Journal of Gerontological Nursing


What You Need to Know

Kathleen C Buckwalter, RN, PhD, FAAN


Answers to Medicare Prescription Drug Coverage Questions


Answers to Medicare Prescription Drug Coverage Questions

Friends, family members, neighbors, and clients are likely to question gerontological nurses about the forthcoming Medicare drug benefit, which begins January 1, 2006. Therefore, this editorial provides some straightforward answers gerontological nurses can use to respond to frequently asked questions about the new Medicare Prescription Drug coverage.

When is the enrollment period?

The 6 -month sign-up period for the new drug coverage begins this month (November 15, 2005) and continues through May 15, 2006.

Who is eligible?

The new Medicare drug benefit is open to anyone enrolled in Medicare Part A or Part B. New Medicare enrollees may sign up for prescription drug coverage when they enroll in Medicare.

What happens to older adults who don't sign up by May 15, 2006?

Those individuals who fail to enroll during the 6 -month sign-up period and who do not have existing drug coverage that is equal to or better than Medicare coverage will have to pay a penalty (1% of the premium for each month they delay) when they sign up at a later date. This penalty will be paid for the rest of their lives, so it is important for nurses to encourage older friends and clients to enroll during the prescribed 6-month period.

What will individuals have to pay under the new coverage plan?

Medicare will contract with private companies to offer prescription drug plans. Several states will have more than 20 Medicare-approved plans. Some will offer additional benefits that may increase premium costs. The average premium for Medicare's standard drug benefit is estimated to be approximately $32 per month, though the monthly premiums for many drug plans will be $25 or less.

Older adults who select a standard benefit drug plan will have to pay the first $250 of drug costs (the deductible) every year. After the deductible is paid, Medicare pays 75% of the next $2,000 in drug costs, and the older adult pays 25%, or $500 (coinsurance). After total drug costs reach $2,250, the older adult pays 100% of costs for the next $2,850 (called the "coverage gap"). Once out-ofpocket costs reach $3,600 ($250 deductible + $500 coinsurance + $2,850 coverage gap), Medicare pays 95% of all remaining drug costs. Many drug plans, however, will have different cost-sharing systems. Some will have zero deductibles, tiered co-payments for generics and brand-name drugs, and coverage for generics in the coverage gap.

What about those with limited resources and incomes who may have difficulty paying the premium and drug costs?

Individuals on Medicare may be eligible for "extra help" paying the premium and some of the drug costs if they meet certain annual income and resource requirements. The Social Security Administration accepts on-line applications for this program at

What will happen to older adults whose prescription drug costs are already covered by Medicaid? Should they sign up for the Medicare drug coverage?

Gerontological nurses should tell their older clients who currently have their prescription drug costs covered by Medicaid that starting January 1, 2006, their drug coverage will be provided by Medicare. They should be automatically enrolled in a Medicare drug plan and receive extra help paying for premiums and drug costs. Nurses should alert older individuals and those who help them with their health care and finances to be on the lookout for mailings from Social Security and Medicare about these issues.

Is the new Medicare prescription drug coverage available to adults residing in nursing facilities?

Anyone on Medicare Part A and/or Part B as of January 1, 2006 is eligible to enroll in a plan, including those in nursing homes. The enrollment period and penalties are the same for nursing home residents as for others. Gerontological nurses may be called on to help nursing home residents find a plan that best meets their needs. To do so, nurses should first find out which long-term care pharmacies the nursing home uses, then determine which Medicare drug plans have these pharmacies in their network. Finally, nurses should make certain that most, if not all, the drugs taken by the nursing home resident are covered by the Medicare plans under consideration. This information is available on the Medicare website -

To whom can I refer individuals to for help in comparing Medicare drug plan options?

Each state has a Senior Health Insurance Information Program (SHIP). These programs provide free one-on-one guidance to older adults and caregivers. Contact information for all the SHIPs is available at www.medicare. gov/contacts/static/allState Contacts. asp

The author acknowledges Mike Klug from the University of Iowa Center on Aging for review and comment on the content of the editorial.

Kathleen C. Buckwalter, RN, PhD, FAAN

Kathleen C. Buckwalter, RN, PhD, FAAN


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