RHODE ISLAND SENIOR BEAT
RELEASE: Friday, October 17, 2008
BY: Larry Grimaldi, Chief of Information & Public Relations
UNDERSTANDING TRUE OUT-OF-POCKET (TrOOP) COSTS
Q. I have a Medicare Prescription Drug Plan. Can you help me understand the True-Out-
of Pocket (TrOOP) costs that are associated with my Part D plan?
A. True Out-of -Pocket (TrOOP) costs are those expenses you incur that count towards a Part D plan. Another way to think of TrOOP is that money which you actually pay for your medications under your part D plan. For 2008, that threshold is $4,050 before the catastrophic coverage of your Part D begins. Your drug plan will track your expenses.
Q. What constitutes the TrOOP?
A. The amount that a you pay for covered prescriptions before their plan begins payment (deductible), the amount a person pays while using your plan (co-payments or co-insurance), and any payments made in the coverage gap phase of your Part D plan.
Please note: if you are on the Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE), your co-payment and what the program pays for your medications count towards the TrOOP. The reason here is quite simple. RIPAE is a benefit program, not an insurance plan.
Q. Are there any restrictions on TrOOP costs?
A. TrOOP counts the payments made for medications on the plan's formulary, drugs that were not on the formulary but will count towards the TrOOP because of a favorable coverage determination, exception process or appeal, drugs that were purchased in a network pharmacy or drugs that were purchased in an out-of-network pharmacy in accordance wit the plan's out-of network pharmacy
Q. What payments count towards the TrOOP?
A. Countable TrOOP payments count if they were made by a person on Medicare, family members or friends, a qualified state pharmacy assistance program (In Rhode Island, this would be the RIPAE), payments made to the plan if you are on Low-Income Subsidy (LIS) and payments made by a charity on your behalf.
Q. What kind of payments don't count towards TrOOP?
A. Monthly plan premiums, drugs purchased outside the country, drugs not covered by the plan, certain categories of drugs not in Medicare plan D programs (such as cosmetic medications, drugs to reduce weight, benzodiazapines, or over-the counter drugs or vitamins) will not count towards your TrOOP.
Q. Are there any other costs that don't count towards the TrOOP?
A. Payments that made by an Group Health Plan such as the Federal Employees Health Benefit Program or other types of insurance including TRICARE, Workers Compensation, Veterans benefits, the State Children's Health Insurance Fund, or federally qualified Rural Health Clinics.
Q. How is the TrOOP affected if a person switches Medicare drug plans?
A. The drug plans keep track of the TrOOP.
Q. What is the total drug plan spending limits?
A. Payments made during the deductible phase, if applicable, in the amount exceeding initial payments of $275, the payments made by coinsurance or co-payments after the deductible is met, the coverage gap where you are responsible for the entire price of the drug are included until the TrOOP reaches $4,050 in 2008. The catastrophic coverage begins after you TrOOP reaches that $4,050 limit.
For more information, contact Medicare at 1-800-MEDICARE (1-800-633-4227) ore do on line to www.medicare.gov.
Individuals with an annual income up to $24,838 and married couples with a combined annual income up to $31,050 receive a 30% discount.
Individuals with an annual income up to $43,470 and married couples with a combined income not exceeding $49,680 receive a 15% discount.
Income guidelines increase each year in accordance with the Social Security Cost-Of-Living Adjustment (COLA).
RIPAE enrollees can purchase all other FDA-approved prescriptions (except for those used to treat cosmetic conditions) at a 15% discount.
Also under RIPAE, Rhode Island residents between 55 and 64 who are receiving Social Security Disability Income (SSDI) payments and who meet specified income limits, can purchase medications (except those prescribed for cosmetic conditions) at a 15% discount. The annual income limits for those receiving SSDI are $43,470 for a single person and $49,680 for a married couple. For RIPAE information, call 462-3000 or THE POINT call resource center at 462-4444.
Questions for Rhode Island Senior Beat may be mailed to the Department of Elderly Affairs, John O. Pastore Center, Hazard Building, 74 West Road, Cranston, RI 02920. Questions can also be e-mailed to larry@dea.state.ri.us. For a confidential discussion with a customer service specialist about questions or problems regarding growing older, call the customer information referral and assistance unit at 462-4000. Seniors, families, and caregivers can also call The Point resource center at 462-4444.
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