If an individual has met a state’s criteria for Medicaid in any month between March and the end of 2005, they are deemed eligible for the full 2006 benefit year for Part D. In August, 2006, CMS will compare state data from 2005 with state data for Medicaid eligibility in 2006 to determine both the spend down eligibles (Medically Needy) and those qualified for the MSP (partial duals) to determine eligibility for Part D in 2007.

• Medicare prescription drug coverage is insurance provided by private companies, Medicare Prescription Drug Plans (PDPs), that have been approved by Medicare.
• The new program starts January 1, 2006, and will be available to everyone with Medicare.
• Individuals can get coverage through the new program in two ways:
• Through Medicare Advantage or other Medicare Health Plans (i.e., Medicare Part C such as HMOs, etc.).
• Through independent Medicare Prescription Drug Plans (PDPs), to which they pay a monthly premium.
• All plans must offer coverage that is at least as good as the current standard Medicare Advantage prescription drug coverage.
• Some plans may offer wider prescription drug coverage with additional drugs for higher monthly premiums.
• Those with limited incomes and resources may be eligible for extra help. See sections on “Costs” and "Extra Help.” 

All people with Medicare are eligible for enrollment in Medicare prescription drug plans, including:

• Fee-for-Service beneficiaries enrolled in the Medicare Part A and/or Part B plan;
• Medicare Advantage beneficiaries enrolled in a Medicare Private Fee-for-Service Plan that does not provide qualified prescription drug coverage; and
• Medicare Advantage beneficiaries enrolled in a Medical Savings Account (MSA) plan.

• Individuals who are eligible for both Medicaid and Medicare will be automatically enrolled by CMS in the lowest premium prescription drug plan. These individuals will no longer receive medications through Medicaid.
• Dual eligibles will be sent a letter in late October-early November, informing them of which plan they have been enrolled in. They may switch plans at any point thereafter, but coverage will begin on January 1, 2006.
• Partial dual eligibles are those that "spend down" to obtain Medicaid coverage. If a person spends down once between August 1, 2005 and November 1, 2005, they will be auto-enrolled in a PDP and qualify for extra help.
• Others who are currently eligible for Medicare Savings plans or Supplemental Security Income will be automatically enrolled into a Medicare prescription drug plan by CMS facilitation by June 2006 and qualify for extra help. These individuals currently have some assistance with Medicare premiums, co-insurance, and/or deductibles, but are not on Medicaid, and are known as "other low-income subsidy eligibles."

• Individuals can begin to voluntarily enroll in a Medicare plan to gain access to prescription drug coverage from November 2005 to May 2006.
• Individuals interested in enrolling in Part D can submit an application to an approved Medicare prescription drug plan that serves their locale.
• Information on the plans in their area will be sent to them in Fall 2005.
• Plan Finder and formulary search tools will be available online at www.medicare.gov.
• If an individual does not enroll by May 2006 and wants to join a Part D plan later, a higher monthly premium will be imposed thereafter (1% for each month). 

Medigap

• New Medigap policies that cover prescription drugs will not be available for purchase after January 1, 2006. 
• In Fall 2005, people with Medicare will receive a notice from their Medigap insurance company describing choices for prescription drug coverage. 

Employer/Union

• Employers and unions are expected to send information to people with Medicare by November 14, 2005, to let them know how their current drug coverage compares to Medicare’s standard prescription drug coverage.
• If the current prescription drug coverage is at least as good as the Medicare prescription drug plan, you can keep it.
• If the current prescription drug coverage is not as good as the Medicare Part D plan, individuals must enroll in a Medicare plan by May 2006 or pay a penalty (1% for each month) thereafter. 

Medicare Advantage (HMO, PPO, PFFS) or other Medicare Health Plan

• Medicare is working with Medicare Advantage (MA) or other Medicare Health Plans to help provide more coverage at lower costs.  Beneficiaries should receive a notice from their plan about prescription drug choices.
• If an individual is currently enrolled in a MA managed care plan, he or she will get drug coverage from that MA plan if he or she decides to stay in that plan.  An individual can switch to another MA plan in his or her area that offers prescription drug coverage, or he or she can switch to the Original Medicare Plan and join an independent Prescription Drug Plan (PDP).

Federal/Veterans

• As long as people with Medicare still qualify, TRICARE, Veterans’ Affairs (VA), and Federal Employee Health Benefits Program (FEHB) coverage is not changing.

Providers working with consumers who have serious mental health disorders, such as case managers, assertive community treatment team members, substance abuse treatment providers and staff in residential and psychiatric hospitals, will have a crucial role in helping consumers access and transition to the new Medicare prescription drug coverage.

The new benefit is extremely important for persons with mental illness. Many of these individuals are currently without drug coverage or are receiving prescription drugs through Medicaid. For those without coverage, the benefit means that they will now be able to participate in a prescription drug program. Without assistance, confusion is likely and some consumers may "fall through the cracks." Many consumers, because of changes in residence, hospitalizations, or cognitive impairments may not even be aware of the changes in their prescription coverage, nor what they must do to access prescribed mental health medications.

• Drug coverage will be provided through independent contractors known as prescription benefit managers or prescription drug plans (PDPs).
• All prescription plans should be announced in September or October 2005 by the Centers for Medicare and Medicaid Services (CMS), with enrollment beginning on November 15, 2005.
• Prescription drug plans will provide information on the specific pharmacies in their networks.
• For more information on the drugs that will be included on the prescription drug plans, see section on “Formularies.”

• All Medicare Advantage Prescription Drug Plans (MA-PDs) and independent Prescription Drug Plans (PDPs) will contract directly with pharmacies across the country.  Each plan will have its own pharmacy network.
• Consumers should review their plan’s pharmacy list to find out where they will have to go to fill their prescriptions.  It is important to note that a consumer’s current pharmacy may not necessarily participate with his or her new PDP.

• If a consumer already has drug coverage, he or she should talk with their current plan, benefits administrator, or insurer before making any decisions about whether Medicare’s prescription drug coverage would be better.  CMS has said that insurers will be getting in touch with their beneficiaries to let them know whether their current plans are at least as good or better than that being offered under Medicare Prescription Drug Coverage.
• If a consumer doesn’t currently take many prescription drugs, he or she might still want to consider signing up for one of the lower premium plans to avoid the penalty charge to enroll later.

• Enrollment is from November 15, 2005 to May 31, 2006.
• If they sign up by December 31, 2005, coverage will begin January 1, 2006.  If they join from January to May 2006, their coverage will begin on the 1st day of the following month.
• If a consumer is not automatically enrolled and does not sign up by May 2006, he or she may have to wait until November 16, 2006 to join, and the premium cost will go up at least 1% per month for every month that he or she waits to enroll.
• Beginning in November 2005, people with Medicare (who are not already automatically enrolled) should be able to contact the prescription drug plans in their area directly to enroll, or may do so by calling 1-800-MEDICARE.