Northside Pharmacies Dawn L. Huth Mary Ann Mansfield

1. Medicare’s New Prescription Drug Benefitfor People in Nursing Homes and Long-Term Care Facilities Northside Pharmacies Dawn L. Huth Mary Ann Mansfield

2. Parts of Medicare • Part A – Coverage of services in hospitals and skilled nursing facilities • Part B – Coverage for medical services, physician office visits, some medications • Part C – Coverage of managed care services • Caution: these managed plans are marketing to our seniors now. Seniors must be sure that the plan participates with their physician, hospital & pharmacy. This is important! • Part D – NEW MEDICARE BENEFIT Coverage for prescription drugs

3. The New Medicare Part D • This is the first time a portion of the Medicare administration has been completely delegated to the private sector • Medicare Part D plans will include: • Prescription Drug Plans (PDP’s) • Private stand alone plans that offer drug-only coverage • Medicare Advantage Plans (MA-PD Plans) • These plans offer both prescription drug and health coverage (HMO-like)

4. Part D Impact on Current Plans Current Enrollment: Will Switch To: Medicare Part A stays Medicare Part A Medicaid (dual eligibles) Medicare Part D Private Pay Medicare Part D Private Rx Insurance Stay with viable plan

5. Medicare Part D Assumptions • The private sector can run this program better than the government • More choices is better • Competition will drive down medication costs and improve quality

6. Timeline • November 15, 2008 - Beneficiaries began signing up for Medicare Part D • January 1, 2009 – The actual benefit begins • November 15 – December 31 each year –Open Enrollment

7. Who is Eligible for Part D? • All Medicare beneficiaries are eligible • The drug benefit is voluntary, so beneficiaries do not have to sign up EXCEPT for people who are dually eligible, that is eligible for both Medicare and Medicaid • A 1% per month penalty on the premium will be charged if you are eligible and sign up after May 15, 2006

8. There Are 3 Levels of Participation • 1) Standard Benefit • 2) Limited Income Benefit • 3) Dual Eligible Benefit

9. Standard Benefit • $32 approximate monthly premium • In Ohio these may range from $14.43 - $68.00) • $275 deductible on some plans, $0 on others • Consider higher co pays when the $275 deductible is waved and you may reach the donut hole $275 faster • The only real way to know is to compare the prescription history to the plan • Medicare will pay 75% of drug costs up to $2,510 and the beneficiary pays 25% • Beneficiary pays 100% of cost between $2,510 & $5,726 • After $4,050 in true out-of-pocket spending (TROOP), Medicare will pay 95% and the beneficiary will pay 5% on all remaining prescriptions

10. Standard Benefit (cont’d) • After Jan 1, 2006 may change benefit plan one time per year • During open enrollment period • Life-changing event • Exception: May change when entering or exiting a nursing facility • When they qualify for extra help • When they first become eligible for Medicare

11. Limited Income Benefit • A beneficiary may be eligible for extra help paying for the premiums, deductibles and co-payments associated with Medicare Part D if they have… • Limited income (below $15,315/individual, $20,535/couple) • And resources (below $11,700/individual, $23,410/couple)

12. How Much Will a Limited Income Eligible Pay for Prescription Drugs? • Reduced or No Premium • Reduced or No Deductible • No Coverage Gap • Reduced CoPays (maybe as little as $1generic/$3brand • In Nursing Homes, $0 Premium, $0 Deductible $0 Copay, No Coverage Gap

13. Dual Eligibles • A dual eligible who is currently receiving state Medicaid benefits had their state Medicaid drug coverage terminated on December 31, 2005 • Dual eligibles will be auto-enrolled into a benchmarked plan, if they haven’t chosen one by December 31 (These plans change every year, so it is important to make certain during open enrollment that their plan is still benchmarked or enrollee must pay difference in premium • They will have the ability to switch out of their auto-assigned plan every 30 days

14. How Much Will a Dual Eligible in a Long Term Care Facility Pay for Prescription Drugs Under Part D? • Premium = $0 • Deductible = $0 • CoPay = $0 (retail setting, $1 generic/$3 brand) • Overall = $0 Unless they receive an excluded drug which would not be picked up by their old Medicaid program

15. Ativan Dalmane Doral Halcion Librium Klonopin ProSom Restoril Serax Tranxene Xanax Valium Examples of Excluded Benzodiazepine Medication Under Part D

16. Other Medications Also Excluded • Barbiturates • Medications for anorexia, weight loss, or weight gain • Prescription vitamins • Cough and cold preparations • Over-the-counter medications • Medications for fertility • Medications for cosmetic purposes or hair growth

17. How Does a Resident Enroll in Part D? • Nursing Home Social Workers, Business Office Staff and Nursing Staff who help with the intake of new residents will likely have to assist with enrollment, within limits set by CMS • 50% of LTC residents have cognitive impairment and few are capable of handling their enrollment directly • Who is their “authorized representative?”

18. How Does a Resident Enroll in Part D? (cont’d) • Part D is complex with 58 available PDP plans in Ohio (of which 15 of these plans are benchmarked, i.e. can accept dual eligible enrollees) • Enrollment forms are available from the facility social worker; by calling the Part D Plan Provider, or on their web site