# Presentation: 005473

## Medicare Prescription Drug Coverage Indian Health Issues

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

## Point of Contact (POC)

- Sites need to decide on a local POC
-  Patient questions and enrollment
- Patient Registration
- Patient Benefits
- Billing Office
- Pharmacy

## Point of Contact

- Need to assist beneficiaries 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)
- Income and Resources
- Existing Coverage (other insurance)
- No existing coverage (Medicare only)

## Extra Help - What is Income

- AI/AN income sheet – SSA# 05-10013
- Trust Income
- Federal Poverty Level
- Under 135% FPL - $12,919 single, $17,320 married
- Under 140% FPL - $13,398 single, $17,962 married
- Under 145% FPL - $13,877 single, $18,604 married
- Under 150% FPL - $14,355 single, $19,245 married

## Extra Help - Resources

- Resources
- Under $11,500 (single), under $23,000 (married) 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

## 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.

## How is Creditable Coverage Determined

- Employers and unions
- Use an actuarial equivalence test
- Does not matter 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

## 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

## Training

- Awareness Trainings – Through June 2005
- Outreach and Education Trainings
- Open Door Forums
- IHS Website with Q&As
- Area specific calls

## 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