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What's New

Serving Wyoming Medicaid Providers

 

 

Medicare Prescription Drug Coverage

Medicare Part D, the new prescription drug benefit, begins on January 1, 2006. Everyone with Medicare will be eligible to enroll. Prescription drug plans (PDPs) are a form of insurance coverage for brand name and generic prescription drugs. All plans must offer a minimum level of coverage as identified by the Centers for Medicare and Medicaid Services (CMS). Premiums will vary based on formulary options and region. Participants in our region will have 48 plans to choose from and about a third will qualify for financial assistance.  More than half of the 41 million people covered by Medicare are expected to contact their health care providers for advice about the new program.

Key Dates

  • October 13, 2005: Medicare online tool for custom plan comparison available at www.medicare.gov
  • October 15, 2005:  Dual eligibles auto-assigned to plans at or below the benchmark
  • November 15, 2005: Enrollment begins
  • December 31, 2005: Medicaid Prescription Drug Coverage ends for full duals
  • January 1, 2006: Drug plans go into effect
  • May 15, 2006: Last day to enroll without penalty

What Part D Means to Your Patients
Relationship to Current Coverage
Your patients likely fall into one of the following categories:

  • No prescription drug coverage The choice for these patients is to join a stand-alone prescription drug plan and keep any other current insurance (i.e. Part B coverage and some Medigap plans), or to join a combined PDP/health coverage plan such as Medicare Advantage or a Medicare Health Plan (formerly called Medicare_Choice). These patients may also elect to do nothing. Failure to enroll in a plan by May 15, 2006 may result in a beneficiary paying a penalty.
  • Drug coverage through an employer, union, VA The key for these patients is to find out if their current coverage is "at least as good as" the standard Medicare prescription drug coverage. By November 15, 2005, former employers and unions are required to send information letting retirees know how their current coverage compares. If their current plan is comparable, they may be able to keep it and preserve the right to later switch to a Medicare PDP without penalty. If their current plan is comparable but will be termed by the former employer or union, the beneficiaries affected will have 63 days from the time the prescription drug coverage ends to enroll in a PDP. If their current plan is not comparable, they would be subject to the same options as your patients without drug coverage.
  • Dually eligible for Medicare and Medicaid Your patients who currently have their drug costs paid for by Medicaid will be automatically enrolled in a Medicare PDP. During the first half of November 2005, full duals will receive notices from CMS informing them, which PDP they have been randomly enrolled to. These patients will have no premiums, no deductibles, no gaps, and will have nominal co-pays if anything. Be aware that these patients may still select the plan of their choice before December 31, 2005. This population should receive a notice from CMS by November 7, 2005 informing them of the PDP that they have been automatically enrolled in. The patients should be encouraged to verify that the plan that they have been auto-enrolled in is the most beneficial plan for them (i.e. includes all drugs that the beneficiaries are currently taking, is contracted with their pharmacy of choice, etc)] If the beneficiaries, do not enroll into another plan, they will remain enrolled in the PDP that they were automatically enrolled in.  Note that patients in this category may always elect to change plans.
  • Medicare Savings Plans (MSP) _ PDAP Beneficiaries who have their Part A and/or B Medicare premium paid for by the Office of Health Care Financing (formerly the Office of Medicaid) have until May 15, 2006 to enroll in a PDP. In spring 2006, these beneficiaries will be automatically enrolled in a Medicare PDP. These patients will have no premiums, no deductibles, no gaps, and will have nominal co-pays if anything. Their PDAP coverage will end on May 31, 2006. Patients in this category can always elect to change plans.

Extra Help or Low Income Subsidy (LIS)


Patients with limited resources and incomes less than $14,355 (or $19,245 for married couples) may qualify for extra help. Unlike dual eligible patients, individuals in this category must apply for extra help through the Social Security Administration or your local State Medical Assistance Office. Social Security already sent applications out to many of those likely to qualify. Please note, though, that these patients must both apply for this assistance and separately enroll in a drug plan. 
Those Medicare beneficiaries eligible for full Medicaid benefits (or dual eligibles) will be deemed eligible for low-income subsidies under Part D. Dual eligibles will be auto-enrolled in a Medicare prescription drug plan in November 2005 to help prevent gaps in their coverage when their Medicaid drug benefits end January 1, 2006. CMS will automatically assign dual eligibles to plans with premiums at or below the regional average cost. Dual eligibles will not pay the Part D premium or deductible, but will pay $1 $2 for generic drugs and $3 $5 for brand-name drugs up to $5,100 in total drug spending.
Other low-income beneficiaries who meet the income and asset test will be eligible for premium and cost-sharing assistance with greater assistance targeted to those with lower incomes and fewer resources. These beneficiaries will have until May 15, 2006 to enroll in a Medicare drug plan on their own, or will be auto-enrolled in a plan by CMS, effective June 1, 2006.
Dual Eligibles
This population is in serous danger of falling through the cracks and having some period of time when they do not have a prescription drug benefit. Finding and helping clients sign up for Part D by 12/31/05 will be a daunting challenge. These beneficiaries will also need to learn a new system for getting their prescriptions and need help with the appeals process when their drug is not on the formulary of their Part D plan.
Knowing where to refer these clients will be key in getting them the assistance that they need.  At a minimum, you and your office staff should be prepared to direct patients and caregivers to do the following:

  • Refer to the  Medicare & You 2006 Handbook
  • Call CMS 1-800-Medicare (1-800-633-4227);  TTY users should call 1-877-486-2048 speak with a live Medicare representative;
  • Go to CMS website at www.medicare.gov; or
  • Contact your local WSHIIP representative @ 1-800-856-4398 for one-on-one guidance.  WSHIIP has counselors available to help with Medicare questions. 

Cost Overview


The Medicare prescription drug plans will work like other forms of insurance. Beneficiaries will pay a monthly premium ranging from less than $20 to $99 in 2006. All dual eligibles will be auto-assigned to plans under the Wyoming benchmark of $33.11.  This is what allows the dual eligibles to only be responsible for paying co-pays.  All other populations will have to pay a deductible of $250 or less. After reaching the initial deductible, Medicare will cover 75 percent of drug costs up to $2,250. At this point, the beneficiary would pay 100 percent of drug costs up to a total of $5,100, or $3,600 in out-of-pocket expenses. Beneficiaries should review plans carefully as some may provide assistance with the clients 100 percent responsibility or donut whole. Medicare then covers 95 percent of any further drug costs.
On the whole, it's difficult to estimate how much the average participant will save in out-of-pocket drug costs by enrolling in PDP. Limited income patients stand to save the most, as they may qualify for extra help paying for premiums and coinsurance costs. For patients with known drug costs, several online cost estimators are available.
CMS cost estimator
AARP cost estimator

Drug Plan Structure


In each of the 34 Medicare prescription drug plan (PDP) regions, (Map) there will be 11 to 20 private organizations offering multiple plans. Every region will have multiple plans, and some may have up to 50 plans to choose from.  Wyoming currently has 17 organizations providing 41 stand-alone prescription drug plans that work with traditional Medicare and 3 organizations providing 7 Medicare Advantage plans that offer drug coverage and other benefits. All 41 PDPs offered as of October 10 are available throughout the state, but only certain Medicare Advantage programs are available in certain counties within the State.  There are many available options. It will be important for patients and their families to know their drug regimen so they can make an informed decision.
Drug Plan Coverage
Drug plans will differ in coverage and premium level. Using formularies, agreements with pharmacy networks, drug companies, and tiered payment mechanisms, PDP organizations will be able to offer unique drug discounts and pharmacy options. All formularies must include at least two drugs from each category and class, as compared to the United States Pharmacopeia (USP) model (view) and other commonly used classification systems. In particular, all formularies include most drugs from the following drug classes: anti-neoplastics, anti-HIV/AIDS drugs, immunosuppressants, anti-psychotics, anti-depressants, and anti-convulsants.
Appeals and Exceptions
All drug plans are required to have a timely exceptions and coverage determination process. The details are still evolving; ultimately the appeals process will play an important role in the new Medicare benefit.
See CMS issue paper

Resources

Information Clearinghouse for the Medicare Prescription Drug Program

Outreach and Enrollment Tools for Providers

Medicare Links for Patients

Training


To learn more about hosting or attending a local CMS training, contact your regional CMS office.
Regional contact information
  


The content of this web page was last updated on 11/28/2005