Medicare Prescription Drug Benefit

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1 Medicare Prescription Drug Benefit Karen Tritz Overview Overview of new Medicare Prescription Drug Benefit The Timing and Process Implications for Working People with Disabilities Overview of Medicare Modernization Act (MMA) Passed December 2003 Public law New voluntary prescription drug benefit, Medicare Part D Begins January 1, 2006 Eligibility The Choices Who is eligible for Part D Drug Benefit? Special rules for those dually eligible for Medicaid and Medicare. Private Prescription Drug Plans (PDP) 26 regions for Medicare managed care plans and 34 for separate PDP plans Approved by Centers for Medicare and Medicaid Services (CMS) 1

2 Drugs Covered Under the New Benefit Part D Covered Drugs Formulary (Standard or Alternative) CMS Process for Approval Appeals and Exceptions State decisions Enrollment in Drug Plan Enrollment occurs directly with the PDP Enrollment periods Automatic enrollment for full-benefit dual eligible beneficiaries in PDP Enrollment in Drug Plan What will it cost beneficiaries? Facilitated enrollment for Medicare Savings Program Groups (Qualified Medicare Beneficiaries, QMB; Specified Low-Income Beneficiaries, SLMB; and Qualified Individuals, QI-1s) It depends on which one of 5 groups the individual is in. Beneficiary spending on drugs counts only if it is for a drug on the PDP formulary or a non-formulary drug that has been granted an exception. Group 1: income >=150% Monthly premium: Varies. Estimated at $37/month $250 deductible Between $ and $2250 in total drug costs, individual pays 25% of the cost Group 1: income >=150% Between $ and $5100 in total drug costs, beneficiary pays 100% of the cost Above $ and above in total drug costs, beneficiary pays 5% of the cost 2

3 Group 2: income between 135 and 150% - low assets Monthly premium, sliding scale up to $37 $50 deductible Coinsurance of 15 percent up to $5100 in total drug costs Group 2: income between 135 and 150% - low assets Co-pays of $2 or $5 once the out-ofpocket limit is reached Group 3: income < 135% & limited assets or dual eligibles with income above 100% FPL Copays of $2 or $5 - increases annually Group 3: income < 135% & limited assets or dual eligibles with income above 100% FPL No co-payments after the person s total drug costs of $5,100 in 2006, increases annually Includes SLMB and QI-1 Group 4: Dual eligibles income at or below 100% FPL Group 4: Dual eligibles income at or below 100% FPL Copays of $1 or $3 No co-payments after the person s total drug costs of $5,100 in 2006 Includes QMB 3

4 Group 5: Dual eligibles in long-term care facilities No co-payments Can others help beneficiaries with cost-sharing? Family or friend A qualified State Pharmacy Assistance Program (SPAP) A bona fide charity Can others help beneficiaries with cost-sharing? Transition for Dual Eligibles Except for payers above, payment by others does not count towards beneficiary s cost-sharing Differences between current Medicaid drug benefit and new Medicare benefit Comparability Types of Drugs Covered Cost of Drugs Transition for dual eligibles CMS criteria for reviewing formularies. Appeals and exceptions process to consider coverage of non-formulary drugs. Require appropriate transition policy for new enrollees. How can individuals get information about options? Medicare Social Security Administration Offices State Health Insurance Assistance Programs (SHIP) (1200 offices nationwide) 4

5 How can individuals get information about options? Administration State Medicaid Offices Listserv at cms.hhs.gov called PART_D_COV_BENE_EDU Application for Low-Income Subsidy Separate from PDP enrollment process. Those automatically eligible (Duals, QMB, SLMB, QI-1s and SSI recipients). Administration Over the next 7 months Application for Low-Income Subsidy Process administered SSA and States. The states may use SSA application but will have to be able to make their own determination if requested. May 2005 SSA send letters low-income subsidy eligible July 2005 Beneficiaries can apply for low-income subsidy. Fall 2005 CMS notifies dual eligibles which plan they will be enrolled in if they don t choose a different one. Over the next 7 mos. Implications for Workers with Disabilities October 13, 2005 Compare prescription drug plans at November 15, 2005 Begin enrollment in prescription drug plans. January 2006 Medicare Part D Begins Changes in Medicaid Eligibility Status Medically Needy Changes in income and assets may affect the cost of the Part D benefit. 5

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