\\\ The ABCs of Part D Helping Consumers Access Medicare Prescription Drug Coverage By

1. \\\ The ABCs of Part D Helping Consumers Access Medicare Prescription Drug Coverage By Judith F. Cox , MA, National Council Consultant and Kristin Battista-Frazee, MSW, Educational Services Manager National Council for Community Behavioral Healthcare October 6, 2005

2. Purpose of this Teleconference • This presentation will help participants: • Understand how the Medicare Modernization Act (MMA) impacts consumers with mental health disabilities. • Formulate specific tasks they can provide to help these consumers access a drug prescription plan that best meets their needs. • Know the resources which are available to providers and consumers for implementing the MMA.

3. The Medicare Prescription Drug Coverage, Improvement, and Modernization Act (MMA) • The Medicare Modernization Act was passed in 2003. • It is also known as the Part D (for Drug) Benefit or Prescription Drug Program. • It will be effective January 1, 2006. • Under this Act all Medicare beneficiaries will have assistance in paying for prescription drugs.

4. Medicareis a federal health insurance program for people: Age 65 years and older Under age 65 with certain disabilities Of any age with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant) Overview: What is Medicare? Source: The Centers for Medicare and Medicaid Service, http://www.cms.hhs.gov/medicare/

5. Medicare has Four Parts: • Part A: the hospital insurance program • Part B: the medical insurance program • Part C: the Medicare Advantage Plan managed care program • Part D: the Prescription Drug Program, created by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 Source: The Centers for Medicare and Medicaid Service (CMS), Outreach Toolkit Medicare Prescription Drug Coverage, June 2005, http://www.cms.hhs.gov/partnerships/tools/materials/medicaretraining/MPDCoutreachkit.asp

6. Who is Impacted by the Part D Prescription Drug Program? • 42 million people in the USA receive Medicare • One quarter of seniors and people with disabilities now receiving Medicare have no drug coverage • Millions more face limitations and rising costs with the current coverage they receive in drug plans

7. Who is Impacted by the Part D Prescription Drug Program • The Part D Benefit will be most used by persons who receive both Medicare and Medicaid as well as other low-income Medicare beneficiaries. • There are 6.3 million individuals who receive both Medicaid and Medicare of which 38% are consumers of mental health services. • There are another 8.1 million low income Medicare beneficiaries. Source: Kaiser Family Foundation, “Medicare Low-Income Assistance Under the Medicare Drug Benefit” June 2005. www.kff.org/medicare/7327.cfm CMS Fact Sheet (January 21, 2005): Final Rules Implementing the New Medicare Law: A New Prescription Drug Benefit for All Medicare Beneficiaries, Improvements to Medicare Health Plans, and Establishing Options for Retirees, www.cms.hhs.gov/media/?media=facts.

8. Provide leadership in helping consumers access benefits. For consumers who are currently receiving prescription drug coverage through Medicaid, assist them transition into the new Part D Benefit by January 1, 2006. After this date, Medicaid will no longer cover their prescription drugs. For consumers who are without drug coverage, assist them in obtaining needed medical & mental health prescription drug coverage. What is the Role of Providers in Implementing the Medicare Part D Prescription Drug Program?

9. Prescription Drug Plans forMedicare Beneficiaries • Beginning January 1, 2006 all Medicare beneficiaries will have the option to enroll in a Medicare drug prescription plan provided through: • Prescription Drug Plans (PDP) which are available to persons in the Original Medicare Fee-for-Service Plan or a Medicare Private Fee-for-Service Plan (PPFS). • A Medicare Health Advantage Plan with prescription drug coverage (MA-PD). • Plans offered by employers and unions to retirees.

10. Beneficiaries Who Have Medicare and Medicaid (Dual Eligible) • These individuals will loose their Medicaid drug prescription coverage on January 1, 2006. • They will be auto-enrolled in a Prescription Drug Plan (PDP) by the Centers for Medicare and Medicaid Services (CMS) before December 31, 2005. • They may experience challenges with this initial enrollment.

11. Medicare Beneficiaries Who Do Not Have Medicaid • These individuals will not be auto-enrolled in a PDP. • As applicable they should enroll in a PDP between November 15, 2005 & May 15, 2006. • If they enroll after May 15, 2006 they will be penalized with higher premium payments. (1% of the average premium per uncovered month)

12. Extra Help Low Income Program • Extra Help is available through the Social Security Administration to defer some costs of the Part D Prescription Drug Program • Who is eligible for Extra Help? • All dual eligible consumers and all other consumers with incomes at or below 150 percent of the poverty level are eligible for the Extra Help program.

13. Extra Help Low Income Program • Who will be automatically enrolled for Extra Help? • People automatically eligible for this assistance are “deemed” and do not have to apply for assistance. They include persons with: • Medicaid and Medicare • Medicare who receive Supplemental Security Income • Partial dual eligibility such as qualified medical beneficiaries, specified low-income Medicare beneficiaries and qualifying individuals • Medicare who are in a Medicare Savings Program • What Medicare consumers should apply ? • All Medicare beneficiaries other than those who are “deemed” will have to apply to receive assistance.

14. A Term to Know • TROOP (True Out–of-Pocket Costs) • Out-of-pocket costs include all prescription drug costs paid by you or another person or organization, including the government. • The out of pocket costs include payment of the deductible, co-insurance, co-payments and medication costs that are not covered by another insurance. • Costs do not include expenses paid by the individual for medications that are not on a plan’s covered list of drugs or for medications excluded from the Medicare prescription drug benefit. • For consumers without extra help programs the highest out of pocket cost is $3,600 per year plus premium cost.

15. What Does a PDP Cost a Beneficiary and How Much Does the Subsidy Program Defer?

16. What Does a PDP Cost a Beneficiary and How Much Does the Subsidy Program Defer?

17. Tammy is a 40 yr. old women with major mental illness, challenges with anorexia and 5 serious suicide attempts. She has a monthly income above 150% of the poverty level. She is now receiving services through a Assertive Community Treatment Program. She is on Medicare but not Medicaid. She has a monthly prescription medication drug cost of $600. Case Study: Tammy

18. Joe is a 62 year old male with chronic heart problems, diabetes and paranoid schizophrenia. He has never worked & has no current income. He currently receives Medicaid and Medicare and was just enrolled in a Case Management Program. He takes four prescription medications. Case Study: Joe

19. Tammy vs. Joe: Costs of Part D coverageadapted from National Council Meet Me Call presented by Dale Jarvis June 27, 2005

20. Extra Help Resources for Consumers • Notices from the SSA were sent in May – August 2005 to approximately 18.6 million people, informing them of the extra help including an application form for the subsidy. • The SSA or state Medicaid offices will provide individuals with information on income and asset requirements for qualifying. They will also assist consumers in completing a low-income subsidy application. Consumers can call 1-800-772-1213 for assistance or their local office. • SSA and state Medicaid agencies began making eligibility determinations on applications for low-income subsidy in July 2005. Individuals may apply on line (www.ssa.gov), by phone or consumers can download an application, and use a tool that helps determine if they qualify for the subsidy benefit.

21. Immediately help consumers determine if they qualify for low-income subsidy assistance. Check with consumers to make sure they have submitted the appropriate subsidy application and used the resources made available to them. Help Consumers Apply for Extra Help

22. Resources to Assist Consumers Obtain Extra Help • Ask consumers if they have received the results of their extra help application. • CMS started mailing notices in May 2005 to beneficiaries deemed eligible for low-income subsidy to notify them that they do not have to apply for the subsidy. Service providers should check with consumers to determine if they have received this notice. If they have not, the provider and the consumer should contact their SSA or local Medicaid office to ensure an application is received.

23. Resources to Assist Consumers Obtain Extra Help • Once a consumer has a extra help determination and knows his/her assigned plan review the consumer’s costs. • Make sure consumers know that Medicare will only cover the lowest PDP premium. If a plan is chosen with a higher premium, consumers will still be responsible for the difference, despite their income subsidy status. • In reviewing costs with consumers, providers should also discuss the impact of extra help on the consumer’s housing, foods stamp benefits, and Medicaid Spend Down, as applicable. The reduction in medical spending will affect eligibility of other benefit programs.

24. How Will Consumers Pay for Co-Pays? • Even the smallest co-pay can represent a hardship for some people. • Co-pays range from $1 to out of pocket costs in the thousands.

25. Alternatives to Helping Consumerswith Co-Pays • Pharmacies are permitted to waive or reduce cost sharing: • For consumers who qualify for the extra help pharmacies can do this on a routine basis. • For consumers who do not qualify for extra help pharmacies can only do this on a non-routine basis. • Pharmacies are restricted from advertising that they can waive costs so providers should prompt consumers to ask for this extra assistance. • Other alternatives are charitable organizations, state pharmacy assistance plans or pharmaceutical company assistance programs.

26. Key Implementation Entities and Service Regions

27. Timeframes for Enrolling Consumers in a Part D Prescription Drug Plan

28. Timeframes for Enrolling Consumers in a Part D Prescription Drug Plan

29. Timeframes for Enrolling Consumers in a Part D Prescription Drug Plan

30. Timeframes for Enrolling Consumers in a Part D Prescription Drug Plan

31. General Provider Tasks to Help Implement the Medicare Part D Drug Program • Review your case loads ASAP to identify Medicare beneficiaries. • Divide Medicare beneficiaries on your caseload into 4 groups based upon their income, dual eligibility and current Medicare drug plans, and then follow relevant enrollment procedures. The four groups are: • Group 1: Beneficiaries in the Original Medicare Fee-for-Service Part A and/or Part B plan and Medicaid. Also know persons in a dual eligible status. • Group 2: Beneficiaries in the Original Medicare Fee-for-Service Part A and/or Part B plan who receive Supplemental Security Income (SSI) or are in a Medicare Savings Program • Group 3: Medicare beneficiaries enrolled in the Original Medicare Fee-or-Service Part A and/or Part B plans who do not receive Medicaid • Group 4: Medicare beneficiaries enrolled in a Medicare Advantage plan but who do not receive Medicaid

32. Groups of Medicare Beneficiaries • Partner with consumers on accessing Part D • Review each consumer’s medications needs, the pharmacy they are using and prescribing physician (consider a standard worksheet) • Assist consumers in applying for extra help • Assist consumers to enroll in a appropriate prescription drug plan • Find out more information-review NMHA’s Medicare workbook for consumers, www.nmha.org • Report major problems consumers have in accessing Part D Drug Program to National Council for Community Behavioral Healthcare

33. A TOOL to Help the Consumer and the Provider Find the Best Plan • Medicare Prescription Drug Plan Finder • This is a web based resource that will be available to consumers and providers beginning October 13, 2005 at www.medicare.gov to compare the plans point by point, such as their premiums, co-payments, drugs they cover (formulary) and pharmacy network information. Program contact and pricing information is displayed at the network pharmacy level. • If you don’t have access to the Internet, you can get the same kind of information by calling Medicare at 1-800-MEDICARE. • A customer representative will send you printed versions of details of all the plans that are available to you. This service, too,will be available after October 13, 2005.

34. The Enrollment and Extra Help Application Procedures for each of the Four Groups of People with Medicare

35. Medicare Beneficiaries Who are Dual Eligible Status & Enrolled in the Original Fee-for-Service PlansPart A and /or Part B PlansGroup 1 • Will they be auto-enrolled in the Part D PDP? • Yes • They will be auto-enrolled by CMS in the Fall 2005 • CMS will randomly assign consumers to drug plans in their region that have the lowest cost plans • Will they automatically receive subsidy assistance? • Yes • They do not have to apply for assistance

36. Medicare Beneficiaries Who are Dual Eligible and Enrolled in the Original Fee-for-Service Plans Group 1 Provider Tasks and Critical Information • In October 2005, partner with consumers to discuss the specific drug plan to which they were auto-enrolled. Review the characteristics of the plan including: • Medications covered and not covered • Co-payment charges, • Grievance procedures, • Pharmacies in the plan’s network • If this plan does not cover the consumer’s prescription medications, review other plans in the Region and select the plan which matches the person’s prescription medication needs. Remember there are at least 2 plans in each region. • Specific information about drug plans in the region can be obtained from the consumer’s pharmacy and online at www.medicare.gov using Plan Finder search tool.

37. Medicare Beneficiaries Who are Dual Eligible and Enrolled in the Original Fee-for-Service Plans Group 1 • When medically necessary, consumers should be permitted to continue utilizing a non-formulary drug (one not covered by a prescription drug plan) that is providing clinically beneficial outcomes. • Each plan should describe how consumers can continue to have access to a non-formulary drug, when there is a known risk for a negative clinical outcome associated with substituting another drug. • Providers should understand the plan’s policy and ensure that the consumer’s coverage continues. See NMHA’s Exceptions and Appeals FAQ provided in Appendix B.

38. Medicare Beneficiaries who are Dual Eligible and Enrolled in the Original Fee-for-Service PlansGroup 1 • In mid December 2005, again discuss with consumers their selected PDP and the plan’s participating pharmacies. • Providers should help consumers make sure that they have a new pharmacy card for the pharmacy in their plan’s network. • Providers should contact the local State Health Insurance Program (SHIP) if they have questions regarding Medicare prescription drug benefits. This is a free counseling service funded by CMS. • In January 2006 or prior to the first visit to the pharmacy, providers should ensure consumers know where their new pharmacies are located and have transportation. For some consumers the provider or a significant other should accompany the consumer on the first visit.

39. Medicare Beneficiaries in the Original Medicare Fee-for-Service Plans who are on SSI or in a Medicare Savings Program Group 2 • Are they auto-enrolled in the Part D PDP? • These individuals will not be auto-enrolled by January 1, 2006 but will be auto-enrolled by May 15, 2006 • They will need to choose and enroll in a plan by May 15, 2006 but can enroll by 12/31/05 • Consumers who do not join a plan by May 15, 2005 will be auto-enrolled in a Part D plan effective June 1, 2006, but this plan may not be consistent with their medication needs. • Will they automatically receive subsidy assistance? • Yes. They do not have to apply for assistance.

40. Medicare Beneficiaries in the Original Medicare Fee-for-Service Plans Who are on SSI or in a Medicare Savings Program Group 2 Provider Tasks and Critical information • Between November 15, 2005 and May 15, 2006, assist consumers in enrolling in an appropriate Drug Plan. • Facilitate the consumer being enrolled in a plan by May 15, 2006 at the latest. If they are not enrolled by this date, Medicare will enroll them in a plan that will be effective June 1, 2006, but this plan may not be consistent with their medication needs. • Similar to Group 1 providers should work in partnership with the consumer to compare their medication needs with the plans available in the region using the available tools and follow steps 3- 7. • Additionally if the consumer is auto-enolled on June 1, 2006 the provider should review the plan to ensure it meets the consumers needs.

41. Beneficiaries Who are Enrolled in the Original Medicare Fee-for-Service Plans but do not Receive MedicaidGroup 3 • How will their prescription drugs be covered as of January 1, 2006? • Individuals in the Original Medicare Plan without drug coverage can enroll in the Medicare Part D PDP. • Medigap consumers should compare their current coverage and make sure it is as good as coverage through a Medicare Part D PDP. • Individuals who have prescription drug coverage through their employer or Union Health need to decide whether they should keep their current plan or enroll in a Medicare part D PDP. • Are they auto-enrolled in a Part D PDP? • No, They must enroll. • Are they auto-enrolled for subsidy assistance? • No, They must apply for this assistance.

42. Beneficiaries Who are Enrolled in the Original Medicare Fee-for-Service Plans but do not Receive Medicaid Group 3 Provider Tasks and Important Information • For consumers with existing prescription drug coverage • Compare the existing plan with the Part D Prescription Drug plans and select the plan that best meets the consumer’s needs. • A SHIP counselor can be contacted to determine if it is in the consumer’s best interest to change plans www.shiptalk.com or call 1-800-MEDICARE. • If a consumer has a Medigap policy or has prescription drug coverage through their employer, they should receive a notice in the Fall of 2005 from Medigap or their employer telling them whether or not their coverage is at least as good as coverage through a Medicare Prescription Drug Plan (PDP).

43. Beneficiaries Who are Enrolled in the Original Medicare Fee-for-Service Plans but do not Receive Medicaid Group 3 • For consumers without drug coverage, inform them about the Part D Prescription Drug Program and the enrollment and extra help processes. • First, assist the consumer in completing an application for the limited income subsidy. Go to www.ssa.gov for an application or apply by phone at 1-800-772-1213. • Review the results of their subsidy application so that consumer knows the costs of the drug plan and that he/she has been approved for the limited subsidy. • Assist consumer in enrolling in an appropriate regional Prescription Drug Plan. With the consumer, compare their medication needs with the plans available in that region.

44. Beneficiaries Who are Enrolled in the Original Medicare Fee-for-Service Plans but do not Receive Medicaid Group 3 • Following enrollment into a plan, review with the consumer their extra help allowance and co-pay charges for each medication. Also discuss the pharmacy in the consumer’s PDP network (name, address and telephone number, methods of transportation to the pharmacy) and make sure consumer has a new pharmacy card for that pharmacy. • Contact the local State Health Insurance Program (SHIP) for additional information which may be needed. • As with Groups 1-3 when needed accompany the consumer to the pharmacy to fill his/her first prescription under the new Medicare Part D Benefit.

45. Medicare Beneficiaries in an Advantage Plan who do not Receive Medicaid Group 4 • How will their prescription drugs be covered as of January 1, 2006? • These individuals can stay in their current Medicare Advantage plan and get prescription drug coverage or enroll in a Part D Plan. • Are they auto enrolled for subsidy assistance? • No. They must apply for this assistance.

46. Medicare Beneficiaries in an Advantage Plan Who Do Not Receive Medicaid Group 4 • Provider Tasks • Meet with consumers to determine is he/she is in a plan without medication coverage. Some of the MA-PD plans do not have drug coverage. • If consumers are without medication coverage and are enrolled in a Medicare Advantage HMO, PPO or SNP, assist the consumer in signing up for a Medicare Advantage Prescription Drug (MA-PD) plan or Part D Plan. • For more information on how to enroll a consumer in the above plans, call 1-800-633-4227 or visit www.medicare.gov. • If needed, the provider should assist consumers with the application for limited income subsidy.Go to www.ssa.gov for an application or apply by phone at 1-800-772-1213.

47. Case Study: Enrollment Procedures for Joe, a Man who receives Medicare and Medicaid

48. Case Study: Enrollment Procedures for Joe a Man who Receives Medicare and Medicaid • Consumer Event- June 2005, Joe receives an informational letter from CMS regarding his transition to a Medicare Prescription Drug Plan. • Provider Response- Provider identifies Joe as a consumer in Group 1 and meets with Joe to review Medicare prescription drug coverage and procedures. • Consumer Event- Fall 2005, Joe’s Medicaid agency mails him a letter to notify him that he will lose his Medicaid prescription drug coverage on January 1, 2006 and that he will be auto-enrolled in a Medicare plan. The letter tells Joe to call 1-800-MEDICARE if he has any questions.

49. Case Study: Enrollment Procedures for Joe a Man who Receives Medicare and Medicaid • Consumer Event- October 27 – November 27, 2005, CMS notifies Joe of the Medicare Prescription Drug Plan he has been enrolled in. • Provider Response- Provider meets with Joe to confirm he has been auto-enrolled in a Prescription Drug Plan, review the contents of the CMS notification and compare the plan Joe has been enrolled in with his medication needs. During this meeting the provider and Joe will work together on the following: • Review the specifics of the plan in which he has been enrolled and make sure that it is the most appropriate plan for him. He and the provider should compare the medical and mental health prescription drugs he needs with those covered by his assigned plan’s formulary.

50. Case Study: Enrollment Procedures for Joe a Man who Receives Medicare and Medicaid • If the assigned plan meets Joe’s needs, he and the provider will review how Joe will get to the participating pharmacy, as this pharmacy may be different from the one he normally uses. • If the plan does not cover Joe’s prescribed medication needs, he should review other plans in his region to find a plan that does. He and the provider can go online at www.medicare.gov and access a software program provided by Medicare to identify the other plans that meet his medication needs. Remember, Joe must change his plan between November 15 and December 31, 2005 to avoid a lapse in coverage. After January 1, 2006, he can change plans every 30 days. • Review the extra help Joe will be receiving and discuss what pharmacy he will be using. The provider and Joe need to keep in mind that the extra help Joe and all other dual eligibles qualify only covers the premium for the lowest-cost plan in his area. Therefore, if Joe chooses a plan with a higher premium, Joe must pay the difference in the cost.