# Presentation: 825880

## Medicare Prescription Drug Coverage Indian Health Issues

- CAPT Robert E. Pittman
- IHS Principal Pharmacy Consultant
- October 18, 2005

## Beneficiaries

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

## 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			Member Health
-   Caremark		         PharmaCare
-   Express Scripts	         Providence
-   Health Net		Rx America
-   Humana			Rx Solutions
-   Medco			Walgreens
-   MedImpacts

## Tribal/Urban Program Agreements

- Tribal/Urban program specific addendum
- Many sites did not receive agreements
- Different terms and reimbursement rates
- Piggyback onto IHS agreements
- IHS will work with plans
- Selecting Plans
- Common I/T/U Plans
- Plans available to dual eligible patients

## Part D Premiums

- Dual eligible - paid by state Medicaid programs
- Medicare only
- Federal Funds - Senate Bill, S. 1239
- Tribal Funds
- 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

- Alternate resource
- Cannot require patient to pay
- Patient has no 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 Medicare Part D drug coverage
- at least as good as standard Medicare drug coverage

## Why is Creditable Coverage Important

- Must have Creditable Coverage letter to switch plans at no penalty
- 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 IHS beneficiaries
- Tribes and Urban Programs
- Employees
- Insurance Plan
- Other not eligible for IHS care

## 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

## True Out-of-Pocket (TrOOP)

- Catastrophic Coverage (Medicare only)
- $2,251 to $5,100
- 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

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