Medicare Part D

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Medicare Part D      

• Eva Shiffrin
• Fall 2008

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Topics covered

• Introduction to Medicare Part D
• Costs for 2009
• Formulary/ Cost Control
• Enrollment
• Choosing a Plan
• The Low Income Subsidy
• Eligibility
• Enrollment in Low-Cost Plans
• Cost-Sharing
• Late Enrollment Penalties

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Troubleshooting

• Drugs Not Covered
• Enrollment Problems
• Formulary Problems
• Billing Problems
• Coordination of Benefits
• Appeals

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Medicaid vs. Medicare

• need based (SSI or low income/assets)
• Comprehensive coverage
• State and Federal program Apply with county

• based on work history (SSDI, title II)
• not comprehensive coverage
• Federal program Apply with SSA for Medicare A/B

Dual eligible person has Medicare and Medicaid
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What is Part D?

• Part D is Medicares prescription drug program.
• To get this benefit, you have to sign up for a
  prescription drug plan. There are usually about
  60 different plans per year in Wisconsin to
  choose from.
• These plans are private companies that contract
  with Medicare to provide this benefit.
• Medicare requires that all plans follow basic
  cost-sharing structures and include a certain
  level of coverage in their formularies.

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Part D

• In 2009, 53 plans (57 in 2008)
• 16 low cost plans (last year there were also 16
  low cost plans)
• No longer low cost in 2009
• DeanCare Classic
• Humana PDP standard
• Medicare Rx Rewards Value
• Prescription Pathways Bronze Reg 16
• Sterling Rx
• All plans cover Wisconsin residents, statewide
• Plans have three main parts
• Cost
• List of covered drugs Formulary
• Pharmacy Network
• The only way to choose a plan www.medicare.gov

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Part D

• Plans change each year.
• Low-income beneficiaries can qualify for help
  with costs and must choose from a smaller group
  of these WI plans to maximize savings.
• Most of the WI plans are national plans that a
  beneficiary can use in another state.
• Premiums in 2009 range
• from 13.70 to 102.70,
• average of 47.13

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Part D types

• Stand alone prescription drug plans
• Prescription drug coverage included as a part of
  a Medicare Advantage plan or a special needs
  plan.
• The basic concepts of cost-sharing are the same
  whether the plan is a Part D plan or within a
  Medicare Advantage plan.

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Medicare Part D costs- Medicare-only- People
with Extra Help

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Basic Principles of D Cost-Sharing

• Premium
• Deductible
• Initial Coverage Period
• Donut Hole or Coverage Gap
• Catastrophic Period
• Total Drug Expenses
• True Out-of-Pocket Expenses
• Co-pays

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Medicare Eligible (No Extra Help)STANDARD
BENEFIT - 2009
Plans can vary from this standard benefit
structure
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Help with Costs the Low-Income Subsidy

• 3 groups of people have LIS
• Full dual eligibles (have both full MA card
  services and Medicare) automatically have full
  extra help.
• MSP (Medicare Savings Program) eligibles have
  full extra help.
• Extra help through Social Security. The SSA has a
  program to help with D costs. You can have full
  or partial extra help under 3.
• Once you have LIS, it lasts until Dec. 31st of
  the calendar year with very few exceptions.

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Full Subsidy 2009
Approx. 6,155 total drug costs
1.10 to 6.00 co-pays
100 Coverage

• No premium in low-cost plans
• No deductible
• No cap on co-pays
• If beneficiary is institutionalized, no co-pays
  apply.

• Full subsidy individuals include
• Individuals with both Medicare and Medicaid
• Individuals with full extra help from Social
  Security
• Individuals in a Medicare Savings Program

co-pay amounts depend on income- 1.10/3.60 or
2.40/6.00
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Partial Extra Help 2009
Reduced premium (depends on income)
Approx. 6,155 total drug costs
60 deductible, if any
2.40 to 6.00 co-pays
85 Coverage





Limits are 150 FPL and assets, in 2008 (figures
for 2009 wont be out until February of 2009,
asset limits will rise too ) Single 1,300 per
month 10,490 assets Married 1,750 per month
20,970 assets Limits above are countable
income limits. Regular Social Security income
counting rules apply (20 disregard for unearned
65 disregard and ½ of the remainder for
earned)

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Strategies to get extra help
Medicaid!
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Medicaid programs

• SSI-related
• Medicare Buy-ins (QMB or SLMB)
• MAPP
• BadgerCare
• All these programs qualify a Medicare beneficiary
  for full extra help
• BadgerCare and MAPP have income limits and asset
  limits more generous than the SSA Part D subsidy
  program

See separate handout
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Extra Help through social security

• Must have assets and income below certain
  amounts.
• Full extra help Income at or below 135 of
  poverty
• Income Single 1,170, Couple 1,575
• Assets Single 6,290, Couple 9,440
• SSI income and asset counting rules apply with a
  few exceptions. Also, these asset limits do not
  include an allowable 1,500 per person burial
  allowance.
• Partial Extra Help Income at or below 150 of
  poverty
• Income Single 1,300, Couple 1,750
• Assets Single 10,490, Couple 20,970

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What Part D Plans Cover Drug Lists /
Formularies
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Part D Drugs are

• Retail pharmacy prescription drugs
• Except.
• Medicare Part B drugs Outpatient drugs that
  require durable medical equipment
• Benzodiazepines / Barbiturates
• Off label prescriptions, drugs not approved by
  FDA
• Prescription vitamins, weight control,
  over-the-counter drugs, cosmetic purposes (hair
  loss), erectile dysfunction drugs
• Generally, Medicare Part B or Medicaid will cover
  excluded drugs.
• (Prior authorization may be required)

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Part B vs. Part D

• The same medication can be Part B or D depending
  on circumstances of the patient.
• The following are Part B drugs
• Anti-cancer
• Oral anti-emetics prescribed within 48 hours of
  chemo if full replacement for IV treatment
• Oral anti-cancer
• Immunosuppressants if transplant covered by
  Medicare
• Durable medical equipment supply drugs (DME)
• When used in patients home
• If the DME was covered by Medicare
• Parenteral nutrition for individual with
  non-functioning digestive tract
• Infusion/injectable drugs if administered by a
  physician
• Other Part B covered items
• DME test strips, lancets, ostomy, etc.

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Drug Plan Cost-Controls

• Formulary
• 2. Utilization management techniques
• Prior authorization
• Quantity limits
• Step therapy
• 3. Tiered cost-sharing
• Most plans Tiers 1-4
• Does not generally apply to low income subsidy
  co-payments (1.10/3.20 or
  2.40/6.00)

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Exceptions /Coverage determinations

• Contact the drug plan to request
• Decision
• 72 hours from receiving doctors supporting
  statement
• expedited process 24 hours
• Further appeals available.
• Step 2 Redetermination
• Step 3 Reconsideration
• ALJ or federal court

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Enrollment Periods

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Part D Enrollment

• Medicare-only - Not automatic
• - Must choose and enroll in a plan during an
  enrollment period.
• Dual eligibles/Extra Help - auto-enrollment
• Random assignment to low cost plan.
• Dual eligibles w/ full Medicaid benefits
  enrollment retroactive to 1st day of MC - do not
  expect timeliness.
• For other extra help enrollment effective at
  least two months after 1st entitled to MC or
  extra help eligibility is determined.

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Enrollment Periods

• Three types
• Initial enrollment period (when first eligible
  for Medicare)
• 7 month window
• 3 months before
• The month first eligible (age 65 or 25th SSDI
  payment)
• 3 months after
• Retroactive Medicare
• Month notice received
• 2 months after
• 2. Annual Enrollment period
• Nov 15 Dec 31 every year
• Everyone with Medicare Part D should check their
  plan to see if it still works for them.

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Enrollment in LIS

• If you are on Medicaid or you go onto Medicare
  with a MSP, you will be put into a low cost
  plan.
• This assignment will be random!
• You can decline this enrollment choice.
• You can also choose a new plan. Once you choose a
  plan, you are considered a chooser. This will
  impact your future treatment under the Medicare
  part D program.
• If you already had a Medicare Part D plan and
  then became eligible for LIS, you will stay in
  your old plan (with some premium relief and
  cost-sharing relief) unless you choose a new low
  cost plan.

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What is a low cost plan?

• A low cost plan, sometimes called a benchmark
  plan, is one with a premium that falls below the
  benchmark figure for your state and be a basic
  plan.
• A basic plan is one that meets certain minimum
  criteria for coverage. Not an enhanced plan.
• The benchmark amount in WI in 2009 is 38.15

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What is an SEP?

• In general, a special enrollment period gives you
  the ability to make one election or choice within
  a period of time. For example, some SEPs allow
  you one election choice within a three month
  period. Others allow this choice within a month
  long period, etc.
• Disenrollment is an election
• Enrollment is an election
• Enrolling in a plan automatically disenrolls
• you from your previous plan!

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Special Enrollment Periods

• Low Income Subsidy ongoing 1X/month SEP
• Move in or out of Wisconsin
• Enter/leave long term care facility
• Maintain Creditable coverage or loss of coverage
• Enroll in Part B during annual enrollment
  (JanMar) Part D SEP (April-June)
• Those enrolled in an SPAP have one SEP per
  calendar year (HIRSP, Chronic Renal Disease and
  Cystic Fibrosis Program, Hemophilia Home Care,
  SeniorCare if gt200 FPL or levels 23, HIRSP)
• Plan terminated
• Other SEPs coordinate with Medicare Advantage
  (Part C) enrollment periods
• Loss of LIS at end of year enrollment period
  between January 1 March 31st
• Others on case-by-case basis

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Plan transitions 2008-2009
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2008 2009 Transition

• Different set of plans available every year.
• Plans change their list of covered drugs and cost
  structure.
• Plans can add prior authorization requirements or
  quantity limits.
• Plans can change drug tiers for particular drugs.
• List of low-cost plans is different.
• Even if you are happy w/ 2008 plan you still
  should evaluate whether it will work for you in
  2009.

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Plan Transition 2008-2009

• Every Part D and Medicare Advantage plan member
  gets an Annual Notice of Change letter
  (explaining changes to a plans benefits and
  costs for 2008) by October 31
• Explains changes from 2008 to 2009
• Remember a plan could have same name but
  different costs, formulary, rules

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Medicare Only AEP

• Can start looking at formulary finder now.
• You can sign up for a new PD plan from Nov.
  15-Dec. 31.
• The new plan is effective January 1st.
• If you have a MAPD, you can switch to another
  MAPD.
• If you have a MAPD, you can go to an MA and a
  stand alone PD
• If you have an MAPD, you can go back to original
  Medicare and a stand alone prescription drug
  benefit.
• There are other enrollment periods as well.

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2008 2009 Transition for People with LIS

• Many people who have LIS will automatically be
  eligible for LIS the following year.
• Dual eligibles and MSPs CMS looks at Medicaid
  data from states SSA in July/ August and uses
  that data to determine who it thinks will remain
  eligible for MA in 2009 it will re-deem those
  people for LIS in 2009. These folks will not get
  a letter telling them that they will still be
  eligible in 2009.
• Those not re-deemed will get a gray letter from
  CMS stating that the individual will LIS in 2009
  and will be given a form to fill out to apply for
  extra help.
• Cont. on next slide

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2008 2009 Transition for People with LIS

• Those who lost eligibility and were not on the
  files in July/ August, but regain MA/MSP before
  the end of 2008 should receive the LIS for 2009
  and will be informed of this status on a purple
  letter.
• This means that those who receive MA, even for
  one month, after the July/August window, will be
  deemed eligible for the subsidy the following
  year.

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2008 2009 Transition for People with LIS

• For those with extra help through social
  security
• Social security periodically checks some of its
  extra help beneficiaries to determine whether
  they remain eligible.
• This year, approximately 250,000 people
  nationwide were sent a letter and forms asking
  them to re-verify that they remain eligible for
  extra help.
• If you did not get this letter, you will get
  extra help in 2009.
• It is very important to fill out these forms.
  Doing nothing will result in the loss of extra
  help.

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2008 2009 Transition for People with LIS

• A beneficiary auto-enrolled into a plan in 2008
  that is no longer a low-cost plan in 2009 will
  get a letter stating that s/he was autoenrolled
  (randomly) in a new low-cost plan for 2009.
• LIS beneficiaries who chose a plan in 2008 that
  is not a low-cost plan in 2009 will stay in that
  plan and have premiums in 2009 if they do nothing.

Both of these groups of people should decide what
plan they want to be in for 2009.
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Plan Selection
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Plan Selection

• The only way to effectively choose a plan for
  most people is by using the computer.
• 1-800-medicare will help people over the phone.
• You can also use the plan finder and formulary
  finder on Medicare.gov to help individuals
  identify plan options.

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Formulary Finder
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Other insurance Part D
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Coordination of Benefits

• Medicaid Part D coordinate well.
• Part D coordinates well with HIRSP. If you have
  HIRSP, you are required to take the HIRSP
  Medicare supplement plan, Plan 2.
• Part D does coordinate with SeniorCare mostly.
• Part D can coordinate with private insurance.

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I have Medical Assistance. Do I have to take Part
D?

• In Wisconsin, if you have Medical Assistance and
  dont sign up for Part D, MA will no longer
  include drug coverage.
• Because you have MA, when you sign up for a Part
  D plan, you will maximize your Medicare
  prescription drug savings because you will be
  eligible for LIS.
• Further, those drugs excluded by law from
  coverage under Part D but covered by MA will
  continue to be covered by MA once you sign up for
  a Part D plan.

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SeniorCare

• SeniorCare works as an alternative to Part D
  (creditable coverage)
• SeniorCare coordinates with Part D
• SeniorCare does NOT coordinate with Medicaid
• This means a person on SeniorCare who becomes
  eligible for Medicaid needs a Part D plan to
  cover their drugs. Ideally, this plan should be
  selected at least the month before the person
  goes onto to Medicaid.

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Senior Care Coordination of Benefits

• Medicare Part D and SeniorCare coordinate.
• Claim submitted to Part D plan first.
• Any remaining charges are submitted to
  SeniorCare.
• SeniorCare can provide some coverage during the
  coverage gap or donut hole.

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HIRSP

• HIRSP (Health Insurance Risk Sharing Plan)
• See www.hirsp.org for more info on HIRSP
• If you have Medicare and HIRSP, you are required
  to take the HIRSP Medicare Supplement Policy
  (this is not the same as a Medigap Supplement
  policy).
• HIRSP and Medicare Part D are designed to
  coordinate.
• Before making a decision to alter your current
  arrangements to take HIRSP, please contact HIRSP.
  It has enrollment periods and pre-existing
  coverage exclusions that you will want to factor
  into any decision-making re HIRSP.

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I have other drug coverage. Do I need Part D?

• If you have other creditable coverage for
  prescriptions, you can decline D with no risk of
  a penalty later.
• You can get a certificate of creditable coverage
  from your employer each year to prove that the
  coverage you have is creditable.
• SeniorCare is creditable coverage.
• Careful!!! Rules are very different for
  Medicare Part B coverage. Part B enrollment
  penalty depends on coverage tied to current
  employment not creditable coverage.

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Private Prescription Insurance and/or COBRA

• Typically do not coordinate well with Part D
  (have one or the other)
• Typically are creditable coverage (works as an
  alternative to Part D)
• Must find out from insurer (get in writing)
• Careful!!! Rules are very different for
  Medicare Part B coverage. Part B enrollment
  penalty depends on coverage tied to current
  employment not creditable coverage

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Part Ds late enrollment penalty

• similar to Part B but not the same

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Late Penalties

• If you decline Part D, you may have a penalty
  when you sign up later.
• People who are LIS or who become LIS eligible
  will not have a penalty.
• The penalty increases annually.

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When is a Part D Penalty assessed?

• If it has been 63 days or longer since either
  the individuals initial enrollment period ended,
  or since the individual was last enrolled in a
  Part D plan, and the individual
• Was eligible for Part D,
• Not enrolled in Part D,
• Not enrolled in creditable coverage, and
• No exception to the penalty applies

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The last day of an individuals initial
enrollment period (IEP) will be

• May 15, 2006 if eligible for MC Jan 2006 or
  earlier
• 3 months after first month of MC eligibility
• If Medicare was awarded retroactively, 2 months
  after the month the Medicare beneficiary receives
  notice of retroactive Medicare
• 3 months after the month beneficiary becomes age
  65 (if eligible for Medicare before age 65) or
• 3 months after the month the enrollee moved out
  of incarceration or moved into the US after
  living abroad.

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Exceptions to the penalty

• Awarded extra help (whether due to Medicaid
  entitlement or approval by SSA) through the end
  of 2008
• Katrina Evacuees if qualified for FEMA assistance
  and enrolled in Part D before Dec 31, 2006.
• Otherwise as determined by CMS.

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Determining the penalty
Time between last day of IEP and Part D
enrollment or time since last Part D enrollment
lt 63 days
gt 63 days
No penalty
Creditable coverage to fill in gap in Part
D Coverage?
YES
NO
Exception to penalty?
YES
NO
Penalty applies full calendar months btw
IEP/last D enrollment and current Part D
enrollment

(
) X
)
(
national base beneficiary premium
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Appeals Process

• Step one Coverage determination LEP notice
• Step two
• 60 days to request reconsideration (form supplied
  w/ LEP notice)
• Decided by IRE Maximus Decisions of IRE are
  final and not subject to appeal
• Good cause extension available

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Reminder

• Part D penalty is different from Part B Penalty.
• Part B penalty does not factor creditable
  coverage but insurance coverage tied to active
  employment instead.

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Marketing

• CMS recently released new marketing guidelines
  due to widespread reports of fraudulent and
  misleading marketing practices.
• These practices often caused beneficiaries to
  join plans that werent right for them.
• Marketing occurs whenever a beneficiary is
  encouraged to join a specific plan or is steered
  toward one of several plans offered by a company.

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Marketing is regulated in terms of

• Unsolicited marketing contacts
• Scope of sales appointments
• Nominal gifts limitation
• Meals prohibition
• Marketing limitations in health care settings
• Co-branding limitations
• Agent/broker requirements
• Training and testing
• State appointment rules
• Reporting terminated agents/brokers
• Agent/broker compensation limitations

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Marketing Violations

• Misrepresenting benefits available under a plan
• Providing meals as part of marketing activities
• Telemarketing, door-to-door solicitation or other
  cold calling
• Cross-selling non-health related products during
  marketing or sales of Medicare plans
• Selling, marketing, or accepting applications in
  locations where health care is delivered
• Selling, marketing, or accepting applications at
  an educational event
• SEPs may be available for beneficiaries enrolled
  through marketing violations.

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• Troubleshooting

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Drug not Covered

• If it is a Part D drug, but is not on your
  formulary, try to use a transition policy, then
  ask for a coverage determination.
• If it is a Part D drug and on your formulary, but
  denied because it is an off-label use, these are
  never successful, except for anti-cancer drugs.
• If it is a Part D drug, but it exceeds the
  quantity limit or requires PA, ask for an
  emergency fill under the transition policy and
  ask for a coverage determination.
• If it is not a Part D drug, see if
• Covered by Forward Card?
• Is there a therapeutically appropriate
  alternative?
• Is there a prescription assistance program?
• If you are LIS, you can always change plans,
  effective the month after the month you enroll.

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Exceptions /Coverage Determinations

• Contact the drug plan to request
• Decision
• 72 hours from receiving doctors supporting
  statement
• expedited process 24 hours
• Further appeals available.
• Step 2 Redetermination
• Step 3 Reconsideration
• ALJ or federal court

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Coverage Gaps

• Occur because of the lag when the individual gets
  LIS and when it is updated in Medicare and/or the
  plans computer.
• Occur because the effective date for an
  individuals LIS or Medicare Part D is wrong.
• Occur because an individual doesnt know about
  prior authorization requirements, formulary
  restrictions, or formulary changes.
• Occur because an individual with LIS is being
  assessed a higher cost-share s/he cant afford.

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Tools to resolve coverage gaps

• Coverage Determination
• Transition Policies
• Formulary change protections
• B v. D issue
• Wellpoint
• Best Available Evidence
• Regional Office

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Transition Policies

• Each plan is required to have a transition policy
  that
• Provides a 30-day fill for individuals new to a
  plan who didnt know about plan restrictions of
  non-formulary Part D drugs or who need the fill
  in order to comply with PA requirements.
• This policy should be in effect for individuals
  90 days into the plan year or 90 days after
  enrollment.

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Formulary Changes

• Plan changes formulary during the year
• It can immediately stop refilling if the change
  is change is for a safety reason.
• If change is for maintenance reason (generic
  substitution, e.g.), it must provide a 60-day
  notice, and if no notice is provided, a 60-day
  supply.
• If the change is for any other reason, the plan
  must fill the medication for the rest of the plan
  year.

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Resolving Part B v. Part D Issues

• Try billing both and see what works.
• Determine which you think it is and ask for an
  expedited coverage determination.
• Contact one of the helplines.
• These can be complex.

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Point-of-Sale Facilitated Enrollment

• Works when Medicare recognizes the individual as
  dual and individual is not enrolled in a plan.
• Wellpoint (Anthem) is the provider.
• Works for a one month fill while the person
  enrolls in a plan.
• http//www.cms.hhs.gov/Pharmacy/Downloads/POSFEFou
  rSteps041808.pdf
• Doesnt always work.

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Best Available Evidence

• If a person is enrolled in a plan, but the plan
  doesnt know that the person is dually eligible,
  the plan is required to take the best available
  evidence that the person receives Medicaid, and
  to structure cost-sharing payment accordingly.
• This could include award letters, emails from ES
  workers, Cares Notice, etc, showing the MA status
  during relevant time.
• The plan is now required to affirmatively
  investigate the individuals status if the
  individual states they have Medical Assistance or
  the low income subsidy.
• Experience on the helplines shows that few of the
  front-line workers know about the best available
  evidence policy you may have to ask for a
  supervisor.

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Resolving Coverage Gaps

• POS Facilitated Enrollment Process
• Finding the right person with the right
  information/ Best Available Evidence
• Transition Policies
• Formulary Change Protections
• Creativity
• Retroactive Enrollment you must demonstrate that
  you have tried other options.
• Complaint Process
• Change plans

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Creativity

• Some individuals can afford a one or two day
  supply while the glitch is worked out and can
  either wait for the reimbursement for the plan or
  ask the pharmacist to rerun the claim and refund
  the difference.
• Id love to hear what else has worked for you!
• Sometimes the pharmacist trusts the patient or
  the DBS/EBS and will fill the medication and run
  the claim after the glitch is resolved.

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Retroactive Enrollment

• Only Medicares regional office can retroactively
  enroll a beneficiary. It can do so at the request
  of a plan or at the request of a beneficiary.
• The regional office only wants to hear from the
  beneficiary or advocate if they have TRIED
  WELLPOINT and it failed AND they are out of
  necessary medications.

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Change plans

• Dont forget that individuals can change plans
  once a month who are LIS.
• Sometimes, this is quicker and easier than other
  methods.

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Billing Problems

• Billing problems are involved and not easily
  solved.
• Premium withholding is difficult and can take
  months to resolve.

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Complaint Process

• Complaints are lodged after coverage
  determinations, transition policies, and other
  mechanisms for resolving coverage gaps have
  failed.
• Complaints can be made to the plan, but if there
  is an emergency, they can also be made directly
  to the regional office.
• Complaints indicating emergency are supposed to
  receive expedited treatment.

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Resources

• Part D and Age 60 and older
• Elderly Benefit Specialists
• Prescription Drug Helpline (CWAG) [phone]
  www.wismedrx.org
• Part D and Under age 60
• Disability Drug Benefit Helpline (DRW)
  [phone]
• Disabilityrightswi.org (click on Part D on the
  left)
• DBSs, HEC, Independent Living Centers
• Medicare Advantage / Medigap
• Medigap Helpline 1(800)242-1060
• http//oci.wi.gov/ for publications

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Part C

• (Medicare Choice Medicare Advantage Medicare
  health plans)
• Approximately 52 private plans
• Eligibility depends on county of residence
• Combines all MC benefits (A D or A - B)
• Opt out of Parts A and B
• Provides same services as A and B but different
  cost sharing may apply
• Large variation in premiums (still pay part B)
• Large variation in coverage

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Part C continued

• Variety of plan types
• HMOs,
• PPOs,
• private fee for service (PFFS) any willing
  provider, may reimburse at a different rate than
  Medicare
• Special Needs Plans (SNP) usually restricted
  dual eligibles or dual eligibles in particular
  nursing homes

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www.medicare.gov Medicare Advantage info

• Go to www.medicare.gov and click on Compare
  Health Plans and Medigap Policies in Your Area
• Search by zip code
• Listed by annual cost estimates - very rough