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Title: ... can provide to help these consumers access a dru


1
\\\ The ABCs of Part D Helping
Consumers Access Medicare Prescription Drug
Coverage By Judith F. Cox , MA, National
Council Consultant and Kristin Battista-Frazee,
MSW, Educational Services Manager National
Council for Community Behavioral
Healthcare October 6, 2005
2
Purpose of this Teleconference
  • This presentation will help participants
  • Understand how the Medicare Modernization Act
    (MMA) impacts consumers with mental health
    disabilities.
  • Formulate specific tasks they can provide to help
    these consumers access a drug prescription plan
    that best meets their needs.
  • Know the resources which are available to
    providers and consumers for implementing the MMA.

3
The Medicare Prescription Drug Coverage,
Improvement, and Modernization Act (MMA)
  • The Medicare Modernization Act was passed
    in 2003.
  • It is also known as the Part D (for Drug) Benefit
    or Prescription Drug Program.
  • It will be effective January 1, 2006.
  • Under this Act all Medicare beneficiaries will
    have assistance in paying for prescription drugs.

4
Overview What is Medicare?
  • Medicare is a federal health insurance program
    for people
  • Age 65 years and older
  • Under age 65 with certain disabilities
  • Of any age with end-stage renal disease
    (permanent kidney failure requiring dialysis or a
    kidney transplant)

Source The Centers for Medicare and Medicaid
Service, http//www.cms.hhs.gov/medicare/
5
Medicare has Four Parts
  • Part A the hospital insurance program
  • Part B the medical insurance program
  • Part C the Medicare Advantage Plan managed care
    program
  • Part D the Prescription Drug Program, created by
    the Medicare Prescription Drug, Improvement, and
    Modernization Act (MMA) of 2003

Source The Centers for Medicare and Medicaid
Service (CMS), Outreach Toolkit Medicare
Prescription Drug Coverage,
June 2005, http//www.cms.hhs.gov/partnerships/to
ols/materials/medicaretraining/MPDCoutreachkit.asp

6
Who is Impacted by the Part D Prescription Drug
Program?
  • 42 million people in the USA receive Medicare
  • One quarter of seniors and people with
    disabilities now receiving Medicare have no drug
    coverage
  • Millions more face limitations and rising costs
    with the current coverage they receive in drug
    plans

7
Who is Impacted by the Part D Prescription Drug
Program
  • The Part D Benefit will be most used by persons
    who receive both Medicare and Medicaid as well as
    other low-income Medicare beneficiaries.
  • There are 6.3 million individuals who receive
    both Medicaid and Medicare of which 38 are
    consumers of mental health services.
  • There are another 8.1 million low income Medicare
    beneficiaries.

Source Kaiser Family Foundation, Medicare
Low-Income Assistance Under the Medicare Drug
Benefit June 2005. www.kff.org/medicare/7327.cfm
CMS Fact Sheet (January 21, 2005) Final Rules
Implementing the New Medicare Law A New
Prescription Drug Benefit for All Medicare
Beneficiaries, Improvements to Medicare Health
Plans, and Establishing Options for Retirees,
www.cms.hhs.gov/media/?mediafacts.
8
What is the Role of Providers in Implementing
the Medicare Part D Prescription Drug Program?
  • Provide leadership in helping consumers access
    benefits.
  • For consumers who are currently receiving
    prescription drug coverage through Medicaid,
    assist them transition into the new Part D
    Benefit by January 1, 2006. After this date,
    Medicaid will no longer cover their prescription
    drugs.
  • For consumers who are without drug coverage,
    assist them in obtaining needed medical mental
    health prescription drug coverage.

9
Prescription Drug Plans forMedicare Beneficiaries
  • Beginning January 1, 2006 all Medicare
    beneficiaries will have the option to enroll in a
    Medicare drug prescription plan provided through
  • Prescription Drug Plans (PDP) which are available
    to persons in the Original Medicare
    Fee-for-Service Plan or a Medicare Private
    Fee-for-Service Plan (PPFS).
  • A Medicare Health Advantage Plan with
    prescription drug coverage (MA-PD).
  • Plans offered by employers and unions to retirees.

10
Beneficiaries Who Have Medicare and Medicaid
(Dual Eligible)
  • These individuals will loose their Medicaid drug
    prescription coverage on January 1, 2006.
  • They will be auto-enrolled in a Prescription Drug
    Plan (PDP) by the Centers for Medicare and
    Medicaid Services (CMS) before December 31, 2005.
  • They may experience challenges with this initial
    enrollment.

11
Medicare Beneficiaries Who Do Not Have Medicaid
  • These individuals will not be auto-enrolled in a
    PDP.
  • As applicable they should enroll in a PDP between
    November 15, 2005 May 15, 2006.
  • If they enroll after May 15, 2006 they will be
    penalized with higher premium payments. (1 of
    the average premium per uncovered month)

12
Extra Help Low Income Program
  • Extra Help is available through the Social
    Security Administration to defer some costs of
    the Part D Prescription Drug Program
  • Who is eligible for Extra Help?
  • All dual eligible consumers and all other
    consumers with incomes at or below 150 percent of
    the poverty level are eligible for the Extra Help
    program.

13
Extra Help Low Income Program
  • Who will be automatically enrolled for Extra
    Help?
  • People automatically eligible for this assistance
    are deemed and do not have to apply for
    assistance. They include persons with
  • Medicaid and Medicare
  • Medicare who receive Supplemental Security Income
  • Partial dual eligibility such as qualified
    medical beneficiaries, specified low-income
    Medicare beneficiaries and qualifying individuals
  • Medicare who are in a Medicare Savings Program
  • What Medicare consumers should apply ?
  • All Medicare beneficiaries other than those who
    are deemed will have to apply to receive
    assistance.

14
A Term to Know
  • TROOP (True Outof-Pocket Costs)
  • Out-of-pocket costs include all prescription drug
    costs paid by you or another person or
    organization, including the government.
  • The out of pocket costs include payment of the
    deductible, co-insurance, co-payments and
    medication costs that are not covered by another
    insurance.
  • Costs do not include expenses paid by the
    individual for medications that are not on a
    plans covered list of drugs or for medications
    excluded from the Medicare prescription drug
    benefit.
  • For consumers without extra help programs the
    highest out of pocket cost is 3,600 per year
    plus premium cost.

15
What Does a PDP Cost a Beneficiary and How Much
Does the Subsidy Program Defer?
16
What Does a PDP Cost a Beneficiary and How Much
Does the Subsidy Program Defer?
17
Case Study Tammy
  • Tammy is a 40 yr. old women with major
    mental illness, challenges with anorexia and 5
    serious suicide attempts. She has a monthly
    income above 150 of the poverty level. She is
    now receiving services through a Assertive
    Community Treatment Program. She is on Medicare
    but not Medicaid. She has a monthly prescription
    medication drug cost of 600.

18
Case Study Joe
  • Joe is a 62 year old male with chronic heart
    problems, diabetes and paranoid schizophrenia. He
    has never worked has no current income. He
    currently receives Medicaid and Medicare and was
    just enrolled in a Case Management Program. He
    takes four prescription medications.

19
Tammy vs. Joe Costs of Part D coverageadapted
from National Council Meet Me Call presented by
Dale Jarvis June 27, 2005
20
Extra Help Resources for Consumers
  • Notices from the SSA were sent in May August
    2005 to approximately 18.6 million people,
    informing them of the extra help including an
    application form for the subsidy.
  • The SSA or state Medicaid offices will provide
    individuals with information on income and asset
    requirements for qualifying. They will also
    assist consumers in completing a low-income
    subsidy application. Consumers can call
    1-800-772-1213 for assistance or their local
    office.
  • SSA and state Medicaid agencies began making
    eligibility determinations on applications for
    low-income subsidy in July 2005. Individuals may
    apply on line (www.ssa.gov), by phone or
    consumers can download an application, and use a
    tool that helps determine if they qualify for the
    subsidy benefit.

21
Help Consumers Apply for Extra Help
  • Immediately help consumers determine if they
    qualify for low-income subsidy assistance.
  • Check with consumers to make sure they have
    submitted the appropriate subsidy application and
    used the resources made available to them.

22
Resources to Assist Consumers Obtain Extra Help
  • Ask consumers if they have received the results
    of their extra help application.
  • CMS started mailing notices in May 2005 to
    beneficiaries deemed eligible for low-income
    subsidy to notify them that they do not have to
    apply for the subsidy. Service providers should
    check with consumers to determine if they have
    received this notice. If they have not, the
    provider and the consumer should contact their
    SSA or local Medicaid office to ensure an
    application is received.

23
Resources to Assist Consumers Obtain Extra Help
  • Once a consumer has a extra help determination
    and knows his/her assigned plan review the
    consumers costs.
  • Make sure consumers know that Medicare will only
    cover the lowest PDP premium. If a plan is chosen
    with a higher premium, consumers will still be
    responsible for the difference, despite their
    income subsidy status.
  • In reviewing costs with consumers, providers
    should also discuss the impact of extra help on
    the consumers housing, foods stamp benefits, and
    Medicaid Spend Down, as applicable. The reduction
    in medical spending will affect eligibility of
    other benefit programs.

24
How Will Consumers Pay for Co-Pays?
  • Even the smallest co-pay can represent a hardship
    for some people.
  • Co-pays range from 1 to out of pocket costs in
    the thousands.

25
Alternatives to Helping Consumerswith Co-Pays
  • Pharmacies are permitted to waive or reduce cost
    sharing
  • For consumers who qualify for the extra help
    pharmacies can do this on a routine basis.
  • For consumers who do not qualify for extra help
    pharmacies can only do this on a non-routine
    basis.
  • Pharmacies are restricted from advertising that
    they can waive costs so providers should prompt
    consumers to ask for this extra assistance.
  • Other alternatives are charitable organizations,
    state pharmacy assistance plans or pharmaceutical
    company assistance programs.

26
Key Implementation Entities and Service Regions
27
Timeframes for Enrolling Consumers in a Part D
Prescription Drug Plan
28
Timeframes for Enrolling Consumers in a Part D
Prescription Drug Plan
29
Timeframes for Enrolling Consumers in a Part D
Prescription Drug Plan
30
Timeframes for Enrolling Consumers in a Part D
Prescription Drug Plan
31
General Provider Tasks to Help Implement the
Medicare Part D Drug Program
  • Review your case loads ASAP to identify Medicare
    beneficiaries.
  • Divide Medicare beneficiaries on your caseload
    into 4 groups based upon their income, dual
    eligibility and current Medicare drug plans, and
    then follow relevant enrollment procedures. The
    four groups are
  • Group 1 Beneficiaries in the Original Medicare
    Fee-for-Service Part A and/or Part B plan and
    Medicaid. Also know persons in a dual eligible
    status.
  • Group 2 Beneficiaries in the Original Medicare
    Fee-for-Service Part A and/or Part B plan who
    receive Supplemental Security Income (SSI) or are
    in a Medicare Savings Program
  • Group 3 Medicare beneficiaries enrolled in the
    Original Medicare Fee-or-Service Part A and/or
    Part B plans who do not receive Medicaid
  • Group 4 Medicare beneficiaries enrolled in a
    Medicare Advantage plan but who do not receive
    Medicaid

32
Groups of Medicare Beneficiaries
  • Partner with consumers on accessing Part D
  • Review each consumers medications needs, the
    pharmacy they are using and prescribing physician
    (consider a standard worksheet)
  • Assist consumers in applying for extra help
  • Assist consumers to enroll in a appropriate
    prescription drug plan
  • Find out more information-review NMHAs Medicare
    workbook for consumers, www.nmha.org
  • Report major problems consumers have in accessing
    Part D Drug Program to National Council for
    Community Behavioral Healthcare

33
A TOOL to Help the Consumer and the Provider Find
the Best Plan
  • Medicare Prescription Drug Plan Finder
  • This is a web based resource that will be
    available to consumers and providers beginning
    October 13, 2005 at www.medicare.gov to compare
    the plans point by point, such as their premiums,
    co-payments, drugs they cover (formulary) and
    pharmacy network information. Program contact and
    pricing information is displayed at the network
    pharmacy level.
  • If you dont have access to the Internet, you can
    get the same kind of information by calling
    Medicare at 1-800-MEDICARE.
  • A customer representative will send you printed
    versions of details of all the plans that are
    available to you. This service, too,will be
    available after October 13, 2005.

34
  • The Enrollment and Extra Help Application
    Procedures for each of the Four Groups of
  • People with Medicare

35
Medicare Beneficiaries Who are Dual Eligible
Status Enrolled in the Original Fee-for-Service
PlansPart A and /or Part B Plans Group 1
  • Will they be auto-enrolled in the Part D PDP?
  • Yes
  • They will be auto-enrolled by CMS in the Fall
    2005
  • CMS will randomly assign consumers to drug plans
    in their region that have the lowest cost plans
  • Will they automatically receive subsidy
    assistance?
  • Yes
  • They do not have to apply for assistance

36
Medicare Beneficiaries Who are Dual Eligible and
Enrolled in the Original Fee-for-Service Plans
Group 1
  • Provider Tasks and Critical Information
  • In October 2005, partner with consumers to
    discuss the specific drug plan to which they
    were auto-enrolled. Review the characteristics of
    the plan including
  • Medications covered and not covered
  • Co-payment charges,
  • Grievance procedures,
  • Pharmacies in the plans network
  • If this plan does not cover the consumers
    prescription medications, review other plans in
    the Region and select the plan which matches the
    persons prescription medication needs. Remember
    there are at least 2 plans in each region.
  • Specific information about drug plans in the
    region can be obtained from the consumers
    pharmacy and online at www.medicare.gov using
    Plan Finder search tool.

37
Medicare Beneficiaries Who are Dual Eligible and
Enrolled in the Original Fee-for-Service Plans
Group 1
  • When medically necessary, consumers should be
    permitted to continue utilizing a non-formulary
    drug (one not covered by a prescription drug
    plan) that is providing clinically beneficial
    outcomes.
  • Each plan should describe how consumers can
    continue to have access to a non-formulary drug,
    when there is a known risk for a negative
    clinical outcome associated with substituting
    another drug.
  • Providers should understand the plans policy and
    ensure that the consumers coverage continues.
    See NMHAs Exceptions and Appeals FAQ provided in
    Appendix B.

38
Medicare Beneficiaries who are Dual Eligible and
Enrolled in the Original Fee-for-Service Plans
Group 1
  • In mid December 2005, again discuss with
    consumers their selected PDP and the plans
    participating pharmacies.
  • Providers should help consumers make sure that
    they have a new pharmacy card for the pharmacy in
    their plans network.
  • Providers should contact the local State Health
    Insurance Program (SHIP) if they have questions
    regarding Medicare prescription drug benefits.
    This is a free counseling service funded by CMS.
  • In January 2006 or prior to the first visit to
    the pharmacy, providers should ensure consumers
    know where their new pharmacies are located and
    have transportation. For some consumers the
    provider or a significant other should accompany
    the consumer on the first visit.

39
Medicare Beneficiaries in the Original Medicare
Fee-for-Service Plans who are on SSI or in a
Medicare Savings Program Group 2
  • Are they auto-enrolled in the Part D PDP?
  • These individuals will not be auto-enrolled by
    January 1, 2006 but will be auto-enrolled by May
    15, 2006
  • They will need to choose and enroll in a plan by
    May 15, 2006 but can enroll by 12/31/05
  • Consumers who do not join a plan by May 15, 2005
    will be auto-enrolled in a Part D plan effective
    June 1, 2006, but this plan may not be consistent
    with their medication needs.
  • Will they automatically receive subsidy
    assistance?
  • Yes. They do not have to apply for assistance.

40
Medicare Beneficiaries in the Original Medicare
Fee-for-Service Plans Who are on SSI or in a
Medicare Savings Program Group 2
  • Provider Tasks and Critical information
  • Between November 15, 2005 and May 15, 2006,
    assist consumers in enrolling in an appropriate
    Drug Plan.
  • Facilitate the consumer being enrolled in a plan
    by May 15, 2006 at the latest. If they are not
    enrolled by this date, Medicare will enroll them
    in a plan that will be effective June 1, 2006,
    but this plan may not be consistent with their
    medication needs.
  • Similar to Group 1 providers should work in
    partnership with the consumer to compare their
    medication needs with the plans available in the
    region using the available tools and follow steps
    3- 7.
  • Additionally if the consumer is auto-enolled on
    June 1, 2006 the provider should review the plan
    to ensure it meets the consumers needs.

41
Beneficiaries Who are Enrolled in the Original
Medicare Fee-for-Service Plans but do not
Receive MedicaidGroup 3
  • How will their prescription drugs be covered as
    of January 1, 2006?
  • Individuals in the Original Medicare Plan without
    drug coverage can enroll in the Medicare Part D
    PDP.
  • Medigap consumers should compare their current
    coverage and make sure it is as good as coverage
    through a Medicare Part D PDP.
  • Individuals who have prescription drug coverage
    through their employer or Union Health need to
    decide whether they should keep their current
    plan or enroll in a Medicare part D PDP.
  • Are they auto-enrolled in a Part D PDP?
  • No, They must enroll.
  • Are they auto-enrolled for subsidy assistance?
  • No, They must apply for this assistance.

42
Beneficiaries Who are Enrolled in the Original
Medicare Fee-for-Service Plans but do not Receive
Medicaid Group 3
  • Provider Tasks and Important Information
  • For consumers with existing prescription drug
    coverage
  • Compare the existing plan with the Part D
    Prescription Drug plans and select the plan that
    best meets the consumers needs.
  • A SHIP counselor can be contacted to determine
    if it is in the consumers best interest to
    change plans www.shiptalk.com or call
    1-800-MEDICARE.
  • If a consumer has a Medigap policy or has
    prescription drug coverage through their
    employer, they should receive a notice in the
    Fall of 2005 from Medigap or their employer
    telling them whether or not their coverage is at
    least as good as coverage through a Medicare
    Prescription Drug Plan (PDP).

43
Beneficiaries Who are Enrolled in the Original
Medicare Fee-for-Service Plans but do not Receive
Medicaid Group 3
  • For consumers without drug coverage, inform them
    about the Part D Prescription Drug Program and
    the enrollment and extra help processes.
  • First, assist the consumer in completing an
    application for the limited income subsidy. Go
    to www.ssa.gov for an application or apply by
    phone at 1-800-772-1213.
  • Review the results of their subsidy application
    so that consumer knows the costs of the drug plan
    and that he/she has been approved for the limited
    subsidy.
  • Assist consumer in enrolling in an appropriate
    regional Prescription Drug Plan. With the
    consumer, compare their medication needs with the
    plans available in that region.

44
Beneficiaries Who are Enrolled in the Original
Medicare Fee-for-Service Plans but do not Receive
Medicaid Group 3
  • Following enrollment into a plan, review with the
    consumer their extra help allowance and co-pay
    charges for each medication. Also discuss the
    pharmacy in the consumers PDP network (name,
    address and telephone number, methods of
    transportation to the pharmacy) and make sure
    consumer has a new pharmacy card for that
    pharmacy.
  • Contact the local State Health Insurance Program
    (SHIP) for additional information which may be
    needed.
  • As with Groups 1-3 when needed accompany the
    consumer to the pharmacy to fill his/her first
    prescription under the new Medicare Part D
    Benefit.

45
Medicare Beneficiaries in an Advantage Plan who
do not Receive Medicaid Group 4
  • How will their prescription drugs be covered as
    of January 1, 2006?
  • These individuals can stay in their current
    Medicare Advantage plan and get prescription drug
    coverage or enroll in a Part D Plan.
  • Are they auto enrolled for subsidy assistance?
  • No. They must apply for this assistance.

46
Medicare Beneficiaries in an Advantage Plan Who
Do Not Receive Medicaid Group 4
  • Provider Tasks
  • Meet with consumers to determine is he/she is in
    a plan without medication coverage. Some of the
    MA-PD plans do not have drug coverage.
  • If consumers are without medication coverage and
    are enrolled in a Medicare Advantage HMO, PPO or
    SNP, assist the consumer in signing up for a
    Medicare Advantage Prescription Drug (MA-PD) plan
    or Part D Plan.
  • For more information on how to enroll a consumer
    in the above plans, call 1-800-633-4227 or visit
    www.medicare.gov.
  • If needed, the provider should assist consumers
    with the application for limited income
    subsidy.Go to www.ssa.gov for an application or
    apply by phone at 1-800-772-1213.

47
Case Study Enrollment Procedures for Joe, a Man
who receives Medicare and Medicaid
48
Case Study Enrollment Procedures for Joe a Man
who Receives Medicare and Medicaid
  • Consumer Event- June 2005, Joe receives an
    informational letter from CMS regarding his
    transition to a Medicare Prescription Drug Plan.
  • Provider Response- Provider identifies Joe as a
    consumer in Group 1 and meets with Joe to review
    Medicare prescription drug coverage and
    procedures.
  • Consumer Event- Fall 2005, Joes Medicaid agency
    mails him a letter to notify him that he will
    lose his Medicaid prescription drug coverage on
    January 1, 2006 and that he will be auto-enrolled
    in a Medicare plan. The letter tells Joe to call
    1-800-MEDICARE if he has any questions.

49
Case Study Enrollment Procedures for Joe a Man
who Receives Medicare and Medicaid
  • Consumer Event- October 27 November 27, 2005,
    CMS notifies Joe of the Medicare Prescription
    Drug Plan he has been enrolled in.
  • Provider Response- Provider meets with Joe to
    confirm he has been auto-enrolled in a
    Prescription Drug Plan, review the contents of
    the CMS notification and compare the plan Joe has
    been enrolled in with his medication needs.
    During this meeting the provider and Joe will
    work together on the following
  • Review the specifics of the plan in which he has
    been enrolled and make sure that it is the most
    appropriate plan for him. He and the provider
    should compare the medical and mental health
    prescription drugs he needs with those covered by
    his assigned plans formulary.

50
Case Study Enrollment Procedures for Joe a Man
who Receives Medicare and Medicaid
  • If the assigned plan meets Joes needs, he and
    the provider will review how Joe will get to the
    participating pharmacy, as this pharmacy may be
    different from the one he normally uses.
  • If the plan does not cover Joes prescribed
    medication needs, he should review other plans in
    his region to find a plan that does. He and the
    provider can go online at www.medicare.gov and
    access a software program provided by Medicare to
    identify the other plans that meet his medication
    needs. Remember, Joe must change his plan
    between November 15 and December 31, 2005 to
    avoid a lapse in coverage. After January 1, 2006,
    he can change plans every 30 days.
  • Review the extra help Joe will be receiving and
    discuss what pharmacy he will be using. The
    provider and Joe need to keep in mind that the
    extra help Joe and all other dual eligibles
    qualify only covers the premium for the
    lowest-cost plan in his area. Therefore, if Joe
    chooses a plan with a higher premium, Joe must
    pay the difference in the cost.

51
Case Study Enrollment Procedures for Joe a Man
who Receives Medicare and Medicaid
  • The provider and Joe should discuss any
    medications he needs that are not on the plans
    formulary. If these medications are medically
    necessary, Joe should be permitted to continue
    utilizing a non-formulary drug that is providing
    clinically beneficial outcomes. Joes plan should
    describe how consumers can continue to have
    access to a non-formulary drug, when there is a
    known risk for a negative clinical outcome
    associated with substituting another drug. Joes
    providers should understand the plans policy and
    ensure that the consumers coverage continues.
  • Consumer Event- January or February 2006, Joe
    will receive a letter from his Medicaid agency
    when his prescriptions run out, reminding Joe
    that he will need to go to the participating
    pharmacy under his new drug plan to get his
    medications.
  • Provider Response- The provider should accompany
    Joe to the pharmacy to fill his first
    prescription under the Part D Program.

52
Case Study Enrollment Procedures for Joe a Man
who Receives Medicare and Medicaid
  • Potential problems Joe may encounter
  • 1. Joe may not be auto-enrolled in a Medicare
    Prescription Drug Plan or automatically qualify
    for extra help because of problems with the
    transmission of state eligibility records.
  • 2. Joes cognitive impairment may prevent him
    from knowing what to do with the instruction
    letter her receives in October 2005, and/or from
    evaluating the plans in his region, including the
    specific formularies, co-payment amounts,
    pre-authorization processes, and available
    pharmacies.
  • 3. The time frame for selecting the most
    appropriate Medicare Prescription Drug Plan
    (11/15/05- 12/31/05) may be too short.
  • 4. Joes low income may create a situation where
    he wont have sufficient funds to pay for
    co-payments every time he gets his medications
    refilled.
  • 5. If Joe needs any drugs that require
    pre-authorization, he may need help with that
    process.
  • 6. If there is an interruption in Joes
    medications, he may need help accessing an
    emergency supply.

53
Frequently Discussed Topics
  • Common characteristics of Part D Prescription
    Drug Plan.
  • Concern about access to urgently needed
    medications.
  • Maintaining continuity of care during transitions
  • Accessing Part D drug benefits for persons in
    institutions.
  • Prescription Drug Plan Part D and Incarceration.
  • The impact of subsidy programs on other benefits.

54
Characteristics of a Part D PDPOrganization
  • What is a PDP?
  • PDPs are Prescription Drug Plans offered by
    insurance and other private companies in 34
    regions comprising the United States. Consumers
    who are eligible for these plans get health care
    benefits through the Original Medicare
    Fee-for-Service Plan or a private fee-for-service
    plan.
  • How are PDPs organized?
  • There are 34 regions of coverage, some of which
    include more than one state. Each region must
    offer at least two plans.

55
Characteristics of a Part D PDP Regions
Participating Pharmacies
  • What pharmacies are participating in the PDP?
  • In Spring 2005, pharmacies participating in the
    PDPs were determined by the insurers
  • A list of participating pharmacies will be given
    to the consumer when they receive information
    about the assigned PDP
  • In October 2005, participating pharmacies will be
    one entity that will have information about the
    PDP a Medicaid and Medicare beneficiary has been
    auto-enrolled

56
Characteristics of a Part D PDPDrug Coverage
  • Prescription Drug Plans vary in what drugs are
    covered and how much a consumer has to pay.
  • All plans must provide at least a standard level
    of coverage, set by CMS.
  • All plans offering Medicare drug coverage must
    provide some drugs in all therapeutic classes,
    but they not required to cover all drugs in each
    class.
  • It is important to make sure that most, if not
    all, a consumers medications are covered by
    their plan, as well as the correct dosages of
    those medications.

57
Characteristics of a Part D PDPDrugs Included
  • The drugs that must be included in Prescription
    Drug Plans are all or substantially all of the
    brand name and generic drugs in the following
    categories
  • Antidepressant
  • Antipsychotic
  • Anticonvulsant
  • Anticancer
  • Immunosuppressant
  • HIV/AIDS

58
Characteristics of a Part D PDP Drugs that may
be Excluded
  • The drugs that are not required to be included in
    the Prescription Drug Plans are
  • Over-the-counter drugs, weight gain weight loss
    drugs.
  • Fertility drugs and cosmetic drugs.
  • Drugs to relieve cold and cough symptoms,
    vitamins and minerals (except prenatal vitamins
    and fluoride).
  • Outpatient drugs for which associated tests or
    monitoring must be purchased exclusively from the
    manufacturer.
  • Barbiturates (i.e.,pentobarbital and
    benzodiazepines (i.e., Xanax, Klonopin).

59
Characteristics of a Part D PDP Plans
Medications that may be Excluded
  • Other drugs which may be excluded are
  • Iressa - not required on formularies (for locally
    advanced or metastatic non-small-cell lung
    cancer).
  • Fuzeon (HIV medication) must be on formularies,
    but may require prior authorization for new
    users.
  • Escitalopram or citalopram (antidepressants)
    one may be left off the formulary, since
    escitalopram is the component of citalopram
    responsible for the antidepressant effects.
  • Fosphenytoin - may be left off formularies. This
    is for seizures.  It is only available as IM or
    IV.
  • It is not required that multi-source brands of
    identical molecular structure be included, that
    extended release products be included, or that
    all dosages of covered drugs be included.

60
Characteristics of a Part D PDP Medications that
may be Excluded
  • The State Pharmaceutical Assistance Program could
    cover any of the above medications that may be
    excluded form the PDPs.
  • The State Medicaid Programs can cover
    barbiturates and benzodiazepines and for those
    consumers who are full benefit dual eligible
    States can receive federal financial
    participation.

61
How are Urgently Needed Medications Obtained?
  • Medications needed urgently are covered while a
    prompt exception process is completed.
  • A physician or authorized representative can help
    the consumer with the exception process.
  • A one-time emergency supply of a medically
    necessary, non-formulary drug may be available
    for at least 30 days.

62
Characteristics of a Part D PDP Formularies
  • Plans can have different formularies
  • It is important to make sure that the majority of
    the consumers medications are included on their
    plans formulary.
  • Within a formulary, medications can be tiered. A
    medication can be Tier 1, 2, or 3. Medications on
    Tier 1 and 2 are considered preferred and have a
    lower co-payment.
  • Medications on Tier 3 are covered by the plan but
    are not preferred and have the most expensive
    co-payments. In most cases, generic medications
    will be Tier 1 and brand name drugs will be Tier
    2 or 3.

63
Is There an Appeals Process to Obtain Medications
Not on the Formulary?
  • Consumers can obtain off-formulary medications.
  • A consumer or his/her physician may file a
    request for an exception to the formulary.
  • All exception requests must be accompanied by the
    prescribing physicians oral or written statement
    supporting the request.
  • The physicians request must demonstrate that the
    drug is medically necessary because all of the
    covered drugs on any tier of the plans formulary
    used to treat the same condition would not be as
    effective for the consumer as the non-formulary
    drug and/or would have adverse effects.

64
Characteristics of a Part D PDP Formularies
  • Who decides what medications are on the
    formulary?
  • Formularies are developed and reviewed by a
    pharmacy and therapeutic (PT) committee.
  • What is the process for changes in the formulary?
  • The PDP may only change the therapeutic
    categories and classes on the formulary at the
    beginning of each year.
  • Plans must provide direct written notification to
    affected consumers at least 60 days prior to a
    formulary change becoming effective. This
    includes both removal of a drug from a formulary
    and any change in the preferred or tiered
    cost-sharing status of a drug.
  • Specific changes in the formulary under a plan,
    including changes to tiered or preferred status,
    shall be made available through on a website
    www.cms.hhs.gov?mmu?hrl/PL108-173summary.asp.

65
Grievances and Appeals
  • Consumers can get off-formulary medications.
  • Consumer or his/her physician may file a request
    for an exception to the formulary.
  • Exception requests must be accompanied by the
    prescribing physicians oral or written statement
    supporting the request.
  • The physicians request must demonstrate that the
    drug is medically necessary because all of the
    covered drugs on any tier of the plans formulary
    used to treat the same condition would not be as
    effective for the consumer as the non-formulary
    drug and/or would have adverse effects.

66
What Should the Consumer do if the Pharmacist
says the Drug is not on the Formulary?
  • Assist the consumer in contacting their plan
    to request an exception. If the plan denies an
    exception, then the consumer can appeal the
    plans decision.

67
Maintaining Continuity of CareDuring
Transitions?
  • Provider Guidelines
  • If a consumer is currently stabilized on a
    non-formulary drug, the plan must describe in
    detail how it will ensure the consumer will
    continue to have access to that drug when there
    are known risks for negative clinical outcomes
    associated with its substitution.

68
Maintaining Continuity ofCare During Transitions?
  • All PDPs must have transition plans for new
    enrollees to ensure that emergency drugs are
    supplied.
  • Generally, If a service provider anticipates a
    problem with drug coverage, a supply of drugs
    determined by the physician to be medically
    necessary may be available. It appears that at
    least a 30 day supply of medications may be the
    standard used for emergencies.
  • Some states may also be able to prevent a lapse
    in coverage by filling a 90-day extended supply
    of prescriptions in December 2005 and still
    receive federal matching funds.

69
How do Individuals in Institutions Apply for
Medicare Part D Prescription Drug Plan ?
  • Eligible persons residing in nursing homes will
    be expected to enroll in a new Medicare Part D
    Prescription Drug Plan (PDP) (or be automatically
    enrolled if they are dual eligible). The new
    plans are expected to contract with long- term
    care pharmacies.
  • For eligible persons temporarily residing in a
    psychiatric facility follow the appropriate group
    1-4 enrollment procedures previously discussed.
  • If a consumer is hospitalized during the Fall
    2005 enrollment period, then providers need to
    coordinate with the institutional staff to ensure
    that the consumer is enrolled the most
    appropriate PDP for their needs.

70
Do Individuals Who are Incarcerated Qualify for
Medicare
  • Individuals who are incarcerated are not eligible
    for Medicare prescription Drug Coverage because
    they are not considered to reside in a
    prescription drug service areas.
  • Providers will need to help these individuals
    upon re-entry into the community and as eligible
    enroll in a PDP and apply for extra help.

71
What is the Impact of Participation in the Part
D Prescription Drug Plan on Food Stamps?
  • With the extra help to defer prescription drug
    costs, a consumer may see his/her Food Stamps
    benefit go down as they spend less on drugs.
    Using the extra help means consumers will have
    more cash to spend on things they need other than
    medications.
  • Changes in medical expenses should be reported
    when the consumer files to renew his/her Food
    Stamps benefit.
  • Providers should give consumers who are receiving
    Food Stamps and are eligible for extra help a
    copy of the CMS Tip Sheet Information Partners
    Can Use on Food Stamps.

Source CMS Tip Sheet Information Partners Can
Use on Food Stamps, 5/25/05, http//www.cms.hhs.g
ov/medicarereform/factsheets.asp
72
What is the Impact of Participation in the Part D
Prescription Drug Plan on Housing Assistance?
  • Consumers will not lose housing assistance
    eligibility if they qualify for subsidy help in
    paying for the Prescription Drug Plan.
  • With extra help to defer prescription drug costs,
    the portion of the rent that a consumer pays may
    increase, but their expenditures on prescription
    drugs will decrease. The increase in the
    consumers rent cost will be more than the offset
    by Medicares extra help.

Source CMS Tip Sheet Information Partners Can
Use on Housing Assistance from the Department of
Housing and Urban Development (HUD), 6/25/05,
http//www.cms.hhs.gov/medicarereform/factsheets.a
sp
73
What is the Impact of Participation in the Part D
Prescription Drug Plan on Housing Assistance?
  • After the consumer knows the amount of extra help
    they qualify for, the provider and the consumer
    should discuss with the agency that handles the
    consumers rent determination the impact of extra
    help on the portion of the rent that the consumer
    will be responsible for.
  • By doing this, the consumer will know whether or
    not their rent will increase at the next
    recertification.
  • Participation in a Medicare PDP does not need to
    be reported until the consumers family income
    and composition is recertified.
  • Review with consumers who are receiving housing
    assistance and are eligible for extra help the
    CMS Tip Sheet Information Partners Can Use on
    Housing Assistance from the Department of Housing
    and Urban Development (HUD).

Source CMS Tip Sheet Information Partners Can
Use on Housing Assistance from the Department of
Housing and Urban Development (HUD), 6/25/05,
http//www.cms.hhs.gov/medicarereform/factsheets.a
sp
74
What is the Impact of Participation in the Part D
Prescription Drug Plan on Medicaid Spend Down?
  • Consumers will not lose Medicaid Spend Down if
    they qualify for subsidy help in paying for the
    new Medicare prescription drug plan costs.
  • If a consumer does spend down to Medicaid
    because they have high drug costs, they may find
    that the new Medicare Prescription Drug Plan
    covers their drug spending but they no longer
    spend down as quickly to become
    Medicaid-eligible.
  • Providers should review with consumers who are
    utilizing the Medicaid Spend Down process and are
    eligible for subsidy assistance the CMS Tip Sheet
    Information Partners Can Use on Medicaid Spend
    Down.

Source CMS Tip Sheet Information Partners Can
Use on Medicaid Spend Down, 5/25/05 http//www.cm
s.hhs.gov/medicarereform/factsheets.asp
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