medicare part d symposium thursday, september 1, 2005 sacramento, ca cathy senderling senior...
TRANSCRIPT
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