Maximizing the Medicare Drug Discount Card Subsidy and Part-D State Implementation Status Update Web-conference December 16, :30 – 5:00 pm EST 3:30 – 3:35Dr. Mark McClellanWelcome 3:35 – 3:50Tim Trysla Moderator, Agenda, Discount Card 3:50 – 4:05Kim Fox State experience with Drug Card Enrollment 4:05-4:20Michael McMullanCMS Timeline 4:20 – 4:35Gale ArdenLow Income Subsidy 4:35 –4:50Donna BoswellSPATC Preliminary Recommendations 4:50 – 5:00 Any Additional Questions/ Wrap Up

Dr. Mark McClellan Welcome Welcome

Tim Trysla Agenda Agenda Discount Card Discount Card

Kim Fox State experience with Drug Card Enrollment State experience with Drug Card Enrollment

Presentation to the National Governors Association Presentation to the National Governors Association Kimberley Fox, Senior Policy Analyst Kimberley Fox, Senior Policy Analyst Rutgers Center for State Health Policy Rutgers Center for State Health Policy December 16, 2004 December 16, 2004 Maximizing Enrollment in Transitional Assistance: Lessons from Medicare Discount Cards and Other Low-Income Enrollment Initiatives

Acknowledgement l Presentation based on: l Study of state pharmacy assistance programs funded by The Commonwealth Fund l Telephone interviews in Spring 2004 with 17 states re: Medicare coordination of benefit issues and discount card experience. Website with more detailed reports: / Website with more detailed reports: / l Findings from the State Solutions project funded by the Robert Wood Johnson Foundation to maximize enrollment in Medicare Savings Programs (QMB/SLMB/QI1s).

Estimated Percent of SPAP Enrollees Eligible for $600 Credit Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming. *Includes disabled persons enrolled in state-only program. Enrollees in Illinois’ Senior Care Pharmacy Plus waiver program are ineligible for transitional assistance and the discount card.

Number of States Mandating Enrollment in Medicare during Discount Card Period Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming. # of States

N=10 States Strategies for Getting SPAP Eligible Persons Enrolled Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming.

State Strategies for Enrolling Members in Transitional Assistance l Autoenrollment in Preferred Card (8 states) l Authorized representative status l Expedited RFP or Expansion of Existing Contract l Opt-out letters – different methods for response. l High participation rates in short period. l Significant state savings reported l Autoenrollment in Multiple Cards (1 state) l Authorized representative status l RFI to card sponsors – data sharing agreement l Opt-out letters l Start-up delays, file-sharing inconsistencies l High participation rates after 6 months. l Savings still being determined.

State Strategies for Enrolling Members in Transitional Assistance (cont.) l Facilitated Enrollment w/ Preferred Card (1) l Expedited RFP or Expansion of Existing Contract l Pre-populating applications l Outcome - ? l Voluntary Enrollment by Individual Members (6) l Outreach varies. l Letter to benes l Use of SHIPs l Outcome – Much lower enrollment rates in states that had data from CMS. l Minimal savings to state. l Two states moving to autoenroll or facilitate enrollment due to low enrollment rates. l Many of those enrolled are not using the $600 credit.

Use of Incentives by SPAPs to Encourage Enrollment State pays all or portion of the 5-10% coinsurance (10 states) State pays all or portion of the 5-10% coinsurance (10 states) Preceded autoenrollment allowance. Preceded autoenrollment allowance. Post autoenrollment maintained to discourage opt-out. Post autoenrollment maintained to discourage opt-out. Outcome – difficult to measure. Outcome – difficult to measure. Waiving other SPAP requirements Waiving other SPAP requirements Enrollment fees Enrollment fees Counting $600 toward state deductible Counting $600 toward state deductible Waiving reapplication for SPAP during discount card period. Waiving reapplication for SPAP during discount card period. Increasing SPAP Benefits Increasing SPAP Benefits Increasing benefit caps Increasing benefit caps SPAP pays first, discount card used only if state does not pay SPAP pays first, discount card used only if state does not pay Incremental impact of Incentives vs. other approaches unknown. Incremental impact of Incentives vs. other approaches unknown. Most states using incentives were also autoenrolling. Most states using incentives were also autoenrolling.

Lessons from Efforts to Enroll Persons in Medicare Savings Programs Community-based outreach important Community-based outreach important One-on-one assistance works best, but expensive One-on-one assistance works best, but expensive Use of SHIPs Use of SHIPs Linking outreach/enrollment with other low-income benefit programs Linking outreach/enrollment with other low-income benefit programs Combined outreach for TA, SPAP, and MSP Combined outreach for TA, SPAP, and MSP Limiting administrative hassles can significantly impact enrollment Limiting administrative hassles can significantly impact enrollment Simplifying application and renewal processes Simplifying application and renewal processes Modifying eligibility and eliminating documentation requirements Modifying eligibility and eliminating documentation requirements Implications for Part D more than Discount Card/TA Implications for Part D more than Discount Card/TA Partnerships with Other Trusted Sources Helpful Partnerships with Other Trusted Sources Helpful Deputization to allow these entities to help fill out applications and submit Deputization to allow these entities to help fill out applications and submit Kiosks at medical clinics. Kiosks at medical clinics. Mixed success with direct mail Mixed success with direct mail

Summary of Enrollment Lessons from Discount Card Autoenrollment the most efficient mode for getting people enrolled. Autoenrollment the most efficient mode for getting people enrolled. Transparent to enrollees. Transparent to enrollees. Nearly 100% of enrollment in transitional assistance is due to SPAP and M+C autoenrollment. Nearly 100% of enrollment in transitional assistance is due to SPAP and M+C autoenrollment. One application process for card and subsidy minimized burden. One application process for card and subsidy minimized burden. Will not be the case under Part D – expect even lower enrollment in subsidies. Will not be the case under Part D – expect even lower enrollment in subsidies. Asset test requirement will also reduce participation in Part D subsidies. Asset test requirement will also reduce participation in Part D subsidies. Left on their own, voluntary enrollment has been extremely low. Left on their own, voluntary enrollment has been extremely low. Voluntary enrollment may be enhanced by offering incentives, but degree of impact unknown. Voluntary enrollment may be enhanced by offering incentives, but degree of impact unknown.

Michael McMullan CMS Timeline CMS Timeline

Gale Arden Low Income Subsidy Low Income Subsidy

Donna Boswell SPATC preliminary recommendations SPATC preliminary recommendations

State Pharmaceutical Assistance Transition Commission (SPATC) Snap Preview of SPATC Recommendations For NGA Part D Implementation Project December 16, 2004

SPATC Charter in MMA Appointed by the Secretary to develop a proposal to advise the Secretary and the Administrator of CMS on ways to address the unique transitional issues facing SPAPs and SPAP participants consistent with the following principles: Appointed by the Secretary to develop a proposal to advise the Secretary and the Administrator of CMS on ways to address the unique transitional issues facing SPAPs and SPAP participants consistent with the following principles: Protection of the interests of program participants in a manner that is least disruptive to such participants and that includes a single point of contact for enrollment and processing of benefits. Protection of the interests of program participants in a manner that is least disruptive to such participants and that includes a single point of contact for enrollment and processing of benefits. Protection of the financial and flexibility interests of States so that States are not financially worse off as a result of the enactment of this title. Protection of the financial and flexibility interests of States so that States are not financially worse off as a result of the enactment of this title. Principles of Medicare modernization under the MMA. Principles of Medicare modernization under the MMA.

Knowledge Through Experience SPATC members believe that the experience gained -- SPATC members believe that the experience gained -- (1) in administering SPAPs for Medicare beneficiaries over the last decade, and (1) in administering SPAPs for Medicare beneficiaries over the last decade, and (2) in helping those beneficiaries deal with the Medicare drug discount cards (2) in helping those beneficiaries deal with the Medicare drug discount cards should be used to inform the part D implementation and to avoid – if possible-- making the same missteps twice!

SPATC Approach For Tackling Complex Issues The problems identified at the first meeting, July 8, 2004, were divided into three groups, and Commission members each served on one of the work groups: The problems identified at the first meeting, July 8, 2004, were divided into three groups, and Commission members each served on one of the work groups: 1) transition of current SPAP beneficiaries: education, eligibility, and enrollment; 1) transition of current SPAP beneficiaries: education, eligibility, and enrollment; 2) benefit design/coordination of SPAPs with the new Part D program; and 2) benefit design/coordination of SPAPs with the new Part D program; and 3) issues affecting the infrastructure of providers, systems, and data collection and management. 3) issues affecting the infrastructure of providers, systems, and data collection and management.

Key Recommendations: 1 SPAPs should be considered authorized representatives of their beneficiaries for the purposes of determining their eligibility for subsidy assistance, enrolling them in one or more preferred PDP sponsors, and paying their Part D premiums. SPAPs should be considered authorized representatives of their beneficiaries for the purposes of determining their eligibility for subsidy assistance, enrolling them in one or more preferred PDP sponsors, and paying their Part D premiums.

To provide seamless and comprehensive benefits coordination, SPAPs should be allowed to choose preferred part D sponsors on behalf of their enrollees. To provide seamless and comprehensive benefits coordination, SPAPs should be allowed to choose preferred part D sponsors on behalf of their enrollees. SPAPs know their beneficiaries’ existing medications and can help select part D plan with appropriate formulary and cost sharing to assure that beneficiary’s transition is smooth. SPAPs know their beneficiaries’ existing medications and can help select part D plan with appropriate formulary and cost sharing to assure that beneficiary’s transition is smooth. The MMA “anti-discrimination” requirement can be met by ensuring that the SPAP provides equivalent subsidy to any of its beneficiaries that wishes to opt for a different part D plan. The MMA “anti-discrimination” requirement can be met by ensuring that the SPAP provides equivalent subsidy to any of its beneficiaries that wishes to opt for a different part D plan. Key Recommendations: 2

The exceptions and appeals process, as proposed in regulations, should be revised- The exceptions and appeals process, as proposed in regulations, should be revised- SPAPs should be given authority to appeal on behalf of beneficiaries, since the SPAPs are at financial risk for formulary denials and high tier copays. SPAPs should be given authority to appeal on behalf of beneficiaries, since the SPAPs are at financial risk for formulary denials and high tier copays. The process should provide denial and appeal rights notices and make the process timelines much quicker for the sake of consumer access and protection. The process should provide denial and appeal rights notices and make the process timelines much quicker for the sake of consumer access and protection. Key Recommendations: 3

CMS should form an advisory committee of SPAP representatives and other stakeholders (like the SPATC) to assist and inform them through the transition of implementing Part D. CMS should form an advisory committee of SPAP representatives and other stakeholders (like the SPATC) to assist and inform them through the transition of implementing Part D. Key Recommendations: 4

A Centralized Data System should be established to facilitate data exchange through a single entry point so that all involved parties have access to timely and accurate data needed – A Centralized Data System should be established to facilitate data exchange through a single entry point so that all involved parties have access to timely and accurate data needed – for the “real-time” coordination of benefits (COB); for the “real-time” coordination of benefits (COB); For the tracking of TrOOP. For the tracking of TrOOP. Key Recommendations: 5

Marketing, enrollment, and educational materials should be appropriate to the beneficiary’s situation, including— Marketing, enrollment, and educational materials should be appropriate to the beneficiary’s situation, including— Information about the availability of SPAP coverage in the State, and Information about the availability of SPAP coverage in the State, and clear explanations of how the SPAP will coordinate prescription benefits with part D plans in the state. clear explanations of how the SPAP will coordinate prescription benefits with part D plans in the state. Key Recommendations: 6

CMS should ensure that SPAPs that do not wish to provide full secondary coverage can supplement the coverage offered by Part D plan’s coverage by— CMS should ensure that SPAPs that do not wish to provide full secondary coverage can supplement the coverage offered by Part D plan’s coverage by— Paying premiums for standard coverage Paying premiums for standard coverage Paying premiums for enhanced alternative coverage Paying premiums for enhanced alternative coverage Paying a flat fee to reduce cost sharing by eliminating the deductible; filling the “donut hole”; or reducing the coinsurance, like the federal subsidy does for the lowest income beneficiaries, or Paying a flat fee to reduce cost sharing by eliminating the deductible; filling the “donut hole”; or reducing the coinsurance, like the federal subsidy does for the lowest income beneficiaries, or Paying cost-sharing for drugs for specific diseases. Paying cost-sharing for drugs for specific diseases. Key Recommendations: 7

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