Special Elections Periods for Dual Eligibility and Extra Help Changes in 2019
Medicare Beneficiaries, Medicare plan providers, and caregivers can expect some significant changes in 2019. The most noticeable is a change to the Special Election Period of a Low-Income Subsidized (LIS) Medicare Beneficiary, the new Open Enrollment Period, and the closing of the coverage gap. All the upcoming changes make it an exciting time and will provide much needed relief to Medicare Beneficiaries
Currently Medicare Beneficiaries that have a Low-Income Subsidy (LIS), or Medicaid, receive a special enrollment period that is ongoing. This special enrollment period is labeled as the LIS/Dual SEP. This means if the Medicare Beneficiary has any level of Medicaid or Extra Help (Low-Income Subsidy) they can change their Medicare Advantage Plan, or Part D Prescription Drug Plan every month is they so desire.
The changes in 2019 will adjust this Special Election Period (SEP) to available only once per quarter, during the first nine months per calendar year. Meaning a Medicare Beneficiary can only make one election, or change, during each of these periods: January – March, April – June, July – September.
The last quarter of the year falls during the Annual Enrollment Period so an additional Special Election Period for that quarter would be redundant. This will be a considerable change for Medicare Beneficiaries that fall into this category as currently they can change coverage plans at any time.
Medicare Beneficiaries Should Track Election Changes
Medicare Beneficiaries that qualify for the Special Election Period will need to know if they have made a change during that quarter. If a change has not been made, the Medicare Beneficiary is eligible to use the Low-Income Subsidy.
Low-Income Subsidy (LIS) / Dual Special Election Period (SEP) for that quarter. Once change has been made and the plan effective date arrives, no further changes can be made until the next quarter.
The Special Enrollment Period will be considered used if the Medicare Beneficiary has already made an election during that period, even if the start date is technically the beginning of the next quarter. In other words, if you selected to change your plan in June for a July 1st effective date, your SEP will be considered used for the second quarter.
New Plan Effective Dates
The effective date for a new plan will be the first day of the month following the election. If you change your plan selection in February, the new plan will begin on March 1st. Medicare Beneficiaries that select a plan change during the Annual Enrollment Period, can expect that plan change to begin on January 1st of the following year.
In some cases, the Center for Medicare and Medicaid Services will allow special provisions for qualifying Medicare Beneficiaries. For example, if a Medicare Beneficiary becomes eligible for Extra Help (LIS) or Medicaid, and that person does not choose a plan, they will be automatically enrolled in a Part D Prescription Drug Plan.
This is an example of a situation that would allow for special provisions should the Medicare Beneficiary decide the imposed Prescription Drug Plan does not meet their needs.
Changes in Low-Income Subsidy or Medicaid Status
Another example in which the Center for Medicare and Medicaid Services would allow an additional Special Enrollment Period provision would be for Medicare Beneficiaries that have a change in their Low-Income Subsidy (LIS) or Medicaid status would be granted the liberty to change their selection.
Qualifying for Medicaid
Medicaid is a program that is run by the individual states. Some states have different names for Medicaid such as Medi-Cal in California, and Sooner Care in Oklahoma. Medicaid is an income-based medical insurance for people with low income. Each state has slightly different levels of income that would allow someone to qualify. Check with your local Medicaid office to get the guidelines for your state.
Low-Income Subsidy (LIS), also known as Extra Help, is a federal program that helps Medicare Beneficiaries with lower than average incomes pay for their drug costs. There are several different levels of Extra Help, which are determined by your income. Some Extra Help options have a lower deductible, if your plan has a deductible. On average, you will pay a lower cost share for your medications.
If you qualify for Full Extra Help, your prescription deductible will be waived completely. Your cost share for your prescriptions will be less than $10, and sometimes as low as $0.
When a Medicare Beneficiary applies for Extra Help, they can also apply for a Medicare Savings Program. (MSA) The MSA program can help the Medicare Beneficiary pay their Part B Medicare Premium.
If You Don’t Qualify for Extra Help, There are Other Programs Available
Most states offer a State Pharmaceutical Assistance Program. (SPAP) These programs assist residents in paying for prescription drugs. Each state’s program works a little bit differently, and the income level to qualify differs from state to state. States may coordinate their assistance programs with Medicare’s Part D prescription drug benefits also.
Another program that Medicare Beneficiaries can turn to is the State Health Insurance Assistance Programs. A SHIP program can help you with many questions regarding Medicare and can help you get assistance, if you qualify.
Protecting Medicare Beneficiaries Against Opioid Addiction.
In 2019 all Medicare Prescription Drug Plans and Medicare Advantage Plans that include drug coverage, will be implementing a drug management plan to monitor and limit Medicare Beneficiaries who are at-risk and have access to frequently abused drugs such as opioids and benzodiazepines.
This will allow Medicare Prescription Drug Plans and Medicare Advantage Plans with drug coverage to “lock-in” Medicare Beneficiaries. This feature will put a limit to selected pharmacies and prescribers, therefore reducing an at-risk Medicare Beneficiary’s ability to change plans with the intent to access frequently abused drugs, such as opioids.
Medicare Beneficiaries that are labeled as “at-risk” will not be allowed to use the LIS/Dual Special Enrollment period while they are labeled as such. Any Medicare Beneficiary labeled as “at-risk” will receive a written notice letting them know that they are not eligible to use their LIS/Dual SEP.
Other Special Election Periods
Medicare has many other Special Election Periods such as, moving out of your plan coverage area. For a full list of Special Election Periods, click here.
With the Annual Enrollment Period and the new Open Enrollment Period starting January 1st of 2019, most Medicare Beneficiaries will have more freedom to select who they will use for their health and drug coverage than in previous years.
Due to the Bi-Partisan act of 2018, Medicare Beneficiaries will have more protection when falling into the coverage gap. This act will limit a Medicare Beneficiary’s exposure to 25% of the cost of brand name drugs. Collectively, these changes are favorable additions for Medicare Beneficiaries.
These changes primarily affect Medicare Part D Prescription Drug Plans, and Medicare Advantage plans. For the most part, Medicare Supplement Plans remain unchanged and provide the most comprehensive coverage for protecting your health.
If you need help deciding on which Medicare plans are right for you, give us a call or complete our online rate form. We work with all the top carriers in your area and can help you understand the ins and outs of Medicare.