1. NSCLC copyright 20061 LAAC Armchair Training Medicare Part D and Low Income Seniors and Individuals with Disabilities Basic Review & Current Hot Topics for California Advocates Fall 2006 Kevin Prindiville Anna Rich National Senior Citizens Law Center

2. NSCLC copyright 20062 Medicare Part D Basics Medicare Part D: the biggest change in government health care programs in 40 years. Medicaid (Medi-Cal) coverage ended on January 1, 2006 for almost all prescription drugs for elderly and disabled. Medicare Part D replaced Medicaid for all dual eligibles.

3. NSCLC copyright 20063 All Medicare Beneficiaries Both seniors (eligible for Social Security) and individuals with disabilities (eligible for Social Security Disability benefits) Entitled to Part A and/or enrolled in Part B Any income level Any resource level Medicare Part D Basics: Eligibility

4. NSCLC copyright 20064 Medicare Part D Basics: Dual Eligibles Prior to January 2006, these individuals got their Rx from Medi-Cal, with a broad formulary and (usually) no co-pays. Dual eligibles are particularly vulnerable. More than twice as likely as other Medicare beneficiaries to be in fair or poor healh; More than 50% are limited in ADLs; 40 % have mental or cognitive impairments; 25% in Long Term Care; many need multiple prescriptions.

5. NSCLC copyright 20065 Medicare Part D Basics: Benefits Part D plan have discretion to design their benefit packages Must cover at least two drugs per category and class Plans have “preferred” and “non-preferred” pharmacies in their networks. Formularies may encourage use of less expensive drugs through “utilization management” techniques, such as prior authorization, step therapy (aka “fail first”), therapeutic substitution, and quantity or dosage limits. Tiering: generic, preferred and non-preferred.

6. NSCLC copyright 20066 Medicare Part D Basics: Coverage Covers prescription drugs, biologicals, insulin. Formularies must cover “all or substantially all” FDA-approved drugs within six classes: Antipsychotics, antidepressants, anticonvulsants, antiretrovirals, immunosuppresants, antineoplastics.

7. NSCLC copyright 20067 Medicare Part D Standard Benefit 2007 CoverageAnnual Drug Costs: Part D Plan Pays: Beneficiary Pays: PremiumsN/AVaries Deductible$0 - $265$0$265 Initial Limit to Coverage $265-$2,40075% ($1,601.25) 25% ($533.75) Coverage Gap (Donut Hole) $2,400- $5,451.25 $0100% ($3,051.25) Coverage Resumes Over $5,451.2595% of remaining costs Up to 5% of remaining costs

8. NSCLC copyright 20068 Medicare Part D Basics: Enrollment of Dual Eligibles Full benefit dual eligibles are auto-enrolled in a Part D plan; Random PDP assignment; may self-select a different plan 10 LIS plans in California for 2006; 9 for 2007 Can disenroll and chose another plan Dual eligibles can change plans once a month, effective the first day of the month following

9. NSCLC copyright 20069 Medicare Part D Basics: ANOC Annual Notice of Change End of October all beneficiaries will receive an Annual Notice of Change (ANOC) from their Part D plan. The ANOC contains information about changes to the plan (costs, formularies, name, etc.) Beneficiaries should review carefully.

10. NSCLC copyright 200610 Medicare Part D Basics: Transitions All plans supposed to institute transition policy and provide notice to participants. Beginning in 2007, enrollees may obtain a 30 day transition supply within first 90 days of enrollment or negative change to formulary. Long-term care patients have longer transition period.

11. NSCLC copyright 200611 Low Income Subsidy Also known as “Extra Help” and as the “Limited Income Subsidy” Generally handled by the Social Security Administration as well as CMS and state Medicaid offices.

12. NSCLC copyright 200612 Low Income Subsidy Group 1 Full Medi-Cal dual eligibles with countable incomes at or below 100% Federal poverty level (FPL) “deemed eligible” Group 2 Full-Medi-Cal dual eligibles above 100% of FPL; QMB, SLMB, QI, SSI-only, “deemed eligible”; and non-dual eligible beneficiaries with countable incomes below 135% FPL and limited countable resources ($6,000 per individual and $9,000 married couple) “determined eligible” Group 3 Beneficiaries with countable incomes below 150% FPL and limited countable resources ($10,000 individual and $20,000 married couple) “determined eligible”

13. NSCLC copyright 200613 Group 1Group 2Group 3 Premium$0 Sliding scale based on income Deductible $250/year; ($265: ‘07) $0 $50 $53 in ‘07 Coinsurance up to $3,600 out of pocket ($3850: ‘07) $1/$3 copay $1/$3.10 in ’07 $2/$5 copay $2.15/$5.35 in 07 15% coinsurance Catastrophic 5% or copay $0 $2/$5 copay $2.15/$5.35 in 07 Low Income Subsidy

14. NSCLC copyright 200614 Low Income Subsidy Enrollment/Application process is ongoing “Deemed eligible” for LIS: all dual eligibles; and all Medicare Savings Plans participants Receive notices from CMS informing them “Determined eligible” (non dual eligibles or MSP) must apply and be assessed

15. NSCLC copyright 200615 Low Income Subsidy Those who must apply (those who are not dual eligible or MSP) can do so at SSA or County Medi-Cal Offices; or online at http://ssa.gov/prescriptionhelp/http://ssa.gov/prescriptionhelp/ Does it matter where you apply? State State/county duty to screen and enroll MSP programs are undersubscribed MSP people are deemed eligible for LIS Can insist on state processing; using Medi-Cal appeals system SSA Application, outreach, funding incentives No duty to screen and enroll, forward info Appeal rights are different than Medi-Cal system

16. NSCLC copyright 200616 Low Income Subsidy for 2007 Reviewing LIS eligibility for 2007 of those eligible in 2006 Redeeming: those who were “deemed” eligible in 2006 will be reviewed by CMS Redetermination: those who were “determined” eligible by SSA will be reviewed by SSA See guide to Redetermination and Redeeming at: http://www.nsclc.org/areas/medicare-part- d/area_folder.2006-09-28.4596471630

17. NSCLC copyright 200617 Issues for Dual Eligibles Reassignment 5 of the 10 “Benchmark“ plans from 2006 will be available as “Benchmark” plans in 2007 Beneficiaries who want to stay in one of these plans do not need to take any action. 1 plan is within the “de minimis” Sierra Rx: Full-subsidy beneficiaries will remain in the plan with no premium; partial subsidy will be liable for their percentage of the benchmark ($21.03) plus $1.37

18. NSCLC copyright 200618 Issues for Dual Eligibles Reassignment 4 plans no longer exist or have premiums above the “de minimis” AARP Medicare Rx (S5820-031) PacifiCare Saver Plan (S5921-002) United Health Rx (S5820-140) Health Net Orange 008 (S5678-008)

19. NSCLC copyright 200619 Issues for Dual Eligibles Reassignment Those in United plans will be moved to AARP Medicare Rx Plan Saver. Beneficiaries who self-enrolled in Health Net Orange 008 will remain in plan and must pay increased premiums or switch plans. Beneficiaries who auto-enrolled into Health Net Orange 008 will be automatically reassigned to Health Net Orange 002.

20. NSCLC copyright 200620 Issues for Dual Eligibles Special Issues: Emergency Drug Benefit. Can help duals access medications in some circumstances; available until January 31, 2007 1) Medicare system problems or errors; 2) Eligibility/enrollment problems; 3) Co-payments charged in excess of LIS requirement; 4) The plan does not respond to a prior authorization/exception request. EDB Bulletin: http://files.medi- cal.ca.gov/pubsdoco/publications/bulletins/notice/20061103_emerge ncy_0516update.pdf http://files.medi- cal.ca.gov/pubsdoco/publications/bulletins/notice/20061103_emerge ncy_0516update.pdf

21. NSCLC copyright 200621 Exceptions and Appeals Exceptions and appeals process can be used: To obtain “medically necessary” drugs that are restricted by or not on the formulary; or To bypass utilization management, such as the need for prior authorization; or To obtain a prescribed drug at a lower cost sharing rate. Details about limitations periods, timeframes, amount-in-controversy requirements and more in NSCLC’s Guide.

22. NSCLC copyright 200622 Appeal Steps 1. Redetermination by plan; 2. Reconsideration by Independent Review Entity (Maximus); 3. Administrative Law Judge Appeal; 4. Medicare Appeals Council; 5. Federal District Court.

23. NSCLC copyright 200623 Reporting Problems Plans that fail to comply with the requirements for exceptions and appeals processes may be reported to CMS: Central office: prit@cms.hhs.govprit@cms.hhs.gov CMS Region IX: PartDComplaints_RO9@cms.hhs.gov PartDComplaints_RO9@cms.hhs.gov

24. NSCLC copyright 200624 Grievances Complaints not relating to specific coverage determinations E.g., service delays, wait times, phone access, misinformation, marketing practices, failure to meet deadlines, plan structure Timeframe: 60 days to file – oral or written complaint is OK. Plan responds within 30 days Expedited grievances (re failure to process expedited requests)—Plan responds w/in 24 hours Importance of filing grievances

25. NSCLC copyright 200625 Resources NSCLC Tools for Advocates http://www.nsclc.org/areas/medicare-part-d/area_folder.2006-09-28.4596471630/area_folder_view?b_start:int=0 Medicare Part D Exceptions and Appeals, A Practical Guide (NSCLC) Exceptions and Appeals: Summary of Ch. 18 of the CMS Prescription Drug Benefit Manual (NSCLC) Exceptions and Appeals: Model Part D: Exceptions/Coverage Determination Request Form (CMS) CMS Prescription Drug Manual, Ch. 18: Enrollee Grievances, Coverage Determinations and Appeals (CMS) Medicare Part D Manual—Draft of Chapter 6 (transitions) Other Resources Appointment of Representative Form (CMS Form-1696): http://www.cms.hhs.gov/CMSForms/CMSForms/itemdetail.asp?filterType=keyword&filterValue=1696&fil terByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS012207 http://www.cms.hhs.gov/CMSForms/CMSForms/itemdetail.asp?filterType=keyword&filterValue=1696&fil terByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS012207 Patient Assistance Programs (PAP): http://www.rxhope.com/http://www.rxhope.com/

26. NSCLC copyright 200626 Call with questions, problems, send client stories National Senior Citizens Law Center Kevin Prindiville 510 663-1055 ext. 307 kprindiville@nsclc.org Anna Rich 510 663-1055 ext. 303 arich@nsclc.org Copyright 2006 by the National Senior Citizens Law Center. All rights reserved. Permission to copy will be granted to non-profit entities with appropriate acknowledgment of credit. Questions