1 Medicare Prescription Drug Coverage AKA Medicare Part D Or Medicare Modernization Act MMA

2 Medicare Prescription Drug Plan Coverage Coverage begins January 1, 2006 Available for all individuals who are entitled to Medicare Part A and/or enrolled in Part B Provided through - Prescription Drug Plans (PDPs) [34 PDP Regions] -Medicare Advantage Plans (MA-PDs) [26 MA-PD Regions] -Some employers and unions to retirees

3 Medicare Prescription Drug Benefit Plans Must offer standard benefit package -Prescription drugs, biologicals, insulin -Certain medical supplies Cost sharing (co-pays & deductibles) based on plan and client income and resources May offer supplemental benefits such as an enhanced benefit package Can be flexible in benefit design however cannot exceed the $ a year out of pocket expenses

4 Formulary Must cover at least two drugs in each of the covered drug classes Coverage of all drugs in certain drug classes, i.e. anti psychotic, anti depressants, HIV, is required for 2006 Excluded drugs -anorexia, weight loss or gain -fertility -cosmetic purposes or hair growth -symptomatic relief of cough & colds -prescription vitamins & mineral products -non-prescription drugs -barbiturates -benzodiazepines Must have an exceptions process in place with 24 hour turnaround on decisions

5 Who is Eligible For Part D? Anyone entitled to Medicare part A and/or enrolled in part B Must reside in plan’s service area Must be enrolled in a Medicare prescription drug plan to receive coverage

6 Who is Eligible for Low Income Subsidy or Extra Help Available for individuals at or below 150% of federal poverty guidelines with assets below a specified amount Provides relief for monthly premium, co-pays, and deductibles Certain populations are deemed eligible for extra help -Medicare/Medicaid dual eligibles -SSI recipients -QMBs. SLMBs, QIs All others must apply for extra help

7 Signing Up Extra Help Application Begins 07/01/05 Can apply at SSA office, on-line or H&W Deemed population does not need to apply Part D Open Enrollment Begins 11/15/05 Ends 05/15/06 Enrolls with selected PDP Deemed will be auto- enrolled 1/1/06 if a PDP has not been selected

8 Extra Help Applications 20 million low subsidy applications will be mailed out starting on 5/26/05 360,000 applications will be mailed each day until 8/19/05 Approximately 2,200 applications will be received by Idaho residents each day Mailed out by the last two digits of the SS # Both English and Spanish applications will be mailed out

9 Standard Out-of-Pocket Expenses 1.Monthly premium of approximately $ $ yearly deductible 3.25% co-pay from $ to $ % co-pay between $ and $ % co-pay over $ Total of 2, 3 & 4 is $ which is the out-of-pocket threshold

10 Out-Of-Pocket Expenses For Those With Extra Help Monthly Premium DeductibleCo-pay Dual Eligible$0.00 $1 – 3.00 Up to 100% of Poverty$0.00 $ % to 135% of poverty$0.00 $3 – % to 150% of povertySliding scale $ %

11 Enrolling In A PDP Plan People with Medicare can enroll –Directly with the plan sponsor –Through a personal representative “Stands in the shoes” of a person with Medicare and has authority to act on his or her behalf This authority comes from state law (e.g., Power of Attorney, guardian) or other applicable law (e.g., tribal or military law) –By enlisting the assistance of others Spouse, relative, friend, caregiver, or advocacy group volunteer

12 Enrollment Options People eligible for Medicare prescription drug coverage may enroll in a –Prescription Drug Plan (PDP) or –Medicare Advantage Prescription Drug plan (MA- PD plan) People enrolled in an MA plan must receive Medicare prescription drug coverage from the MA-PD plan except if –Enrolled in a PFFS plan without drug coverage; or –Enrolled in an MSA plan People enrolled in a cost plan can elect to receive Medicare prescription drug coverage from the cost plan or enroll in a PDP People must obtain Medicare prescription drug coverage from their PACE organization if it is offered

13 Auto-Enrollment in a PDP Medicaid prescription drug coverage for full-benefit dual eligibles ends 12/31/05 Full-benefit dual eligibles who do not enroll in a plan by 12/31/05 –will be automatically and randomly enrolled in a prescription drug plan with a premium covered by the low-income premium assistance –Their Medicare prescription drug coverage will begin 1/1/06 Full-benefit dual eligibles have an on-going SEP –Can change plans any time

14 Ten Month Timeline MayJuneJulyAugustSeptember SSA mailing starts CMS mailing starts Staff training begins SSA & CMS mailings continue DHW starts taking client calls Staff training continues SSA mailings continue Extra help enrollment begins Monthly report to CMS complete SSA mailings continue Extra help enrollment continues CMS mailing re part D enrollment begins CMS announces the PDP’s OctoberNovemberDecemberJanuaryFebruary Extra help enrollment continues Clients start choosing a PDP Open enrollment for Part D begins Duals get letter of PDP assignment Open enrollment continues Medicaid drug coverage ends for duals Open enrollment continues Duals are auto enrolled Part D coverage for duals begins Duals start changing their assigned PDP Open enrollment continues Duals continue changing their assigned PDP

15 What’s Next? Help qualified clients apply for the extra help subsidy Make sure staff is ready to provide assistance to clients trying to decide on a PDP Educate staff on the new way of doing business as it relates to drug coverage