Medicare Modernization Act, Part D Prescription Drug Benefit

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Medicare Modernization Act, Part DPrescription
Drug Benefit

• Presentation for County Program Administrators
• September 1, 2005

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Part D Provisions General Policy Those At or Above 150 of FPL Between 135 and 150 of FPL Under 135 of FPL Dual-Eligible
Annual Premium 35 per month (20 annually) Sliding Scale None None
Deductible (person pays in full) 250 50 None None
Co-payment 25 for drug costs between 250 and 2,250 100 for drug costs between 2,250 and 5,100 15 for drug costs between 50 and 5,100 2 - 5 co-pays for drug costs up to 5,100 Under 100 FPL 1 - 3 copays for drug costs up to 5,100 Above 100 FPL 2 - 5 co-pays for drug costs up to 5,100 No copays for drug costs over 5,100
Doughnut Hole 2,850 gap in coverage n/a n/a n/a
Catastrophic Coverage for drug costs over 5,100 5 or copays 2-5 Co-pays of 2-5 100 covered 100 covered
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Timeline When It All Happens
Date Action
May 31, 2005 CMS will begin sending mailings to Dual Eligibles and Low-Income subsidy eligible beneficiaries
June 20-30, 2005 CMS mails letters to Dual Eligibles explaining the transition to Part D
July 2005 CMS launches discussion phase of message campaign
July 1, 2005 SSA and State Medicaid offices can begin accepting applications for Low-Income subsidies
October 1, 2005 Approved Part D plans can begin marketing to beneficiaries
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Timeline When It All Happens
October 15, 2005 CMS Web Portal of PDPs and MA-PDs itemizing drug benefits goes live.
Oct 27 Nov 10., 2005 CMS mails auto-enrollment information to Dual Eligibles
November 15, 2005 Enrollment in Part D Drug Plans Begins
January 1, 2006 Medicaid Drug Benefit for Dual Eligible Ends
May 15, 2006 Initial Enrollment Period for Part D Ends
Nov 15 through Dec 31 Annual Coordinated Election Period (beginning in 2007)
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II. Impacts

• On Client
• On County Clinicians
• On County Psychiatrists
• On County Budgets

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Client Impacts

• Client Awareness. Many of county mental health
  clients are isolated and do not have the benefit
  of family members to help them understand and
  navigate this process.
• Coverage of PDP and/or MA-PD plans.
• Formularies. CMS guidance indicates that PDPs and
  MA/PDs must cover all or substantially all
  medications in six pharmaceutical classes.
• Step Therapy. PDPs and/or MA-PDs may require the
  use of step therapy prior to authorizing the
  payment of other medications.
• Pharmacies May Not Contract with All PDPs or
  MA/PDs.

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Client Impacts

• Client Co-pays and Deductibles.
• Extra Help Low Income Subsidy May Not Cover All
  the Costs.
• For Medi-Medi clients, the transition period is
  insufficient.
• Co-payments create an undue hardship
• Cost control mechanisms may deny access to
  current medications (e.g. step therapy)
• Bait and switch - plans offer generous,
  inclusive coverage initially and reduce access
  through subsequent plan amendments.
• Coverage that Follows Client with Transitions to
  Other Levels of Care.
• Transitional Levels of Care. There may be
  unintended consequences for transfers to other
  levels of care such as PHFs, IMDs, Jail, Juvenile
  Hall, etc.

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Impact on Clinician

• Increased case management.
• Educating clients
• Cross-referencing plan coverage with psychotropic
  medication needs/prescriptions.
• If client is not full benefit dual eligible, but
  is Medicare eligible, the clinician will need to
  help these individuals complete the Extra Help
  Low Income Subsidy.
• Continuity of Care. Ensuring plan coverage takes
  place during transitions to other levels of care.

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Impact on County Psychiatrists

• Formularies
• Tier 1 is lowest cost sharing
• Subsequent tiers have higher cost sharing in
  ascending order
• CMS will review to identify drug categories that
  may discourage enrollment of certain people with
  Medicare by placing drugs in non-preferred tiers.
• Plan must have exceptions procedures for tiered
  formularies. Psychiatrists will need to know what
  the exceptions procedures are. And, each plan may
  have different exceptions procedures.

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Impact on County Psychiatrists

• TAR Process. Knowledge and understanding of TAR
  process and which drugs will fall under the TAR.
• Medication Coverage
• Six classes (including antidepressants and
  antipsychotics). CMS guidance indicates PDPs and
  MA-PDs are required to cover all or
  substantially all medications.
• Other health conditions may actually define
  consumer choice of PDPs or MA-PDs.
• Knowledge of plan benefits and drug coverage.

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Impact on County Mental Health

• Increase in staff time for case management, both
  at the front end (enrollment) and through the
  Appeals Process.
• Increase in staff time for administrative
  functions and problem resolution, including
  fiscal administration, navigating CMS system, and
  complaint/resolution process.
• Increase in ER visits due to loss of eligibility
  and/or difficulty in navigating.
• Depending upon county decisions, resources, and
  feasibility, counties could potentially be in the
  position of having to pick up a share or shares
  of cost.

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III. Coordination with Inter-county agencies

• County Welfare
• Extra Help Low Income Subsidy. What directives
  do county welfare agencies want county mental
  health to follow in terms of enrolling clients in
  the LIS?

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III. Coordination with Inter-county agencies

• County Health Care
• Who should be the lead in ensuring the
  clients PDP/MA-PD plan covers all health
  medication needs and all mental health needs?
• What kind of protocol makes sense?
• What happens when a PCP changes a clients health
  care medication and realizes that the medication
  is not covered under the clients current PDP or
  MA-PD and advocates a change in plan for client?
  How will county mental health know about this
  change and how will it impact psychotropic
  script?

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County Inter-agency

• County Pharmacies
• What role will county pharmacies play?