Transcript New Medicare Drug Benefit

The Medicare Drug Benefit:
What Is It and What Does it Mean for Mental
Health?
© 2005 National Mental Health
Association
Today We’ll Learn About…
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New Medicare Drug Benefit Basics
Impact on Dual Eligibles
Enrolling in the New Benefit Program
Extra Help for People with Low Incomes
Access to Mental Health Medications
Exceptions and Appeals
Medicare Drug Benefit Basics
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Medicare now will offer insurance to help people pay
for prescription drugs
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This is a voluntary program – you must choose to
sign-up
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This will be available to all people enrolled in
Medicare, including:
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People with Medicare and Medicaid (called dual eligibles)
Other low-income Medicare recipients
General Medicare recipients
Begins January 1, 2006
Mental Illness Is Real to People on
Medicare
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37% of older adults show signs of depression when
they visit their primary care physician
Older adults have the highest rate of suicide of any
age group in the country
Over half of all under-65 Medicare recipients with
disabilities have problems with mental functioning.
38% of dual eligibles (approximately 2.5 million
people) have a mental or cognitive impairment
(MedPAC, 2004).
How the New Drug Benefit Works
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Private insurance plans will cover prescription drugs:
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Prescription Drug Plans (PDPs) only offer the Medicare
drug benefit
Medicare Advantage Prescription Drug Plans (MA-PD) are
managed care plans (e.g., HMOs) offering comprehensive
health care services (including drug benefits)
Each plan will have its own formulary (list of drugs)
listing which drugs are covered
At least two plans will be offered in each region.
Key Dates
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May-August 2005: Government Letters Sent
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September 2005: Approved Plans Announced
October 2005: Information regarding plan options available
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SSA Extra Help applications sent to individuals under 150% FPL
Extra Help Applications now accepted by mail/online. Apply Now!
CMS mailed letters to duals to inform them of the new benefit and
extra help they will receive
Plan Finder available on www.medicare.gov
Letters to dual eligibles regarding auto-enrollment sent
November 15, 2005 - May 15, 2006 – Initial enrollment period
January 1, 2006 – Medicare Rx benefit begins
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Medicaid prescription drug coverage for dual eligibles
ends
Cost of the Basic Benefit
Costs for General Medicare Population:
 Estimated average $32 a month premium (in addition to
Part B)
 $250 annual deductible
 25% of drug costs between $250 and $2,250 annually
 100% of drug costs between $2,250 and $5,100
(known as the “doughnut hole”) annually
 “Catastrophic benefit,” above $5,100 in total drug costs,
greater of:
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5% of drug costs; or
$2 for generics and $5 for brand drugs
Medicare Rx Benefit and Dual Eligibles
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People with both Medicare and Medicaid
coverage are “dual eligibles.”
Duals are automatically enrolled in a
prescription drug plan but may choose a
different plan.
As of Jan. 1, 2006, Medicare will pay for
prescription drugs. Medicaid drug coverage
for dual eligibles will end.
Benefit Costs for Dual Eligibles
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No premiums or deductibles
$1-$5 co-payments
No doughnut hole in coverage
No co-payments for drug costs over $5,100
Enrollment for Dual Eligibles
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October 2005: Letters from CMS will notify
duals about automatic enrollment in a plan
with lowest premium in their area.
Duals can sign up for plans with premiums
higher than $32 per month, but must pay
difference of premium.
All Duals can switch plans up to once a
month.
Enrollment for Everyone Else
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New drug benefit is voluntary
October 2005 - information regarding plan
options will be available
Initial enrollment period:
Nov. 15, 2005 – May 15, 2006
Enroll by applying to private plans offering
coverage in your area
Late Enrollment
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Penalties apply if you wait to sign up after deadline and
do not have comparable drug coverage in the mean
time.
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Premiums increase by 1% for every month without coverage
after May 15, 2006
No penalties if you have comparable drug coverage
through other sources:
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Former or current employers
Veteran’s, military or federal benefits
Private individual insurance
Extra Help for Low-Income People
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Under 135% of poverty and minimal assets:
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No premiums or deductible
$2-$5 co-payments
No “doughnut hole” or gap in coverage
No co-payments for drug costs over $5,100
Under 150% of poverty and minimal assets:
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Premiums on a sliding scale
$50 deductible
15% co-payment on drug costs up to $5,100
No “doughnut hole” or gap in coverage
$2-$5 co-payments for drug costs over $5,100
Enrollment for Low-Income People
Enrollment is a two step process.
1.
Apply for Extra Help through Social Security
Administration or State Medicaid agency, except:
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2.
If you receive full Medicaid or Medicaid assistance with
Medicare premiums or co-payments, you will receive
assistance automatically
If you receive Supplemental Security Income (SSI), you
will receive assistance automatically
Sign up for the drug benefit itself by applying to
private plans offering coverage in your
area – no later than May 15, 2006.
Access to Mental Health Medications
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Minimum requirement to cover two drugs per class
CMS guidance states a “all or substantially all” drugs must
be covered in six categories including anti-psychotics,
anti-depressants, and anti-convulsants
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Requirement applies through 2006 contract year.
Extended release forms not included – exception will be required
for refills.
Existing prescriptions for non-formulary medications will be refilled,
according to CMS, without requiring an exception step.
Some drugs are excluded from coverage by statute
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Benzodiazepines, barbiturates, and drugs to treat anorexia for
example
State Medicaid programs may still cover these
medications and receive federal matching funds.
Access to Mental Health Medications
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CMS requires plans to offer at least 30-day supply of
existing medication for non-formulary medications.
Plans may change formularies to remove drugs or
change co-payments with:
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60 days notice to affected prescribers and CMS;
AND
60 days notice to affected enrollees, OR
60-day supply of the drug
Utilization management
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Tiered co-pays and prior authorization may apply
Step therapy (for new patients)
Exceptions and Appeals
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Private plans offering new drug benefit must
have process to allow exceptions to tiered
cost-sharing and to lists of covered drugs
(formularies)
Prescribing physician must file statement
supporting the exception request
The plans determine criteria for granting
exception and for determining medical
necessity
Exceptions and Appeals
Process does not start until:
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consumer requests formal determination or exception
regarding coverage of a drug (or co-pay)
Physician statement supporting medical necessity is
received by plan
Plans must respond to initial exception request
within 72 hours (24 hours in emergency situation)
Multiple appeals levels
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No external review (outside the plan) until the 3rd level of
appeal (up to 17 days after initial request)
Plans not required to provide existing drug
during appeal after initial transition supply
Key Dates
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May-August 2005: Government Letters Sent
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September 2005: Approved Plans Announced
October 2005: Information regarding plan options available
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SSA Extra Help applications sent to individuals under 150% FPL
Extra Help Applications now accepted by mail/online. Apply Now!
CMS mailed letters to duals to inform them of the new benefit and
extra help they will receive
Plan Finder available on www.medicare.gov
Letters to dual eligibles regarding auto-enrollment sent
November 15, 2005 - May 15, 2006 – Initial enrollment period
January 1, 2006 – Medicare Rx benefit begins
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Medicaid prescription drug coverage for dual eligibles
ends