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Medicare Part D Symposium

Medicare Part D Symposium. Thursday, September 1, 2005 Sacramento, CA Cathy Senderling Senior 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.

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Medicare Part D Symposium

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  1. Medicare Part D Symposium Thursday, September 1, 2005 Sacramento, CA Cathy Senderling Senior Legislative Advocate, CWDA

  2. Overview • Part D Basics • Enrollment Options • How Plans Will Work • Cost Sharing • “Extra Help” Program • Potential Impacts and Issues

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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)

  11. 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

  12. 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

  13. 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”

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Underscore Importance of: • Outreach • Education • Training • Partnerships

  21. Questions?

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