www.MedicareRights.org

Dear Marci,
I have Medicaid and someone said I should consider enrolling in a Special Needs Plan. Could you please tell me more about these plans?  —Eugenie

Dear Beatrice,

A Special Needs Plan (SNP) is a Medicare Advantage plan (a Medicare private health plan) that exclusively serves at least one of the following groups:

• People who live in a nursing home or Intermediate Care Facility for the Mentally Retarded (either specific nursing homes or those in a certain area) and people who live in the community but require an institutional level of care;
• People who have both Medicare and Medicaid (dual eligibles);
• People who have a specific chronic, severe or disabling condition, as defined by the plan (such as HIV/AIDS, diabetes or heart disease).

SNPs should be designed to provide Medicare-covered health care and services that meet the special needs of people in the groups they serve. SNPs must include drug coverage (Medicare Part D) as part of their benefits packages.

—Marci

Dear Marci,
I am about to turn 65 but I do not wish to enroll in a Part D plan at this time. Will I face a penalty if I delay enrollment?  —Alfred

Dear Alfred, If you do not enroll in the Medicare prescription drug benefit (Part D) when you first become eligible, and you choose to enroll at a later date, you may have to pay a premium penalty. The premium penalty will be 1 percent for every month you delay enrollment (1 percent of the national base beneficiary premium). For example, the national base beneficiary premium in 2012 is $31.08 a month. If you delayed enrollment for seven months, your monthly premium penalty would be $2.18 ($31.08 x 1% = $0.3108 x 7 = $2.18), which will be added to your plan’s monthly premium.

If you have to pay the premium penalty, and you do not qualify for Extra Help, you will have to do so for as long as you are enrolled in the Medicare prescription drug benefit. This penalty will increase every year, as the national base beneficiary premium increases.

In some specific circumstances you will not have to pay the premium penalty. You will not have to pay a premium penalty for late enrollment if:

• You already have prescription drug coverage at least as good as Medicare’s (“creditable coverage”). In order to avoid a premium penalty, you cannot have been without creditable drug coverage for more than 63 days. Speak with your insurer or your company’s human resources department to find out if your current drug coverage is as good as Medicare’s or better.
• You qualify for Extra Help and enroll in a Medicare private drug plan.
• You show that you received inadequate information about whether your drug coverage was creditable.

—Marci

Dear Marci,
My Extra Help application was denied. I am struggling to afford my drugs. What should I do?  —Nigel

Dear Nigel,

If your Extra Help application is going to be denied, you will receive a Pre-Decisional Notice telling you this in advance. This notice will tell you that you may not be eligible for Extra Help and show which information from your application will cause you to be rejected (for example, your income is too high). If you receive this notice and the information is wrong, you can use this opportunity to correct your application. You have 10 days from the date on the notice to correct the information.

Once the Social Security Administration (SSA) has reviewed your application, you may receive a Notice of Denial that says you do not qualify or a “Notice of Award” that says you qualify only for partial Extra Help. If you disagree with the SSA’s decision, you can appeal.

It is best not to reapply for Extra Help in either case. It is important to appeal, because if you win, your Extra Help will be effective from the first day of the month that you originally submitted an application. In order to appeal, you should:

• Request a review of your case (a hearing) within 60 days of receiving notice of SSA’s decision on your application.
• Set a date for a hearing. Call your local SSA office or the national hotline (800-772-1213). You can also download an online form and mail it in to request a hearing.

Hearings are held by phone. You will get a notice in the mail that confirms your hearing date and tells you what number to call (the number will be toll-free). This notice will also explain how to send in evidence supporting your case (for example, bank statements that show your assets). If you have a scheduling conflict, you can reschedule once or twice if you have good cause (for example, if you were in the hospital).

If you do not want a hearing, you can ask for a case review, where an SSA agent will review your application and any additional information you send in.

—Marci

The Medicare Rights Center is dedicated to helping people with Medicare get the health care and medications they need and make the most of their Medicare rights and options. They also offer comprehensive services to help people with Medicare and their caregivers fully understand the options and sources of support that are available to them. Learn more on the website at MedicareRights.org