The Medicare Drug Benefit What Is It and

The Medicare Drug Benefit: What Is It and What Does it Mean for Mental Health? Get Educated, Get Enrolled An NMHA Medicare Rx Benefit Campaign © 2005 National Mental Health Association

Today We’ll Learn About… l l l New Medicare Drug Benefit Basics Impact on Dual Eligibles Enrolling in the New Benefit Program Extra Help for People with Low Incomes Access to Mental Health Medications Exceptions and Appeals

Medicare Drug Benefit Basics l Medicare now will offer insurance to help people pay for prescription drugs l This is a voluntary program – you must choose to sign-up l This will be available to all people enrolled in Medicare, including: – – – l People with Medicare and Medicaid (called dual eligibles) Other low-income Medicare recipients General Medicare recipients Begins January 1, 2006

Mental Illness Is Real to People on Medicare l l 37% of older adults show signs of depression when they visit their primary care physician Older adults have the highest rate of suicide of any age group in the country Over half of all under-65 Medicare recipients with disabilities have problems with mental functioning. 38% of dual eligibles (approximately 2. 5 million people) have a mental or cognitive impairment (Med. PAC, 2004).

How the New Drug Benefit Works l Private insurance plans will cover prescription drugs: – – l l Prescription Drug Plans (PDPs) only offer the Medicare drug benefit Medicare Advantage Prescription Drug Plans (MA-PD) are managed care plans (e. g. , HMOs) offering comprehensive health care services (including drug benefits) Each plan will have its own formulary (list of drugs) listing which drugs are covered At least two plans will be offered in each region.

Key Dates l May-August 2005: Government Letters Sent – – – l l September 2005: Approved Plans Announced October 2005: Information regarding plan options available – – l l SSA Extra Help applications sent to individuals under 150% FPL Extra Help Applications now accepted by mail/online. Apply Now! CMS mailed letters to duals to inform them of the new benefit and extra help they will receive Plan Finder available on www. medicare. gov Letters to dual eligibles regarding auto-enrollment sent November 15, 2005 - May 15, 2006 – Initial enrollment period January 1, 2006 – Medicare Rx benefit begins – Medicaid prescription drug coverage for dual eligibles ends

Cost of the Basic Benefit Costs for General Medicare Population: l Estimated $32 a month premium (in addition to Part B) l $250 annual deductible l 25% of drug costs between $250 and $2, 250 annually l 100% of drug costs between $2, 250 and $5, 100 (known as the “doughnut hole”) annually l “Catastrophic benefit, ” above $5, 100 in total drug costs, greater of: – – 5% of drug costs; or $2 for generics and $5 for brand drugs

Medicare Rx Benefit and Dual Eligibles l l l People with both Medicare and Medicaid coverage are “dual eligibles. ” Duals are automatically enrolled in a prescription drug plan but may choose a different plan. As of Jan. 1, 2006, Medicare will pay for prescription drugs. Medicaid drug coverage for dual eligibles will end.

Benefit Costs for Dual Eligibles l l No premiums or deductibles $1 -$5 co-payments No doughnut hole in coverage No co-payments for drug costs over $5, 100

Enrollment for Dual Eligibles l l l October 2005: Letters from CMS will notify duals about automatic enrollment in a plan with lowest premium in their area. Duals can sign up for plans with premiums higher than $32 per month, but must pay difference of premium. All Duals can switch plans up to once a month.

Enrollment for Everyone Else l l New drug benefit is voluntary October 2005 - information regarding plan options will be available Initial enrollment period: Nov. 15, 2005 – May 15, 2006 Enroll by applying to private plans offering coverage in your area

Late Enrollment l Penalties apply if you wait to sign up after deadline and do not have comparable drug coverage in the mean time. – l Premiums increase by 1% for every month without coverage after May 15, 2006 No penalties if you have comparable drug coverage through other sources: – – – Former or current employers Veteran’s, military or federal benefits Private individual insurance

Extra Help for Low-Income People l Under 135% of poverty and minimal assets: – – l No premiums or deductible $2 -$5 co-payments No “doughnut hole” or gap in coverage No co-payments for drug costs over $5, 100 Under 150% of poverty and minimal assets: – – – Premiums on a sliding scale $50 deductible 15% co-payment on drug costs up to $5, 100 No “doughnut hole” or gap in coverage $2 -$5 co-payments for drug costs over $5, 100

Enrollment for Low-Income People Enrollment is a two step process. 1. Apply for Extra Help through Social Security Administration or State Medicaid agency, except: l l 2. If you receive full Medicaid or Medicaid assistance with Medicare premiums or co-payments, you will receive assistance automatically If you receive Supplemental Security Income (SSI), you will receive assistance automatically Sign up for the drug benefit itself by applying to private plans offering coverage in your area – no later than May 15, 2006.

Access to Mental Health Medications l l l Minimum requirement to cover two drugs per class CMS guidance states a “all or substantially all” drugs must be covered in six categories including antipsychotics, anti-depressants, and anti-convulsants Some drugs are excluded from coverage e. g. , benzodiazepines, barbiturates, and drugs to treat anorexia – State Medicaid programs may still cover these medications and receive federal matching funds.

Access to Mental Health Medications l Plans may change formularies to remove drugs or change co-payments with: – – – l 60 days notice to affected prescribers and CMS; AND 60 days notice to affected enrollees, OR 60 -day supply of the drug Utilization management – – Tiered co-pays and prior authorization may apply Step therapy (for new patients)

Exceptions and Appeals l l l Private plans offering new drug benefit must have process to allow exceptions to tiered cost-sharing and to lists of covered drugs (formularies) Prescribing physician must file statement supporting the exception request The plans determine criteria for granting exception and for determining medical necessity

Exceptions and Appeals l l l Process does not start until consumer requests formal determination or exception regarding coverage of a drug (or co-pay) Many levels of appeal Consumer does not have an external review until the 3 rd level of appeal (may be up to 17 days after initial appeal)

Key Dates l May-August 2005: Government Letters Sent – – – l l September 2005: Approved Plans Announced October 2005: Information regarding plan options available – – l l SSA Extra Help applications sent to individuals under 150% FPL Extra Help Applications now accepted by mail/online. Apply Now! CMS mailed letters to duals to inform them of the new benefit and extra help they will receive Plan Finder available on www. medicare. gov Letters to dual eligibles regarding auto-enrollment sent November 15, 2005 - May 15, 2006 – Initial enrollment period January 1, 2006 – Medicare Rx benefit begins – Medicaid prescription drug coverage for dual eligibles ends