Illinois Cares Rx Elimination: What you Need to Know and
Transcription
Illinois Cares Rx Elimination: What you Need to Know and
Illinois Cares Rx Elimination: What you Need to Know and How to Help Your Clients Make Medicare Work Coalition (MMW) • Co-led by AgeOptions, Health & Disability Advocates, and Progress Center for Independent Living • Outreach, training, and advocacy on health care issues affecting older adults and people with disabilities, with a focus on vulnerable/at risk populations • Training for professionals who assist clients in accessing health care services and supports • Began to educate consumers and professionals about Part D What We Will Cover Today • Background: Illinois Cares Rx Elimination • Options for Clients Losing Illinois Cares Rx Coverage • Medicaid Spenddown Background: Illinois Cares Rx Elimination SB2840 • Senate Budget Bill for FY2013 (begins July 1, 2012) • Passed House and Senate 5/24/2012 • Governor signed 6/14/2012 • Included many cuts and changes to Medicaid and other programs ICRx Elimination • Illinois Cares Rx program will end for everyone July 1, 2012 • People with ICRx coverage will receive a letter from the Department of Healthcare and Family Services (HFS) – Began mailing Tuesday, June 12 – Referral to 1-800 Medicare, Senior Health Insurance Program (SHIP) and Senior Health Assistance Program (SHAP) agencies for assistance ICRx Elimination • Effective July 1, 2012, individuals will be responsible for: – Part D plan’s monthly premium – Annual deductible (any portion that has not already been paid by ICRx and the member this year) – Part D plan’s applicable co-pays by tier (the amount the plan charges) – Costs during the “donut hole” • After 7/1/12, discount received will be 50% off of brand names and 14% off generics ICRx Elimination • People on Medicare and ICRx will have a Special Enrollment Period (SEP) to change their Medicare Part D plan. This SEP will run from June 1, 2012 to August 31, 2012. People With ICRx and Extra Help • People with FULL Extra Help will NOT be affected! • Important to find out if a client has Full or Partial Extra Help – Can do this by: • visiting www.medicare.gov and do a personalized plan search • calling 1-800-Medicare or Social Security at (800)772-1213 People With ICRx and Extra Help • People with Extra Help may have to start paying partial premiums, higher co-pays/coinsurance – If in AARP Medicare Rx Preferred - $4 monthly premium • AARP Preferred is $4 above the Extra Help benchmark amount • ICRx was paying the $4 for ICRx members also in Extra Help • Extra Help benchmark is $30.23 in 2012 – ICRx members with partial Extra Help and an ICRx coordinating plan may have pay a higher premium and up to 15% coinsurance for drugs since ICRx will no longer pay the difference People With ICRx and Extra Help • People with Extra Help may have to start paying full price for Medicare excluded drugs, such as benzodiazepines and barbiturates. • Illinois Cares Rx was assisting with any medication on the Medicaid formulary. • Once Illinois Cares Rx disappears, there will be no assistance with the costs of these drugs by Extra Help because Extra Help does not cover them. • If the person still has current Medicaid eligibility for a given month, Medicaid will pick up the costs of those Medicare excluded drugs for the month. Options for Clients Losing Illinois Cares Rx Coverage Immediate Assistance • If possible, have client obtain a prescription for a 3-month supply of his/her drugs from doctor and fill before July 1 – before ICRx is eliminated • Ask doctor for drug samples Immediate Assistance • Review drug list with doctor to determine if it’s possible to switch to a generic or less expensive drug • Consider switching to a mail order option though the Part D plan – Mail order is sometimes less expensive – Check with plan to find out if mail order is available • All four of the ICRx coordinating stand-alone plans offer mail order in 2012 Screen Clients for Extra Help • Full Extra Help: – Income • $1,257/month (individual) OR $1,702/month (couple) – Assets: • $8,440 (individual) OR $13,410 (couple) • Note: asset requirements above include $1,500 prepaid burial plan • No monthly Part D premium – If in a basic Part D plan at or below the Extra Help benchmark amount • Benchmark in 2012 is $30.23 • No deductible • Low co-pays – $1.10/$2.60 for generics or $3.30/$6.50 for brand names Screen Clients for Extra Help • Partial Extra Help: – Income: • $1,396/month (individual) OR $1,891/month (couple) – Assets: • $13,070 (individual) or $26,120 (couple) – • Note: asset requirements above include $1,500 prepaid burial plan • Sliding Scale premium • Deductible : $0-$65 • Co-pays of $2.60/$6.50 or 15% coinsurance • Can apply online at www.ssa.gov or www.benefitscheckup.org Other Options • Charities – Assistance paying for drugs prescribed for specific diseases or conditions – Assistance based on availability of funds • Co-Pay Assistance Programs – Many of these programs require you have other insurance and will help pay for the co-pay not covered by insurance – MMW Co-pay Assistance Chart: http://www.ageoptions.org/whatWeDo/documents/C haritiesPAPsDiscountCards6-6-12.pdf Drug Discount Cards • Drug Discount Cards – Cannot be used with other insurance – Anyone can use the card – Can use for drugs not covered by plan or if in the donut hole and the discount is greater – Print and ready to use – Use at participating pharmacies • http://www.needymeds.org/drugcard/index.htm • http://www.easydrugcard.com/ Patient Assistance Program • Patient Assistance Programs (PAP’s) – Programs offered through drug manufacturers – Low cost or free drugs – Each program has different set of rules and eligibility criteria – Find out if a program for a specific drug is available by visiting www.rxassist.org or www.needymeds.org. HIV/AIDS and ADAP • People with HIV/AIDS can use the Aids Drug Assistance Program (ADAP) to get help paying for their HIV/AIDS medications • Should enroll in the ADAP as soon as possible to help transition from ICRx to ADAP • Visit http://www.idph.state.il.us/health/aids/adap.htm to apply online or call Phone (217) 782-4977 for more information Loss of ICRx Special Enrollment Period • People on Medicare will receive a special enrollment period (SEP) to switch to a Part D plan that is more affordable and better suits their drug needs • Remember they can also switch during annual enrollment period (October 15 - December 7 of each year) with a January 1, 2013 effective date Medicaid Spenddown Dual Eligibles • Automatically eligible for Full Extra Help • Defined as those that are enrolled in Medicare and Medicaid in at least ONE relevant month. • If you are enrolled in Medicaid in JanuaryJune, you get Full Extra Help for the rest of the year. • If you are enrolled in Medicaid in JulyDecember, you get Full Extra Help for the current year and next year How Do You Get Medicaid Eligibility in Illinois (AABD Medicaid)? • 65 or Older or under 65 and meet definition of disability • With no spenddown, countable income limit of 100% of FPL and countable asset limit of $2000 individual/$3. • With spenddown, must incur or pay qualified medical expenses down to the countable income or asset limit. Countable Income • Take $25 general income disregard and count rest of unearned. • Net employment income minus: – $25 deduction if not used on unearned – Earned income deduction: first $20 of earnings and ½ of the next $60 – Mileage to work 19 cents/mile – Lunch: between $3 - $9 month depending – Special Tools or Uniforms – Day care cost up to $160/ mo per child or $128 if working part time – Special Work Expenses – like IRWE Spenddown Calculation Example Mary is single, living with MS, and receives a Social Security Disability check of $1500. She lives in her own home and only has about $900 in the bank. She has no other assets. She applies for Medicaid. She will be found eligible for AABD with a spenddown of approximately $544. $1500 gross unearned income-$25 disregard$931 (100%FPL) = $544. How Does Mary Meet this $544 Spenddown? • Incur $544 in allowable medical expenses • Spend $544 in allowable medical expenses • Pay $544 to the state of Illinois • All three above What are Allowable Medical Expenses (Non-Exhaustive List)? • DRS Home Services or Community Care Program • Medicare premiums (if not on QMB, SLIB QI-1) • Medicare co-pays and deductibles • Medical expense covered by Medicaid or recognized under state law • Over the counter drugs and items ordered by a doctor (gauzes, aspirin, mouthwash, etc.) Whose Medical Expenses? • Your own • Your husband or wife • Your children under 18 who are living with you What Unpaid Medical Bills Can Be Used? • It does not matter when the medical care or supplies were given for an unpaid bill. • The unpaid bill must be dated no earlier than the 6th month before the month you use it. • For example, bill dated in January can be used for any month January through July. What Paid Medical Bills Can Be Used? • Receipt can show that bill is paid. • Paid bill can be used in month paid or for 6 months after you pay it. • Again, if you paid it in January, it can be used for any month January through July. • DHS automatically considers Medicare premiums paid. What Must Receipt or Bill Show? • • • • • • Type of medical care, drugs or supplies Who gave the care Who got the care The date the care was given The cost The date of the bill or receipt What is Pay In Spenddown? • Allows enrollee to simply pay the spenddown amount or do a combination of bills/receipts and pay the difference. • Send enrollment form into Springfield. • Given statement that you return with payment. What Month is Chosen for Medicaid Eligibility? • Right now, potential enrollees want it to be effective in July or later if solely using this for Full Extra Help eligibility. • If a person does not state preference, he/she is given eligibility in the month in first month in which receipts and bills meet the spenddown amount. • Enrollee must tell them if they want eligibility the next month…….so if a person goes in right now and meets spenddown, they should tell them they want eligibility for July. Why is this So Important Now? • Without Illinois Cares Rx, a percentage of enrollees will be choosing between paying for food and medicine. • These are the exact same clients that could possibly enroll in Medicaid and receive Full Extra Help. • If we get them enrolled effective in July or later, they are “covered” through 2013! Back to Mary…….. • Let’s say Mary comes into your office on June 25 and says she is going stop taking her medication because she simply cannot afford it. • First, have her get a 3 month supply now! • Next, Mary could qualify for Medicaid for July. • She has paid Medicare premiums January-July of $699.30 that all can be used to meet her spenddown in July of $544. Some Things to Remember • You need to tell them to count the Medicare premiums. • If you say nothing, they will give Medicaid for the month of application. Because of this, it is probably easiest to go in July so there is no confusion. • Submit bills with the application so spenddown can be met. Otherwise, it will sit until you do. What are the Down Sides? • Medicaid applications are not processed in real time. They are supposed to take 45-60 days, can be longer. • Establishing Medicaid eligibility requires completing application, and where applicable, having proper receipts etc. • Medicaid eligibility to Full Extra Help does not happen in real time. Don’t Forget….Best Evidence Rule • Use to get Plan to charge Full Extra Help co-pay when not showing up as such in system. • Step 1: Gather evidence of Medicaid status (or other Extra Help documentation). • Step 2: Submit Evidence to Plan (call and find out how they want this) • Step 3: Ask Plan for assistance in confirming if necessary. One Last Time with Mary • Mary has met spenddown and goes to fill her meds…… • No such luck. They are telling her she owes $1500. • Mary (or her support) should contact the plan about submitting her Medicaid card as proof of eligibility for Extra Help. Final Review of Steps • 3 month supply now. • Medicaid spenddown application and all documentation submitted in July or later for July or later. • Best Evidence Rule ready for first trip to pharmacy. • Don’t forget that this will have to be done in the second half of 2013 too! Tips for Filing a Medicaid Application with Spenddown • Get to know your local DHS Office Managers and Secretaries. – Local offices hold Community Quality Council (CQC) Meetings – it is a good idea to attend these meetings and get to know your local office staff. Upcoming CQC meetings at the suburban Cook County DHS offices are as follows: • Wednesday, June 20, 2012, 9:30-12:00pm- West Suburban DHS Office, 2701 West Lake Street, Melrose Park, Illinois • Wednesday, July 25, 2012, 9:30-12:00pm - South Suburban DHS Office, 3301 Wireton Road, Blue Island, Illinois • Wednesday, July 25, 2012, 2:00-4:00pm- Northern DHS Office, 8020 St. Louis Avenue, Skokie, Illinois Tips for Filing a Medicaid Application with Spenddown • A Medicaid Medical benefits application (2378B) will not be approved unless you provide enough documentation of medical expenses to meet spenddown for 1 month. • Do not try and contact your local DHS office on a Monday or at the beginning of the month. • Ask your local DHS office for their preferred method of receiving documentation. Ask if they would like you to address all documents to a specific person or area. Tips for Filing a Medicaid Application with Spenddown • If you are going to apply on-line make sure your application is flawless. • If you do an on-line Medicaid application, make sure you fax or scan/email all required documents to the local office. Mention that you have just completed an online application and that these are the supportive documents. Make sure all documents submitted with an application have the clients SS# clearly marked on all pages. Tips for Filing a Medicaid Application with Spenddown • If your clients go to the DHS office make sure they sign into the VIS System. (Visitor’s Information System) This way DHS will have a record that they were in the office and cannot deny receiving documents. • Some of the local offices have gone to a system called Case Banking, which means that clients will not have an assigned case worker but a team. The office managers serve as contact points for clients. Links – Applying for Medicaid • You can apply for Medicaid using HFS Form number 2378B. Here is a link to that form: http://www.dhs.state.il.us/OneNetLibrary/27897/docum ents/Forms/IL444-2378B.pdf • The online application is on the Department of Human Services (DHS) website here: http://fspp.dhs.state.il.us/register/wb/wbHomePre.do Thank You! Please submit Questions using our ICRx Q&A Survey Monkey link, which will be shared after the webinar.