Transcript The Impact of New Changes in the Medicare Drug Benefit on

The 2012 Medicare Drug Benefit and
Dual Eligibles with
Developmental Disabilities
Beverly Roberts
Director, Mainstreaming Medical Care
The Arc of New Jersey
Webinar, Nov. 29, 2011
[email protected]
What is a “Dual Eligible”?
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A dual eligible is a person who has both
Medicaid and Medicare benefits
Most dual eligibles receive their
prescription drugs from Medicare Part D
Dual eligibles – No deadline
to enroll in new Medicare drug plan
There is a massive marketing campaign on
TV, radio and newspapers, saying that
Dec. 7 is the deadline to enroll in a new
Medicare Part D drug plan.
 But that deadline is NOT APPLICABLE
to the dual eligibles.
 Dual eligibles can switch to a new
Medicare drug plan at any time!

Why so many people with developmental
disabilities are dual eligibles
When the parent of a person with a
developmental disability starts to collect
Social Security benefits, the adult child
starts to receive a Social Security Disability
(SSD) check each month.
 24-months later, the adult child starts to
receive Medicare. The person with a
disability receives both Medicaid and
Medicare, and is a “dual eligible.”

What is a DAC?
The term Disabled Adult Child (DAC) is
used by the Social Security system for
adults with developmental disabilities.
 When a person is coded in the computer
as a DAC, it allows for an override of the
usual Social Security rules. Those rules
would have disqualified a person with a
disability who gets a larger SSD check
from also receiving Medicaid.

DAC (cont.)
 If
a person with a developmental
disability is getting a monthly SSD
check and is notified that Medicaid
will be cut-off:
– Find out if the consumer is coded as a
“DAC” by the Social Security computer
system.
– Apply for Medicaid at the county level
and explain the DAC status.
Federal Oversight for the
Medicare Drug Benefit
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The Medicare prescription drug benefit is
called Medicare Part D
The federal agency that has authority over
all aspects of Medicare – including
Medicare Part D – is the Centers for
Medicare and Medicaid Services (CMS)
Important Terms
Low Income Subsidy (LIS): Medicare
beneficiaries with limited income and
resources may qualify for extra help, in
the form of a Low Income Subsidy (LIS),
to pay for prescription drug costs.
 Dual eligibles are automatically
eligible for the LIS.

Important Terms, cont.
Prior Authorization: A cost-containment
procedure that requires a prescriber to obtain
permission from the prescription drug plan
(PDP) to prescribe a medication
 Step Therapy: The practice of beginning drug
therapy for a medical condition with the most
cost-effective drug, and progressing to more
costly drug therapy only if necessary; the
primary goal is cost-containment

Important Terms, cont.

Quantity Limits: For safety and cost
reasons, a drug plan may limit the amount
of pills that they cover for a particular
drug. With the physician’s documentation
of medical necessity, this requirement may
be waived.
The 2012 MEDICARE PART D
Information
for New Jersey’s
Dual Eligibles
What is a “Benchmark” drug plan?
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A dual eligible may enroll in a benchmark drug plan,
without paying any monthly premium fee.
Although the Medicare drug plans do require a monthly
fee, for the dual eligibles, that fee is subsidized by CMS
up to a specific amount (which is known as the
benchmark).
There are two types of drug plans: Basic and Enhanced,
but only the Basic plans can qualify as benchmark plans.
For 2012, the benchmark amount in NJ is $36.
Therefore, dual eligibles may enroll in any Basic
benchmark drug plan and not pay a monthly
premium.
Overview of Benchmark Drug Plans
for NJ’s Dual Eligibles
In 2011, there were 6 benchmark plans
available for NJ’s dual eligibles.
 Beginning January 1, 2012, 9 benchmark
plans will be available in NJ.
 1 of the benchmark drug plans from 2011
won’t be available in 2012; 1 plan is no
longer benchmark; and NJ will have 5
new benchmark plans.

2012 Benchmark Plans in NJ
COMPANY NAME
PLAN NAME
Monthly Premium for
Dual Eligibles in 2012
Aetna Medicare (NEW)
Aetna CVS Pharmacy Prescription Drug
Plan (formerly “Essentials”)
$0
Bravo Health (NEW)
BravoRx
$0
SilverScript Insurance Co.
CVS Caremark
$0
EnvisionRx Plus
EnvisionRxPlus Silver
$0
First Health Part D (NEW)
First Health Part D – Premier
$0
Humana Insurance
Humana Walmart-Preferred Rx Plan
$0
Medco Medicare Prescription Plan
Medco Medicare Prescription Plan-Value
$0
United American Insurance Co. (NEW)
United American - Select
$0
WellCare (NEW)
WellCare Classic
$0
Drug plan no longer participates
with Medicare Part D
Company Name: Rx America
 Plan Name: Advantage Star by Rx
America
 Everyone enrolled in this Medicare drug
plan will be automatically re-assigned to
another plan.

AARP drug plan:
Not benchmark in 2012
Company Name: UnitedHealthcare
Plan Name: AARP MedicareRx
Preferred
This change will impact many dual
eligibles in NJ!
 How to deal with this change?

Notification of Changes for 2012
Letters mailed by CMS to dual eligibles in
New Jersey enrolled in Advantage Star by
Rx America or AARP Medicare Preferred:
■ Termination Letter - on Blue Paper
■ Reassignment Letter - on Blue Paper
■ A second letter
■ “Choosers” Letter - on Tan Paper
Blue Termination Letter
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The blue termination letter
explains that the current drug
plan (Advantage Star by Rx America)
will be terminating in 2012.
■
Consumers who receive this letter
will be randomly auto-enrolled
in a new $0 premium drug plan.
Blue Termination Letter (cont.)
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Blue Termination Letter will outline these options:
1) Medicare will auto-enroll consumer in a new fully subsidized $0
premium drug plan. This will be a random enrollment, with no
attempt to match dual eligibles to a plan that best meets
their needs
This will happen automatically unless other action is
taken
2) Dual eligible can choose to enroll in a different drug plan that
has a $0 premium
Requires a phone call to a different drug plan to
enroll
Blue Reassignment Letter
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The blue reassignment letter is sent to dual eligibles who
were in the AARP Medicare Preferred drug plan
because they were assigned to that plan (as
distinguished from having chosen that plan).
The letter explains that the AARP Medicare Preferred
plan will have a cost increase that will exceed the
benchmark amount, making it no longer eligible for the
full low income subsidy.
If no action is taken after receipt of blue reassignment
letter, these dual eligibles will be randomly autoenrolled in a new $0 premium drug plan, to begin
Jan. 1, 2012.
Blue Reassignment Letter (cont.)
Three Choices:
1) Dual eligibles can choose to remain in
the AARP drug plan and pay the
premium fee of $2.60 per month.

Requires a phone call to the current
AARP drug plan to indicate desire to
remain in that drug plan, or
Recipients of a Blue Letter
2) Dual eligibles can stay in the drug plan
that was assigned in the Blue letter.
 If considering staying in the newly assigned drug
plan: Call the new plan to find out if all current
medications are covered without restrictions, and
if current pharmacy is affiliated with the drug
plan.
 If current medications are not covered, find out if
other benchmark drug plans will cover them.
Recipients of a Blue Letter (cont.)
3) Dual eligibles can choose to enroll in
another benchmark drug plan (different
from the one assigned in the Blue letter).
 Requires a phone call to a
different drug plan to enroll .
Affordable Care Act (ACA) Notice
on Blue Paper

In late December, everyone who received a blue
reassignment letter will get a second blue
letter.

Letter tells all reassigned persons:
– Differences between their 2011 drug plan and 2012
plan based on drug utilization
– Explains the process to get an exception
– Explains appeals process
– Provides beneficiary-specific drug information
Tan “Choosers” Letter
A Tan letter was sent to all dual eligibles who
are enrolled in the AARP Medicare Preferred
drug plan if they had chosen that plan.
■ The important distinction is having chosen the
AARP drug plan rather than being autoenrolled.
■ The letter will say that the current Medicare
drug plan premium will no longer be fully
subsidized, starting Jan. 1, 2012.
■ If dual eligibles, currently enrolled in the AARP
Medicare Preferred plan, receive the tan letter
and do not switch to another drug plan, they
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will be required to pay a $2.60 premium
every month.
Tan “Choosers” Letter (cont.)
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A Tan letter was also sent to all dual eligibles who are
currently enrolled in other non-benchmark drug plans.
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These dual eligibles are currently paying a monthly
premium fee, but the fee may change in January.
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Example: Dual eligibles currently in Healthnet Orange
Option 1 are paying $5.00/month. This will increase to
$20.00 per month in Jan. 2012 if they stay with this plan
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If dual eligibles, currently enrolled in any non-benchmark
drug plan, do not switch to another drug plan, they
will be required to pay a premium every month.
Tan “Choosers” Letter (cont.)
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The Tan “Choosers” letter will outline
these options:
1) Stay in the current plan and pay a premium fee
each month.
This will happen automatically unless
another action is taken
2) Switch to one of the 9 benchmark Medicare drug
plans that offer a fully subsidized $0 premium plan
Requires a phone call to the new plan to
enroll
New Identification cards

Everyone who will be in a new Medicare
drug plan should look for the new drug
plan’s ID card in the mail.

Bring the new ID card to the pharmacy.
Disenrollment for non-payment of
monthly premium
Dual eligibles enrolled in a benchmark drug plan
have no monthly premium fee.
 If dual eligibles who are enrolled in nonbenchmark plan don’t pay the premium, the
drug plan will disenroll them, i.e., no access to
medications from that plan!
 CMS will auto-enroll them into a benchmark
plan, BUT there may be a period of noncoverage of prescription drugs before this
occurs.
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How to get drug coverage if
terminated from drug plan

Ask the pharmacist to enroll them in
LINET: Limited Income Newly Eligible
Transition Program, with Humana.

This process allows pharmacist to enroll
dual eligible (or other Low Income Subsidy
person) into a temporary Part D plan
(LINET Humana) in order to get
medications immediately.
Medicare Part D co-pays
for dual eligibles
In NJ, Part D co-pays for dual eligibles
started July 1, 2011.
 For most dual eligibles with developmental
disabilities, drug co-pays are $1.10 for
each generic and $3.30 for each brand
name drug.
 For dual eligibles on the Community Care
Waiver (CCW): Starting Jan. 1, 2012, no
co-pays for Medicare Part D drugs.

No “lock-in” for dual eligibles!
Dual eligibles are not “locked in” to a drug
plan. Therefore, the Medicare drug plan
ads that say Dec. 7th is the end of open
enrollment do NOT apply to dual eligibles
 If dual eligibles want to switch drug plans
and they don’t get it done in December,
they can switch in anytime next year.
 Drug plan changes are always effective
the first day of the next month.

Formulary Changes that May
Affect All Dual Eligibles
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Every year, in January, Medicare drug
plans are permitted to change their
formulary (the list of drugs they pay for)
Even if dual eligibles did not receive a blue
or tan letter, they should find out if their
current prescription drugs will still be
covered in January, 2012.
Monthly Fee if a Dual-Eligible
Selects a Non-Benchmark plan
 Wide
variation in monthly premiums
for dual eligibles in non-benchmark
plans
- For 2012: The lowest monthly
premium for a non-benchmark plan
is $2.60 per month (AARP Medicare
Rx Preferred)
Why would dual eligible select
a non-benchmark drug plan?
If a dual eligible needs medications not available
on formulary of benchmark drug plans, but
available in non-benchmark plan – it may be
more cost-effective to pay a relatively low
monthly premium to get the needed
medications.
 This decision needs to be made on an individual
basis.
 The next slide shows the monthly premium fees
for NJ’s Basic non-benchmark plans.

Consumer’s Pharmacy Must be
Affiliated with the Drug Plan’s Network
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Before switching to a new Medicare drug
plan, check with your pharmacy to be
certain that it is affiliated with the new
drug plan.
Most of the major pharmacy chains are
affiliated with all of the Medicare drug
plans.
Small pharmacies may not have as many
affiliations.
Coverage of Benzodiazepines and
Barbiturates for Dual Eligibles
Drugs classified as Benzodiazepines or
Barbiturates will continue to be excluded Part
D drugs, even though some plans may cover
them through an enhanced benefit (additional
premium will apply for Duals).
■ These drugs will be covered by the Medicaid
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HMO, but prior authorization is required.
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Dual eligibles need to show the Medicaid HMO
ID card at pharmacy.
Barbiturates Covered by NJ Medicaid
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Bellaspas
Bel-Tabs
Butisol Sodium
Eperbel-S
Ergocaff-PB
Fioricet
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Fiorinal
Mebaral
Phenobarbital
Phenobarbital Sodium
Seconal Sodium
Spastrin
Benzodiazepines Covered by NJ Medicaid
Alprazolam
Alprazolam Intensol
■ Ativan
■ Chlordiazepoxide HCL
■ Clonazepam
■ Clorazepate Dipotassium
■ Dalmane
■ Diazepam
■ Estazolam
■ Flurazepam HCL
■ Halcion
■ Klonopin
■ Librium
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Lorazepam
Lorazepam Intensol
■ Midazolam HCL
■ Niravam
■ Oxazepam
■ Prosom
■ Restoril
■ Serax
■ Temazepam
■ Tranxene T-Tab
■ Triazolam
■ Xanax
■ Xanax XR
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Transition Policy for dual eligibles
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For the first 90 days of 2012, CMS expects all Part D
plans to cover one fill for drugs which the member is
currently taking that are either:
a) not on the formulary, or
b) are on the formulary but require prior
authorization or step therapy
Pharmacist should print out a message from drug plan at
the point of sale, saying that this is a one-time transition
fill.
CMS requires the Part D plans to send written notice to
each enrollee who receives a transition fill, within 3
business days
Aspects of Medicare Part D that
Do Not apply to the Dual Eligibles
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Monthly premium fees
 As long as dual eligibles are enrolled in a benchmark
plan, there is no premium fee
The “Donut Hole” – doesn’t exist for duals.
■ No Deductibles for dual eligibles
■ Drug tiers
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 As long as a drug is on the formulary, it does not
matter which tier it is on
■
No lock-in for dual eligibles; can switch to
another drug plan at any time
How to obtain answers for
Medicare Part D questions
Check the www.Medicare.gov website
Call 1-800-MEDICARE
Call the current drug plan and speak with a
customer service representative
■ Contact a SHIP counselor (State Health
Insurance Assistance Program). SHIP counselors
are VERY busy until Dec. 7th when open
enrollment for non-dual eligibles ends.
■ The next slide provides phone numbers for free
Medicare counseling from the NJ SHIP program.
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State Health Insurance Assistance Program (SHIP) Telephone Numbers
Local County Office
Telephone
Atlantic
888-426-9243
Bergen
201-336-7413
Burlington
609-894-9311, ext. 1494
Camden
856-858-3639
Cape May
609-886-8138
Cumberland
856-459-3090
Essex
973-643-5710
Gloucester
856-468-1742
Hudson
201-369-5280, Press1, then ext. 4258
Hunterdon
908-788-1361
Mercer
609-924-2098 Ext.14
Middlesex
732-745-3295
Monmouth
732-728-1331
Morris
973-784-4900 Ext. 101
Ocean
800-668-4899
Passaic
973-569-4060
Salem
856-339-8622
Somerset
908-704-6319
Sussex
973-579-0555 Ext.1223
Union
908-273-6999
Warren
908-475-6591