Kidney Medicare Drugs Awareness and Education Initiative

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Medicare How Its Changing To Help More People
Coordinating Coverage Helping Your Patients
Coordinate the New Medicare Prescription Drug
Coveragewith Medicaid and Other Coverage

• Presented by
• Kidney Medicare Drugs
• Awareness and Education Initiative
• www.kidneydrugcoverage.org

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Introduction

• August 16 teleconference overview and
  low-income subsidy
• Todays focus is on coverage coordination
• Adding a Medicare drug plan to current drug
  coverage
• Replacing current drug coverage with a Medicare
  drug plan
• Knowing what choices jeopardize other health (not
  just drug) coverage

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Our Experts

• Dolph Chianchiano, Senior VP of Health Policy
  Research, National Kidney Foundation
• Christine Hinds, Division of Drug Plans Policy,
  Centers for Medicare Medicaid Services
• Heather Holland, Division of Beneficiary
  Communications, Centers for Medicare Medicaid
  Services
• Linda Keegan, Executive Director, Kidney Care
  Partners
• Janet Miller, Division of Partnerships, Centers
  for Medicare and Medicaid Services
• Wendy Schrag, NKFs Council of Nephrology Social
  Workers, Renal Care Group, Inc. Patient Services
  Manager

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Medicare in General

• Medicare Part A hospital, hospice, skilled
  nursing, some home health free for most
• Medicare Part B doctors and outpatient,
  including dialysis
• Pays 80 as primary payer
• Does not pay for most take-home drugs (EPO and
  anti-rejection drugs are exceptions)

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Medicare Prescription Drug Coverage

• Coverage starts January 1, 2006
• Coverage for drugs under A or B will not change
• Available to anyone with Medicare A and/or B
• Optional for all but
• People with Medicare and full Medicaid
• People with Supplemental Security Income (SSI)
  without Medicaid
• People with Medicare Savings Programs (QMB, SLMB,
  QI)

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Medicare Drug Plans

• Advertising starts this fall
• If have Medicare Health Plans (e.g., HMO, PPO)
• Coverage may include health and drugs
• Coverage may not include drugs
• If have Original Medicare
• Coverage is for health and few drugs
• Add Medicare prescription drug plan for drug
  coverage

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Resources

• Medicare Prescription Drug Plan Finder Tool
• Compares Medicare drug plans
• Found at www.medicare.gov
• General advice (not kidney-specific)
• Medicare You 2006 booklet
• 1-800-MEDICARE or 1-877-486-2048 (TTY)
• State Health Insurance Assistance Program (SHIP)
• Kidney-specific advice
• www.kidneydrugcoverage.org

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Factors to Consider in Choosing a Medicare Drug
Plan

• 1-800-MEDICARE can send list of plan options
  based on what is important to each person
• What drugs does each plan cover?
• How much does each plan cost
• How much do drugs cost on each plan
• What drug stores contract with each PDP
• Look for a kidney-friendly plan

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What Are Costs and Benefits?

• Coverage is not free for anyone
• Standard Medicare drug plan
• Premium average of 32.20 per month
• Deductible 250 per year
• Coinsurance 25 of drug costs from 251 to
  2,250, up to 500
• Coverage Gap 100 of drug costs from 2,251 to
  5,100, up to 2,850 out-of-pocket
• Catastrophic benefit once drugs cost 5,100 or
  3,600 true out-of-pocket (TrOOP), Medicare pays
  95 of covered drug costs for year
• Plans may vary but must pay out this much

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Tracking TrOOP?

• Coordination of benefits contractor tracks what
  is paid by
• Patient out-of-pocket
• State Pharmacy Assistance Programs (SPAPs)
• Foundations and charities
• Value of free drugs at manufacturers cost
• Family and friends

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Joining a Medicare Part D Plan

• Anyone with Medicare can join
• Apply 11/15/05 5/15/06 or first 6 months of
  Medicare
• Apply to the Medicare drug plan
• Apply online at www.medicare.gov
• Apply by phone at 1-800-MEDICARE or
  1-877-486-2048 (TTY)

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Key Dates Limited Income Resources Medicare
Drug Plan Enrollment
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What is Creditable Coverage? Why Does It
Matter?

• Definition Coverage that is, on average, as
  good as the standard Medicare Prescription Drug
  Coverage.
• If join a Medicare drug plan before gap of 63
  days from creditable coverage
• No premium penalty
• No waiting for open enrollment
• If wait too long, pay more and limited to joining
  November 15-December 31

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Notice of Creditable Coverage

• Notices must be sent by
• Employer or union, including COBRA and government
• Medigap plans
• Medicare Advantage plans
• Notice must be received by 11/15/05
• Notice must be clear and stand out
• Samples - www.cms.hhs.gov/partnerships

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How Social Workers Can Help

• Ask patients for copies of letters from
  government agencies, employers, payers, PDPs
• To explain contents
• To know whether coverage is creditable
• To have proof of what patient was told

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Coordination Medicaid

• Medicare replaces Medicaid for drugs 1/1/06
• Both have formularies
• Medicare drug plans
• No limit on number of prescriptions per month
• No cap on amount spent on drugs
• Can use out-of-network pharmacies in certain
  cases
• Co-pays for those with low-income subsidy
• Medicaid may pay for drugs excluded by Medicare
  Prescription Drug Coverage, more if funds and
  policies allow

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Coordination Employer/Union (Including COBRA)

• Must send notice by November 15
• If coverage is creditable
• Can have both, but may not need Medicare drug
  plan now
• May want to join a Medicare drug plan later
• No penalty or delay
• With creditable coverage notice
• If join before 63 gap in coverage occurs

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Coordination Employer/Union (Including COBRA)

• If coverage isnt creditable
• Can add Medicare drug plan to current coverage by
  May 15, 2006 or in 1st 6 months of Medicare
• If wait longer, pay higher premium and join only
  November 15-December 31 each year

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Advice for Employees/Retirees

• Alert! Patients who drop current health coverage
  to get a Medicare drug plan may not be able to
  get it back
• Alert! Patients on COBRA should NOT sign up for
  Medicare to get a Medicare drug plan or employer
  can stop COBRA protect COBRA rights by getting
  Medicare before COBRA
• Ask health benefits administrator about options
• Kidney disease is an expensive illness
• Having a good health plan is key

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Especially For About Employers

• Medicare will pay employers a tax free retiree
  drug subsidy of 28of drug costs
• Employers dont get the subsidy if a retiree
  joins a Medicare drug plan
• Contact 1-800 MEDICARE if employer drops coverage
• Contact EEOC if employers urge only those with
  kidney disease to drop EGHP health or drug
  coverage (ADA prohibits)

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Coordination Medigap Plans H, I, J

• No new Medigap policies with drug coverage can be
  sold after 12/31
• Cant have Medigap drug plan and a Medicare drug
  plan
• Look for creditable plan notice 9/15-11/15
• Medigap drug plans may not be creditable

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Options If Medigap Plan With Drugs Is Not
Creditable

• Keep Medigap plan, disenroll from drug coverage
  only for lower premium, join Medicare drug plan
• Switch to Medigap A, B, C, F, K, L and join
  Medicare drug plan (see Medicare Pub. 02110)
• Use prior coverage to meet pre-existing waiting
  period
• Use free look month to test satisfaction with
  plan
• Join Medicare Advantage plan with drug coverage
• Not currently an option for dialysis patients
• May be option for someone with successful
  transplant
• Keep Medigap plan after 5/15/06 or 1st 6 months
  of Medicare
• Limits time to join/change to 11/15-12/31 yearly
• Leads to premium penalty of 1 per month since
  eligible

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Coordination Medicare Advantage

• If plan has drug coverage, look for creditable
  coverage notice in 10/05
• If creditable and continuing in 2006, keep plan
• If plan has no drug coverage or is not creditable
• Switch to MA plans with drugs
• Even ESRD may do this if in same company
• Switch to Original Medicare
• Alert! Will owe coinsurance if cant get Medigap
  plan
• Alert! May not get as comprehensive coverage

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Coordination VA, TRICARE, FEHB

• Coverage not expected to change and considered
  creditable, but
• Can have Medicare drug plan too
• If lose plan less than 63 days
• Can join Medicare drug plan later with no penalty
• Can join right away
• Alert! If 63 days or more since coverage lost
• Must wait to join until 11/15-12/31 yearly
• Penalty of 1 per month since first eligible

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Low-Income Subsidy and VA Coverage

• May have VA and Medicare drug plan too
• With Medicare drug plan may be able to use a
  neighborhood pharmacy
• May have lower co-pays with Medicare drug plan
• VA and Medicare drug plan cannot pay on the same
  drug at the same time so must choose one or the
  other each time patient fills prescription

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CoordinationIndian Health Service

• IHS, tribes and urban Indian organizations still
  provide drug coverage
• Can pay premiums and cost sharing for PDP so
  patients will have no co-pays
• Help provided may not count toward TrOOP
• Contact IHS or other Indian organization about
  changes in 2006

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CoordinationState Pharmacy Assistance Programs

• 21 federally recognized SPAPs in U.S.
• States can continue these programs
• SPAPs can help qualifying state residents
• Pay premiums
• Pay cost share
• Pay monthly per capita payment
• Contact SPAP about changes in 2006

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CoordinationState Kidney Programs

• Limited number of programs offering different
  benefits
• Some offer drug assistance
• Some are SPAPs but others are not
• Ask how program may change in 2006

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CoordinationDrug Cards

• Medicare-approved drug discount cards
• End the earlier of May 15, 2006 or when Medicare
  drug plan starts
• Deadline to apply for transitional assistance
  12/31/05 and get pro-rated credit to use in 2006
  until Medicare drug plan starts
• Other discount drug cards
• Ask card provider what will change in 2006

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Coordination Pharmaceutical Assistance Programs

• Programs may or may not continue to offer free
  drugs through providers
• Only manufacturing cost of drug counts toward
  TrOOP
• Companies may donate to foundations or charities
  to
• Pay some or all of out-of-pocket costs
• Pay premiums for basic or expanded Medicare drug
  plan coverage
• Ask program what will change in 2006

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Questions?
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Key Messages

• Medicare drug plan will help some others may not
  need it
• Most information you read is for the average
  person with Medicare
• Kidney Medicare Drugs Awareness and Education
  Initiative provides kidney-specific information
• Kidney friendly plans provide the most help
• Ask patients to bring notices to review, advise
  about creditable coverage, keep for appeals

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The right information at the right time
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Thank You For Participating

• Visit www.kidneydrugcoverage.org
• Complete evaluation
• Print your certificate of attendance
• Ask your licensing board if certificate can be
  used for continuing education credit
• Submit questions about Medicare Part D to
  info_at_kidneydrugcoverage.org
• Listen in at noon ET on October 18, 2005 for
  information on choosing a plan