Have a Grant with HealthWell? How to Decide if the Medicare Prescription Payment Plan is Right for You
The prescription drug law that went into effect in January 2023 was designed to help save money for people with Medicare. One of the law’s provisions – effective January 1, 2025 – caps yearly Part D out-of-pocket prescription drug costs at $2,000, a significant savings for millions of Americans.
The law also provides an option for Medicare beneficiaries to pay their out-of-pocket drug costs in monthly amounts over the plan year. This new payment option, the Medicare Prescription Payment Plan (MPPP, sometimes referred to as “smoothing”), will be offered by all Medicare drug plans and Medicare health plans with drug coverage (such as a Medicare Advantage plan with drug coverage).
Beneficiary participation in the MPPP is voluntary and there is no cost to participate. If beneficiaries select this payment plan option, they will continue to pay their plan premium (if they have one) and will receive a monthly bill from their health or drug plan to pay for their prescription drugs, instead of paying at the pharmacy. Beneficiaries may opt in to and out of the MPPP at any time by notifying their Medicare plan.
Impact of MPPP on Charitable Grant Recipients
Charitable Patient Assistance Programs (CPAPs) like the HealthWell Foundation have been anticipating the MPPP’s rollout for two years and are working to educate grant recipients about the program to help them determine whether opting in to the MPPP is right for them. We asked HealthWell’s Chief Operations Officer, Fred Larbi, to share some insights.
Larbi stressed that while the MPPP may change the logistics of how HealthWell grant recipients pay for their medications, the HealthWell grant process remains the same. Patients must meet the Foundation’s long-established eligibility criteria:
- They must have a diagnosis for a disease covered under a HealthWell Disease Fund.
- They must have some form of health insurance (i.e., Medicare).
- Their medication must be listed under the Disease Fund associated with the grant.
- Their income must fall within HealthWell’s guidelines.
- They must be receiving treatment in the United States.
Things to Consider before Opting in to MPPP
Larbi encouraged Medicare beneficiaries to consider several variables when deciding whether to opt in to the MPPP.
Fred Larbi
“The MPPP may be a good option for beneficiaries who incur high prescription costs earlier in the year, those who have difficulties paying for their prescriptions all at once, and those who take multiple medications,” he said. “However, for Medicare beneficiaries who have a grant with a CPAP like HealthWell, the benefit may not be as great because the grant will immediately cover the cost of their medications. They would not have to be billed by their health plan, pay that bill, submit a claim to the CPAP, and then wait to be reimbursed by their grant.”
Larbi reiterated that because Medicare beneficiaries can opt out of the MPPP at any time, those who sign up for the program early in the year and then are awarded a CPAP grant later in the year can opt out of MPPP to accommodate their new situation.
Medicare beneficiaries eligible for Medicare’s Extra Help program (for those with household incomes of 150% of the federal poverty level or below) are another group that may not benefit from opting in to the MPPP according to Larbi. That is because enrolling in this program provides beneficiaries with a more advantageous out-of-pocket responsibility than the MPPP.
“If someone is eligible for Extra Help, they should enroll in that first because it negates the need to enter the MPPP,” he said.
How MPPP Works at the Pharmacy
The new $2,000/year cap on prescription drugs will be applied at the pharmacy automatically. Medicare beneficiaries will not need to do anything to receive the benefit if they are enrolled in a Part D plan. (Some plans may apply an even lower cap.)
For those enrolled in the MPPP, the prescription drug law requires pharmacies to notify beneficiaries about the MPPP if they have out-of-pocket drug costs of $600 or more a year, although Medicare does not provide a mechanism to opt in to the program directly at the pharmacy.
Larbi offered advice for those with grants from HealthWell:
- Ask the pharmacy how much their copay and out-of-pocket costs are for each transaction.
- Check that the pharmacy has HealthWell’s BIN and PCN numbers (the information the pharmacy needs to bill the CPAP for the covered medication).
- Request that the pharmacy bill HealthWell in the secondary position instead of the MPPP if they have opted in to the program.
“Make sure the pharmacy knows that you have a grant and ask them to use that grant before using the MPPP option,” he stressed.
Additional MPPP Resources
HealthWell’s Contact Center representatives are available, Monday through Friday from 9am to 5pm to help answer grant recipient questions about the MPPP. Reach them at 800-675-8416. The HealthWell website also has links to related resources.
In addition, the official Medicare website offers several resources for patients, caregivers, and others interested in learning more about the Medicare Prescription Payment Plan:
- What the prescription drug law means for Medicare beneficiaries: https://www.medicare.gov/about-us/prescription-drug-law
- Things to know before opting in to the MPPP: https://www.medicare.gov/prescription-payment-plan/before-payment-option
- Examples of how the MPPP works in different situations: https://www.medicare.gov/prescription-payment-plan/examples
- An interactive Q&A designed to help patients decide if the MPPP will help them: https://www.medicare.gov/prescription-payment-plan/will-this-help-me
- What to know about using the MPPP: https://www.medicare.gov/prescription-payment-plan/using-payment-option
