Transcript Medicare Part D Training for Low Income Health Advocates

Medicare Part D
Drastic Threats to Rx for Low
Income Elderly and Disabled
Pathways to Justice Conference
San Francisco June 2005
Jeanne Finberg
National Senior Citizens Law Center
Medicare Prescription Drug,
Improvement and
Modernization Act of 2003
(MMA)
Biggest Change in Government
Health Care Programs in 40 years
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Medicaid coverage ends on January 1,
2006 for virtually all prescription drugs for
elderly and disabled
Medicare Part D replaces Medi-Cal for all
dual eligibles
NO EXCEPTIONS
NO EXTENSIONS
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Who is affected?
• 43 Million Medicare beneficiaries Nationally
• 6.8 Million Dual Eligibles
• More than 1 million in CA
– 937,000 Fee for Service
– 137,000 Managed Care
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Who is Eligible
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All Medicare Beneficiaries Nation-wide
Elderly and Disabled people
Entitled to Part A and/or Enrolled in Part B
Any Income level
Any resource level
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Dual Eligibles: a vulnerable
group
• Duals are more than twice as likely to be
in fair or poor condition as other Medicare
beneficiaries
• More than 50% are limited in activities of
daily living
• Almost 4 in 10 have mental or cognitive
impairments
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Duals: a vulnerable population
• Need multiple prescriptions
• Nearly 25% are in LTC
• Are likely to need assistance
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Auto enrollment of Duals
• Part D Health Plan
• Low Income Subsidy
• Numerous barriers
– Confusion
– Random assignment
– Obtaining Information
– Restrictions on Drugs
– Lack of Continuity
– Gaps in coverage
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Key Dates
• July 1, 2005
• October 2005
Subsidy applications
Part D Plans known
Dual eligibles auto-enrolled
• November 15, 2005 Part D Enrollment
• January 1, 2006
Part D benefit begins
• January 1, 2006 Medi-Cal drug coverage
ends
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Part D Plans -- PDPs
• CA State-wide region
• CMS will initially approve formularies
– Must be choice of at least 2 drugs within
certain categories
– Change with 60 day notice
• PDP will make the determination of what is
medically necessary
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MULTIPLE AGENCIES
• Centers for Medicare and Medicaid
Services (CMS)
– Medicare Part D
• Social Security Administration (SSA)
– LIS application, processing
• State of CA (DHS)
– IDs duals
– Enroll in LIS -- reluctantly
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Key Differences between
Medicare Part D and Medi-Cal
• Medicare Part D plans will be private plans
• Plans will likely be more restrictive –
– Plans have greater flexibility in designing and changing
formularies
– Utilization tools – prior authorization, limits
– May have tiers – preferred drugs
– Network Pharmacies
• Duals will have co-payments for each prescription
(probably of $1 to $3) which cannot automatically be
waived
• May need to pay a premium for any plan above the
“benchmark” plan
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Medicare Part D Generally
• Costs: premiums, deductibles, cost
sharing thresholds will increase annually
• Plans may vary considerably – alter amts,
etc, so long as basic benefit same or
better
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Example of Standard Prescription
Drug Coverage
• $37 monthly premium
• $250 deductible
• Coinsurance of 25% of drug costs from
$250 to $2,250
– Medicare pays 75%
• 100% of drug costs from $2,250 to $5,100
• After $3,600 in out-of-pocket costs,
Medicare pays approximately 95%
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Medicare Standard Drug Benefit 2006
Coverage
Annual Drug
Costs:
Premiums
Part D Plan
Pays:
Beneficiary
Pays:
none
About $37/mo
Deductible
$0 - $250
$0
$250
Initial Limit to
Coverage
$251 - $2,250
75% ($1,500)
25% ($500)
Coverage Gap
(Donut Hole)
$2,251 - $5,100
$0
100% ($2,850)
Coverage
Resumes
Over $5,100
95% of
remaining costs
Up to 5% of
remaining costs
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Part D Enrollment period
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This year:
11/15/05 to 5/15/06
Future years: 11/15 to 12/31
Lock in for year for most beneficiaries
Duals may change every month
Others: very limited opportunity to disenroll
– Move out of service area
– LTC enter, leave or reside in
– Loss of creditable coverage
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Voluntary?
• Dual Eligibles – Lose Medi-Cal
No other coverage
• Others may enroll or not, but penalty for
postponed enrollment unless creditable
coverage
• 1% of base premium for each month delay
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AUTO ENROLLMENT
• Duals auto-enrolled into PDP or MA-PDP
in October 2005, effective 1/1/06
• May change plans prior to 1/1/06
• May change each month
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LOW INCOME SUBSIDY
• Group 1
– Full-benefit dual eligibles with incomes at or below
100% Federal poverty level (FPL)
• Group 2
– Full-benefit dual eligibles above 100% of FPL; QMB,
SLMB, QI, SSI-only, or non-dual eligible
beneficiaries with incomes below 135% FPL and
limited resources ($6,000 per individual and $9,000
married couple)
• Group 3
– Beneficiaries with incomes below 150% FPL and
limited resources ($10,000 individual and $20,000
married couple)
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LOW INCOME SUBSIDY
Group 1
Group 2
Group 3
Premium
$37/month
$0
$0
Sliding scale
based on income
Deductible
$250/year
$0
$0
$50
Coinsurance
up to $3,600
out of pocket
$1/$3 copay
$2/$5 copay
15%
coinsurance
Catastrophic
5% or $2/$5
copay
$0
$0
$2/$5 copay
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Low Income Subsidy
• Applications at SSA or County
• Income up to 150% FPL
– $19,245 Couple
– $14,355 Individual
• Assets
– $10,000 Individual
– $20,000 Couple
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Auto-enrolled into LIS
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Dual Eligibles
SSI Beneficiaries
MSPs: QMBs, SLMBs, QI-1
Notices out this month from CMS telling
them that they are enrolled, don’t need to
apply
• All others must apply to LIS (and Part D)
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LIS Income and Resources
• Use SSI Rules
• Income: Higher levels, but count applicant
and spouse; deductions and exemptions,
in kind income rules the same.
• Assets: Exempt assets include the home,
small amounts for life insurance policies,
burial accounts
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LOW INCOME SUBSIDY
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SSA notice and application
Mailing to 20 million potential eligibles
Duals auto-enrolled
July 1, 2005, applications processed
English and Spanish, language assistance
Scannable
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LOW INCOME SUBSIDY
• Does it matter where you apply?
• State
– State/county duty to screen and enroll
– MSP programs are undersubscribed
– MSP people are deemed eligible for LIS
• SSA
– application, outreach, funding incentives
– No duty to screen and enroll, forward info
– Appeal rights are different
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How to Enroll
• Enrolling in a Plan
– Directly with PDP
– Assistance of others
– Authorized Representative under state law
• Enrolling in LIS
– Beneficiary
– Personal representative
– Assistant
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Exceptions and Appeals
To obtain drug or lower cost sharing rate:
• File Exception Request
– 24 hours Emergency; otherwise 72
• 5 level appeal
– Redetermination by plan
– Reconsideration – Independent Review Entity
– ALJ Hearing
– Medicare Appeals Council
– Federal District Court
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Long Term Care
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No Co-pays
Special rules for participating pharmacies
All residents
Packaging and on call service
Guidance re emergency
Transition
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Client Concerns
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Limited English Proficient
Cognitive Impairments
Physical Disabilities
Confusion
Need for individual assistance
Mistakes, computer glitches
Reduced coverage; reduced health status
Transition, emergency supply
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State Implementation Issues
• Part D excluded drugs – benzodiazepines,
barbiturates, over the counter meds
• Emergency and transition coverage
• Co-payment and premium assistance
• Processing the Low Income Subsidy
applications
• Assistance with choosing plan
• Outreach and education
• Trouble shooting/problem solving
• State regulation of Part D plans
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TROOP: True Out of Pocket
Expenses
• Includes:
• Expenses Paid by Medicare Beneficiary
• Friend, Family Member, Charity
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Excludes:
Most 3rd party payments –e.g. employers
Drugs not on Plan’s formulary
Over the counter drugs
Drugs purchased from Canada, Mexico
Total for 2006 $3,600
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Citations, Reference
• Medicare Part D Statute and Regs
– 42 USC § 1395, Tit. XVIII.
– 70 Fed. Reg. 4194 (January 28, 2005).
– 42 CFR Parts 400,403,411,417 and 423.
• www.cms.gov
• Low Income Subsidy
– 70 Fed Reg 10558 (March 4, 2005).
– 20 CFR Part 418.
– POMS Section HI 03001.000 et seq
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Consumer information
• www.Medicare.gov
– TTY users 1977-486-2048
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www.cms.gov
1 800 Medicare
Medicare and You 2006 Handbook
HICAPs
Legal Services Programs -- HCAs
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Questions?
Call with questions, problems, send client stories
Jeanne Finberg
National Senior Citizens Law Center
405 14th Street Suite 1400
Oakland, CA 94610
510 663-1055
[email protected]
Copyright 2005 by the National Senior Citizens Law Center. All rights reserved.
Permission to copy will be granted to non profit entities with appropriate acknowledgment of
credit.
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