Executive Budget Changes - EPIC - SFY 2012-2013 - Key Points & Additional FAQs
Key Points on 2012-2013 Enacted Budget
Beginning January 1, 2013, the EPIC program will be restored with the following provisions:
- All seniors must be enrolled in a Medicare Part D drug plan in order to receive EPIC benefits and maintain EPIC coverage.
- The EPIC Fee plan will be restored for members with incomes up to $20,000 single or $26,000 married; members will pay quarterly EPIC fees based on income.
- The EPIC Deductible plan will be restored for members with income ranging from $20,001 to $35,000 single or $26,001 up to $50,000 married; members will receive a credit to their EPIC deductible to help them pay their Part D plan premium.
- EPIC will provide secondary coverage for EPIC and Medicare Part D covered drugs after any Part D and/or EPIC deductible is met.
- EPIC will also cover many Medicare Part D excluded drugs, e.g. prescription vitamins, prescription cough and cold preparations.
- EPIC will continue to pay the Part D plan premiums up to the benchmark amount ($39.79 in 2012) for members with income up to $23,000 single or $29,000 married; Deductible plan members with income in those ranges will not receive a credit to their EPIC deductible since EPIC pays for Part D.
Frequently Asked Questions (FAQ)
January 1, 2013 Changes
Q1. How will members find out about the changes to EPIC?
All EPIC members will be notified of the changes and how they will be affected by letter.
Q2. How will EPIC change in 2013?
Beginning January 1, 2013, the EPIC program will have two plans again. The Fee plan will be for members with incomes up to $20,000 single or $26,000 married. Members will be required to pay an EPIC annual fee based on their income. The Deductible plan will be for members with incomes ranging from $20,001 to $35,000 single or $26,001 to $50,000 married. They will have to meet an annual EPIC deductible based on their income before they receive EPIC benefits. All members will have to be enrolled in a Part D drug plan and use it as primary drug coverage. EPIC will provide secondary coverage for EPIC and Medicare Part D covered drugs purchased after any Medicare deductible is met. EPIC will also cover many Part D excluded drugs. (Refer to Q13 for excluded drug information.) EPIC will continue to provide Part D premium assistance for members with incomes up to $23,000 single or $29,000 married.
Q3. I am income eligible for the EPIC Fee program. How will the new program work?
As a Fee Plan member, you will pay an annual EPIC fee ranging from $8 to $300 based on your income. You must be enrolled in a Medicare Part D drug plan and use it as primary prescription insurance. After you pay the Medicare Part D deductible (if you have one), you will only pay EPIC co-payments ranging from $3 to $20 for covered drugs. EPIC will pay the Part D drug plan premiums up to the benchmark amount for a basic plan ($39.79 in 2012). Members will be responsible to pay any excess premiums if their plan premium is higher than the basic plan amount.
Q4. I am income eligible for the EPIC Deductible plan. How will it work?
As an EPIC Deductible Plan member, you do not pay EPIC fees but must meet an annual out-of-pocket EPIC deductible ranging from $530 to $1,715, based on your income. You must be enrolled in a Medicare Part D drug plan and use it as primary drug insurance. If your income is over $23,000 single or $29,000 married, you will be responsible to pay your Medicare Part D drug plan premium and your EPIC deductible will be lowered by the annual Part D premium for a basic Medicare drug plan ($477 in 2012). If your income is between $20,001 - $23,000 single or $26,001 - $29,000 married, EPIC will pay your Part D drug plan premium up to the benchmark amount for a basic plan ($39,79 in 2012) and you will not have a lower EPIC deductible. After paying your Medicare Part D deductible amount (if you have one), out-of-pocket drug costs for covered drugs will be applied to your EPIC deductible. After meeting your EPIC deductible, you will only pay an EPIC co-pay ranging from $3 to $20.
Q5. I am in the EPIC Deductible plan and EPIC is paying my Medicare Part D drug plan premium each month. Will I receive a lower EPIC deductible?
No. Since EPIC is paying your Medicare Part D plan premium, you will not receive a lowered EPIC deductible. After you pay any Medicare Part D Deductible, any out-of-pocket drug costs for Part D covered Drugs or Part D excluded drugs will be applied to your EPIC deductible. After meeting your EPIC deductible, you will only pay an EPIC co-pay ranging from $3 to $20 for drugs.
Q6. Are there any changes to the EPIC eligibility requirements beginning January 1, 2013?
No. All EPIC members must be enrolled in a Medicare Part D drug plan. 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.
Q7. I am not eligible to join a Medicare Part D drug plan. Can I enroll in EPIC and use it as primary drug coverage?
No. EPIC only provides supplementary drug coverage for members enrolled in Medicare Part D drug plans. If you are not eligible to join Part D you will not be able to receive EPIC benefits. You may be eligible to use county drug discount cards or manufacturers' patient assistance programs to reduce your drug costs. EPIC also has a Patient Assistance Resources flyer that lists organizations that may provide financial assistance to help pay for medications. Please call the EPIC Helpline at 1-800-332-3742 for more information or visit the EPIC web site at http://www.health.ny.gov and click on EPIC for Seniors.
Q8. Will members need to be enrolled in Medicare Part D? What if Part D coverage is dropped?
If a member cancels their Medicare Part D coverage, they will not receive any benefits from EPIC and coverage may be canceled. Members must have Part D in order to receive EPIC benefits and maintain EPIC coverage.
Q9. Will EPIC continue to enroll members into Medicare Part D plans?
EPIC no longer facilitates enrollment of members into Part D plans. However, the program will continue to assist members in selecting and enrolling in Part D plans if a member requests it.
Q10. How will members with the Extra Help Low Income Subsidy (LIS) be affected?
If a member has Full or Partial Extra Help from Medicare, is in a Medicare Savings Program or has a Medicaid spenddown, EPIC will continue to help pay the Part D plan premiums. Members with full Extra Help will not have to pay any EPIC fees. Members with Partial Extra Help will pay the quarterly EPIC fee beginning January 1, 2013.
Effective January 1, 2013, EPIC will supplement the out-of-pocket drug costs for members with Full or Partial Extra Help for Part D covered drugs and Part D excluded drugs. Partial Help members must satisfy the Part D deductible ($65 in 2012) before EPIC coverage begins. EPIC will continue to provide Part D premium assistance for Partial LIS members and those with Full LIS in enhanced plans.
Q11. Will EPIC continue to apply for the Medicare Extra Help Low Income Subsidy (LIS) and Medicare Savings Programs (MSP) for members?
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 $2.65 for generic drugs and $6.60 for brand drugs in 2013 and have no coverage gap.
Q12. What drugs will be covered under the new EPIC program?
Beginning January 1, 2013, EPIC will only cover EPIC and Medicare Part D covered drugs after a member pays any out-of-pocket Medicare deductible. EPIC will supplement drugs purchased in Part D initial coverage, coverage gap (donut hole) and catastrophic phases. EPIC will also cover many Medicare Part D excluded drugs. (Refer to Q13. for excluded drug information.)
Q13. What Medicare Part D excluded prescription drug categories will be covered by EPIC in the coverage gap through 2013?
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
Q14. What will the EPIC co-payments be effective January 1, 2013?
EPIC co-payments have not changed. For Part D covered drugs purchased after any Medicare Part D or EPIC deductibles are met and covered Part D excluded drugs, 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 |
Q15. Will EPIC payments apply toward true out-of-pocket (TrOOP) amount?
Yes. However, payments for Part D excluded drugs will not count toward TrOOP. (Refer to Q.13.)
Q16. Will a member still be able to get up to a 90-day temporary supply or a 3-day emergency supply of any prescription that requires a Prior Authorization (PA) under their Medicare Part D plan?
No. Beginning January 1, 2013, EPIC will only cover Part D covered drugs after a member pays any Medicare Deductible and covered Part D excluded drugs. (Refer to Q13. for excluded drug information.) Therefore, members will have to work with their prescriber and pharmacist to get coverage for drugs that are not covered by their plan.
Q17. Will EPIC help members submit appeals to Part D plans for non covered drugs?
No. Beginning January 1, 2013, members will have to work with their pharmacist and prescriber to submit appeals to the Part D plan for non-covered drugs.
Q18. Will EPIC members still have an SEP (special enrollment period) in 2013?
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 be creditable coverage in 2013 when the new program begins?
No. Since EPIC is a secondary payer and Part D is primary drug coverage, 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. It will also pay Part D premiums for members with incomes up to $23,000 single or $29,000 married.
