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

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


1
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

2
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

3
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

4
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

5
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!

6
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

7
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

8
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?

9
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)

10
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)

11
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

12
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

13
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

14
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

15
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

16
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

17
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)

18
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)

19
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

20
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

21
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)

22
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.

23
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

24
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
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