Transcript Medicare Part D

Medicare
Part D
Nari Wang
Health Law Unit
199 Water Street
Center for Independence of the Disabled, NY
February 23, 2010
New York, NY 10038
212-577-3315
Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
Other Parts of Medicare

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Part A – covers hospital, skilled nursing facility,
home health, and hospice care
Part B – covers medically necessary doctor visits,
outpatient services, durable medical equipment,
preventative care, lab tests, x-rays, mental health,
and some home health and ambulance services
Part C – plans that offer Part A , Part B, and Part D
services, also known as a Medicare Advantage
plans
Part D – prescription drug plan
Other Parts of Medicare




Part A – covers hospital, skilled nursing facility,
home health, and hospice care
Part B – covers medically necessary doctor visits,
outpatient services, durable medical equipment,
preventative care, lab tests, x-rays, mental health,
and some home health and ambulance services
Part C – plans that offer Part A , Part B, and Part D
services, also known as a Medicare Advantage
plans
Part D – prescription drug plan
Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
I. What is Medicare Part D

Since January 1, 2006, Medicare prescription drug
coverage has been available to everyone with
Medicare. Known as Part D, this benefit provides
outpatient prescription drug coverage.

Private companies provide the drug coverage.
Beneficiaries choose the drug plan and pay a
monthly premium. Like other insurance, if a
beneficiary decides not to enroll in a drug plan
when they are first eligible, they may pay a penalty
if they choose to join later.
Two Types of Coverage
Medicare Advantage
Plans (MA-PD)


These are health plans offered
by private companies that
provide Medicare Part A and B
services as well as the Part D
drug benefit
Also known as Part C
Stand-alone Prescription
Drug Plans (PDP)

These plans only offer the Part
D drug benefit
Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
II. What does Part D Cover?
Each drug plan has a Formulary, a list of all drugs
covered by that plan. Formularies must include “all
or substantially all” drugs in 6 classes of clinical
concern
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Antidepressants
Antipsychotics
Anticonvulsants
Antineoplastic (cancer)
Immunosuppressant (for organ and tissue transplant patients)
Antiretroviral (for treatment of HIV/AIDS)
*Formularies can change but notice is given prior to change.
Excluded drugs are not included in any basic
Medicare Part D plan. Some examples of this are
“off label” drugs, OTC drugs, prescription vitamins
and minerals, and benzodiazepines
Utilization Management –
A Plan’s restrictions on how certain drugs will be covered

prior authorization- where the prescribing MD
must request permission from the plan

step therapy – where the plan will not cover the
drug until beneficiary shows they tried alternative
drugs and they didn’t work

quantity limits – where the plan will only cover a
limited number of pills per month
Exceptions and Appeals –
when you disagree with a plan’s decision

When a plan requires utilization management for
your drug

Your doctor prescribes a medically necessary drug
but its not on the plan’s formulary

Your drug is removed from the plan’s formulary
mid year
Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
III. The Co$ts of Part D

All PDPs have a monthly premium
In 2010, premiums range from $19.50/month to $117.50/month

Some PDPs have an annual deductible
The maximum deductible in 2010 is $310

In the Initial Coverage period, beneficiaries are
responsible for co-payments or coinsurance
Co-payment is a fixed dollar amount for the drug and coinsurance is a
percentage of the drug cost that the beneficiary pays

Full cost of drugs while in Coverage gap/ Donut
Hole
Coverage Gap/Donut Hole
All plans have a coverage gap, also known as
the donut hole. Once a beneficiary reaches
the gap, she must pay for 100% of the drug
costs until she reaches catastrophic
coverage. After reaching catastrophic
coverage, the beneficiary would be
responsible for approximately 5% of the
drug cost.
The Donut Hole – an illustration
Coverage gap
Deductible
Initial Coverage Period
Catastrophic Coverage
Low Income Subsidy/ Extra Help
A federal subsidy that helps low income Medicare
beneficiaries pay for costs related to Part D
coverage. Extra Help reduces or eliminates Part D
related costs such as the monthly premiums,
annual deductible, co-payments, and the costs
incurred during the coverage gap/donut
mentioned earlier.
Low Income Subsidy/Extra Help
FULL Extra Help
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Premium – will pay premium up to a certain
amount, called a “benchmark”, in 2010 is $33.32.
In 2010, there are 10 plans within the benchmark.
Deductible – no deductible!
Co-payments – copays range from $0 - $6.30
No coverage gap/donut hole!
Low Income Subsidy/Extra Help
PARTIAL Extra Help
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Premium – will pay 25% to 75% of plan’s
premium based on an income based sliding scale
Deductible – $63 or lower
Co-payments – 15% of drug cost
No coverage gap/donut hole!
3 Ways of Getting Extra Help
Extra Help
Having Medicaid
which makes you
a Dual Eligible
Having a Medicare
Savings Program
(MSP)
Applying for it
Through the Social
Security Administration
(SSA)
Medicare Savings Program (MSP)
All three have different eligibility levels and offer
various cost saving benefits for other Medicare
costs, including Part A and Part B costs.
QMB – Qualified Medicare Beneficiary
 SLMB – Specified Low Income Medicare
Beneficiary
 QI-1 – Qualifying Individual Program

Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
IV. How to Enroll with Part D
Initial Enrollment Period –
A 7 month period to enroll in a drug plan. Begins 3 months before and ends 3
months after the month of a) beneficiary’s 65th birthday or b) the month of
getting Medicare due to disability
Annual Coordinated Election Period –
November 15 – December 31, effective January 1 –you can enroll or change the
drug plan
Special Enrollment Periods – many different situations can give a
beneficiary a SEP. Example: having Extra Help you have a SEP that
allows you to change your plan every month. Another common
example is when you lose your previous drug coverage plan that was
creditable
* Take care* Penalties can be placed if you enroll too late after
losing creditable drug coverage
Part D Automatic Enrollment
All Dual Eligibles (Medicare and Medicaid) must
join a Part D plan. A Dual Eligible will be
automatically enrolled in a plan if they don’t
choose a plan in time.
 Those with an MSP or Extra Help will also be
automatically enrolled if they don’t choose a plan
in time. The plan is randomly chosen, so its best
for you to choose the plan so you can make sure all
your drugs are covered.

Medicare Part D – an overview
I.
What is Medicare Part D?
II.
What does Part D cover?
III.
How much does it co$t?
IV.
How do I enroll?
V.
How does Part D work with other drug
coverage?
V. Part D with Other Types of Drug
Coverage
 Medicaid (dual eligible)
 EPIC
 New York Prescription Saver Card
 Medigap
 Patient Assistance Program
 Veterans
health care
Part D and Medicaid- Dual Eligibles
Medicaid acts as the secondary payer, Part D plan will
be primary except as noted below.

Will pay for Part D excluded drugs, as mentioned earlier “off label” drugs, certain OTC drugs, prescription vitamins
and minerals, and benzodiazepines were a few examples.

Medicaid will wrap around 4 classes of drugs
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Antidepressants
Antipsychotics
Immunosuppressant (for organ and tissue transplant patients)
Antiretroviral (for treatment of HIV/AIDS)
Since these classes are all within the 6 classes of clinical
concern mentioned earlier in a plan’s Formulary, this
Medicaid wrap is not usually needed
Part D and EPIC –
EPIC is NYS drug program for seniors (65+) with
income under $35k for singles, $50k for couples
If a drug is covered by both Part D and EPIC, Part D is
primary payer and EPIC is secondary
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As of July 1, 2007, most EPIC enrollees had to join a Part D
plan
EPIC covers excluded drugs, as long as its on EPIC
formulary
EPIC will also cover drugs not on your plan’s formulary
(EPIC Wrap)
As of October 1, 2008, EPIC started encouraging use of
generic drugs for their members who have EPIC as a
primary payer
EPIC Co-payment chart
Total drug cost
EPIC co-pay
<$15
$3
$15-$35
$7
$36-$55
$15
>$55
$20
Part D and
New York Prescription Saver Card
a prescription discount card

Who can join – New York State residents are
eligible if they are not already receiving Medicaid
and are:
Either age 50 up to 65, or persons with a disability who
have been determined disabled by the Social Security
Administration; AND
 Have annual household income less than $35,000
(single) or $50,000 (married).

Part D and
New York Prescription Saver Card
 You can’t use Part D plan card and your NYPS
at the same time.
 When can you use it?
1. To buy drugs that are not on your plan’s formulary or
are excluded from all Part D plans.
2. When you’re in your Deductible or Coverage gap - but
if you want the money you spend to count
towards TROOP (the running total amount you and others
have paid for drugs thus far), you need to save receipts
and submit them to your plan.
Questions
Contact:
Health Law Helpline
Open Tuesdays
212-577-3575