Get Ready! Get Set! Go! Medicare Part D in Minnesota

Transcription

1 Get Ready! Get Set! Go! Medicare Part D in Minnesota Videoconference Training For State Operated Services January 31, 2006 Kelli Jo Greiner, Minnesota Board on Aging and MN-DHS Continuing Care

2 MMA: Overview Overview -Medicare Changes -Medicare Part D -Exceptions and Appeals -Dual Eligibles (Medicare and Medicaid) -Plan Options in Minnesota -Demo of the Prescription Drug Plan Finder Tool -Help for MN beneficiaries

3 MMA: Overview MMA: Minnesota s Medicare Population 700,000 Medicare beneficiaries in MN Of this number: 610,000 are age 65 and older 90,000 are persons with disabilities (below 65) 7,000 are enrolled in MA-EPD 50% have no drug coverage 120,000 have income below 135% of federal poverty level (FPL) 95,000 are eligible for both Medical Assistance and Medicare (dual eligibles) 8,000 were enrolled in the state s PDP program

4 MMA: Overview The Four Parts of Medicare Part A Hospital SNF Home Health Care Hospice Blood Part B Physician services Outpatient services Lab services Durable Medical Equipment PT, OT, ST Home Health Care Blood

5 MMA: Overview The Four Parts of Medicare Part C Previously known as Medicare + Choice, now Medicare Advantage Part D created by the Medicare Prescription Drug and Modernization Act of 2003 Medicare Prescription Drug Coverage

6 MMA: Overview MMA: More than a drug benefit Biggest change to Medicare in 40 year history Changed Part B premium and deductible formulas Created new Medigap options Created Medicare Advantage Added new preventive care coverage Added Medicare Prescription Drug Benefit (Part D)

7 MMA: New Preventive Care Coverage Welcome to Medicare Physical MMA: Overview IPPE: Initial Preventive Physical Examination Part B deductible applies Once in a lifetime benefit available if enrolled in Part B on or after 1/1/05 Must obtain physical within 6 months of enrolling in Part B

8 MMA: New Preventive Care Coverage Cardiovascular screening blood test Once every 5 years Covered tests include cholesterol, lipoproteins and triglyceride levels MMA: Overview

9 MMA: New Preventive Care Coverage Diabetes Screening Test Tests covered twice per year Individuals at risk of diabetes Covered tests include Fasting blood glucose Post glucose test Challenge tests MMA: Overview

10 Our Region MMA: Part D MT ND MN CA AK OR W A NV ID AZ UT WY HI N M CO SD NE KS OK TX IA M O AR LA WI IL MS IN MI TN AL KY OH GA W V SC PA N Y VA FL NC VT N HMA C T NJ ME R I DE M DC Note: A Medicare Advantage (MA) region is one color. A difference in shading indicates that there are multiple Prescription Drug Plan (PDP) regions nested within the MA region No change indicates that the MA and PDP regions are the same. For example, Wisconsin and Illinois are in one MA region; they are each a separate PDP region. Each territory is its own PDP region.

11 MMA: Overview Medicare Part D Key Points Voluntary BUT Most must opt in to get the benefit Enroll in plan to receive benefit Creditable Coverage Penalty Formularies Available to ALL Medicare beneficiaries Eligibility not based on income or assets

12 MMA: Overview Medicare Part D the Penalty 1% for every month beneficiary did not have creditable coverage 63 consecutive days Begins 5/15/05 1% is NOT added to premium beneficiary pays, but is based on the national Part D premium average. $32.20 in 2006 For people who become eligible for Medical Assistance and did not enroll in Part D will have to pay penalty Capped only for this group at 20% for 5 years

13 Part D Standard Benefit No Subsidy Beneficiary Costs Part D Plan 5% 95% Catastrophic Benefit 100% Drug Costs Over $5,100 $2,251 - $5,100 25% 75% $250 Deductible $251 - $2,250 $0 - $250 Premiums - est. $32.20/mo.

14 Standard Benefit True out of pocket costs (TROOP) Monthly premium does not count Plans do not have to be structured as in previous slide but each beneficiary is required to have $3,600 in TROOP before reaching catastrophic coverage $250 annual deductible $500 (25% of drug costs $251-$2250) Plan pays $1500 $2,850 (100% of drug costs $2251-$5100) Plan pays $0 Reach $3,600 annual TROOP, catastrophic coverage begins Plan pays 95% Beneficiary pays 5% MMA: LIS

15 MMA: LIS Standard Benefit True out of pocket costs (TROOP) Rx drugs purchased outside of U. S. cannot be applied toward TROOP (includes Canada) Non-formulary drugs paid for by beneficiary DO NOT count towards TROOP, unless exception is granted or appeal won

16 MMA: Overview Medicare Part D Key Points Extra Help (Low Income Subsidy-LIS) available to eligible beneficiaries 150% of FPG or less; Assets $10,000/$20,000 Helps pay premiums, coinsurance, deductible Partial LIS (135%-150% of FPG) Reduced premium Reduced deductible Reduced coinsurance Full LIS (134%-less than 100% of FPG) Only pay copays of $1 - $5 per prescription

17 Part D Partial Subsidy (LIS) Lower Premiums Lower Deductible Lower Coinsurance No Doughnut Hole Beneficiary Costs Part D Plan Co- Pays $2/$5 Catastrophic Benefit Drug Costs Over $5,100 15% 85% $50 Deductible Sliding Scale Premiums $51- $5,100 $0 -$50 will vary

18 Part D Full Subsidy (LIS) No Premiums No Deductible No Coinsurance No Doughnut Hole Beneficiary Costs Part D Plan Co-Pays $1/$3 <100% FPL $2/$5 >100% FPL Co-Pays Catastrophic Benefit 100% Plan No copays No premiums No deductibles Drug Costs Over $5,100 $0 - $5,100

19 Current Monthly Federal Poverty Level (FPL) Amounts 100 % FPL 120% FPL 135% FPL 150% FPL 200% FPL $ 798 $958 $1077 $1197 $1596 QMB FULL LIS SLMB Full LIS QI-1 Full LIS Extra Help/LIS Partial LIS Based on a household size of 1 FPL amounts change each July in MN

20 MMA: Overview Medicare Part D MN Specifics Medical Assistance drug coverage for dual eligibles will end 12/31/05 Dual eligibles will get their prescription drug benefit from a Medicare Part D plan $20 monthly Rx copay cap will not apply for duals MN Prescription Drug Program ended 12/31/05

21 MMA: Overview Medicare Part D MN Specifics Full Duals in MN are deemed eligible for Full LIS (no SSA application needed) LIS Benchmark premium of $33.11 Only out of pocket costs will be copays of $1- $5 per prescription as long as enrolled in plan that meets LIS subsidy benchmark premium and is not an enhanced plan If beneficiary wants plan that does not meet LIS benchmark, they must pay the premium difference and other related costs

22 MMA: Overview Medicare Part D MN Specifics 14 Minnesota Benchmark Plans BCBS Medicare BlueRx Option 1 Humana PDP Standard Medco YouRx plan MemberHealth Community Care Rx Basic PacifiCare Saver Plan Penn Life Prescription Pathway Bronze Plan Rx America Advantage Star Rx America Advantage Freedom Silverscript Unicare Medicare Rx Rewards United HealthCare United Health Rx United HealthCare AARP Medicare Rx Plan United HealthCare Medicare MedAdvance WellCare Signature

23 MMA: Overview Medicare Part D MN Specifics There are plans in MN that have a premium of less than $33.11 but they do not meet the benchmark because they are enhanced plans These include: Coventry AdvantraRx Value ($21.05) Humana PDP Enhanced ($4.91) Unicare Medicare RX Rewards Plus ($28.56)

24 MMA: Overview Medicare Part D MN Specifics Full Duals in MN are deemed eligible for Full LIS (no SSA application needed) Medical Assistance IS NOT a back up payment source for drugs not on a plan formulary. Medical Assistance will only cover excluded drugs for dual eligibles that were on the MA formulary

25 MMA: Overview Medicare Part D MN Specifics Non formulary drugs Get drug from plan for transitional period. Most plans have a 30 day transition period Request change in medication from physician to a drug on plan formulary Request exception from plan to cover drug for beneficiary If no action, can choose to pay for drug 100% out of pocket. Cost of non formulary drugs does not apply toward $5100 in annual drug costs OR toward TROOP for non LIS

26 MMA: Overview Medicare Part D MN Specifics The following Dual Eligible Enrollees will qualify for Full LIS Elderly Persons with disabilities Employed disabled (MA-EPD) Waiver programs Enrollees with a spend down

27 All Full Subsidy Eligible (Except SNF and ICF/MR residents) Pay copays until the ANNUAL total of their prescription drug costs reaches $5,101 The cap is a total of $5,101 in annual Rx costs, NOT in copays Pharmacists can waive copays, but cannot do it routinely and cannot promote it

28 Why Connect to MSP? Medicare Part B monthly premium in 2006 will be $88.50 ($78.20 in 2005) Medicare Part B annual deductible in 2006 will be $ ($110 in 2005) All MSPs will be eligible for Part D LIS/extra help (up to 135% of FPL) Not all LIS will be eligible for MSP, but many will be (LIS up to 150% of FPL)

29 Covered Drugs Medicare Prescription Drug Coverage Available only by prescription Prescription drugs, biologicals, insulin Medical supplies associated with injection of insulin A PDP or MA-PD may not cover all drugs Brand name and generic drugs will be in each formulary

30 Covered Drugs Excluded Drugs Drugs for Anorexia, weight loss, or weight gain Fertility Cosmetic purposes or hair growth Symptomatic relief of cough and colds Prescription vitamins and mineral products Except prenatal vitamins and fluoride preparations Non-prescription drugs Barbiturates Benzodiazepines

31 Minnesota Medical Assistance Medical Assistance will continue to cover only a few types of drugs for people who have Medicare: Benzodiazapines; Barbituates; Over-the-counter drugs currently covered by MA;

32 Minnesota Medical Assistance Certain drugs used to promote weight gain; Certain prescription and over-thecounter drugs used for symptomatic relief of cough and colds; and Certain over-the-counter and prescription vitamin and mineral products.

33 Covered Drugs Exceptions Process Ensures access to medically necessary Medicare covered prescription drugs Provides process for enrollee to Obtain a covered Medicare prescription drug at a more favorable cost-sharing level Obtain a covered Medicare prescription drug not on the formulary

34 Covered Drugs Exception Requests Enrollees may request an exception if The enrollee is using a drug that has been removed from the formulary A non-formulary drug is prescribed and is medically necessary The cost-sharing status of a drug an enrollee is using changes A drug covered under a more expensive costsharing tier is prescribed because the drug covered under the less expensive cost-sharing tier is medically inappropriate

35 Beneficiary Protections Exception Procedures Adjudication timeframes: A plan must notify an enrollee of its determination no later than 24 or 72 hours as appropriate Failure to meet adjudication timeframes: Forward enrollee s request to IRE Generally, plans are prohibited from requiring additional exceptions requests for refills and from creating a special formulary tier or other cost-sharing requirement applicable only to Medicare covered prescription drugs approved under the exceptions process

36 Covered Drugs 5-Level Appeals Process Redetermination by plan sponsor Reconsideration by Independent Review Entity Review by Administrative Law Judge Review by Medicare Appeals Council Review by Federal District Court

37 MMA: Overview Medicare Part D Key Points How will Minnesotans with Medicare get the benefit? Stand alone Prescription Drug Plans (aka PDP) Local Medicare Advantage HMO plans Regional Medicare Advantage PPO Local Medicare Advantage PFFS Medicare Advantage SNPs

38 MMA: Policy Impacts Minnesota and Part D UPDATE 17 Organizations offering 41 Stand Alone PDP in MN Only provide Part D benefit Each of the 41 plans has its own formulary Each of the 41 plans has its own pharmacy network All 41 plans are available in 7 state region

39 MMA: Policy Impacts Minnesota and Part D UPDATE 1 Organization offering 3 Regional Medicare Advantage Preferred Provider Organization (PPO) Provides Medicare Part A, B and D 3 Organizations offering 6 Local Medicare Advantage HMO Provides Medicare Part A, B and D

40 MMA: Policy Impacts Minnesota and Part D UPDATE 2 Organizations offering 8 Medicare Cost plans with Part D 3 Organizations offering 3 Medicare Advantage Private Fee For Service plans Provides Medicare Part A, B and D 8 Organizations offering 11 Medicare Advantage Special Needs Plans Provides Medical Assistance and Medicare Part A, B and D

41 Where to turn for more information, MMA: Roles and Partners answers and help Subscribe to the MN Medicare Part D listserv Linkage Lines (MA-EPD) Medicare

42 Linkage Line MMA: Roles and Partners Outreach & Education Low Income Subsidy (LIS) application assistance Plan enrollment assistance 400+ volunteers Help available in all 87 counties of MN 7 call centers Extended hours 8:00 am 7:00 pm Monday through Friday 8:00 am 12:00 Saturday

43 MMA: Roles and Partners Linkage Line SHIP State Health Insurance Assistance Program for MN Assists all MN Medicare beneficiaries including ESRD, seniors, people with disabilities

44 MMA: Overview THE DEMO Landscape of Local Plans Prescription Drug Plan Finder Tool Formulary Finder

45 MMA: Roles and Partners Contact Information Kelli Jo Greiner Medicare Part D Coordinator, Minnesota Board on Aging and Minnesota Dept. of Human Services [email protected]