Executive Budget Changes - EPIC - SFY 2011-2012 - Key Points & Additional FAQs
Key Points on 2011-2012 Enacted Budget
- Beginning July 1, 2011
- EPIC will expand Part D premium assistance from the current annual income levels of $20,000 if single and $26,000 if married to $23,000 if single and $29,000 if married.
- The EPIC deductible credit (currently $464) will be eliminated.
- Beginning January 1, 2012
- EPIC will be free, having no fees or deductibles and will pay Part D premiums for members with incomes up to $23,000 if single and $29,000 if married.
- All seniors must be enrolled in a Medicare Part D plan in order to maintain EPIC coverage.
- EPIC will provide secondary coverage for prescription medications when an enrollee reaches the Medicare Part D coverage gap (aka donut hole).
Frequently Asked Questions (FAQ)
Q1. I don't understand the EPIC changes. Is EPIC being eliminated? Will there still be a fee and deductible plan? How will EPIC work?
No, EPIC is not being eliminated. It will continue as a State-sponsored supplemental pharmaceutical insurance coverage program for income eligible NYS residents age 65 or older.
Effective January 1, 2012, EPIC will provide one free plan with no fees or deductibles. You will be responsible to pay any Part D deductible (if you have one), and Part D co-payments until you reach the Medicare coverage gap (donut hole). If you reach the coverage gap, EPIC will provide supplemental coverage to lower your out-of-pocket expense, as it does now. EPIC will also pay your Part D plan premium if your income is up to $23,000 single or $29,000 married. If your income is higher, you will have to pay your monthly Part D plan premium.
Q2. Will EPIC eligibility requirements change?
Beginning on January 1, 2012, all members must be enrolled in a Part D plan, without exceptions, in order to receive EPIC benefits and maintain EPIC coverage. EPIC eligibility limits remain the same: NYS resident, 65 or older, with income up to $35,000 single or $50,000 married. Applicants cannot be receiving full Medicaid benefits but may have a Medicaid spenddown.
Q3. What will the EPIC co-payments be effective January 1, 2012?
EPIC co-payments have not changed. For Part D covered drugs and Part D excluded drugs purchased in the coverage gap (donut hole) they will continue to be:
|If your prescription costs:||You pay only|
|Up to $15.00||$3.00|
|$15.01 - $35.00||$7.00|
|$35.01 - $55.00||$15.00|
|$55.01 and over||$20.00|
Q4. How do I find out about the changes to EPIC?
All EPIC members will be notified of the changes and how they will be affected by letter.
Q5. I am enrolled in the EPIC Deductible Plan. How will my EPIC coverage change?
Beginning July 1, 2011, if you are single with income between $20,001 and $23,000 or married with income between $26,001 and $29,000, EPIC will pay your Part D premiums up to $38.69 per month for you. Your deductible credit (up to $464) will be eliminated. This means you will be responsible for meeting an additional $464 toward your deductible even if you have already met your EPIC deductible for the year.
Beginning July 1, 2011, if you are single with income $23,001 or more or married with income $29,001 or more, your deductible credit (up to $464) will be eliminated. This means you will be responsible for meeting an additional $464 toward your Deductible even if you have already met your EPIC deductible for the year. You will continue to pay your monthly Part D premiums.
Beginning January 1, 2012, EPIC will provide coverage for covered Part D medications when you reach the coverage gap (aka donut hole), subject to the copayments indicated in question 3. EPIC will also cover the Medicare part D excluded drugs purchased in the coverage gap.
Q6. I am enrolled in the EPIC Deductible Plan. If I already met a portion or all of my deductible, how will the elimination of the deductible credit affect me?
Your deductible will be raised back to its original level, prior to the deductible credit being applied. Any claims paid to date that already were credited to your deductible will not be impacted. You will be responsible for meeting an additional $464 toward your EPIC deductible.
Q7. I am enrolled in the EPIC Deductible Plan. If I haven't met any portion of my deductible, how will the elimination of the deductible credit affect me?
Your deductible will be raised back to its original level prior to the deductible credit being applied. You will be responsible for meeting an additional $464 toward your EPIC deductible.
Q8. I heard that EPIC will stop paying my Part D premiums, is that true?
No. EPIC will continue to pay Part D premiums for its Fee Plan members. Beginning July 1, 2011, EPIC will expand Part D premium assistance to low income Deductible Plan members from the current annual income levels of $20,001 if single and $26,001 if married to $23,000 if single and $29,000 if married.
Q9. Will I still have to pay EPIC fees?
You will still have to pay your quarterly EPIC fee up to December 31, 2011. As of January 1, 2012 fees will be eliminated and the program will be free.
Q10. I have Extra Help, what will happen to me?
If you have Full or Partial Extra Help from Medicare, nothing will change on July 1, 2011. EPIC will continue to help pay your Part D plan premiums and if you have Full Extra Help you will not have any EPIC fee. If you have Partial Extra Help you will have to pay your quarterly EPIC fee through December 31, 2011 and EPIC will continue to help pay your Part D premiums.
Effective January 1, 2012, your co-payments will be determined by your Medicare Part D plan. Since you do not have a Part D coverage gap, EPIC will not provide any supplemental drug coverage for you. EPIC will continue to pay Part D premiums for Partial LIS members and those with Full LIS in enhanced plans.
Q11. Will I still need to have Medicare Part D? What if I drop my Medicare Part D coverage?
If you cancel your Medicare Part D coverage, you could lose your EPIC coverage. As of January 1, 2012 you must have Part D in order to receive EPIC benefits.
Q12. I'm in a Medicare Advantage/MA (HMO) plan and I was told that I don't need Part D. Does this change affect me?
Yes, all EPIC members must have Medicare Part D prescription coverage as of January 1, 2012. EPIC will facilitate you into your plan's Medicare Part D option before the end of 2011 for coverage beginning January 1, 2012. You are encouraged to contact your plan to discuss adding drug coverage.
Q13. What drugs will be covered under the new plan?
EPIC will only cover drugs that are covered first by your Medicare Part D plan after you reach the coverage gap (donut hole). EPIC will also cover the Medicare Part D excluded drugs purchased during the coverage gap.
Q14. What Medicare Part D excluded prescription drug categories will be covered by EPIC in the coverage gap through 2012?
The Medicare Part D excluded prescription drug categories that will be covered by EPIC in the coverage gap include the following:
- Agents when used for anorexia, weight loss or weight gain (e.g. orlistat)
- Agents such as tretinoin and finasteride for dermatological treatments
- Agents when used for symptomatic relief of cough and colds (e.g. guaifenesin with codeine)
- Prescription vitamin and mineral preparations
- Barbiturates (e.g. phenobarbital for seizure control)
- Benzodiazepines (e.g. alprazolam for anxiety)
Q15. Will EPIC payments made in the coverage gap apply toward TrOOP?
Yes. However payments for Part D excluded drugs such as benzodiazepines and barbiturates will not count toward TrOOP.
Q16. Will I still be able to get a 90-day temporary supply or a 3-day emergency supply of any prescription that requires a Prior Authorization under my Medicare Part D plan?
EPIC's Temporary Coverage Request Helpline will be available until December 31, 2011 enabling you to receive an interim supply of the drug while your physician requests authorization from the Part D plan to cover the drug.
Beginning January 1, 2012, EPIC will only cover drugs that are covered first by the Medicare Part D plan after a member reaches the coverage gap (donut hole). Therefore, you will have to work with your pharmacist and physician to get coverage for drugs that are not covered by your plan.
Q17. Will EPIC still help me submit an appeal to my Part D plan for drugs?
EPIC will continue to work with physicians to assist them in submitting Part D appeals until December 31, 2011.
Beginning January 1, 2012, you will have to work with your pharmacist and physician to submit appeals to the Part D plan for non-covered drugs.
Q18. Will EPIC members still have an SEP (special enrollment period) in 2012?
Yes. EPIC will remain a qualified SPAP (state pharmacy assistance program) and as such members have an opportunity to switch Medicare Part D plans using the SEP. They will also be able to join a Part D plan at any time of the year when they enroll in EPIC but they will not maintain EPIC coverage or receive benefits until they join a Part D plan.
Q19. Will EPIC continue to enroll seniors in Medicare Part D plans?
EPIC will facilitate enrollment of members who are eligible for Part D but not in a plan, including MA (HMO) members in the fall. EPIC will also reassign members into plans based on Medicare Part D benchmark status. Coverage will be effective January 1, 2012. Effective January 1, 2012, EPIC will no longer facilitate enrollment of members into Part D plans. However, the program will continue to assist members in selecting and enrolling in Part D plans.
Q20, Will EPIC continue to help income eligible members apply for Medicare Extra Help Low Income Subsidy (LIS) and Medicare Savings Programs (MSP)?
Yes. All income eligible members will be required to complete a Request for Additional Information form to enable EPIC to electronically apply to Social Security Administration and Medicaid for LIS and MSP benefits. Enrollment into either of these benefit programs enables members to receive total or reduced Part D premium assistance from Medicare, pay co-payments as low as $2.50 for generic drugs and $6.30 for brand drugs and have no coverage gap.
Q21. Will EPIC be creditable coverage in 2012 when the new program begins?
No. Since EPIC will only cover prescription drugs purchased in the Medicare Part D coverage gap, it is no longer considered to be creditable coverage (equal or better than Part D coverage). EPIC will supplement Part D coverage and provide a safety net to those with higher drug costs who reach the Part D coverage gap. It will also pay Part D premiums for members with incomes up to $23,000 single or $29,000 married.