1 Medicare Part D for Professionals Overview and Updates for 2013 Eva Shiffrin, Ginger Rogers, Nate Vercauteren, October, 2012
2 What is Medicare Part D? Part D is Medicare s prescription drug insurance program. Part D is offered solely through private insurance plans who contract with Medicare to provide the benefit. Medicare only approves the contracts if the plan meets with certain minimum Medicare requirements. Unless a beneficiary receives the Low Income Subsidy (LIS), s/he must proactively enroll in Medicare Part D during certain times (enrollment periods) or risk periods of non-coverage or late enrollment penalties.
3 Part D plan types Beneficiaries can enroll in a plan that offers only Part D. Beneficiaries can enroll in a Medicare Advantage (MA) Plan, sometimes called a Medicare Health Plan, that bundles together Parts A, B, AND D. To get Part D with certain types of MA plans, the beneficiary must get it as a MAPD. Basic concepts of Part D cost sharing are the same in Medicare Part D (PDP) plans or Medicare Advantage plans with Prescription Drug coverage (MAPD).
4 Plan statistics 2013 In 2013 Wisconsin has 30 Medicare Part D plan offerings. Of these, 10 plans have $0 premium for those with the full LIS (low cost plans). The premiums range from $15.00 to $ Of the 31 plans, all but 4 are national plans (you get the same benefit outside of Wisconsin that you do in Wisconsin at network pharmacies).
5 Part D income-based premiums Some individuals with higher incomes have a higher Medicare premium. Only 5% of all Medicare Part D beneficiaries are subject to the premium increase. Click here for more information.
6 Medicare Part D Eligibility A beneficiary is eligible for Part D if: S/he is entitled to Part A and/or Enrolled in Part B and Lives in the service area of the plan.
7 How Med D works Each plan has different premiums, costs, formularies, formulary limits, and pharmacy networks. Each plan can change each year in any of these areas. Beneficiaries can only enroll in these plans during certain enrollment periods.
8 Plan Structure Medicare has a basic plan structure, but also allows for enhanced plan structures or plans that are the actuarial equivalent of the basic plan. Enhanced plans can offer coverage in addition to that required by Medicare Part D. The actuarial equivalent plan allows variation from the plan structure as long as it can demonstrate in a variety of measures that it is statistically the same as the basic plan structure.
9 Part D and Medicare Advantage Part D can be bundled into the MA plans with Parts A & B. Part D works the same way within a MA Plan as it does as a stand alone. The beneficiary can always check to see if some MA plans have lower Med D costs than PDPs, but of course, that should not be the sole factor in plan selection. Certain types of MA plans require that a beneficiary get drug coverage through that plan if s/he wants drug coverage.
10 Plan Formularies Medicare covers most retail prescription drugs. Excluded drugs include, but are not limited to: drugs covered by Part B; over the counter (OTC) drugs; prescription vitamins; and drugs when not used for a medically acceptable indication. Medicare Part B or Medical Assistance may cover some drugs excluded by law from Part D.
11 Part B drugs Click here to learn more about drugs covered by Part B The most common Part B drugs are: Infused drugs & drugs that go in a nebulizer Drugs injected by a medical provider if of the type normally injected by a medical provider Immunosuppressive drugs if Medicare paid for transplant and in a few other circumstances Oral anti-cancer drugs in most instances
12 Benzodiazepines and Barbiturates The exclusion of coverage for Benzodiazepines and Barbiturates is lifted starting 1/1/2013. Their coverage is still subject to other rules, such as medically acceptable indications. Medically acceptable indications for these drugs include: epilepsy, cancer pain, and treatment of chronic mental illness.
13 Formulary Restrictions Plans can impose three kinds of formulary restrictions Prior Authorization (PA) Step Therapy (ST) Quantity Limits (QL) (now on planfinder)
14 Medicare Part D costs Medicare Only: Standard Benefit Deductible can be no more than $325 Initial coverage limit $2,970 OOP threshold $4,750 Catastrophic cost sharing $2.65(G) $6.60(B)
15 Medicare Part D costs: a timeline Standard Benefit D Initial Coverage Period Costs either 75% plan/ 25% member or by statistically equivalent tier structure. Coverage Gap Costs to member=47.5% of brand name drugs + 79% of generic drugs. Catastrophic Period Co-pays: Brand Name: $6.60 Generics: $2.65 From January 1, 2013 (or at start date for those who begin Med D after January 2, 2013)
16 Closing Coverage Gap 2011 & 2012: drug manufacturer discounts of 50% of total drug cost. 2012: 14% federal subsidy for generics in addition to brand savings. 2013: federal subsidy for brands reduces beneficiary cost to 47% of total drug cost and generic federal subsidy increases to 21%. Each year until 2020, the federal subsidies will increase until the maximum beneficiary cost is 25% for both brands and generics. *Beneficiaries also received federal subsidy of small amount this year.
17 Year Costs for Brand Name Drugs in the Coverage Gap Costs for Generic Drugs in the Coverage Gap % 86% % 79% % 72% % 65% % 58% % 51% % 44% % 37% % 25% Note: Dispensing fees are not discounted. 04/02/
18 Medicare.gov resources Closing the Coverage Gap Medicare Prescription Drugs Are Becoming More Affordable Your Guide to Medicare Prescription Drug Coverage
19 New rule for long term care residents Also, starting on 1/1/2013, beneficiaries in long term care facilities receiving brand name drugs will be dispensed in 14 day increments or less, although they can t be charged cost sharing in excess of the normal 30 day fill cycle.
20 Brand Name discounts The 50% manufacturer s discount will be treated as if it were paid by the beneficiary for purposes of calculating TROOP (won t delay end of the coverage gap). Discounts taken when the beneficiary is at the pharmacy. No rebates or paperwork required. Applies to portions of straddle claims that fall within donut hole.
21 The Low Income Subsidy Medicare Part D costs are subsidized meaning costs are significantly lower- for three groups of individuals: Those with full benefit Medical Assistance (Medical Assistance is often called Medicaid or Title 19). Those with a Medicare Savings Program (MSP) Those who apply for and receive extra help through Social Security.
22 Full Benefit Medical Assistance Receive full subsidy A list of full benefit Medical Assistance can be found at section 21.2 here It includes but is not limited to: Elderly Blind and Disabled Medicaid including Medical Assistance Purchase Plan. Badger Care Plus for families with children. SSI-related Medical Assistance Home and Community based long term care programs.
23 Medicare Savings Programs Medicaid programs that pay for certain Medicare costs. Gives full subsidy for Med D. Information about these programs, including how to apply, can be found here. Includes QMB (100%FPL), SLMB(120%FPL), or SLMB+(135%FPL) Asset limits are $6,940 for an individual and $10,410 for a couple for QMB, SLMB, & SLMB+ as of the date of this training. These asset limits and the FPLs change annually.
24 Extra Help through Social Security Can be full or partial Information, including information about applying, can be found here. Full extra help is for those with incomes up to 135% of FPL, and those with limited assets. Asset limits as of 9/27/2012 are $6,940 for individual and $10,410 (these figures do not include a $1,500 per person burial exclusion). These asset limits change annually. Asset rules more favorable to beneficiary than with Medical Assistance or MSP.
25 Benefits of full low income subsidy No premiums in 10 of the 30 WI plans. Sometimes called low cost plans or benchmark plans. Lower premiums in the other plans. No coverage gap. Low copays No deductible. No copays when total drug costs reach catastrophic level. Once the beneficiary receive the subsidy, s/he has it for the remainder of the calendar year with very few exceptions.
26 Low Cost Plans in WI for 2013 AARP Medicare Rx Saver Plus Aetna CVS/Pharmacy Prescription Drug Plan Cigna Medicare Rx Plan One Envision Rx Plus Silver First Health Part D Premier Humana Wal-Mart Preferred Rx Plan Reader s Digest Value Rx Plan SilverScript Basic Smart Rx Saver United American-Select
27 Medicare Part D LIS costs: a timeline Initial Coverage Period Co-Pays: Institutionalized: $0 HCBWS: $0 Either $1.15 generics & $3.50 brands or $2.65 generics & $6.60 brands. Catastrophic Period Co-pays: Brand Name: $0 Generics: $0 From January 1, 2013 (or at start date for those who begin Med D after January 2, 2013)
28 How to find out the LIS status of a beneficiary? Use a personalized search on the planfinder at Call Medicare. Ask for notices from Social Security and/or Medicare/ Centers for Medicare and Medicaid Services (CMS). Keep in mind that a person might be entitled to the LIS, but CMS may not indicate LIS status in their system. It is always a good idea to confirm with Medicare the LIS status of the beneficiary.
29 $0 Copays for HCBWS recipients Starting on January 1, 2012, HCBWS recipients (Family Care and classic waivers) were to be charged $0 copays for drugs, similar to institutionalized individuals. We are still seeing many problems with this. If you see a problem either an individual who is charged co-pays OR an individual not reimbursed back to January 1, 2012 for copays already incurred, please call a helpline.
30 Medicare Part D partial LIS costs: a timeline D Initial Coverage Period Co-pay no more than 15% for beneficiary Catastrophic Period Co-pays: Brand Name: $2.65 Generics: $6.60 Partial Help has three different levels. This represents the maximum beneficiary liability. From January 1, 2013 (or at start date for those who begin Med D after January 2, 2013)
31 Choosing a Plan Only way practical way choose a plan is to use You must enter the individual s drugs, dosages, and frequency accurately to get the most accurate results. The planfinder gives a list of plans that are the least expensive to the beneficiary based on his/ her drug needs and allows you to sort this information in a variety of ways.
32 Personalized Searches The planfinder allows a beneficiary to enter his/ her actual data when searching for a plan. This is best because it then it creates a retrievable record of the individual s drug list. It also allows the beneficiary to confirm what Medicare knows regarding enrollment status, current enrollment, and future enrollment.
33 Mistakes in Plan Choice Choosing a plan based on a low premium, deductible, gap coverage, low cost generics, or free generics may not be a good strategy. For most individuals, the cost of the drugs themselves is the single biggest factor impacting plan costs over the course of a year. In a few instances, you may want to use the sort options of formulary limitations, premiums cost, etc. to either choose or narrow down plan options.
34 Preferred pharmacies Plans can negotiate different prices with different pharmacies. Plans can negotiate further savings with preferred pharmacies. You MUST choose a pharmacy when you use planfinder. You can choose two. You don t know when you select a pharmacy whether it is preferred for any plans.
35 Preferred Pharmacy issue In pharmacy selection, planfinder offers no information on preferred pharmacies for plans. Last year didn t force a pharmacy selection, allowing planfinder to default to cheapest option for a zip code- often a preferred pharmacy for a particular plan. Now, you must select a plan within the results list to find out whether that plan has a preferred pharmacy network. You can also select the View Drug Benefits Summary tab in drug costs and coverage to find out whether the plan has a preferred pharmacy option and it s cost sharing, although it won t tell you which pharmacies are preferred.
36 Planfinder updates Low performing plans will retain old members, will appear on the planfinder, and can accept new members, but online enrollment will be disabled. We won t get official word on low performing plans until after October 1 st, but you will know them because they will appear on planfinder with the enroll button. Plan data has been decluttered. Drug pricing data with floor and ceiling pricing is more accurate. Current profile now includes effective dates. You can now select mail order or retail for each drug and can select either 30 day refills or 90 day refills for each drug.
37 Help Learning Planfinder Use it! Planfinder tutorial on Medicare.gov, click on Watch Medicare Planfinder Online Demo on this page. Medicare training scenarios click here. GWAAR tip sheet for seniors on using planfinder. Wisconsin specific planfinder training included with these materials.
38 Enrolling in a Plan Online With plan directly At Medicare Through the plan s website Through the mail
39 After enrollment The beneficiary will receive a letter, followed by a card. The beneficiary will receive membership materials and contact information for the plan.
40 Enrollment Periods Initial Enrollment Period Annual Enrollment Period Special Enrollment Periods
41 Initial Enrollment Period When the beneficiary is first eligible for Part D Runs three months before eligibility, the month of eligibility, and three months after. Unless the beneficiary has the LIS, s/he must sign up for Med D during this time, or s/he can only enroll during the annual enrollment period or a special enrollment period. For retroactive Medicare, it runs from the month the beneficiary receives notice of Medicare eligibility and for three months after (it can t go back to date of Medicare eligibility)
42 Annual Enrollment Period (AEP) Sometimes called Open Enrollment Period or Annual Coordinated Enrollment Period. Runs from October 15 to December 7. Everyone with Med D should revisit plan choices during this time of year.
43 Annual Enrollment Period choices Sign up for different PDP Sign up for PDP for first time If current coverage is a Medicare Advantage plan with prescription drug coverage (MAPD), the beneficary can switch to another MAPD. If current coverage is MAPD, s/he can switch to a MA and a PDP (with the right MA plan type, remember) Disenroll from Med D (for example for SeniorCare) Go from MA of any kind to original Medicare and PDP.
44 Special Enrollment Periods Periods of time outside of the other enrollment period when the beneficiary can enroll into a new or different Part D plan. When the beneficiary uses a valid SEP, it automatically disenrolls him/her from the previous plan, there is no need to disenroll!
45 Enrollment effective date Enrollments are effective the first calendar day of the month following the month of enrollment. In initial enrollment period, however, coverage cannot start earlier than actual eligibility date.
46 Notices Medicare beneficiaries receive lots of mailings and notices. A linkable list of these mailings can be found here.
47 Medication Therapy Managment Medication therapy management is designed to ensure that beneficiaries with complex medication needs understand their medications and their usage, possible adverse effects, and drug interactions. Medication Therapy Management has been around since However, starting in 2013, Part D MUST offer an annual comprehensive medication review to all eligible beneficiaries as a part of MTM. You may see more beneficiaries with questions about MTM as a result. Beneficiaries can opt-out. Planfinder will now have information on each plans MTM eligibility criteria.
48 SeniorCare: Beyond 2012 The big question about SeniorCare is whether it will be around after December 31, The answer to that question isn t clear at this time. The funding for the program is set to expire as of that date unless the federal Department of Health and Human Services decides to renew it. The Wisconsin Department of Family Services requested this renewal from HHS on August 31, 2012 and we are currently awaiting HHS s decision. If it is approved, the SC program will be funded through It is not known when HHS s decision will come down, only that it will have to occur at some point prior to December 31. In my opinion it is very likely that the program will be extended. 48
49 SeniorCare SeniorCare is a state-administered prescription drug program available only to Wisconsin residents. There are some people who would benefit from SeniorCare to help with the donut hole or to cover otherwise uncovered drugs. After determining that someone is ineligible for any form of low income subsidy, if the person is a WI resident and 65 or older, s/he may want to consider SeniorCare to reduce costs as a replacement or supplement to Medicare Part D.
50 Basic requirements $30 annual application fee Must be 65 years of age or older No asset test Income test based on gross income of individual or couple. Benefit lasts 12 months, starts month after application, subject to yearly renewals. 50
51 What Kind of Income Counts? As with many other public benefit programs, the level of benefit for Seniorcare depends on income. There are rules regarding what counts as income. If a person applying for SeniorCare is married, keep in mind that the income of both spouses is counted if they are living together, with a few exceptions. 51
52 How Does Gross Annual Income Determine Benefit? SeniorCare will place an applicant in 1 of 4 benefit levels depending on what his or her gross annual income is. 52
53 SeniorCare Level One SeniorCare level 1 participants have no spenddown or deductible and pay $5 and $15 for generic and brand name drugs. Once they pay their $30 annual application/renewal fee they get immediate access to the $5 and $15 copays. Income at or below 160% FPL: $17,872 per individual or $24,208 per couple annually ($1,489/month-$2,017/ month). 53
54 Level 2 SeniorCare level 2a and 2b participants have no spend-down but do have a $500 (2a) and $850 (2b) deductible that must be met during each 12-month benefit period before they can participate at the $5 and $15 co-pay level. During the deductible period, the participant will pay the SeniorCare rate on most covered drugs. The SeniorCare rate is a discounted rate for most covered drugs. 54
55 Level 2a Income Limit Income greater than 160% but less than or equal to 200% of the FPL $17,873 to $22,340 per individual and $24,209 to $30,260 per couple annually ($1,490 to $1,861 per month individual; $2,017 to $2,521 per couple) Annual Out-of-Pocket Expense Requirements and Benefits -$500 deductible per person. -SeniorCare rate applies to cost of drugs until the deductible is met. -After deductible is met, $5 and $15 co-pays. 55
56 Level 2b Income Limit Income greater than 200% but less than or equal to 240% FPL $22,341 to $26,808 per individual and $30,261 to $36,312 per couple annually ($1,862 to $2,234 per month individual; $2,522 to $3,026 per couple) Annual Out-of-Pocket Expense Requirements and Benefits -$850 deductible per person. -SeniorCare rate applies to cost of drugs until the deductible is met. -After deductible is met, $5 and $15 co-pays. 56
57 Level 3 SeniorCare level 3 participants have a spend-down and an $850 deductible that must be met during each 12-month benefit period before they can participate at the $5 and $15 co-pay level. 57
58 What s a Spend-Down? The amount of the spend-down is equal to the difference between a participant s gross annual income and 240% of the current FPL ($26,809/$36,313). Participants in the spenddown phase pay the retail price on covered drugs. After the spend-down is met, each person will have an individual $850 deductible requirement. 58
59 Level 3 Income Limit Greater than $26,809 per individual $36,313 per couple annually. (Income greater than 240%) ($2,235 per individual/$3,026 per couple Annual Out-of-Pocket Expense Requirements and Benefits Pay retail price for drugs equal to the difference between $26,809 per individual or $35,313 per couple. This is called spend-down. -Covered drug costs for spend-down will be tracked automatically. During the spend-down, there is no discount on drug costs. After spend-down is met, meet an $850 deductible per person. -Pay SeniorCare rate for most covered drugs until the $850 deductible is met. --After deductible is met, $5 and $15 co-pays. 59
60 SeniorCare & Part D SeniorCare can either be used all by itself or in conjunction with Part D SC is creditable coverage SC coordinates with Part D (may provide coverage during the coverage gap) SC does not coordinate with Medicaid (cannot be on both) SC works in institutions as long as pharmacy accepts SeniorCare 60
61 Why have SeniorCare & Part D? Depending on a beneficiary s circumstances, it will save them $ SeniorCare can provide coverage in the Part D donut hole SeniorCare can reduce the co-pay of a Part D drug Part D can provide drug coverage while someone is in the SeniorCare deductible or spend-down phase 61
62 SeniorCare/Part D Coordination of Benefits When someone is enrolled in both Part D and SeniorCare, Part D is billed first and SeniorCare second. If a particular drug is covered by both Part D and SeniorCare then Part D will pay its share and, if the resulting Part D co-pay to the beneficiary is greater than $5 or $15, SeniorCare will then pay the difference between the applicable $5 or $15 co-pay and the Part D co-payment amount (assuming the enrollee has no SeniorCare spend-down or deductible--or has already satisfied the spend-down and/or deductible). 62
63 SeniorCare/Part D Coordination of Benefits If the beneficiary s drug is not covered by their Part D plan (either because it is never covered by that plan or they are in their Part D deductible or donut-hole) and is covered by SeniorCare then SeniorCare will cover the cost (again assuming the enrollee has no SeniorCare spend-down or deductible--or has already satisfied the spend-down and/or deductible) and the enrollee will pay the applicable $5 or $15 SeniorCare copay. 63
64 SeniorCare/Part Coordination of Benefits: TROOP Only SeniorCare level 2b and 3 costs paid by SeniorCare count towards TROOP costs for Med D. For levels 1 and 2a, ONLY what the SeniorCare beneficiaries actually paid for drugs counts toward TROOP. 64
65 Medicare Part D Special Enrollment Periods Related to SeniorCare Individuals can use multiple SEPs for Med D to enroll or disenroll in SeniorCare and thus take advantage of SeniorCare during different times in Med D coverage. Useful SEPs include SPAP (only for 2b or 3 SeniorCare plans) and SEP to disenroll from Part D/Advantage Plan to enroll in or maintain other creditable coverage. 65
66 SEPs Are Useful These Special Enrollment Periods are important because they allow beneficiaries to buy (for $30) their way into or out of a Part D plan once during any part of the year when they would otherwise have to wait until the Part D Annual Enrollment Period to do so. 66
67 Enrollment rules, plan transitions, and more
68 General Enrollment rules Those without LIS must enroll at certain prescribed times. If the beneficiary fails to enroll at one of these times, s/he will have to wait, and may have a period of time with no coverage. Beneficiaries with a gap with incoverage may have a late enrollment penalty.
69 General Enrollment Rules Individuals who fail to enroll during initial enrollment period must wait until the annual enrollment period to enroll unless they have a Special Enrollment period. Enrollments during annual enrollment period are effective on 1/1/2013. Enrollments at other times are effective the first calendar day of the month following enrollment in most instances.
70 Special Enrollment Periods (SEPs) Periods outside of initial and annual enrollments when beneficiaries can enroll in Part D. Length of time of the SEP can vary. Usually give one extra opportunity to enroll within a certain period of time. Most allow any type of transition, but some limit enrollment choices.
71 Special Enrollment Period Examples: unrelated to LIS or calendar year transitions Beneficiary moves out of plan service area Certain changes to creditable coverage (drug coverage as good as or better than Medicare s). State Pharmaceutical Assistance Programs (1 extra enrollment choice/ year) includes certain levels of SeniorCare, HIRSP, WI Chronic disease programs. Institutionalized individuals going into or out of institution SEPs to coordinate with certain MA/ Part B enrollment periods. 5-star SEP Etc.
72 5-star SEP One per year, from any plan (including a 5-star plan) into a 5-star plan. Allows beneficiary to enroll into any MA or PDP with 5-star rating. If the beneficiary has an MA and use 5-star to enroll in plan without a PDP, s/he gets a SEP into a PDP (if that MA allows both). If beneficiary uses it to go from MAPD into a PDP, s/he will have original Medicare plus PDP. Starts December 8 of 2012, ends November 30, A good resource on this SEP is from the National Center for Benefits Outreach and Enrollment here. Wisconsin has no stand alone 5-star PDPs, but has several Medicare Advantage 5-star plans. See list of 5-star Medicare Advantage plans.
73 Special Enrollment Period around calendar year transitions Plan non-renewal or termination MA disenrollment coordinating part D SEP
74 Medicare Advantage Disenrollment PDP SEP From 1/1/2013 through 2/14/2013, individuals who disenroll from MA to go into original Medicare get SEP into PDP. Use in January, new plan effective 2/1/2013. Use in February, new plan effective 3/1/2013 Use it by enrolling into PDP (automatically disenrolls the beneficiary from MA) or use it to disenroll from MA, which gives coordinating PDP SEP.
75 2012 Plan non-renewals Each year, some plans don t renew contracts and others are terminated. Individuals in this situation receive a letter informing them of the change and letting them know that they need to choose a new plan for These individuals can use AEP to get into new plan for 2013, but also have SEP lasting from December 7 until end of February. Effective first calendar day of month after the new choice is made.
76 Special Enrollment Periods related to LIS Monthly SEP for all beneficiaries with LIS SEP from January through March for those who lose LIS as of January 1. Takes effect first calendar day of month following new enrollment choice.
77 Enrollment rules for LIS Different enrollment rules apply to those with the LIS.
78 LIS enrollment when first Medicare eligible Individuals are automatically enrolled into a low cost plan automatically. Enrollment effective first day of Medicare eligibility. We see problems with this process.
79 LIS enrollment for individual already in Med D plan. If an individual has a Part D plan in place when s/he becomes eligible for the subsidy, they are called a chooser. Medicare doesn t disrupt plan choices for choosers, so the individual will not be moved to new plan. These individuals will receive a notice that they are eligible for the LIS and a list of plans for which they will pay no premium. These individuals can choose to change plans or can stay with current plan. If the current plan of individual isn t low cost plan, the premium will go down, but they will still have premium liability.
80 LIS enrollment for those already in Part D plan The effective date of the LIS status goes back to the date LIS eligibility first established. The plan should reimburse beneficiary for excess charges (difference in copays/ premiums/ etc.) already paid out since the date of LIS eligibility. This should occur within 45 days.
81 LIS enrollment for individual without Part D plan who gets LIS These individuals are automatically enrolled into a low cost plan. The effective date of the new plan can vary, depending on when Medicare finds out they have the LIS and the type of LIS they are awarded. This should not include individuals in a MA which does not allow concurrent enrollment with a PDP.
82 Autoenrollment Autoenrollment is when Medicare enrolls a LIS beneficiary into a low cost plan. The plan selection is random- it will NOT be based on the drugs the person actually takes. An individual autoenrolled (an autoenrollee) CAN switch plans and will then become a chooser. All autoenrollments are effective on the first day of the second month after CMS identifies beneficiary as LIS. Autoenrollees with Medicaid will get a yellow notice from CMS, either this notice or this notice. Autoenrollees with a subsidy through Social Security or an MSP will get this green notice. LIS individuals in a terminating plan will get reassigned/ autoassigned to a new LIS plan randomly unless they choose a new plan themselves.
83 Problems with autoenrollment Date of autoenrollment can be long after person becomes eligible for the LIS. Wisconsin sends its data only once/ month to CMS.
84 Treatment of full benefit dual eligibles Full benefit dual eligibles are automatically enrolled into the temporary part D plan (LINET, or Humana LINET) as soon as CMS receives the information of dual eligibility. This enrollment will be retroactive to the date of eligibility for full benefit dual eligibility. The beneficiary will receive information about how to receive reimbursements for out of pocket costs incurred in retro period. May have to submit receipts. If not already enrolled in LINET but have evidence of Medicaid, can enroll into LINET immediately. The beneficiary can also choose a plan and it will be effective on the first calendar day of the month following the month of enrollment.
85 All other LIS recipients Can use evidence of current LIS eligibility to immediately enroll into LINET (see later slides). Can choose a plan effective first calendar day following month of enrollment.
86 LIS Notices Beneficiaries with the LIS receive lots of notices. A guide to consumer mailings can be found here. When LIS eligibility first established, beneficiaries receive a notice. If eligibility is through Medical Assistance or MSPs, the beneficiary will receive a purple notice from Medicare informing them of eligibility. If eligible through Social Security, beneficiary will get notice from them.
87 Plan transitions Each year plans can change. Costs, premiums, deductibles, formularies, formulary restrictions, and tiers can change. Some plans go out of business. Some plans buy out other plans. Some plans become low cost plans. Some plans lose low cost plan designation. This is why everybody should check their coverage every year during the AEP.
88 Annual Notice of Change Every Part D and Medicare Advantage Plan member gets an Annual Notice of Change letter explaining the changes to the plans benefits and structure from one year to the next. Must be sent out by September 30. Not specific to the way that changes will impact any particular beneficiary.
89 Plan mapping CMS allows plans to merge or buy out other plans. When a parent company buys another plan or merges two plans, it can ask Medicare to allow members from the old plans to remain in the parent or new plan. Medicare allows these requests when the receiving plan is similar to the old plan. This is called mapping or crosswalking and it can occur even when we might not consider the plans similar. The individual will receive notice of this change through the ANOC.
90 Plan mapping this year Official plan mapping data is unavailable until after October 1, although individuals are already receiving information about plan changes from the plan. We therefore know that CVS Caremark plans are simply being renamed SilverScript plans are absorbing Health Net and Community CCRx Basic plans.
91 Plan mapping SilverScript Basic Community CCRx Basic HealthNet Orange Option 1 CVS Caremark Value SilverScript Plus Community CCRx Choice HealthNet Orange Option 2 CVS Caremark Plus
92 Non-renewals of Medicare Advantage plans These individuals have additional options. These options must be carefully weighed with an understanding of the related Medigap rights. Please attend a MA training to understand these options.
93 Annual notice of change for LIS beneficiaries LIS beneficiaries will get an additional rider each year along with the Annual Notice of change. This notice provides specific information about how the plan changes will impact the beneficiary.
94 Plan transitions: re-deeming If a beneficiary has the LIS in 2012, s/he may automatically receive the LIS in 2013 through redeeming. Wisconsin sends CMS a list of those individuals with Medicaid or a MSP every month. In July, CMS redeems those on the list for the LIS for (remember that any individual on this list already gets the LIS through the end of the calendar year). Those re-deemed will get NO notice of LIS eligibility for 2013, although they should get the LIS rider. No news is good news!
95 Re-deeming cont. Any individual not on that list who currently has the LIS will get a gray letter from CMS in September informing them of the loss of the LIS at the end of the calendar year. This notice is sent with an application for extra help through Social Security. Individuals can also work to establish eligibility again through Medicare or a MSP.
96 Re-Deeming Any beneficiary who receives Medical Assistance or a MSP in any month after July until the end of the calendar year will not only receive the LIS if they don t already have it for 2012, but will also be re-deemed for the subsidy for This is true even if eligibility for Medical Assistance or a MSP is established even for one month from July through December.
97 Plan transitions: LIS and extra help through Social Security Social Security screens its LIS recipients using a computer program. If it believes the beneficiary may not remain eligible, SSA sends a letter in September asking them to fill out an eligibility review form. Failure to fill out this form will result in a loss of LIS for 2013 if the individual doesn t establish eligibility through Medical Assistance, a MSP, or a new Social Security extra help application within the requisite timelines. Again, no news is good news.
98 Plan Transitions: Reassignments Autoenrollees (LIS beneficiaries automatically enrolled into a plan by Medicare) in a 2012 low cost plan that is no longer offered or no longer low cost in 2013 will be automatically enrolled into 2013 low cost plan. The selection of the new plan will be random. Individuals reassigned will receive a blue notice (one of three indicated on the mailing calendar).
99 2012 plans no longer low cost HealthNet Orange Option 1 and Community CCRx Basic are being absorbed into SilverScript Basic, which is a low cost plan, so these individuals should not be reassigned. HealthSpring Presc. Drug Plan-Reg. 16 (no longer low cost). Note: CVS Caremark Value is now called Silverscript Basic.
100 New Low Cost Plans AARP Medicare Rx Saver Reader s Digest Value Rx (new plan to WI, also low cost) Smart Rx Saver (new plan to WI, also low cost)
101 LIS Plan transition: Choosers Any chooser not in a low cost plan will receive this tan notice informing them of their option to join a low cost plan in 2013 and eliminate any premium liability.
102 LIS Plan Transitions: change in copays Individuals who see a change in income that triggers a change in their copay amount will receive this orange letter informing them of the change and its effective date of 1/1/2013.
103 Social Security extra help recipients Many Social Security extra help applicants are eligible for a MSP. To ensure this happens wherever possible, Social Security automatically transfers applicant data to Wisconsin (unless applicant checks an opt-out box). The state automatically sends out a letter asking these individuals to fill out a full Medical Assistance application (this is WI s application for the MSP). Completed applications in response to this letter have an effective date of the date of the transfer of the data from Social Security.
104 Beneficiaries will get a letter from the State Health Insurance (SHIP) program encouraging them to complete the application and providing resources for assistance with the process. Many agencies are going to continue with data sharing agreements allowing them to conduct outreach to these beneficiaries directly. The State of Wisconsin also sends out a letter to beneficiaries informing them of their potential eligibility explaining how to finalize this process. Click here for more information on this process. Click here for a sample letter.
105 If you work with someone who applied for extra help through Social Security but is eligible for a MSP, you don t have to wait for this process. You can go ahead and assist them with the application for Medical Assistance through Access.
106 Plan Selection Considerations for LIS recipients Benzodiazepines are no longer a consideration when selecting a plan! Medicare Part D now covers benzodiazepines and barbiturates starting in These drugs must be used to treat epilepsy, cancer, or chronic mental health problems. Plan selection for full subsidy individuals is driven the availability of drugs on a plan s formulary and after that, choices are narrowed by looking at which of those plans has the fewest restrictions. If no low cost plan covers the drugs, please call a helpline or contact a benefit specialist for assistance with plan choice.
107 Medical Assistance and Part D If the beneficiary wants drug coverage and has Medical Assistance and Medicare, s/he must get it through Medicare Part D. If beneficiary declines Part D, NO drugs will be covered by Part D. If beneficiary takes D, those drugs excluded by law from Medicare Part D but covered by Medicaid WILL BE covered by Medical Assistance (prescribed vitamins and OTCs for example). No cap on copays with Medicare Part D.
108 Solving Med D Problems Exceptions Request/ Coverage Determination / Appeals Grievance Transition Policies Point of Sale Facilitated Enrollment Best Available Evidence
109 Exceptions Request Asks for an exception to the plan s formulary or formulary limitations (QL, PA, ST). Will not allow coverage of drugs excluded by law from Med D program (not for medically acceptable usage under FDA or certain compendia, OTCs, etc.) Can be used to put the drug in a lower tier (less expensive) Coverage denial notices should be provided to the beneficiary at the pharmacy counter. They describe beneficiary rights. Beneficiary needs help from his/her prescriber for most of these. Click here for more information on exceptions and appeals.
110 Exceptions Request In an emergency, beneficiary can ask for an expedited coverage determination. Must make a request for a coverage determination within a certain period of time. The plan must make a decision after the request within a certain period of time. At this level, the plan must respond to the request within 72 hours, or 24 for an expedited request.
111 Appeals If the coverage determination is denied, there are multiple levels of appeal: Redetermination from the Plan Review by an Independent Review Entity Hearing before an Administrative Law Judge Review by the Medicare Appeals Council Judicial Review by a district court. Each level has different time limits within which an appeal must be filed and within which a decision must be made. For information on appeals, click here.
112 Grievance If the beneficiary has a concern about the plan that is not about coverage of a particular medication, s/he may want to file a grievance. Grievances are used to complain about the quality of care received from a plan. Grievances are used when the beneficiary believes the plan isn t following certain policies, such as billing. Medicare can help decide whether a complaint or a grievance is the right choice. Grievances include complaints about the plan s benefits or plan design, the failure to follow appropriate guidelines and timelines, difficulty with customer service, problems with a plan s communications, If in doubt, appeal.
113 Transition Policies Used to receive a one-time fill to allow the beneficiary enough time to obtain appropriate authorizations and/or file a coverage determination. It is at most a 30 day fill, although it can be extended if the beneficiary goes through a coverage determination process. It applies to individuals new to a plan who didn t know about plan restrictions or non-formulary drugs. In effect for individuals 90 days into a new plan year or 90 days after enrollment. Click here for a good resource on the transition policy or check
114 Point of Sale Facilitated Enrollment/ LINET enrollment Puts individuals WITH the LIS but WITHOUT A PART D PLAN into a temporary plan with no restrictions and a broad formulary until enrollment into a plan can be processed. Happens at the pharmacy Humana is the current temporary plan provider. Gives immediate coverage Requires proof of eligibility for LIS
115 POS continued Does NOT require that an E1 query show LIS eligibility Does require the beneficiary to show current LIS eligibility through provision of certain documents or information. Pharmacists are NOT required to attempt LINET enrollment. LINET also handles retroactive periods of Med D eligibility for LIS eligibles. Individuals enrolled into LINET get no card, only a letter.
116 POS/LINET LINET also handles reimbursements for past claims. This coverage is more expansive for full benefit dual eligibles. Four steps for pharmacists document includes the BIN/PCN and instructions for pharmacists. CVS uses condor code instead of BIN: Humana LINET phone: TTY: FAX:
117 Best Available Evidence Used when a person with LIS is in a plan but the plan is treating them as if they don t have the LIS or when the beneficiary is receiving the wrong copays. This is the process to use to help HCBWS recipients who are still being charged copays. The beneficiary must provide proof of LIS eligibility to PLAN (not pharmacist). CARES & Forward health notices, electronic printouts, award notices, etc. Most customer service individuals have no idea what you are talking about and you have to ask for a supervisor. A good document on BAE from CMS can be found here.
118 Other Med D issue areas Late Enrollment Penalties Coordination with other insurance Failure to pay premiums
119 Late Enrollment Penalty If it has been 63 days or longer since the individual s IEP ended or since last enrolled in a Part D plan, and the individual: Was eligible for Part D Not enrolled in Part D Did not have other creditable coverage. No exception to the penalty applies. A penalty will be assessed.
120 Creditable Coverage Generally defined as drug coverage as good as or better than Medicare s. The other insurance is required to provide a certificate of creditable coverage. Remember that creditable coverage does not determine penalties or enrollment periods for Part B.
121 Exceptions to the penalty Awarded extra help Katrina evacuees Otherwise as determined by CMS
122 Calculating the penalty If the beneficiary is subject to a penalty it is calculated by: converting the # of full calendar months between the IEP/ last Med D enrollment and current Part D enrollment into a percentage AND Multiplying it by the national base beneficiary premium, which for 2013 is $31.17.
123 LEP appeals The late enrollment penalty has a separate appeals process. If you get a late enrollment penalty question from a client, feel free to contact a helpline or benefit specialist.
124 Coordination of Med D with other insurance Medicare and Medical Assistance Coordinate well. Part D coordinates well with the HIRSP Medicare Supplement Policy. Part D does coordinate with SeniorCare mostly. Part D can coordinate with other insurance, although this can be more complicated.
125 Med D and coordination with other insurance If the beneficiary is eligible eligible for Part D and other insurance, please make sure s/he understands the following before making any changes. The implications on Medicare: who is primary, who is secondary, how they will coordinate, etc., whether it is creditable coverage for Part D, etc. Implications on the other insurance of taking or declining any part of Medicare, including Part D.
126 Those with other creditable coverage for drugs CAN decline Part D with no risk of a Part D penalty later. Part B CAN be declined without later penalty or consequences in SOME instances, mostly related to employer group health plans related to active employment. The rules on when a beneficiary can decline Part D without consequence and when s/he can decline Part B without consequence are different. Creditable coverage is not a concept for Part B penalties. COBRA is often creditable coverage for Part D, but COBRA does not necessarily avoid a penalty under Part B. For many types of employer or private coverage, once declined, it may not be available again, or may only be available during certain periods. Many private or employer plans have rules about the implications of taking or declining different parts of Medicare.
127 Employer group health plans with Medicare Part D drug subsidies. Employers who provide health benefits to retirees can do so through the provision of a Medicare Part D or MA plan. These employers can choose to extend benefits beyond those provided by the PDP or MA plan. If you work with a beneficiary who has or is eligible for one of these Medicare subsidized retiree plans, beneficiaries need to carefully consider their options before declining the employer s benefit(s).
128 Potential consequences Due to potential negative consequences, CMS tries to block individuals in Employer group health plans with Med D drug subsidies from enrolling in free standing PDPs, but it is still a good idea to be aware of the potential consequences.
129 Potential Consequences cont. Choosing a free standing PDP could trigger disenrollment from the Employer plan entirely The employer plan may cover benefits not covered by Medicare/ Part D. Some retiree plans do not permit reenrollment once disenrolled. May have consequences for family members covered under EGH. On the other hand; Some EGHPs allow drug coverage to be separated from other benefits. with the EGHP, the LIS savings don t apply. Also, some retirees might also be eligible for Medicaid, which could be a better option for some.
130 HIRSP (Health Insurance Risk Sharing Program) The HIRSP Medicare Supplement Plan may be a good option for some individuals who are ineligible for the LIS, but still having trouble with drug costs. For more information on HIRSP, see HIRSP and Medicare Part D coordinate well.
131 Failure to Pay Premiums Failure to pay premiums can result in termination. The plan must provide adequate notices. The plan must provide a grace period of no less than two months. If the beneficiary uses premium withholding to pay for premiums, termination for failure to pay premium is impermissible. After termination, payment of past due premiums does not create an SEP.
132 Reinstatement for good cause for failure to pay premiums. Good cause includes federal government error Prolonged illness, hospitalization, or institutionalization Death or serious illness of spouse or other family member Loss of home by fire, or other exceptional circumstance beyond beneficiary s control.
133 Not good cause Allegation that notice not received due to unreported change of address, vacation, etc. Authorized representative did not pay timely. Lack of understanding of ramifications of not paying premium. Couldn t afford them. Make Good cause reinstatement requests to Medicare.
134 Last Resort Have a problem or issue not mentioned in the powerpoint? Have an issue that didn t resolve the way described in this presentation? Call a Benefit Specialist or a Med D helpline.
135 Pharmaceutical Assistance Programs Clinics, nurses, and doctor s offices often help with this paperwork. These programs are offered by drug manufacturers and others. Each of them has different eligibility criteria. Most require new applications each year. Many preclude Med D beneficiaries, but some allow coverage gap programs. Planfinder includes information on PAP programs.
136 Resources Part D helpline for those age 60 & over: Disability Drug Benefit Helpline for those under 60: Greater Wisconsin Area Agency on Aging Benefit Specialists, for a list click here
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