Medicare Part D Symposium

Thursday, September 1, 2005Sacramento, CA

Cathy SenderlingSenior Legislative Advocate, CWDA

Overview

Part D Basics Enrollment Options How Plans Will Work Cost Sharing “Extra Help” Program Potential Impacts and Issues

Part D Basics

Creates new prescription drug coverage program for Medicare

Eliminates state matching funds under Medicaid program

Shifts those funds to the new Medicare program

Part D Basics

All Medicare beneficiaries eligible Different rules for different groups

Coverage begins January 1, 2006 Enrollment Nov 15 ’05 to May 15 ’06 Some individuals automatically enrolled

Low-income beneficiaries can receive “Extra Help” (a.k.a. Low Income Subsidy) Different rules for different groups

Enrollment Options Most beneficiaries must choose and

enroll in a drug plan to get coverage Prescription drug plans (PDPs) Medicare Advantage plans (MA-PDs) Some employers/unions for retirees

Some will be auto-enrolled in a plan Duals – on Nov 15 ’05 QMB/SLMB/QI-1 – on May 15 ’06

Enrollment Options (cont.) People with Medicare can enroll:

Directly with a plan Through a personal representative

Has authority to act on their behalf I.E., Power of Attorney, Public Guardian

By asking others to help them Spouses, friends, relatives Caregivers Advocacy groups

Enrollment Options (cont.) If in Program for All-Inclusive Care for the

Elderly, must get coverage from PACE program Special rules when a person:

Permanently moves to another area Enters/leaves a long-term care facility Involuntarily loses coverage or coverage is reduced

Some can choose not to enroll at all, but there are consequences to waiting Increased premiums (1% increase per month) Applies when moving from coverage that is not as

good as the Medicare coverage

Enrollment Options (cont.) Dual-Eligibles will be impacted

Medicare will now pay for drugs (not Medi-Cal)

Can choose a plan or will be automatically enrolled on Nov 15 ’05

Can change plans after autoenrollment Medi-Cal will pay for some non-covered

prescription drugs QMB/SLMB/QI-1 also impacted

Enrollment Options (cont.)

If enrolled between Nov 15 ’05 and Dec 31 ’05 – Coverage will begin on Jan 1 ’06

If enrolled between Jan 1 ’06 and May 15 ’06 – Coverage begins on first day of month

following the month in which they enroll

How Plans Will Work

Must offer a basic drug benefit “Standard” benefit

May offer supplemental benefits “Enhanced” benefits

Can be flexible in benefit design Example: Enhanced benefit might give

coverage where it would otherwise not be provided (i.e., reduce out-of-pocket)

How Plans Will Work Requirements

Must process applications timely Must notify of acceptance/denial Will track participant deductibles Must have formularies approved by CMS

Marketing to beneficiaries May begin marketing in October ’05 Must follow marketing guidelines

Cost Sharing for those >135% FPL

Premiums About $37/month in 2006 Separate from Part B premium Enhanced coverage may cost more

Deductibles $250 annually

Cost Sharing for those >135% FPL

Beneficiary Copayment Equals 25% from $250 to $2,250 annually 100% between $2,250 and $5,100 5% starting at $5,100 and thereafter

Coverage Gap Beneficiary pays ALL costs between

$2,250 and $5,100 of expenditures Also known as “doughnut hole”

Extra Help Program (LIS)

Aimed at those with limited resources Lower co-pays, premiums, deductibles No coverage gap/doughnut hole Must meet both income and asset tests Must live in the United States Must be enrolled in Medicare

Extra Help Program (LIS) Some automatically enrolled by SSA

Dual eligibles or “Medi-Medi’s” Medicare Savings Program (QMB/SLMB/QI-1) SSI recipients

Others can apply in-person and on-line Eligibility determined by SSA or state DHS Applications available at county Medi-Cal offices Applications also being mailed out by SSA now Applications available at www.ssa.gov

Cost Sharing for those <135% FPL

Premiums None

Deductibles None

Co-Pays $2-$5 for drug costs up to $5,100 None after $5,100 in drug costs

Cost Sharing between 135% - 150%

Premiums Sliding Scale

Deductibles $50 annually

Co-Payments 15% for drug costs of $50 to $5,100 $2-$5 after $5,100 of drug costs

Cost Sharing for Dual Eligibles

Premiums None

Deductibles None

Co-Payments Under 100% FPL: $1-$3 up to $5,100 Above 100% FPL: $2-$5 up to $5,100 None after $5,100 in drug costs

Potential Impacts and Issues Extra Help application/autoenrollment Appeal process Costs to clients and Share of Cost Potential for changes to formularies Provider impacts Impacts across county departments Interaction with state, federal

government, non-profits, advocates

Underscore Importance of:

Outreach Education Training Partnerships

Questions?