Anne Donnelly

1
Medicare Part D Getting Californians with
HIV/AIDS Ready

• Anne Donnelly
• Public Policy Director
• Project Inform
• 415.558.8669x208
• Adonnelly_at_projectinform.org

2
Medicare And HIV

• Nationally there are 60,000 80,000 Medicare
  beneficiaries with AIDS
• 70 85 also qualify for Medicaid - dual
  eligibles
• In CA, roughly 13,500 dual eligible people with
  AIDS
• Use Medicare for most primary medical care
• Currently use Medi-Cal for prescription drugs and
  gaps in Medicare coverage
• ADAP maximizes Medi-Cal benefits by paying share
  of cost (SOC)
• In CA, most Medicare only beneficiaries rely on
  ADAP

3
Medicare Part D What do we know? Medicare only
Standard Benefit

• Voluntary enrollment BUT penalty for not
  participating if they dont have and keep
  creditable coverage
• Likely 1 premium increase for each month delay
• Cost Sharing All cost sharing obligations
  associated with the Medicare benefit (except
  premiums) will be indexed to the cost of the
  benefit so will rise each year
• Expected average annual premium in 2006 - 420
  37 monthly
• Annual Deductible - 250
• Initial benefit 251 - 2250
• 25 co-pay
• Doughnut hole (no coverage) - 2251 - 5,100
• Catastrophic coverage begins once beneficiary
  pays out of pocket expense of 3,600 and reaches
  drug expenditure of gt 5,100
• greater of 5 co-pay or 2 preferred, 5
  non-preferred

4
Medicare only Standard Benefit

• Beneficiary is locked in to plan choice for one
  year
• Plans may change benefits at will
• ADAP interaction
• ADAP can, by law, pay premiums and deductibles if
  a person qualifies for ADAP can also choose not
  to serve Part D eligible clients
• It can pay cost sharing but it cant count toward
  out of pocket expenditure (TrOOP)
• If ADAP assists clients they will never reach the
  catastrophic coverage level or a meaningful
  coverage unless they can pay 3600 out of pocket.

5
Medicare only Standard Benefit

• CA ADAP
• Will likely continue to cover eligible Part D
  clients but only if they enroll and pay premiums
  in Part D
• It is unknown if CA will/can pay premiums for
  Part D
• ADAP cant pay premiums so any payment would
  likely administered through CARE-HIPP
• Staffing very low in that program
• Funding too low currently
• Still unclear how payments paid to CMS or plans
  or both
• Clients must use ADAP participating pharmacies to
  access assistance that are also in the clients
  PDP
• Very small savings to ADAP
• ADAP clients who are eligible but dont enroll
  and pay premiums in Part D will incur penalty

6
Medicare Only - Low Income Subsidy (LIS) People
below 150 FPL will receive additional help with
their Medicare benefit

• Full subsidy eligible Income below 135 FPL
  (12,919 for a single) asset limits of 6000
  per person 9000 per couple
• Must apply and be accepted for Low Income Subsidy
  
• In CA, likely not a large group
• Subsidy
• No premium
• No deductible
• No gap in coverage
• Prescription co-pay
• Institutionalized no co-pay
• Below 100 of FPL - 1 generic 3 brand
• Above 100 FPL 2 generic 5 brand
• No co-pays after 5,100 drug expenditure (this
  needs clarification from CMS)

7
Medicare Only - Low Income Subsidy - Below 135
FPL ADAP interaction

• Advocates are working with government officials
  to allow ADAP to assist with co-pays
• Challenge is ensuring ADAP participating
  pharmacies are included in individuals Medicare
  Prescription Drug Plan (PDP)
• If an accessible pharmacy is not in the PDP and
  the ADAP network, ADAP cant pay co-pay

8
Medicare Only - Low Income Subsidy Between
135FPL and 150FPL

• Subsidy eligible
• Below 150 FPL (14,355 for a single) and assets
  at or below 10,000 single 20,000 couple and
  above 6000 single and 9000 couple
• Must apply for Low Income Subsidy (LIS)
• In CA, not large group
• Subsidy
• Premium - sliding scale not higher than 420
  annually
• 50 deductible
• 15 co-pay until the annual out-of-pocket cap of
  3,600 is reached for 2006
• After meeting TrOOP, 2 preferred 5
  non-preferred

9
Medicare Only - Low Income Subsidy Between
135FPL and 150FPL ADAP Interaction

• ADAP is not set up to pay premiums
• Same challenges associated with the standard
  benefit premium
• If ADAP assists with premium and deductible and
  co-pays, client will never reach catastrophic
  coverage
• Client must use ADAP participating pharmacies in
  their PDP to get assistance
• Still represents savings to ADAP

10
Dual Eligibles

• Lose Medicaid prescription drug coverage on
  January 1, 2006
• MUST enroll in Medicare Part D not voluntary
• Only eligible for cost average plans unless
  extra premium is paid
• Automatically eligible for best LIS plan
• Auto-assigned to a plan starting October, 2005
• CMS will auto-assign if no change is made client
  auto-enrolled January 1
• Duals can change plans each month

11
Dual Eligibles State Role

• States can cover drugs that are excluded from
  Part D coverage by law, such as benzodiazapines,
  over the counter drugs covered under Medi-Cal,
  vitamins and minerals, and weight loss and weight
  gain drugs (excluding anti-wasting drugs) and
  still receive Medicaid federal match
• CA will cover
• States cant provide coverage for drugs that are
  not covered by PDP or MA-PD and receive federal
  match
• States with a State Prescription Assistance
  Program (SPAP) can wrap around the benefit
• California doesnt have one

12
Dual Eligibles

• Dual eligible including those on Medicare savings
  programs (MSPs)
• Receiving Supplemental Security Income (SSI)
• Subsidy
• No premium
• No deductible
• No gap in coverage
• Prescription co-pay
• Institutionalized no co-pay
• Below 100 of FPL - 1 generic 3 brand name
• Above 100 FPL 2 generic 5 brand name
• No co-pays after 5,100 in drug cost (needs
  clarification from CMS)

13
Dual Eligibles

• ADAP interaction
• ADAP is likely to be able to assist with co-pays
  for the drugs on the ADAP formulary if the client
  can use ADAP participating pharmacies
• Share of Cost Dual Eligibles
• Must incur or meet one monthly SOC to be eligible
  for LIS
• For plan year 2006, most if not all people with
  AIDS will qualify for LIS
• As of January, 2006, ADAP will no longer be able
  to pay Medi-Cal Share of Cost for dual eligibles
• We believe there are about 3,500 SOC duals in CA
• Some clients may be able to transfer to an MSP
• It is very unclear what will happen for clients
  who need vision, long term care, dental services
  or other Medi-Cal only services

14
A Closer Look at Formularies

• CMS issued guidance (did not require) that plans
  should cover substantially all or all of certain
  drugs, including anti-HIV and mental health drugs
• CMS clarified in guidance that all HIV drugs will
  be on formularies only Fuzeon can have
  pre-approval
• Plans encouraged (not required) to comply with
  federal guidelines PHS HIV specific guidelines
  are not mentioned
• Required to carry two drugs in each therapeutic
  class
• Model formulary includes four classes of HIV
  drugs
• Plans not required to cover drugs for off-label
  use
• CMS says it will review process for requesting
  coverage cant be burdensome
• Plans can change formulary at will

15
A Closer Look at Formularies

• CMS reviews formularies to ensure they dont
  discriminate against specific populations
• Drug plan Pharmacy and Therapeutic Committees are
  required to have physician representation
• Only two members are required to have no ties to
  the plan or pharmaceutical companies
• No requirement to have HIV or any other disease
  expert consultation
• Plans have 90 days to make formulary decisions
  for newly approved drugs 180 days to include drug

16
Exceptions And Appeals

• May ask for exception for drug not on formulary
  only if provider determines no other formulary
  drug as effective and/or adverse affects
• Standard exception process 72 hours
• Expedited exception process 24 hours to
  provider must be initiated and/or supported by
  provider
• Emergency supply of meds not required
• Appointed rep, including provider, allowed to
  file on behalf of beneficiary
• If a Part D sponsor maintains formulary tier in
  which it places very high cost and unique items
  the sponsor may design its exception process so
  that very high cost or unique drugs are not
  eligible for a tiering exception. Final
  Regulation, Federal Register
• The appeal process is much longer and is used
  when plan denies and beneficiary must go out of
  plan

17
Getting Ready What Can You Do Now ?

• Largest public benefit change in nearly forty
  years
• Although all Medicare beneficiaries affected the
  priority concern is the dual eligibles
• Most vulnerable, often multiply diagnosed and the
  transfer from Medicaid to Medicare is mandatory
  on January 1, 2006
• Medi-Cal will continue to cover Part D excluded
  drugs for duals
• Others have until May 2006 to sign up before
  penalty
• Make sure that clients keep all paperwork
  received from CMS, Social Security Administration
  (SSA), or California Department of Health
  Services (DHS)

18
Getting Ready What Can You Do Now ?

• Ensure that clients fill out and submit their
  extra help or LIS application
• Ensure that the clients submitting LIS
  applications are screened for Medi-Cal or
  Medicare Savings Programs (MSPs)
• Provide reassurance that advocates and the state
  are working to ensure as much coverage as
  possible and more information will be available
  in October

19
Getting Ready October - January

• Counseling on understanding and comparing plans
• Standard benefit likely to have more affordable
  choices but will have annual lock in requirement
  - once yearly change in plans
• Dual eligibles cost average plan unless can pay
  additional premium but can change as often as
  needed
• Cost sharing, formularies, premiums. preferred
  drug lists, exceptions and appeals processes
• Counseling for Medicare only clients on
  enrollment financial penalties
• Dual eligibles who have a share of cost should be
  counseled on keeping Medi-Cal vs. entering a MSP
• In January, duals who have slipped through the
  cracks may need assistance enrolling others
  assistance accessing
• Insurance trouble shooting (exceptions/appeals/pla
  n changes) will likely become a bigger part of
  client services