Basic Reimbursement - Medicare Part D Specifics

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1 Basic Reimbursement - Medicare Part D Specifics R8-V1 (c) 2012 Amgen Inc. All rights reserved

2 2 This information is provided for your background education and is not intended to serve as guidance for specific coding, billing, and claims submissions. The decision on which codes best describe the services provided must be made by the individual providers based on specific payor guidance and requirements.

3 Discussion Topics Medicare Part D Basics Eligibility for Medicare Part D Stand-alone Prescription Drug Plans (PDP) vs. Medicare Advantage Prescription Drug Plans (MA-PD) Enrollment periods Navigating Part D drug utilization Part D exceptions Part D Low Income Subsidy (LIS) Understanding State Pharmacy Assistance Programs Additional resources for Part D 3

4 Inception of Medicare Part D Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) 1 Benefits began January 1, 2006 Provides Medicare beneficiaries with optional prescription drug coverage Oral medications Self-administered Physician administered if not covered under Medicare Part A or B 1. Centers for Medicare and Medicaid Services (CMS), Medicare Program; Medicare Prescription Drug Benefit. F3Column.pdf. Accessed October 25,

5 Offered Through Two Types of Plans Stand-alone Prescription Drug Plans (PDP) Medicare Advantage Drug Plans (MA-PD) Traditional Medicare Part A and B Elect Medicare Advantage (Part C) Medicare health plans that include Medicare prescription drug coverage Stand-Alone Part D Plan 1. Centers for Medicare and Medicaid Services (CMS), Medicare Program; Medicare Prescription Drug Benefit. Accessed October 25,

6 Eligibility For Medicare Part D 1 General Medicare Eligibility People Age 65+ People under age 65 with certain disabilities People of all ages diagnosed with End-Stage Renal Disease (ESRD) To enroll in a PDP Beneficiary must have Medicare Part A or B To enroll in a MA-PD Beneficiary must have both Medicare Part A and B 1. CMS, Medicare & You Accessed October 25,

7 Beneficiary Enrollment Periods for Medicare Part D 1 Initial Enrollment Period (IEP) The IEP occurs during the 7 months surrounding Medicare eligibility Medicare Open Enrollment Period Between October 15 December 7 each year Coverage effective January 1 of the next calendar year Special Enrollment Periods (SEP) Periods outside of the usual IEP and Medicare Open Enrollment Period when an individual may elect a plan or change his or her current plan election There are various types of SEPs Medicare Advantage Dis- Enrollment Period Between January 1 February 14 each year Individuals can switch from Medicare Advantage plans to Original Medicare Those who switch to Original Medicare during this period have until February 14 to join Medicare Prescription Drug Plan to add drug coverage 1. CMS. Understanding Medicare Enrollment Periods. Accessed October 25,

8 How to Enroll in a Part D Plan Through a Part D plan sponsor website Go to plan sponsor website Follow instructions for enrolling into selected plan Through the Medicare Part D plan Finder Tool Select enroll now to be redirected to plan sponsor website Certain Low-income beneficiaries are autoenrolled into a Part D plan Subsequent to Low-Income Subsidy (LIS) approval 8

9 2013 Part D Overview and Coverage 1 Coverage gap ends and catastrophic coverage begins at $6, in total drug spend Low-income subsidy enrollees do not have doughnut hole in benefit Initial coverage limit $2,970 Beneficiary paid Insurer paid Manufacturer paid Catastrophic Coverage Insurer & Medicare pay 95% of costs Coverage Gap (Doughnut Hole) 50% of Costs 75% Paid by Insurer Paid ($1,983.75) by Insurer ($2,113) CMS. Advance Notice of Methodological Changes for Calendar Year 2013 for MA Capitation Rates, Part C and Part D Payment Policies and 2013 Call Letter. Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2013.pdf. Accessed October 29, % cost sharing through catastrophic coverage (beneficiary has paid $4,750 out-of-pocket to reach catastrophic coverage) Beneficiary pays 47.5% (max of $1,787.79) in Rx spending on brand drugs through the doughnut hole (100% counts toward catastrophic coverage) Coverage gap program provides 52.5% discount (max of $1,975.97) on brand name drugs through the coverage gap Beneficiary pays 25% coinsurance ($661.25) Beneficiary pays $325 deductible 9

10 Key Medicare Part D Reforms 1 Rebate to beneficiaries in coverage gap in 2010 The federal government provided a one-time $250 rebate for all Medicare Part D beneficiaries that had out of pocket spending in the coverage gap ( doughnut hole ) Manufacturer discount on brand drugs in the coverage gap through 2020 Manufacturers will provide 50% discounts (off the negotiated price) for all brand name drugs provided to Part D beneficiaries in the coverage gap in 2013 and will provide the discount every year until 2020 Phase out of the coverage gap by 2020 Using a phased approach, the coverage gap provision of Medicare Part D will be closed Manufacturers will continue to provide a discount on brand drugs Between now and 2020, plans will also increase their benefits for both generic and brand drugs; ultimately, beneficiaries will be responsible for 25% coinsurance for both brand and generic drugs (until catastrophic coverage is reached) 1. Kaiser Family Foundation, Explaining Healthcare Reform: Key Changes to the Medicare Part D. Accessed October 25,

11 Indentifying Type of Part D Coverage 1 Standard Medicare Prescription Drug ID Card Stand-alone PDP plans generally have an ID format of SXXXX-XXX MA-PD plans generally have an ID format of HXXXX-XXX 1. CMS, Announcement of Fall Software Changes. Accessed October 25,

12 Understanding Part D Exceptions A beneficiary or a provider may request an exception for a drug not on a plan s formulary or to reduce the cost-sharing, step therapy or quantity limits Tier Exceptions 1 Permits enrollees to obtain a non-preferred drug in a preferred tier: Written and/or oral request must state why a tier request is being requested Request must state why other products have failed, or specific concern over adverse reactions 24 hours (expedited requests) or 72 hours (standard requests) Formulary Exceptions 1 Allows enrollees to gain access to Part D drugs not included on its formulary: Written and/or oral request must state why the formulary request is being requested Request must state that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be ineffective, or the alternative listed on the formulary or required to be used in accordance with step therapy has been or is likely to be ineffective. 24 hours (expedited requests) or 72 hours (standard requests) 1.CMS, Medicare Prescription Drug Benefit Manual - Exceptions. Grievances/MedPrescriptDrugApplGriev/Exceptions.html. Accessed October 25,

13 Extra Help for Low-Income Part D Beneficiaries Extra help in paying for Part D co-pays Provides subsidized assistance for Part D costs Premiums Part D deductible Coverage gap Part D Low Income Subsidy (LIS) Incomes at or below 150% the federal poverty level (FPL) 13

14 2013 Part D Low-Income Subsidy (LIS) 1 Income 100% FPL <135% FPL <150% FPL Standard Asset Test 2 None $6,940 single $10,410 couple $11,570 single $23,120 couple None Premium 3 Fully subsidized Fully subsidized Sliding scale $30 Deductible Fully subsidized Fully subsidized $66 $325 Patient copay/ coinsurance $1.15 generic $3.50 brand $2.65 generic $6.60 brand 15% up to catastrophic limit 25% up to $ in drug expense Gap in Coverage None None None 47.5% between $2,970 and $6, in drug expense Catastrophic Coverage No cost sharing No cost sharing $2.65 generic $6.60 brand copay above limit 5% after $4,750 in OOP Medicare Part D Call Letter. Letter.pdf. Accessed October 25, CMS Resource and Cost-Sharing Limits for Low-Income Subsidy (LIS). Accessed October 25, Health and Human Services. Medicare prescription drug premiums to remain steady for third straight year. Accessed October 29,

15 By Phone TTY Online Four Ways to Apply for Part D LIS In-person at a Social Security field office Contact the state Medicaid office 15

16 Understanding State Pharmaceutical Assistance Programs (SPAP) 1 State Pharmacy Assistance Programs (SPAP) are state-funded programs that pay a portion of prescription costs for eligible enrollees. SPAPs also include subsidies and discount programs for eligible seniors Eligibility requirements include: Low-income and medically needy seniors Persons with disabilities who do not qualify for Medicaid Discount programs generally rely on the large-volume purchasing power of the state to negotiate a sizable discounts on a wide selection of prescription products Third party charitable organizations may also be available to assist qualifying patients with prescription costs 1. IHS. State Pharmacy Assistance Programs MMA Final Rule Fact Sheet. _%3D_NextPart_001_01C50000.E6C27987&T=application%2Fpdf;%20name=%22SPAPFactSheet.pdf%22&N= SPAPFactSheet.pdf&attachment=q&XSS=3. Accessed October 25,

17 Educational Resources for Part D Prescription Drug Benefit Manual Medicare & You 2013 Part D Plan Finder tool Apply on-line for Part D LIS 17

18 Summary Beneficiaries enrolled in Part A or B can elect a stand-alone PDP Must be enrolled in Part A and B to elect MA-PD PDP benefit structures are based on the standard benefit but will vary by plan Part D exceptions and appeal processes are standardized across all plans There is extra help for low-income beneficiaries SPAPs are available in some states to provide further assistance 18

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