Transcript MEDICARE PART D

MEDICARE PART D
Are We Ready?
Medicare Part D Overview
Medicare Part A and B covers individuals
• Age 65 and older
• Those with a disability who have collected Social Security for a
minimum of 2 years
• Those with kidney failure or who need a kidney
transplant
42 Million Medicare beneficiaries growing
Medicare Part D Overview
• On 1/1/06, Medicare Part D – the largest Medicare
reform in 40 years began
• Medicare Part D is a voluntary Insurance program for
prescription drugs through Medicare prescription drug
plans and other health plan options.
• Insurance companies and other private companies will
work with Medicare to provide a choice of plans that
cover both brand name and generic drugs.
Medicare Part D Overview
Part D Drug Coverage
• Includes prescription drugs, biological products,
certain vaccines, insulin, and diabetic medical
supplies
• Excludes, among other categories, OTC drugs,
barbiturates, benzodiazepines, weight loss or
weight gain meds, meds for relief of cough, and
any drug covered by Medicare Part A or B
Medicare Part D Overview
Part d is a voluntary program except for low income
dual-eligible formerly on Medicaid
• Medicare eligible persons may remain on their current
employer sponsored retiree Rx plans, participate in a
MA-PD plan or PDP plan, be auto-enrolled in a dualeligible plan, or not participate in any plan.
Beginning 1/1/06, the current Medicaid Rx coverage for
dual-eligible will change to federally managed Medicare
Part D Rx
Medicare Part D Overview
Dual-Eligibles (Medicare and Medicaid)
• Dual-eligibles (eligible for Medicare and Medicaid) are
covered. An estimated 60% of Medicaid prescriptions come
from persons that are also eligible for Medicare
- At or below 135% of poverty level
• Will be randomly auto-enrolled into one of the national plans
that meets the benchmark pricing within a given area
- Plan may not meet their particular medication needs
- Over 6 million dual eligibles have already been randomly
auto-enrolled into a Part D plan
• Medicaid prescription coverage will end beginning January 1,
2006 unless the drug is in a non-covered drug category
Medicare Part D Overview
Dual-Eligible (Medicare and Medicaid)
• No monthly premiums
• No deductible
• Low or no co-payments (may be higher than current
Medicaid program)
• Possible differences in drug coverage and co-payments than
current Medicaid plan
• Wrap around state public assistance programs
(SPAPs) benefits or state Medicaid may apply to
non-covered categories
• Can switch plans monthly into another available
Part D plan - during the first year
Medicare Part D Overview
Non-Dual eligible (Medicare Only)
• Voluntary enrollment Nov 15, 2005 thru May 15, 2006
(1% per month premium penalty for enrollment after
5/15/06)
• Non-dual eligible must take action to enroll… many
choices between available Part D plans and plan
designs
• Some low income will qualify for extra assistance
Medicare Part D Overview
Non-Dual eligible (Medicare Only)
• Monthly premiums
• Deductible
• Co-payments
• Can only switch plans once a year into
another available Part D plan
Medicare Part D Overview
Ability to Change Plans
• Non-dual-eligibles will have the opportunity to change
between plans only once a year.
• Dual-eligibles will have the opportunity to change
between plans once a month, starting in November
2005.
Medicare Part D Overview
Standard Benefit
• Monthly premiums from participants will be paid
for most plans
- (Average premium is around $32.30 per month)
• $250 beneficiary deductible
• For non-dual eligibles, Medicare will pay 75% of
drug costs up to $2,250. The beneficiary will pay
25% of these costs
• Beneficiary will pay 100% of drug costs between
$2,250 and $5,100
• After $3,600 in out-of-pocket spending, Medicare
will pay approximately 95%
Medicare Part D Overview
Drug
Costs
Patient
Pays
Payment
up to
Cumulative
payment
Up to $250
100%
$250
$250
$250 $2,250
25%
$500
$750
$2,251 $5100
More than
$5,100
100%
$2,850
$3,600
5%
$3,600
$36,00 plus
5% of
additional
costs
Medicare Part D Overview
Total Drug
Expenditures
$5,100+
Beneficiary
Out of Pocket
Expenditures
82% Government
Contribution
5%
coins
$3,600+
100% Enrollee Payment
“Coverage Gap”
$2,250
75% PDP Contribution
($1,500 total)
$250
$0
13%
PDP
Beneficiary
Out of Pocket
Expenditures
25%
co-ins
$750
$250
$250 Enrollee Deductible
$0
Medicare Part D Overview
Standard Benefit
(dual eligibles & non-dual eligibles co-payments)
Income Test
Asset Test
Premium/Deductibl
e
Co-payment
Under 100% of
Federal Poverty
Level (FPL)
$6,000 individual
$9,000 couple
$0/$0
$1 generic/ $3
brand to Gap $0
after Gap
100% - 135% of
FPL
$6,000 individual
$9,000 couple
$0/$0
$2 generic/ $5
brand to Gap $0
after Gap
135% - 150% of
FPL
$10,000 individual
$20,000 couple
Sliding scale
premium/$50
15% of Part D
costs from $50 $3,600/$2 for
generic/ $5 brand
after Gap
Medicare Part D
Beneficiary Enrollment
Medicare Part D
General Enrollment
• Medicare Part D is an insurance product
• Pharmacists and pharmacy staff members may not enroll
participants in any plan but may offer information and advice to
participants
• In pharmacies choosing to endorse a particular plan, there might
be opportunities for insurance brokers to enroll participants within
their pharmacies or clinics.
• Endorsement also requires agreement to promote the plan,
provide enrollment information, explain the benefits of enrollment,
describe the rules that apply to enrollees, explain how services
are covered, communicate with individuals on operational policies,
rules and procedures, provide marketing and informational
materials to participants
Medicare Part D
General Enrollment
• Voluntary enrollment
• Non-dual eligibles will have an opportunity to enroll in
one of a number of PDP or MA-PD Medicare Part D
plans in their area beginning November 15, 2006
• Non-dual eligibles have financial penalties (1% per
month after May 15, 2005) for late enrollment
• Non-dual eligible participants are only able to change
from the plan in which they participate, once a year
• Must consider the plan’s formulary coverage of the
medications they are taking, the deductible, the copayment structure, and the monthly premium before
selecting a plan in their area.
Medicare Part D
Auto-Enrollment
Limited to only the dual-eligibles
Randomly assigned to selected prescription plans within
their local areas
Plans selected to participate in auto-enrollment process
were at or less than benchmark in the Medicare Part D
bid process
May change plans monthly http://www.medicare.gov or
http://www.id-health.com
Plan coverage begins January 1, 2006
Medicare Part D
Prescription Drug Plans (PDP)
• There are 10 approved nationwide PDPs
• Aetna Life Insurance Company
• Connecticut General Life Insurance Company
• Coventry Health & Life Insurance/First Health Life & Health
Insurance/ Cambridge Life Insurance
• Medco Containment Life Insurance Company
• MemberHealth, Inc
• Pacificare Life and Health Insurance Company
• Silverscript Insurance Company
• Wellpoint
• United Health Care Insurance Company
• Wellcare Health Plans
Medicare Part D
There are hundreds of regional, state, and county PDP
and MA-PD plans in addition to thousands of employer
sponsored equivalent plans
- A list of the regional PDP and MA-PD plans designated to
receive auto-enrollees within each state is available on the
on the http://www.tachc.org web site.
Medicare Part D
So some of the questions are:
“What if I don’t take any prescription drugs?”
“How do I chose a Medicare Part D plan that meets my
needs?”
“How do I enroll?”
“What happens to my Medicare-approved drug discount
card when I enroll and can I still use any credits left on the
card?”
Medicare Part D
“What if I don’t take any prescription
drugs?”
Even if you don’t use any or a lot of prescription drugs
now, you should still consider joining a Medicare
prescription drug plan. As we age, most people need
prescription drugs to stay healthy. For most people,
joining as soon as possible means you will pay the lowest
monthly premium.
Medicare Part D
“How do I chose a Medicare Part D plan
that meets my needs?”
This is not an easy question to answer, because it involves
determining the plans available, what medications their
plans have on the formulary, costs, what pharmacy
contracts with them, etc.
Later we will look at a website
http://www.MyMedicareMatters and
show you how to select a plan.
Medicare Part D
“How do I enroll?”
Paper applications through the drug plan
On the Plan’s web site
http://www.medicare.gov
1-800-MEDICARE (1-800-633-4227) TTY 1-800-4862048
Medicare Part D
“What happens to my Medicare-approved drug
discount card when I enroll and can I still use
any credits left on the card?”
You can use your Medicare-approved drug discount card
until May 15, 2006 or until you join a Medicare Prescription
Drug Plan, whichever is first.
Medicare Part D
For Additional Details and Information on Medicare,
please refer to the following web sites:
• Centers for Medicare and Medicaid (CMS) website:
http://www.cms.hhs.gov OR http://www.cms.gov
• Official US Government Medicare website
http://www.medicare.gov
• NACDS website:
http://www.nacds.org/wmspage.cfm?parm1=3899
• Kaiser foundation website on Medicare:
http://www.kff.org/medicare/index.cfm
• US Department of Health and Human Services website
http://www.dhhs.gov/
• Office of Pharmacy Affairs: http://www.hrta.gov.opa/
Medicare Part D
Most helpful web site:
MyMedicareMatters
http://mymedicarematters.org/
http://mymedicarematters.org/ZipFinder/
Medicare Part D
Remember
Medicare Part D
Pharmacy benefit coverage
begins in all states on
January 1, 2006
Medicare Part D
“Questions?”