2016 Medicare Training for Professionals

Transcription

1 2016 Medicare Training for Professionals Refresher and Updates for the 2016 Plan Year for Medicare Part D & C Plans and Medicare Supplements September 28 and October 1,

2 Housekeeping Materials Registrants should have received an with today s materials. If you did not register and would like a copy of the materials, please Ginger Rogers at Ginger.Rogers@drwi.org Archived Webcast A copy of today s webcast will be saved to the Department of Health Services website. You can find it at the following link: Questions? If you are watching the live webcast, you can send your questions by clicking the question icon on your screen. 2

3 Today s Agenda 8:30 9 AM Registration 9 10 AM Medicare Part D: The Basics Lisa Clay Foley, DRW 10 10:15 AM Break 10:15 10:25 AM Plan Finder Problems Phoebe Hefko, DHS 10:25 10:40 AM Wisconsin s Senior Care Prescription Drug Assistance Program (Madison) Kate Schilling, GWAAR (Milwaukee) Pamela Franke, SeniorLaw 10:40 Noon Medicare Part D: Advanced Topics Ginger Rogers, DRW Noon 1PM Lunch on your own 1:00 2:00 PM Medicare Advantage Plans Vicki Buchholz and Jill Helgeson, Medigap Helpline 2:00 2:15 PM Break 2:15 3:15 PM Medicare Supplement Insurance and Employer Plans - Vicki Buchholz and Jill Helgeson, Medigap Helpline 3:15 PM 3:30 PM Medicare and the Marketplace - Vicki Buchholz and Jill Helgeson, Medigap Helpline 3

4 Medicare Part D Plans: The Basics 4

5 The Basics Overview Medicare Part D What are Part D plans? What are Part D costs? What do Part D plans cover? Enrollment When can you enroll? What is the Part D Late Enrollment Penalty? What is the Low Income Subsidy? How do you choose a plan? Resources 5

6 Overview What is Medicare Part D? What are Part D plans? What are Part D costs? What do Part D plans cover? 6

7 What is Medicare Part D? Medicare s prescription drug program Helps subsidize cost of prescription drugs and prescription drug insurance costs Began January 1, 2006 Consists of private prescription drug plans or PDPs Has premiums, co-pays and deductibles Must enroll to get coverage 7

8 Who is eligible for Part D? Beneficiaries must: Be entitled to Part A and/or enrolled in Part B, Live in the service area of the prescription drug plan, and Enroll in a plan. 8

9 Creditable Coverage Current or past prescription drug coverage For example, employer group health plans, retiree plans, Veterans Affairs, TRICARE, the Indian Health Service, and the Federal Employee Health Benefits Program Creditable if it pays, on average, as much as Medicare s standard drug coverage Plans inform yearly about whether creditable With creditable coverage may not have to pay a late enrollment penalty 9

10 What are the drug plans? Known as prescription drug plans or PDPs All plans must follow basic cost-sharing structures and include a certain level of coverage in their formularies Offered by private insurance companies who contract with Medicare 10

11 Types of Part D Plans Two Types: Stand-alone prescription drug plan (PDP) Prescription drug coverage included as a part of a Medicare Advantage plan (MA-PDP) Basic concepts of cost-sharing are the same whether the plan is a Part D plan or included in a Medicare Advantage plan 11

12 Wisconsin Part D Plans In 2016, there are 25 Part D plans available in Wisconsin. Of these, there are 7 low-cost plans. 12

13 PDP Changes for 2016 Not available for 2016 Aetna Medicare Rx Premier Cigna-HealthSpring Rx Secure-Max Transamerica MedicareRx Choice SmartD Rx Basic Name change for 2016 Cigna-HealthSpring Rx Secure-Xtra to Cigna-HealthSpring Rx Secure-Extra Symphonix Premier Rx to Symphonix PrimeSaver Rx New Plans for 2016 Wellcare Classic (low cost) Wellcare Extra No longer Low Cost for 2016 AARP Medicare Rx Saver Plus Sanctioned United American-Select United American-Essential 13

14 What are Part D plan costs? Premiums All plans have a monthly premium In 2016, premiums range from $ $ Individuals with an income over $85,000 for an individual or $170,000 for a couple will have a higher Part D premium. Called D-IRMAA (Part D Income Related Monthly Adjustment Amount) This higher premium is limited to approximately 5% of Medicare Part D beneficiaries Plans may have a deductible and a coverage gap All plans have catastrophic coverage 14

15 2016 Medicare Part D Costs Medicare Standard Benefit Deductible No more than $360 Initial Coverage Limit $3,310 Out of Pocket Threshold $4,850 Catastrophic Minimum Costsharing $2.95 generic drugs $7.40 brand name drugs 15

16 2016 Medicare Part D Costs D Initial Coverage Period Coverage Gap Catastrophic Period Beneficiary pays either 25% or actuarially equivalent tier structure. Beneficiary pays 45% of brand name drugs and 58% of generic drugs. Beneficiary pays min. cost of 5% or $2.95/generics & $7.40/brand names. 16 From January 1, 2016 (or at start date for those who begin Med D after January 1, 2016)

17 Closing the Coverage Gap 2016: The federal subsidy for brand name medications beneficiary cost remains 45% of the total drug cost, and the federal subsidy for generic medications reduces beneficiary cost to 58% of the drug cost Each year until 2020, the federal subsidies will increase until the maximum beneficiary cost is 25% for both brand name and generic medications, bringing the cost to the same percentage as the Initial Coverage Period 17

18 Closing the Coverage Gap 18

19 Generic Drug Subsidies in the Coverage Gap In 2016, beneficiaries will pay 58% of the costs of generics in the coverage gap. Only that 58% will count towards beneficiaries Total Out of Pocket Costs Example: A beneficiary paid $5.80 for a generic drug. The drug cost was $ Because this drug was a generic, only $5.80 will count towards TROOP and getting out of the coverage gap. 19

20 Brand Name Discounts in the Coverage Gap These are automatic discounts applied by drug manufacturers to beneficiaries drug purchases, i.e., beneficiaries don t have to do anything to obtain the discount What the beneficiary pays and the manufacturer s discount count as out-of-pocket costs What the plan pays toward the drug cost does not count toward out-of-pocket costs Discounts only to portions of straddle claims 20

21 Enhanced Coverage For an additional cost, plans may offer enhanced benefits, which include benefits that are not required by the laws governing Part D plans Examples include Part D excluded drugs such as vitamins Costs associated with enhanced benefits do not count towards out of pocket costs used to determine when a beneficiary has met his/her deductible or made it to the coverage gap or to the catastrophic coverage level Plans may not be cheaper for beneficiaries than purchasing these items outside of the plan 21

22 What do Part D plans cover? Retail pharmacy prescription drugs Requires a prescription Used for an FDA medically accepted indication Do not have to cover all medications that are available except for certain categories 22

23 Part D Covered Prescriptions Prescription drugs, but plans are allowed to put certain restrictions on coverage. Must cover all or substantially all drugs in these 6 categories: Antidepressant medications Antipsychotic drug medications Anticonvulsant medications Antineoplastic drugs (used by cancer patients) Immunosuppressant (used by transplant patients) Antiretroviral (used by patients with HIV). Cover at least 2 options in all other drug categories. 23

24 Excluded Drugs Excluded drugs: Medicare Part B drugs, e.g., outpatient drugs that require durable medical equipment like an external infusion pump See CMS Medicare Parts B/C Coverage Issues chart Off label prescriptions Drugs not approved by FDA Prescription vitamins, weight loss drugs, over-the-counter drugs, drugs for cosmetic purposes (e.g., hair loss), erectile dysfunction drugs 24

25 Additional Plan Requirements Make sure you have convenient access to retail pharmacies. Have a process in place to get medically necessary drugs that are not on the formulary (see Part D appeals, Exceptions ). Provide useful information, such as how formularies work, how to save money with generic drugs, and how to navigate the grievance and appeals processes. Link to information on Part D formulary 25

26 Controlling Part D Plan Costs Formularies Utilization Management Tools Prior authorization Quantity limits Step therapy Medication Therapy Management (MTM) Tiered Cost-sharing 26

27 Utilization Management Prior Authorization (PA) Plan will require a prior authorization before coverage of certain medications. The plan makes the coverage determination. Quantity Limits Excess amounts from the most common dosage level. This will require a coverage determination. Step Therapy Try another drug before covering the prescribed medication. Coverage determination is needed to override this requirement. Medication Therapy Management Designed to ensure beneficiaries with complex needs under their meds, usage, adverse effects, and drug interactions. 27

28 Tiering Plans group medications for payment purposes. Each tier has separate co-pay amount. For example, for each prescription, a plan may charge $5 for Tier 1 drugs, $45 for Tier 2 drugs, $80 for Tier 3 drugs, and 33% of the cost for Tier 4 drugs. Important to know any tiered cost sharing plan has. 28

29 Formulary Exceptions Part D plan members have the right to challenge denials of drug coverage Plan members can also request exceptions: Coverage of a drug that s not on a formulary; Challenge a plan s PA requirement, step therapy, or quantity limit requirements; or Change a drug s tiered cost sharing 29

30 Denied at the pharmacy? Request a transition fill Contact the prescriber Contact the plan to obtain a coverage determination in case the person chooses to pursue a formulary exception Explore other plans to see if another plan might provide better coverage, if beneficiary has a SEP or any other enrollment period that be currently available. 30

31 Enrollment When can you enroll? What is the Part D Late Enrollment Penalty? 31

32 When can you enroll? Initial Enrollment Period Annual Enrollment Period Special Enrollment Period 32

33 Initial Enrollment Period 7-month window 3 months before the first month you are eligible (turn 65 or 25 th month you receive SSDI payments), Month you become eligible, and 3 months after the month you become eligible What if you receive Medicare retroactively? Month you receive notice of eligibility for Medicare, and 3 months after the month you receive notice from SSA 33

34 Annual Enrollment Period Also known as the Open Enrollment Period October 15 th December 7 th Beneficiaries should reassess their plan choice every year 34

35 What can you do during the AEP? Sign up for a new PDP Switch PDPs If you have a MA-PDP, you can switch to another MA-PDP If you have a MA-PDP, you can go to Medicare Advantage and a stand-alone PDP If you have a MA-PDP, you can go back to Original Medicare and a standalone PDP You can disenroll from a PDP 35

36 Special Enrollment Period (SEP) Generally, a SEP gives a beneficiary the ability to make one election or choice within a period of time Disenrollment Enrollment Enrolling in a plan automatically disenrolls you from your previous plan Special Needs Plans(SNP) have different SEPs Medicare publishes a tip sheet for Part C and D enrollment periods 36

37 Special Enrollment Periods Some examples: Ongoing SEP for those with Extra Help or Low Income Subsidy (LIS) Moving out of a service area Entering or leaving a long term care facility Loss of creditable prescription drug coverage Enrollment in Part B during Annual Enrollment Period (Jan Mar) triggers Part D SEP (April-June) Plan terminated/ not renewed by Medicare Loss of Extra Help or LIS Enrollment in 5-Star Plan Non-renewals 37

38 SEP for Non-Renewals Beneficiaries in non-renewed plans can sign up for a plan during the OEP If beneficiaries have not signed up for a new plan by December 7, they can sign up for a new plan before the end of February The new plan is effective the first calendar day of the month following enrollment Plan termination SEPs are handled differently and may be appropriate referrals to the Prescription Drug Benefit Helpline 38

39 AUTO AND FACILITATED ENROLLMENT Full Benefit Dual Eligibles (FBDE) who have not selected a Part D plan will be auto-enrolled in a low cost plan by CMS SSI recipients Other LIS eligible individuals have facilitated enrollment. MSP only FBDE Medicaid Extra help through SSA Auto enrollment is usually effective the first of the month of Medicare eligibility. Facilitated enrollment is effective the first of the 2 nd month after the month of Medicare enrollment. 39

40 The Part D Late Enrollment Penalty Individuals will be assessed a penalty if: If it has been 63 days or longer since either the individual s initial enrollment period ended, or since the individual was last enrolled in a Part D plan, and the individual: Was eligible for Part D, Not enrolled in Part D, Not enrolled in creditable coverage, and There is no applicable exception. People who have LIS or who become eligible for LIS will not have a penalty 40

41 What is the Low Income Subsidy? Also known as LIS or Extra Help For low income and low assets individuals Provides assistance with premium, deductible and copayments costs A person with a subsidy has lower Part D costs than a person without a subsidy 41

42 Who receives LIS? Three groups of people receive LIS: 1. Full dual eligibles (full Medicaid card services and Medicare) automatically have the full subsidy 2. Medicare Savings Program (MSP) recipients automatically have the full subsidy 3. Extra Help individuals through Social Security have a subsidy. The subsidy is full or partial depending on income and assets 42

43 Medicaid/Medicare Dual Eligibles Provides full LIS Needs-based (SSI or low income/assets) Apply with local IM consortia office or by using ACCESS 43

44 Low Income Subsidy through Medicare Savings Programs Also known as Medicare Buy-ins QMB, SLMB, SLMB+ and QDWI Provide full LIS Apply through local IM consortia via Medicaid application 44

45 Extra Help through Social Security Provides full or partial LIS Must have assets and income below certain amounts A few assets are treated more generously by Social Security than Medicaid Apply through Social Security 45

46 Low Cost Plans and LIS A low cost plan, benchmark plan, has a premium below the benchmark dollar figure for Wisconsin, and is a basic not enhanced plan. To maximize savings with a subsidy, a LIS beneficiary must be in one of these plans Full subsidy LIS individuals have no premium in one of these plans The benchmark for Wisconsin for 2016 is $

47 LOW COST PLANS De Minimus plans CMS has a process to allow some plans over the benchmark limit to receive LIS members with no premium. Using the benchmark limit to define these plans yourself could result in error. 47

48 Full LIS Costs 2016 Level 1 Income 101% of Federal Poverty Level (FPL) Cost sharing $2.95 generic / $7.40 Name Brand Level 2 Income 100% FPL Cost sharing $1.20 generic / $3.60 Name Brand Level 3 Institutionalized/HCBS waiver recipients at NH LOC Cost sharing $0 48

49 2016 Medicare Part D LIS Costs Initial Coverage Period Co-Pays: Institutionalized: $0 HCBWS: $0 $1.20 generics & $3.60 brand names $2.95 generics & $7.40 brand names Catastrophic Period Co-pays: Brand Name: $0 Generics: $0 49 From January 1, 2016 (or at start date for those who begin Med D after January 1, 2016)

50 2016 Medicare Part D partial LIS costs D Initial Coverage Period Co-insurance no more than 15% for beneficiary Catastrophic Period Co-pays: Brand Name: $7.40 Generics: $2.95 Partial Help has three different levels. This represents the maximum beneficiary liability. From January 1, 2016 (or at start date for those who begin Med D after January 1, 2016) 50

51 2016 LOW COST PLANS Landscape of 2016 Wisconsin Low Cost Plans 51

52 How do you choose a plan? MEDICARE will help people over the phone. Call a plan directly. But, the most effective way to choose a plan for most people is to use the online Plan Finder 52

53 Beneficiaries often fail to choose the best plan Majority of people do not select the lowest cost Part D plan. Fewer than 10% of all seniors picked the Part D plan that was best for them. Fewer than 15% picked one of two lowest cost plans for them. Even if you look at the cheapest 25% of plans available to a person in a particular state, only 50% of Medicare beneficiaries chose one of those plans. Bottom Line: Clients should revisit their plan choice every year! 53

54 Why revisit plan every year? Low premium may not be the lowest cost plan. Low deductible may not be the lowest cost plan. Generic coverage during coverage gap may not be the lowest cost plan. Enhanced coverage may not save you money. Basing plan choice on coverage of one drug may not lead to best plan choice. 54

55 Medicare s Plan Finder Plan Finder Website CMS Plan Finder Toolkit Medicare has a training site that looks just like the real site DRW Helpline and Medigap Helpline staff are available to provide Plan Finder trainings 55

56 Plan Finder Tips Always do a personalized search Confirm the drug list (if already entered) is accurate Note current enrollment status and whether Medicare has identified the client as LIS eligible in My Current Profile Identify any restrictions in the footnotes on the client s drugs when reviewing the plan s coverage Enter client s pharmacies Plan s preferred pharmacies may not mean lower costs May enter up to two pharmacies Remind clients that Plan Finder costs (except for premiums and deductibles) are estimates Generally, the best strategy when you run into a glitch is to try again later! 56

57 Part D NOTICES 57

58 CMS Notices CMS publishes a list of its mailings each year 58

59 NOTICES Beneficiaries who get Extra Help through Social Security will get an award letter and instructions on what to do. Beneficiaries who are found eligible through Medicaid or MSPs who are deemed eligible for LIS, will get a PURPLE letter informing them of this and instructions on what to do. Beneficiaries who are not already in a plan when they get the LIS will get a YELLOW or GREEN notice informing them that they will be placed in a part D plan, which plan, and the effective date of that plan. These notices will tell the beneficiary how to use the LINET (Limited Income Newly Eligible Transition Program) process to obtain coverage in any uncovered or retroactive period of eligibility 59

60 REDEEMING NOTICES CMS looks at Medicaid data from states in July of every year and uses that data to determine LIS eligibility for the upcoming year Eligible for LIS Those who receive Medicaid, even for one month, after the July window, will be deemed eligible for the subsidy for the remainder of 2015 through December Will NOT receive a letter. Losing LIS GRAY letter - In September, from CMS stating that the individual will lose LIS as of 12/31/2015, and will be given an SSA Extra Help application. Regaining LIS PURPLE letter - Those who lost eligibility or were not on the state upload files in July, and regain Medicaid/MSP before the end of 2015, are re-deemed and will receive LIS for the full year of 2016 NO NEWS IS GOOD NEWS 60

61 Other Notices Tan Letters Premium Change TAN Letter LIS beneficiaries who originally chose a plan that will no longer be a low-cost plan will stay in that plan and have premiums or increased premiums in 2016, if they do nothing. These choosers will get a tan letter informing them that if they switch plans, they could save premium costs. 61

62 Blue Letter Individuals Reassigned - BLUE letter If Medicare auto-enrolled, Medicare will automatically reassign to a new plan. Individuals can supersede this selection and choose their own plan. The blue notices are for both PDPs and MA plans. 62

63 Orange Letter Co-Pay Change Orange Letter Still have the copays, but amounts are changing due to a change in beneficiary s income. 63

64 PLAN MAILINGS AND NOTICES Every Part D and Medicare Advantage plan member gets an Annual Notice of Change letter from their plan by September 30 th Explains changes for the coming year Plan could have same name but different costs, formulary, and rules Different set of plans available every year Plans change their list of covered drugs and cost structure. Plans can add prior authorization requirements or quantity limits Plans can change drug tiers for particular drugs Even if individual is happy with the current plan, should always revisit choice during Annual Enrollment Period 64

65 Creditable Coverage Notices Creditable coverage letter sent by October 15 Sent by current health insurance plan Ex. Employer group health plans retiree plans, Veterans benefits, TRICARE, the Indian Health Service (IHS, and the Federal Employee Health Benefits Program. Beneficiary should keep copy of this notice. 65

66 Medicare Plan Finder Problems Report errors in formularies or costs to the Part D plan. Report technical problems or malfunctions with the online Medicare plan finder tool at to: Phoebe Hefko, Wisconsin SHIP Director phoebe.hefko@wisconsin.gov (608) Use the attached intake form. Details are important. As a liaison for our state, I will convey problems to CMS, track their response and report back to you. If you need help filling out the form, contact me.

67 MEDICARE PART D ADVANCED TOPICS 67

68 TOPICS 1.LIS and Best Available Evidence 2.Disenrollment for Failure to Pay Premium 3.Good Cause for Reinstatement after Loss of Plan 4.Convenient Access to Retail Pharmacies 5.Exception Requests & Appeals 6.Part A v Part B v Part D 7.Miscellaneous 68

69 BEST AVAILABLE EVIDENCE (BAE) CMS Policy Acceptable BAE The state of Wisconsin and BAE When to submit How to submit 69

70 CMS Policy on BAE Part D sponsors are required to accept BAE Accept different forms of evidence Must establish the subsidy status Must update their system within hours Provide access to covered Part D drugs at reduced cost-sharing Policy is found here 70

71 ACCEPTABLE BAE A copy of a state document that confirms active Medicaid status A printout from Forward Health Interchange enrollment file A screen shot from CARES showing Medicaid status Other state documentation, e.g. notice of decision SSA award letter for extra help 71

72 The State of Wisconsin Sends a file to CMS every month Every person who is Medicare/Medicaid eligible Information is not always timely CARES must be updated to reflect waiver in Forward Health Interchange 72

73 BAE and HCBS HCBS zero copays The BAE is the functional screen page Other evidence, e.g. remittance advice showing Medicaid payment, etc. Qualifies if receiving HCBS services since 1/1/12 or currently eligible. Challenges in establishing subsidy level for Wisconsin HCBS clients. Forward Health Interchange enrollment file must reflect waiver for zero copays 73

74 Waiver in CARES Waiver must show in Forward Health May need a F (formerly 3070) to update CARES Then submit BAE to plan 74

75 How to Submit BAE Call the plan Fax Here is the link for BAE contacts, click on Part D Contacts under Related Links header near bottom of the page: tml Practice tip: Include a cover sheet/memo about your client, outlining FBDE status effective date, a short statement that the state of Wisconsin has not uploaded the information. and any other information you feel that will get the subsidy in place faster 75

76 Disenrollment for Failure to Pay Premium 76

77 Failure to Pay Premiums Plans may take one of these two actions: Do nothing, i.e., allow the member to remain enrolled in the PDP Disenroll after a grace period and proper notice May not disenroll members for failure to pay premiums or D- IRMAA if member has requested premiums be withheld from SSA check. Disenrollment may occur if premium withhold has been rejected, failed or been unsuccessful, or; If member requests status be changed to direct bill instead of premium withhold. 77

78 Disenrollment Policy Plan must apply policies consistently across all plan members LIS is not a protection for failure to pay Plan must make a reasonable effort to collect Grace period notice must be provided Partial payment does not guarantee protection from disenrollment If no payment within the grace period plan must notify the member in writing of the effective date of disenrollment Policy and sample letters for disenrollment are found here 78

79 Grace Period A minimum of 2 calendar months Begins on the first of month for which the premium is due and unpaid Must provide an opportunity to pay 79

80 Reinstatement for Good Cause Applies only to involuntary disenrollment for nonpayment of plan premium or D-IRMAA Member must request reinstatement within 60 calendar days of disenrollment effective date Must have a creditable reason regarding the circumstance that prevented timely payment Must pay all overdue premiums within three (3) months of the disenrollment date in order for reinstatement to occur 80

81 Good Cause Criteria Serious illness, institutionalization and/or hospitalization Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, spouse, caregiver/authorized representative Recent death of spouse, immediate family member or caregiver Home severely damaged by fire, natural disaster or other unexpected event Extreme weather event declared as federal or state level of emergency preventing payment 81

82 Not considered Good Cause Allegations that bills or notices were not received due to unreported change of address, out of town for vacation, visiting family members, etc. Authorized representative did not pay timely Lack of understanding Could not afford to pay premiums during the grace period Need for prescription medicines or other plan services 82

83 Plan Determines Good Cause If criteria are met, a favorable determination will be issued when; Request is received within 60 calendar days of disenrollment date Plan gets creditable statement regarding the circumstance Obtain affirmation of willingness and ability to pay; and Amount due is paid within 3 months of disenrollment If criteria not met, an unfavorable decision will be issued Not appealable Former member can file a grievance against the plan related to the involuntary disenrollment 83

84 Convenient Access to Retail Pharmacies Preferred cost sharing Beneficiaries should have access within a certain mile radius Urban beneficiaries have the most problem with access 84

85 Preferred Cost Sharing Pharmacies (PCSP) Offer lower cost sharing levels Convenient access standard similar to the TriCare standard 90% in urban areas have access within 2 miles 90% in suburban areas have access within 5 miles 70% in rural areas have access within 15 miles There is no access standard for PCSP network CONVENIENT ACCESS STANDARD APPLIES TO PLAN S ENTIRE NETWORK. 85

86 COVERAGE DETERMINATIONS AND EXCEPTIONS Any decision made by the Part D plan regarding Receipt of or payment for a prescription medication the member may think is covered Tiering or formulary exception request Amount of copay Quantity limit Step therapy Prior authorization 86

87 EXCEPTION REQUEST A type of coverage determination Tiering exception Formulary exception Usually granted when a plan determines that a requested medication is medically necessary. Prescriber must submit a supporting statement Usually granted within 72 hours. Expedited requests with supporting prescriber statement is decided within 24 hours. If unfavorable, can request reconsideration and appeal 87

88 Transition Fills Available first 90 days of enrollment in plan. Does have to include medications with utilization requirements One time only 30 day fill Not for new medications, only existing ongoing medication therapies If medication not on plan s formulary Plan will send letter within 3 business days about coverage and ability to request an exception Memo on Transition Fill is found here 88

89 RECONSIDERATION AND APPEALS Five levels of appeals Redetermination Reconsideration ALJ hearing MAC review Review by a Federal District Court Medicare Part D Appeal Process is here Click on Flow Chart in the Download box 89

90 COORDINATION OF BENEFITS Medicaid & Part D coordinate well. Part D does mostly coordinate with SeniorCare. Part D can coordinate with private insurance. 90

91 Part A v Part B v Part C v Part D 91

92 Medicare Drug Coverage A v B v C v D is found here A v B v D is found here Comparison of A, B, C and D appeal process is here 92

93 2016 Changes to the Requirement for Part D Prescribers Starting no later than January 1, 2016 all Part D prescribing physicians and other medical prescribers must enroll in Medicare and receive a valid NPI. Law does not affect prescribing pharmacists with a valid NPI and allowed to prescribe by their state. Law goes into effect June 1, 2016 If no Medicare enrollment by prescriber, prescription will be rejected by plan. Guidance is still under development 93

94 Observation Stay v 2-Midnight Inpatient Admission They can overlap Observation stay fact sheet Beneficiary is not formally admitted to the hospital Part D may pay for self administered medications Beneficiary must submit a claim to plan Hospital pharmacies are not in network 2-Midnight Rule Fact sheet is found here Is admission reasonable and necessary If admitted payable under Part A 94

95 Miscellaneous Incarcerated disenrolled and then re-enrolled by CMS Unlawful presence will be involuntarily disenrolled Non-preferred generic tier will not be available for 2016 There will be maximum copay and coinsurance thresholds for plans with 3 or more tiers Plans are encouraged to offer $0 or low cost sharing for vaccines. Fact Sheet Especially if there is a 5 or 6 tier formulary that includes a dedicated vaccine only or Select care/select diabetes tier which includes vaccines. LTC facilities cannot involuntarily disenroll beneficiaries Memo is found here 95

96 Resources DRW Disability Drug Benefit Helpline Prescription Drug Helpline Medigap Helpline MEDICARE Medicare.gov Medicare Publications Example: How Medicare Prescription Drug Plans and Medicare Advantage Plans with Prescription Drug Coverage Use Pharmacies, Formularies, and Common Coverage Rules CMS National Training Program Library Example: Plan Finder Toolkit Medicare Learning Network s Web-Based Training 96

97 RESOURCES Elder Benefit Specialists Part D for Age 60 and older Medigap Prescription Drug Helpline

98 RESOURCES Part D for Under age 60: Disability Benefit Specialists: A list of disability benefit specialists can be found at Disability Drug Benefit Helpline (DRW): Disabilityrightswi.org (click on Part D on the left) 98

99 QUESTIONS? 99