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Medicare Part D Nari Wang Health Law Unit 199 Water Street New York, NY 10038 212-577-3315 Center for Independence of the Disabled, NY February 23, 2010.

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Presentation on theme: "Medicare Part D Nari Wang Health Law Unit 199 Water Street New York, NY 10038 212-577-3315 Center for Independence of the Disabled, NY February 23, 2010."— Presentation transcript:

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2 Medicare Part D Nari Wang Health Law Unit 199 Water Street New York, NY Center for Independence of the Disabled, NY February 23, 2010

3 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

4 Other Parts of Medicare  Part A – covers hospital, skilled nursing facility, home health, and hospice care  Part B – covers medically necessary doctor visits, outpatient services, durable medical equipment, preventative care, lab tests, x-rays, mental health, and some home health and ambulance services  Part C – plans that offer Part A, Part B, and Part D services, also known as a Medicare Advantage plans  Part D – prescription drug plan

5 Other Parts of Medicare PPart A – covers hospital, skilled nursing facility, home health, and hospice care PPart B – covers medically necessary doctor visits, outpatient services, durable medical equipment, preventative care, lab tests, x-rays, mental health, and some home health and ambulance services PPart C – plans that offer Part A, Part B, and Part D services, also known as a Medicare Advantage plans PPart D – prescription drug plan

6 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

7 I. What is Medicare Part D  Since January 1, 2006, Medicare prescription drug coverage has been available to everyone with Medicare. Known as Part D, this benefit provides outpatient prescription drug coverage.  Private companies provide the drug coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

8 Medicare Advantage Plans (MA-PD) These are health plans offered by private companies that provide Medicare Part A and B services as well as the Part D drug benefit Also known as Part C Stand-alone Prescription Drug Plans (PDP) These plans only offer the Part D drug benefit Two Types of Coverage

9 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

10 II. What does Part D Cover? Each drug plan has a Formulary, a list of all drugs covered by that plan. Formularies must include “all or substantially all” drugs in 6 classes of clinical concern  Antidepressants  Antipsychotics  Anticonvulsants  Antineoplastic (cancer)  Immunosuppressant (for organ and tissue transplant patients)  Antiretroviral (for treatment of HIV/AIDS) *Formularies can change but notice is given prior to change. Excluded drugs are not included in any basic Medicare Part D plan. Some examples of this are “off label” drugs, OTC drugs, prescription vitamins and minerals, and benzodiazepines

11 Utilization Management – A Plan’s restrictions on how certain drugs will be covered  prior authorization- where the prescribing MD must request permission from the plan  step therapy – where the plan will not cover the drug until beneficiary shows they tried alternative drugs and they didn’t work  quantity limits – where the plan will only cover a limited number of pills per month

12 Exceptions and Appeals – when you disagree with a plan’s decision  When a plan requires utilization management for your drug  Your doctor prescribes a medically necessary drug but its not on the plan’s formulary  Your drug is removed from the plan’s formulary mid year

13 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

14 III. The Co$ts of Part D All PDPs have a monthly premium In 2010, premiums range from $19.50/month to $117.50/month Some PDPs have an annual deductible The maximum deductible in 2010 is $310 In the Initial Coverage period, beneficiaries are responsible for co-payments or coinsurance Co-payment is a fixed dollar amount for the drug and coinsurance is a percentage of the drug cost that the beneficiary pays Full cost of drugs while in Coverage gap/ Donut Hole

15 Coverage Gap/Donut Hole All plans have a coverage gap, also known as the donut hole. Once a beneficiary reaches the gap, she must pay for 100% of the drug costs until she reaches catastrophic coverage. After reaching catastrophic coverage, the beneficiary would be responsible for approximately 5% of the drug cost.

16 The Donut Hole – an illustration Coverage gap Deductible Initial Coverage PeriodCatastrophic Coverage

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18 Low Income Subsidy/ Extra Help A federal subsidy that helps low income Medicare beneficiaries pay for costs related to Part D coverage. Extra Help reduces or eliminates Part D related costs such as the monthly premiums, annual deductible, co-payments, and the costs incurred during the coverage gap/donut mentioned earlier.

19 Low Income Subsidy/Extra Help FULL Extra Help  Premium – will pay premium up to a certain amount, called a “benchmark”, in 2010 is $ In 2010, there are 10 plans within the benchmark.  Deductible – no deductible!  Co-payments – copays range from $0 - $6.30  No coverage gap/donut hole!

20 Low Income Subsidy/Extra Help PARTIAL Extra Help  Premium – will pay 25% to 75% of plan’s premium based on an income based sliding scale  Deductible – $63 or lower  Co-payments – 15% of drug cost  No coverage gap/donut hole!

21 3 Ways of Getting Extra Help Extra Help Having Medicaid which makes you a Dual Eligible Having a Medicare Savings Program (MSP) Applying for it Through the Social Security Administration (SSA)

22 Medicare Savings Program (MSP) All three have different eligibility levels and offer various cost saving benefits for other Medicare costs, including Part A and Part B costs.  QMB – Qualified Medicare Beneficiary  SLMB – Specified Low Income Medicare Beneficiary  QI-1 – Qualifying Individual Program

23 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

24 IV. How to Enroll with Part D Initial Enrollment Period – A 7 month period to enroll in a drug plan. Begins 3 months before and ends 3 months after the month of a) beneficiary’s 65 th birthday or b) the month of getting Medicare due to disability Annual Coordinated Election Period – November 15 – December 31, effective January 1 –you can enroll or change the drug plan Special Enrollment Periods – many different situations can give a beneficiary a SEP. Example: having Extra Help you have a SEP that allows you to change your plan every month. Another common example is when you lose your previous drug coverage plan that was creditable * Take care* Penalties can be placed if you enroll too late after losing creditable drug coverage

25 Part D Automatic Enrollment  All Dual Eligibles (Medicare and Medicaid) must join a Part D plan. A Dual Eligible will be automatically enrolled in a plan if they don’t choose a plan in time.  Those with an MSP or Extra Help will also be automatically enrolled if they don’t choose a plan in time. The plan is randomly chosen, so its best for you to choose the plan so you can make sure all your drugs are covered.

26 Medicare Part D – an overview I. What is Medicare Part D? II. What does Part D cover? III. How much does it co$t? IV. How do I enroll? V. How does Part D work with other drug coverage?

27 V. Part D with Other Types of Drug Coverage  Medicaid (dual eligible)  EPIC  New York Prescription Saver Card  Medigap  Patient Assistance Program  Veterans health care

28 Part D and Medicaid- Dual Eligibles Medicaid acts as the secondary payer, Part D plan will be primary except as noted below.  Will pay for Part D excluded drugs, as mentioned earlier - “off label” drugs, certain OTC drugs, prescription vitamins and minerals, and benzodiazepines were a few examples.  Medicaid will wrap around 4 classes of drugs  Antidepressants  Antipsychotics  Immunosuppressant (for organ and tissue transplant patients)  Antiretroviral (for treatment of HIV/AIDS) Since these classes are all within the 6 classes of clinical concern mentioned earlier in a plan’s Formulary, this Medicaid wrap is not usually needed

29 Part D and EPIC – EPIC is NYS drug program for seniors (65+) with income under $35k for singles, $50k for couples If a drug is covered by both Part D and EPIC, Part D is primary payer and EPIC is secondary  As of July 1, 2007, most EPIC enrollees had to join a Part D plan  EPIC covers excluded drugs, as long as its on EPIC formulary  EPIC will also cover drugs not on your plan’s formulary (EPIC Wrap)  As of October 1, 2008, EPIC started encouraging use of generic drugs for their members who have EPIC as a primary payer

30 EPIC Co-payment chart <$15$3 $15-$35$7 $36-$55$15 >$55$20 Total drug costEPIC co-pay

31 Part D and New York Prescription Saver Card a prescription discount card  Who can join – New York State residents are eligible if they are not already receiving Medicaid and are:  Either age 50 up to 65, or persons with a disability who have been determined disabled by the Social Security Administration; AND  Have annual household income less than $35,000 (single) or $50,000 (married).

32 Part D and New York Prescription Saver Card  You can’t use Part D plan card and your NYPS at the same time.  When can you use it? 1.To buy drugs that are not on your plan’s formulary or are excluded from all Part D plans. 2. When you’re in your Deductible or Coverage gap - but if you want the money you spend to count towards TROOP (the running total amount you and others have paid for drugs thus far), you need to save receipts and submit them to your plan.

33 Questions Contact: Health Law Helpline Open Tuesdays


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