AIDS Institute Logo

Frequently Asked Questions - Medicare Part D and ADAP

General Information

Do I have to enroll in Medicare Part D?

Yes, you have to enroll in Medicare Part D if you have ADAP, and Medicare A or Medicare A & B, but don't have other comprehensive or "creditable" insurance. For more information on health insurance, please see the "People with Insurance" section.

Can I keep my ADAP coverage when I enroll in Medicare Part D?

Yes, ADAP can help with the co-payments and deductibles which are part of most Medicare Part D plans.

Why do I have to enroll in Medicare Part D?

ADAP is federally funded through the Ryan White HIV/AIDS Treatment Extension Act of 2009. ADAP funding pays for prescription coverage and health care services only when they cannot be paid by another program. Since Medicare covers prescription drugs, if you qualify for Medicare, you must enroll.

How will Medicare Part D help me?

All Medicare Part D plans are required to cover all antiretroviral medications. Plans are also required to cover at least two drugs in every other drug class. Plans wll cover more medications than ADAP.

Will I be terminated from ADAP if I don't enroll in Medicare Part D?

You will receive frequent reminders to enroll in Medicare Part D. If you do not enroll, your ADAP eligibility will be suspended.

Are there penalties if I choose not to enroll in a Medicare Part D plan?

There is a monthly premium for Medicare Part D. If you have comprehensive health insurance that will pay for your prescriptions, you might not have to enroll in Medicare Part D. ADAP is NOT comprehensive health insurance. If you don't have other insurance, and do not enroll in Medicare Part D plan within 3 months of your eligibility month, your monthly premium will increase by 1% for every month that you delay enrollment. All premium increases are permanent. ADAP cannot help pay increases in premiums because of penalties.

What costs are there if I enroll in Medicare Part D?

Depending on how much money you make and how much you have in the bank, you may have to pay Medicare Part D co-payments, deductibles, and premiums. There are several different ways that you can receive financial help with these. Some people will have very low costs associated with Medicare Part D.

Will ADAP pay for my co-payments and deductibles if I enroll in Medicare Part D?

Yes, ADAP can help with the co-payments and deductibles that are part of Medicare Part D. If a drug is covered by ADAP and Medicare Part D, ADAP will pay any charges not covered by your Medicare plan. But, if the drug is not on ADAP's list of covered drugs, ADAP will not be able to pay the co-payments and deductibles.

What is the "donut hole?"

Medicare Part D has different benefit levels based on your income and the money you have in the bank. According to the 2012 Federal Poverty Level (FPL), people in the highest income group or "standard" benefit category will pay a $320 deductible plus 25% of the first $2,610 in drug expenses. Once total drug expenses reach $2,930 (the $320 deductible plus $2,610 for drug expenses) Medicare does not cover the next $3,727.50 in medication expenses. This coverage gap period is called the "donut hole." Once the individual and Medicare spend $6,657.50 in drug expenses, the "catastrophic level" is reached. From this point to the end of the year, Medicare pays 95% of the individual's drug costs. Drug costs, deductibles and/or co-payments paid by ADAP will count toward the $6,657.50 in total expenditures needed to get through the "donut hole" and reach the catastrophic coverage level.

Will ADAP pay for the montly Medicare Part D premium?

If the cost of your Medicare Part B and D premiums, deductibles, and co-payments would keep you from getting care, you might be eligible for the ADAP Plus Insurance Continuation (APIC) program. APIC can pay for your Part D premium.

Now that Medicare offers more comprehensive coverage, can the Medicare B premium be covered by APIC?

No, we can only assist with the Medicare Part D premiums. We cannot pay the cost of Medicare B premiums.

Which plan should I pick? Is there a Medicare prescription drug plan that is best for ADAP participants?

Each participant will need to find the plan that is best for them. Some medications ADAP does not cover may be covered by one or more of the Medicare Part D plans. You should look for a plan that covers these drugs at the lowest cost to you. You can learn more at www.medicare.gov .

Is there someone to help me choose a Medicare prescription drug plan?

  • Call 1-800-MEDICARE (1-800-633-4227)
  • Go to www.medicare.gov and use the Medicare Prescription Drug Plan Finder, which contains detailed information about the drugs covered by the plans in your area.
  • Look for information about events in your local newspaper or listen for information on the radio.
  • Talk to a family member, friend or other caregiver to help you decide what drug coverage will best meet your needs.
  • Talk to your case manager or social worker about Medicare.
  • Refer to your Local Office of Aging.

Will my pharmacy accept whatever plan I choose?

Your pharmacy may enroll in several plans or only a few. Call your pharmacy and ask which plans they are working with before you choose a Medicare Part D plan. Make sure your pharmacy has a copy of both your ADAP card and your Medicare Part D card and is aware that you have both kinds of coverage.

I got a letter from the Social Security Administration saying I could get "extra help". What is "extra help" and how do I get it?

"Extra help" is available for some people who don't make enough money to pay for the premiums, deductibles, and co-payments that are part of Medicare Part D. If you make less than 150% of Federal Poverty Level (FPL) - about $16,755 - and don't have a lot of money in the bank you need to apply for "Extra Help." If your income is a little more than $16,755, you should still apply. "Extra Help" is free, but you must apply for it. The Federal Poverty Level (FPL) changes every year. You can apply for "Extra Help" by calling the Social Security Administration at 1-877-772-1213 or go online to their www.socialsecurity.gov.

How do I join a Medicare Prescription Drug Plan?

  • By paper applications: Contact the company offering the drug plan you choose and ask for an application. Then complete and mail or fax it back to the company.
  • On the plans' websites: You may be able to join online.
  • You can also join the plan at www.medicare.gov

Once I choose a Plan what happens if I don't like it?

You may switch plans once a year, during the annual open enrollment period (October 15 - December 7). New coverage will take effect January 1 of the following year. If you have both Medicare and Medicaid, you are considered a "dual eligible" individual. "Dual eligible" people may change plans once every thirty days.

Will ADAP cover a drug that is on the ADAP drug list if the plan does not cover it?

Yes, but only if the drug is on the list of drugs ADAP covers. All plans are required to cover all antiretroviral medications. Most plans will cover all drugs on the ADAP drug list.

What about ADAP participants over 65 years of age?

Many people age 65 and older need medications not covered by ADAP. A Medicare Part D plan will be able to pay for many of these drugs. An additional program that can help with drug costs is New York State's Elderly Pharmaceutical Insurance Coverage (EPIC). ADAP participants over 65 should think about enrolling in EPIC as well. If EPIC pays part of your drug costs, those payments will help to move you through the "donut hole". You can reach EPIC at 1-800-332-3742 (TTY 1-800-290-9138).

People with Medicaid

I am dually eligible for Medicare and Medicaid. How will Medicare Part D work with Medicaid?

Most individuals who are Medicaid active are automatically enrolled in a Medicare Part D plan. If you are not enrolled, you need to do so. Once enrolled, Medicare Part D will be your primary drug coverage. Have your pharmacy check with Medicare to find out which plan you are enrolled in. The pharmacy will need to know the last 4 digits of your Social Security Number and your date of birth.

I have a Medicaid Spenddown - How will Medicare Part D work with Medicaid? What part will ADAP play?

Medicare drug coverage cannot be used to meet your spenddown/surplus, but it is important to keep your Medicaid active as it pays for services that are not covered by Medicare. ADAP can still help to meet your Medicaid Spenddown. When your Medicaid is active, it will be secondary payor and will cover drugs and services not covered by Medicare. At the beginning of each month you should check to make sure your Medicaid is active for that month (your pharmacist, social worker, Medicaid worker, or an ADAP representative can tell you). If your Medicaid is not active, your ADAP card can be used by your pharmacist to pay for enough medication to meet your spenddown. Ask the pharmacist to give you a receipt or wait to receive a letter and special receipt from ADAP. You will need to bring one of these receipts to Medicaid. For ADAP to meet your Spenddown, it is very important that we have accurate information. Make sure you have sent ADAP a copy of your most recent "Notice of Decision" letter from Medicaid.

People with Insurance

What if I have other insurance?

If you have comprehensive health insurance (full medical and prescription coverage), you probably don't need to enroll in Medicare Part D. Your insurer should have sent a letter telling you whether your coverage is "creditable" (the prescription coverage is equal to, or better than, Medicare Part D). If it is "creditable," you don't need to apply for Medicare Part D. If you do not get a letter from your insurance company call to make sure the coverage is "creditable."

What if I have insurance that is not full coverage (i.e., caps on prescriptions and/or high deductibles/co-payments)?

You need to enroll in Medicare Part D because your insurance is not "creditable." You should receive information from your insurance company. If you have not received information from your insurance comapny, call or write them for answers about your coverage.

If I find out that my current insurance is not "creditable" is it possible to upgrade it so that it becomes "creditable?"

It may be possible, but you will need to discuss this with your insurance company. Some companies which offer Medicare Supplemental policies or Medi-gap insurance have mailed notices to participants concerning "upgraded" or "enhanced" insurance coverage which includes a Mediare Part D prescription drug plan.