Transcript Golden Buckeye Rx Program - Ohio Association of Health

Ohio
Department of Aging
2006 Medicare
Prescription Drug
Coverage
Speaker team
Joyce Aldridge
Arlene Conaway
Patricia Palmer
Gary Panek
(419)
(330)
(513)
(614)
382-7060 ext 29
896-9172 ext 3010
721-1025 ext 657
466-3583
1
Welcome!
Today's presentation will introduce
to you the new Medicare Prescription
Drug Coverage that begins in Jan.
Please follow along as we discuss
this program and note the items that
may affect you.
Feel free to ask questions.
2
Medicare
Modernization Act (MMA)
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Enacted by Congress in 2003
Medicare-approved drug
discount card 2004-05
Medicare prescription drug insurance
benefit starts Jan. 1, 2006

Replaces Medicare-approved drug
discounts cards
3
Golden Buckeye Card
Yes,
continue
to use
No, Medicare-approved drug
card program will end
4
Medicare Prescription
Drug Coverage (Part D)

Optional coverage for any person
that has Medicare Part A and/or B

Insurance provided by private
companies approved by Medicare
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Pay monthly premium for benefit

Premium will vary by plan and benefits
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Drug Plan Differences

Understand specific plan information
 Coverage available, monthly
premiums
 Plan deductibles, co-pays and
limits of coverage
 Participating pharmacies
 List of drugs covered by the plan
(formulary)
6
“Model” Coverage

Monthly insurance premium
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Estimated at $32 per month
Does not count as out-of-pocket expense

$250 annual deductible each Jan. 1
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Co-insurance
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Senior pays 25% of drug costs
Co-insurance limit of $2,000 ($500 paid by
senior/$1,500 paid by insurance)
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“Model” Coverage

Coverage gap (“donut hole”)
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Senior pays all of next $2,850 in
drug expenses ($3,600 total)
“Catastrophic” coverage

Once senior has paid $3,600 out of
pocket in year, senior then pays 5%
of drug cost, insurance pays 95%
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Medicare Prescription Drug
Coverage- Formulary

Minimum of two drugs in each drug
category, except all drugs covered for
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Antidepressant
Antipsychotic
Anticonvulsant
Anticancer
Immunosuppressant
HIV/AIDS
Benzodiazepines and barbiturates
not covered in base plan by law
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Late Enrollment Penalty


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Penalty of additional 1 percent per
month ($ .322) added to premium
No maximum on penalty
If don’t enroll by May 15, 2006, must
wait until next open enrollment period
(Nov. 15 – Dec. 31, 2006)

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7 percent late penalty ($2.25)
12 percent late penalty (~$4.00)
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Enrollment Choices Based
on Current Coverage


Options and choices will vary based
on the type of Medicare and
prescription coverage you now have
Select a plan or make changes by
May 15 (you have 6 months to make a
decision and avoid penalty)

Coverage is effective the 1st day of
the month following enrollment (but
not before Jan. 1)
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If You Have Medicare Only
No current drug coverage
Options
1. Refer to “Medicare & You” book from
Medicare
2. You may select an insurance
program that is right for you
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If You Receive VA
Health Care Benefits
If VA meets your needs, continue VA
coverage

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No penalty to change in future
Consider Medicare coverage if:
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Qualify for extra help (lower co-pays)
Nursing home care is not covered by VA
VA services are not convenient for you
Options
1. Refer to “Medicare & You” book
13
Creditable Coverage

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Coverage is creditable if the value of
the coverage equals or exceeds the
value of the standard Medicare
prescription drug coverage
Any plan with current drug coverage
must determine if present benefit is
creditable and notify beneficiary by
Nov. 15, 2005
14
If You Have Current
Medigap/Supplement Policy
You will receive a notice by Nov. 15 from
your Medigap provider with specific
information about the future of current
coverage and available choices
Options
1. Review options outlined in letter
2. Obtain OSHIIP book explaining plans
3. Make decision to continue existing
coverage or select new coverage
15
If You Have Coverage From
Former Employer or Union
You will receive a notice by Nov. 15 from
your Plan Administrator with specific
information about the future of current
coverage and available choices
Options
1. Continue with current coverage
2. You may need to select another
insurance plan that is right for you
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If you have OPERS,
STRS, SERS, OP&F, HPRS
You will receive notice by Nov. 15 from
your Plan Administrator with specific
information about the future of current
coverage and available choices
Options
If your current coverage is creditable,
remain in that plan
If not, choose a Medicare prescription
drug program that best meets your needs.
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If You Have Medicare
Advantage or Other Health Plan

You will receive a notice by Nov. 15
from your current plan provider with
specific information about present
coverage and available choices
Options
1. Continue (or modify) current coverage
2. Select another insurance program that
is right for you
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If You Have
Medicaid and Medicare
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You will be notified by ODJFS of options
Will be automatically enrolled in a plan
but may select different plan by Dec. 31
Drugs not covered under Medicare will
continue to be paid for by Medicaid
Coverage starts Jan. 1, 2006
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$0 monthly premium, $0 deductible
$1 generic/$3 brand name drug co-pays
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People with
Special Circumstances
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Medicaid Spend down
Medicare Savings Program (QMB,
SLMB, QI-1)
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Supplemental Security Income (SSI)
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Long-term care facilities
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PASSPORT or PACE
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People with
Medicaid Spend down
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Will receive notification from ODJFS
as to specific drug options available
Must re-qualify for drug benefit
annually
Program covers drugs only
For other Medicaid benefits, there is
no change to current process
21
People with
Medicaid Spend Down
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For drug coverage, if spend down
requirement is met in any one month
from Aug. – Nov., 2005, you will
automatically receive drug coverage
Jan. 1 – Dec. 31, 2006
Otherwise, beginning after the
month when you first meet spend
down requirement in 2006, you will
be enrolled for drug coverage for the
balance of current year
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People with Medicare Savings
Programs (QMB, SLMB, QI-1) or
Supplemental Security Income (SSI)
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Will receive a letter from Medicare in
early summer explaining changes and
options available to you
May select a plan
If you don’t choose a plan by May 15,
you will be automatically enrolled
(tentative) in a plan effective June 1
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People in Long-term
Care Facilities
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Dual-eligibles (70%) – same benefit as
people with Medicaid but $0 co-pays
after one full calendar month
Full pay (30%) – same options as
people with Medicare
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Can apply for extra help
May choose insurance provider
Find a plan that includes the LTC
pharmacy that is providing dispensing
services in the facility
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People with
PASSPORT or PACE
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Dual-eligibles will receive standard
Medicare-Medicaid benefit
People 60-65 with disabilities and
Medicaid only will continue to receive
current Medicaid benefit (no change)
PACE will have no drug co-pays
PASSPORT may have drug co-pays

Co-pays will count toward client liability
payments
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Extra Help Program
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Special program to help lower the
high cost of drugs for seniors with
modest means
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Seniors on fixed incomes
No price controls on drugs
Need to apply today for extra help
More than 30% of Ohio seniors
qualify for this extra help
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Help for People with Limited
Income and Resources
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Program helps pay cost of insurance
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$0 monthly premium
$0 deductible
Prescription co-pay of
$1-3 generic or
$3-5 brand name drug
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Qualifications
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Monthly income below $1,077 (single)
or $1,443 (married and living with spouse)
Resources below $11,500/$23,000
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House and car not included
Savings, investments, stocks are
included
Tremendous benefit for those living on
Social Security alone or that have only a
modest income!
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Other Help for
Greater Incomes
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Special program for people with
monthly incomes of
$1,078 to $1,196 single,
$1,444 to $1,603 couple
Resources below $11,500/$23,000
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Benefit
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Partial premium payment
$50 deductible
You pay 15% of drug costs
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Why Apply?
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Significant money can be saved
on buying drugs!
Drug company patient assistance
programs may end for seniors
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Old program qualification –
Medicare-eligible
New program qualification –
not Medicare-eligible
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Extra Help
Application Process
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Must apply to receive extra help!!
4 page questionnaire, 16 questions
Application form available from local
SSA office, or call 1-800-772-1213
Apply on-line at www.SSA.gov
SSA will notify you of approval or
disapproval
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Extra Help
Application Process
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Children, grandchildren and others
can assist with completion of
application - no need for legal Social
Security representative to fill out
application form
Encourage others that you know to
fill out application
When in doubt, fill it out!
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Extra Help
Select a Plan

After submitting application for
extra help and receiving approval,
still need to select a plan
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Choosing a Part D Plan
What do you do next?
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What To Do Next
Plan Selection Process
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Write down list of all medications
you take including name, dosage
strength and quantity
Locate Medicare card
Call 1-800-Medicare to order a
report of actual plan costs using your
specific drug information (available
24 hrs a day and 7 days a week)
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What To Do Next
Plan Selection Process
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Review report and select plans
with features important to you
Refer to explanations found in
“Medicare & You 2006” book from
Medicare
Compare top plans and benefits
and decide what is best choice
for you
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What To Do Next
Plan Selection Process
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Don’t feel rushed or pressured to
enroll
Complete enrollment materials for
selected plan
Application form company/agent
 1-800-MEDICARE and OSHIIP
can help you enroll over phone
 Internet

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Fraud Prevention
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Don’t sign anything until you have had a
chance to review all options and discuss
with those you trust
Protect personal information and
Medicare number
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No door-to-door solicitation
No payment over phone or internet
Report suspected
fraud (1-800-MEDICARE)
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Consumer Resources –
Web-based Information Tool
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Available at www.Medicare.gov
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Also available by calling 1-800-MEDICARE
Compare different plans and coverages
side-by-side
No personal information needed
to get basic information on all plans
Authentication of user needed to
customize information or enroll
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Consumer Resources –
General Information
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www.GoldenBuckeye.com/MedicareRx/
“Medicare & You 2006” book
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1-800-MEDICARE (1-800-633-4227)
24 hours a day, 7 days a week
www.Medicare.gov
OSHIIP – Dept. of Insurance
Ohio Senior Health Insurance Information Program

1-800-686-1578 M-F, 7:30 am to 5:00 pm
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Benefits Check-Up
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Free easy to use web site to identify
potential benefits available to seniors
and people with disabilities
Local, county, state, national programs
More than 1,300 different programs
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drugs, heating, rent, meal services,
nutrition, legal matters, medical costs,
property tax rebates, Veteran’s benefits
Medicare Prescription Drug Program info
www.BenefitsCheckUp.org
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Aging Network Resources
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www.GoldenBuckeye.com/MedicareRx/
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Centers for Medicare & Medicaid Services
www.cms.hhs.gov/partnerships
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Access to Benefits Coalition
www.accesstobenefits.org/Helpful%20Resource
s/Tools%20You%20Can%20Use/default.aspx
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SSA Information for Organizations
www.ssa.gov/organizations/medicareoutreach2
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Questions?
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Golden Buckeye Program
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Available to OH residents 60+ and
persons with disabilities (18-59)
Automatically sent on birthday
18,000+ merchants state wide
Provides discount drug card benefit
Golden Buckeye
Prescription Drug Program
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Helps people who pay out-of-pocket
for prescriptions
24.5% / $12.84 average savings
$28 M direct savings for seniors
2,100+ harmful interactions ID
Savings 78% of time
Plan will continue in 2006
Pharmacy Co-payment
“Pharmacies are permitted to waive or
reduce cost-sharing amounts provided
they do so in an unadvertised, nonroutine manner after determining that
the beneficiary in question is financially
needy or after failing to collect the
cost-sharing amount despite
reasonable efforts.” (CMS Q&A #5115)
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“Model” Coverage

Insurance plans may provide you a
benefit that costs Medicare the
same amount it would have paid
using the “Model Coverage”
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