SeniorCare Prescription drug coverage for Wisconsin residents age 65+ Utilizes rebates with drug manufacturers 1,200 participating pharmacies within the state DHS website: https://www.dhs.wisconsin.gov/seniorcare/information.htm

SrCare Waiver Renewal SeniorCare operates on a waiver approved by CMS The waiver is effective through December 31, 2028. https://www.dhs.wisconsin.gov/seniorcare/input.htm

Basic requirements $30 annual fee Must be 65 years+ No asset test No income limit 4 different benefit levels Renew annually No SEP necessary—enroll anytime!

SeniorCare Creditable coverage (avoids Part D penalty) Alternative or a supplementary to Medicare Part D Help with copays, coinsurance, deductibles, or to cover otherwise uncovered drugs Online formulary available at Forward Health’s website: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Provider/DrugSearch.aspx

How Does Gross Annual Income Determine Benefit Level? SeniorCare will place an applicant in a benefit level depending on the amount of their gross annual income. Levels are 1, 2a, 2b, and 3

SeniorCare Level 1 No deductible Income at or below 160% FPL: $19,984 per individual (under $1,665.33/month) $27,056 per couple (under $2,254.67/month) No deductible Pay $5 and $15 for generic and brand name drugs

SeniorCare Level 2a $500 deductible Income between 160% to 200% of the FPL: $24,980 per individual ($2,081.67/month) $33,820 per couple ($2,818.33/month) $500 deductible During the deductible period, the participant pays discounted SeniorCare rate on most covered drugs. After meeting the deductible: $5 copay on generics and $15 copay on brand name prescriptions.

SeniorCare Level 2b $850 deductible Income between 200-240% FPL $29,976 per individual ($2,498/month) $40,584 per couple ($3,382/month) $850 deductible During the deductible period, the participant pays discounted SeniorCare rate on most covered drugs. After deductible: $5 copay on generics; $15 on brand name prescriptions.

SeniorCare Level 3 Both a spend-down and a $850 deductible Income above 240% FPL Above $29,977 for individuals ($2,498.08/month) Above $40,585 for couples ($3,382.08/month) Both a spend-down and a $850 deductible Pay retail price during spend-down. Pay SeniorCare rate during deductible.

What is a Spend-Down? The amount of the spend-down is equal to the difference between a participant’s gross annual income and 240% of the current FPL. Participants in the spend-down phase pay the retail price on covered drugs. After the spend-down is met, each person will have an individual $850 deductible requirement.

Why have both SeniorCare & Part D? Save $$ Reduce the copay, coinsurance, deductible Part D can provide drug coverage while someone is in the SeniorCare deductible or spend-down phase SeniorCare can provide drug coverage while someone is in a Part D deductible period

Coordination of Benefits Part D is primary and SeniorCare secondary If a particular drug is covered by both Part D and SeniorCare: Part D will pay first If the resulting Part D co-pay to the beneficiary is greater than $5/$15, SeniorCare will pay the difference. (Assuming not in a spend-down or deductible period for SeniorCare.)

Coordination of Benefits If the drug is covered by SeniorCare but not Part D: SeniorCare will cover the cost (assuming no spend-down or deductible period applies). Enrollee will pay the applicable $5/$15 SeniorCare copay. This scenario occurs most often due to the beneficiary having a Part D deductible period or potentially not on the Part D plan’s formulary.

SeniorCare and TrOOP “True Out of Pocket” expenses: expenses that count toward a person’s Medicare Part D out-of-pocket threshold of $6,350 (the 2020 True Out of Pocket threshold). SeniorCare Level 1 or 2a: Only what the member pays counts toward Part D TrOOP SeniorCare Level 2b or 3: Both the payments issued by SeniorCare and the member are applied to the TrOOP amount.

State Pharmaceutical Assistance Program (SPAP) Only Parts 2b and 3 of SeniorCare qualify as a SPAP See definition of SPAP in federal statute 42 CFR 423.464 SeniorCare Parts 1 and 2a do not meet the criteria for a SPAP— excluded because they draw down federal Medicaid matching funds (a section 1115 demonstration program).

Enrollment into SeniorCare Can Generate a Special Enrollment Period

State Pharmaceutical Asst Program (SPAP) SEP Levels 2b & 3 only Allows enrollment into a new plan or to change between plans Enrollment into new plan typically drops old plan automatically Exceptions: (cost plans, PFFS plans)

Other creditable coverage SEP Any level of SrCare One way pass OUT of a Part D plan or Advantage plan with Rx Does not allow a change of plan or enrollment into a new plan

SeniorCare considerations

SeniorCare Easy to use Works alone or with Part D Creditable coverage PROS CONS Easy to use Works alone or with Part D Creditable coverage Low copays & annual fee No coverage gap Counts towards TROOP Does not cover diabetic supplies, i.e. syringes (unless pre-filled) Vaccines are not covered Does not work if on Medicaid People on Medicare Savings Program (MSP) must have Part D as primary No out-of-network coverage: Out of state Hospital observational stay/ER

Non-covered medications Vaccines Prescription drugs administered in a dr’s office Drugs that are experimental or cosmetic OTC drugs such as vitamins and aspirin, even if prescribed by dr except for insulin Prescription drugs for which prior authorization has been denied. Brand name drugs unless medically necessary (per dr) Drugs from manufacturers who have not signed a rebate agreement with the state.

CAUTION Certain people must enroll in a Part D plan as primary to SrCare SeniorCare will not work without a Part D plan if the person is deemed eligible for LIS due to being in a Medicare Savings Program (QMB, SLMB, or SLMB+). SeniorCare remains in place, just requires a primary payer to be billed These cases apparently show up as quasi-Medicaid in the SeniorCare computer system.

CAUTION No drug coverage for out-of-network claims: Emergency room or hospital observational status Most hospital inpatient pharmacies are not in-network No coverage out of state No self-submission of claims

Retroactive Medicaid (Dual Eligibles) A person is not eligible for SeniorCare if on Medicaid Card services LTC Medicaid Medicaid applications may take months to process & be approved Medicaid is often approved retroactively Person is then dis-enrolled retroactively from SrCare Must utilize LINET for drug coverage Should be auto-enrolled into a Part D plan going forward

Retroactive Medicaid (Dual Eligibles) LINET will not work in the following situations: Person opted out of Medicare auto-enrollment Person is already enrolled in a Part D plan Person has employer/retiree coverage Person is in Advantage plan w/o drug coverage CMS Region V (retroactive dis-enrollment from Adv plan or to MA-PD plan) SHIP counselor designation required

SeniorCare FAQ’s Q: Does SrCare cover Novolog that is used in an insulin pump? A: Yes

SeniorCare FAQ’s Q: What if my income was slightly higher than I expected and put on my annual application? A: Annual income is determined prospectively from the month of application through the next 12 calendar months. (Good faith, best estimate.)

SeniorCare FAQ’s Q: What if I retire mid-year and my income is much less than I anticipated? A: A person can submit a new application and $30 fee at anytime to re- establish a new benefit category. Hint: you would only want to do this if you would go down to a lower level of SeniorCare

SeniorCare FAQ’s Q: If my spouse moved to a NH, do I still have to include his income in my application? A: SeniorCare counts the income of both spouses if they live together. Exceptions: One spouse in a NH and expected to remain there for > 30 days, Both spouses are in a NH; Married, but living separately; or Applicant’s spouse is on SSI.

Summary SeniorCare: is creditable coverage can either be used by itself or with Part D coordinates well with Part D does not coordinate with Medicaid works in nursing homes if pharmacy accepts SeniorCare, and if person is not on Medicaid.

SeniorCare resources Medicaid Eligibility Handbook section 33 http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm WI DHS SeniorCare page and link to application https://www.dhs.wisconsin.gov/seniorcare/index.htm WI SeniorCare customer service number 1-800-657-2038