1 / 41

Medicare Part D

Medicare Part D. The New Prescription Drug Benefit and Implications for CARE Act Clients. Mary Vienna Division of Training and Technical Assistance HIV/AIDS Bureau Health Resources and Services Administration Department of Health and Human Services. Medicare Part D and Ryan White Overview.

thane-gay
Download Presentation

Medicare Part D

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Medicare Part D The New Prescription Drug Benefit and Implications for CARE Act Clients Mary Vienna Division of Training and Technical Assistance HIV/AIDS Bureau Health Resources and Services Administration Department of Health and Human Services

  2. Medicare Part D and Ryan WhiteOverview • The new Medicare benefit called Medicare Part D • How that will change care for our clients on Medicare • How it will impact grantees

  3. Medicaid Federal and State program with State flexibility Means-tested Takes into account financial resources Poor AND Disabled on SSI Parents, children, pregnant women Medically Needy Prescription drug benefit 200,000 with HIV/AIDS (44% of those in care) $10.4 billion (Federal and State) in 2005 Medicare Federal program No means testing 65 or older OR Permanently disabled Under 65 and receiving SSDI for 2 years No prescription drug benefit Approx 80,000 with HIV/AIDS (19% of those in care) More likely to have AIDS diagnosis and T4 count 0-199* $2.9 billion in 2005 Medicaid versus Medicare • SOURCE: Bozzette, et al. “The Care of HIV-Infected Adults in the United States.” NEJM, Vol. 339, No. 26. • December, 1998

  4. What is Dual Eligible? • 70-85% of Medicare beneficiaries with HIV/AIDS also qualify for Medicaid • Disabled, poor and at end-stage illness • Use Medicaid for access to medications People Living with HIV/AIDS Medicaid 200,000 Medicare 60,000 - 80,000 Dual Eligible 50,000 – 60,000

  5. Medicare Modernization Act • Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 signed into law on December 8, 2003 • Biggest change to Medicare in 40 years • Adds a prescription drug benefit to Medicare called Medicare Part D • Benefit starts January 1, 2006

  6. Basic Prescription Drug Benefit • Enrollment period from November 15, 2005 to May 15, 2006 • Medicare beneficiary chooses to enroll in Medicare Part D • Medicare beneficiary then chooses either: • A stand-alone prescription drug plan [PDP] for those in traditional fee-for-service (Part A and B) Medicare • A managed care plan (Medicare Advantage) that includes a prescription drug plan [MA-PD] for those in Part C • Beneficiaries will have a choice of at least two prescription drug plans • Choices and plans will vary between regions • Plans have flexibility (subject to certain constraints) to establish varying features: • Levels of cost-sharing requirements and coverage limits other than “standard” coverage • Lists of drugs to include on their formulary, and on which tier • Cost management tools

  7. Basic Prescription Drug Benefit • Generally, people are enrolled in a plan for a year. In special circumstances people can change plans. Dual eligibles can change plans at any time. • Expected premium in 2006 of $32.20 per month but will vary by plan • Basic benefit will have deductibles, coinsurance and co-pays • People with limited resources will receive low-income subsidies (LIS) for these costs • Most Medicare beneficiaries with HIV/AIDS will qualify for some type of LIS • CMS pays subsidies directly to the plan • All beneficiary costs and subsidy eligibility will be adjusted annually

  8. Basic Prescription Drug Benefit • This benefit is different for Medicare • Subsidies are means tested • Benefit will vary by region • Implementation requires coordination between CMS, the Social Security Administration and State Medicaid Agencies • Many Medicare beneficiaries have other drug coverage--requires coordination (e.g., retiree plans, VA, Tricare)

  9. Medicare Part D and Dual Eligibles • As of January 1, 2006, Medicaid will no longer provide federal matching funds for Medicare beneficiaries’ prescription drug coverage • Dual eligibles will be switched to Medicare for drug coverage • Impact dependent on differences between previous State Medicaid plan and Medicare drug plans available in the area

  10. Medicare Part D and Dual Eligibles • The switch from Medicaid to Medicare will take place on January 1, 2006 • No transitional period • To ensure continuity of drug coverage, CMS will auto-enroll all dual eligibles and notify them of their plan assignment in October • Dual eligibles can choose another plan at any time – no annual election period

  11. Ensuring a Smoother Transition • Letter to State Medicaid Directors promising Federal matching funds for early refills and 30-90 day prescriptions near the end of 2005 • PDPs must have a transition process for new enrollees, with outreach efforts and a transition timeframe to introduce formulary requirements

  12. Standard Benefit: Beneficiary Cost Per Year (for 2006), Excluding LIS • Expected monthly premium of $32.20 • $250 deductible • 25% coinsurance from $251 to $2,250* • 100% coinsurance from $2,251 to $5,100 (coverage gap commonly referred to as the “donut hole”) • Catastrophic coverage level: co-pay of 5% or $2/$5 (whichever is greater) after total drug costs reach $5,100 AND beneficiary has paid $3,600 in true out-of-pocket costs (TrOOP) • Coinsurance is a term used in Medicare Part D that refers to the beneficiary’s contribution toward prescription drug costs until the catastrophic coverage limit has been reached

  13. Standard Benefit in 2006 Out-of-pocket Threshold Catastrophic Coverage $250 $2250 $5100 Total Spending 75% Plan Pays Coverage Gap 80% Reinsurance $ + Deductible ≈ 95% 25% Coinsurance Total Beneficiary Out-Of-Pocket $250 $750 $3600 TrOOP 15% Plan Pays 5%Coinsurance Direct Subsidy/ BeneficiaryPremium BeneficiaryLiability Medicare Pays Reinsurance

  14. Case Study: Peter Jones • 65 years old, HIV positive, aged into Medicare • Income $1,600 per month (200% FPL) • Antiretroviral regimen is Efavirenz (Sustiva) + FTC/TDF (Truvada) • Drugs cost $1,300 per month • Peter pays: • $32.20 per month in premiums • Month 1: $250 deductible plus $262 (25% coinsurance) towards $1050 balance • Month 2: $237 coinsurance (25% of $950 balance to reach $2250 co-insurance limit) plus $350 (100% coinsurance for balance of $1300 pharmacy cost) • Month 3: $1,300 prescription cost (100% coinsurance) [Peter has now paid $2,399 out-of-pocket towards his drugs] • Month 4: $1,201 prescription cost (100% coinsurance for a total of $3,600 in out-of-pocket costs). Total drug costs are also $5,200 (above the $5,100 limit) so the catastrophic coverage level has been reached. • Months 5-12: $65 per month (5% co-pay) • Peter pays $4,506.40 for the year [$386.40 in premiums, $3600 out-of-pocket and $520 in co-pays]

  15. Who Qualifies for a Low Income Subsidy (LIS)? • Medicare beneficiaries who are automatically qualified for a full subsidy (known as “deemed eligible”) are : • Dual eligible (receive full Medicaid benefits) • 70-85% of Medicare beneficiaries living with HIV/AIDS • In a Medicare Savings Program • Qualified Medicare Beneficiary (QMB) • Specified Low-Income Medicare Beneficiary (SLMB) • Qualifying Individual (QI) • Receiving SSI benefits • Medicare will notify them May-June • Dual eligibles will be auto-enrolled in October and may choose a different plan

  16. Who Qualifies for a Low Income Subsidy (LIS)? • Other Medicare beneficiaries who qualify for a full or partial subsidy, but not automatically, are: • Single with an annual income below $14,355 and resources less than $11,500 in 2005* • Married with a combined annual income below $19,245 and resources less than $23,000 in 2005* • These individuals must apply to the Social Security Administration or Medicaid State Agency to qualify • SSA sending nearly 19 million letters and applications this summer. Can apply by mail, SSA’s 1-800, online, or in person. • Medicaid State Agencies who qualify Medicare beneficiaries for LIS must also screen them for eligibility for Medicaid and Medicare Savings Programs • Medicare will enroll those who don’t choose a plan by May 15 *Higher in Alaska, Hawaii and for certain reasons

  17. LIS for Dual Eligibles • No premiums unless beneficiary chooses an above-average cost PDP • Then pay balance of premium cost • No deductible or coinsurance • Prescription co-pay • Below 100% FPL: $1 generic/$3 brand drug co-pay • Above 100% FPL: $2 generic/$5 brand drug co-pay • No cost after total drug costs of $5,100 and $3,600 out-of-pocket limit is reached • Subsidy counts toward out-of-pocket costs • What someone pays out-of-pocket + what Medicare pays as the extra help = $3,600

  18. Case Study: Jane Matthews • On SSDI, Medicare and Medicaid (dual eligible) • SSDI benefit $780/month (less than100% FPL) • Antiretroviral regimen is Sustiva + Truvada • Drugs cost $1,300 per month • Jane pays $6 in co-pays per month for two scripts (income < 100% FPL so $3 brand name co-pay applies) for three months • By 4th month, total drug costs of $5,200 exceeds $5,100 catastrophic coverage level ($1,300 x 4) • No cost to Jane after that • Jane pays $18 for the year [3 months of $6 co-pay]

  19. Full Low-Income Subsidy • Those eligible for this subsidy include Medicare beneficiaries who are: • In a Medicare Savings Program (QMB, SLMB, QI) • Receiving SSI benefits • Have an income below 135% FPL and resources of no more than $7,500 single/$12,000 per couple* • No premiums unless beneficiary chooses an above-average cost PDP • No deductible or coinsurance • Prescription co-pay • $2 generic/$5 brand drug co-pay • No cost after total drug costs of $5,100 and $3,600 out-of-pocket limit is reached • Subsidy counts toward out-of-pocket costs and reaching catastrophic level • Adjusted annually; resources include burial exclusion of $1500 for individual, $3,000 per couple.

  20. Case Study: Joseph Black • On SSDI and Medicare • SSDI benefit is $950/month (less than120% FPL) • Antiretroviral regimen is Sustiva + Truvada • Drugs cost $1,300 per month • Joseph pays $10 in co-pays per month for two scripts ($5 brand name co-pay times two) for three months • By 4th month, total drug costs of $5,200 exceeds $5,100 catastrophic coverage level ($1,300 x 4) • No cost to Joseph after that • Joseph pays $30 for the year [3 months of $10 co-pay]

  21. Partial Low Income Subsidy (2006)* • Those eligible for this subsidy include Medicare beneficiaries who are: • Below 150% FPL and with resources of no more $11,500 (individuals) and $23,000 (couples) • Benefit • Sliding scale premium • $50 deductible • 15% coinsurance up to catastrophic coverage level • $2 generic/$5 brand name drug co-pay after total drug costs of $5,100 and $3,600 out-of-pocket limit is reached • Subsidy counts toward out-of-pocket costs and reaching catastrophic coverage level * Adjusted annually

  22. Sliding Scale Premium Assistance *Numbers are for 2006

  23. Case Study: Jason Smith • On SSDI, Medicare and small private disability insurance benefit • Income $1,100 per month (138% FPL) • Antiviral regimen is Sustiva + Truvada • Drugs cost $1,300 per month • Jason pays: • About $8 per month in premiums (75% subsidy of $32.20) • Month 1: $50 deductible plus $187.50 (15% coinsurance of $1,250 balance) • Month 2: $195 coinsurance (15% coinsurance of $1,300) • Month 3: $195 coinsurance (total drug costs $3,900) • Month 4: $180 coinsurance (on $1200 balance of $5100 total drug cost limit for catastrophic coverage level) • Months 5-12: $10 per month ($5 brand name co-pay on two scripts) • Jason pays $983 for the year [$96 in premiums, $807.50 in deductible and coinsurance, $80 in co-pays]

  24. Plan Pays Beneficiary Pays $250 $2250 $5100 $ + About 95% 75 % $5100 $ + $2 - $5 co-pays apply 100 % Numbers are for 2006 Standard Drug Benefit for beneficiaries with income >150% FPL or less than 150% FPL but more than the resource limit $32.20 monthly estimated premium Full-benefit dual eligibles with income >100% FPL $0 monthly premium and no deductible Full-benefit dual eligibles with income  100% FPL* $0 monthly premium and no deductible $5100 $ + $1 - $3 co-pays apply 100 % *Cost sharing is $0 if the beneficiary is a full-benefit dual eligible and institutionalized.

  25. Plan Pays Beneficiary Pays $5100 $ + $2 - $5 co-pays apply $50 $5100 100 % $2 - $5 co-pays apply 85 % Numbers are for 2006 SSI Recipients, Medicare Savings Programs Groups, Applicants with income < 135% FPL who also meet resource test ($7,500 individual / $12,000 couple) $0 monthly premium and no deductible Applicants with income <150% FPL who also meet resource test ($11,500 individual / $23,000 couple) Sliding scale premium assistance

  26. How to Apply for Help • The Social Security Administration (SSA) will mail applications to people who may qualify • Those who think they may qualify should • Complete the application form • Mail it to the address on the back of the form • Use the enclosed postage-paid envelope • Use original forms only • Do not photocopy the application • Photocopying the application could delay timely processing • Apply--even if they’re not sure they qualify

  27. Other Ways to Apply for Extra Help • Apply on the Social Security website at http://www.socialsecurity.gov • Apply at a Social Security sponsored event • Apply by phone by calling Social Security at 1-800-772-1213 • Apply at a State Medicaid Office • Apply at a community event that will offer opportunities to apply • State Health Insurance Program (SHIP) counselors will offer free personalized counseling starting in the fall of 2005

  28. Further Help With Costs • AIDS Drug Assistance Programs (ADAP), in accordance with State program policy, can pay: • Premiums • Deductible • Coinsurance (15%, 25% and 100%) • Co-pays • ADAP contributions do not count toward the $3,600 in TrOOP costs needed to reach the catastrophic coverage level

  29. What Counts Toward TrOOP? • Payments made by: • The beneficiary • Another individual (e.g. family or friends) • Certain charities • A State Pharmacy Assistance Program (SPAP) • A personal health savings vehicle (Flexible Spending Accounts, Health Savings Accounts, and Medical Savings Accounts) • Co-pays waived by a pharmacy • CMS to the plan as low income subsidies

  30. What Doesn’t Counts Toward TrOOP? • Premiums • Payments made by: • AIDS Drug Assistance Programs (ADAP) • Group health plans (employer/retiree plans) • Federal government programs (e.g., Indian Health, Medicaid,Tricare, VA, FQHCs) • State-run programs that are not SPAPs • Workman’s Compensation • Automobile/No-Fault/Liability • Part D plans’ supplemental or enhanced benefits

  31. What Doesn’t Count Toward TrOOP? • Payments never count toward TrOOP when made for: • Non-covered drugs that are not obtained through an exceptions or appeal process • Drugs purchased outside the U.S. • Non-Part D drugs • Part B drugs • Drugs excluded in the Part D benefit (e.g. benzodiazepines, barbiturates)

  32. Access to Drugs: Formulary Issues • PDPs have the flexibility (within certain constraints) to establish: • Different levels of cost-sharing requirements and coverage limits other than “standard” coverage • Lists of drugs to include on their formulary • Tiers of drug co-payments • Cost management tools • If a plan uses a formulary, it must include at least two drugs in each therapeutic category and class • The U.S. Pharmacopoeia (USP) has designed a model guideline of therapeutic categories and classes of drugs. Medicare drug plans can use the USP model but they are not required to do so. • CMS will review formularies to assure that prescription drugs for HIV/AIDS are included • A prescription drug plan will not be approved if the formulary design would discourage enrollment of certain groups

  33. HIV Drug Categories in USP Model Formulary

  34. Access to Drugs: Formulary Issues •  In order to protect against discrimination, CMS will review six drug classes in the formulary to ensure there is access to all drugs in that class: • Antidepressants • Antipsychotics • Anticonvulsants • Antiretrovirals • Antineoplastics • Immunosuppressants

  35. Issues for HIV/AIDS Care • Access to medications • Two drugs in each therapeutic class or category with six exceptions • True drug benefit will be determined by plan formulary • Plan can change drugs in formulary while the non-dual beneficiary must remain in plan for one year • Reliance on exceptions and appeals process • Costs • Prevents ADAP from contributing toward TrOOP costs • Drugs not covered by plan do not count towards catastrophic coverage level • Unlike Medicaid, no access to medication for failure to pay co-pay • Pharmacy can waive co-pay • 60 and 90 day prescriptions lower co-pay costs • Requires those eligible for full low-income subsidies to pay premium balance for above-average cost plans

  36. Issues and Challenges for Beneficiaries • Deciding whether to enroll in Part D in 2006 if they have a choice • Financial penalties for delayed enrollment • Enrolling in low-income subsidy program • Will beneficiaries know they are eligible? • Will they sign up? • Comparing plans and deciding which to join • Could face wide variations in premiums, benefit design, formularies and preferred drug lists each year. • Facing potential consequences of a poor plan choice • Annual enrollment period for non-duals • While the plan is responsible for tracking TrOOP costs, the beneficiary is expected to inform the plan of other prescription drug benefits

  37. Challenges for Beneficiaries with HIV/AIDS are Obligations and Opportunities for Ryan White • Initial transition period raises unique challenges • How to educate ourselves • How to educate dual eligibles and enrollees • How to ensure a smooth transition for individual health and public health reasons • Clients will need information and assistance in: • Applying for subsidy programs • Enrolling in Medicare Part D • Choosing a plan that works for them • Providers and case managers must know resources available for help • Once enrolled, clients will look to providers for help with appeals and exceptions • Non-dual Medicare clients comfortable on ADAP programs will need to be encouraged to enroll in Medicare Part D

  38. It’s Happening Fast • May-June2005 • CMS mails notices to people with Medicare who automatically qualify for the low income subsidy and do not need to apply • Applications for subsidies accepted • Summer • SSA mails applications to potential eligibles who don’t automatically qualify • October 2005 • 2006 “Medicare and You” handbook with comparative drug plan information mailed to every beneficiary • Online tool to help select plan on www.Medicare.gov • CMS notifies dual eligibles of the plan Medicare will enroll them in if they do not choose one on their own by December 31, 2005 • November 15, 2005 • Beneficiaries can begin enrollment in Medicare Part D by choosing and enrolling in a Medicare plan • January 1, 2006 • All dual eligibles switched to Medicare • April 2006 • CMS notifies other people who qualify for the low-income subsidy that if they do not choose a plan by April 2006, CMS will facilitate their enrollment in a plan on their behalf, with coverage effective June 1, 2006 • May 15, 2006 • Initial enrollment period for Medicare Part D complete

  39. What’s HAB Doing? • HAB Medicare Workgroup • Expertise and resource to programs and project officers on Medicare Part D • Technical assistance and outreach plan • Venues to reach grantees • HAB project officer training • HAB website information • Qs & As

  40. Who Do I Go To For Answers? • HAB Project Officers • CMS Regional Office • Medicaid State Agency • Social Security Administration • State Health Insurance Program • State ADAP • Title I and II programs • HIV and Professional Organizations

  41. Website Resources • http://hab.hrsa.gov/specialprojects.htm • Medicare Part D webpage • Qs & As http://www.hrsa.gov/medicare/HIV/qa.htm • Links • http://www.cms.hhs.gov/medicarereform/pdbma • Information about Medicare Part D • http://www.cms.hhs.gov/medicarereform/AIDS.pdf • Medicare HIV/AIDS Fact Sheet • http://www.medicare.gov • Click on “Learn About Your Medicare Prescription Coverage Options” • Information for Medicare beneficiaries

More Related