# Presentation: 242591

## Medicare Prescription Drug Coverage General Information

- CAPT Robert E. Pittman
- IHS Principal Pharmacy Consultant
- October 13, 2005

## Background

- Medicare Prescription Drug Coverage
- Starts January 1, 2006
- Prescription Drug Plans (PDP)
- Medicare Advantage Drug Plans (MA-PD)

## Plan Agreements

- Need to bill for medications
- Any willing pharmacy
- IHS agreements
- Medicaid reimbursement rates
- Electronic or paper claims
- Government specific addendum

## IHS Agreements

- Argus
- Caremark
- Express Scripts
- Health Net
- Humana

## IHS Agreements

- Medco
- MedImpacts
- Member Health
- PharmaCare
- Providence

## IHS Agreements

- Rx America
- Rx Solutions
- Walgreens

## Tribal Agreements

- Tribal specific addendum
- Did not receive agreements
- Different terms and rates
- Piggyback onto IHS agreements
- IHS will work with plans

## Beneficiaries

- Approximately 100,000 beneficiaries
- Dual Eligible ~ 30,000
- Medicare Only ~ 35,000
- Medicare and Insurance ~35,000

## Point of Contact (POC)

- Sites need to decide the POC
-  Patient questions and enrollment
- Patient Registration
- Patient Benefits
- Billing Office
- Pharmacy

## Point of Contact

- Need to assist with
- Extra Help (Low Income Subsidy) enrollment
- Medicare Plan Finder
- Plan enrollment

## Enrollment

- Don’t Want to Enroll
- Don’t understand the need to enroll
- There might be out of pocket costs
- Voluntary program – don’t have to enroll

## Why Enroll

- Reimbursement
- Sites bill for services
- Able to provide additional services
- Saves Contract Health Service funds

## Why Enroll

- Medicare is an alternate resource
- Need to signup if no out-of-pocket cost
- Dual eligible beneficiaries (no cost)
- Medicare only (I/T/U pays premiums)

## Why Enroll

- Increases Choices
- Medications from ITU facility
- Medications from retail pharmacy (CHS)
- Medication from retail pharmacy (Out-of-pocket)
- Mail order (Out-of-pocket)

## Beneficiaries

- Dual Eligible (Medicare and Medicaid)
- Extra Help (Low Income Subsidy)
- Existing Coverage (other insurance)
- No existing coverage (Medicare only)
-    Tab D – Crosswalk Chart

## Full Dual Eligible

- No Premiums (premiums paid by state)
- No Deductible
- Minimal Co-pay (None at I/T or  CHS)
- $1 - $3 if less than or equal 100% of FPL

## Dual Eligible (Other Medicaid)

- QMB, SLMB, QI, MN
- No Premiums (paid by state)
- No Deductible
- Minimal Co-pay (None at I/T or CHS)
- $2 - $5 if under 135% of FPL
- under $6,000 assets

## Extra Help (Low Income Subsidy)

- Must apply through Social Security Admin.
- _[www.ssa.gov/organizations/medicareoutreach2/](http://www.ssa.gov/organizations/medicareoutreach2/)_

## What is Income

- AI/AN income sheet – SSA# 05-10013
- Under $11,500 (single) resources
- Under $23,000 (married) resources

## Resources

- bank accounts
- Stocks
- Bonds
- savings bonds
- mutual funds
- Individual Retirement Accounts (IRA)
- any other cash

## Resources

- Real Estate
- Except the home you live in
- Do NOT include
- Home
- Vehicles
- Funeral expenses
- Burial plots
- Personal possessions

## Extra Help

- Under 135% FPL
- $12,919–single, $17,320–married
- No Premium
- $50 Deductible
- 15% Co-pay
- No Coverage Gap
- $2 or $5 Co-pay

## Extra Help

- Under 140% FPL
-  $13,398 single, $17,962 married
- 25% of Premium
- $50 Deductible
- 15% Co-pay
- No Coverage Gap
- $2 or $5 Co-pay

## Extra Help

- Under 145% FPL
- $13,877 single, $18,604 married
- 50% of Premium
- $50 Deductible
- 15% Co-pay
- No Coverage Gap
- $2 or $5 Co-pay

## Extra Help (Low Income Subsidy)

- Under 150% FPL
- $14,355-single, $19,245-married
- 75% of Premium
- $50 Deductible
- 15% Co-pay
- No Coverage Gap
- $2 or $5 Co-pay

## Existing Coverage

- Another source of prescription coverage
- Quality of current coverage
- Keep current coverage
- Don’t add drug plan
- Add Medicare drug plan
- Drop current coverage
- Add Medicare drug plan
- May not be able to get it back.
- May lose health coverage.

## Medicare Only

- New benefit, not previously covered
- May need to select a plan if
- I/T/U can pays premium cost
- Out-of-pocket costs - retail pharmacy

## Medicare Information

- Dual Eligible Letter from Medicare - October
- Medicare and You Handbook – October
- Talk to I/T/U patient registration staff
- 1-800-MEDICARE (1-800-633-4227)
- TTY users 1-877-486-2048

## Medicare Information

- IHS specific materials www.pharmacyissues.ihs.gov
- Your Guide to Medicare Prescription Drug Coverage (CMS Pub No 11109) at
-    1-800-MEDICARE or www.medicare.gov

## Part D Premiums

- Dual eligible - paid by state Medicaid programs
- Medicare only
- I/T/U pay - Senate Bill, S. 1239
- Patient - for out of pocket drugs

## How Are Premiums Paid

- Deducted from Social Security Check
- Sending a check directly to the PDP
- Paid by group payment (I/T/U)

## How Are Premiums Paid

- I/T cannot require patient to pay
- Patient has not out-of-pocket costs
- At I/T/U pharmacy
- at a retail pharmacy when referred by CHS

## Creditable Coverage

- Prescription drug coverage that
- is not  part of Part D drug coverage
- at least as good as standard Medicare drug coverage

## Why is Creditable Coverage Important

- Penalty if don’t join when eligible
- 63 days or longer
- 1% penalty per month

## Who Determines Creditable Coverage

- IHS Headquarters
- certifying the entire I/T/U health system
- IHS is only certifying for beneficiaries
- Tribes and Urban Programs
- Employees
- Insurance Plan
- Other not eligible for HIS care

## How is Creditable Coverage Determined

- Employers and unions
- Use an actuarial equivalence test
- Does mater who pays
- Attestation by a qualified actuary
- www.cms.hhs.gov/medicarereform/CCguidances.asp

## How is Creditable Coverage Determined

- Not an employer or union
- Brand and generic prescriptions
- Reasonable access to retail providers
- Pays on average at least 60% drug costs
- Integrated health coverage
- no more than a $250 deductible per year
- no annual benefit maximum or >$25,000
- no less than a $1,000,000 lifetime combined benefit

## Are I/T/Us Creditable Coverage

- I/T/U system meets requirements

## Creditable Coverage Notification

- Prepare list of Medicare beneficiaries
- Identify local point of contact for questions
- Sample letter developed by IHS
- Letters mailed by individual sites
- State coverage is creditable
- Notify by November 14, 2005 and annually

## September 2005

- Medicare signs contracts with plans
- Plans and formularies announced

## October 2005

- Part D plans begin marketing
- CMS mails auto-enrollment information to duals
- Creditable coverage letters sent out
- Medicare Plan Finder available October 13th

## November 2005

- Enrollment begins November 15th

## January 2006

- Part D coverage begins for enrolled beneficiaries
- Dual eligibles auto enrollment takes effect

## Costs and Coverage

- Generally less than $32 monthly premium
- $250 deductible
- Coinsurance of 25%
- for costs from $250 to $2,250
- Medicare pays 75%
- 100% of drug costs from $2,251 to $5,100
- After $3,600 in out-of-pocket costs
- Medicare pays approximately 95%

## True Out-of-Pocket (TrOOP)

- Cost paid by
- Enrollee
- On behalf of enrollee by another person
- A charitable organization or
- A State Pharmaceutical Assistance Program

## What does not count towards Troop

- Paid by former employee
- An insurer (e.g., group health or retirement plan)
- Other third party arrangement, or
- A government program
- Includes IHS and tribes (federal appropriated funds)

## TrOOP Facilitator

- NDCHealth
- Pharmacy network switches
- IHS Lead
- CAPT Pam Schweitzer - Phoenix Area Office

## Formularies

- Each plan has a formulary
- Beneficiaries notified 60 days before a change
- Exception process for needed medications
- At least two drugs in every drug class

## Evaluating Formularies

- Information Needed
- Medications
- Dosage
- Strength
- Monthly cost of medication
- RPMS drug file
- Any out-of pocket costs for medications
- Medicare Plan Finder

## Issues in Selecting a Plan

- All medications from one I/T/U facility
- All medications from two or more I/T/U sites
- Care in different regions
- Some out-of-pocket medications
- Using CHS funds

## A Single Facility

- Auto enrollment (Dual Eligible)
- Eligible for Extra Help
- Plan Cost
- Formulary
- Reimbursement

## Two or More Facilities

- Common Plan Agreements for all sites
- Need for national or regional plan
- Auto enrollment (Dual Eligible)
- Eligible for Extra Help
- Plan Cost
- Formulary
- Reimbursement

## Care in Different States/Regions

- Common Plan Agreements for all sites
- Need for national or regional plan
- Auto enrollment (Dual Eligible)
- Eligible for Extra Help
- Plan Cost
- Formulary
- Reimbursement

## Some out-of-pocket medications

- Common Plan Agreements – ITU/Retail sites
- Auto enrollment (Dual Eligible)
- Eligible for Extra Help
- Plan Cost
- Formulary
- Co-pays, tiered costs
- Additional benefits
- Reimbursement

## Using CHS Funds

- CHS agreement with Retail Pharmacies
- Common Part D Plan Agreements – ITU/Retail sites
- Auto enrollment (Dual Eligible)
- Eligible for Extra Help
- Plan Cost
- Formulary
- Co-pays, tiered costs
- Additional benefits

## Enrollment Process - Duals

- Is the person dual eligible (Medicare and Medicaid)
- Yes.  Has the person been auto-enrolled in a plan.
- No.  May not be full-dual eligible, need to check

## Enrollment Process - Duals

- Is the person dual eligible (Medicare and Medicaid)
- Yes.  Has the person been auto-enrolled in a plan.
- Yes.  Does site has an agreement with the plan
- No.  Negotiate agreement or switch to another plan

## Enrollment Process - Duals

- Is the person dual eligible (Medicare and Medicaid)
- Yes.  Has the person been auto-enrolled in a plan.
- Yes.  Does site has an agreement with the plan
- Yes.  Does formulary include all/most of patient’s
-              prescription medications
- No.  Consider other plans

## Enrollment Process - Duals

- Is the person dual eligible (Medicare and Medicaid)
- Yes.  Has the person been auto-enrolled in a plan.
- Yes.  Does site has an agreement with the plan
- Yes.  Does formulary include all/most of patient’s
-              prescription medications
- Yes.  Does plan have good reimbursement
- Yes.  Recommend keeping auto-enrolled plan.

## Enrollment Process – Extra Help 

- Does the person have a letter from SSA saying they automatically qualify for extra help?
- Yes. Have they been auto-enrolled in a plan
- Yes. See previous slide
- No. Will I/T/U will pay premium costs and if yes, enroll them in a plan
- No.  Does the person meet the requirements extra help
- Yes.  Have them apply on-line for extra help
-        https://s044a90.ssa.gov/apps6a/il020/main.html
- No.  Will I/T/U will pay premium costs and if yes, enroll them in a plan

## General Enrollment Process

- Outside prescription coverage (insurance)
- Does patient have outside drug coverage
- Yes.  Is coverage Creditable
- Yes. Can keep current coverage or drop and add PDP
- If drops coverage may not be able to get back in
- No. Will I/T/U will pay premium costs and if yes, enroll them in a plan
- No. Will I/T/U will pay premium costs and if yes, enroll them in a plan
- See Tab F (Pages 21-22)

## Number of Prescription Drug Plans 

-     Between 11 and 23 organizations are offering these stand alone prescription drug plans in each region.  For more information contact Christopher Powers christopher.powers@cms.hhs.gov.
- 					Stand	Auto	Weighted      # less
- Region	State(s)		  	Alone	Enroll	Premium    Than $20
- 	01	NH, ME		18	10	$35.69		1
- 	02	CT, MA, RI, VT	18	  7	$30.53		4
- 	03	NY			21	10	$32.45		6
- 	04	NJ			19	  9	$32.09		4
- 	05	DE, DC, MD		21	13	$33.63		3
- 	06	PA, WV		23	13	$32.79		2

## Number of Prescription Drug Plans

- 					Stand	Auto	Weighted      # less
- Region	State(s)			Alone	Enroll	Premium    Than $20
- 	07	VA			18	13	$34.19		2
- 	08	NC			16	10	$36.86		2
- 	09	SC			20	13	$34.89		1
- 	10	GA			18	12	$33.17		1
- 	11	FL			20	  5	$33.01		4
- 	12	AL, TN		18	  7	$33.29		1
- 	13	MI			18	12	$33.22		1
- 	14	OH			20	  8	$32.89		3
- 	15	IN, KY			18	11	$35.85		1
- 	16	WI			18	12	$31.49		4

## Number of Prescription Drug Plans

- 					Stand	Auto	Weighted      # less
- Region	State(s)			Alone	Enroll	Premium    Than $20
- 	17	IL			17	11	$31.85		1
- 	18	MO			17	  8	$33.30		2
- 	19	AR			16	11	$35.45		2
- 	20	MS			16	10	$36.39		2
- 	21	LA			17	  9	$36.85		1
- 	22	TX			21	13	$32.63		2
- 	23	OK			17	  9	$35.75		2
- 	24	KS			16	  9	$33.12		2
- 	25	IA, MN, MT, ND	17	10	$32.82		4
- 		NE, SD, WY

## Number of Prescription Drug Plans

- 					Stand	Auto	Weighted      # less
- Region	State(s)			Alone	Enroll	Premium    Than $20 26	NM			18	  7	$29.02		6
- 	27	CO			18	  9	$28.52		3
- 	28	AZ			19	  5	$28.08		4
- 	29	NV			19	  6	$30.32		3
- 	30	OR, WA		21	11	$30.05		5
- 	31	ID, UT			19	11	$33.65		3
- 	32	CA			19	  7	$25.41		6
- 	33	HI			12	  6	$27.44		3
- 	34	AK			11	  6	$34.66		0

## Affect on Current Drug Coverage

- Pages 11-14 provide additional details about benefit

## IHS Pharmacist Bethel, AK (1964) – Ron Gilbert (?)

## Medicare Part B

- Pharmacies as Distributors

## Marketing

- Sites Asked to develop marketing plan on how to get the word out to Medicare beneficiaries
- Some Activities
- SSA and CMS presentations
- SSA Posters and pamphlet
- CMS posters and DVD
- Letters from IHS
- New Benefit Letter
- Creditable coverage

## Marketing

- Local materials
- Signs
- Do you have Medicare
- new benefit starting January 1
- Need to fill out materials in October (Extra Help)
- Need to fill out application in November
- Identify site contact
- Outreach efforts
- Senior centers, etc.

## Marketing

- Share ideas
- Share best practices

## Tracking Success

- Sites and Areas need to track activities and outcomes
- Marketing efforts
- Extra Help Applications and Results
- Part D Enrollment
- T/U – Plan Agreements
- Readiness for Billing

## Questions

- Robert Pittman
- (301) 443-1190
- _[Robert.pittman@ihs.gov](mailto:Robert.pittman@ihs.gov)_
- Kitty Marx
- (301) 443-6307
- _[Kitty.marx@ihs.gov](mailto:Kitty.marx@ihs.gov)_
- Elmer Brewster
- (301) 443-2419
- _[Elmer.brewster@ihs.gov](mailto:Elmer.brewster@ihs.gov)__ _