CENTER FOR MEDICARE ADVOCACY INC MEDICARE PART D

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CENTER FOR MEDICARE ADVOCACY, INC. MEDICARE PART D: The Impact on Dual Eligible Beneficiaries

CENTER FOR MEDICARE ADVOCACY, INC. MEDICARE PART D: The Impact on Dual Eligible Beneficiaries Vicki Gottlich, Esq. March 2006 www. medicareadvocacy. org

PART D ISSUES FOR PEOPLE WITH MEDICARE & MEDICAID § Problems caused by random

PART D ISSUES FOR PEOPLE WITH MEDICARE & MEDICAID § Problems caused by random assignment to low-income Part D plans. § Difficulties in accessing medically necessary drugs. § Inability to meet minimal cost sharing requirements. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 2

RANDOM ASSIGNMENT TO PART D PLANS Random assignment results in unequal access caused by

RANDOM ASSIGNMENT TO PART D PLANS Random assignment results in unequal access caused by variations in coverage of drugs. § OIG Report: • • 1/3 of duals assigned to plans covering less than 85% of 178 most common Part D drugs. Only 18% assigned to plans covering all 178 drugs. § Avalere Health Issue Brief: • • Many California duals have worse coverage than under Medi-Cal (Medicaid). Number of drugs on formularies varies from 530 -3360. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 3

RANDOM ASSIGNMENT TO PART D PLANS Potential gaps in coverage for duals § Issues

RANDOM ASSIGNMENT TO PART D PLANS Potential gaps in coverage for duals § Issues for duals who change plans: • Between 6 and 18 low-income plans. • Difficulties in determining which plan is “best”. • Communication issues may delay enrollment in new plans. § New duals may lose all drug coverage • • Lose Medicaid when become Medicare eligible. Will they be enrolled in a Part D plan in time? www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 4

ACCESS TO MEDICALLY NECESSARY DRUGS § Transitions process issue: • Plans not providing 30

ACCESS TO MEDICALLY NECESSARY DRUGS § Transitions process issue: • Plans not providing 30 day “first fills” for non • • formulary drugs. CMS’s extension of transition process from 30 to 90 days is voluntary. Enrollees not informed to either get a new prescription or to seek an exception before transition period ends on March 31, 2006. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 5

ACCESS TO MEDICALLY NECESSASRY DRUGS § Exceptions and appeals processes: • • Vary from

ACCESS TO MEDICALLY NECESSASRY DRUGS § Exceptions and appeals processes: • • Vary from plan to plan. Exceptions require participation by doctors. • Some doctors charging fees to fill out forms. • • Enrollees may not have sufficient information to pursue appeals. No supply of drugs pending appeal for most duals. § Barriers to switching to formulary drugs • Issues in getting doctors’ appointments. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 6

INABILITY TO MEET COST SHARING REQUIREMENTS § Duals pay co-payments of $0 -$5/drug depending

INABILITY TO MEET COST SHARING REQUIREMENTS § Duals pay co-payments of $0 -$5/drug depending on income level, residence. • • • Cost sharing obligations new for some duals. Cost sharing could be waived under Medicaid but not under Medicare. Cost sharing amounts to be indexed yearly. § Medicaid does not wrap around Part D benefit. • • Unlike for other Medicare services, Medicaid doesn’t pick up cost sharing. States vary in Medicaid coverage for Part D excluded drugs. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 7

INABILITY TO MEET COST SHARING REQUIREMENTS § Institutionalized duals have no cost sharing. §

INABILITY TO MEET COST SHARING REQUIREMENTS § Institutionalized duals have no cost sharing. § Duals who live in assisted living, board & care facilities are not institutionalized. • Pay all but small amount of their income to • facility for care. Must pay co-payments – costs often exceed personal needs allowance. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 8

RECOMMENDATIONS § Increase funding to organizations that assist individual beneficiaries. § Assign duals to

RECOMMENDATIONS § Increase funding to organizations that assist individual beneficiaries. § Assign duals to plans whose formularies match their needs- “intelligent random assignment. ” § Simplify Part D by standardizing • • • benefit packages transition policies exceptions and appeals processes. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 9

RECOMMENDATIONS § Eliminate cost-sharing for all duals receiving long-term care services, regardless of setting.

RECOMMENDATIONS § Eliminate cost-sharing for all duals receiving long-term care services, regardless of setting. § Allow Medicaid to “wrap around” Part D. § Ensure seamless transition from Medicaid to Medicare drug coverage. § Add a drug benefit to traditional Medicare. www. medicareadvocacy. org Copyright © Center for Medicare Advocacy, Inc. 10

CENTER FOR MEDICARE ADVOCACY, INC. MEDICARE PART D: The Impact on Dual Eligible Beneficiaries

CENTER FOR MEDICARE ADVOCACY, INC. MEDICARE PART D: The Impact on Dual Eligible Beneficiaries For continually updated information go to www. medicareadvocacy. org

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