The 2013 Medicare Drug Benefit and Dual Eligibles with Developmental Disabilities

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1 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

2 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

3 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.

4 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.

5 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.

6 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.

7 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)

8 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.

9 Important Terms, cont. Prior Authorization: A cost-containment 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 containment

10 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 s documentation of medical necessity, this requirement may be waived.

11 The 2013 MEDICARE PART D Information for New Jersey s Dual Eligibles

12 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 $ New Jersey dual eligibles may enroll in any Basic benchmark drug plan and not pay a monthly premium.

13 Overview of Benchmark Drug Plans for NJ s s Dual Eligibles In 2012, there were 9 benchmark plans available for NJ s 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.

14 2013 Benchmark Plans in NJ UnitedHealthcare (NEW) Aetna Medicare EnvisionRx Plus COMPANY NAME PLAN NAME AARP MedicareRx Saver Plus Aetna CVS Pharmacy Prescription Drug Plan EnvisionRxPlus Silver Monthly Premium for Dual Eligibles in 2013 $0 $0 $0 Medco Medicare Prescription Plan Humana Insurance HealthMarkets Medicare (NEW) SilverScript Insurance Company SmartD Rx (NEW) United American Insurance Co. WellCare Express Scripts Medicare Value Humana Walmart-Preferred Rx Plan Reader's Digest Value Rx SilverScript Basic SmartD Rx Saver United American - Select WellCare Classic $0 $0 $0 $0 $0 $0 $0

15 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 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 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.

16 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.

17 First Health drug plan: Not benchmark in 2013 First Health Part D Premier is not benchmark, starting Jan. 1, 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.

18 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

19 Blue Termination Letter The blue termination letter explains that the current drug plan (Bravo Rx) will be terminating in Consumers who receive this letter will be randomly auto-enrolled in a new $0 premium drug plan.

20 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 This will happen automatically unless other action is taken 2) Dual eligible can choose to enroll in another drug plan that has a $0 premium, or 3) Dual eligible can choose to enroll in another drug plan that has a monthly fee Requires a phone call to a different drug plan to enroll

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24 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.

25 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. Requires a phone call to the current First Health Part D Premier drug plan to indicate desire to remain in that drug plan, or

26 Blue Reassignment Letter 2) Dual eligibles can stay in the drug plan that was assigned in the Blue letter. 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. If current medications are not covered, find out if other benchmark drug plans will cover them.

27 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. Requires a phone call to a different drug plan to enroll.

28 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

29 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. assigned. The tan letter will say that the current Medicare drug plan premium will no longer be fully subsidized, starting Jan. 1, 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.

30 Tan Choosers Letter (cont.) A Tan letter was also sent to all dual eligibles who are currently enrolled in other non- benchmark 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.

31 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. 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 Requires a phone call to the new plan to enroll

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34 New drug plan identification cards Everyone who will be in a new Medicare drug plan should look for the new drug plan s s ID card in the mail. Bring the new ID card to the pharmacy.

35 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 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.

36 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.

37 Medicare Part D co-pays for dual eligibles In NJ, Part D co-pays for dual eligibles started July 1, 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.

38 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).

39 Barbiturate Drugs Bellaspas Bel-Tabs Butisol Sodium Eperbel-S Ergocaff-PB Fioricet Fiorinal Mebaral Phenobarbital Phenobarbital Sodium Seconal Sodium Spastrin

40 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-TabT Tab Triazolam Xanax Xanax XR

41 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 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 p will not cover it, and the doctor will need to prescribe a medication from another drug class.

42 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.

43 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 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.

44 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.

45 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)

46 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 s Basic non-benchmark plans in 2013.

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48 Consumer s s Pharmacy Must be Affiliated with the Drug Plan s 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.

49 Aspects of Medicare Part D that Do Not apply to the Dual Eligibles Monthly premium fees As long as dual eligibles are enrolled in a benchmark plan, there is no premium fee The Donut Hole doesn t t exist for duals. No Deductibles for dual eligibles Drug tiers 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

50 How to obtain answers for Medicare Part D questions Check the website Call 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 non- dual eligibles ends. The next slide provides phone numbers for free Medicare counseling from the NJ SHIP program.

51 State Health Insurance Assistance Program (SHIP) Telephone Numbers Local County Office Telephone Atlantic Bergen Burlington , ext Camden Cape May Cumberland Essex Gloucester Hudson , Press1, then ext Hunterdon Mercer Ext.14 Middlesex Monmouth Morris Ext. 101 Ocean Passaic Salem Somerset Sussex Ext.1223 Union Warren

52 Navigating the Medicare Plan Finder for Dual Eligibles Presenter: Mary McGeary NJ State Health Insurance Assistance Program SHIP ARC of NJ Webinar November 15,

53 What is the Medicare Plan Finder? Internet Tool on official Medicare web site Helps people learn about drug coverage and Review current Medicare enrollment Compare Part D plans & Medicare Advantage Health Plans (HMOs or DSNPs) Identify which plans cover your prescriptions at most affordable cost Enroll in a Part D or Medicare Advantage plan 2

54 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 Medicare Card Other Health Insurance cards Subsidy eligibility o Medicaid, LIS, PAAD 3

55 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

56 Getting to the Drug Plan Finder Go to Click Compare Drug and Health Plans Or Or call Medicare Customer Service Assistance for choosing a plan & enrolling available 24 hrs a day English and Spanish speaking CSRs 5

57 Homepage 6

58 Plan Finder Home Page: Step 1 Tutorial 7

59 If General Search: Important to answer questions about low income assistance Can leave blank Click here if Dual 8

60 Step 2: Enter Your Drugs Can type in drug name Or search drug by first letter 9

61 Pop-up box to indicate dosage NEW QUESTION ON TYPE OF PHARMACY 10

62 Info to Notice: Write down ID for future searches Click here when drug list complete 11

63 Option to search Generic or Brand 12

64 New Pop-up will warn when have added both a brand drug & its generic equivalent to the list 13

65 Step 3: Pharmacy Consumer Uses Click here to expand list of pharmacies Click here to see map 14

66 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

67 Step 5: Compare Your Plan Results $0 premium means benchmark plan Premium shown is amount over benchmark, consumer must pay this 16

68 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

69 Sorting Options 18

70 Looking at coverage Click here Click here 19

71 Example of Good Plan Choice $0 Premium Benchmark Plan No PA or Step Therapy All drugs on formulary 20

72 Example of Good Plan Choice All drugs on formulary WellCare Classic (PDP) No PA or Step Therapy Excluded drug covered by Medicaid 21

73 Example of Bad Plan Choice CIGNA Medicare Rx Premium Plan- Not Benchmark Drugs not on formulary PA restriction 22

74 Understanding the Tier Footnotes Avoid plans with drugs Not on Formulary 15 Plan DOES NOT cover this drug PAAD/Senior Gold or Medicaid will NOT pay If private pay, costs for this drug will not count towards deductibles or out of pocket limits Options Switch to generic or similar drug covered by the plan with doctor s approval (example: switch from Lipitor to simvastatin) Ask plan for exception to cover the drug for you because alternative will not work (need doctors input) Pay full price for the drug out of pocket Switch Plans to one with drug on Formulary allowed enrollment period 23

75 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 If have state Medicaid some excluded drugs covered under wraparound (ex: vitamins) 24

76 Comparing Plans for those with LIS 25

77 Compare Plan Details for Look at 5 Factors: Non-Duals 1.Costs: Estimated Annual Cost Most Important 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

78 Cost Details Health Reform Discounts show here 27

79 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 New to Medicare (IEP) Annual Enrollment Period (AEP) Special Enrollment 28Periods (SEP)

80 How to Enroll By Phone 1 (800) Medicare Call Plan Directly By Internet Plan s website IMPORTANT: Get enrollment confirmation Advise not to pay premium by automatic deduction from Social Security check 29

81 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 (Horizon DSNP is high performing with 3.5 rating) Cannot enroll in these plans on-line. Must call the plan directly 30

82 To increase print size on screen Additional Tools If need to edit the drug list 31

83 QUESTIONS? Submit your questions by to 32