Medicare Part D. MMA establishes a standard Part D drug benefit, which consists of four components or phases.

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1 Medicare Part D The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) added voluntary prescription drug coverage to Medicare, the federal health insurance program for seniors age 65 or older and permanently disabled persons under the age of 65. This prescription drug benefit, known as Medicare Part D, began on January 1, 2006 and is administered by the federal Centers for Medicare and Medicaid Services (CMS). Individuals on Medicare may obtain the Part D drug benefit through two types of private insurance plans: prescription drug plans (PDPs) and Medicare Advantage prescription drug plans. PDPs only cover prescription drugs, and so individuals who join these plans continue to get their other Medicare benefits through Medicare Part A (hospital services) and Medicare Part B (medical services). Medicare Advantage plans are comprehensive health plans, such as health maintenance organizations, that cover prescription drugs and all other Medicare benefits. Plans compete for enrollees on the basis of premiums, benefits and pharmacy networks. All Part D plans must offer a standard drug benefit that is defined in the federal act, or an alternative that is of equivalent actuarial value. In addition to this required coverage, plans may offer enhanced coverage for an additional premium. Each year, plans wanting to offer a Part D drug benefit must submit a bid to CMS together with information on the covered drugs, the actuarial value of the coverage, and the geographic region to be served. If the plan complies with federal requirements, CMS approves the plan and enters into a twelve month contract. Part D enrollees pay a monthly premium as well as any deductibles and cost sharing (i.e., copayments or coinsurance) for their prescription drugs. The monthly premium charged to enrollees is equal to the difference between their plan s total premium and the amount subsidized by the federal government. For all Part D enrollees, the federal subsidy pays for 74.5 percent of the standard drug coverage enhanced coverage is not subsidized. Additional subsidies are provided to low income individuals with limited resources, helping to pay their monthly premium, annual deductible and other cost sharing. Part of the funding for the Medicare Part D program comes from a mandatory monthly state payment to the federal government, known as the clawback payment. Part D Benefit Design MMA establishes a standard Part D drug benefit, which consists of four components or phases. Annual deductible. During this initial phase, individuals pay the full cost of prescription drugs until they reach the annual deductible amount. Initial coverage. After the deductible is met, the plan pays 75 percent of total drug costs and the individual pays 25 percent up to the initial coverage limit. 1

2 Doughnut hole. Once the initial coverage limit is reached, individuals enter the coverage gap or doughnut hole. Prior to 2011, enrollees paid the full cost of drugs purchased in this phase; however, federal health care reform will reduce enrollee spending as explained below. Catastrophic coverage. When individuals reach the out of pocket threshold, they qualify for catastrophic coverage and pay 5 percent of drug costs. The plan pays the balance, but is reimbursed for 80 percent by Medicare through reinsurance payments; hence the net cost to the plan is actually 15 percent. The deductible, initial coverage limit, and out of pocket threshold are defined in the MMA and are indexed to increase each year. For 2011, the standard benefit includes a $310 deductible, an initial coverage limit of $2,840 and an out of pocket threshold of $4,550. This represents $6, in total drug spending (the combined cost to the individual and the plan) before catastrophic coverage is triggered. Payments for drugs not covered by the Part D plan formulary do not count towards the outof pocket costs paid by the enrollee. The table below details the cost sharing for enrollees under the 2011 standard benefit. Cost-Sharing for 2011 Standard Part D Benefit Enrollee Costs Deductible Drug costs up to $310 $ Initial Coverage Period 25% of drug costs or Drug costs above $310 and up to $2,840 $ Coverage Gap or "Doughnut Hole" 50% of brand name drugs Drug costs above $2,840 and up to $6, % of generic drugs Catastrophic Coverage Period Drug costs above $6, % of drug costs The Affordable Care Act of 2010 (federal health care reform) included provisions that close the doughnut hole over a ten year period, beginning in 2011, so that Part D enrollees pay only 25 percent of total drug costs by In 2011, the federal government will provide a 7 percent subsidy for generic drugs purchased in the coverage gap and pharmacy manufacturers will offer a 50 percent discount on the price of brand name drugs. Enrollees will thus pay 93 percent of the generic drug costs and 50 percent of the brand name drug costs until they reach the catastrophic threshold. Medicare will gradually increase the subsidy for generic drugs each year so that it reaches 75 percent by 2020 enrollees will pay the remaining 25 percent. Beginning 2013, Medicare will phase in a subsidy for brand name drugs which, when combined with the 50 percent manufacturer discount, will leave enrollees responsible for 25 percent of cost by The brand name drug subsidy will be 3 percent in 2013 and gradually increase to 25 percent by

3 Formulary The formulary is the list of covered drugs, including generic drugs and brand name drugs. Part D plans can choose what drugs to include on their formulary. All plans must submit their formularies to CMS for review to assure that they meet the minimum federal requirements. Federal law requires Medicare plans to cover at least two drugs in each therapeutic class or category of covered Part D drugs. CMS established minimum formulary requirements to help ensure that plans do not offer formularies that discriminate against or discourage enrollment of certain types of individuals. All Part D plans are required to provide access to a broad range of medically appropriate drugs, including a majority of drugs in the following six classes: anti depressants, anti HIV/AIDS drugs, anti psychotics, immunosupressants, anti neoplastics, and anti convulsants. Federal law requires Medicare to exclude the following drugs: benzodiazepines (commonly used for anxiety, muscle spasms or seizures); barbiturates; drugs used for anorexia, weight loss or weight gain; fertility drugs; drugs used for cosmetic purposes or hair growth; cough and cold medicines; prescription vitamins and minerals; and over the counter drugs. Pennsylvania Part D Plans Medicare beneficiaries are able to choose among an array of stand alone PDP plans that vary in terms of monthly premiums, drugs covered, cost sharing for covered drugs (i.e., co payments and co insurance), and coverage during the doughnut hole. In addition to the standard benefit, the federal government allows plans to offer actuarially equivalent coverage or enhanced coverage. Actuarially equivalent plans have the same actuarial value as the standard benefit, but have a different benefit structure. For example, these plans may reduce or eliminate the annual deductible, but require the enrollee to pay more than the standard 25 percent of drug costs during the initial coverage period. Enhanced plans offer supplemental coverage that exceed the value of the standard benefit. Examples of supplemental benefits include prescription drugs not on the standard formulary, coverage during the doughnut hole, and reductions in enrollee cost sharing (i.e., co insurance or co payments for prescriptions) that increase the actuarial value of the coverage. Plans with more generous benefits often have a higher premium cost. For 2011, CMS approved 38 stand alone PDPs to provide Medicare Part D drug coverage in Pennsylvania. This is significantly lower than previous years, reflecting the impact of recent CMS regulations designed to eliminate duplicate plan offerings that offer no real difference. Monthly premiums range from a low of $14.80 for a standard plan to a high of $ for an enhanced plan. Twenty one plans offer basic coverage, including the standard drug benefit (five PDPs) and actuarially equivalent benefits (sixteen PDPs). Seventeen PDPs offer enhanced drug benefits. 3

4 Nineteen PDPs have no deductible. For those plans with a deductible, fourteen PDPs will charge the standard $310 deductible and five PDPs will charge a lower amount. Thirteen plans offer coverage in the doughnut hole. The average premium for these plans is $84.33, or nearly twice that of plans with no gap coverage ($43.85). However, eight of the thirteen plans limit their gap coverage to generic drugs only, requiring enrollees to pay their full share of brand name drug costs while in the doughnut hole. The table below summarizes key trends regarding the stand alone prescription drug plans (PDPs) available in Pennsylvania since the Part D program began in Pennsylvania Stand-Alone PDPs, 2006 through Total number of PDPs Benefit Design Standard Benefit Plans (% of total PDPs) 12% 15% 17% 16% 16% 13% Actuarially Equivalent Plans (% of total PDPs) 44% 39% 33% 33% 35% 42% Enhanced Benefit Plans (% of total PDPs) 44% 45% 49% 51% 49% 45% Benefit Features Plans with a Deductible (% of total PDPs) 42% 38% 43% 46% 60% 50% Plans with Gap Coverage (%of total PDPs) 15% 29% 27% 23% 20% 34% PDP Monthly Premiums Lowest Cost Plan $16.94 $14.80 $15.40 $13.70 $16.70 $14.80 Highest Cost Plan $68.61 $ $99.00 $ $ $ Average of all Plans $38.69 $35.68 $38.17 $45.89 $46.55 $56.35 Low Income Subsidy Medicare will subsidize (either in full or in part) the monthly premiums and other Part D costs for individuals with low income and modest resources. As explained below and summarized in the table on the next page, these subsidies are designed to eliminate or reduce the monthly premium, annual deductible, co payments, and costs in the doughnut hole. Approximately 407,000 Pennsylvanians benefited from the low income subsidy in Full Subsidy Individuals receiving the full subsidy have no premium, no deductible, and no gap in coverage (i.e., no doughnut hole ). Their only costs are small co payments for each prescription, which vary depending upon income; however, these co payments disappear once they reach the catastrophic threshold. To receive the full subsidy at zero premium cost, individuals must enroll in a PDP that has a monthly premium below the benchmark premium (determined annually by CMS) for basic prescription coverage. If they select a plan with a higher premium, they must pay the difference each month. 4

5 Dual eligibles (i.e., low income seniors or people with disabilities who are enrolled in both Medicare and Pennsylvania s Medical Assistance program) and persons receiving SSI benefits are automatically eligible for the full subsidy. Other Medicare beneficiaries must have annual incomes less than 135 percent of federal poverty and limited resources, and must submit an application to determine if they qualify for the full subsidy. Partial Subsidy Medicare provides a partial subsidy of premium, deductible and co insurance for Medicare beneficiaries with incomes from 135 percent to 150 percent of federal poverty and with limited assets. Based on their income, individuals pay a sliding scale monthly premium that ranges between 25 percent and 75 percent of the benchmark premium. They pay a reduced deductible and pay a reduced share of the drug costs until they reach the catastrophic threshold, and thereafter their only costs are small co payments for each prescription. The table below shows the reduced costs that Pennsylvanians will pay for Medicare Part D in 2011 under the full subsidy and partial subsidy, compared to the standard benefit which is shown in the first column. Twelve of the thirty eight PDPs available in Pennsylvania have monthly premiums below the benchmark premium of $34.07 and are thus available at zero premium cost for those Pennsylvanians who are eligible for the full subsidy Low-Income Subsidy Groups and Enrollee Out-of-Pocket Costs FULL SUBSIDY PARTIAL SUBSIDY MEDICARE PART D Dual Eligibles Dual Eligibles Persons Persons Between 2011 PENNYSLVANIA Up to 100% Over 100% Up to 135% 135% and 150% STANDARD BENEFIT of Poverty of Poverty of Poverty of Poverty Monthly Premium: sliding scale $34.07 benchmark $0 $0 $0 up to $25.55 Annual Deductible: $310 $0 $0 $0 $63 Initial Coverage: co-pays: co-pays: co-pays: 25% of drug costs $1.10 generic $2.50 generic $2.50 generic 15% of $3.30 brand $6.30 brand $6.30 brand drug costs Donut Hole: co-pays: co-pays: co-pays: 93% of generic costs $1.10 generic $2.50 generic $2.50 generic 15% of 50% of brand name costs $3.20 brand $6.30 brand $6.30 brand drug costs Catastrophic Coverage: co-pays: 5% of drug costs $0 $0 $0 $2.50 generic $6.30 brand 5

6 Financing Medicare Part D (State Clawback Payment) Medicare Part D is funded with three revenue sources: the monthly premium paid by enrollees, general federal revenues; and monthly payments from the states. This state payment known as the clawback is a mandatory payment to the federal Medicare that began January The clawback is a provision inserted by Congress into the Medicare Modernization Act to shift a portion of the cost of the Part D drug benefit to the states and thereby keep the act within the limits of predetermined budget constraints. Specifically, the 2003 Congressional budget debate produced a joint resolution allocating a net $400 billion in new federal spending for Medicare over a ten year period. This budget constraint necessitated the coverage gap in the Part D drug benefit; however, even with the doughnut hole and adjustments to the low income subsidy, MMA costs were outside the agreed to budget constraint. The conference committee added the state clawback payment, prior to final passage of the act, as a mechanism to offset the cost of Medicare Part D. The effective date of the clawback payment is significant because that is when the federal government assumed financial responsibility for providing prescription drug benefits to dual eligibles these are lowincome elderly or disabled individuals who are enrolled in both Medicare and Medicaid. Prior to Medicare Part D, the state Medicaid programs provided prescription drug benefits for their dual eligible population. Federal assumption of drug coverage for the dual eligible population relieved states of substantial pharmacy costs in their Medicaid budgets. (For Pennsylvania, covering drug benefits for its 260,000 dual eligibles cost the Medical Assistance program, the name of Pennsylvania s Medicaid program, approximately $400 million per year.) However, rather than allowing states to keep their savings, the MMA required states to pay most of their estimated savings to the Medicare program to help finance the Part D drug benefit. This payment requirement became known as the clawback to signify the federal government grabbing a share of the state savings. The formula for determining the amount of the clawback payment, termed in statute as the phased down State contribution, is specified in the MMA and detailed by CMS in federal regulation. The clawback payment does not reflect actual Part D costs and is based on factors not related to Medicare spending. It is intended to reflect a portion of expenditures that the state would have incurred had it continued to pay, through its Medicaid program, the prescription drugs costs for its dual eligibles. Each state s monthly payment is determined by the following three factors: Per Capita Expenditures, the number of Dual Eligibles, and the Phase Down Percentage. MMA specifies the method for computing each of these factors. Per Capita Expenditures is based on estimated state pharmacy costs for dual eligibles in calendar year This state baseline amount is inflated annually by CMS using the estimated national growth in per capita prescription drug spending. Dual Eligibles is the monthly number of dual eligibles enrolled in Part D. 6

7 The Phase Down Percentage is set at 90 percent in 2006, decreasing annually until the phasedown reaches 75 percent in The monthly payment is determined by the following formula: Per Capita Dual Phased Down Expenditures Eligibles Percentage Monthly State "Clawback" Payment = State share of monthly per capita Medicaid expenditures on prescription drugs covered under Part D for dual eligibles during 2003, trended forwarded x Number of dual eligibles enrolled in a Medicare Part D plan in the month for which the payment is based x Phase down percentage for the year as specified in the MMA (e.g., 81 2/3% in 2011) The formula for calculating the clawback payment has several flaws, beginning with Per Capita Expenditures which is the basis for determining each state s monthly payments. The 2003 baseline is not necessarily an accurate proxy for how much a state would save annually when prescription coverage for dual eligibles shifted to the federal government. States that had a high per capita drug cost for dual eligibles in 2003, but lowered their drug costs in following years, will have their clawback amounts computed each year on the higher 2003 base. This will put them at a perpetual disadvantage. The trend factor itself is another weakness in the clawback formula. CMS uses a national drug spending factor to annually inflate each state s 2003 baseline estimate. If the increase in a state s prescription drug spending is less than the national growth rate, the clawback formula will yield a required annual payment that is too high. A new state appropriation, Payment to the Federal Government for the Medicare Drug Program, was added in 2006 to fund the mandated monthly payment that Pennsylvania must make to help finance the Part D drug benefit for dual eligible persons. Each month the federal government sends the Department of Public Welfare an invoice for the dual eligibles enrolled in Medicare Part D. For the five fiscal years since the program began (2005/06 through 2009/10), Pennsylvania has made clawback payments to the federal government totaling $1.75 billion. 7

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