Medicare Prescription Drug Congress November 2 2005 MMA
Medicare Prescription Drug Congress November 2, 2005 MMA Implementation: MMA Part D Long Term Care Implementation
Medicare Modernization Act of 2003 Ø Ø A Shift In Paradigm Issues For LTC Facilities Operators Issues For Pharmacy Providers Questions 2
Medicare Modernization Act of 2003 A Shift In Paradigm Ø One Payor For 65% Of Residents to 10 Plus Payors For These Residents Is Your Pharmacy Contracted ü Are Your Residents Enrolled ü Does Your Facility Understand The Plans ü Residents Should Make A Choice, Can They? ü How Can You Assist Residents ü Multiple Plans Means Multiple Complexities ü 3
Medicare Modernization Act of 2003 A Shift In Paradigm Ø All Medicare/Medicaid Dual Eligibles Have A Benefit Equal To Or Superior To That Offered Under Part D Ø ALF Residents Under Waiver Programs Will Have Less Of A Benefit Ø Medicare Only Have A New Benefit Where One Did Not Exist, Small Subset Of The LTC Population 4
Medicare Modernization Act of 2003 Issues For Facility Operators 5
Medicare Modernization Act of 2003 Issues For Facility Operators Ø Pharmacy Relationship – One Provider Ø Resident Enrollment Marketing Materials October 1, 2005 ü Special Enrollment Periods – SNFs Only ü Auto Enrollment – Late October 2005 ü Open Enrollment – November 15, 2005 ü Enrollment Process Post January 1, 2006 ü Who Has What Coverage ü 6
Medicare Modernization Act of 2003 Issues For Facility Operators Ø Updating Admissions Process Ø Patients Pending Coverage Ø Medical Staff Know How To “Write” For Medicaid Formularies Ø Prior Authorizations and Exceptions Are Anticipated To Increase Many Fold Increasing Burden on Facility, Docs, Pharmacies 7
Medicare Modernization Act of 2003 Issues For Facility Operators Ø Educating Nursing, Business Office and Physician Staff Ø Being Prepared To Deal With Ongoing Change And Guidance in: ü Formularies ü PDPs and Plans ü Guidance From CMS 8
Medicare Modernization Act of 2003 Issues For Facility Operators Ø Education Effort For Residents / Families Ø Understanding Local PDP Offerings Ø Managing The Variety Of PDPs Operational Complexity From Multiple Formularies, Exceptions, Processes, Forms ü Variety Is The Enemy Of Quality ü What Can Facilities Convey And Not Convey ü Our Residents Are Challenged To Choose ü 9
Medicare Modernization Act of 2003 Issues For Facility Operators Pharmacies Ability To Contract Widely Ø If Not Contracted Widely, Who Pays For Non. Covered Meds? Ø If Not Contracted Widely, How Are Residents Moved to Contracted Plans Given Marketing Guidelines? Forced To Use A Second Pharmacy Ø 75% of Residents Are Cognitively Impaired Ø 10
Medicare Modernization Act of 2003 Issues For Pharmacy Providers 11
Medicare Modernization Act of 2003 Issues For Pharmacy Providers Ø CMS Defined LTC Pharmacy Standards 24/7 Coverage ü Delivery ü Special Packaging ü IVs ü Compounding ü Emergency Kits ü Ø Reimbursement for Special Services 12
Medicare Modernization Act of 2003 Issues For Pharmacy Providers Ø PDP Issues ü ü ü ü Identifying The PDPs Ensuring We Are Contracted Reimbursement Ensuring Formularies Are Reasonable For Pharmacy And Nursing Center Residents Access To Medically Necessary Medications Operational Complexity, Current Medicaid Times XX Multiple Organizations To Police And Policing You 13
Medicare Modernization Act of 2003 Issues For Pharmacy Providers Ø PDP Issues ü ü They Are Not Medicaid They Do Not Understand Our Industry Or Our Residents Needs (IVs, Immediate Need, Acuity) Contracting With Any Willing Provider Does Not Mean Equal Terms Will CMS Ensure They Follow The Rules Educating Customers And Residents Ø Ensuring Residents Have Coverage Ø 14
Medicare Modernization Act of 2003 Summary LTC Facilities Look To Their Pharmacies To Deal with Pharmacy Related Issues Ø Substantial Additional Burden Is Being Placed On the Facilities And Pharmacies To Manage The Complexity Of Many Plans Ø The Paradigm Shift May Decrease The Benefits Offered To Many Residents Ø CMS Marketing Guidelines Do Not Reflect The LTC Environment Ø 15
Medicare Modernization Act of 2003 Summary CMS Wanted To Increase Competition And Lower Cost In LTC Pharmacy Ø Contracting With PDPs Has Created A Multi Tier Reimbursement Structure That Favors Larger Pharmacies, Long Term That May Decrease Competition Ø Overburdened Nursing Centers Will Have More Responsibility For Pharmacy And More Work To Do Without Additional Financial Resources Ø 16
Medicare Modernization Act of 2003 Questions ? ? ? 17
Medicare Modernization Act of 2003 Thank You !!! 18
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