Transcript Medicare Cases - Module 3 - 379.5 KB

Medicare Part D Cases
Module #3
Jayashri Sankaranarayanan PhD
Assistant Professor
Department of Pharmacy Practice,
College of pharmacy
University of Nebraska Medical Center
[email protected]
Phone: 402-559-5267
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PROCESS
A series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and
answer
Step # 3: Proceed to additional modules
or take a break
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Objectives
Three module Overview
Upon completion the learner will be able to
describe:
• The Medicare Program, its eligibility and
various health insurance options
• The new Medicare D, Outpatient Prescription
Drug Benefit in terms of eligibility criteria, the
cost benefit structure, drugs covered and
enrollment process
• Guidance that can be given to the Medicare
beneficiaries in various case scenarios
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Decisions for Medicare Beneficiaries, 2006
Enroll in Part D Plan
Medicare Advantage (MA-PD)
Traditional Medicare
No Part D
coverage
Part D
Prescription
Drug Plan
(PDP)
HMO
PPO
Private Fee(local) (regional) for-Service
Apply for Low-Income Subsidy
Dual
Eligibles
Social Security
Office
Medicaid
Office
Meet Income and Resource Test?
If yes, qualify for:
Below 100% FPL:
Below 135% FPL:
Below 150% FPL:
No premium or deductible,
$1/generic Rx, $3/brand name
Rx, pay nothing after $5,100 in
Rx costs
Subsidy for premium, no
deductible, $2/generic Rx,
$5/brand name Rx, pay nothing
after $5,100 in Rx costs
Subsidy for premium on sliding
scale, $50 deductible, 15%
coinsurance to $5,100 in Rx
costs, $2/generic Rx, $5/brand
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name Rx after $5,100
Medicare Part D Options for Beneficiaries
• Medicare Advantage (MA) changes to MA-PD*
which has drug coverage (Part D)
– Medicare HMO and Others (private fee-for-service plan,
preferred provider organizations, provider sponsored
organizations)
• Traditional Medicare (Part A and B)+ Medigap**
(without drug coverage) + PDP (Part D)
• Traditional Medicare + Medicaid (“duals” for non
Part D drugs) + PDP (for Part D drugs only)
• Traditional Medicare (or MA) + retiree plan (only
for selected individuals) can consider PDP (or
MA-PD) if retiree plan not creditable
* Formerly known as MA without drug coverage / M+ C/ Part C,
** Medigap; Medicare supplemental private insurance intended to fill the “gaps” in
traditional Medicare may or may not be sold, issued or renewed on or after 1/1/06
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Medicare Beneficiary Cases
 Case Study 1 - Patient without prior prescription
coverage enrolling in the standard benefit – enroll to
avoid future penalties
 Case Study 2a, 2b and 2c - Patient who receive
creditable prescription coverage from a former
employer (retiree) or other sources (TRICARE/VA).
 Case study 3 - Patient without prior prescription
coverage qualifying for low income subsidy and
enrolling for the low-income benefit
 Case study 4 - Patient with prior Medicaid prescription
coverage.
 Case Study 5 - Patient in a long-term care or assisted
living facility
 Case Study 6 - Patient in a Medigap plan
 Case Study 7 - Patient in a Medicare Advantage plan
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Case Study - 1
John is a senior with no prior prescription drug
coverage since he does not take any
medications and is in good health. He asks
why does he need to enroll into a Medicare
Part D plan?
What are important things for him to know?
1.
2.
3.
4.
His current state of no prescription drug coverage is not “Creditable.”
It is in his interest to enroll into a least expensive plan to avoid future
penalties on late enrollment and to have some protection from future
unanticipated drug expenses incurred.
No automatic enrollment if he does not enroll
Standard benefit (Premium, Out of pocket costs), low income subsidy
application process and yearly enrollment dates.
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Case Study - 2a
Jim is a senior with retiree coverage. He asks
you about Medicare Part D enrollment decision
What are important things for him to know?
1. His current plan has to inform whether his current
coverage is “Creditable.” If they do not inform him, he has
to contact his plan.
2. If his current coverage is creditable, he can switch later
without penalty on late enrollment
3. No automatic enrollment if he does not enroll
4. Can supplement with a less expensive PDP but check with
retiree coverage administrator before enrolling, because
you cannot regain retiree coverage that is dropped or lost
5. Standard benefit - Premium, Out of pocket costs, and
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yearly enrollment dates.
Case Study - 2b
Beth is a senior with TRICARE or FEHBP
coverage, who asks you about Medicare
Part D enrollment decision
What are important things for her to know?
For individuals with current prescription drug coverage
through TRICARE, or FEHBP
– It is advisable to keep current coverage without any
changes, because it is creditable.
– However, those with limited income and resources,
may qualify for extra help from Medicare.
– Contact benefits administrator or FEHBP insurer for
information about TRICARE, or FEHB coverage
before making any changes.
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Case Study - 2c
Ed is a senior with VA coverage, who asks you
about Medicare Part D enrollment decision
What are important things for his to know?
1. For individuals with current prescription drug coverage
through the VA –
–
–
It is advisable to keep current coverage without any changes.
However, those with limited income and resources, may qualify
for extra help from Medicare.
Contact the VA benefits administrator for information about VA
coverage before making any changes.
2. VA beneficiaries can enroll in the new Medicare
prescription plan in addition to VA benefits for the
convenience and choice of getting prescriptions written by
non-VA providers and filled by local pharmacies outside
the VA system.
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Case Study - 3
Jack is a Medicare beneficiary with
limited income and resources, who asks
about Medicare Part D
What are important things for him to know?
1. Can apply for low income subsidy anytime using income and
resource information
2. Duals (Medicare + Medicaid) beneficiary (need not apply)
while non duals low income and resource beneficiary (need
to apply to SSA) and then enroll in a plan too.
3. Benefit – Premium, Deductible, Co-insurance/Co-payment
depends on marital status, family size and federal poverty
level (determined by income and resources)
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Case Study - 4
Peggy is a Medicare dual beneficiary, who asks
about Medicare Part D benefit for dual eligibles.
What are important things we can tell her?
1. Dual eligibles (Medicare + Medicaid) automatically qualify
for extra help (i.e. low income subsidy and do not need to
apply to SSA)
2. Duals pay no premium or deductible but do have to pay
small co-payment, (if they are not living in nursing homes
or assisted living facility).
3. If duals did not choose to enroll in a plan by December 31,
2005, they have been automatically and randomly
enrollment into a PDP plan by CMS.
4. Duals can switch plans monthly and there is no penalty on
switching plans
5. For duals, Medicare covers Part D drugs and Medicaid
covers drugs not covered by Medicare Part D
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Case Study - 5
Ted is a Medicare dual beneficiary, who asks about
Medicare Part D benefit for persons living in
nursing home or assisted living facilities.
What are important things we can tell him?
1. Dual eligibles living in nursing homes will pay nothing (no
premium, no deductible, no co-payment).
2. Dual eligibles living in Assisted living or Adult Living Facility
(ALF) or a Residential Home will pay a small co-payment
for each covered prescription drug. However, duals in ALF
in Nebraska pay nothing since Nebraska Medicaid will pay
their co-payments.
3. Can take help of an authorized representative to enroll into
a plan
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Case Study - 6
Kate is a Medicare beneficiary with Traditional
Medicare and Medigap. She asks about Medicare
Part D benefit.
What are important things we can tell her?
1.
2.
3.
4.
5.
Medigap is not considered creditable drug coverage
Better to enroll in a PDP to prevent future penalties
Can choose to keep her Medigap plan without drug
coverage, and enroll into a PDP
Cannot have Medigap drug coverage and Part D
Alternately, she can drop Medigap policy and join a
Medicare Advantage or other Medicare health plan with
prescription drug coverage.
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Case Study - 7
Jill is a Medicare beneficiary with Medicare
Advantage plan. She asks about Medicare Part D
benefit.
What are important things we can tell her?
1. She can choose to keep her MA plan and enroll into a PDP
from her MA insurance company or other company.
2. She can switch to a MA-PD plan from MA plan from same
or different company if she wants all in one package.
3. She can switch to the Original Medicare plan and enroll into
a PDP
4. If she does not enroll into a PDP or switch to a MA-PD plan
to have creditable coverage, she may incur penalties on
later enrollment.
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References
All Part D cases reviewed here
developed by the presenter. The
guidance is based on information of
CMS fact sheets from
www.medicare.gov website.
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