PDP Question

[Slade]

A client is turning 65 on July 1, 2010. She has been on Medicare and enrolled in a PDP for two years due to disability.

She will reach her coverage gap in mid June with her existing PDP plan. If she uses her open enrollment to change PDP plans to another carrier, will her initial coverage level of $2,830 be refreshed?

 

[jdeasy]

A client is turning 65 on July 1, 2010. She has been on Medicare and enrolled in a PDP for two years due to disability.

She will reach her coverage gap in mid June with her existing PDP plan. If she uses her open enrollment to change PDP plans to another carrier, will her initial coverage level of $2,830 be refreshed?

The open enrollment does not give her an SEP to change her PDP. Even if it did, the coverage gap would not re-set with a new plan.

 

[Slade]

Thanks for your response. After referencing "Medicare and You", although it isn't perfectly clear on the matter, I am in agreement with your statement.

I had the mistaken impression that age 65 provided a SEP.

 

[G.Gordon]

Nope... you get ONE IEP and then the normal AEP like everyone else. SEP's are for special circumstances and that does not include T65.

I have had people that have thought that since they have another Open Enrollment Season on medsupps they get another shot at PDP's.

 

[Josh]

The open enrollment does not give her an SEP to change her PDP. Even if it did, the coverage gap would not re-set with a new plan.

If a Medicare beneficiary switches from one PDP to another then it usually does reset. If someone is on PDP X for 1/1 effective and then switches to PDP Y for a 4/1 effective, they usually get the initial coverage limit reset.

 

[jdeasy]

If a Medicare beneficiary switches from one PDP to another then it usually does reset. If someone is on PDP X for 1/1 effective and then switches to PDP Y for a 4/1 effective, they usually get the initial coverage limit reset.

They might just because of a system error or the system not picking it up, but, technically, it does not reset.

It can rarely happen. About the only way it would happen is a person leaving an MAPD during OEP or a person moving out of the service area and getting an SEP.

The continuous SEP people, QMB, QI1, LIS, etc., don't have the coverage gap anyway, so, it's not an issue.

 

[Josh]

They might just because of a system error or the system not picking it up, but, technically, it does not reset.

It can rarely happen. About the only way it would happen is a person leaving an MAPD during OEP or a person moving out of the service area and getting an SEP.

As long as they're flipping carriers it will happen every time. CMS can barely keep track of enrollments, let alone actual utilization. Carriers don't tell each other how much of a members RX benefit they've used. You can call it a "loop hole" if you'd like, but it's a cool trick I like to point out. if they get 3 month scripts in January and another 3 months at the end of March it can effectively give them an total of 6 months of drugs per health insurance carrier. This works out especially great if they have two companies they like for the ma-pd coverage or if they can't chose between an MA-PD or a PDP and a supp, let them start the year with one and finish it with the other.

 

[G.Gordon]

The only people that "trick" will help is going to those that switch MAPD's during OEP be it MAPD to MAPD or MAPD to medsupp/PDP or the adverse. Those on LIS already have coverage through the gap so there is no need to them to "play" the system.

Another thought: As an insurance professional I wouldn't be telling folks about this trick. I'd view it as receiving benefits that they were not eligible for and therefore if somehow an audit of the system caught them they could be asked for that money back. It happens in medicaid all the time. So if you're telling them, they do it, they get caught, they'll finger you in a heart beat.

 

[Josh]

Another thought: As an insurance professional I wouldn't be telling folks about this trick. I'd view it as receiving benefits that they were not eligible for and therefore if somehow an audit of the system caught them they could be asked for that money back. It happens in medicaid all the time. So if you're telling them, they do it, they get caught, they'll finger you in a heart beat.

I have to disagree. They're receiving benefits they're more than entitled too. This is something that is completely legitimate and just an opportunity for Medicare beneficiaries to be able to maximize their Medicare benefit. They can "finger" me all they'd like, but there is nothing wrong with it. You're comparing it to Medicaid fraud, which is a completely different situation. Defrauding the system to obtain benefits they're not eligible for is much different than someone understanding the way Medicare works and receiving what they're entitled too.

 

[G.Gordon]

... whatever.

Medicare part D gives a certain dollar amount in benefits to each beneficiary per year. To receive more than that is crossing the line. I ain't saying I can blame them, but I wouldn't personally be "teaching" the lesson just to CYA.