11

Medicare Part DMedicare Part DThe New Prescription Drug The New Prescription Drug Benefit and Implications for Benefit and Implications for

CARE Act ClientsCARE Act Clients

Mary ViennaDivision of Training and Technical AssistanceHIV/AIDS BureauHealth Resources and Services AdministrationDepartment of Health and Human Services

22

Medicare Part D and Ryan WhiteMedicare Part D and Ryan WhiteOverviewOverview

The new Medicare benefit called Medicare The new Medicare benefit called Medicare Part DPart D

How that will change care for our clients How that will change care for our clients on Medicareon Medicare

How it will impact granteesHow it will impact grantees

33

Medicaid versus MedicareMedicaid versus Medicare MedicaidMedicaid

Federal and State program Federal and State program with State flexibilitywith State flexibility

Means-testedMeans-tested• Takes into account financial Takes into account financial

resourcesresources Poor ANDPoor AND

• Disabled on SSIDisabled on SSI• Parents, children, pregnant Parents, children, pregnant

women women • Medically NeedyMedically Needy

Prescription drug benefitPrescription drug benefit 200,000 with HIV/AIDS200,000 with HIV/AIDS

(44% of those in care)(44% of those in care) $10.4 billion (Federal and $10.4 billion (Federal and

State) in 2005State) in 2005

MedicareMedicare Federal programFederal program No means testingNo means testing 65 or older OR65 or older OR Permanently disabledPermanently disabled

• Under 65 and receiving SSDI Under 65 and receiving SSDI for 2 yearsfor 2 years

No prescription drug benefitNo prescription drug benefit Approx 80,000 with HIV/AIDS Approx 80,000 with HIV/AIDS (19% of those in care) (19% of those in care)

• More likely to have AIDS More likely to have AIDS diagnosis and T4 count diagnosis and T4 count

0-199*0-199* $2.9 billion in 2005$2.9 billion in 2005

•SOURCE: Bozzette, et al. “The Care of HIV-Infected Adults in the United States.” NEJM, Vol. 339, No. 26. December, 1998

44

What is Dual Eligible?What is Dual Eligible?

70-85% of Medicare 70-85% of Medicare beneficiaries with beneficiaries with HIV/AIDS also qualify HIV/AIDS also qualify for Medicaidfor Medicaid

Disabled, poor and at Disabled, poor and at end-stage illness end-stage illness

Use Medicaid for Use Medicaid for access to medicationsaccess to medications

Medicaid 200,000

Medicare60,000 - 80,000

Dual Eligible50,000 – 60,000

People Living with HIV/AIDS

55

Medicare Modernization Act Medicare Modernization Act

Medicare Prescription Drug, Improvement Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and Modernization Act (MMA) of 2003 signed into law on December 8, 2003signed into law on December 8, 2003

Biggest change to Medicare in 40 years Biggest change to Medicare in 40 years Adds a prescription drug benefit to Adds a prescription drug benefit to

Medicare called Medicare Part DMedicare called Medicare Part D Benefit starts January 1, 2006Benefit starts January 1, 2006

66

Basic Prescription Drug BenefitBasic Prescription Drug Benefit Enrollment period from November 15, 2005 to May 15, 2006Enrollment period from November 15, 2005 to May 15, 2006

Medicare beneficiary chooses to enroll in Medicare Part DMedicare beneficiary chooses to enroll in Medicare Part D Medicare beneficiary then chooses either:Medicare beneficiary then chooses either:

• A stand-alone prescription drug plan [PDP] for those in traditional fee-A stand-alone prescription drug plan [PDP] for those in traditional fee-for-service (Part A and B) Medicare for-service (Part A and B) Medicare

• A managed care plan (Medicare Advantage) that includes a prescription A managed care plan (Medicare Advantage) that includes a prescription drug plan [MA-PD] for those in Part C drug plan [MA-PD] for those in Part C

Beneficiaries will have a choice of at least two prescription drug Beneficiaries will have a choice of at least two prescription drug plansplans

Choices and plans will vary between regionsChoices and plans will vary between regions Plans have flexibility (subject to certain constraints) to establish varying Plans have flexibility (subject to certain constraints) to establish varying

features:features: Levels of cost-sharing requirements and coverage limits other than Levels of cost-sharing requirements and coverage limits other than

“standard” coverage“standard” coverage Lists of drugs to include on their formulary, and on which tier Lists of drugs to include on their formulary, and on which tier Cost management toolsCost management tools

77

Basic Prescription Drug BenefitBasic Prescription Drug Benefit Generally, people are enrolled in a plan for a year. In Generally, people are enrolled in a plan for a year. In

special circumstances people can change plans. Dual special circumstances people can change plans. Dual eligibles can change plans at any time.eligibles can change plans at any time.

Expected premium in 2006 of $32.20 per month but will Expected premium in 2006 of $32.20 per month but will vary by planvary by plan

Basic benefit will have deductibles, coinsurance and co-Basic benefit will have deductibles, coinsurance and co-payspays

People with limited resources will receive low-income People with limited resources will receive low-income subsidies (LIS) for these costssubsidies (LIS) for these costs

Most Medicare beneficiaries with HIV/AIDS will qualify for some Most Medicare beneficiaries with HIV/AIDS will qualify for some type of LIStype of LIS

CMS pays subsidies directly to the planCMS pays subsidies directly to the plan All beneficiary costs and subsidy eligibility will be All beneficiary costs and subsidy eligibility will be

adjusted annuallyadjusted annually

88

Basic Prescription Drug BenefitBasic Prescription Drug Benefit

This benefit is different for MedicareThis benefit is different for Medicare Subsidies are means tested Subsidies are means tested Benefit will vary by regionBenefit will vary by region Implementation requires coordination between Implementation requires coordination between

CMS, the Social Security Administration and CMS, the Social Security Administration and State Medicaid AgenciesState Medicaid Agencies

Many Medicare beneficiaries have other drug Many Medicare beneficiaries have other drug coverage--requires coordination (e.g., retiree coverage--requires coordination (e.g., retiree plans, VA, Tricare)plans, VA, Tricare)

99

Medicare Part D and Dual EligiblesMedicare Part D and Dual Eligibles

As of January 1, 2006, Medicaid will no As of January 1, 2006, Medicaid will no longer provide federal matching funds for longer provide federal matching funds for Medicare beneficiaries’ prescription drug Medicare beneficiaries’ prescription drug coveragecoverage

Dual eligibles will be switched to Medicare Dual eligibles will be switched to Medicare for drug coveragefor drug coverage

Impact dependent on differences between Impact dependent on differences between previous State Medicaid plan and previous State Medicaid plan and Medicare drug plans available in the areaMedicare drug plans available in the area

1010

Medicare Part D and Dual EligiblesMedicare Part D and Dual Eligibles

The switch from Medicaid to Medicare will The switch from Medicaid to Medicare will take place on January 1, 2006take place on January 1, 2006 No transitional periodNo transitional period

To ensure continuity of drug coverage, To ensure continuity of drug coverage, CMS will auto-enroll all dual eligibles and CMS will auto-enroll all dual eligibles and notify them of their plan assignment in notify them of their plan assignment in OctoberOctober

Dual eligibles can choose another plan at Dual eligibles can choose another plan at any time – no annual election periodany time – no annual election period

1111

Ensuring a Smoother TransitionEnsuring a Smoother Transition

PDPs must have a transition process for PDPs must have a transition process for new enrollees, with outreach efforts and a new enrollees, with outreach efforts and a transition timeframe to introduce formulary transition timeframe to introduce formulary requirementsrequirements

1212

Standard Benefit: Beneficiary Cost Standard Benefit: Beneficiary Cost Per Year (for 2006), Excluding LISPer Year (for 2006), Excluding LIS

Expected monthly premium of $32.20 Expected monthly premium of $32.20 $250 deductible$250 deductible 25% coinsurance from $251 to $2,250*25% coinsurance from $251 to $2,250* 100% coinsurance from $2,251 to $5,100 100% coinsurance from $2,251 to $5,100

(coverage gap commonly referred to as the (coverage gap commonly referred to as the “donut hole”)“donut hole”)

Catastrophic coverage level: co-pay of 5% or Catastrophic coverage level: co-pay of 5% or $2/$5 (whichever is greater) after total drug $2/$5 (whichever is greater) after total drug costs reach $5,100 AND beneficiary has paid costs reach $5,100 AND beneficiary has paid $3,600 in true out-of-pocket costs (TrOOP)$3,600 in true out-of-pocket costs (TrOOP)

•Coinsurance is a term used in Medicare Part D that refers to the beneficiary’s contribution toward prescription drug costs until the catastrophic coverage limit has been reached

1313

Standard Benefit in 2006Standard Benefit in 2006

$250 $2250 $5100

$ +

Beneficiary Liability

DeductibleCoverage

Gap

Total Spending

≈ 95%

80% Reinsurance

15% Plan Pays

Catastrophic

Coverage

5% Coinsurance

Medicare Pays Reinsurance

75% Plan Pays

25% Coinsurance

Out-of-pocket

Threshold

Direct Subsidy/Beneficiary Premium

$750 $3600 TrOOPTotal

BeneficiaryOut-Of-Pocket

$250

1414

Case Study: Peter Jones Case Study: Peter Jones 65 years old, HIV positive, aged into Medicare65 years old, HIV positive, aged into Medicare Income $1,600 per month (200% FPL)Income $1,600 per month (200% FPL) Antiretroviral regimen is Efavirenz (Sustiva) + FTC/TDF (Truvada)Antiretroviral regimen is Efavirenz (Sustiva) + FTC/TDF (Truvada) Drugs cost $1,300 per month Drugs cost $1,300 per month Peter pays:Peter pays:

$32.20 per month in premiums $32.20 per month in premiums Month 1: $250 deductible plus $262 (25% coinsurance) towards $1050 balance Month 1: $250 deductible plus $262 (25% coinsurance) towards $1050 balance Month 2: $237 coinsurance (25% of $950 balance to reach $2250 co-insurance Month 2: $237 coinsurance (25% of $950 balance to reach $2250 co-insurance

limit) plus $350 (100% coinsurance for balance of $1300 pharmacy cost)limit) plus $350 (100% coinsurance for balance of $1300 pharmacy cost) Month 3: $1,300 prescription cost (100% coinsurance) [Peter has now paid Month 3: $1,300 prescription cost (100% coinsurance) [Peter has now paid

$2,399 out-of-pocket towards his drugs]$2,399 out-of-pocket towards his drugs] Month 4: $1,201 prescription cost (100% coinsurance for a total of $3,600 in out-Month 4: $1,201 prescription cost (100% coinsurance for a total of $3,600 in out-

of-pocket costs). Total drug costs are also $5,200 (above the $5,100 limit) so the of-pocket costs). Total drug costs are also $5,200 (above the $5,100 limit) so the catastrophic coverage level has been reached.catastrophic coverage level has been reached.

Months 5-12: $65 per month (5% co-pay)Months 5-12: $65 per month (5% co-pay) Peter pays $4,506.40 for the year [$386.40 in premiums, $3600 out-of-Peter pays $4,506.40 for the year [$386.40 in premiums, $3600 out-of-

pocket and $520 in co-pays]pocket and $520 in co-pays]

1515

Who Qualifies for a Who Qualifies for a Low Income Subsidy (LIS)?Low Income Subsidy (LIS)?

Medicare beneficiaries who are automatically Medicare beneficiaries who are automatically qualified for a full subsidy (known as “deemed qualified for a full subsidy (known as “deemed eligible”) are :eligible”) are : Dual eligible (receive full Medicaid benefits)Dual eligible (receive full Medicaid benefits)

• 70-85% of Medicare beneficiaries living with HIV/AIDS70-85% of Medicare beneficiaries living with HIV/AIDS In a Medicare Savings ProgramIn a Medicare Savings Program

• Qualified Medicare Beneficiary (QMB)Qualified Medicare Beneficiary (QMB)• Specified Low-Income Medicare Beneficiary (SLMB)Specified Low-Income Medicare Beneficiary (SLMB)• Qualifying Individual (QI) Qualifying Individual (QI)

Receiving SSI benefits Receiving SSI benefits Medicare will notify them May-JuneMedicare will notify them May-June

Dual eligibles will be auto-enrolled in October and Dual eligibles will be auto-enrolled in October and may choose a different planmay choose a different plan

1616

Who Qualifies for a Who Qualifies for a Low Income Subsidy (LIS)?Low Income Subsidy (LIS)?

Other Medicare beneficiaries who qualify for a full or partial subsidy, Other Medicare beneficiaries who qualify for a full or partial subsidy, but not automatically, are:but not automatically, are:

Single with an annual income below $14,355 and resources less than Single with an annual income below $14,355 and resources less than $11,500 in 2005*$11,500 in 2005*

Married with a combined annual income below $19,245 and resources Married with a combined annual income below $19,245 and resources less than $23,000 in 2005*less than $23,000 in 2005*

These individuals must apply to the Social Security Administration These individuals must apply to the Social Security Administration or Medicaid State Agency to qualifyor Medicaid State Agency to qualify

SSA sending nearly 19 million letters and applications this summer. SSA sending nearly 19 million letters and applications this summer. Can apply by mail, SSA’s 1-800, online, or in person.Can apply by mail, SSA’s 1-800, online, or in person.

Medicaid State Agencies who qualify Medicare beneficiaries for LIS Medicaid State Agencies who qualify Medicare beneficiaries for LIS must also screen them for eligibility for Medicaid and Medicare must also screen them for eligibility for Medicaid and Medicare Savings Programs Savings Programs

Medicare will enroll those who don’t choose a plan by May 15Medicare will enroll those who don’t choose a plan by May 15

*Higher in Alaska, Hawaii and for certain reasons

1717

LIS for Dual EligiblesLIS for Dual Eligibles

No premiums unless beneficiary chooses an No premiums unless beneficiary chooses an above-average cost PDPabove-average cost PDP Then pay balance of premium costThen pay balance of premium cost

No deductible or coinsuranceNo deductible or coinsurance Prescription co-payPrescription co-pay

• Below 100% FPL: $1 generic/$3 brand drug co-payBelow 100% FPL: $1 generic/$3 brand drug co-pay• Above 100% FPL: $2 generic/$5 brand drug co-payAbove 100% FPL: $2 generic/$5 brand drug co-pay

No cost after total drug costs of $5,100 and No cost after total drug costs of $5,100 and $3,600 out-of-pocket limit is reached $3,600 out-of-pocket limit is reached

Subsidy counts toward out-of-pocket costsSubsidy counts toward out-of-pocket costs What someone pays out-of-pocket + what Medicare What someone pays out-of-pocket + what Medicare

pays as the extra help = $3,600 pays as the extra help = $3,600

1818

Case Study: Jane MatthewsCase Study: Jane Matthews

On SSDI, Medicare and Medicaid (dual eligible)On SSDI, Medicare and Medicaid (dual eligible) SSDI benefit $780/month (less than100% FPL)SSDI benefit $780/month (less than100% FPL) Antiretroviral regimen is Sustiva + Truvada Antiretroviral regimen is Sustiva + Truvada Drugs cost $1,300 per monthDrugs cost $1,300 per month Jane pays $6 in co-pays per month for two scripts Jane pays $6 in co-pays per month for two scripts

(income < 100% FPL so $3 brand name co-pay applies) (income < 100% FPL so $3 brand name co-pay applies) for three monthsfor three months

By 4By 4thth month, total drug costs of $5,200 exceeds $5,100 month, total drug costs of $5,200 exceeds $5,100 catastrophic coverage level ($1,300 x 4)catastrophic coverage level ($1,300 x 4)

No cost to Jane after thatNo cost to Jane after that Jane pays $18 for the year [3 months of $6 co-pay]Jane pays $18 for the year [3 months of $6 co-pay]

1919

Full Low-Income Subsidy Full Low-Income Subsidy Those eligible for this subsidy include Medicare beneficiaries who Those eligible for this subsidy include Medicare beneficiaries who

are:are: In a Medicare Savings Program (QMB, SLMB, QI)In a Medicare Savings Program (QMB, SLMB, QI) Receiving SSI benefits Receiving SSI benefits Have an income below 135% FPL and resources of no more than Have an income below 135% FPL and resources of no more than

$7,500 single/$12,000 per couple*$7,500 single/$12,000 per couple* No premiums unless beneficiary chooses an above-average cost No premiums unless beneficiary chooses an above-average cost

PDPPDP No deductible or coinsuranceNo deductible or coinsurance Prescription co-payPrescription co-pay

• $2 generic/$5 brand drug co-pay$2 generic/$5 brand drug co-pay No cost after total drug costs of $5,100 and $3,600 out-of-pocket No cost after total drug costs of $5,100 and $3,600 out-of-pocket

limit is reachedlimit is reached Subsidy counts toward out-of-pocket costs and reaching Subsidy counts toward out-of-pocket costs and reaching

catastrophic levelcatastrophic level

•Adjusted annually; resources include burial exclusion of $1500 for individual, $3,000 per couple.

2020

Case Study: Joseph BlackCase Study: Joseph Black

On SSDI and MedicareOn SSDI and Medicare SSDI benefit is $950/month (less than120% FPL)SSDI benefit is $950/month (less than120% FPL) Antiretroviral regimen is Sustiva + Truvada Antiretroviral regimen is Sustiva + Truvada Drugs cost $1,300 per monthDrugs cost $1,300 per month Joseph pays $10 in co-pays per month for two scripts Joseph pays $10 in co-pays per month for two scripts

($5 brand name co-pay times two) for three months($5 brand name co-pay times two) for three months By 4By 4thth month, total drug costs of $5,200 exceeds $5,100 month, total drug costs of $5,200 exceeds $5,100

catastrophic coverage level ($1,300 x 4)catastrophic coverage level ($1,300 x 4) No cost to Joseph after thatNo cost to Joseph after that Joseph pays $30 for the year [3 months of $10 co-pay]Joseph pays $30 for the year [3 months of $10 co-pay]

2121

Partial Low Income Subsidy (2006)*Partial Low Income Subsidy (2006)*

Those eligible for this subsidy include Medicare Those eligible for this subsidy include Medicare beneficiaries who are:beneficiaries who are:

Below 150% FPL and with resources of no more $11,500 Below 150% FPL and with resources of no more $11,500 (individuals) and $23,000 (couples) (individuals) and $23,000 (couples)

BenefitBenefit Sliding scale premium Sliding scale premium $50 deductible$50 deductible 15% coinsurance up to catastrophic coverage level15% coinsurance up to catastrophic coverage level $2 generic/$5 brand name drug co-pay after total drug costs of $2 generic/$5 brand name drug co-pay after total drug costs of

$5,100 and $3,600 out-of-pocket limit is reached $5,100 and $3,600 out-of-pocket limit is reached Subsidy counts toward out-of-pocket costs and reaching Subsidy counts toward out-of-pocket costs and reaching

catastrophic coverage levelcatastrophic coverage level* Adjusted annually

2222

Sliding Scale Premium AssistanceSliding Scale Premium Assistance

FPL & Assets FPL & Assets % of Premium % of Premium Subsidy AmountSubsidy Amount

Income at or below 135% FPL, and with assets that do Income at or below 135% FPL, and with assets that do not exceed $11,500 (individuals) or $23,000 (couples) not exceed $11,500 (individuals) or $23,000 (couples)

100% 100%

Income above 135% FPL but at or below 140% FPL, Income above 135% FPL but at or below 140% FPL, and with assets that do not exceed $11,500 and with assets that do not exceed $11,500 (individuals) or $23,000 (couples) (individuals) or $23,000 (couples)

75% 75%

Income above 140% FPL but at or below 145% FPL, Income above 140% FPL but at or below 145% FPL, and with assets that do not exceed $11,500 and with assets that do not exceed $11,500 (individuals) or $23,000 (couples) (individuals) or $23,000 (couples)

50% 50%

Income above 145% FPL but below 150% FPL, and Income above 145% FPL but below 150% FPL, and with assets that do not exceed $11,500 (individuals) or with assets that do not exceed $11,500 (individuals) or $23,000 (couples) $23,000 (couples)

25% 25%

*Numbers are for 2006

2323

Case Study: Jason SmithCase Study: Jason Smith On SSDI, Medicare and small private disability insurance benefitOn SSDI, Medicare and small private disability insurance benefit Income $1,100 per month (138% FPL)Income $1,100 per month (138% FPL) Antiviral regimen is Sustiva + Truvada Antiviral regimen is Sustiva + Truvada Drugs cost $1,300 per month Drugs cost $1,300 per month Jason pays:Jason pays:

About $8 per month in premiums (75% subsidy of $32.20)About $8 per month in premiums (75% subsidy of $32.20) Month 1: $50 deductible plus $187.50 (15% coinsurance of $1,250 Month 1: $50 deductible plus $187.50 (15% coinsurance of $1,250

balance)balance) Month 2: $195 coinsurance (15% coinsurance of $1,300)Month 2: $195 coinsurance (15% coinsurance of $1,300) Month 3: $195 coinsurance (total drug costs $3,900) Month 3: $195 coinsurance (total drug costs $3,900) Month 4: $180 coinsurance (on $1200 balance of $5100 total drug cost Month 4: $180 coinsurance (on $1200 balance of $5100 total drug cost

limit for catastrophic coverage level)limit for catastrophic coverage level) Months 5-12: $10 per month ($5 brand name co-pay on two scripts)Months 5-12: $10 per month ($5 brand name co-pay on two scripts)

Jason pays $983 for the year [$96 in premiums, $807.50 in Jason pays $983 for the year [$96 in premiums, $807.50 in deductible and coinsurance, $80 in co-pays]deductible and coinsurance, $80 in co-pays]

2424

Standard Drug Benefit for beneficiaries with income >150% FPL or less than 150% FPL but more than the resource limit $32.20 monthly estimated premium

Beneficiary PaysPlan Pays

Full-benefit dual eligibles with income 100% FPL*$0 monthly premium and no deductible $5100 $ +

100 %$1 - $3 co-pays apply

*Cost sharing is $0 if the beneficiary is a full-benefit dual eligible and institutionalized.

Full-benefit dual eligibles with income >100% FPL$0 monthly premium and no deductible

$250 $2250 $5100 $ +

75 % About 95%

$5100 $ +

$2 - $5 co-pays apply

100 %

Numbers are for 2006

2525

SSI Recipients, Medicare Savings Programs Groups, Applicants with income < 135% FPL who also meet resource test ($7,500 individual / $12,000 couple)$0 monthly premium and no deductible

Applicants with income <150% FPL who also meet resource test ($11,500 individual / $23,000 couple)Sliding scale premium assistance

$5100

85 %

$50

$2 - $5 co-pays apply

Numbers are for 2006

Beneficiary PaysPlan Pays

$5100 $ +

$2 - $5 co-pays apply

100 %

2626

How to Apply for HelpHow to Apply for Help The Social Security Administration (SSA) will mail The Social Security Administration (SSA) will mail

applications to people who may qualifyapplications to people who may qualify• Those who think they may qualify shouldThose who think they may qualify should

• Complete the application formComplete the application form Mail it to the address on the back of the formMail it to the address on the back of the form Use the enclosed postage-paid envelopeUse the enclosed postage-paid envelope Use original forms onlyUse original forms only Do not photocopy the applicationDo not photocopy the application Photocopying the application could delay timely Photocopying the application could delay timely

processingprocessing• Apply--even if they’re not sure they qualifyApply--even if they’re not sure they qualify

2727

Other Ways to Apply for Extra HelpOther Ways to Apply for Extra Help

Apply on the Social Security website at Apply on the Social Security website at http://www.socialsecurity.govhttp://www.socialsecurity.gov

Apply at a Social Security sponsored eventApply at a Social Security sponsored event Apply by phone by calling Social Security at Apply by phone by calling Social Security at

1-800-772-12131-800-772-1213 Apply at a State Medicaid OfficeApply at a State Medicaid Office Apply at a community event that will offer Apply at a community event that will offer

opportunities to applyopportunities to apply State Health Insurance Program (SHIP) State Health Insurance Program (SHIP)

counselors will offer free personalized counseling counselors will offer free personalized counseling starting in the fall of 2005starting in the fall of 2005

2828

Further Help With CostsFurther Help With Costs

AIDS Drug Assistance Programs (ADAP), in AIDS Drug Assistance Programs (ADAP), in accordance with State program policy, can pay:accordance with State program policy, can pay: PremiumsPremiums DeductibleDeductible Coinsurance (15%, 25% and 100%)Coinsurance (15%, 25% and 100%) Co-paysCo-pays

ADAP contributions do not count toward the ADAP contributions do not count toward the $3,600 in TrOOP costs needed to reach the $3,600 in TrOOP costs needed to reach the catastrophic coverage levelcatastrophic coverage level

2929

What Counts Toward TrOOP?What Counts Toward TrOOP?

Payments made by:Payments made by: The beneficiaryThe beneficiary Another individual (e.g. family or friends)Another individual (e.g. family or friends) Certain charitiesCertain charities A State Pharmacy Assistance Program (SPAP)A State Pharmacy Assistance Program (SPAP) A personal health savings vehicle (Flexible Spending A personal health savings vehicle (Flexible Spending

Accounts, Health Savings Accounts, and Medical Accounts, Health Savings Accounts, and Medical Savings Accounts)Savings Accounts)

Co-pays waived by a pharmacyCo-pays waived by a pharmacy CMS to the plan as low income subsidiesCMS to the plan as low income subsidies

3030

What Doesn’t Counts Toward What Doesn’t Counts Toward TrOOP?TrOOP?

PremiumsPremiums Payments made by:Payments made by:

AIDS Drug Assistance Programs (ADAP)AIDS Drug Assistance Programs (ADAP) Group health plans (employer/retiree plans)Group health plans (employer/retiree plans) Federal government programs (e.g., Indian Health, Federal government programs (e.g., Indian Health,

Medicaid,Tricare, VA, FQHCs) Medicaid,Tricare, VA, FQHCs) State-run programs that are not SPAPsState-run programs that are not SPAPs

• Workman’s CompensationWorkman’s Compensation Automobile/No-Fault/LiabilityAutomobile/No-Fault/Liability Part D plans’ supplemental or enhanced benefitsPart D plans’ supplemental or enhanced benefits

3131

What Doesn’t Count Toward What Doesn’t Count Toward TrOOP?TrOOP?

Payments never count toward TrOOP Payments never count toward TrOOP when made for:when made for: Non-covered drugs that are not obtained Non-covered drugs that are not obtained

through an exceptions or appeal processthrough an exceptions or appeal process Drugs purchased outside the U.S.Drugs purchased outside the U.S. Non-Part D drugsNon-Part D drugs

• Part B drugsPart B drugs• Drugs excluded in the Part D benefit (e.g. Drugs excluded in the Part D benefit (e.g.

benzodiazepines, barbiturates) benzodiazepines, barbiturates)

3232

Access to Drugs: Formulary IssuesAccess to Drugs: Formulary Issues PDPs have the flexibility (within certain constraints) to establish:PDPs have the flexibility (within certain constraints) to establish:

Different levels of cost-sharing requirements and coverage limits other Different levels of cost-sharing requirements and coverage limits other than “standard” coveragethan “standard” coverage

Lists of drugs to include on their formularyLists of drugs to include on their formulary Tiers of drug co-payments Tiers of drug co-payments Cost management toolsCost management tools

If a plan uses a formulary, it must include at least two drugs in each If a plan uses a formulary, it must include at least two drugs in each therapeutic category and classtherapeutic category and class

The U.S. Pharmacopoeia (USP) has designed a model guideline of The U.S. Pharmacopoeia (USP) has designed a model guideline of therapeutic categories and classes of drugs. Medicare drug plans therapeutic categories and classes of drugs. Medicare drug plans can use the USP model but they are not required to do so.can use the USP model but they are not required to do so.

CMS will review formularies to assure that prescription drugs for CMS will review formularies to assure that prescription drugs for HIV/AIDS are included HIV/AIDS are included   

A prescription drug plan will not be approved if the formulary design A prescription drug plan will not be approved if the formulary design would discourage enrollment of certain groupswould discourage enrollment of certain groups

3333

5858 AntiviralsAntivirals Anti-CMV AgentsAnti-CMV Agents

5959 Anti-HIV Agents, Fusion InhibitorsAnti-HIV Agents, Fusion Inhibitors

6060 Anti-HIV Agents, Protease InhibitorsAnti-HIV Agents, Protease Inhibitors

6161 Anti-HIV Agents, Non-nucleoside Reverse Anti-HIV Agents, Non-nucleoside Reverse Transcriptase InhibitorsTranscriptase Inhibitors

6262 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase InhibitorsTranscriptase Inhibitors

6363 Anti-HIV Agents, OtherAnti-HIV Agents, Other

6464 Antihepatitis Agents, InterferonsAntihepatitis Agents, Interferons

6565 Antihepatitis Agents, VaccinesAntihepatitis Agents, Vaccines

6666 Antihepatitis Agents, OtherAntihepatitis Agents, Other

HIV Drug Categories in USP Model Formulary

3434

Access to Drugs: Formulary IssuesAccess to Drugs: Formulary Issues

  In order to protect against discrimination, CMS In order to protect against discrimination, CMS will review six drug classes in the formulary to will review six drug classes in the formulary to ensure there is access to all drugs in that class:ensure there is access to all drugs in that class: AntidepressantsAntidepressants AntipsychoticsAntipsychotics AnticonvulsantsAnticonvulsants AntiretroviralsAntiretrovirals AntineoplasticsAntineoplastics ImmunosuppressantsImmunosuppressants

3535

Issues for HIV/AIDS CareIssues for HIV/AIDS Care Access to medicationsAccess to medications

Two drugs in each therapeutic class or category with six exceptionsTwo drugs in each therapeutic class or category with six exceptions True drug benefit will be determined by plan formularyTrue drug benefit will be determined by plan formulary Plan can change drugs in formulary while the non-dual beneficiary must Plan can change drugs in formulary while the non-dual beneficiary must

remain in plan for one yearremain in plan for one year Reliance on exceptions and appeals processReliance on exceptions and appeals process

CostsCosts Prevents ADAP from contributing toward TrOOP costsPrevents ADAP from contributing toward TrOOP costs Drugs not covered by plan do not count towards catastrophic coverage Drugs not covered by plan do not count towards catastrophic coverage

levellevel Unlike Medicaid, no access to medication for failure to pay co-payUnlike Medicaid, no access to medication for failure to pay co-pay

• Pharmacy can waive co-payPharmacy can waive co-pay• 60 and 90 day prescriptions lower co-pay costs60 and 90 day prescriptions lower co-pay costs

Requires those eligible for full low-income subsidies to pay premium Requires those eligible for full low-income subsidies to pay premium balance for above-average cost plansbalance for above-average cost plans

3636

Issues and Challenges for BeneficiariesIssues and Challenges for Beneficiaries

Deciding whether to enroll in Part D in 2006 if they have Deciding whether to enroll in Part D in 2006 if they have a choicea choice

Financial penalties for delayed enrollment Financial penalties for delayed enrollment Enrolling in low-income subsidy programEnrolling in low-income subsidy program

Will beneficiaries know they are eligible?Will beneficiaries know they are eligible? Will they sign up?Will they sign up?

Comparing plans and deciding which to joinComparing plans and deciding which to join Could face wide variations in premiums, benefit design, Could face wide variations in premiums, benefit design,

formularies and preferred drug lists each year.formularies and preferred drug lists each year. Facing potential consequences of a poor plan choiceFacing potential consequences of a poor plan choice

Annual enrollment period for non-dualsAnnual enrollment period for non-duals While the plan is responsible for tracking TrOOP costs, While the plan is responsible for tracking TrOOP costs,

the beneficiary is expected to inform the plan of other the beneficiary is expected to inform the plan of other prescription drug benefitsprescription drug benefits

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Challenges for Beneficiaries with HIV/AIDS are Challenges for Beneficiaries with HIV/AIDS are Obligations and Opportunities for Ryan WhiteObligations and Opportunities for Ryan White

Initial transition period raises unique challengesInitial transition period raises unique challenges How to educate ourselvesHow to educate ourselves How to educate dual eligibles and enrolleesHow to educate dual eligibles and enrollees How to ensure a smooth transition for individual health and public health How to ensure a smooth transition for individual health and public health

reasonsreasons Clients will need information and assistance in:Clients will need information and assistance in:

Applying for subsidy programsApplying for subsidy programs Enrolling in Medicare Part DEnrolling in Medicare Part D Choosing a plan that works for themChoosing a plan that works for them

Providers and case managers must know resources available for Providers and case managers must know resources available for helphelp

Once enrolled, clients will look to providers for help with appeals Once enrolled, clients will look to providers for help with appeals and exceptionsand exceptions

Non-dual Medicare clients comfortable on ADAP programs will need Non-dual Medicare clients comfortable on ADAP programs will need to be encouraged to enroll in Medicare Part Dto be encouraged to enroll in Medicare Part D

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It’s Happening FastIt’s Happening Fast May-JuneMay-June 20052005

CMS mails notices to people with Medicare who automatically qualify for the low income subsidy CMS mails notices to people with Medicare who automatically qualify for the low income subsidy and do not need to applyand do not need to apply

Applications for subsidies acceptedApplications for subsidies accepted SummerSummer

SSA mails applications to potential eligibles who don’t automatically qualifySSA mails applications to potential eligibles who don’t automatically qualify October 2005October 2005

2006 “Medicare and You” handbook with comparative drug plan information mailed to every 2006 “Medicare and You” handbook with comparative drug plan information mailed to every beneficiarybeneficiary

Online tool to help select plan on www.Medicare.govOnline tool to help select plan on www.Medicare.gov CMS notifies dual eligibles of the plan Medicare will enroll them in if they do not choose one on CMS notifies dual eligibles of the plan Medicare will enroll them in if they do not choose one on

their own by December 31, 2005their own by December 31, 2005 November 15, 2005November 15, 2005

Beneficiaries can begin enrollment in Medicare Part D by choosing and enrolling in a Medicare Beneficiaries can begin enrollment in Medicare Part D by choosing and enrolling in a Medicare planplan

January 1, 2006January 1, 2006 All dual eligibles switched to MedicareAll dual eligibles switched to Medicare

April 2006April 2006 CMS notifies other people who qualify for the low-income subsidy that if they do not choose a CMS notifies other people who qualify for the low-income subsidy that if they do not choose a

plan by April 2006, CMS will facilitate their enrollment in a plan on their behalf, with coverage plan by April 2006, CMS will facilitate their enrollment in a plan on their behalf, with coverage effective June 1, 2006effective June 1, 2006

May 15, 2006May 15, 2006 Initial enrollment period for Medicare Part D completeInitial enrollment period for Medicare Part D complete

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What’s HAB Doing?What’s HAB Doing?

HAB Medicare WorkgroupHAB Medicare Workgroup Expertise and resource to programs and Expertise and resource to programs and

project officers on Medicare Part Dproject officers on Medicare Part D Technical assistance and outreach planTechnical assistance and outreach plan Venues to reach granteesVenues to reach grantees HAB project officer trainingHAB project officer training HAB website informationHAB website information Qs & AsQs & As

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Who Do I Go To For Answers?Who Do I Go To For Answers?

HAB Project OfficersHAB Project Officers CMS Regional OfficeCMS Regional Office Medicaid State AgencyMedicaid State Agency Social Security AdministrationSocial Security Administration State Health Insurance ProgramState Health Insurance Program State ADAPState ADAP Title I and II programs Title I and II programs HIV and Professional OrganizationsHIV and Professional Organizations

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Website ResourcesWebsite Resources

http://http://hab.hrsa.gov/specialprojects.htmhab.hrsa.gov/specialprojects.htm Medicare Part D webpageMedicare Part D webpage Qs & As Qs & As http://www.hrsa.gov/medicare/HIV/qa.htmhttp://www.hrsa.gov/medicare/HIV/qa.htm LinksLinks

http://www.cms.hhs.gov/medicarereform/pdbmahttp://www.cms.hhs.gov/medicarereform/pdbma Information about Medicare Part DInformation about Medicare Part D

http://www.cms.hhs.gov/medicarereform/AIDS.pdfhttp://www.cms.hhs.gov/medicarereform/AIDS.pdf Medicare HIV/AIDS Fact SheetMedicare HIV/AIDS Fact Sheet

http://www.medicare.govhttp://www.medicare.gov Click on “Learn About Your Medicare Prescription Coverage Click on “Learn About Your Medicare Prescription Coverage

Options”Options” Information for Medicare beneficiariesInformation for Medicare beneficiaries