Medicare Prescription Drug Benefit Impact on Consumers with Medicaid Benefits

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Medicare Prescription Drug Benefit Impact on
Consumers with Medicaid Benefits

• Ohio Department of Job and Family Services
• Office of Ohio Health Plans
• Bureau of Consumer Program Support

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Session Topics

• Medicare vs. Medicaid Whats the Difference?
• What are Dual Eligibles Deemed Eligibles?
• Enrollment for Dual Eligibles and Deemed
  Populations
• What about Medicare beneficiaries with a Medicaid
  Spenddown?
• Extra Help/CDJFS Role
• Questions and Answers

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Medicare vs. Medicaid

• Medicare
• For those 65 and over, those with disabilities or
  ESRD
• Administered by Federal Government
• Same benefits throughout U.S.
• Eligibility not related to financial need

• Medicaid
• For children, pregnant women, families, seniors,
  blind and disabled
• Administered by Federal Government and State
• Differs from State to State
• Eligibility related to financial need

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Dual Eligibles

• In Ohio, there are over 200,000 Medicare
  beneficiaries who also get benefits through
  Medicaid
• Includes Medicare beneficiaries who
• also qualify for full Medicaid benefits or
• are enrolled in a Medicaid Home Community Based
  Waiver (i.e., PASSPORT) or
• are enrolled in Medicaids PACE program
  Cleveland and Cincinnati area only
• Currently get prescription coverage through
  Medicaid

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Medicaid also helps

• Medicare beneficiaries with low-incomes with the
  cost of Medicare Part A B premiums,
  co-insurance and deductibles.
• Also known as QMBs, SLMBs, QI-1s
• No prescription coverage provided to this
  population by Medicaid

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Deemed Eligible

• To assist low-income Medicare beneficiaries, CMS
  will deem certain individuals eligible for the
  extra help with drug costs and enroll them in a
  PDP
• Deemed eligibles will NOT have to complete an
  application
• States work with CMS to process deemed population

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Whos a Deemed Eligible?

• Full-benefit dual eligibles
• Supplemental Security Income (SSI) recipients
• Medicare Savings Program groups, e.g., QMBs,
  SLMBs, QIs

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Not Deemed Population

• Medicare beneficiaries who have limited resources
  and low income
• DO NOT have SSI or Medicaid or a Medicare
  Savings Program
• Must apply for the help with drug plan costs

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Auto-Enrollment

• Full-benefit dual eligibles who do NOT enroll in
  a plan by 12/31/05 will be automatically enrolled
  in a PDP and get the extra help with drug costs
• Will only be responsible for prescription
  co-payments
• Full-benefit dual eligibles can change plans any
  time.
• Their Medicare prescription drug coverage will
  begin 1/1/06
• Medicaid prescription drug coverage for
  full-benefit dual eligibles ends 12/31/05

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Enrollment for QMBs, SLMBs, QI1s and others

• Outreach to this group is vital!
• CMS is facilitating the enrollment of additional
  people with Medicare if they do not choose a plan
  by May 15, 2006
• Includes QMBs, SLMBs, QI-1s, SSI-only, and those
  who apply and are determined eligible for the
  extra help with drug costs
• Coverage effective June 1, 2006
• If PDP is selected by 12/31/05, coverage extra
  help can begin on Jan. 1, 2006!

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Medicare Beneficiaries with a Medicaid Spenddown

• Can apply for drug benefit at any time
• Are those who meet all eligibility requirements
  for Medicaid, with the exception of income
• Meet monthly spenddowns to qualify for Medicaid
  by incurring medical expenses or by paying
  monthly amount
• Starting Jan. 1, 2006, Medicaid prescription
  coverage will NOT be available to Medicare
  beneficiaries who meet their Medicaid Spenddown.

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Medicare Beneficiaries with a Medicaid Spenddown

• Those who meet their Spenddown between August and
  November 2005
• Deemed eligible for January and remainder of the
  2006 CALENDAR year
• December 2005 and forward
• Deemed eligible within two months of meeting
  spenddown (no guarantee for January) and
  remainder of the 2006 CALENDAR year
• Will be responsible for prescription co-pays once
  spenddown is met
• Prescription co-pays can be applied toward
  beneficiarys monthly spenddown.

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People Eligible For Extra Help

• Group 1
• Full-benefit dual eligibles with incomes at or
  below 100 Federal poverty level (FPL)
• Group 2
• Full-benefit dual eligibles with incomes above
  100 of FPL QMB, SLMB, QI, SSI-only or other
  beneficiaries with incomes below 135 FPL and
  limited resources (7,500 per individual and
  12,000 married couple)
• Group 3
• Beneficiaries with incomes below 150 FPL and
  limited resources (11,500 individual and 23,000
  married couple)

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Extra Help
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No Cost Sharing

• Dual eligibles who reside in Long-Term Care
  Facilities
• PACE enrollees

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County Role with Extra Help

• Give applications to beneficiaries and assist
  them with completing the application
• Collect and mail completed applications by the
  next business day
• Advise beneficiaries on where they can obtain
  additional information
• Screen eligibility for Medicaid programs, if
  requested

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Review

• Medicaid prescription coverage for people with
  Medicare ends December 31, 2005
• Dual eligibles will be auto-enrolled in a PDP if
  they do not choose a plan
• Dual eligibles may change plans any time
• QMBs, SLMBs and QI-1s should be advised to pick a
  PDP before 12/31/05
• Medicare beneficiaries with a Spenddown should
  try to meet it before November 2005 for coverage
  to begin January 2006
• Must pay copayments of up to 5 (depending on
  income)

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For More Information

• Visit www.medicare.gov (beneficiaries)
• Visit www.cms.hhs.gov (others)
• Visit www.socialsecurity.gov
• Publications such as
• Medicare You handbook
• Facts About Medicare Prescription Drug Plans
• 1-800-MEDICARE
• Call Social Security at 1-800-772-1213
• Call OSHIIP at 1-800-686-1578
• www.jfs.ohio.gov/ohp

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Question and Answer