Part D and LIS Overview

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Part D and LIS Overview

• Marisa Scala-Foley
• Associate Director, ABC

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Agenda

• Overview of the Medicare Prescription Drug
  Benefit (Part D)
• Low-income subsidy
• Application/enrollment process and timeline

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Medicare Prescription Drug Benefit (Part D)

• Begins January 1 2006
• Optional benefit
• Beneficiaries must opt-in
• 1 premium penalty for each month delay enrolling
• Open to anyone enrolled in Part A and/or in Part
  B
• Special assistance for people with low incomes
  and assets
• As of January 1, 2006, dual eligibles receive
  prescription coverage under Part D, instead of
  through Medicaid

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How the benefit works Plans

• Choice between
• Original (fee-for-service) Medicare, with access
  to prescription drug plans (PDPs)
• Medicare Advantage plans (MA-PDs) offering
  medical benefits and prescription coverage
• Change plans once/year during open enrollment
  (November 15-December 31) except for dual
  eligibles
• Country carved up into regions
• 34 PDP regions
• 26 Medicare Advantage regions
• Each region must have at least 2 PDPs OR a PDP
  and a MA-PD plan
• If not, CMS must contract with a fallback plan
  to serve as a PDP in that region

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How the benefit works Beneficiary costs

• Estimated 35-37/month premium
• 250 deductible
• 0-250 (deductible) Beneficiary pays 100 of
  costs
• 251-2250 Medicare pays 75 of drug costs
• 2,250-5,100 (doughnut hole) Beneficiary pays
  100 of costs
• Above 5,100 Medicare pays 95 of drug costs

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Low-income subsidy

• Special assistance for people with low incomes
  and assets
• Covers 85-100 of costs
• Estimated 14 million people eligible for these
  subsidies
• Over 6 million dual eligibles
• 3 groups deemed automatically eligible for the
  full subsidy
• Dual eligibles
• People with Medicare receiving SSI
• People enrolled in Medicare Savings Programs

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Subsidy Categories
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Subsidy Categories (continued)
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For people with low incomes, there is a 2-step
application/enrollment process
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Special issues for dual eligibles under Part D

• Prescription drug coverage will come from private
  plans under Medicare Part D, rather than state
  Medicaid plans beginning January 1, 2006
• Shortened time frame (6 weeks) for making
  decisions and enrolling in a plan
• Will be auto-enrolled in a randomly assigned
  plan, if dont choose a plan during open
  enrollment
• Can change plans at anytime
• Co-payments
• Different appeals process
• Key questions
• Will duals be able to make this transition
  without falling through the cracks?
• Will they be able to get the medications they
  need under Part D plans?

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Key questions for beneficiaries

• Do I enroll?
• In what?
• PDP or MA-PD plan?
• Do I qualify for the low-income subsidy?
• Am I a dual?
• Am I below 100 FPL? 135 FPL? 150 FPL?
• Do I meet the asset test?
• Which plan?
• What will my premiums and cost sharing be?
• Will my drug be covered?

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State work groups

• Each state particularly those with SPAPs has
  a working group discussing issues related to Part
  D
• Examples
• Now is the time to get involved!

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Upcoming Part D training topics

• More about the low-income subsidy
• Special issues for dual eligibles
• Part D SNF residents
• Part D and Medigap
• Part D and retiree health plans
• Plan structure
• Other topics