The 2013 Medicare Drug Benefit and Dual Eligibles with

The 2013 Medicare Drug Benefit and
Dual Eligibles with
Developmental Disabilities
Beverly Roberts
Director, Mainstreaming Medical Care
The Arc of New Jersey
Webinar, Nov. 15, 2012
[email protected]
What is a “Dual Eligible”?
■
A dual eligible is a person who has both
Medicaid and Medicare benefits
■
Most dual eligibles receive their
prescription drugs from Medicare Part D
Dual eligibles – No deadline
to enroll in new Medicare drug plan
„ Dual
eligibles can switch to a new
Medicare drug plan at any time! The
enrollment deadlines that are
announced in marketing materials
are not applicable to the dual
eligibles.
Why so many people with developmental
disabilities are dual eligibles
„
When the parent of a person with a
developmental disability starts to collect Social
Security benefits, the adult child starts to receive
a Social Security Disability (SSD) check each
month.
„
24-months later, the adult child starts to receive
Medicare. The person with a disability receives
both Medicaid and Medicare, and is a “dual
eligible.”
What is a DAC?
„
The term Disabled Adult Child (DAC) is used
by the Social Security system for adults with
developmental disabilities.
„
When a person is coded in the computer as a
DAC, it allows for an override of the usual Social
Security rules. Those rules would have
disqualified a person with a disability who gets a
larger SSD check from also receiving Medicaid.
DAC (cont.)
„ If
a person with a developmental
disability is getting a monthly SSD
check and is notified that Medicaid
will be cut-off:
– Find
out if the consumer is coded as a
“DAC” by the Social Security computer
system.
– Apply for Medicaid at the county level and
explain the DAC status.
Federal Oversight for the
Medicare Drug Benefit
■
The Medicare prescription drug benefit is
called Medicare Part D
■
The federal agency that has authority over
all aspects of Medicare – including
Medicare Part D – is the Centers for
Medicare and Medicaid Services (CMS)
Important Terms
„ Low
Income Subsidy (LIS): Medicare
beneficiaries with limited income and
resources may qualify for extra help, in
the form of a Low Income Subsidy (LIS),
to pay for prescription drug costs.
„ Dual
eligibles are automatically
eligible for the LIS.
Important Terms, cont.
„
Prior Authorization: A cost-containment
procedure that requires a prescriber to obtain
permission from the prescription drug plan
(PDP) to prescribe a medication
„
Step Therapy: The practice of beginning drug
therapy for a medical condition with the most
cost-effective drug, and progressing to more
costly drug therapy only if necessary; the
primary goal is cost-containment
Important Terms, cont.
„ Quantity
Limits: For safety and cost
reasons, a drug plan may limit the amount
of pills that they cover for a particular
drug. With the physician’s documentation
of medical necessity, this requirement may
be waived.
The 2013 MEDICARE PART D
Information
for New Jersey’s
Dual Eligibles
What is a “Benchmark” drug plan?
„
„
„
„
A dual eligible may enroll in a benchmark drug plan,
without paying any monthly premium fee.
Although the Medicare drug plans do require a monthly
fee, for the dual eligibles, that fee is subsidized by CMS
up to a specific amount (which is known as the
benchmark).
There are two types of drug plans: Basic and Enhanced,
but only the Basic plans can qualify as benchmark plans.
For 2013, the benchmark amount in NJ is $37.04.
New Jersey dual eligibles may enroll in any Basic
benchmark drug plan and not pay a monthly
premium.
Overview of Benchmark Drug Plans
for NJ’s Dual Eligibles
„
In 2012, there were 9 benchmark plans available
for NJ’s dual eligibles.
„
Beginning January 1, 2013, 10 benchmark plans
will be available in NJ.
„
1 of the benchmark drug plans from 2012 won’t
be available in 2013; 1 plan is available, but no
longer benchmark; and NJ will have 3 new
benchmark plans.
2013 Benchmark Plans in NJ
COMPANY NAME
PLAN NAME
Monthly Premium for
Dual Eligibles in 2013
UnitedHealthcare (NEW)
AARP MedicareRx Saver Plus
$0
Aetna Medicare
Aetna CVS Pharmacy Prescription
Drug Plan
$0
EnvisionRx Plus
EnvisionRxPlus Silver
$0
Medco Medicare Prescription Plan
Express Scripts Medicare Value
$0
Humana Insurance
Humana Walmart-Preferred Rx
Plan
$0
HealthMarkets Medicare (NEW)
Reader's Digest Value Rx
$0
SilverScript Insurance Company
SilverScript Basic
$0
SmartD Rx (NEW)
SmartD Rx Saver
$0
United American Insurance Co.
United American - Select
$0
WellCare
WellCare Classic
$0
Caution: Possible confusion between
two AARP drug plans
„
The AARP Medicare Rx Preferred drug plan was benchmark in
2011, but it is not benchmark in 2012 or 2013. Some dual eligibles
who had chosen this drug plan in 2011 and stayed with it in 2012
had to pay a premium fee of $2.60 per month. Dual eligibles
who are enrolled in the AARP Medicare Rx Preferred drug
plan for 2013 are required to pay an increased premium fee
of $5.10 per month.
„
For 2013: There is a new AARP benchmark drug plan, but it is not
the same as the AARP plan that was benchmark in 2011. The new
AARP benchmark drug plan is called the AARP Medicare Rx Saver
Plus. Dual eligibles enrolled in the "Saver Plus" drug plan will
not have any monthly premium fee.
„
Because the names of these two AARP drug plans are so similar,
they can easily be confused. Please be careful if deciding between
these two AARP drug plans.
Other important changes for 2013
„ The
Bravo Rx drug plan no longer
participates with Medicare Part D
„ Every
dual eligible enrolled in this
Medicare drug plan will be automatically
re-assigned to another plan.
First Health drug plan:
Not benchmark in 2013
„
First Health Part D Premier is not
benchmark, starting Jan. 1, 2013. Dual
eligibles can choose to remain in this drug
plan, but they are required to pay a fee of
$3.80/month.
„
Dual eligibles who are impacted by the
Bravo Rx and First Health Premier changes
should receive a letter from CMS.
Notification of Changes for 2013
Letters mailed by CMS to dual eligibles in
New Jersey enrolled in Bravo Rx or First
Health Part D - Premier:
■ Termination Letter - on Blue Paper
■ Reassignment Letter - on Blue Paper
■ “Choosers” Letter - on Tan Paper
Blue Termination Letter
■
The blue termination letter explains that
the current drug plan (Bravo Rx) will be
terminating in 2013.
■
Consumers who receive this letter will be
randomly auto-enrolled in a new $0
premium drug plan.
Blue Termination Letter (cont.)
The Blue Termination letter will outline these options:
1)
Medicare will auto-enroll consumer in a new fully subsidized $0
premium drug plan. This will be a random enrollment, with
no attempt to match dual eligibles to a plan that best meets
their needs
ÎThis will happen automatically unless other
action is taken
2)
3)
Dual eligible can choose to enroll in another drug plan that has
a $0 premium, or
Dual eligible can choose to enroll in another drug plan that has
a monthly fee
ÎRequires a phone call to a different drug plan
to enroll
Blue Reassignment Letter
The blue reassignment letter is sent to dual eligibles
who were in the First Health Part D Premier drug
plan because they were assigned to that plan (as
distinguished from having chosen that plan).
■ The letter explains that the First Health Part D
Premier plan will have a cost increase that will
exceed the benchmark amount.
■ If no action is taken after receipt of blue
reassignment letter, these dual eligibles will be
randomly auto-enrolled in a new $0
premium drug plan, to begin Jan. 1, 2013.
Blue Reassignment Letter (cont.)
Three Choices:
1) Dual eligibles can choose to remain in
the First Health Part D Premier plan and
pay the premium fee of $3.80 per
month.
Î
Requires a phone call to the current
First Health Part D Premier drug plan
to indicate desire to remain in that
drug plan, or
Blue Reassignment Letter
2) Dual eligibles can stay in the drug plan
that was assigned in the Blue letter.
Î If considering staying in the newly assigned drug
plan: Call the new plan to find out if all current
medications are covered without restrictions, and
if current pharmacy is affiliated with the drug
plan.
Î If current medications are not covered, find out if
other benchmark drug plans will cover them.
Blue Reassignment Letter (cont.)
3) Dual eligibles can choose to enroll in
another benchmark drug plan (different
from the one assigned in the Blue letter),
or they can enroll in any other drug plan
and pay a monthly fee.
Î Requires a phone call to a
different drug plan to enroll .
Affordable Care Act (ACA) Notice
on Blue Paper
„
In late December, everyone who received a blue
reassignment letter will get a second blue
letter.
„
Letter tells all reassigned persons:
– Differences between their 2012 drug plan and 2013
plan based on drug utilization
– Explains the process to get an exception
– Explains appeals process
– Provides beneficiary-specific drug information
Tan “Choosers” Letter
■
■
■
■
A tan colored letter was sent to all dual eligibles
who are enrolled in the First Health Part D
Premier plan if they had chosen that plan.
The important distinction is having chosen the
First Health Part D Premier drug plan rather
than being auto-assigned.
The tan letter will say that the current Medicare
drug plan premium will no longer be fully
subsidized, starting Jan. 1, 2013.
If dual eligibles, currently enrolled in the First
Health Part D Premier plan, receive the tan
letter and do not switch to another drug plan,
they will be required to pay a $3.80 fee
every month.
Tan “Choosers” Letter (cont.)
■
A Tan letter was also sent to all dual eligibles
who are currently enrolled in other nonbenchmark drug plans.
■
These dual eligibles are currently paying a
monthly premium fee, but the fee may change
in January.
■
Example: Dual eligibles currently in AARP
MedicareRx Preferred are paying $2.60/month.
This will increase to $5.10 per month in Jan.
2013, if they stay with this plan.
Tan “Choosers” Letter (cont.)
The Tan “Choosers” letter will outline these
options:
1) Stay in the current plan and pay a premium fee
each month.
Î This will happen automatically unless another
action is taken
2) Switch to one of the 10 benchmark Medicare drug
plans that offer a fully subsidized $0 premium plan
Î Requires a phone call to the new plan to enroll
New drug plan identification cards
„ Everyone
who will be in a new Medicare
drug plan should look for the new drug
plan’s ID card in the mail.
„ Bring
the new ID card to the pharmacy.
Disenrollment for non-payment of
monthly premium
„
„
„
Dual eligibles enrolled in a benchmark drug plan
have no monthly premium fee.
CAUTION: If dual eligibles are enrolled in a
non-benchmark plan, and they don’t pay the
monthly fee, the drug plan will disenroll them,
i.e., no access to prescription medications!
If this happens, CMS will auto-enroll them into a
benchmark plan, BUT there may be a period of
non-coverage of prescription drugs before this
occurs.
How to get drug coverage if
terminated from drug plan
„ Ask
the pharmacist to enroll the dual
eligible in LINET: Limited Income Newly
Eligible Transition Program, with Humana.
„ This
process allows pharmacist to enroll
dual eligible (or other Low Income Subsidy
person) into a temporary Part D plan
(LINET Humana) in order to get
medications immediately.
Medicare Part D co-pays
for dual eligibles
„ In
NJ, Part D co-pays for dual eligibles
started July 1, 2011.
„ For most dual eligibles with developmental
disabilities, drug co-pays for 2013 will be
$1.15 for each generic and $3.50 for
each brand name drug.
„ For dual eligibles on the Community Care
Waiver (CCW): No co-pays for Medicare
Part D drugs. This started Jan. 1, 2012.
NEW! Changes in Coverage of
Benzodiazepines and Barbiturates
■
■
Currently, the Medicaid HMOs cover all of the
medications in the benzodiazepine and
barbiturate drug classes, and there is no drug
co-pay for dual eligibles.
Beginning Jan. 1, 2013, the Part D drug plans
(not the Medicaid HMOs) will cover medications
in these drug classes.
■ Dual eligibles who use a drug from the
benzodiazepine or barbiturate drug classes will have
the same copay that is paid for other drug categories
(except for dual eligibles on the CCW who don't have
any copay).
Barbiturate Drugs
■
■
■
■
■
■
Bellaspas
Bel-Tabs
Butisol Sodium
Eperbel-S
Ergocaff-PB
Fioricet
■
■
■
■
■
■
Fiorinal
Mebaral
Phenobarbital
Phenobarbital Sodium
Seconal Sodium
Spastrin
Benzodiazepine Drugs
■
■
■
■
■
■
■
■
■
■
■
■
■
Alprazolam
Alprazolam Intensol
Ativan
Chlordiazepoxide HCL
Clonazepam
Clorazepate Dipotassium
Dalmane
Diazepam
Estazolam
Flurazepam HCL
Halcion
Klonopin
Librium
■
■
■
■
■
■
■
■
■
■
■
■
■
Lorazepam
Lorazepam Intensol
Midazolam HCL
Niravam
Oxazepam
Prosom
Restoril
Serax
Temazepam
Tranxene T-Tab
Triazolam
Xanax
Xanax XR
New! Changes in coverage of
Benzodiazepines & Barbiturates
„
„
„
Check the drug plan formulary to find out if the drugs
needed in these two categories are covered by the
consumer’s drug plan. If the drug is not on the current
formulary, consider switching to another drug plan.
Sometimes these drugs are on the formulary, but may
require prior authorization from the Part D plan.
Important Note: Drugs in the Barbiturate category will
be covered by Medicare Part D plans only if prescribed to
treat these diagnoses: epilepsy, chronic mental health
conditions, or certain cancers.
– If a barbiturate is prescribed for another diagnosis, the drug plan
will not cover it, and the doctor will need to prescribe a
medication from another drug class.
Transition Policy for dual eligibles
■
For the first 90 days of 2013, CMS expects all Part D
plans to cover one 30-day fill for drugs which the
member is currently taking that are either:
a) not on the formulary, or
b) are on the formulary but require prior
authorization or step therapy
■
Pharmacist should print out a message from drug plan at
the point of sale, saying this is a one-time transition fill.
■
CMS requires the Part D plans to send written notice to
each enrollee who receives a transition fill, within 3
business days.
No “lock-in” for dual eligibles!
„ Dual
eligibles are not “locked in” to a
Medicare drug plan.
„ If
dual eligibles want to switch drug plans
and they don’t get it done in December,
they can switch anytime next year.
„ Drug
plan changes are always effective
the first day of the next month.
Formulary Changes that May
Affect All Dual Eligibles
■
Every year, in January, Medicare drug
plans are permitted to change their
formulary (the list of drugs they pay for)
■
Even if dual eligibles did not receive a blue
or tan letter, they should find out if their
current prescription drugs will still be
covered in January, 2013.
Monthly Fee if a Dual-Eligible
Selects a Non-Benchmark plan
„ Wide
variation in monthly premiums
for dual eligibles in non-benchmark
plans
- For 2013: The lowest monthly
premium for a non-benchmark plan
is $3.80 per month (First Health
Part D Premier)
Why would dual eligible select
a non-benchmark drug plan?
„
„
„
If a dual eligible needs medications not available
on formulary of benchmark drug plans, but
available in non-benchmark plan – it may be
more cost-effective to pay a relatively low
monthly premium to get the needed
medications.
This decision needs to be made on an individual
basis.
The next slide shows the monthly premium fees
for NJ’s Basic non-benchmark plans in 2013.
Consumer’s Pharmacy Must be
Affiliated with the Drug Plan’s Network
Before switching to a new Medicare drug
plan, check with your pharmacy to be
certain that it is affiliated with the new
drug plan.
■ Most of the major pharmacy chains are
affiliated with all of the Medicare drug
plans.
■ Small pharmacies may not have as many
affiliations.
■
Aspects of Medicare Part D that
Do Not apply to the Dual Eligibles
■
Monthly premium fees
Î As long as dual eligibles are enrolled in a benchmark
plan, there is no premium fee
■
■
■
The “Donut Hole” – doesn’t exist for duals.
No Deductibles for dual eligibles
Drug tiers
Î As long as a drug is on the formulary, it does not
matter which tier it is on
■
No lock-in for dual eligibles; can switch to
another drug plan at any time
How to obtain answers for
Medicare Part D questions
■
■
■
■
■
Check the www.Medicare.gov website
Call 1-800-MEDICARE
Call the current drug plan and speak with a
customer service representative
Contact a SHIP counselor (State Health
Insurance Assistance Program). SHIP counselors
are VERY busy until open enrollment for nondual eligibles ends.
The next slide provides phone numbers for free
Medicare counseling from the NJ SHIP program.
State Health Insurance Assistance Program (SHIP) Telephone Numbers
Local County Office
Telephone
Atlantic
888-426-9243
Bergen
201-336-7413
Burlington
609-894-9311, ext. 1494
Camden
856-858-3639
Cape May
609-886-8138
Cumberland
856-459-3090
Essex
973-643-5710
Gloucester
856-468-1742
Hudson
201-369-5280, Press1, then ext. 4258
Hunterdon
908-788-1361
Mercer
609-924-2098 Ext.14
Middlesex
732-745-3295
Monmouth
732-728-1331
Morris
973-784-4900 Ext. 101
Ocean
800-668-4899
Passaic
973-569-4060
Salem
856-339-8622
Somerset
908-704-6319
Sussex
973-579-0555 Ext.1223
Union
908-273-6999
Warren
908-475-6591
Navigating the
Medicare Plan
Finder
for Dual Eligibles
Presenter:
Mary McGeary
NJ State Health Insurance Assistance Program
SHIP
ARC of NJ
Webinar November 15, 2012
1
What is the Medicare Plan Finder?
™Internet Tool on official Medicare web site
™ Helps people learn about drug coverage and
¾ Review current Medicare enrollment
¾ Compare Part D plans & Medicare
Advantage Health Plans (HMOs or DSNPs)
¾ Identify which plans cover your
prescriptions at most affordable cost
¾ Enroll in a Part D or Medicare Advantage
plan
2
Getting Started:
What You Will Need
™ Consumer’s zip code
™ List of consumer’s prescription drugs
o strength and quantity
o if can take generics
™ Pharmacy consumer uses
™Other Helpful Information
¾ Medicare Card
¾ Other Health Insurance cards
¾ Subsidy eligibility
o Medicaid, LIS, PAAD
3
6 STEP Process
1. Enter Consumer Information
2. Enter List of Current Medications
3. Select Pharmacy
4. Refine Search Results
5. Compare Plans
6. Enroll
4
Getting to the
Drug Plan Finder
™ Go to www.Medicare.gov
¾ Click “Compare Drug and Health Plans”
¾ Or www.medicare.gov/find-a-plan
™
Or call 1-800-Medicare
¾ Customer Service Assistance for choosing a
plan & enrolling
¾ available 24 hrs a day
¾ English and Spanish speaking CSRs
5
www.Medicare.gov
Homepage
6
Plan Finder Home Page: Step 1
Tutorial
7
If General Search: Important to answer
questions about low income assistance
Can leave blank
Click here if Dual
8
Step 2: Enter Your Drugs
Can type in drug name
Or search drug by first letter
9
Pop-up box to indicate dosage
NEW QUESTION ON TYPE OF PHARMACY
10
Info to Notice:
Write down ID for future searches
Click here when drug list
complete
11
Option to search
Generic or Brand
12
New Pop-up will warn when have added both a
brand drug & its generic equivalent to the list
13
Step 3: Pharmacy Consumer
Uses
Click here to expand list of pharmacies
Click here to see map
14
Step 4: Refine Results :
Looking at Stand Alone Plans (PDPs) or
Health Plans with drug coverage (MAPDs) ?
Also click here if
want to look at DSNPs
15
Step 5: Compare Your Plan Results
$0 premium means “benchmark plan”
Premium shown is amount over benchmark, consumer must pay this
16
For Medicare/Medicaid consumers
(Duals):
Look for plans that meet 3 criteria:
1. Qualify for $0 premium with LIS (called
“benchmark plans”)
2. All of consumer’s meds are on plan’s
formulary (unless in excluded class)
3. No or minimum restrictions on meds
17
NOTE: If cannot find $0 premium plan to meet
all above, can look at non-benchmark plans
and ask if consumer can pay the premium
difference
17
Sorting Options
18
Looking at coverage
Click here
Click here
19
Example of Good Plan Choice
$0 Premium Benchmark Plan
No PA or Step Therapy
All drugs on formulary
20
Example of Good Plan Choice
WellCare Classic (PDP)
All drugs on formulary
“Excluded” drug covered by Medicaid
21
No PA or
Step Therapy
Example of Bad Plan Choice
CIGNA Medicare Rx
Premium Plan- Not Benchmark
Drugs not on
formulary
PA restriction
22
Understanding the Tier Footnotes
™ Avoid plans with drugs Not on Formulary 15
¾ Plan DOES NOT cover this drug
¾ PAAD/Senior Gold or Medicaid will NOT pay
¾ If private pay, costs for this drug will not count towards
deductibles or “out of pocket” limits
™ Options
¾ Switch to generic or similar drug covered by the plan
with doctor’s approval (example: switch from Lipitor to
simvastatin)
¾ Ask plan for “exception” to cover the drug for you
because alternative will not work (need doctors input)
¾ Pay full price for the drug out of pocket
¾ Switch Plans to one with drug on Formulary allowed enrollment
period
23
Understanding the Tier Footnotes
„ Not on Formulary 4
“By law this drug is EXCLUDED from being
covered under Medicare program.”
Options
•Pay out of pocket for full cost of drug
•See if drug manufacturer has “Patient
Assistance Program (PAP)”
•For other excluded categories may need “Enhanced
Plan” for coverage
yIf have state Medicaid some excluded drugs
covered under “wraparound” (ex: vitamins)
24
Comparing Plans for those with LIS
25
Compare Plan Details for
Non-Duals
™Look at 5 Factors:
1.Costs: “Estimated Annual Cost” Most
Important
¾ Lowest Premium May NOT be lowest cost plan
2.Coverage – Is drug on Plan Formulary?
3.Drug Restrictions
4.Pharmacy Network
5.Coordination with other benefits
26
Cost Details
Health Reform Discounts show here
27
STEP 6 : Enroll
™If nursing home resident, LIS or Dual can
enroll or switch plans each month
™Will be AUTOMATICALLY disenrolled
from current plan when enroll in new
plan
™Non-duals enrollments Limited to
Medicare Enrollment Periods
¾ New to Medicare (IEP)
¾ Annual Enrollment Period (AEP)
¾ Special Enrollment28Periods (SEP)
How to Enroll
„ By Phone
y 1 (800) Medicare
y Call Plan Directly
„ By Internet
y www.medicare.gov
y Plan’s website
IMPORTANT:
¾ Get enrollment confirmation
¾ Advise not to pay premium by automatic
deduction from Social Security check
29
Low Performing Plans
!
„ Plans with less than 3 star rating for 3
years in a row
„ 3 of the 4 NJ Special Need Plans for
Duals (DSNPs) are Low Performing
y
(Horizon DSNP is high performing with 3.5 rating)
„ Cannot enroll in these plans on-line.
Must call the plan directly
30
Additional Tools
To increase print size on screen
If need to edit the
drug list
31
QUESTIONS?
Submit your questions
by email to
[email protected]
32