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We are dedicated to making Medicare's program work well for all beneficiaries. Your feedback from your own or your client's concerns and experiences with Medicare, will guide our Medicare advocacy efforts with key policy and decision-makers in both California and nationally with the Centers for Medicare and Medicaid Services (CMS) and Congress.

  • 24May

    While we wish is was as simple as telling apples from oranges, Medicare Part B and Medicare Part D coverage is quite different in how they cover outpatient drugs. It depends on the drug, where you receive it, and whether you are in Original Medicare or have a Medicare Advantage plan. Understanding how Medicare covers drugs can help you address denials and avoid unnecessary expenses. Below are a few points to help in understanding this difference, summarized by the Medicare Rights Center in one of their Medicare Minute publications.

    Point 1: Understand how you get Medicare prescription drug coverage. You can get Medicare prescription drug coverage through a Part D stand-alone prescription drug plan or through a Medicare Advantage Plan that includes prescription drug coverage. The Part B benefit also covers certain prescriptions. You have the Part B benefit regardless of whether you have Original Medicare or a Medicare Advantage Plan.

    Point 2: Understand which part of Medicare covers which outpatient prescription drugs. Most outpatient prescription drugs are covered under Part D, as long as they’re on your plan’s formulary, which is the list of drugs they cover. Certain outpatient drugs are covered by Part B, however. For example, Part B should cover your flu shot. Antigens – a type of prescription drug often used to treat allergies – are also covered by Part B, not Part D. The general rule is that Part B covers drugs that usually can’t be self-administered, meaning you need a provider’s help to take or inject them. Part B also covers a limited number of prescriptions from the pharmacy (mainly oral anti-cancer drugs).

    Some drugs may be covered by either Part B or by Part D, depending on the situation. For example, if you use an insulin pump, you probably get your insulin and pump from a durable medical equipment supplier, and Part B will cover it. If you inject insulin using a needle, Part D will cover it. If you are a hospital outpatient, Part B should cover all medications that relate to the reason for your hospital visit; however, Part D will cover medications that you administer yourself and do not relate to the hospital visit.

    Your pharmacist, your provider, or your plan (when applicable) can help you understand your prescription coverage. For objective counseling and assistance, you can also contact your local Health Insurance Counseling and Advocacy Program (HICAP). HICAP can explain which part of Medicare should cover your drugs, depending upon your circumstances.

    Point 3: Understand the costs and coverage for your prescription drugs. Your costs and coverage depend upon which part of Medicare covers your drug. It also depends upon whether you are in Original Medicare or have Medicare Advantage. If you are in a Medicare Advantage Plan, your coverage and costs will depend upon what plan you have. If Part D covers your drug, make sure it is included in your plan’s formulary and that you use a preferred network pharmacy. Under Part D, you typically pay a set co-payment for your medications, after you meet a deductible. However, these amounts will vary depending on your plan and how much you have spent on prescriptions so far this calendar year.

    If Part B covers your drug and you are in Original Medicare, you or your supplemental insurance typically pay a 20 percent coinsurance, after meeting the Part B deductible. If you have a Medicare Advantage Plan, your out-of-pocket cost will vary based upon your plan. Those costs may also be higher than the 20 percent coinsurance under Original Medicare. If you get your medications from a pharmacy, make sure the pharmacy will submit claims for your Part B covered drugs to avoid unnecessary expenses.

    If Medicare denies coverage for a drug taken as a hospital outpatient, it may be that you can submit the charges to your Part D plan. Contact your plan to find out what steps to follow. You can also contact your SHIP for help understanding your coverage and addressing denials.

    If charges for medicines you didn’t receive show up on your Medicare statements, your Medicare number may have been used in a scheme to falsely bill Medicare. If you receive calls offering you a prescription drug discount card and requesting your bank account number, it is a scheme aimed at stealing your money. Contact our California Senior Medicare Patrol program (SMP) for help at 1-855-613-7080.

    Action steps to take:

    1) Make sure you understand which part of Medicare covers your prescription drugs.

    2) If you were denied coverage because your drug was billed to the wrong part of Medicare, contact your plan to find out what steps to follow.

    3) If you need help understanding Medicare’s prescription drug coverage or addressing denials, contact your local Health Insurance Counseling and Advocacy Program to discuss your options.

    4) If you receive suspicious offers or charges, contact our California Senior Medicare Patrol at 1-855-613-7080 to discuss and report potential abuse or fraud.

  • 30Mar

    Nobody likes penalties, especially when it means paying more money. When it comes to Medicare, most people can avoid penalties by enrolling in Parts A, B and D when first eligible, during their Initial Enrollment Period. Those who don’t enroll during this time, may have a penalty. The IEP is different for different parts of Medicare. This article reviews the Part D late enrollment penalty (LEP) and exceptions.

    Unlike Part A and B late enrollment penalties that don’t start until someone has delayed enrollment for 12 or more months, the Part D LEP begins accruing 63 days after one’s initial enrollment period has ended. The penalty amount varies depending on how long one delays enrolling in Part D after becoming eligible. To calculate the cost, Medicare multiplies 1% of the national average Part D premium ($34.10 in 2016) by the number of months without coverage. And this penalty is paid for eternity….well, not exactly, but the point is the penalty stays and one will pay it as long as s/he has Part D coverage.

    Are there exceptions?

    Yes, there are a couple of exceptions. The LEP is waived if you had “creditable drug coverage” during the months of delayed enrollment. To be considered creditable, the coverage must be at least as good as Medicare’s standard drug coverage. This could be coverage from an employer, union, TRICARE, Veterans Affairs, Indian Health Services or a Medicare Advantage plan with drug coverage. Each year you should receive a letter from your health plan stating that your coverage is creditable. Hold onto this letter. You may need it if you sign up for Part D at a later time.

    Another exception is for people who qualify for the Part D low-income subsidy, known as Extra Help that covers most premium and deductible costs. Those who qualify do not have to pay a penalty, regardless of how long they didn’t have drug coverage.

    See Prescription Drugs for more information on Medicare Part D, and our section on late enrollment penalties for more info on Part A and B LEPs.

  • 04Mar

    Did you know that drug costs rose 12.2% in 2014 alone which is 5 times as fast as the year before? And that the price of the 50 top most-used generic drugs has soared over 373% between 2010-2014? What’s happening and how can we as consumers save money and be savvy about our prescriptions? One thing that’s happening is company mergers, currently leaving 3 companies in control of 40% of the generic drug market. Also, some of the newest drugs are prohibitively expensive, such as the new Hepatitis C treatment Sovaldi which is $1,000 a pill for an 84-pill treatment.

    With prices and rising costs like these, it’s no wonder that insurance companies look for ways to shift more costs to consumers and make it harder to receive the higher costs drugs. For example, many drug plans have increased the number of drug tiers in their formulary (covered drugs) from just 2 tiers (one for generics, one for brand name drugs) to 3, 4 and even 5 tiers – with each tier corresponding to higher costs. This makes it confusing for consumers to know what exactly their drug costs will be when comparing plan formularies. Drug plans have also increased the number of drugs requiring step therapy or prior authorization. Such strategies shift rising drug costs to consumers and put up a barrier to receiving the higher cost medicines.

    So what are some ways to save money? Money Magazine’s March 2016 edition details some good cost-saving strategies, several of which are summarized below.

    • Change your medication. If you’re taking a brand name drug, ask your doctor for its generic equivalent. Also, if you’re taking multiple medications, see if there’s one medication that can be used for multiple conditions. That option does exist in some circumstances.
    • Use mail-order to fill and refill your prescriptions. You can get a 90-day supply and will generally have a lower copay than if you get a 90-day supply at a retail store.
    • Watch out for online pharmacy scams. According to a 2013 Government Accountability Report, many of the online “Canadian pharmacies” are illegitimate. Some have been found selling drugs with lethal contaminants such as lead or rat poison. If you do use an online pharmacy, make sure the website URL ends in “.pharmacy”. This means the site meets certain regulation requirements and has been approved by the National Association of Boards of Pharmacy.
    • Use your Medicare Part D plan’s coverage determination and exceptions processes to get affordable coverage for the drug(s) you need.
    • Change your insurance. One of the most effective ways to reduce drug costs is to change your drug plan. Medicare Part D drug plans change their coverage every year, and just because one plan meets your drug needs and is affordable one year, does not guarantee it will be the same the next year. During Medicare’s Open Enrollment period (Oct 15 – Dec 7) each year, you have the option to switch plans. Review your plan’s coverage for the coming year and shop around. California’s Health Insurance Counseling and Advocacy Program (HICAP) literally helped clients save millions of dollars this year by helping them find a plan that meets their mediation needs. You can use Medicare’s Plan Finder tool at Medicare.gov. This tools allows you to easily search for compatible plans by entering your medication, dosage, frequency, and preferred pharmacies. The plan finder will then give you a list of plans with your estimated out-of-pocket costs.

    See our website for more information on Medicare Part D prescription drug coverage.

  • 02Oct

    Medicare Open Enrollment is a once-a-year window from October 15 – December 7 where beneficiaries can review and change their Medicare health plan and/or their Part D prescription drug plan. While people don’t have to switch plans, it’s important to review how their current plan will change in the new year. Otherwise people can end up paying hundreds of dollars for a drug that was covered under this year’s formula but not next year’s. This is especially true as certain drug prices have soared in the past few years. For example, a generic cholesterol medication recently went up from $27 for a year’s supply to $196. Doxycycline hyclate, a common antibiotic jumped from $20 for 500 capsules to $1,849 between Oct 2013 and April 2014.

    Open Enrollment is also an important time to be on heightened alert for scams. With so much information being thrown at seniors, the potential for confusion is high, and scammers feed off of this confusion. In a recent article, our Senior Medicare Patrol Project Director, Micki Nozaki, gave some important tips to avoid fraud, including:

    • Do not move out of your Medicare plan unless you want to.
    • Be leery of free prizes, giveaways or other gifts offered in exchange for signing Medicare forms.
    • Beware of unsolicited phone calls or knocks at your door by people claiming to be Medicare agents (Medicare will not call you or come to your door).
    • If someone calls saying you must switch Medicare plans to keep your doctor, contact the doctor’s office yourself to confirm.
    • Never give out your Social Security or Medicare number to strangers.

    For questions about your coverage and help reviewing your health care and drug plan options, contact your local Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222. They provide free, individual and unbiased counseling on Medicare and other health insurance related issues. To report suspected fraud, call our California Senior Medicare Patrol (SMP) at 1-855-613-7080.

    Read the article, Medicare Sticker Shock: Soaring Drug Prices Could Trip Up Seniors, for more information on rising drug costs, tips on reviewing your coverage and ways to avoid scams. And, great job to Margaret Reilly, HICAP Program Manager, Micki Nozaki, our SMP Project Director, and Rajul Patel, assistant professor at University of the Pacific pharmacy school and one of our CHA board members, all quoted in this article. :-)

    Also, see our webpage on Medicare Open Enrollment.

  • 30Dec

    Earlier this year, the Centers for Medicare and Medicaid Services (CMS) revised its guidance on payment of Part D covered drugs for beneficiaries on Medicare hospice as beneficiaries were having trouble accessing their Part D covered medications due to too many prior authorization requirements put on these drugs. The Medicare Part A hospice benefit covers drugs used for pain control and symptom relief related to terminal illness. These drugs are excluded from Part D.

    Under the new guidance, Part D plans are strongly encouraged to only impose prior authorization on 4 drug categories (the ones most used in and covered under hospice care). These are:

    • Analgesics
    • Anti-nauseants
    • Laxatives
    • Anti-anxiety (anxiolytics)

    For more details, see CMS’ guidance, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice (pdf). See our section on Part D appeals for information on how to file an appeal.

  • 18Nov

    Did you know it’s illegal for Medicare beneficiaries to use coupons for their Part D drugs? Most people don’t….but it is. Coupons are a way that drug companies can entice beneficiaries to use drugs whose copayment, let alone the full cost of the drugs, would otherwise be too expensive. This means Medicare is then footing the bill for these more expensive brand name drugs that without coupons beneficiaries wouldn’t use. They would instead use lower cost generics. Drug companies are supposed to use safeguards to ensure beneficiaries don’t use coupons to get these high cost drugs, but such efforts are lacking, according to a recent Office of Inspector General report (PDF). The OIG found that up to 7% of beneficiaries use coupons to purchase their drugs, which amounts to about 2 million people buying more expensive drugs than they would otherwise and hence racking up Medicare’s Part D drug tab.

    While beneficiaries are just doing what seems like a smart and legit way to get the drugs they require at a price they can afford, this coupon use is illegal and drug companies are most likely letting it go unchecked to protect and sustain their own profit margins.

    For more information, see:

    The OIG report, Manufacturer Safeguards May Not Prevent Copayment Coupon Use for Part D Drugs (PDF)

    The Wall Street Journal article, Did Someone say Kickbacks? HHS Warns About Medicare Part D Coupons

  • 05Nov

    Low Performing Plans (LPP) get one more year. LPPs, which are Medicare Advantage plans or prescription drug plans with overall ratings of fewer than 3 stars for 3 consecutive years, were supposed to be terminated as of Dec 31, 2014, but the Centers for Medicare and Medicaid Services (CMS) has decided to give them one more year.

    About 165,000 beneficiaries throughout the U.S. and Puerto Rico are in consistently low-performing plans and will receive a notice from CMS reminding them that they can switch to a higher performing plan during the Annual Election Period (AEP) between Oct 15 – Dec 7. If they miss the AEP opportunity, they still have a Special Election Period (SEP) to change to a plan with 3 or more starts in 2015. To use this SEP, beneficiaries must call 1-800-MEDICARE.

    Note that:

    • This is a one-time SEP for individuals enrolled in a plan indicated with the Low Performance Icon in the Medicare Plan Finder.
    • The SEP can only be effectuated by CMS.
    • All enrollments under this SEP are prospective (no retro-active enrollments).
    • Individuals may use the SEP to disenroll from Medicare Advantage (MA) into Original Medicare.
    • A Part D coordinated SEP exists for individuals to enroll in Part D if they select an MA Private-Fee-for-Service plan as long as they make that enrollment at the same time.

    Beneficiaries with questions about their plan choices can call their local Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222. HICAP provides free, individual and unbiased counseling on Medicare questions and ways to supplement Medicare.

  • 14Oct

    Clinics scheduled in Stockton, Tracy, Lodi, Berkeley, San Jose, San Francisco, and Oakland

    One of our California Health Advocates board members, Rajul Patel and his pharmacy students at University of the Pacific’s Thomas J. Long School of Pharmacy & Health Sciences will be offering health clinics in 7 cities throughout Northern California this fall to help Medicare beneficiaries save on their prescription drug costs and better understand their medications. The clinics will also offer a variety of health care screenings and services.

    Now in its 8th year, Rajul and his students participating in Pacific’s Mobile Medicare Clinics have served a total of 2,911 Medicare enrollees and saved seniors and other beneficiaries more than $2.2 million on their out-of-pocket Medicare Part D prescription drug costs, for an average savings of $769 per person per year.

    This year’s clinics will be offered during the annual Medicare Open Enrollment period, Oct. 15th through Dec. 7, in 4 Bay Area cities – Berkeley, San Jose, San Francisco and Oakland – as well as 3 Central Californian cities – Lodi, Stockton and Tracy. (Dates and locations are listed below.)

    Trained pharmacy students will assist beneficiaries with Part D plan review and enrollment, determine if they qualify for additional government assistance to help lower their out-of-pocket medication costs, and explore other cost-savings opportunities.

    Attendees will also receive a comprehensive review of all of their medications and have all of their medication-related questions answered. Since the program’s inception, Pacific student pharmacists have identified 137 potentially severe medication-related issues among clinic attendees, including severe drug-drug interactions and sub-optimal drug therapy that warranted physician follow-up.

    Under the supervision of licensed pharmacists, the student pharmacists will also offer vaccinations, including the flu and pneumococcal vaccines; diabetes screening; and blood pressure, cholesterol and bone-density testing.

    All told, pharmacy students have held 73 clinics in 16 California cities since the program first began, volunteering a combined 9,072 hours of time.

    If you would like to have your Part D plan reviewed and/or have a comprehensive evaluation of your medication, please call for an appointment. Phone numbers for each clinic site are listed below.

    IMPORTANT: Beneficiaries attending the clinic should bring the following:
    • Their red, white, and blue Medicare card
    • All of their medications

    Bay Area clinics

    San Jose
    Oct. 26, Sunday, 10 a.m. – 5 p.m.
    Seven Trees Community Center, 3590 Cas Dr., San Jose
    Call for an appointment: (209) 946-7728

    Oakland
    Nov. 1, Saturday, 10 a.m. – 6 p.m.
    Allen Temple, 8501 International Blvd., Oakland
    Call for an appointment: (510) 343-2473

    San Francisco
    Nov. 9, Sunday, 10 a.m. – 6 p.m.
    Jewish Community Center of San Francisco, 3200 California St., San Francisco
    Call for an appointment: (415) 292-1200

    Berkeley
    Nov. 22, Saturday, 10 a.m. – 6 p.m.
    Ed Roberts Campus, 3075 Adeline St., Berkeley
    Call for an appointment: (510) 841-4776 ext. 3112

    Central Valley Area clinics

    Lodi
    Oct. 23, Thursday, 1 p.m. – 6 p.m.
    LOEL Center and Gardens, 105 S. Washington St., Lodi
    Call for an appointment: (209) 369-1591

    Nov. 11, Thursday, 1 p.m. – 7 p.m.
    Hutchins Street Square (Room: Kirst Hall), 125 S. Hutchins St., Lodi
    Call for an appointment: (209) 369-6921

    Stockton
    Oct. 17, Friday, 1 p.m. – 5 p.m.
    Franco Center, 144 Mun Kwok Lane, Stockton
    Call for an appointment: (209) 466-4697

    Oct. 18, Saturday, 10 a.m. – 6 p.m.
    University of the Pacific, 751 Brookside Road, Stockton
    Call for an appointment: (209) 946-7658

    Oct. 25, Saturday, 10 a.m. – 6 p.m.
    Harvest House, 1609 N. Wilson Way, Stockton
    Call for an appointment: (209) 477-0378

    Nov. 2, Sunday, 10 a.m. – 6 p.m.
    O’Connor Woods, 3400 Wagner Heights Rd., Stockton
    Call for an appointment: (209) 956-3400

    Nov. 14, Friday, 1 p.m. – 6 p.m.
    First Congregational Church, 3409 Brookside Rd., Stockton
    Call for an appointment: (209) 951-8545

    Nov. 20, Thursday, 1 p.m. – 6 p.m.
    Northeast Community Center, 2885 E. Harding Way, Stockton
    Call for an appointment: (209) 468-3918

    Tracy
    Oct. 28, Tuesday, 1 p.m. – 6 p.m.
    Tracy Community Center, 950 East Street, Tracy
    Call for an appointment: (209) 831-4230

    For general information about the program, visit go.pacific.edu/medicare or contact them at (209) 932-2958. See the pdf of the 2014 outreach schedule for a printable copy.

    This article is edited from a Sept 29, 2014 University of the Pacific press release.

  • 23Sep

    Did you know that although the U.S. comprises 5% of the world’s population, it holds 50% of pharmaceutical company profits? On a per capita basis, Americans spend about $1,000 per person each year on drugs. That’s approximately 40% more than the next highest spending country, which is Canada.

    There are a number of reasons why this spending imbalance is occurring and some of these are discussed in the PBS articles linked to below. Americans use more drugs and have more access to the newest drugs on the market. They also pay more for them. U.S. prices for brand-name drugs are 50% to 60% higher than in France and twice as high as what citizens of the United Kingdom or Australia pay. That’s because in many countries, government agencies essentially regulate the prices of medicines and limit the amount they will reimburse. There is also a technique called “pay for delay,” in which brand-name manufacturers pay generic manufacturers settlements to keep their competition from producing identical drugs. Another option drug manufacturers use is called “evergreening.” This strategy is to redirect the customer from the drug they are taking to another brand drug the same company is making in an effort to keep them from purchasing the generic alternative

    See the PBS Newshour articles below for more information on why Americans spend so much more on pharmaceuticals than citizens in other democratic countries.

  • 20Aug

    This short infograph demonstrates both visually and statistically some disturbing facts of Americans being overmedicated, so much so that every 19 minutes someone dies of a medication overdoes. While many commonly taken medications are taken as a way to “enhance” people’s lives by allowing people to sleep better, stay awake longer, get more work done, are people’s lives improving? Or in some cases, are these medications masking symptoms and in turn causing more problems? This info graphic shares some revealing data regarding these questions.

    Medicated to Death

    Source: TopRNtoBSN.com

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