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Licensed Medicare Part D agents represent virtually every insurer in the United States. No one knows the rules and regulations of the Medicare industry better than the local insurance agent.

Medicare Insurance Plans

Dual Eligibles And Medicare Part D: They Are Auto-Enrolled

prescription part d

Dual Eligibles And Medicare Part D

The so-called Medicare dual eligibles and the Medicare Part D are somewhat synonymous, that is, if you ever hear about Part D, you will almost always hear about dual eligibles.

But what are dual eligibles?

A dual eligible is a person who is eligible to receive the benefits of both Medicare and Medicaid. There are around 6.4 million dual eligible Medicare recipients and of them, 500,000 have developmental disabilities.

People with disabilities who are at the same time dual eligible usually also receive Social Security benefits and Supplemental Security Income (SSI).

There are some key facts that dual eligibles need to know about Medicare Part D. And just what are these keys facts?

Medicaid’s prescription drug coverage for dual eligibles has been replaced by private prescription drug plans or PDP’s. All Medicaid prescription drug plans ceased on December 31, 2006.

The PDPs may not provide the same prescription drug coverage that was once provided by the Medicaid programs of many states.

There are complicated procedures and rules governing Medicare’s PDPs.

If a person is only receiving Medicaid, he or she is not affected by changes in Medicare’s prescription drug coverage.

Medicare beneficiaries are not required to enroll themselves in a Part D plan. However, if a dual eligible dis-enrolls from a Part D plan, he will not have any prescription drug coverage at all. In case you didn’t know it, Medicare automatically enrolls dual eligibles to a PDP. Dual eligibles are allowed to switch from their auto-enrolled PDP programs to another PDP program. If they dis-enroll from their existing program but do not enroll in another program, they will not have any prescript drug coverage at all.

In sum, while there is a lot of press on how Medicare Part D is a voluntary program for Medicare beneficiaries, it is not the case for dual eligibles – they are auto-enrolled in Medicare Part D plans.

Dual eligibles can choose to dis-enroll from their auto-enrolled program to another program. There are so many plans to choose from. There are at a least 17 programs available throughout the United States, and there are additional programs available in each state.

Criteria For Choosing A Plan

In choosing a plan, the main things that dual eligibles must consider is the rates and their needs. There is no sense assuming that a PDP program automatically assigned to a dual eligible is going fits perfectly to his or her needs. Every year, the PDP plans change. Their formularies may also change too. It always pays to check if your auto-assigned plan really fits your needs.

But here are some tips in choosing a PDP plan:

Dual eligibles and/or their caregivers should evaluate the formularies (or list of drugs) of the various plans to check if the plan covers all their needed prescription drugs. It also pays to check if there restrictions in accessing those drugs.

If none of the plans cover the dual eligible’s prescription drug needs, dual eligibles and/or their caregiver need to consult their doctor. The doctor can do two things: appeal to seek exception to the chosen plan, or prescribe safe substitutes to the dual eligible’s prescription medicines.

JM-07-2012