The New Medicare Prescription Drug Coverage and Extra Help for Those with Limited Incomes

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The New Medicare Prescription Drug Coverage and
Extra Help for Those with Limited Incomes

• Marisa Scala-Foley
• Associate Director, ABC
• Kristen Kiefer
• Research Associate, ABC

2
Agenda

• The Access to Benefits Coalition (ABC)
• Overview of the Medicare Prescription Drug
  Coverage (Part D)
  
• Extra help available (low-income subsidy)
• Key dates for Medicare Prescription Drug Coverage

3
Access to Benefits Coalition (ABC)

• ABC was formed in 2004 to help limited-income
  Medicare beneficiaries lower their prescription
  drug costs
  
• Hundreds of organizations in coalitions
  throughout the U.S. helped tens of thousands of
  Medicare beneficiaries with limited incomes
  enroll in the Transitional Assistance credit (and
  other prescription savings programs) in
  2004-2005
• In addition to ABCs efforts, hundreds of other
  organizations also put resources into
  Transitional Assistance enrollment

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ABC Accomplishments to Date

• Created and supported a nationwide infrastructure
  that is ready, willing and able to turn to
  Medicare Prescription Drug Coverage.
  
• Developed new knowledge about cost-effective
  approaches for identification, outreach,
  education, decision support and enrollment.
  
• Enhanced and created new ABC technology tools to
  make the enrollment process more efficient and
  more likely to close the deal.

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More about ABC technology tools

• BenefitsCheckUpRx is an AoA/CMS-sponsored web
  tool. You can find it on the AoA.gov or
  Medicare.gov home pages, or at www.BenefitsCheckUp
  Rx.org
• It helps consumers and the agencies helping them
  find out which Rx assistance programs they
  qualify for, including
  
• Medicare Prescription Drug Coverage for People
  with Limited Incomes and Resources (Extra
  Help/LIS) Includes link to SSA online
  application form
• Medicare-Approved Prescription Drug Discount
  Cards (through December 2005) Includes online
  enrollment
  
• State Pharmacy Assistance Programs (SPAP)
• Manufacturer-sponsored Prescription Assistance
  Programs (PAP) VA Health Care System
  
• Medicaid
• Medicare Savings Programs
• Supplemental Security Income (SSI)
• Facilitates enrollment into programs by providing
  quick access to over 250 application forms
  eforms, fillable PDFs and for some, online
  enrollment
• And AoA is making a special Organizational
  Edition available to 2,000 members of the aging
  services network
  

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Medicare Prescription Drug Coverage (Part D)

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

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Key Questions for Beneficiaries

• Do I enroll?
• In what?
• Stand alone prescription drug plan (PDP) or
  Medicare Advantage prescription drug plan
  (MA-PD)?
  
• Which plan?
• What will my premiums and cost sharing be?
• Will my drug be covered?
• 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?

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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 32/month premium (vary by region and
  plan)
  
• 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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How the Benefit Works Plan Selection

• Initial enrollment period for Medicare
  prescription drug coverage November 15, 2005
  May 15, 2006
  
• Key considerations when choosing a plan
• Costs
• How much is the monthly premium and will I be
  able to afford this amount?
  
• How much do the drugs I need cost under the
  plan?
  
• Access
• Are the drugs that my doctor has prescribed for
  me covered in the plan?
  
• Is the pharmacy I prefer to use in the plans
  network?
  
• What is the exceptions and appeals process if a
  drug I need is not covered by the Part D plan or
  is removed from the plan after I have enrolled?
  
• What is the exceptions and appeals process if I
  cannot afford the cost- sharing requirements for
  a drug that my doctor says I need?
  
• Centers for Medicare Medicaid Services (CMS)
  will release the Medicare Prescription Drug Plan
  Finder Tool in mid-October
  
• The tool will enable Medicare beneficiaries and
  their caregivers to obtain information on
  Medicare prescription drug plan options available
  to the beneficiary in order to facilitate choice
  and enrollment in a drug plan. 
• Will be available at www.medicare.gov

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Extra Help for those with Limited Means
(Low-income subsidy)

• Special assistance for people with low incomes
  and assets
  
• Covers 85-100 of costs
• Estimated 14.4 million people eligible for these
  subsidies
  
• 7.2 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
FULL SUBSIDY
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Subsidy Categories (continued)
PARTIAL SUBSIDY
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For people with low incomes, there is a 2-step
application/enrollment process
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Low-income Subsidy Application

• Application for Help with Prescription Drug Plan
  Costs
  
• SSA mailed LIS applications to people potentially
  eligible for the LIS between May and August 2005
  
• 2 ways to submit the application
• By mail using SSAs scannable paper form
• Online application via SSA web site (www.ssa.gov
  or www.socialsecurity.gov)
  
• SSAs paper form is available in both English and
  Spanish online application in English only
  
• Forms translated into 14 different languages for
  side-by-side comparisons to use with clients
  
• BUT, forms must be submitted in English
• If beneficiaries or the people who assist them
  have questions about the application, they can
  call SSA at 1-800-772-1213
  
• If a paper application is incomplete, SSA will
  follow-up via telephone with clients
  
• Online forms can only be submitted if all
  questions are completely answered

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TO VIEW A SAMPLE OF THE APPLICATION, VISIT
http//www.ssa.gov/organizations/medicareoutreach2
/Medicare20App20Form_1020_INST2.pdf
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Medicare Prescription Drug Coverage Key Dates

• July 2005 SSA and state Medicaid agencies began
  making eligibility determinations for the extra
  help (low-income subsidy)
  
• October 1, 2005 - Medicare Part D plans can begin
  to advertise to Medicare beneficiaries
  
• Mid-October
• Medicare You handbook sent to beneficiaries
• Medicare Prescription Drug Plan Finder Tool
  becomes available at www.medicare.gov
  
• November 15, 2005 Open enrollment for plan
  selection begins
  
• December 31, 2005 Last day of Medicaid
  prescription drug coverage for full dual
  eligibles
  
• January 1, 2006 Medicare Prescription Drug
  Coverage begins
  

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For More Information

• Marisa Scala-Foley, Associate Director, ABC
• [phone] or marisa.scala-foley_at_ncoa.org
• Kristen Kiefer, Research Associate, ABC
• [phone] or kristen.kiefer_at_ncoa.org
• www.accesstobenefits.org