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Medicare Today…More Choices, Better Benefits

Instructor’s Name

Event

Date

244375 9/06

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Topics/Modules

• Medicare’s Covered Preventive Care Services• Basics of Medicare Prescription Drug Coverage• Picking and Switching Medicare Plans• How to Get Extra Help with Costs• What Drugs Do Medicare Plans Cover? All About

Formularies• What Is the “Donut Hole?”• Important Dates for Medicare

Medicare’s Covered Preventive Care

Services

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Medicare Has More to Offer

• Preventive services

• Prescription drug plan coverage

• New Medicare Health Plan options

• Extra help for those who need it most

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Benefits and Options

• Increased coverage of preventive services in 2005

• Outpatient prescription drug coverage available January 1, 2006

• Offered new Medicare Health Plan options in 2006

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Covered Preventive Services

• Designed to help you stay healthy

• Began January 2005– “Welcome to Medicare” physical exam– Cardiovascular screening blood tests– Diabetes screening tests

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Initial Preventive Physical Examination (IPPE)

• “Welcome to Medicare” Physical• Who is eligible?

– All Medicare beneficiaries whose Part B coverage began on or after January 1, 2005

• When?– Once during the first 6 months of Part B coverage

• Cost to beneficiary?– Part B deductible and copayment/coinsurance

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Cardiovascular Disease Screening

• Who is eligible?– All asymptomatic Medicare beneficiaries

• When?– Every 5 years

• Cost to beneficiary?– No deductible, no co-payment, no

coinsurance

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Elements of Cardiovascular Screening

• Total Cholesterol• HDL• Triglycerides• Provides opportunity assess and discuss

cardiovascular risk factors, such as– Family history - Smoking– Diet - Stress– Obesity - Diabetes

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Diabetes Screening

• Who?– Beneficiaries diagnosed with pre-diabetes

and at-risk non-diabetic beneficiaries• When?

– 2 tests per year for pre-diabetic beneficiaries

– 1 test per year for undiagnosed, non-diabetic beneficiaries

• Cost to beneficiary?– No deductible, no copay/coinsurance

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Diabetes Self-Management Training (DSMT)

• Who is eligible?– Beneficiaries recently diagnosed with diabetes or

at risk for complications from diabetes or who were diagnosed with diabetes before becoming Medicare eligible

• When?– A plan of care must be written to include number

of sessions, frequency, and duration (up to 10 hours for initial training, up to 2 hours per year thereafter)

• Cost to beneficiary?– Part B deductible, copayment/coinsurance

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Other Covered Screening Tests

• Breast cancer

• Colorectal cancer

• Prostate cancer

• Cervical & vaginal cancer

• Bone Density

• Glaucoma

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Covered Vaccinations

• Influenza

• Pneumococcal

• Hepatitis B

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Smoking Cessation Counseling

If diagnosed with a smoking related illness:• Inpatient or Outpatient Counseling

– Up to 8 face-to-face counseling sessions per 12 month period

Basics of Medicare Prescription Drug Coverage

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Medicare Prescription Drug Coverage: Why Should You Get It?

• If you are going to join it’s important to join a plan when you are first eligible– Many people with Medicare need or likely

will need prescription drugs to stay healthy– Medicare prescription drug coverage may

help protect against high out-of-pocket costs

– Enrolling when first eligible may mean that you pay a lower premium

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Types of Medicare Prescription Drug Plans

There are two types of plans available:• Prescription Drug Plans (PDPs)

– Provide prescription drug coverage only

• Medicare Advantage - Prescription Drug Plans (MA-PDs) – Formerly known as Medicare+Choice– Provide Medicare Parts A & B medical and

hospital care and prescription drug coverage under the same plan

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What Drugs Are Covered?

Medicare drug plans will cover most outpatient prescription drugs (and biologics)

• The drug (or biologic) must be:– Available by prescription only– Approved by the FDA

• Drugs in clinical development will not be covered

• Some vaccines, insulin and medical supplies used to inject insulin are also covered

• Part B covers diabetes supplies. Part B does not change.

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Pharmacies Under Part D

• Part D plans must provide pharmacy options:– Network of retail pharmacies– Long-term care pharmacies– Home infusion providers

• Mail order pharmacies are permitted– 90-day supplies are available through retail

and mail options

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How to Sign Up for a Medicare Prescription Drug Plan

There are several ways to enroll:

• Call the plan directly

• Visit the plan’s website

• Call 1-800-Medicare

• Visit www.medicare.gov

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Enrollment for Those Who Need Help Paying for a Plan

• People who have both Medicare and Medicaid coverage (dual eligibles) are automatically enrolled into a Medicare drug plan by CMS– They are notified of their enrollment– They can switch plans monthly if they are not

satisfied or cannot get the medicines they need

• Others with limited resources must apply for extra help to determine eligibility

Picking or Switching Medicare Prescription Drug

Plans

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Decide What Kind of Plan You Want

• Medicare Advantage with Prescription Drugs (MA-PD):– New name for Medicare+Choice plans– Medicare Managed Care Plans covering medical

and hospital care and prescription drugs– Includes Medicare HMOs, Preferred Provider

Organization Plans (PPOs)

• Prescription Drug Plan (PDP):– Only covers drugs– Can be coupled with traditional Medicare Program

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If you join a Medicare Advantage Plan …

• You are still in the Medicare program

• You have all your Medicare rights and protections

• You will get all the basic Medicare coverage

• You may get more benefits

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Pointers for Picking a Medicare Prescription Drug Plan

• Most people will want to pick a plan with low yearly costs considering all associated costs:– Monthly Premiums + Copays/Coinsurance + Deductible

• Other things to consider:– Use of a preferred pharmacy or mail order– Getting prescriptions during travel (e.g., snowbirds)– Limits such as prior authorization, step therapy

requirements, and quantity limits on the patient’s medications

– Reputation of the plan

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Steps for Picking a Plan

1. Go to www.medicare.gov and click on “Find and Compare Plans.” Follow the instructions to use the Prescription Drug Plan Finder ;

OR

Call 1-800-MEDICARE and ask the representative to enter your information in the Prescription Drug Plan Finder

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Steps for Picking a Plan (continued)

2. Choose if you want to do a “Personalized…” or a “General Plan Search”. You will also need to pick the type of plan you want:• Prescription Drug Plan only (PDP)• Medicare Advantage Plan (MA-PD)

(List your medications and strengths when prompted)

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Steps for Picking a Plan (continued)

3. The Prescription Drug Plan Finder will list all the plans in your area. You can check up to three plans at one time to compare plan information

4. Select 3 or 4 possible plans from the Prescription Drug Plan Finder

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Steps for Picking a Plan – (continued)

5. Contact each plan to get more information:– How is the plan’s Customer Service? Are they

quick to answer your call? Helpful in answering your questions? Courteous?

– Are there restrictions on your medications, such as prior authorization requirements?

– Can you get your drugs if you travel part of the year?

– Is mail order available if you want it?

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Steps for Picking a Plan – (continued)

6. Decide on the right plan you want and sign up using the options below:– Call the plan directly– Call 1-800-MEDICARE– Visit the web site of the plan sponsor– Visit www.medicare.gov– Submit a paper form provided by the plan

sponsor

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Comparing Plans• Why do some plans cost more than

others?– Every plan is different and has different benefits

that may increase its costs compared to other plans

• For example, depending on the medications you take, some plans may be more expensive because your medicines are not on their preferred drug lists

• Other plans may offer additional services

• Paying more doesn’t mean it’s a better plan!– You should find the plan that best fits your needs

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Evaluating Your Current PlanOpen enrollment is a time to do a satisfaction

check of your current plan• Ask yourself the following questions:

– Are the medicines my doctor prescribed on the plan’s formulary (drug list)?

– If I hit the coverage gap (donut hole), am I still able to afford my medicines, or should I look for a plan with better coverage options during the gap?

– Would enrolling in a Medicare Advantage plan be a better option than a stand-alone Prescription Drug Plan where I can get both medical and pharmaceutical coverage?

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Pros and Cons of Switching to a Different Plan

Pros:• You may:

– Save money if you pick a lower cost plan

– Be more satisfied if you pick a plan that covers all your medications

Cons:• It may require research

and time to pick a new plan

• You may have concerns about the new plan that are unknown at the time of enrollment

How to Get Extra Help with Medicare Part D Costs

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Help for Those Who Need it Most

• Those with the lowest incomes pay no premiums or deductibles and have small or no copayments

• Those with slightly higher incomes pay a little more

• You may qualify if your annual income is less than 150% of the Federal Poverty Level and you are– Single and annual income less than $14,700– Married and annual income less than $19,800

• Some people will automatically qualify

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Applying for Extra Help

• Apply for Low Income Subsidy (LIS) through the Social Security Administration (SSA)– Online at www.socialsecurity.gov – Look up the local SSA in your phone book for

the local telephone number

• Apply through your State Medical Assistance Office

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Other Sources of Help Paying for Prescription Drugs

• State Pharmaceutical Assistance Programs– Certain states have programs for people who meet age and

income requirements– Examples: EPIC (New York), PAAD (New Jersey), PACE

(Pennsylvania)

• Pharmaceutical Manufacturer Programs– Check with the company that makes your

medication to see if you qualify for their assistance program or online at www.pparx.com

• Charitable Organizations

What Drugs Do Medicare Plans Cover?

Information About Formularies

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Plan FormularyMedicare Drug Plans• Do not cover every drug • Generally have a list of drugs they cover, called a

formulary• Must cover prescription drugs in all defined categories

and classes– Must include more than one drug in each class– Includes brand and generic drugs

• Certain drugs are excluded by law– For example, Medicare cannot pay for benzodiazepines,

barbiturates, drugs for weight loss or gain, and drugs for relief of colds.

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Plan Formulary• Using drugs on a plan’s list will save money

– You will pay lower prices for drugs that are “preferred” by the plan

• Choosing a covered generic drug instead of a brand-name medication may also save money– You should always check with your doctor

before agreeing to have your medicines changed or to have your prescription filled with a generic

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Plan Formulary• Plans manage drug use with the following:

– Prior authorization – requiring plan approval before a Rx can be filled

– Step therapy – encouraging the use of generic or less expensive drugs first

– Quantity limits

• Processes are available to you that can help you get the medicines your doctor feels you need through– Transition supply– Exceptions process– Appeals process

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Plan Formulary• Plans must fill prescriptions that are not on

the plan’s list– For new enrollees– For residents of Long-term Care (LTC) facilities

• This will allow time for you and your doctor– To find another acceptable formulary drug– To request an exception so the plan will cover

your drug, even if it is not on their formulary

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Plan Formulary• Exception requests may be warranted

if a:– Patient has tried covered drugs and they

don’t work, or– Physician believes the patient requires a

specific non-covered drug

• If a request is approved, the plan will cover the drug

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Exception Requests• Anyone can request an exception• Contact the drug plan and they will advise

– How to submit a request– What information needs to be submitted

• Physician must submit supporting documentation– Must demonstrate that requested drug is “medically

necessary”

• Plan must notify patient of its decision within– 72 hours for standard processing (after receiving

physicians statement), or– 24 hours for expedited processing

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Appeals Process

• A person can appeal a Medicare drug plan’s unfavorable exception decision

• First level appeal is to the plan• Expedited appeals take only a few days• An appointed representative may appeal• Generally, appeals must be made in writing• You should get information about the appeals

process upon enrollment• You may have as many as 5 levels of

appeal/review

What Is the Coverage Gap or “Doughnut Hole?”

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What is the Coverage Gap or Doughnut Hole?

• The coverage gap is that time when beneficiaries must pay 100% of their drug costs

• Medicare is set up as a cost sharing benefit. In 2007, beneficiaries will pay – A deductible (if applicable)– A monthly premium– A co-pay for each prescription drug– 25% of the first $2,400 of total drug spend– 100% of the next $3,051 of total drug spend– 5% of any additional drug spend beyond $5,451

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2007 Drug Plan Cost Sharing

Source:Kaiser Family Foundation

Medicare Part D benefit

Out-of-pocket spending

Catastrophic coverage

Partial coverage up to limit

Deductible

5%

$3,051 Gap

“Donut hole”

25%

$5,451

$2,400

$265

95%

75%

Percent of Rx spend

“Medicare Part D benefit”

“Medicare Part D benefit”

“Out-of-pocket”

“Out-of-pocket”

“Out-of-pocket”

“Out-of-pocket”

Act

uar

ial

Eq

uiv

alen

ce

100%

Beneficiary

Responsibility

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What Can You Do About Costs in the Coverage Gap?

• Apply for Medicare’s Low Income Subsidy (LIS) if you have not already done so

• If your State has a Pharmaceutical Assistance Program (SPAP), apply for it

• Check with the pharmaceutical companies that make your medications about whether they have a Patient Assistance Program to help you with costs

• Talk with your pharmacist or doctor about applying to charitable organizations for medication assistance

• Continue to use your Medicare Plan’s card when you pay for prescriptions - your payments will be counted toward the amount you must spend before “catastrophic” coverage begins

Important Dates for Medicare Services

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Important Dates

January 1

2005

New preventive services began…

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Important Dates

October/ November

2006

Watch your mail for the Medicare & You handbook, which will have information about the plans in your area

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Important Dates

October 2006

You can begin to compare Medicare prescription drug plans… – www.medicare.gov– 1-800-MEDICARE– Local SHIP office– Local community

groups

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Important Dates

November 15 through

December 31

each year

You can enroll in a Medicare prescription drug plan, or change plans!

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Important Dates

January 1

Medicare prescription drug coverage begins for those who are enrolled…

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For More Information

• Medicare & You 2007 handbook• www.medicare.gov• 1-800-MEDICARE (1-800-633-4227)

– TTY users call 1-877-486-2048

• www.mymedicarematters.org• www.mimedicareimporta.org (Spanish)• State Health Insurance Program (SHIP)• Community groups (Local Agency on Aging)• www.eldercare.gov