I applied for Extra Help, but my application was denied. I am struggling to afford my drugs. What should I do?
If your application is turned down and you receive a “Pre-Decisional Notice,” saying you “may not be eligible” for Extra Help, it should show which information from your application caused you to be rejected. If 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 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’s best not to reapply but 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 within 60 days of receiving notice of SSA’s decision on your application. 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, such as 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 provide.
I am about to turn 65. I don’t take many medications and am considering waiting to enroll in a Part D plan. Will I be penalized for doing this?
If you do not enroll in the Medicare 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 of the national base beneficiary premium for every month you delay. For example, the national base beneficiary premium in 2011 is $32.34 a month. If you delayed enrollment for seven months, your monthly premium penalty would be $2.26 ($32.34 x 1% = $0.3234 x 7 = $2.26), which would 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 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. In order to avoid a premium penalty, you can’t 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 also won’t be penalized if you qualify for Extra Help and enroll in a Medicare private drug plan. The premium could be waived if you show that you received inadequate information about whether your drug coverage was creditable.
I have a chronic health condition, and an acquaintance suggested that I enroll in a special needs plan. Could you please tell me more about these plans?
A Special Needs Plan is a private Medicare Advantage 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 challenged and people who live in the community but require an institutional level of care; people who have both Medicare and Medicaid; or people who have a specific chronic, severe or disabling condition 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. Special needs plans must include drug coverage, Medicare Part D, as part of their benefits package.
Marci’s Medicare Answers is a service of the Medicare Rights Center (medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare.