Deprescribing. Medicare 101. Deprescribing. Webinar #9 Webinar #1. Jessica Visco, PharmD, CGP SeniorPharmAssist. Jessica Visco, PharmD, CGP

Transcription

1 August 24, 2016 Webinar #9 Webinar #1 Medicare 101 Deprescribing Jessica Visco, PharmD, CGP SeniorPharmAssist Jessica Visco, PharmD, BCGP Clinical Pharmacist Senior PharmAssist Deprescribing Jessica Visco, PharmD, CGP SeniorPharmAssist

2 Disclosures No commercial support has influenced the planning of the educational objectives and content of the activity. Any commercial support will be used for events that are not CE related. There is no endorsement of any product by DUHS associated with the session. No influential financial relationships have been disclosed by planners or presenters which would influence the planning of the activity. If any arise, an announcement will be made at the beginning of the session. This program is supported by a Geriatric Workforce Enhancement Program (GWEP) grant (U1QHP28708) from the U.S. Bureau of Health Professions Health Resources and Services Administration (HRSA).

3 Objectives Explain the basics of Medicare; A B C D Explain the difference between Original Medicare and Medicare Advantage products Describe the 2018 Medicare-approved drug benefit Share local, state and federal resources that help with Medicare Part D

4 Case Ms. Ford is a 76 year old woman History of diabetes, hypertension, arthritis, seasonal allergies Lives alone in Durham; daughter lives close by Been living independently for the last 5 years Fell down the steps and injured her hip Being evaluated for a possible hip fracture

5 Case Ms. Ford has: Original Medicare Medicare Supplement Medicare Part D plan How does Medicare A, B, C and D work?

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7 What is Medicare? Federally sponsored individual health plan providing coverage for medically necessary procedures and service Health Insurance for people 65 and older Under 65 with certain permanent disabilities Any age with End Stage Renal Disease ALS (amyotrophic lateral sclerosis Lou Gehrig s disease)

8 Your Medicare Coverage Choices

9 Part A Hospital Insurance Coverage Part A Hospital Insurance helps cover Inpatient hospital care Inpatient skilled nursing facility care Blood (inpatient) Certain inpatient non-religious, non-medical health care in approved religious non-medical institutions Home health care Hospice care

10 Part B Medical Insurance Coverage Part B Medical Insurance helps cover Doctors services Outpatient medical and surgical services, supplies Clinical lab tests Durable medical equipment Diabetic testing supplies Preventive services

11 What does Original Medicare not cover? Prescription medications Routine dental care Routine vision care and eyeglasses Hearing aids Foreign travel Cosmetic procedures and treatments Long Term Care

12 Medicare Secondary Medical Coverage Commercially available Medicare supplements (Medigap policies) fit the coverage gaps of traditional Medicare: pays A and B cost-sharing for Medicare approved services Other types of secondary coverage include Medicaid or Employer health plans Note: Medicare beneficiaries only have guarantee issue rights to an affordable supplement when new to Medicare and in a few select other situations

13 Provider Choices with Medicare Participating - accept assignment 100% of what traditional Medicare allows Non-participating do not accept Medicare assignment allowed to charge 15% above Medicare assigned charges; person usually pays up-front and Medicare reimburses him/her Opt-out don t file with Medicare and can charge whatever they want Accept traditional Medicare but not any or all of the replacement plans - Medicare Advantage

14 2003 Medicare Modernization Act Replaced existing Medicare + Choice program with a new program called Medicare Advantage program Part B premiums would increase for higher income beneficiaries Added a voluntary drug benefit (Part D) that began January 1, 2006

15 Medicare Part C Medicare Advantage Plans Health plan options approved by Medicare Another way to get your Medicare coverage Still part of the Medicare Program Run by private companies Medicare pays the plan an amount For each member s care May have to use network providers Types of plans available may vary

16 Medicare Part C Medicare Advantage Plans If you join a Medicare Advantage (MA) Plan Still in Medicare with all rights and protections Still get those services covered by Part A and Part B But the MA Plan covers those services instead May have different cost-sharing May choose a plan that includes extra benefits Such as vision or dental offered at the plan s expense (not covered by Medicare) May have a premium

17 Ms. Ford Ms. Ford is admitted to the hospital for a hip replacement Discharged to skilled nursing facility after 4 day admission Then discharged home with home health Requires: PT Walker Diabetes testing supplies Observation vs admitted and SNF coverage

18 Part A What You Pay

19 Part B What You Pay

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21 DME Suppliers

22 DME Suppliers

23 DME Suppliers

24 How They Work

25 Medicare Part D Everyone who has Medicare Part A or B (regardless of income) can choose a Medicare prescription drug plan A voluntary benefit; with late enrollment penalties It is administered by private companies as insurance model with cost-sharing requirements Medicare beneficiaries with limited incomes and resources may qualify for extra help or a low income subsidy via the Social Security Administration

26 Medicare Part D NOT reflected in Medicare website: Penalty clock - not having creditable coverage when eligible; if June (1% of national base premium); $35.02/month X 139 months = $48.70/,month); penalty is gathered by Part D plan and transferred to CMS Income-Related Medicare Adjustment Amount (IRMAA) - $85k/single or $170k/couple or higher pay higher Part D premiums via your SS check (like B)

27 Medicare Beneficiaries Out-of-Pocket Drug Spending Under Medicare Rx Benefit, 2018 Catastrophic Coverage 5% Part D Plan pays 15% & Medicare pays 80% $8,418 Beneficiary Out-of-Pocket Spending Coverage Gap 65% discount on covered BRAND Rxs 56% discount on covered GENERIC Rxs Partial Coverage up to Limit 25% Part D plan pays 75% $3,750 Deductible $405 Medicare Drug Benefit

28 Annual Adjustments for Standard Benefit Benefit Parameters Deductible $400 $405 Initial Coverage Limit $3,700 $3,750 Out-of-Pocket Threshold $4,950 $5,000 Full LIS Copayments Institutionalized $0 $0 Up to or at 100% FPL $0 or $1.20/$3.70 $0 or $1.25/$3.70 Other Full LIS $3.30/$8.25 $3.35/$8.35

29 Full Low Income Subsidy (LIS) or Extra Help Medicare beneficiaries with limited incomes and resources receive additional help: 135% federal poverty level (FPL) and below $16,281/single or $21,924/couple Liquid assets less than $8,890/S or $14,090/C (includes $1,500 per person for burial expenses) Pay $ /Rx for formulary meds in 2018 No monthly premiums, deductibles, or donut holes / coverage gap

30 Partial Low Income Subsidy (LIS) or Extra Help Medicare beneficiaries with limited incomes and resources receive additional help: < or = 150% FPL $18,090/single or $24,360/couple Liquid assets less than $13,820 or $27,600 (includes $1,500 per person for burial expenses) Sliding scale monthly premiums (25-75%) $83 annual deductible in % co-payments for formulary medications but no official donut holes /coverage gap

31 PDP Plans: Considerable Discretion Formularies; TrOOP true out-of-pocket Medicines not on formulary are full cost without a limit on expenditures, unless individual successfully appeals to have it covered Utilization Management tools - prior authorization, step therapy & quantity limits Tiered cost sharing 4-6 levels generic/brand preferred and non-preferred and specialty tier Exceptions and appeals processes begins with Coverage Determination Request Form Pharmacy co-branding - preferred, network/standard retail cost-sharing, and non-network; mail order can be MORE expensive

32 Medication Requirements Federal law requires plans to include at least two drugs from each class of drug category on their formulary All or substantially all of the medications for the following conditions must be covered (can still be $$$) by Medicare drug plans, including: Anti-depressants Anti-psychotics Anti-convulsants Chemotherapeutic agents Anti-retrovirals Immunosuppressants

33 Medicare Excluded Classes Benzodiazepines and some barbiturates now covered Drugs for: Anorexia Weight loss Weight gain Fertility Hair growth Cosmetic purposes Symptomatic relief of coughs and colds Prescription vitamins and mineral products; OTCs Medications intended for sexual or erectile dysfunction Drugs covered by Medicare Part A or B Outpatient drugs requiring monitoring by manufacturer Enhanced Plans can cover some of these products but does not count towards TrOOP

34 Steps to Choosing a Plan CMS website: - Medicare Find Health and Drug Plans can see annual costs via different plans after entering meds, dosages, zip code; pharmacy Must enter a pharmacy Critical to also view utilization management tools Can see if MTM program available

35 LI NET Limited Income Newly Eligible Transition Program Humana/Argus/Relay Health Allows individuals with partial or full LIS to receive immediate Rx coverage at the point-of-sale if not already enrolled into a Part D plan. Can be retroactive if full dual Temporary coverage - open formulary, no utilization management restrictions, or pharmacy networks

36 Transition Fill AKA first-fill policy of CMS (NOT related to income) 1. Time to get on another medication 2. File an exception request 3. For those with LIS enroll in a different plan Automatic override If a new plan or current plan drops your medication or places utilization management restrictions; when experience a change in level of care (home to SNF, etc.) Plan must provide a 30 day supply (unless a lesser amt. is prescribed) of an ongoing medication within the first 90 days of the plan membership

37 Transition Fill Doesn t include excluded Part D drugs, but does cover non-formulary drugs & those subject to ST and PA Plans must give written notice within 3 days of transition fill Part D sponsors may need to extend transition periods on a case-by-case basis LTC 31 day supply and honor multiple 31 day fills while exception is being processed; Jan SNF has 14-day short-cycle on brand-name meds and controlled substances

38 Ms. Ford insurance coverage Ms. Ford has Traditional Medicare Medicare supplement Part D plan Her gross monthly income $1809 Difficulty paying for her medicines Wants to learn more about Original Medicare/supplements vs Medicare Advantage plans

39 Senior PharmAssist We help any Durham Medicare beneficiary (any age/income) REVIEW & UNDERSTAND their Medicare hospital, medical and drug insurance choices. We CHECK to see if you might be eligible for help We CONNECT Durham Seniors to other community resources and programs to help them stay as healthy and independent as possible for as long as possible. Through Medication Reviews, we EDUCATE Durham seniors (60 & older) about the most economical, safe and effective medicines. Durham seniors with gross monthly income up to $2010 single/$2707 couple may qualify for our PRESCRIPTION CARD PROGRAM ($2 & $5 monthly co-pays for drugs we cover).

40 Open Enrollment October 15-December 7 Durham County SHIIP site Senior PharmAssist 406 Rigsbee Avenue Suite 201 Durham, NC Call for screening and appointments Call Medicare Medicare ( ) Seniors Health Insurance Information Program (SHIIP)

41 Where can I get help? Seniors Health Insurance Information Program (SHIIP) Social Security Medicare or Employer health benefits administrator Medicaid Local county Social Services Senior PharmAssist

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43 Questions???

44 Continuing Education Credits 1 hour of CE credit is being offered for this webinar. For the live webinar, to obtain the credit you must: Add your name to the chat box (to verify attendance) Complete the survey. The survey will open automatically at the end of the webinar and the link will be sent in a follow-up . If you did not register for this webinar and would like CE credit, contact gero@duke.edu