Eligibility and Enrollment in the Medicare Prescription Drug Program

1
Eligibility and Enrollment in the Medicare
Prescription Drug Program

• Danielle Moon, J.D., M.P.A.
• Acting Deputy Director
• Medicare Enrollment and Appeals Group
• Centers for Medicare and Medicaid Services

2
Eligibility for Medicare Prescription Drug
Coverage

• An individual is eligible for Medicare
  prescription drug coverage, provided that he or
  she
• Is entitled to Part A OR enrolled in Part B
• Lives in the service area of a prescription drug
  plan plan

3
Enrollment Options

• Someone who is eligible for Medicare Rx coverage
  can enroll in a
• Prescription Drug Plan (PDP)
• Medicare Advantage Prescription Drug plan (MA-PD
  plan) or
• Retain existing coverage from employer/union
  plan, other federal programs, etc.
• Generally, someone must have Medicare Part A and
  Part B to join a Medicare Advantage Plan.
• There are some exceptions
• Private Fee For Service plans without Rx, MSAs

4
Initial Enrollment Period (IEP)

• Start of the Drug Benefit Program
• Nov 15, 2005 to May 15, 2006 for individuals who
• Are currently Part D eligible, or
• Will become Part D eligible in November,
  December, 2005, and January 2006
• Effective dates for enrollment
• Jan 1, 2006 for an enrollment received before Dec
  31, 2005
• The first day of the calendar month following
  enrollment for an enrollment received between Jan
  1 and May 15, 2006

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Initial Enrollment Period

• Individuals Initial Eligibility
• In general, the initial enrollment period is
  similar to the initial enrollment period for Part
  B.
• This is a 7-month enrollment period
• 3 months before eligibility for Part D,
• the month of eligibility, and
• 3 months after eligibility for Part D
• Effective dates for enrollment
• An enrollment made prior to the month of
  eligibility for Part D is effective the first day
  of the month of eligibility
• An enrollment made during or after the month of
  eligibility for Part D is effective the first day
  of the calendar month following the enrollment

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Initial Enrollment Period Example

• Mrs. Jones is turning 65 on June 26, 2006.
• She is eligible for Medicare on June 1, 2006.
• Mrs. Jones is eligible to enroll in a Part D plan
  beginning on March 1, 2006.
• She can enroll as late as September 30, 2006.
• Her coverage cannot be effective any earlier than
  June 1.

7
Annual Coordinated Election Period (AEP)

• For the 1st year, the AEP is the same as the
  Initial Enrollment Period
• Enrollment is effective
• Jan 1, 2006, if received before Dec 31, 2005
• First day of the calendar month following
  enrollment, if received between Jan 1 and May 15,
  2006
• In 2006 and after, the AEP is from Nov 15 to Dec
  31 of each year
• Enrollment is effective
• Jan 1 of the following calendar year

8
2006 PDP Enrollment Periods
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
DEC
NOV
Initial Enrollment Period (IEP)
Annual Coordinated Election Period (AEP)
AEP
Does not reflect Special Enrollment Periods
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Special Enrollment Periods

• Most people with Medicare will remain enrolled in
  a prescription drug plan for a year.
• Full-benefit dual eligibles have an SEP by law,
  meaning they can change at any time (once/month).
• Beneficiaries with employer/union coverage have
  an SEP to enroll in or disenroll from MA-PD or PDP

10
Enrollment Opportunities

• Each Medicare beneficiary has at least 2 Part D
  enrollment opportunities from November 15, 2005
  through May 15, 2006
• IEP for Part D
• AEP
• Medicare beneficiaries eligible for MA will have
  these two opportunities PLUS a third, through
  June 30, 2006
• IEP for Part D
• AEP
• MA OEP (and coordinating PDP SEP) may apply
• Additionally
• Beneficiaries can cancel enrollment prior to the
  effective date without using an election
• SEPs could apply

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Enrollment Process

• Part D plans must accept paper applications
• CMS has provided model enrollment forms
• May also accept enrollments via secure website
• May also participate in CMS Online Enrollment
  Center
• May also accept enrollments via telephone
• Cannot attempt to enroll on out-bound calls
• Calls must be recorded, records retained
• Cannot ask for financial information during call
• Group enrollment and disenrollment process
  allowed for employer/union groups
• Streamlined process, can be electronic, at plan
  and employer/union option

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Enrollments Received Prior to November 15, 2005

• Plans cannot solicit enrollments prior to Nov 15
  and must remind beneficiaries they cannot submit
  enrollment requests before November 15, 2005
• If any enrollments are received
• Plan must contact beneficiary (via phone or mail)
  to confirm enrollment prior to submitting
  transaction to CMS
• Contact must be documented

13
Special Two-Step Enrollment Process

• Applies to those who enroll and whose employer is
  claiming them for retiree subsidy
• Enrollment edit will check for retiree subsidy
  designation and notify plan
• Plan must send notice advising beneficiary of
  employer coverage and possible consequences
• Model notice provided in guidance
• Enrollment not processed until beneficiary
  responds
• After 30 days, enrollment request denied,
  beneficiary notified accordingly

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Consequences of Late Enrollment

• Beneficiary charged an additional 1 of the base
  premium for every full month a beneficiary
• Was eligible to enroll in Part D plan but not
  enrolled
• Did not have creditable drug coverage (coverage
  on average as good as Medicare) for a period of
  time 63 consecutive days or longer

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Late Enrollment -- Example

• Mrs. Jones does not enroll in a Part D plan
  during her initial enrollment period, which ends
  September 30, 2006.
• Her next chance to enroll will be November 15,
  2006, during the AEP. Coverage is effective Jan
  1, 2007.
• Because Mrs. Jones is without creditable drug
  coverage for 3 full months (October, November,
  and December), she pays a penalty of 3 of the
  base beneficiary premium.

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Low-Income Subsidy Basics

• Provides people with limited income and resources
  extra help with their Medicare prescription drug
  plan costs, including their premiums and cost
  sharing.
• A person must enroll in a Medicare prescription
  drug plan to receive this assistance.
• Beneficiaries can apply via SSA website, field
  office, or toll-free phone number, or State
  Medicaid office

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Low-Income Subsidy Eligibility

• People with limited income and resources (less
  than 11,500/single and 23,000/couple).
• Certain groups are automatically eligible for a
  full subsidy and dont have to apply.
• These groups are
• Full-Benefit Dual Eligible Individuals (People
  with Medicare and full Medicaid benefits)
• SSI recipients (but no Medicaid)
• Medicare Savings Program Groups (QMBs, SLMBs, and
  QIs)

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Amount of Assistance Available

• Full Subsidy (Deemed groups)
• Full premium assistance up to the premium subsidy
  amount.
• Nominal cost sharing up to out-of-pocket
  threshold.
• No coverage gap.
• Other Low-Income Subsidy
• Sliding scale premium assistance.
• Reduced deductible.
• Reduced coinsurance.
• No coverage gap.

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Notice to Those Deemed Eligible

• CMS will notify beneficiaries who are deemed
  eligible for the low-income subsidy and do not
  need to apply.
• This notice will explain the following
• On January 1, 2006, all people with Medicare can
  get Medicare prescription drug coverage.
• Some people will receive letter from SSA telling
  them to apply to get help. You dont need to
  apply for this help.
• The Medicare and You 2006 handbook includes
  information about how to pay for your drug costs
  and what you need to do.
• Medicaid will stop paying for your prescription
  drug coverage after December 31, 2005. (Specific
  to dual eligible notice)

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Auto-Enrollment Procedures

• Full-benefit dual eligible beneficiaries will be
  enrolled based on where they currently get their
  Medicare Part A and/or Part B benefits, and the
  amount of the prescription drug plans premium.
• Beneficiaries in Medicare Advantage plans will be
  enrolled in an MA-PD plan by the MA organization.
• Beneficiaries in Original Medicare will be
  assigned randomly to a PDP in their area with a
  premium at or below the low-income benchmark
  premium amount.
• Beneficiaries will be auto-enrolled regardless of
  employer/union coverage

21
Auto-Enrollment Notification

• CMS will notify full-benefit dual eligibles of
  their auto-enrollment.
• This notice will provide
• An explanation of how to choose a Medicare
  prescription drug plan.
• The name of the Medicare prescription drug plan
  that Medicare will enroll them in if they dont
  choose a plan by 12/31/2005. We will also
  include that plans toll free member services
  number and website.
• A reminder that their Medicaid drug coverage ends
  12/31/2005 they qualify for extra help with
  their drug plan costs and they can change plans
  at anytime.
• An explanation of their right to affirmatively
  decline Part D.
• The 1-800-MEDICARE number for questions.

22
Facilitated Enrollment Procedures and Notification

• CMS will facilitate the enrollment of additional
  categories of beneficiaries if they do not choose
  a plan on their own by the end of the initial
  enrollment period.
• These categories include MSPs, SSI recipients,
  and people who apply and are determined eligible
  for the low-income subsidy.
• Starting in April 2006, we will notify these
  individuals if they do not choose a plan by May
  15, 2006, we will facilitate their enrollment in
  a plan on their behalf, with coverage effective
  June 1, 2006.
• Beneficiaries will not be enrolled if claimed by
  employer for retiree subsidy

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Key Dates for Enrollment

• November 15th Enrollment begins.
• December 31st
• Last day to enroll for a January 1st effective
  date.
• Full-benefit dual eligibles must opt-out of their
  assigned plan by this date or they will be
  auto-enrolled.
• Medicaid drug coverage ends for full-benefit dual
  eligibles.
• January 1st Medicare prescription drug coverage
  begins.

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Key Dates for Enrollment

• February CMS mails a reminder notice to people
  who have not yet enrolled in a plan.
• April CMS mails a notice to people who qualify
  for the low-income subsidy, identifying the plan
  in which Medicare will facilitate their
  enrollment, effective June 1, 2006, if they do
  not choose a plan on their own by May 15, 2006.
• May 15th Initial Enrollment Period ends for
  people who are currently eligible.

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Resources for More Information

• PDP Enrollment and Disenrollment Guidance
• http//www.cms.hhs.gov/pdps/PDP_enrollmentguidanc
  eexhibits_FINAL_8-29-05.pdf
• MA-PD Enrollment and Disenrollment Guidance
• http//www.cms.hhs.gov/healthplans/enrollment/