People With Medicare and HIV/AIDS

If you have Medicare and have HIV/AIDS, you need to know

1. Starting January 1, 2006, Medicare prescription drug coverage becomes available to everyone with Medicare.

2. If you have both Medicaid and Medicare, then Medicare will help pay for your prescription drugs starting January 1, 2006. Your Medicaid drug coverage ends on December 31, 2005.
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3. You may qualify for extra help paying for your Medicare prescription drug costs.

4. All Medicare drug plans will cover all antiretroviral medications.

5. Even if you don't qualify for extra help, you should join a Medicare drug plan by May 15,2006, to pay lower premiums.

1. What Is a Medicare Drug Plan?

Medicare prescription drug coverage becomes available to everyone with Medicare starting January 1, 2006. Medicare drug plans provide insurance coverage for prescription drugs. These plans will be offered by insurance companies and other private companies. Plans will cover both generic and brand-name prescription drugs. You can choose and join the plan that meets your needs. There are two types of Medicare drug plans. There will be Medicare Prescription Drug Plans that add coverage to the Original Medicare Plan.

There will also be prescription drug coverage that is part of Medicare Advantage Plans (like HMOs and PPOs) and other Medicare Health Plans. You would get all of your Medicare health care through these plans.

People with Medicare with HIV/AIDS can benefit substantially from Medicare's new drug coverage. Medicare will cover about 50% of the drug bill for the average person and even more, 96%, for those with limited incomes and resources. For most people, joining now means you will pay a lower monthly premium in the future since you may have to pay a penalty if you choose to join later.

2. If You Have Both Medicaid and Medicare, What Happens to Your Drug Coverage?

If you have both Medicaid and Medicare, then starting January 1, 2006, Medicare will help pay for your drugs. Medicaid drug coverage ends for people with Medicare on December 31, 2005. To make sure that you don't lose a day of coverage, Medicare will automatically enroll you in a Medicare drug plan if you don't join one on your own. You will get a notice in the mail in October which tells you more about the drug plan you will be enrolled in and how you can choose a different plan if you wish. You can join a Medicare drug plan starting November 15, 2005.

If you have Medicare and Medicaid, you automatically qualify for extra help paying your Medicare drug plan costs. You will have no or low copayments when you join a Medicare drug plan:

• You will have no copayments if you live in an institution such as a nursing home.

• You will have copayments of up to $1 for generic drugs and up to $3 for brand name drugs if you have a yearly income at or below $9,570 ($12,830 for married couples living together).*

• You will have copayments of up to $2 for generic drugs and up to $5 for brand name drugs if you have a yearly income above $9,570 ($12,830 for married couples living together).*

3. Do You Qualify for Extra Help Paying Prescription Drug Costs?

You may qualify for extra help if you have limited income and resources. If you get Medicaid, belong to a Medicare Savings Program (such as QMB, SLMB, or QI), or get Supplement Security Income (SSI) benefits, you automatically qualify for extra help and don't need to apply. Others with limited incomes and resources need to apply:

What Are the Income Limits?

If your annual income is below $14,355 (or $19,245 if you are married and living with your spouse), you may qualify. These amounts may be higher if

• you provide at least half of the support of other relatives living in your household or

• you reside in Alaska or Hawaii, or

• you are working

There are also income exclusions for the working blind and disabled.

What Are the Resource Limits?

To get the extra help with Medicare drug plan costs, your countable resources generally must be valued below $11,500 (or $23,000 for married couples living together). The resource limits include $1,500 per person for burial expenses. Resources include the value of things you own. Some examples of countable resources are

• real estate (other than your primary residence)

• bank accounts, including checking, savings and certificates of deposit

• stocks

• bonds, including U.S. Savings Bonds

• IRAs

• mutual funds

• cash at home, or anywhere else

Some things are not counted as resources, such as

• your primary residence

• your vehicle(s)

• your household goods and personal possessions -- resources you could not easily convert to cash, such as farm machinery and livestock, jewelry and home furnishings

• federal income tax refunds

• property you need for self-support such as rental property, or land you use to grow produce for home consumption

• life insurance policies owned by an individual with a combined face value of $1,500 or less. An individual and spouse could have a total of $3,000.

Starting the end of May and through August 16, 2005, the Social Security Administration (SSA) is sending people with certain incomes an application for extra help paying for Medicare prescription drug coverage. If you think you may qualify, fill out the application and return it in the postage paid envelope. If you don't get an application in the mail, but think you may qualify, you can request one by calling SSA at 1-800-772-1213. Beginning July 1, 2005, you can go to www.socialsecurity.gov on the web to apply online. After you apply, you will get a notice in the mail that tells you if you qualify for extra help. If you live in the territories, each territory will design its own program for providing extra help to their residents with limited income and resources.

If You Qualify for Extra Help

• you need to join a Medicare drug plan in your area that meets your drug needs. You can enroll in a plan beginning November 15, 2005. If you don't choose and enroll in a plan by May 15, 2006, Medicare will enroll you in a plan so you don't miss out on this important coverage.

If You Don't Qualify for Extra Help

• you can still join a Medicare drug plan that meets your drug needs. You will have to pay a monthly premium (generally around $32 per month in 2006), the deductible, and copayments. You can enroll in a plan beginning November 15, 2005.

• if you don't currently have prescription drug coverage that is at least as good as standard Medicare prescription drug coverage, you should enroll in a Medicare drug plan by May 15, 2006, to avoid paying a penalty.

  Your future opportunities to enroll may be limited to November 15 - December 31 of each year. The penalty is that your premium cost will go up at least 1% per month for every month that you wait to enroll. You will have to pay this penalty for as long as you have Medicare prescription drug coverage.