Medicare Today

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Medicare TodayMore Choices, Better Benefits
Instructors Name Event Date
244375 9/06
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Topics/Modules

• Medicares Covered Preventive Care Services
• Basics of Medicare Prescription Drug Coverage
• Picking and Switching Medicare Plans
• How to Get Extra Help with Costs
• What Drugs Do Medicare Plans Cover? All About
  Formularies
• What Is the Donut Hole?
• Important Dates for Medicare

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Medicares Covered Preventive Care Services
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Medicare Has More to Offer

• Preventive services
• Prescription drug plan coverage
• New Medicare Health Plan options
• Extra help for those who need it most

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Benefits and Options

• Increased coverage of preventive services in 2005
• Outpatient prescription drug coverage available
  January 1, 2006
• Offered new Medicare Health Plan options in 2006

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Covered Preventive Services

• Designed to help you stay healthy
• Began January 2005
• Welcome to Medicare physical exam
• Cardiovascular screening blood tests
• Diabetes screening tests

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Initial Preventive Physical Examination (IPPE)

• Welcome to Medicare Physical
• Who is eligible?
• All Medicare beneficiaries whose Part B coverage
  began on or after January 1, 2005
• When?
• Once during the first 6 months of Part B coverage
• Cost to beneficiary?
• Part B deductible and copayment/coinsurance

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Cardiovascular Disease Screening

• Who is eligible?
• All asymptomatic Medicare beneficiaries
• When?
• Every 5 years
• Cost to beneficiary?
• No deductible, no co-payment, no coinsurance

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Elements of Cardiovascular Screening

• Total Cholesterol
• HDL
• Triglycerides
• Provides opportunity assess and discuss
  cardiovascular risk factors, such as
• Family history - Smoking
• Diet - Stress
• Obesity - Diabetes

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Diabetes Screening

• Who?
• Beneficiaries diagnosed with pre-diabetes and
  at-risk non-diabetic beneficiaries
• When?
• 2 tests per year for pre-diabetic beneficiaries
• 1 test per year for undiagnosed, non-diabetic
  beneficiaries
• Cost to beneficiary?
• No deductible, no copay/coinsurance

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Diabetes Self-Management Training (DSMT)

• Who is eligible?
• Beneficiaries recently diagnosed with diabetes or
  at risk for complications from diabetes or who
  were diagnosed with diabetes before becoming
  Medicare eligible
• When?
• A plan of care must be written to include number
  of sessions, frequency, and duration (up to 10
  hours for initial training, up to 2 hours per
  year thereafter)
• Cost to beneficiary?
• Part B deductible, copayment/coinsurance

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Other Covered Screening Tests

• Breast cancer
• Colorectal cancer
• Prostate cancer
• Cervical vaginal cancer
• Bone Density
• Glaucoma

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Covered Vaccinations

• Influenza
• Pneumococcal
• Hepatitis B

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Smoking Cessation Counseling

• If diagnosed with a smoking related illness
• Inpatient or Outpatient Counseling
• Up to 8 face-to-face counseling sessions per 12
  month period

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Basics of Medicare Prescription Drug Coverage
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Medicare Prescription Drug Coverage Why Should
You Get It?

• If you are going to join its important to join a
  plan when you are first eligible
• Many people with Medicare need or likely will
  need prescription drugs to stay healthy
• Medicare prescription drug coverage may help
  protect against high out-of-pocket costs
• Enrolling when first eligible may mean that you
  pay a lower premium

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Types of Medicare Prescription Drug Plans

• There are two types of plans available
• Prescription Drug Plans (PDPs)
• Provide prescription drug coverage only
• Medicare Advantage - Prescription Drug Plans
  (MA-PDs)
• Formerly known as MedicareChoice
• Provide Medicare Parts A B medical and hospital
  care and prescription drug coverage under the
  same plan

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What Drugs Are Covered?

• Medicare drug plans will cover most outpatient
  prescription drugs (and biologics)
• The drug (or biologic) must be
• Available by prescription only
• Approved by the FDA
• Drugs in clinical development will not be covered
• Some vaccines, insulin and medical supplies used
  to inject insulin are also covered
• Part B covers diabetes supplies. Part B does not
  change.

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Pharmacies Under Part D

• Part D plans must provide pharmacy options
• Network of retail pharmacies
• Long-term care pharmacies
• Home infusion providers
• Mail order pharmacies are permitted
• 90-day supplies are available through retail and
  mail options

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How to Sign Up for a Medicare Prescription Drug
Plan

• There are several ways to enroll
• Call the plan directly
• Visit the plans website
• Call 1-800-Medicare
• Visit www.medicare.gov

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Enrollment for Those Who Need Help Paying for a
Plan

• People who have both Medicare and Medicaid
  coverage (dual eligibles) are automatically
  enrolled into a Medicare drug plan by CMS
• They are notified of their enrollment
• They can switch plans monthly if they are not
  satisfied or cannot get the medicines they need
• Others with limited resources must apply for
  extra help to determine eligibility

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Picking or Switching Medicare Prescription Drug
Plans
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Decide What Kind of Plan You Want

• Medicare Advantage with Prescription Drugs
  (MA-PD)
• New name for MedicareChoice plans
• Medicare Managed Care Plans covering medical and
  hospital care and prescription drugs
• Includes Medicare HMOs, Preferred Provider
  Organization Plans (PPOs)
• Prescription Drug Plan (PDP)
• Only covers drugs
• Can be coupled with traditional Medicare Program

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If you join a Medicare Advantage Plan

• You are still in the Medicare program
• You have all your Medicare rights and protections
• You will get all the basic Medicare coverage
• You may get more benefits

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Pointers for Picking a Medicare Prescription Drug
Plan

• Most people will want to pick a plan with low
  yearly costs considering all associated costs
• Monthly Premiums Copays/Coinsurance
  Deductible
• Other things to consider
• Use of a preferred pharmacy or mail order
• Getting prescriptions during travel (e.g.,
  snowbirds)
• Limits such as prior authorization, step therapy
  requirements, and quantity limits on the
  patients medications
• Reputation of the plan

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Steps for Picking a Plan

• Go to www.medicare.gov and click on Find and
  Compare Plans. Follow the instructions to use
  the Prescription Drug Plan Finder
• OR
• Call 1-800-MEDICARE and ask the representative
  to enter your information in the Prescription
  Drug Plan Finder

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Steps for Picking a Plan (continued)

• Choose if you want to do a Personalized or a
  General Plan Search. You will also need to
  pick the type of plan you want
• Prescription Drug Plan only (PDP)
• Medicare Advantage Plan (MA-PD)
• (List your medications and strengths when
  prompted)

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Steps for Picking a Plan (continued)

• The Prescription Drug Plan Finder will list all
  the plans in your area. You can check up to
  three plans at one time to compare plan
  information
• 4. Select 3 or 4 possible plans from the
  Prescription Drug Plan Finder

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Steps for Picking a Plan (continued)

• 5. Contact each plan to get more information
• How is the plans Customer Service? Are they
  quick to answer your call? Helpful in answering
  your questions? Courteous?
• Are there restrictions on your medications, such
  as prior authorization requirements?
• Can you get your drugs if you travel part of the
  year?
• Is mail order available if you want it?

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Steps for Picking a Plan (continued)

• Decide on the right plan you want and sign up
  using the options below
• Call the plan directly
• Call 1-800-MEDICARE
• Visit the web site of the plan sponsor
• Visit www.medicare.gov
• Submit a paper form provided by the plan sponsor

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Comparing Plans

• Why do some plans cost more than others?
• Every plan is different and has different
  benefits that may increase its costs compared to
  other plans
• For example, depending on the medications you
  take, some plans may be more expensive because
  your medicines are not on their preferred drug
  lists
• Other plans may offer additional services
• Paying more doesnt mean its a better plan!
• You should find the plan that best fits your needs

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Evaluating Your Current Plan

• Open enrollment is a time to do a satisfaction
  check of your current plan
• Ask yourself the following questions
• Are the medicines my doctor prescribed on the
  plans formulary (drug list)?
• If I hit the coverage gap (donut hole), am I
  still able to afford my medicines, or should I
  look for a plan with better coverage options
  during the gap?
• Would enrolling in a Medicare Advantage plan be a
  better option than a stand-alone Prescription
  Drug Plan where I can get both medical and
  pharmaceutical coverage?

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Pros and Cons of Switching to a Different Plan

• Pros
• You may
• Save money if you pick a lower cost plan
• Be more satisfied if you pick a plan that covers
  all your medications

• Cons
• It may require research and time to pick a new
  plan
• You may have concerns about the new plan that are
  unknown at the time of enrollment

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How to Get Extra Help with Medicare Part D Costs
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Help for Those Who Need it Most

• Those with the lowest incomes pay no premiums or
  deductibles and have small or no copayments
• Those with slightly higher incomes pay a little
  more
• You may qualify if your annual income is less
  than 150 of the Federal Poverty Level and you
  are
• Single and annual income less than 14,700
• Married and annual income less than 19,800
• Some people will automatically qualify

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Applying for Extra Help

• Apply for Low Income Subsidy (LIS) through the
  Social Security Administration (SSA)
• Online at www.socialsecurity.gov
• Look up the local SSA in your phone book for the
  local telephone number
• Apply through your State Medical Assistance Office

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Other Sources of Help Paying for Prescription
Drugs

• State Pharmaceutical Assistance Programs
• Certain states have programs for people who meet
  age and income requirements
• Examples EPIC (New York), PAAD (New Jersey),
  PACE (Pennsylvania)
• Pharmaceutical Manufacturer Programs
• Check with the company that makes your medication
  to see if you qualify for their assistance
  program or online at www.pparx.com
• Charitable Organizations

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What Drugs Do Medicare Plans Cover? Information
About Formularies
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Plan Formulary

• Medicare Drug Plans
• Do not cover every drug
• Generally have a list of drugs they cover, called
  a formulary
• Must cover prescription drugs in all defined
  categories and classes
• Must include more than one drug in each class
• Includes brand and generic drugs
• Certain drugs are excluded by law
• For example, Medicare cannot pay for
  benzodiazepines, barbiturates, drugs for weight
  loss or gain, and drugs for relief of colds.

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Plan Formulary

• Using drugs on a plans list will save money
• You will pay lower prices for drugs that are
  preferred by the plan
• Choosing a covered generic drug instead of a
  brand-name medication may also save money
• You should always check with your doctor before
  agreeing to have your medicines changed or to
  have your prescription filled with a generic

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Plan Formulary

• Plans manage drug use with the following
• Prior authorization requiring plan approval
  before a Rx can be filled
• Step therapy encouraging the use of generic or
  less expensive drugs first
• Quantity limits
• Processes are available to you that can help you
  get the medicines your doctor feels you need
  through
• Transition supply
• Exceptions process
• Appeals process

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Plan Formulary

• Plans must fill prescriptions that are not on the
  plans list
• For new enrollees
• For residents of Long-term Care (LTC) facilities
• This will allow time for you and your doctor
• To find another acceptable formulary drug
• To request an exception so the plan will cover
  your drug, even if it is not on their formulary

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Plan Formulary

• Exception requests may be warranted if a
• Patient has tried covered drugs and they dont
  work, or
• Physician believes the patient requires a
  specific non-covered drug
• If a request is approved, the plan will cover the
  drug

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Exception Requests

• Anyone can request an exception
• Contact the drug plan and they will advise
• How to submit a request
• What information needs to be submitted
• Physician must submit supporting documentation
• Must demonstrate that requested drug is
  medically necessary
• Plan must notify patient of its decision within
• 72 hours for standard processing (after receiving
  physicians statement), or
• 24 hours for expedited processing

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Appeals Process

• A person can appeal a Medicare drug plans
  unfavorable exception decision
• First level appeal is to the plan
• Expedited appeals take only a few days
• An appointed representative may appeal
• Generally, appeals must be made in writing
• You should get information about the appeals
  process upon enrollment
• You may have as many as 5 levels of appeal/review

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What Is the Coverage Gap or Doughnut Hole?
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What is the Coverage Gap or Doughnut Hole?

• The coverage gap is that time when beneficiaries
  must pay 100 of their drug costs
• Medicare is set up as a cost sharing benefit. In
  2007, beneficiaries will pay
• A deductible (if applicable)
• A monthly premium
• A co-pay for each prescription drug
• 25 of the first 2,400 of total drug spend
• 100 of the next 3,051 of total drug spend
• 5 of any additional drug spend beyond 5,451

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2007 Drug Plan Cost Sharing
Out-of-pocket spending
Medicare Part D benefit
Catastrophic coverage
95
5
Medicare Part D benefit
5,451
100 Beneficiary Responsibility
Out-of-pocket
3,051 Gap Donut hole
Actuarial Equivalence
Out-of-pocket
2,400
Partial coverage up to limit
25
75
Medicare Part D benefit
Out-of-pocket
265
Deductible
Out-of-pocket
Percent of Rx spend
Source Kaiser Family Foundation
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What Can You Do About Costs in the Coverage Gap?

• Apply for Medicares Low Income Subsidy (LIS) if
  you have not already done so
• If your State has a Pharmaceutical Assistance
  Program (SPAP), apply for it
• Check with the pharmaceutical companies that make
  your medications about whether they have a
  Patient Assistance Program to help you with costs
• Talk with your pharmacist or doctor about
  applying to charitable organizations for
  medication assistance
• Continue to use your Medicare Plans card when
  you pay for prescriptions - your payments will be
  counted toward the amount you must spend before
  catastrophic coverage begins

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Important Dates for Medicare Services
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Important Dates
New preventive services began
January 1 2005
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Important Dates
Watch your mail for the Medicare You handbook,
which will have information about the plans in
your area
October/ November 2006
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Important Dates

• You can begin to compare Medicare prescription
  drug plans
• www.medicare.gov
• 1-800-MEDICARE
• Local SHIP office
• Local community groups

October 2006
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Important Dates
You can enroll in a Medicare prescription drug
plan, or change plans!
November 15 through December 31 each year
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Important Dates
Medicare prescription drug coverage begins for
those who are enrolled
January 1
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For More Information

• Medicare You 2007 handbook
• www.medicare.gov
• 1-800-MEDICARE (1-800-633-4227)
• TTY users call 1-877-486-2048
• www.mymedicarematters.org
• www.mimedicareimporta.org (Spanish)
• State Health Insurance Program (SHIP)
• Community groups (Local Agency on Aging)
• www.eldercare.gov