Transcript Medicare Prescription Drug, Improvement, and Modernization

MMA
Medicare Modernization Act
PL 108-173
Most sweeping reform since program
inception
 Incredibly short timeframes to
implementation
 New partnerships between Medicare and
Medicaid, SSA and States
 New ground for Medicare – “means
testing!”

MMA
Title I
Medicare Prescription Drug Benefit
Medicare-Approved Drug Discount Card
MMA
We will cover….
A (very brief) mention of the drug card
 A Part D Overview
 A look at the Low Income Subsidy
 State roles and responsibilities

Medicare Approved
Drug Discount Card

Help for many people with Medicare

REAL discounts on prescription drugs

Voluntary Program

Bridge to Part D Prescription Drug benefit
Medicare Approved
Drug Discount Card

Enrollment began on May 3, 2004

Discounts began June 1, 2004

Program sunsets on December 31, 2005
(or whenever Part D kicks in…)
So much for the drug card
..
. . . on to Part D!
Part D
Medicare Prescription Drug Plans

Effective: January 1, 2006

Called “Medicare Prescription Drug
Plans” – MPDPs (v. Part D)

Eligibility?
•
Must be entitled to Part A or enrolled in
Part B
(Have Medicare Card)
Part D
Medicare Prescription Drug Plans

Enrollment for Part D
•
Voluntary
•
Medicare beneficiaries who opt for Part D must
actively choose a plan
Part D
Medicare Prescription Drug Plans

If enrolled in fee-for-service Medicare


Receive Part D benefits through a Prescription
Drug Plan (PDP)
If enrolled in Medicare Advantage (MA) Plan

Receive Part D benefits through Medicare
Advantage Prescription Drug Plan (MA-PD)
Standard Medicare Drug Benefit
Benefit (Rx costs)
Monthly Premium
Annual Deductible ($0-$250)
Initial Rx Benefit ($250-$2,250)
Beneficiary
TrOOP
Averages
$37/month
$250
$500 (25%
coinsurance)
100% Coinsurance ($2,250-$5,100)
$2,850
Catastrophic Benefit Period
(>$5100)
Greater of 5% or
$2 after $3,600
spent above
Dual Eligibles

Medicare Beneficiaries

Who receive some or all Medicaid
Benefits
Full Benefit Dual Eligibles

Medicare beneficiaries

With full (comprehensive) Medicaid
benefits
Full Benefit
Dual Eligibles
Coverage Under Part D

Full Medicaid Benefits
As of January 1, 2006, there will be no
Medicaid match available for prescription
drugs States provide to full benefit duals

other than “excludable drugs”(weight loss and
certain psych drugs) not covered by Medicare
Full Benefit
Dual Eligibles
Coverage under Part D

Critical for States and CMS to help full
benefit dual eligibles (FBDE) transition to
Part D plan

Good transition to talk about the Low Income
Subsidy…..
Low Income Subsidy Assistance
 Low-income
 Extra
Medicare beneficiaries
assistance with premium and
cost sharing under the new drug
benefit.
Low Income Subsidy (LIS)
Assistance
Federal Help in Paying
Deductibles
 Premiums
 Co-payments
 Coinsurance
Note – these are forms of “cost sharing”

Low Income Subsidy Assistance

Certain groups (deemed) are automatically eligible
for a subsidy.

Low income subsidy “applicants” (undeemed)
will have to “apply” and meet an income and asset
test.

Eligibility determinations?
 SSA or the State Medicaid Agency
Low Income Subsidy - Process
Important!
For LIS Beneficiaries, it’s a 2-step
process!
1. “Apply” for LIS
2. “Enroll” in MPDP
Low Income Subsidy Eligibles – Who are those guys?
Mechanism
Deemed by
law
Subsidy Group
Subsidy Category
FBDEs at or below
100% FPL
Full subsidy eligible –
lowest co pays ($1/$3)
FBDEs above 100%
FPL
SSI recipients
Deemed by
regulation
Medicare Savings
Program Groups (QMB,
SLMB, QI)
Must Apply
(Undeemed)
“Applicants”
Other non-dual, lowincome beneficiaries
Full subsidy eligible –
nominal co pays ($2/$5)
May qualify for 1 of 3
groups: 2nd FSE group
above, or 2 other “notfull subsidy” groups
Low Income Subsidy for FBDEs
Benefit
TrOOP for FBDEs
@/b 100% FPL over 100% FPL
Monthly Premium
$0
$0
Annual Deductible
$0
$0
Initial Rx Benefit
($0-$5,100)
$1/$3 co pays
$2/$5 co pays
100% Coinsurance
Catastrophic Benefit
Period >$5100
Institutionalized pay $0
N/A
N/A
$0
$0
FBDEs are Treated Specially

Certain duals get lower cost-sharing.



< 100% FPL  lower co-pays $1 to $3
institutionalized  no cost sharing
FBDEs auto-assigned to a plan with
opportunity to change plans.
LIS for non-FBDEs
TrOOP for non-FBDEs
Below
Below
Below 150%
Benefit
135% FPL 135% FPL
FPL & higher
& limited & higher
resources
resources resources
Mon. Premium
$0
$0
Sliding Scale
Annual.Deduct
$0
$50
$50
$2/$5
Initial Rx
Max 15%
Max 15%
Benefit
coinsur.
coinsur.
co pays
100% Coinsur.
N/A
N/A
N/A
Catastrophic
Period >$5100
$0
$2/$5
$2/$5
What is the process for deeming?
States
Identify
FBDEs, MSPs
Some overlap
SSA
Identify
SSI/Medicare
recipients with
no Medicaid
Notices sent,
“You are
eligible!”
Low-Income Subsidy
SSA & State Roles

Both States and SSA are required to make low
income subsidy eligibility determinations.

Both States and SSA are also required to conduct
redeterminations and appeals of denials of
eligibility.

Given similar roles, coordination will be
necessary.
When applying for LIS,
how is income considered?
Countable
Income
Income
Standard
Compare to
Use SSI rules
Based on FPL for size of the family
When applying for LIS,
how are resources counted?
Countable
Resources
Resource
Standard
Compare to
2 types of standard:
Full Subsidy = < 3 x SSI limit
($6k individual, $9k couple)
Other Low-income Subsidy =
Alternate standard
(<$10k individual, < $20k couple)
Phased Down State Contributions




States make monthly payments to Medicare for a
portion of the drug expenditures for dual eligibles
(state contribution).
The contribution will based on a state’s own per
capita spending for dual eligibles
By no later than October 15, 2005 and October 15
of each succeeding year, the Secretary will notify
the states of their per capita amount
Questions to: [email protected]
Rulemaking Process
Final CMS Rule was published January 28,
2005
 Addressed 8,000 comments received on
NPRM
 SSA’s Proposed Rule on the LIS process
published March 4; no Final Rule as of yet.

Wrap-up
Part D: State Issues
Low-Income Subsidy Process
 Coordination Between CMS, SSA &
States
 Educating beneficiaries
 Data for Part D phased-down state
contributions
 Coordination of benefits

Thanks for listening!
Questions?