for extra help.

Claiming a Dependent
You may claim a personal exemption for yourself and for your dependents, and this will impact the number of people in your household for purposes of calculating whether you qualify for extra help under the Medicare prescription drug benefit. You are entitled to claim a person as a dependent, if that person:

1. is your relative (if he/she is your immediate relative, he/she does not have to live with you),
2. earns less than $3,100 (or is a full-time student and under age 24),
3. receives over half of his or her support from you,
4. is a citizen or resident alien of the United States, Canada, or Mexico, and
5. does not file a joint return with his or her spouse.

For more detailed information, go to:
http://taxes.about.com/od/taxglossary/a/Dependents.htm#

No, only out of pocket payments for the cost of medications count.

People with Medicare above 150% of the Federal Poverty Level (FPL)

• Premium:
• The individual pays a monthly premium. This will vary depending on the plan chosen, but is expected to average about $32/month.
• Deductible:
• The individual pays a deductible of $250/year for prescriptions.
• Other prescription drug costs:
• After reaching the deductible, the patient pays 25% of the total cost of his or her drug from $250-$2,250 per year (At this point, the patient will have paid $750 in out of pocket expenditures, not including the premium cost).
• After drug costs reach $2,251, the individual pays for 100% of prescription drug costs until total drug costs reach $5,100/year (At this point, the patient will have paid $3,600 in out of pocket expenditures, not including the premium cost).
• After drug costs reach $5,100 in one year, the patient will pay 5% of any remaining drug costs or co-pays of $2 and $5.

An individual may qualify for help if his or her income is less than 150% of the Federal Poverty Level (FPL). This is equivalent to $14,355 for an individuals and $19,245 for a married couple living together, with resources less than $11,500 for an individual and $23,000 for a married couple living together for 2005 and may increase in future years.

Primary homes, cars, and personal possessions are not counted as assets, while other real estate, bank accounts, and stocks and bonds are counted.

The Social Security Administration (SSA) sent letters to individuals who may be eligible for additional assistance during the summer of 2005.

People with Medicare between 135% and 150% of FPL

• Equal to incomes between $12,919 and $14,355 for an individual and incomes between $17,320 and $19,245 for a couple; and assets between $7,500 and $11,500 for an individual and between $17,320 and $23,000 for a couple.
• There will be a monthly premium calculated on a sliding scale and a $50 deductible.
• They will pay 15% of total drug costs as co-insurance.
• Once their total out-of-pocket spending reaches $3,600, they will pay $2 generic and $5 brand name.

People with Medicare under 135% of FPL

• Equal to incomes below $12,919 for an individual and below $17,320 for a couple; and assets below $7,500 for an individual and below $12,000 for a couple.
• There will be no premium or deductible, and their co-pays will be $2/generic and $5/brand-name.
• No co-pays once out of pocket costs reach $3,600/year.

People with both Medicare and Medicare (known as “dual eligibles”)

• Dual eligibles automatically qualify for financial assistance called Extra Help. Their prescription drug coverage will switch from Medicaid to Medicare on January 1, 2006. CMS will automatically enroll these patients into a new Medicare prescription drug plan in the fall of 2005.
• For dual eligibles, there will be no premiums or deductibles, and their co-pays are $1/generic drug and $3/brand-name drug if their income is under 100% of FPL or $2/generic drug and $5/brand-name drug if their income is over 100% of FPL.
  • No co-pays if in an institution such as a nursing home or psychiatric hospital.
  • No co-pays once out of pocket costs reach $3,600/year.