MMA Medicare Modernization Act PL 108-173

1. MMAMedicare Modernization ActPL 108-173 • Most sweeping reform since program inception • Incredibly short timeframes to implementation • New partnerships between Medicare and Medicaid, SSA and States • New ground for Medicare – “means testing!”

2. MMA Title I Medicare Prescription Drug Benefit Medicare-Approved Drug Discount Card

3. MMA We will cover…. • A (very brief) mention of the drug card • A Part D Overview • A look at the Low Income Subsidy • State roles and responsibilities

4. Medicare ApprovedDrug Discount Card • Help for many people with Medicare • REAL discounts on prescription drugs • Voluntary Program • Bridge to Part D Prescription Drug benefit

5. Medicare ApprovedDrug Discount Card • Enrollment began on May 3, 2004 • Discounts began June 1, 2004 • Program sunsets on December 31, 2005 (or whenever Part D kicks in…)

6. So much for the drug card . . . . . on to Part D!

7. Part D Medicare Prescription Drug Plans • Effective: January 1, 2006 • Called “Medicare Prescription Drug Plans” – MPDPs (v. Part D) • Eligibility? • Must be entitled to Part A or enrolled in Part B (Have Medicare Card)

8. Part DMedicare Prescription Drug Plans • Enrollment for Part D • Voluntary • Medicare beneficiaries who opt for Part D must actively choose a plan

9. Part DMedicare Prescription Drug Plans • If enrolled in fee-for-service Medicare • Receive Part D benefits through a Prescription Drug Plan (PDP) • If enrolled in Medicare Advantage (MA) Plan • Receive Part D benefits through Medicare Advantage Prescription Drug Plan (MA-PD)

10. Standard Medicare Drug Benefit

11. Dual Eligibles • Medicare Beneficiaries • Who receive some or all Medicaid Benefits

12. Full Benefit Dual Eligibles • Medicare beneficiaries • With full (comprehensive) Medicaid benefits

13. Full Benefit Dual Eligibles Coverage Under Part D • As of January 1, 2006, there will be no Medicaidmatch available for prescription drugs States provide to full benefit duals • other than “excludable drugs”(weight loss and certain psych drugs) not covered by Medicare Full Medicaid Benefits

14. Full BenefitDual EligiblesCoverage under PartD • Critical for States and CMS to help full benefit dual eligibles (FBDE) transition to Part D plan • Good transition to talk about the Low Income Subsidy…..

15. Low Income Subsidy Assistance • Low-income Medicare beneficiaries • Extra assistance with premium and cost sharing under the new drug benefit.

16. Low Income Subsidy (LIS)Assistance Federal Help in Paying • Deductibles • Premiums • Co-payments • Coinsurance Note – these are forms of “cost sharing”

17. Low Income Subsidy Assistance • Certain groups (deemed) are automatically eligible for a subsidy. • Low income subsidy “applicants” (undeemed) will have to “apply” and meet an income and asset test. • Eligibility determinations? • SSA or the State Medicaid Agency

18. Low Income Subsidy - Process Important! For LIS Beneficiaries, it’s a 2-step process! 1. “Apply” for LIS 2. “Enroll” in MPDP

19. Low Income Subsidy Eligibles – Who are those guys?

20. Low Income Subsidy for FBDEs

21. FBDEs are Treated Specially • Certain duals get lower cost-sharing. • < 100% FPL  lower co-pays $1 to $3 • institutionalized  no cost sharing • FBDEs auto-assigned to a plan with opportunity to change plans.

22. LIS for non-FBDEs

23. What is the process for deeming? Identify FBDEs, MSPs States Notices sent, “You are eligible!” Some overlap Identify SSI/Medicare recipients with no Medicaid SSA

24. Low-Income Subsidy SSA & State Roles • Both States and SSA are required to make low income subsidy eligibility determinations. • Both States and SSA are also required to conduct redeterminations and appeals of denials of eligibility. • Given similar roles, coordination will be necessary.

25. When applying for LIS, how is income considered? Countable Income Income Standard Compare to Use SSI rules Based on FPL for size of the family

26. When applying for LIS,how are resources counted? Countable Resources Resource Standard Compare to 2 types of standard: Full Subsidy = < 3 x SSI limit ($6k individual, $9k couple) Other Low-income Subsidy = Alternate standard (<$10k individual, < $20k couple)

27. Phased Down State Contributions • States make monthly payments to Medicare for a portion of the drug expenditures for dual eligibles (state contribution). • The contribution will based on a state’s own per capita spending for dual eligibles • By no later than October 15, 2005 and October 15 of each succeeding year, the Secretary will notify the states of their per capita amount • Questions to: MMAphasedown@cms.hhs.gov

28. Rulemaking Process • Final CMS Rule was published January 28, 2005 • Addressed 8,000 comments received on NPRM • SSA’s Proposed Rule on the LIS process published March 4; no Final Rule as of yet.

29. Wrap-up Part D: State Issues • Low-Income Subsidy Process • Coordination Between CMS, SSA & States • Educating beneficiaries • Data for Part D phased-down state contributions • Coordination of benefits

30. Thanks for listening! Questions?