Medicare Part D - North Texas Myeloma Support...

Medicare Part D

Tracy FosterSenior Vice President, Policy Strategies

Copyright © 2006 Lash Group All rights reserved. 2

Overview

● 3 key points to understand about Part D● Key changes that could impact Medicare

beneficiaries in 2007● Resources for navigating Part D


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


#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.


#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)


Figure 1 – Number of Medicare Part D Plans by Region (2006)

4347 39

38

414343

47

44 43 40 41

43

40

41

52

4138

4142

4242

45

42

45

44

27

29

40

4641

4744 44


#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


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.


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.


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


Figure 2 - States With Qualified State Pharmaceutical Assistance Programs

States with Qualified SPAPS


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


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.


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.


Figure 3 - Copay Assistance Charities

Sample Disease FundsCharities●Hodgkin’s Disease●Kidney Cancer●Lung Cancer●Lymphoma●Multiple Myeloma●Myelodysplastic Syndrome●Non-Hodgkin’s Lymphoma●Oncology Cytoprotection●Pancreatic Cancer●Prostate Cancer●Psoriasis●Psoriatic Arthritis●Rheumatoid Arthritis●Secondary Hyperparathyroidism●Wilm’s Tumor

●Acute Porphyria●Anemia ●Ankylosing Spondylitis●Asthma●Breast Cancer●Chemotherapy Induced Nausea & Vomiting●Chemotherapy Induced Neutropenia●Chronic MyelocyticLeukemia ●Colorectal Cancer●Cutaneous T-Cell Lymphoma●Gastrointestinal Stromal TumorsHead& Neck Cancer ●Growth Hormone Deficiency

Chronic Disease Fund877-968-7233 www.cdfund.org

HeathWell Foundation (800) 675-8416 www.healthwellfoundation.org

National Organization for Rare Disorders(866) 828-8902 www.rarediseases.org

Patient Access Network (866) 316-7263www.patientaccessnetwork.org

Patient Advocate Foundation (866) 512-3861www.pap.patientadvocate.org

Patient Services Inc.(800) 366-7741 www.uneedpsi.org


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.


Figure 4 - Number of Medicare Part D Plans by Region (2007)

5860 53

53

575753

55

5455 53 53

61

54

53

51

5666

5351

59

56

5456

54

57

57

56

45

46

58

61

5753


Figure 5 - Increase in the Number of Part D Plans by Region (2006 to 2007)

DE47

12

1513 14

19

161410

8

1012 13 12

18

14

12

914

1318

18

14

1214

9

15

12

18

17

18

15

1312 7


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.


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.


Figure 6 – New Improved Plan Finder


Figure 7 - Total Monthly Cost Estimator


Figure 8 – Resources to Help Navigate Part D

www.medicare.gov1-800-Medicare

Drug Plan finder Tool (revised October 12, 2006)

Formulary Finder ToolMedicare Plan Comparison Tool

Centers For Medicare and Medicaid Services

(CMS)

www.eldercare.govwww.medicarerxeducation.org

www.rxassist.org

www.accesstobenefits.orgwww.medicarerights.org

Additional Online Resources:

Contact your local SHIP or SPAPMay be able to provide wrap around coverage or information on financial

assistance

State Health Insurance Programs (SHIP)

orState Pharmacy

Assistance Programs (SPAP)

Local SSA officeor

www.socialsecurity.gov

Information on applying for additional assistance

Social Security Administration (SSA)

Patent Support Solutions (PSS)1-888-423-5436

www.pssprogram.com

Patient Assistance and Reimbursement Support Services

Referrals to co-pay assistance programs

Manufacturer Sponsored Programs

Contact InformationServices ProvidedSource of Information


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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