Transcript PPT - CALegalAdvocates.org

LAAC Armchair Training
Medicare Part D and Low Income Seniors
and Individuals with Disabilities
Basic Review & Current Hot Topics
for California Advocates
Fall 2006
Kevin Prindiville
Anna Rich
National Senior Citizens Law Center
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Medicare Part D Basics
Medicare Part D: the biggest change in
government health care programs in 40
years.
 Medicaid (Medi-Cal) coverage ended on
January 1, 2006 for almost all
prescription drugs for elderly and
disabled.
 Medicare Part D replaced Medicaid for
all dual eligibles.

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Medicare Part D Basics: Eligibility

All Medicare Beneficiaries
Both seniors (eligible for Social Security)
and individuals with disabilities (eligible for
Social Security Disability benefits)
 Entitled to Part A and/or enrolled in Part B
 Any income level
 Any resource level

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Medicare Part D Basics: Dual
Eligibles

Prior to January 2006, these individuals got
their Rx from Medi-Cal, with a broad formulary
and (usually) no co-pays.
 Dual eligibles are particularly vulnerable.




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More than twice as likely as other Medicare
beneficiaries to be in fair or poor healh;
More than 50% are limited in ADLs;
40 % have mental or cognitive impairments;
25% in Long Term Care;
many need multiple prescriptions.
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Medicare Part D Basics: Benefits

Part D plan have discretion to design their benefit
packages


Must cover at least two drugs per category and class
Plans have “preferred” and “non-preferred” pharmacies in
their networks.

Formularies may encourage use of less expensive
drugs through “utilization management” techniques,
such as prior authorization, step therapy (aka “fail
first”), therapeutic substitution, and quantity or dosage
limits.

Tiering: generic, preferred and non-preferred.
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Medicare Part D Basics: Coverage
Covers prescription drugs, biologicals,
insulin.
 Formularies must cover “all or
substantially all” FDA-approved drugs
within six classes:


Antipsychotics, antidepressants,
anticonvulsants, antiretrovirals,
immunosuppresants, antineoplastics.
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Medicare Part D Standard Benefit
2007
Coverage
Annual Drug
Costs:
Premiums
Part D Plan
Pays:
Beneficiary
Pays:
N/A
Varies
Deductible
$0 - $265
$0
$265
Initial Limit to
Coverage
$265-$2,400
75%
($1,601.25)
25% ($533.75)
Coverage Gap
(Donut Hole)
$2,400$5,451.25
$0
100%
($3,051.25)
Coverage
Resumes
Over $5,451.25 95% of
remaining
costs
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Up to 5% of
remaining
costs
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Medicare Part D Basics:
Enrollment of Dual Eligibles

Full benefit dual eligibles are auto-enrolled in a
Part D plan;



Random PDP assignment; may self-select a
different plan
10 LIS plans in California for 2006; 9 for 2007
Can disenroll and chose another plan

Dual eligibles can change plans once a month,
effective the first day of the month following
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Medicare Part D Basics: ANOC

Annual Notice of Change
End of October all beneficiaries will receive
an Annual Notice of Change (ANOC) from
their Part D plan.
 The ANOC contains information about
changes to the plan (costs, formularies,
name, etc.)
 Beneficiaries should review carefully.

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Medicare Part D Basics: Transitions

All plans supposed to institute transition
policy and provide notice to participants.

Beginning in 2007, enrollees may obtain
a 30 day transition supply within first 90
days of enrollment or negative change to
formulary.

Long-term care patients have longer
transition period.
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Low Income Subsidy
Also known as “Extra Help” and as the
“Limited Income Subsidy”
 Generally handled by the Social Security
Administration as well as CMS and state
Medicaid offices.

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Low Income Subsidy

Group 1
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Group 2
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Full Medi-Cal dual eligibles with countable incomes at or
below 100% Federal poverty level (FPL) “deemed eligible”
Full-Medi-Cal dual eligibles above 100% of FPL; QMB, SLMB,
QI, SSI-only, “deemed eligible”; and non-dual eligible
beneficiaries with countable incomes below 135% FPL and
limited countable resources ($6,000 per individual and $9,000
married couple) “determined eligible”
Group 3

Beneficiaries with countable incomes below 150% FPL and
limited countable resources ($10,000 individual and $20,000
married couple) “determined eligible”
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Low Income Subsidy
Group 1
Group 2
Group 3
Premium
$0
$0
Sliding scale
based on income
Deductible
$250/year;
($265: ‘07)
$0
$0
$50
Coinsurance
up to $3,600
out of pocket
($3850: ‘07)
$1/$3 copay
Catastrophic
5% or copay
$53 in ‘07
$2/$5 copay
15%
coinsurance
$1/$3.10 in ’07 $2.15/$5.35 in 07
$0
$0
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$2/$5 copay
$2.15/$5.35 in 07
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Low Income Subsidy
Enrollment/Application process is
ongoing
 “Deemed eligible” for LIS: all dual
eligibles; and all Medicare Savings Plans
participants



Receive notices from CMS informing them
“Determined eligible” (non dual eligibles
or MSP) must apply and be assessed
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Low Income Subsidy

Those who must apply (those who are not dual eligible
or MSP) can do so at SSA or County Medi-Cal Offices;
or online at http://ssa.gov/prescriptionhelp/

Does it matter where you apply?

State
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State/county duty to screen and enroll
MSP programs are undersubscribed
MSP people are deemed eligible for LIS
Can insist on state processing; using Medi-Cal appeals system
SSA

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Application, outreach, funding incentives
No duty to screen and enroll, forward info
Appeal rights are different than Medi-Cal system
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Low Income Subsidy for 2007

Reviewing LIS eligibility for 2007 of those
eligible in 2006


Redeeming: those who were “deemed” eligible in
2006 will be reviewed by CMS
Redetermination: those who were “determined”
eligible by SSA will be reviewed by SSA

See guide to Redetermination and Redeeming at:
http://www.nsclc.org/areas/medicare-partd/area_folder.2006-09-28.4596471630
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Issues for Dual Eligibles

Reassignment

5 of the 10 “Benchmark“ plans from 2006
will be available as “Benchmark” plans in
2007


Beneficiaries who want to stay in one of these
plans do not need to take any action.
1 plan is within the “de minimis”

Sierra Rx: Full-subsidy beneficiaries will remain
in the plan with no premium; partial subsidy will
be liable for their percentage of the benchmark
($21.03) plus $1.37
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Issues for Dual Eligibles

Reassignment

4 plans no longer exist or have premiums
above the “de minimis”
AARP Medicare Rx (S5820-031)
 PacifiCare Saver Plan (S5921-002)
 United Health Rx (S5820-140)
 Health Net Orange 008 (S5678-008)

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Issues for Dual Eligibles

Reassignment
Those in United plans will be moved to
AARP Medicare Rx Plan Saver.
 Beneficiaries who self-enrolled in Health Net
Orange 008 will remain in plan and must
pay increased premiums or switch plans.
 Beneficiaries who auto-enrolled into Health
Net Orange 008 will be automatically
reassigned to Health Net Orange 002.

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Issues for Dual Eligibles

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Special Issues: Emergency Drug Benefit.
Can help duals access medications in some
circumstances; available until January 31, 2007

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1) Medicare system problems or errors;
2) Eligibility/enrollment problems;
3) Co-payments charged in excess of LIS requirement;
4) The plan does not respond to a prior authorization/exception
request.
EDB Bulletin:

http://files.medical.ca.gov/pubsdoco/publications/bulletins/notice/20061103_emerge
ncy_0516update.pdf
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Exceptions and Appeals

Exceptions and appeals process can be used:

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To obtain “medically necessary” drugs that are
restricted by or not on the formulary; or
To bypass utilization management, such as the
need for prior authorization; or
To obtain a prescribed drug at a lower cost sharing
rate.
Details about limitations periods, timeframes,
amount-in-controversy requirements and more
in NSCLC’s Guide.
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Appeal Steps
1.
2.
3.
4.
5.
Redetermination by plan;
Reconsideration by Independent
Review Entity (Maximus);
Administrative Law Judge Appeal;
Medicare Appeals Council;
Federal District Court.
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Reporting Problems

Plans that fail to comply with the
requirements for exceptions and appeals
processes may be reported to CMS:

Central office: [email protected]

CMS Region IX:
[email protected]
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Grievances

Complaints not relating to specific coverage
determinations

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Timeframe:

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E.g., service delays, wait times, phone access,
misinformation, marketing practices, failure to meet
deadlines, plan structure
60 days to file – oral or written complaint is OK.
Plan responds within 30 days
Expedited grievances (re failure to process
expedited requests)—Plan responds w/in 24 hours
Importance of filing grievances
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Resources

NSCLC Tools for Advocates
http://www.nsclc.org/areas/medicare-part-d/area_folder.2006-09-28.4596471630/area_folder_view?b_start:int=0
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Medicare Part D Exceptions and Appeals, A Practical Guide (NSCLC)
Exceptions and Appeals: Summary of Ch. 18 of the CMS Prescription Drug Benefit Manual (NSCLC)
Exceptions and Appeals: Model Part D: Exceptions/Coverage Determination Request Form (CMS)
CMS Prescription Drug Manual, Ch. 18: Enrollee Grievances, Coverage Determinations and Appeals
(CMS)
Medicare Part D Manual—Draft of Chapter 6 (transitions)
Other Resources

Appointment of Representative Form (CMS Form-1696):
http://www.cms.hhs.gov/CMSForms/CMSForms/itemdetail.asp?filterType=keyword&filterValue=1696&fil
terByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS012207

Patient Assistance Programs (PAP): http://www.rxhope.com/
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Questions
Call with questions, problems, send client stories
National Senior Citizens Law Center
Kevin Prindiville
510 663-1055 ext. 307
[email protected]
Anna Rich
510 663-1055 ext. 303
[email protected]
Copyright 2006 by the National Senior Citizens Law Center. All rights reserved.
Permission to copy will be granted to non-profit entities with appropriate acknowledgment of credit.
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