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

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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
• www.kidneydrugcoverage.org

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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
  Services
• Dolph Chianchiano, Senior VP of Health Policy and
  Research, National Kidney Foundation
• Janice Mosby, Deputy Associate Commissioner of
  External Affairs, Social Security Administration

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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

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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

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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
  money!

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Medicare Prescription Drug Coverage Is Optional
EXCEPT for

• 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

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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

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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?

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Resources for Choosing a PDP

• Medicare You 2006 booklet
• Advertising from PDPs
• Medicare Prescription Drug Finder Tool
• Compares Medicare prescription drug plans
• Found at www.medicare.gov
• Kidney-specific www.kidneydrugcoverage.org
• General advice (not kidney-specific)
• 1-800-MEDICARE or 1-877-486-2048 (TTY)
• State Health Insurance Assistance Program (SHIP)

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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)

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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

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Who Does Medicare Prescription Drug Coverage Help
Most

• 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

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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

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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

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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
  teleconference

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Joining a Prescription Drug Plan (PDP)

• Anyone with Medicare can join
• Apply 11/15/05 5/15/06 or first 6 months of
  Medicare
• Send application to the Plan
• Apply online at www.medicare.gov
• Apply by phone at 1-800-MEDICARE

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Why Should Patients Join Now?

• Prescription Drug Coverage is insurance
  protection
• 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)

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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
  month
• (NOTE most others can only join or change plans
  November 15-December 31 annually)

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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

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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
  month

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Medicare Prescription Drug Coverage Low-Income
Subsidy

• 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)

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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.

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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 www.medicare.gov
• Apply online at www.socialsecurity.gov
• Social workers should keep copies of letters from
  government agencies, PDP, current insurer for
  future appeals, if needed

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Thank You For Coming

• Visit www.kidneydrugcoverage.org
• 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 info_at_kidneydrugcoverage.org
• Listen in on September 20, 2005 for information
  on Medicare Prescription Drug Coverage and other
  drug coverage