As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
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Janell Sluga
Q: I used to have EPIC, but don't know if I do anymore. It didn't help me at all this year. Do I still need EPIC?
A: I have heard this type of question a lot lately. First let me explain what EPIC is for those who don't know already.
EPIC is a New York State Pharmacy Assistance Program that provides very good prescription drug coverage to those who qualify. EPIC stands for Elderly Pharmaceutical Insurance Coverage. EPIC requires that you be 65 or older and a resident of New York state. EPIC has income guidelines, and the program uses your previous calendar year's income to determine your eligibility. The income guidelines require that a single person make less than $35,000 annually and a married couple make less than $50,000.
Within those income guidelines are two different programs. For a single person, the fee plan income guideline is up to $20,000, and for those with income between $20,000 and $35,000 there is the deductible plan. For a married couple, the fee plan income guideline is up to $26,000, and for those with income between $26,000 and $50,000 there is the deductible plan.
EPIC has no set enrollment period. It allows open enrollment all the time. If you want to apply, you can apply anytime as along you meet the previously described criteria. EPIC has a co-pay structure which is $3, $7, $15 or $20 for each prescription.
Some seniors were on EPIC at one time and then dropped it because they felt it didn't do them any good. I completely disagree. EPIC is almost always a wonderful secondary coverage for your prescription drugs. I say almost always because EPIC requires you be in a Medicare Approved Part D Plan. (That is one of the plans that are available to all seniors in our region.) EPIC is not able to be secondary coverage to retiree or employee plans.
If you have Medicare Part D coverage, EPIC would be secondary to that coverage. EPIC for some, will help to pay for that Medicare Part D coverage. If your income is below $23,000 for a single person or $29,000 for a married couple, EPIC will pay for the Medicare Part D plan up to the monthly premium of $42.33. If your monthly Medicare Part D premium is more than that, you will only pay the difference.
If your income is above those amounts ($23,001 - single or $29,001 - married) EPIC will reduce your deductible by $519 to help offset the cost of your Medicare Part D plan. You reach your deductible sooner, which saves you money. Many seniors have seen significant savings using both Medicare Part D and EPIC together.
A new rule for EPIC in 2013 is that it will not help cover the cost of medications while you are in your Part D plan deductible, (if your plan has one). The advice I am giving to those with EPIC is choose a plan that does not have a deductible. There are many plans with the $325 deductible, but there are many plans with a lower deductible or no deductible at all. Having a Part D plan with no deductible in 2013 will help you save more money if EPIC is your secondary coverage for your medications.
If you have veteran's benefits, you can use a Part D Plan and EPIC for those medications you buy outside of the VA system. You may find that this combination makes your medications cost less than VA medications, depending on the medications you take. The combination allows you to purchase medications outside the VA healthcare system.
I encourage all seniors to review their income every year to see if they qualify for EPIC. Many seniors rely on their investments, or other type of incomes that vary year to year. EPIC uses your income figures from last year. Those figures can be obtained from your tax return, if you file; if you don't file, use your 1099 tax statements. You still receive these, even if you are not required to file taxes.
If you are not sure if you qualify for EPIC, call the EPIC helpline at 1-800-332-3742 and talk with their staff. I have found them to be helpful with many of my questions. They can answer your questions, or send you information.
Very few states in the U.S. have pharmacy assistance programs, and EPIC is truly one of the best. You may not receive EPIC if you have Medicaid, unless your spend-down is more than $100 per month.
Seniors that have had their spouse pass away recently could also qualify, if they find they are not making as much money as they used to. Often when a spouse dies, you lose a significant portion of your income and you may need the extra help that EPIC can give you. Applying for EPIC could help your prescription dollars stretch farther. When you get ready to complete the EPIC application in this situation, I encourage you to call the EPIC helpline and have them help you with this particular situation.
What I like about EPIC is it is easy to understand and easy to use at any pharmacy in New York state. The formulary is very inclusive, and I have found few medications that it doesn't cover.
If you take a medication that your current plan doesn't cover, you could use EPIC to help get prescription coverage for that medication. In recent years this was not true, but EPIC now does "wrap around" your Part D Plan.
The application is very easy to fill out and requires little time to complete. The application is one piece of paper, both sides must be completed and remember to sign and date. They require proof of your date of birth, so include a copy of your driver's license or birth certificate. If you have many sources of income, you may want to include proof of this, or a copy of the front page of your 1040 tax form from the previous year.
If you have any questions or concerns, call EPIC at 1-800-332-3742. They can answer your questions, fill out an application over the phone or mail you the information you require. EPIC helps over 280,000 seniors across New York state pay for medications. Let EPIC help you too.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.
You may submit questions to be answered in later columns to Janell Sluga at Senior Life Matters, 737 Falconer St., Jamestown, NY 14701, or call 716-720-9797, or by email at janells@lutheran-jamestown.org.
Please remember that not all questions can be answered in this format, but as many as can be, will be.