MMA Medicare Modernization Act Richard Stefanacci, DO, MGH, MBA, AGSF, CMD Health Policy Institute.
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Transcript of MMA Medicare Modernization Act Richard Stefanacci, DO, MGH, MBA, AGSF, CMD Health Policy Institute.
MMAMedicare
Modernization Act
Richard Stefanacci, DO, MGH, MBA, AGSF, CMD
Health Policy Institute
MMA
Enrollment Outreach
• Education
• Plan Selection
• Authority to Enroll
• Special Enrollment Period
Medicare Prescription Plans
Fallback PDP Adm Fees
PDP Cost
MA - PDP Value
(Traditional Medicare)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$1
$184
$367
$550
$733
$916
$1,099
$1,282
$1,465
$1,648
$1,831
$2,014
$2,197
$2,380
$2,563
$2,746
$2,929
$3,112
$3,295
$3,478
$3,661
$3,844
$4,027
$4,210
$4,393
$4,576
$4,759
$4,942
$5,125
$5,308
$5,491
$5,674
$5,857
$6,040
$6,223
$6,406
$6,589
$6,772
$6,955
W/o
W/
$0 $250 $2250 $5100 $7000
Annual Initial Donut Hole Catastrophic Deductible Benefit No Coverage of Costs Coverage
W/O
W/
< 100% FPL - $1/3 <135% - $2/5
135%-150%
©Richard Stefanacci, DO, MGH, MBA, AGSF, CMD
Formulary Requirements
• Not CMS’ intention to build the operating framework of a sponsor’s formulary
• Formulary must include:– At least one drug in each of 209 therapeutic
categories as published in regulation and solicitation
– At least 55% of the 209 categories must include a generic offered for a discount
Non-Formulary
• Physician must determine that all drugs on the formulary for the treatment of the same condition:
• would not be as effective
• have adverse effects
• Definite exclusions: – OTC, weight-related, fertility, cosmetic, symptomatic relief cough or
colds, vitamins (except prenatal), barbiturates, benzodiazepines
– Drugs that would be covered under Medicare, including under Part B for that individual in that instance
(Medicaid can cover with federal matched funds)
‘Transitioning’
Medicaid -> MedicareCommunity -> Hospital -> SNF -> NF
Misalignment of formularies could result in:Inappropriate med changes
Limited transition time between meds
Medication Therapy Management ServicesSec 1860D-4(c)
Beneficiaries targeted:Multiple chronic conditions
Using “multiple prescriptions” Incur significant drug spending
Services Include:DispensingMonitoring
coveredunder Part Dthrough PDPs
Drug Therapy QualitySCRIPT: Study of Clinically Relevant Indicators for Pharmacologic Therapy
• Coronary Artery Disease– Beta Blockers– ACEI– Lipid Treatment– Lipid Testing
• Heart Failure– ACEI– Beta Blockers– Monitoring K, Renal Function
• Atrial Fibrillation– Warfarin– Monitoring K, Renal Function, INR
CMS Funded Study 7/16/04
Specialized MA PlansSec. 231
Special Needs:– Institutionalized – Dual Eligibles– Chronically ill
Example Programs:• EverCare
• Wisconsin Partnership
Rx Factor
LTC Endorsed Sponsors
• Computer Sciences Corporation*• National Community Pharmacist Association • Senior Care Pharmacy Alliance
• PBM Plus, Inc*• Omnicare
• Long Term Care Pharmacy Alliance, LLC• Omnicare• NeighborCare• Pharmerica• Kindred Health Care
170
Preparing for the Storm….
• Education, Educations, Education……..
• Preparation
• Collaboration
Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD [email protected]