The Medicare Drug Benefit: The Role of Specialty Societies

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• The Medicare Drug Benefit The Role of Specialty
  Societies

Susan Nedza M.D., M.B.A., FACEP Chief Medical
Officer Chicago Regional Office Centers for
Medicare Medicaid Services 312-886-5341
Susan.nedza_at_cms.hhs.gov
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Perspectives on Medicare

• 2003
• Medicare paid 272.6 billion dollars
• 2004
• Nearly 42 million persons in Medicare
• 2030
• Projected 70.5 million persons over 65
• Almost doubled in only 30 years

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Medicine has changed and so must Medicare

• Move to cover preventive services
• Paying for medications that are critical to the
  health of our patients

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What Does this Mean for Physicians?

• Medicare must reach physicians and the patients
  that they care for about these important changes.

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WHY IS YOUR HELP CRITICAL? Where do these
populations go for information? (12/04)
38
(04/05) 49
Your doctor
A Medicare office, website or phone number
Your pharmacist
A health insurance company
Friends or family members
A Social Security office, website or phone number
A local seniors group or community organization
An employer or union
Source Kaiser Family Foundation Health Poll
Report survey (conducted December 2-5, 2004)
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The Medicare Drug Benefit

• The benefit is available to all people with
  Medicare
• There is additional help for those with limited
  resources and income
• The benefit pays for brand name as well as
  prescription drugs
• Refer patients and their medical decision makers
  to www.medicare.gov or 1- 800- MEDICARE.

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Eligibility and Enrollment Prescription Drug
Benefit

• Must have Part A and/or Part B
• Enrollment in drug coverage is voluntary
• If do not enroll, subject to late enrollment
  penalties
• Enrollment begins 11/15/05, continues through
  5/15/06
• Will NOT be enrolled automatically must make a
  decision to sign up for drug plan

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Standard Prescription Drug Benefit

• 37 monthly premium (average)
• 250 beneficiary deductible
• Medicare will pay 75 of drug costs up to 2,250
• The beneficiary will pay 25 of these costs
• Beneficiary will pay 100 of drug costs between
  2,250 and 5,100
• After 3,600 in out-of-pocket spending, Medicare
  will pay approximately 95

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Summary of Choices

• A prescription drug-only plan (PDP) in addition
  to traditional fee-for-service Medicare or
  private fee-for-service Medicare
• A Medicare Advantage plan either a regional
  PPO, local PPO, HMO, or special needs MA plan
• A qualified employer or union plan
• New enrollees will not be able to sign up for a
  Medigap drug plan, but existing beneficiaries
  will be able to renew Medigap H, I, or J plans
  where they are available
• A fallback drug-only plan, if an insufficient
  number of PDPs or PPOs emerge in a particular
  area

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Timeline

• 5/05 SSA sends out enrollment packages for
  low-income
• 9/14/05 CMS awards bids to PDPs, MA-PDs
• 10/05 CMS mails Medicare Handbook PDP Compare
• 11/15/05 Enrollment in Prescription Drug
  Plan begins
• 12/31/05 Medicaid Drug Coverage ends for
  dual-eligible
• 1/1/06 Medicare Drug Prescription Plan,
  retiree options begin
• 5/15/06 Last day to enroll before penalties

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What Is the Message to Your Members?

• Encourage patients to fill out low income subsidy
  application.
• Refer patients to 1-800 MEDICARE for information
  or to the SHIP.
• CMS will work through your society to provide
  training, materials and information about the
  drug benefit to your members and their staffs.

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The State Health Insurance Assistance Program
SHIP Program

• A national program that offers one-on-one
  counseling and assistance to people with
• Medicare and their families.
• SHIPs provide free counseling and assistance via
  telephone and face-to-face interactive sessions,
  public education presentations and programs, and
  media activities

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The State Health Insurance Assistance Program
SHIP Program

• Beneficiary Contact
• Senior Health Insurance Information Program
  (SHIIP)Illinois Department of Insurancehttp//ww
  w.ins.state.il.us/Ship/ship_help.htm 800-548-9034
  (In-State calls only) 217-785-9021
  (Out-of-State calls)

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Conclusions

• Physicians need to be engaged in efforts to meet
  the challenges of transforming the healthcare
  system.
• Physicians must continue to be patient advocates
  in these efforts.

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For More Information

• Visit www.medicare.gov
• Visit www.cms.hhs.gov
• Visit www.socialsecurity.gov
• Publications such as
• Medicare You handbook
• Facts About Medicare Prescription Drug Plans
• 1-800-MEDICARE
• Call Social Security at 1-800-772-1213
• SHIP 1- 800-548-9034

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Questions?

• Susan Nedza MD, MBA FACEP
• 1-312-886-5341
• Susan.nedza_at_cms.hhs.gov