Medicare. Medicare? What does it have to do with me? Alan Farkas, M.S., R.Ph.

Transcription

1 Medicare Medicare? What does it have to do with me? Alan Farkas, M.S., R.Ph. 1

2 Resources Medicare.gov Medicare & You 2018 (PDF version) Optional background reading =1850 Pharmacy Management: Essentials for All Practice Settings, 4e Chapter 28, Medicare portion

3 Objectives: 1. Identify eligibility requirements for Medicare enrollment 2. Identify and define the different Parts of Medicare (A, B, C, and D) 3. Identify and define the different options beyond basic Medicare 3

4 Objectives (cont.): 4. Explain the standard structure of Medicare Part D Prescription Drug Plans and possible changes that can be made by insurance companies 5. Explain the components of a Prescription Drug Plan 6. Explain the methods for beneficiaries to obtain financial assistance with Part D. 4

5 What is Medicare? A health insurance program for People 65 years of age and older People under age 65 with certain disabilities People of all ages with End-Stage Renal Disease or ALS (Lou Gehrig s disease) It was enacted in 1965 by President Lyndon Johnson. Former president Harry Truman and his wife Bess were presented with the first two Medicare cards. 5

6 What is Medicare? Medicare is the nation s largest health insurance program, currently covering about 56 million Americans. Projected to be 77 million by 2030 Administered by Centers for Medicare & Medicaid Services (CMS) Enrollment by Social Security Administration or Railroad Retirement Board 6

7 Original Medicare Card (front) 7

8 Original Medicare Card (back) 8

9 Original Medicare Card (front) New in 2018

10 A, B, C, D? In general: Part A is considered Hospital Coverage Part B is Medical Insurance Part C is Managed Care Part D is Prescription Drug 10

11 Medicare pathways diagram. Source: IMPACT OF HEALTH POLICY ON HEALTH CARE DELIVERY, Pharmacy Management: Essentials for All Practice Settings, 4e Citation: Zgarrick DP, Alston GL, Moczygemba LR, Desselle SP. Pharmacy Management: Essentials for All Practice Settings, 4e; 2016 Available at: Accessed: February 22, 2017 Copyright 2017 McGraw-Hill Education. All rights reserved

12 Part B Drug Coverage Injectables given in doctor s office Drugs administered through Part B-covered DME Such as nebulizer or insulin pump Blood glucose testing supplies In patient s home EPO for ESRD Three categories of oral drugs with special requirements Oral anti-cancer drugs Oral anti-emetic drugs Oral immunosuppressive drugs And other non-oral forms

13 General Rules for Medications? Parts A, B, or D? Where it will be used? Used in the hospital (A), doctor s office (B) or used at home (D) What it is for? For example: oral methotrexate used for arthritis (D) or as immunosuppressive / cancer treatment (B)? How it will be used? For example: Insulin for pump (B) or Insulin for syringe (D)

14 Why is drug list so confusing? Prior to Part D, Medicare was not in the drug business Selectively picked medications and devices for inclusion in Part A and Part B; generally do not cover outpatient drugs When Part D was implemented, they didn t want to change the rules, so Part D was added to pick up outpatient drugs 14

15 Medicare Part D Easy to remember, D for drug The largest change in insurance processing in retail pharmacy history Millions who had no prescription drug coverage now had an option Not a single entity. Beneficiaries need to voluntarily enroll and select a plan. Run by private insurance companies, but CMS sets minimum standards. 15

16 Phasing it in Medicare Modernization Act of 2003 Discount cards from pharmaceutical industries in 2004 and 2005 Educating the public and healthcare professionals, especially the pharmacy profession 16

17 Exhibit 11 Whether to Enroll in a Medicare Drug Plan Depends on Many Factors, Including Current Source of Coverage No Drug Coverage Medigap Medicaid Medicare Savings Programs Veterans Employer- Sponsored Coverage State Pharmacy Assistance Program Indian Health Service Medicare Advantage TRICARE AIDS Drug Assistance Program Medicare- Approved Drug Discount Card

18 Who could benefit from Part D enrollment? Eligible patients without prescription benefits. Eligible patients with inadequate prescription benefits. If they have insurance already, their current insurance plan is required to report whether the insurance plan is equivalent to Part D or not Dual eligible (those qualifying for both Medicaid and Medicare) 18

19 The options Prescription drug coverage through: Stand-alone prescription drug plans (PDPs) Offers prescription drug coverage only Medicare Advantage prescription drug plans (MA-PDs) 47 PDPs originally in the Indiana and Kentucky region In 2015, there were 31 PDPs, now MA-PDs in zip code 2 MA in without prescription benefits 19

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21 Initial Enrollment Prescription drug plans were finalized and announced on October 15, 2005 Initial enrollment began November 15, 2005 Ended May 15 th, 2005 Late penalties were applied after this date. Formerly, November 15 December 31 each year Since 2011, changed to October 15 December 7 21

22 Enrollment Periods 7 month period (Starts 3 months before month of eligibility, month of, and 3 months after, same as Part B) Special Enrollment Periods Permanently move out of your plan s service area Lose other creditable Rx coverage Inadequately informed your other coverage was not creditable/was reduced and no longer creditable Enter, live in or leave a long term care facility Dual-Eligible or Extra Help can change at any time Or in exceptional circumstances 22

23 Consequences of Late Enrollment Late-enrollment penalty (1% per month) Based on every full month a beneficiary Was eligible to enroll in Part D plan but was not enrolled Did not have creditable drug coverage for 63 consecutive days or longer 23

24 Part D Drugs Benefits only apply to covered Part D drugs Formularies for each plan are DIFFERENT Not all Medicare approved drugs will be on formulary Each PDP must have AT LEAST two drugs in each category and class Also includes the following Biological products Insulin Medical supplies associated w/insulin injection (syringes, needles, alcohol swabs, and gauze) Certain vaccines not covered under Part A or B 24

25 Part D Exclusions Barbiturates, Benzodiazepines (coverage began in 2014) Anorexia, weight loss, or weight gain Fertility promotion Erectile dysfunction drugs unless used to treat another FDA approved condition Drugs for cosmetic or lifestyle purposes (e.g., hair growth, wrinkles) Symptomatic relief of cough and colds Prescription vitamin and mineral products (except prenatal vitamins and fluoride preparations) Non-prescription drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale 25

26 Formulary: Definitions a list of prescription drugs that the plan covers Prior authorization: doctor has to show there is a medically necessary reason why the person must use that particular drug Step therapy: a type of prior authorization; must first try less expensive drugs Quantity limits: limits quantity for period of time 26

27 Formularies Formularies are allowed by law Will differ among plans Can be multi-tiered Usually 2-3. Generic vs. brand Non-formulary drugs do not count toward (True Out Of Pocket Costs) TrOOP Several safeguards, including exceptions and appeals processes 27

28 Formulary Requirements Drug categories and classes generally change only once a year Formulary drugs (and tiers) can change at any time, but plans must provide 60 days written notice to affected enrollees, pharmacists, prescribers, etc. Beneficiaries (and authorized representatives) have right of appeal if plan denies coverage or does not include drug in preferred tier Pharmacies will have to provide standard notice to beneficiaries when this occurs 28

29 Other Part D Limitations Drug must be provided for a medically accepted indication If a drug could also be considered Part A or Part B, Part A or Part B will pay for the drug Example: methotrexate for cancer would be Part B, for rheumatoid arthritis, Part D 29

30 Standard Benefits for 2018 Parameters established by law: Monthly premium (median ~$39) Our region ranges from $17.70 to $ Annual deductible of $405 (some plans as low as $0) 25% coinsurance (can be flat amount) Initial coverage limit of $3.750 Gap in coverage from $3,750 to ~$7,509 (Donut Hole) Catastrophic coverage after ~$7,509 $5,000 true out-of-pocket costs (TrOOP) 30

31 How TrOOP Works Plans are required to calculate and keep track of a beneficiaries out-of-pocket expenses Beneficiaries must report other qualified payments to plan for calculations Misrepresentation = termination of coverage Plan sends beneficiary a monthly statement describing his/her TrOOP toward the $5,000 Once catastrophic coverage is reached, co-pay is 5% 31

32 Standard Benefit in 2010 Total $310 Spending $2830 $6440 Catastrophic Coverage Deductible 75% Plan Pays 25% Copay Coverage Gap (beneficiary pays 100%) 80% Medicare Re-insurance 95% 15% Plan Pays Beneficiary Cost $310 $940 $4550 TrOOP 5% Coinsurance Beneficiary Cost Direct Subsidy/ Beneficiary Premium Medicare Pays Reinsurance 32

33 2010 Rebate To assist beneficiaries in the Donut Hole, a one-time $250 rebate was mailed out to those who exceeded the initial coverage limit and had to pay full price for their medications. This is the first step in eliminating the Donut Hole by

34 Standard Benefit in 2018 Total Spending $405 $3750 $7509 Catastrophic Coverage Deductible 75% Plan Pays 25% Copay Brand 35% of price Generic 44% 80% Medicare Re-insurance 95% 15% Plan Pays Beneficiary Cost $405 $1343 $5000 TrOOP 5% Coinsurance Beneficiary Cost Direct Subsidy/ Beneficiary Premium Medicare Pays Reinsurance 34 34

35 Payment flow Beneficiary Monthly premium PDP Deductible and Copay Drug Cost minus Copay Pharmacy 35

36 Payment flow in the Gap Beneficiary monthly PDP Drug cost Optional for plan Pharmacy 36

37 Payment flow in the Gap for 2018 Beneficiary monthly PDP 35% cost on brand, 44% cost on generic Pharmacy 65% cost of brand. 56% cost on generic 37

38 Low-Income Benefit More comprehensive than standard benefit Referred to as extra assistance or extra help in beneficiary literature from CMS Based on Federal Poverty Levels (FPLs) and asset test Sliding scale up to 150% of the FPL $24,250 for married couple $17,655 for single person Individuals who are eligible should have received a notice in the mail from Social Security. Very important to encourage people to fill it out. 38

39 CMS online tool Option 1: Enter their identification to get personalized information when they use the tool Beneficiaries will need to enter either their Medicare number, heath insurance claim number (HICN), or social security number; last name; date of birth; Part A or Part B effective date; zip code; and whether they receive any additional prescription drug assistance Option 2: Do not enter any identification and use the tool anonymously 39

40 Tool Plan Identification Options Beneficiaries will be asked to enter the medications they take 25-drug limit Choose the pharmacy they prefer to use Based on this information, the tool will provide a detailed cost breakdown of available plans Sorted by cost to beneficiary 40

41 Information Provided A list of plans sorted by the lowest to highest overall costs to the beneficiary A cost breakdown of each plan (premium, deductible, cost-sharing amount, etc.) Formulary information specific to the medications the beneficiary is taking Information on pharmacies participating in each plan and whether or not the pharmacy is preferred or non-preferred Information on any drug tiers, step therapy, prior authorization requirements 41

42 Medicare.gov Online Enrollment If beneficiaries select a plan while using the CMS tool, they can enroll online immediately Will then receive information in mail from plan If beneficiaries enroll in >1 plan through the tool, the last plan they select up to Dec. 7th will be their plan for the next year. Premium payment options: Deducted from S.S. check Pay monthly, either send in check or automatic electronic transfer Charged to credit or debit card monthly 42

43 1-800-MEDICARE Beneficiaries can have a customer service representative walk them through the online tool and enroll them over the phone. Upon request, CMS will mail an individualized, written comparison of the plans to the beneficiary 43

44 Call the PDP directly Mail in form PDP s own website Direct Enrollment 44

45 Help With Decision Making Many patients will turn to their pharmacists (because we all know that all pharmacists are fully educated about this and have tons of free time to spend with this ) CMS conducting extensive outreach State resources State Health Insurance Programs (SHIPs) Area agencies on aging 45

46 CMS Marketing Guidelines Pharmacists CAN Provide the names of plans with which they contract/participate Provide information and assistance in applying for the limited-income subsidy Provide objective information on specific plan formularies, based on a particular patient s medications/health care needs Provide objective information regarding specific plans Covered benefits, cost sharing, and utilization management tools 46

47 CMS Marketing Guidelines Pharmacists CAN Distribute PDP marketing materials, including enrollment application forms Distribute MA and/or MA-PD marketing materials, excluding enrollment application forms For PDPs and MA-PDs, must inform individuals where they can obtain information on all available options within the service area MEDICARE 47

48 CMS Marketing Guidelines Pharmacists CAN Refer patients to other sources of information Print out and share information with patients from CMS s Web site Use comparative marketing materials comparing plan information created by a non-benefit/service providing third party 48

49 Marketing Guidelines Pharmacists CANNOT Direct, urge, or attempt to persuade any prospective enrollee to enroll in a particular plan or to insure with a particular company based on financial or any other interest of the provider Collect enrollment applications Offer inducements to persuade beneficiaries to enroll in a particular plan or organization 49

50 CMS Marketing Guidelines Pharmacists CANNOT Health screen when distributing information to patients, as health screening is a prohibited marketing activity Offer anything of value to induce plan enrollees to select them as their provider Expect compensation in consideration for the enrollment of a beneficiary Expect compensation directly or indirectly from the plan for beneficiary enrollment activities 50

51 Questions??????