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Medicare: How Its Changing To Help More People Understanding Medicare Part D: Overview of Benefit an


... How It's Changing To Help More People ... Medicare Prescription Drug Coverage is not free ... Who Does Medicare Prescription Drug Coverage Help Most. Those who ... – PowerPoint PPT presentation

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Title: Medicare: How Its Changing To Help More People Understanding Medicare Part D: Overview of Benefit an

Medicare How Its Changing To Help More People
Understanding Medicare Part D Overview of
Benefit and Low-Income Subsidy for Medicare
Beneficiaries with Limited Income and Resources
  • Presented by
  • Kidney Medicare Drugs
  • Awareness and Education Initiative

Our Experts
  • Teri Arthur Browne, NKF Council of Nephrology
    Social Workers, social worker at Fresenius
    Medical Care, N.A.
  • Susie Butler, Division of Partnership
    Development, Centers for Medicare and Medicaid
  • Dolph Chianchiano, Senior VP of Health Policy and
    Research, National Kidney Foundation
  • Janice Mosby, Deputy Associate Commissioner of
    External Affairs, Social Security Administration

Medicare in General
  • Medicare Part A hospital, hospice, skilled
    nursing, some home health free for most
  • Medicare Part B doctors and outpatient,
    including dialysis and a few drugs (EPO and
    anti-rejection in certain cases) premium 78.20
    per month in 2005

More on Medicare
  • Original Medicare (fee-for-service)
  • Medicare Advantage (managed care)
  • Currently, people with ESRD may have before but
    cannot get after kidneys fail
  • Transplant recipients may be eligible
  • In the future, dialysis patients may be able to
    join special needs MA plans

Medicare Prescription Drug Coverage (Part D)
  • Coverage starts January 1, 2006
  • Available to anyoneincluding those with kidney
    diseasewho have
  • Medicare A or Medicare B
  • Medicare A and B
  • Medicare Prescription Drug Coverage is not free
  • Those with Medicare must take action to save

Medicare Prescription Drug Coverage Is Optional
  • Auto-enrolled by December 31, 2005
  • People with Medicare and full Medicaid
  • Facilitated enrolled by May 15, 2006
  • People with Supplemental Security Income (SSI)
  • People with Medicare Savings Programs
  • Qualified Medicare Beneficiary
  • Specified Low-Income Medicare Beneficiary
  • Qualifying Individual

Prescription Drug Plans (PDPs)
  • Medicare approves companies plans
  • In October 2005
  • Medicare announces PDPs
  • Plans announce formularies
  • Medicare sends Medicare You 2006
  • October 13, 2005 begin comparing plans

Advising Patients on Choosing a PDP
  • What drugs do you take now?
  • What drugs might you need in the future? Ask
    your doctor, nurse, and/or dietitian.
  • Changes in health
  • Changes in type of treatment
  • Which PDP formulary are these drugs on?

Resources for Choosing a PDP
  • Medicare You 2006 booklet
  • Advertising from PDPs
  • Medicare Prescription Drug Finder Tool
  • Compares Medicare prescription drug plans
  • Found at
  • Kidney-specific
  • General advice (not kidney-specific)
  • 1-800-MEDICARE or 1-877-486-2048 (TTY)
  • State Health Insurance Assistance Program (SHIP)

Medicare Prescription Drug Coverage Savings
  • Most will save
  • How much depends on
  • Drug expenses now
  • Expected future drug expenses
  • Whether drugs are on the PDP formulary
  • Eligibility for extra help (low-income subsidy)

Standard Medicare Prescription Drug Coverage
Plan(or Actuarial Equivalent)
  • Premium average of 32.20 per month
  • Deductible 250 per year
  • Coinsurance 25 of drug costs from 251 to
    2,250, up to 500
  • Coverage Gap 100 of drug costs from 2,251 to
    5,100, up to 2,850 out-of-pocket
  • Catastrophic benefit over 5,100 of drug costs
    (or 3,600 out-of-pocket), Medicare will pay 95
    of cost of covered drugs the rest of the year

Who Does Medicare Prescription Drug Coverage Help
  • Those who
  • Have no or limited drug coverage
  • Spend 70 a month on drugs
  • Spend less than 2,250 a year for drugs
  • Spend more than 5,100 a year for drugs
  • Have a transplant and no Medicare Part B coverage
    for anti-rejection drugs
  • Are on home dialysis and who may not get Part B
    drugs given to dialysis patients

What Expenses Do Not Count Toward Coverage Gap
  • Drugs not on the PDPs formulary
  • 20 for drugs covered by Medicare Part B
  • Drugs bought outside the U.S.
  • Medicare Prescription Drug Coverage premium

Prescription Drug Plans (PDPs)
  • Must cover at least two drugs in each drug class
  • May offer expanded benefits at higher premium
  • May encourage patients to use generic drugs
  • Transplant recipients should never be switched
    from one brand name to a generic or from one
    generic to another without checking with doctors
    and notifying the patient first
  • Urge patients to talk with doctors before taking
    any generic drugs

Formulary Changes
  • PDPs can withdraw a drug from a formulary with 60
    days notice
  • Doctors can write exception requests
  • Patients have appeal rights
  • More on exceptions and appeals in a future

Joining a Prescription Drug Plan (PDP)
  • Anyone with Medicare can join
  • Apply 11/15/05 5/15/06 or first 6 months of
  • Send application to the Plan
  • Apply online at
  • Apply by phone at 1-800-MEDICARE

Why Should Patients Join Now?
  • Prescription Drug Coverage is insurance
  • If need an expensive drug later pay for it
    out-of-pocket for up to a year if patient does
    not have Medicare Prescription Drug Coverage
  • Premium penalty for late enrollment -- 1 per
    month adds up fast if current drug coverage is on
    average not as good as Medicare Prescription Drug
    Coverage (called creditable coverage)

Those with Medicare and Full Medicaid
  • Auto-enrolled if dont choose a plan
  • Notice of assigned Plan in October
  • Can switch if assigned plan doesnt meet needs
  • Can change any month and plan starts the next
  • (NOTE most others can only join or change plans
    November 15-December 31 annually)

What If Medicaid Spenddown
  • Provide medical bills to Medicaid caseworker
    September 1 to December 31,2005
  • If bills meet spenddown, get low-income subsidy
    all the next year
  • Social workers can help patients understand how
    much this can help

Limited Income
  • May be eligible for Medicare Savings Program
  • Qualified Medicare Beneficiary (QMB)
  • Specified Low-Income Medicare Beneficiary (SLMB)
  • Qualifying Individual (QI)
  • If eligible, get low-income subsidy
  • Apply at State Medicaid office
  • Have until May 15, 2006 to join a PDP
  • (New) Those with QMB, SLMB, or QI can change PDPs
    any month and plan starts the next month
  • (New) Those with SSI (no Medicaid) can switch
    plans once a year and the plan starts the next

Medicare Prescription Drug Coverage Low-Income
  • Pays the premium, deductible and all or part of
    the coinsurance for Medicare Prescription Drug
    Coverage for
  • Those with Medicare and full Medicaid, SSI or
    Medicare Savings Programs (CMS letter)
  • Those with limited income and assets (SSA letter)

Extra Help for Others
  • Who qualifies
  • Singles Income lt 14,355
  • Singles Assets lt 11,500
  • Couples Income lt 19,245
  • Couples Assets lt 23,000
  • Includes 1,500 per person for burial expenses
  • Families with more dependents, where a spouse
    works, or who live in Alaska or Hawaii can have
    more and still qualify.

Low-Income Subsidy Eligibility
  • Contact Social Security 1-800-772-1213 about
    countable income and assets
  • Use Medicare Prescription Drug Benefit Subsidy
    Eligibility Information tool on
  • Apply online at
  • Social workers should keep copies of letters from
    government agencies, PDP, current insurer for
    future appeals, if needed

Thank You For Coming
  • Visit
  • Complete evaluation
  • Print your certificate of attendance
  • Ask your licensing board if certificate can be
    used for continuing education credit
  • Submit questions about Medicare Prescription Drug
    Coverage to
  • Listen in on September 20, 2005 for information
    on Medicare Prescription Drug Coverage and other
    drug coverage