Medicare

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Medicares New Prescription Drug Program

• Mike Klug, J.D.
• Program Consultant
• Univ. of Iowa Center on Aging

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Goals

• Provide background on the new Medicare program
• Identify key factors in making enrollment and
  plan selection decisions
• Identify information resources

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Background Medicare Part D

• Open to all people with Medicare Parts A and/or B
  
• People with Medicare and Medicaid and/or
  Supplemental Security Income (SSI) will be
  enrolled automatically
• Low income individuals will qualify for extra
  help
• Social Security sent applications

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Background Medicare Part D

• Do seniors plan to enroll in a drug plan?
• 43 percent dont yet know
• 37 percent do not plan to enroll
• 20 percent plan to enroll
• Kaiser Family Foundation Survey, November 10,
  2005
• About 50 percent plan to enroll
• Wall Street Journal, November 2005

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Key Factors in Making Decisions

• Extra Help Program
• Current Insurance Coverage for Drugs
• Enrolling in a Medicare Drug Plan
• Selecting a Medicare Drug Plan

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Extra Help Program

• For those with limited financial means
• Monthly Income up to 1,196 (1) 1,604 (2)
• Assets up to 10,000 (1) 20,000 (2)
• Helps with premiums, deductibles, co-payments or
  coinsurance
• Social Security accepts applications
• www.ssa.gov

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Extra Help Program

• Covers dual eligibles
• People with Medicaid, SSI, or Medicare Savings
  Programs (QMB, SLMB, QI)
• Covers others with limited means
• No premiums, low co-payments for people with
  Medicaid
• Lower premiums and co-payments for others

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Current Insurance Coverage?

• Retiree plans
• VA benefits or TRICARE-for-Life
• Medicare Supplement Insurance
• Medicare Advantage (MA) plans
• Medicaid
• Drug coverage ends for dual eligible people on
  December 31, 2005

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Approved Part D Drug Plans

• Medicare approved drug plans must provide
• Coverage equal to the standard benefit, or extra
  coverage to enhance it
• Access to medically necessary drugs
• Formulary standards for drug selection
• Access to convenient retail pharmacies
• Drugs to nursing homes
• Medication Therapy Management

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Medicare Part D Standard Benefit

• Covers brand name and generic drugs
• Annual deductible of 250
• Covers 75 of next 2,000 in drug costs (up to
  2,250 in total drug costs)
• No coverage of the next 2,850 in drug costs
  until out-of-pocket costs reach 3,600
• Catastrophic benefit Medicare pays 95 after
  drug costs reach 5,100
• Average monthly premium estimated at 32

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Medicare Part D Standard Benefit Drug Plan
You could pay 5 of anything over 5,100 in
drug costs ___3600 out of pocket__ The next
2850 The next 500 The first 250
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Covered Drugs

• Cancer medications
• Antidepressants
• Antipsychotics
• Anticonvulsive treatments for epilepsy and other
  conditions
• Immunosuppressants
• HIV/AIDS treatments

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Excluded Drugs

• Benzodiazepines, i.e. minor tranquilizers
• Barbiturates
• Drugs for weight loss or gain
• Drugs for relief of colds
• Over-the-counter drugs
• They may be provided at no cost
• Drugs covered by Medicare Part B

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Enroll in a Drug Plan?

• People without prescription drug coverage
• People whose coverage is less than equivalent to
  Medicares standard plan
• The issue of creditable coverage
• Penalties for late enrollment

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Enroll in a Drug Plan?

• Initial Enrollment Period November 15, 2005 to
  May 15, 2006
• Coverage Starts January 1, 2006
• Next Enrollment Period November 15, 2006 to
  December 31, 2006
• Auto-enrollment for Medicaid patients

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Penalty for Delay

• For those without creditable coverage
• Next open enrollment period (Nov.15 Dec. 31,
  2006)
• Coverage effective on Jan. 1, 2007
• Premium goes up AT LEAST 1 per month for every
  month delayed
• Premium remains in effect for the entire time the
  benefit is used

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Which Drug Plan to Select?

• Prescription Drug Plans (PDP)
• Stand alone work with Original Medicare
• 41 plans from18 plan sponsors
• Premiums 1.87 to 99.90 per month
• Medicare Advantage Drug Plans (MA-PD)
• Medicare HMOs, Regional PPOs, PFFS plans
• 22 plans from 8 plan sponsors
• Premiums 0 to 53.90 per month

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Which Drug Plan to Select?

• Monthly Premiums
• Annual Deductible
• Medications on Plan Formulary?
• Coinsurance or Co-payment Levels (Tiers)
• Network Pharmacies
• Drug Utilization Management Protocols

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Plans Need Not Cover All Prescribed Medications

• Access to all medically necessary drugs
• At least two drugs in each treatment class
• Review formularies to see if drug plan covers
  your drug(s)
• Medicare drug plans must provide a transition
  period while trying alternatives
• Exceptions may be requested denials appealed

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Iowa Stand-Alone Prescription Drug Plans
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Comparison of 3 Plans
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Comparing Plans Tips

• Make list of medications
• Check the drug plans formulary to make sure your
  drugs are covered
• Check the drug plans pharmacy network
• Compare out-of-pocket costs in light of your
  budget
• Consider cost-benefit of enhancements

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Drug Plan Marketing

• Medicare Drug Plans can market by
• Direct mail
• Phone calls
• TV and radio
• Distributing information at health fairs
• Providing lunch at informational meetings
• Offering incentives/gifts up to 15.00 in value

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Drug Plan Marketing

• Medicare drug plans cannot
• Sell door-to-door, unless invited.
• Ask for personal information during marketing
  activities.
• Ignore the National Do-not-Call Registry.
• Compare one plan to another by name.
• Use the words Medicare Endorsed.

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Resources

• Medicare
• 1-800-MEDICARE
• www.medicare.gov (Drug plan and formulary finder
  tools, fact sheets, QA)
• www.cms.hhs.gov (Outreach and public education
  tools provider and partner ListServs)

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Resources

• Iowa Senior Health Insurance Information Program
  (SHIIP)
• 1-800-351-4664 (statewide)
• www.shiip.state.ia.us
• Free, objective, one-on-one counseling
• University of Iowa Center on Aging
• www.centeronaging.uiowa.edu
• Free Brochure, Educational programs

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Resources

• Iowa Insurance Division Consumer Hotline
• 877-955-1212
• HHS Office of Inspector General (Medicare Fraud
  and Abuse)
• 800-447-8477

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Resources Health CareProviders

• Educate (avoid recommending a plan)
• Make information materials available
• Refer to appropriate information sources
• Key messages
• Dont rush!
• Seek help from family, friends, objective helpers

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Special Thanks

• Lori Benz Center on Aging
• Steve Maravetz Health Sciences Public Relations
• Greg Jensen, Vika Pecherskikh, UIHC Social
  Services Staff
• Jay Currie, Michael Kelly and Julie Urmie
  College of Pharmacy
• Health Assistance Partnership