Microsoft PowerPoint - IMF Presentation.ppt

Medicare Part D
Tracy Foster
Senior Vice President, Policy
Strategies

Overview
3 key points to understand about Part D
Key changes that could impact Medicare
beneficiaries in 2007
Resources for navigating Part D
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Medicare Part D 3 Key Points of
Understanding
#1
Complex benefit structure
#2
Number of plan options
#3
Financial assistance available at no cost to
lower income beneficiaries
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#1 Complex Benefit Structure
Premium - monthly amount of money a beneficiary pays for
coverage
Deductible - annual amount of money a beneficiary must pay
out of pocket before they receive health plan benefits
Tiered formularies with associated costs
Copayments - a fixed dollar amount per tier
Examples include: $15, $25, $35
Coinsurance - a percentage of cost
Example includes: 25%
Coverage gap - the period in which beneficiaries are responsible
for 100% of part D drug costs.*
Catastrophic coverage - coverage provided when a person's
prescription drug expenses exceed a set level** established by
the federal government. At this level, the most assistance is
provided to beneficiaries and the government pays up to 95% of
any additional expenses, with no upper limit. Beneficiary pays
5% of prescription drug costs.
*When drug costs exceed $2,250 but less than $3,600 (2006), $3,850 (2007)
**$3,600 out-of-pocket in 2006, $3,850 in 2007.
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#2 - Number Of and Variation Among
Plan Options
Benefit structure (premiums, deductibles, copays,
cost-sharing, gap coverage)
Formulary (what drugs are covered)
Utilization restrictions (prior-authorization, appeals
processes)
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Figure 1 Number of Medicare Part D
Plans by Region (2006)
41
45
46
41
40
45
44
44
44
52
43
47
44
42
43
41
40
42
41
47
38
42
41
41
43
43
40
42
38
47
39
27
43
29
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#3 Financial Assistance Available
Low Income Subsidy (LIS) is available to help Medicare beneficiaries
who have limited income and resources pay for Medicare Part D
prescription drug coverage
LIS is often referred to as "extra help"
For most patients qualifying for LIS
No premium, no deductible
Copay $1(generic) - $5 (brand)
No coverage gap
No cost sharing under catastrophic coverage
Financial qualifications
Qualifications vary and relate to more/less robust assistance
Most generous criteria:
Income <=150% FPL (14,700 for single, $19800 for couple)
Assets <=$10,000 for single, $20,000 for couple
Some beneficiaries are automatically eligible for assistance
Full-benefit, dual-eligible individuals (people with Medicare and full
Medicaid)
Medicare beneficiaries that receive Supplemental Security Income
(SSI)
Medicare beneficiaries that are part of a Medicare Savings Program
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The Medicare Part D Experience 2006
Highlights
Enrollment
After 6 months of open enrollment (from November May) 23.8 million
beneficiaries were reported as enrolled in a PDP or MA-PDP plan (June 2006)
Launch.
Overwhelming number of plan options and complicated plan designs
Long hold times at payers. Some pharmacists reported 2-3 hour hold times in
Jan 2006.
Progress?
By May 2006...Payer hold times were no longer an issue. Polls revealed that
most seniors felt the process for enrolling in Part D plan was not difficult and
saved them money
As of June 2006, CMS identified approximately 3.25 million potential LIS
eligible had not yet applied for LIS.
Sept 22, 2006 "National Donut Hole Day"
Many negative reviews published on "donut hole day" explaining that
beneficiaries cannot afford prescriptions. Some beneficiaries said they stopped
taking certain medications due to cost. Many seniors are shopping around for
best price when they meet donut hole.
However, polls say many seniors are saving money overall and very happy with
Part D. Providers are not hearing that Part D is a problem for beneficiaries.
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Key Learnings
1. Many beneficiaries and advocates were not well
prepared to successfully navigate the plan assessment
and selection process.
2. It is important to understand the "donut hole" or
"coverage gap".
3. Beneficiaries who may qualify for the LIS should
apply.
· Online for immediate determination, at SSA office, via paper
application.
4. There are solutions for beneficiaries at low to middle
incomes to address affordability issues.
· While patients can't buy supplemental insurance for Part D,
Patients can/should review plan selection to see if higher
premium plan can reduce cost sharing in donut hole.
· Patients at moderate incomes may qualify for supplemental
coverage through a state program or a copay assistance
charity.
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State Pharmaceutical Assistance
Programs (SPAPs)
Benefits vary among SPAPs
Covers Part D deductible up to certain amount
May cover Part D co-pay/coinsurance
Beneficiary may be required to pay minimal co-pay and program may pay
remainder
May have annual fee
May cover costs for generic products only
Qualified program payments count toward TrOOP
Eligibility requirements vary amont SPAPs
Age requirement is typically 65+
Enrolled in a Medicare Part D plan and not qualified for LIS
State residency typically required
Financial criteria
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Figure 2 - States With Qualified State
Pharmaceutical Assistance Programs
States with Qualified SPAPS
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Resources for Identifying SPAP
Availability
State Health Insurance Programs (SHIP)
SHIP toll-free number or Website
Volunteers may be able to provide assistance with determining SPAP
eligibility and application assistance
www.medicare.gov
Searchable database by state that includes program contact
information and basic eligibility requirements
http://www.cms.hhs.gov/States/07_SPAPs.asp
Patient advocacy organizations (AARP, www.Medicarerights.org)
Manufacturer patient assistance programs
Some programs provide alternate insurance research support and may
be able to provide instructions on SPAP application process and
eligibility requirements
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12

Co-pay Assistance Charities
Charitable foundations assist patients with out-of-pocket costs
Patients who have insurance but can't afford deductibles, copays,
coinsurance, coverage gap and, in some cases, premiums
Disease state specific funds
Assistance is typically limited to a dollar amount per year. Patients
are typically asked to reapply on an annual basis.
For Part D enrollees, donations by charities count towards patient
TrOOP
How to access assistance
Charities can be reached by phone (and many by web) where the
patient or their healthcare provider can complete a pre-screen
If the patient appears to qualify, an application is provided.
Patient portion typically asks for patient demographics, insurance
information and general income information.
Healthcare provider portion typically asks for attestation of treatment.
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Co-pay Assistance Charities (cont.)
How to access assistance (cont.)
Once approved
patient may receive a benefit card which would allow the patient to use the
card at the pharmacy and have claims adjudicated electronically without the
need to provide cash and submit receipts for retrospective reimbursement.
For physician administered drugs, the patient or their healthcare provider
can submit a "proof of expenditure" form (similar to a secondary claim) for
reimbursement by the charity.
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Figure 3 - Copay Assistance Charities
Charities
Sample Disease Funds
Chronic Disease Fund
Acute Porphyria
Hodgkin's Disease
877-968-7233
Anemia
Kidney Cancer
www.cdfund.org
Ankylosing
Lung Cancer
Spondylitis
Lymphoma
HeathWell Foundation
Asthma
Multiple Myeloma
(800) 675-8416
www.healthwellfoundation.org
Breast Cancer
Myelodysplastic
Chemotherapy
Syndrome
National Organization for Rare
Induced Nausea &
Non-Hodgkin's
Disorders
Vomiting
Lymphoma
(866) 828-8902 www.rarediseases.org
Chemotherapy
Oncology
Induced Neutropenia
Cytoprotection
Patient Access Network
Chronic Myelocytic
Pancreatic Cancer
(866) 316-7263
Leukemia
www.patientaccessnetwork.org
Prostate Cancer
Colorectal Cancer
Psoriasis
Patient Advocate Foundation (866)
Cutaneous T-Cell
Psoriatic Arthritis
512-3861
Lymphoma
Rheumatoid
www.pap.patientadvocate.org
Gastrointestinal
Arthritis
Stromal TumorsHead
Secondary
Patient Services Inc.
& Neck Cancer
Hyperparathyroidism
(800) 366-7741
Growth Hormone
www.uneedpsi.org
Wilm's Tumor
Deficiency
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Key Changes for 2007
Open enrollment for 2007 occurs November 15, 2006 through
December 31, 2006
2007 enrollment period allows one chance to either select or change
plan
Dual eligibles and some limited income beneficiaries are auto-enrolled
Beneficiaries turning 65 in 2007 have 7 month enrollment window
Plan options increased
All enrollees have option to change plans during enrollment window
Some plans are not continuing into CY 2007 and beneficiaries will need
enroll in another plan
Beneficiaries satisfied with current plan will not need to take action
Some patients who were automatically eligible and enrolled in
the Low Income Subsidy in 2006 will no longer be automatically
eligible and will need to reaapply.
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Figure 4 - Number of Medicare Part D
Plans by Region (2007)
53
57
61
53
54
54
51
57
56
66
61
56
54
56
54
53
55
53
53
55
51
57
57
59
53
57
58
53
56
60
53
45
58
46
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Figure 5 - Increase in the Number of Part
D Plans by Region (2006 to 2007)
12
12
15
12
9
14
7
13
12
14
DE
18
947
10
14
13
12
12
13
12
8
18
15
16
18
10
14
18
19
14
13
14
18
15
17
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Variability Among Plans Remains in 2007
Part D premiums in CY 2007 range from less than $2 per
month to over $135 per month. There are, however, many
premiums below the national average of $24.95 per month.
60% (1,157) of Part D plans offer $0 deductible options. That
is over 300 more plans providing first dollar coverage than
last year.
The maximum national standard deductible is $265.00.
And the number of plans providing some form of coverage
through the gap nearly doubled from 220 to 550 (29% of all
plans)
25 plans (1%) report coverage through the gap for all formulary
drugs
465 Plans (24%) limit coverage in the gap to generics only.
Catastrophic Coverage: Catastrophic coverage is 5% for
covered drugs after the beneficiary has incurred a true out-
of-pocket of $3850.
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Two Key Challenges that Remain for
Patients: Plan Assessment and Selection
Enhancements to Plan Finder (www.medicare.gov) will
assist both patients and their advocates
Changes in the layout and design of the tool based on usability
testing.
A decrease in the number of steps leading to plan comparisons
and results.
Total Monthly Cost Estimator functionality will provide a graph
of the month-by-month cost share for a selected plan. In this
way, users will be able to view how their cost share may
change on a monthly basis as reflected by the coverage levels
of the drug benefit.
The information will reflect the beneficiary's low income
subsidy status as well as their drug list and pharmacy
selection.
The revised plan finder tool is accessed at
www.medicare.gov and were released mid-October with
2007 updates.
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Figure 8 Resources to Help Navigate Part D
Source of
Services Provided
Contact Information
Information
Patient Assistance and
Patent Support Solutions (PSS)
Manufacturer Sponsored
Reimbursement Support Services
1-888-423-5436
Programs
Referrals to co-pay assistance
www.pssprogram.com
programs
Drug Plan finder Tool (revised
Centers For Medicare
October 12, 2006)
www.medicare.gov
and Medicaid Services
Formulary Finder Tool
1-800-Medicare
(CMS)
Medicare Plan Comparison Tool
Local SSA office
Social Security
Information on applying for
or
Administration (SSA)
additional assistance
www.socialsecurity.gov
State Health Insurance
Programs (SHIP)
May be able to provide wrap around
or
coverage or information on financial
Contact your local SHIP or SPAP
State Pharmacy
assistance
Assistance Programs
(SPAP)
www.eldercare.gov
Additional Online
www.accesstobenefits.org
www.medicarerxeducation.org
Resources:
www.medicarerights.org
www.rxassist.org
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Resources to Help
1-800 Medicare has counselors that not only assist with questions about the
Part D benefit but can also walk callers who do not have internet access
through the Medicare Drug Plan Finder Tool in order to help the beneficiary
narrow down their options for plan selection.
Patients who need extra help can either go to their social security
administration's local office or complete the application process online at
www.socialsecurity.gov.
Again, if you have a State Pharmacy Assistance Program in your area, that
program may be providing extra help to Part D enrollees. You or your patient
will need to contact your local SPAP to confirm what kind of coverage is
available. Local State Health Insurance Programs or SHIPs are also available
to provide education on navigating the choices of Part D, however they do not
provide any insurance or wrap around coverage. A list of local SHIPs can be
found online on the Medicare website.
The Access to Benefits Coalition is working through local community
coalitions to provide information to beneficiaries, their families, and their
healthcare providers. Their focus includes helping beneficiaries with limited
incomes know about and make the best use of all available resources for
accessing prescription drugs and reducing their costs. You can find contact
information for your local coalition on this website
www.medicarerights.org provides up-to-date information and the most recent
news associated with Medicare Part D.
www.medicarerxeducation.org includes frequently asked questions, a
Medicare Part D checklist to help beneficiaries make an enrollment decision,
and other useful resources for beneficiaries.
www.eldercare.gov helps beneficiaries and providers locate Medicare Part D
educational support in their communities.
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