1. Medicare Part D Cases Module #3
Jayashri Sankaranarayanan PhD
Assistant Professor
Department of Pharmacy Practice,
College of pharmacy
University of Nebraska Medical Center
Phone:
Welcome to the modules on “Medicare Basics, the New Medicare Prescription Drug Coverage, and Beneficiary Modules.” I am Dr. Jayashri Sankaranarayanan, an Assistant Professor from the University of Nebraska College of Pharmacy and will be talking on Medicare Part D Cases in this concluding module on Medicare for the mini-fellowship program administered by the University of Nebraska Geriatrics Education Center.

2. PROCESS A series of modules and questions
Step #1: Power point module with voice overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or take a break
Our process will be to review the topic of Medicare: Basics, the New Medicare Prescription Drug Coverage, and Beneficiary scenarios” on PowerPoint modules with voice overlay. This will be followed by case based questions with answers to explain the right and wrong answers. Then you will have the option to continue with this last module on Medicare part D cases or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed” on the main page of the minifellowship to indicate your completion.

3. Objectives Three module Overview
Upon completion the learner will be able to describe:
The Medicare Program, its eligibility and various health insurance options
The new Medicare D, Outpatient Prescription Drug Benefit in terms of eligibility criteria, the cost benefit structure, drugs covered and enrollment process
Guidance that can be given to the Medicare beneficiaries in various case scenarios
The first module provided an overview of Medicare basics including eligibility criteria and various health insurance options for beneficiaries.
The second module familiarized you with the new Medicare Outpatient Prescription Drug Benefit in terms of its eligibility criteria, the cost-benefit structure of the health insurance plans, drugs covered, and the enrollment process.
Lastly in module three we will review various case scenarios of Medicare beneficiaries that you might encounter in your practice setting and the guidance and direction you can offer to them as health professionals.

4. Decisions for Medicare Beneficiaries, 2006
Enroll in Part D Plan
Traditional Medicare
Medicare Advantage (MA-PD)
No Part D coverage
Part D Prescription Drug Plan (PDP)
HMO (local)
PPO (regional)
Private Fee-for-Service
Apply for Low-Income Subsidy
Dual Eligibles
Social Security Office
Medicaid Office
Meet Income and Resource Test?
A Medicare beneficiary is faced with many decisions in 2006 and every year, regarding their choice of plan (PDP or MA-PD) and their eligibility for low-income subsidies from Medicare. This slide gives a decision tree that can be used by beneficiaries to make decisions on enrolling into a Medicare Part D plan.
(JS; DO YOU HAVE PERMISSION TO USE THE PICTURE? IF FROM CLIP ART IN POWER POINT YOU CAN USE. IF YOU DO NOT HAVE PERMISSION I SUGGEST YOU ADD A PICTURE OF AN OLDER PERSON FROM CLIP ART)
If yes, qualify for:
Below 100% FPL: No premium or deductible, $1/generic Rx, $3/brand name Rx, pay nothing after $5,100 in Rx costs
Below 135% FPL: Subsidy for premium, no deductible, $2/generic Rx, $5/brand name Rx, pay nothing after $5,100 in Rx costs
Below 150% FPL: Subsidy for premium on sliding scale, $50 deductible, 15% coinsurance to $5,100 in Rx costs, $2/generic Rx, $5/brand name Rx after $5,100

5. Medicare Part D Options for Beneficiaries
Medicare Advantage (MA) changes to MA-PD* which has drug coverage (Part D)
Medicare HMO and Others (private fee-for-service plan, preferred provider organizations, provider sponsored organizations)
Traditional Medicare (Part A and B)+ Medigap** (without drug coverage) + PDP (Part D)
Traditional Medicare + Medicaid (“duals” for non Part D drugs) + PDP (for Part D drugs only)
Traditional Medicare (or MA) + retiree plan (only for selected individuals) can consider PDP (or MA-PD) if retiree plan not creditable
* Formerly known as MA without drug coverage / M+ C/ Part C, ** Medigap; Medicare supplemental private insurance intended to fill the “gaps” in traditional Medicare may or may not be sold, issued or renewed on or after 1/1/06
Next Medicare beneficiaries like Jack and Jill have various options as outlined here, after the implementation of Medicare’s new prescription drug coverage of 2006.
JS; NEED SOME DESCRIPTION OF MEDCARE ADVANTAGE
Beneficiaries having Traditional or original Medicare (Part A and Part B) with Medigap or Medicaid have the option to enroll into a PDP plan.
Selected individuals may have Traditional Medicare or Medicare advantage with retiree coverage plan. Still others may have Veterans Administration or TRICARE or FEHBP coverage. Please note that employer union or retiree or Veterans Administration or TRICARE or FEHBP coverage are all considered creditable coverage i.e. actuarially equivalent or as good as or better than current Medicare Part D plans.

6. Medicare Beneficiary Cases
Case Study 1 - Patient without prior prescription coverage enrolling in the standard benefit – enroll to avoid future penalties
Case Study 2a, 2b and 2c - Patient who receive creditable prescription coverage from a former employer (retiree) or other sources (TRICARE/VA).
Case study 3 - Patient without prior prescription coverage qualifying for low income subsidy and enrolling for the low-income benefit
Case study 4 - Patient with prior Medicaid prescription coverage.
Case Study 5 - Patient in a long-term care or assisted living facility
Case Study 6 - Patient in a Medigap plan
Case Study 7 - Patient in a Medicare Advantage plan
We will review seven common cases you will encounter in your practice and what to advice them.

7. Case Study - 1 What are important things for him to know?
John is a senior with no prior prescription drug coverage since he does not take any medications and is in good health. He asks why does he need to enroll into a Medicare Part D plan?
What are important things for him to know?
His current state of no prescription drug coverage is not “Creditable.”
It is in his interest to enroll into a least expensive plan to avoid future penalties on late enrollment and to have some protection from future unanticipated drug expenses incurred.
No automatic enrollment if he does not enroll
Standard benefit (Premium, Out of pocket costs), low income subsidy application process and yearly enrollment dates.
John is a senior with no prior prescription drug coverage since he does not take any medications and is in good health. He asks why does he need to enroll into a Medicare Part D plan?
Things he should know are that his current state of no prescription drug coverage is not “Creditable.” (JS; WHAT IS THE DEFINITION OF CREDITIBLE) THAT IS THAT IN it is in his interest to enroll into the least expensive plan to avoid future penalties on late enrollment and to have some protection from future unanticipated drug expenses incurred. There is no automatic enrollment if he does not enroll now. Also to keep him informed, it might be a good idea to educate John on the standard benefit (Premium, Out of pocket costs), low income subsidy application process and yearly enrollment dates.
JS; I ELIMINATED THE CUSTOM ANIMATION, AS IT DOES NOT WORK WELL IN THE MODULES. ALL THE PICTURE ITEMS I ADDED ARE FROM CLIP ART WHICH IS PUBLIC DOMAIN

8. Case Study - 2a What are important things for him to know?
Jim is a senior with retiree coverage. He asks you about Medicare Part D enrollment decision
What are important things for him to know?
His current plan has to inform whether his current coverage is “Creditable.” If they do not inform him, he has to contact his plan.
If his current coverage is creditable, he can switch later without penalty on late enrollment
No automatic enrollment if he does not enroll
Can supplement with a less expensive PDP but check with retiree coverage administrator before enrolling, because you cannot regain retiree coverage that is dropped or lost
Standard benefit - Premium, Out of pocket costs, and yearly enrollment dates.
Jim has retiree coverage from his employer. Things he should know is that his current plan has to inform whether his current coverage is “Creditable.” If they do not inform him, he has to contact his plan.
If his current coverage is creditable, he can switch later without penalty on late enrollment
There is no automatic enrollment if he does not enroll now. He can supplement with a less expensive PDP, but has to check with retiree coverage administrator before enrolling, because changes due to enrollment into a PDP may make him lose retiree coverage that cannot be regained when dropped or lost. Also it might be a good idea to explain the standard benefit - Premium, Out of pocket costs, and yearly enrollment dates to Jim to keep him informed.

9. Case Study - 2b
Beth is a senior with TRICARE or FEHBP coverage, who asks you about Medicare Part D enrollment decision
What are important things for her to know?
For individuals with current prescription drug coverage through TRICARE, or FEHBP
It is advisable to keep current coverage without any changes, because it is creditable.
However, those with limited income and resources, may qualify for extra help from Medicare.
Contact benefits administrator or FEHBP insurer for information about TRICARE, or FEHB coverage before making any changes.
Beth is a senior with TRICARE or FEHBP coverage, who asks you about Medicare Part D enrollment decision. It is advisable for Beth to keep her current coverage without any changes because it is creditable. However, those with limited income and resources, may qualify for extra help from Medicare. Beth can contact benefits administrator or FEHBP insurer for information about TRICARE, or FEHB coverage before making any changes or enrolling into a Part D plan. If Beth joins a Medicare drug plan after May 15, 2006, but within 63 days of losing TRICARE or FEHBP coverage, in most cases, she will avoid payment penalty.

10. Case Study - 2c
Ed is a senior with VA coverage, who asks you about Medicare Part D enrollment decision
What are important things for his to know?
For individuals with current prescription drug coverage through the VA -
It is advisable to keep current coverage without any changes.
However, those with limited income and resources, may qualify for extra help from Medicare.
Contact the VA benefits administrator for information about VA coverage before making any changes.
VA beneficiaries can enroll in the new Medicare prescription plan in addition to VA benefits for the convenience and choice of getting prescriptions written by non-VA providers and filled by local pharmacies outside the VA system.
It is advisable for Ed to keep his current coverage without any changes because it is creditable. However, those with limited income and resources, may qualify for extra help from Medicare. Ed can contact the VA benefits administrator for information about VA coverage before making any changes or enrolling into a Part D plan.
It will be good for Ed to know that VA beneficiaries can enroll in the new Medicare prescription plan in addition to VA benefits for the convenience and choice of getting prescriptions written by non-VA providers and filled by local pharmacies outside the VA system. Generally, the VA coverage will not pay for medications prescribed by providers or filled by non-VA pharmacies outside the VA system (i.e. those under the new Medicare prescription drug plan).
If Ed joins a Medicare drug plan after May 15, 2006, but within 63 days of losing VA coverage, in most cases, he will avoid payment penalty.

11. Case Study - 3
Jack is a Medicare beneficiary with limited income and resources, who asks about Medicare Part D
What are important things for him to know?
Can apply for low income subsidy anytime using income and resource information
Duals (Medicare + Medicaid) beneficiary (need not apply) while non duals low income and resource beneficiary (need to apply to SSA) and then enroll in a plan too.
Benefit – Premium, Deductible, Co-insurance/Co-payment depends on marital status, family size and federal poverty level (determined by income and resources)
When Jack, a Medicare beneficiary with limited income and resources, asks about Medicare Part D you can tell him that he can apply to Social Security Administration for low income subsidy anytime using his annual income and resource information. Further, duals (Medicare + Medicaid) beneficiary (need not apply) while non duals low income and resource beneficiary (need to apply to SSA) and then enroll in a plan too. If duals didn’t choose to enroll in a plan by December 31, 2005, they are automatically and randomly enrollment into a PDP plan by CMS. Duals have to check whether their medications are covered in the plan they have been auto enrolled into. The no or low premium and deductible, and no or low Co- insurance/Co-payment ($1-5 or 15%) of the new Medicare prescription drug benefit for persons with limited income and resources depends on marital status, family size and federal poverty level (determined by their income and resources). We discussed this in great detail in module two.

12. Case Study - 4
Peggy is a Medicare dual beneficiary, who asks about Medicare Part D benefit for dual eligibles.
What are important things we can tell her?
Dual eligibles (Medicare + Medicaid) automatically qualify for extra help (i.e. low income subsidy and do not need to apply to SSA)
Duals pay no premium or deductible but do have to pay small co-payment, (if they are not living in nursing homes or assisted living facility).
If duals did not choose to enroll in a plan by December 31, 2005, they have been automatically and randomly enrollment into a PDP plan by CMS.
Duals can switch plans monthly and there is no penalty on switching plans
For duals, Medicare covers Part D drugs and Medicaid covers drugs not covered by Medicare Part D
When Peggy, a dual eligible, asks about Medicare Part D you can tell her that she automatically qualifies for extra help (i.e. low income subsidy and do not need to apply to SSA). “Duals” pay no premium or deductible but do have to pay small co-payments, (if they are not living in nursing homes or assisted living facility). If “duals” did not choose to enroll in a plan by December 31, 2005, they have been automatically and randomly enrollment into a PDP plan by CMS. However, “duals” need to check whether their medications are covered in the plan they have been auto enrolled into. “Duals” can switch plans monthly and there is no penalty on switching plans. For “duals”, Medicare covers Part D drugs and State Medicaid will make decisions on continuing to cover drugs that are not covered by Medicare Part D.

13. Case Study - 5
Ted is a Medicare dual beneficiary, who asks about Medicare Part D benefit for persons living in nursing home or assisted living facilities.
What are important things we can tell him?
Dual eligibles living in nursing homes will pay nothing (no premium, no deductible, no co-payment).
Dual eligibles living in Assisted living or Adult Living Facility (ALF) or a Residential Home will pay a small co-payment for each covered prescription drug. However, duals in ALF in Nebraska pay nothing since Nebraska Medicaid will pay their co-payments.
Can take help of an authorized representative to enroll into a plan
If Ted is a dual living in a nursing home, he will pay nothing (no premium, no deductible, no co-payment). If he is a dual eligible living in Assisted living or Adult Living Facility (ALF) or a Residential Home, Medicare required a small co-payment for each covered prescription drug. However, if he is a dual living in an ALF in Nebraska, he pays nothing, since Nebraska Medicaid will pay his co-payments.

14. Case Study - 6
Kate is a Medicare beneficiary with Traditional Medicare and Medigap. She asks about Medicare Part D benefit.
What are important things we can tell her?
Medigap is not considered creditable drug coverage
Better to enroll in a PDP to prevent future penalties
Can choose to keep her Medigap plan without drug coverage, and enroll into a PDP
Cannot have Medigap drug coverage and Part D
Alternately, she can drop Medigap policy and join a Medicare Advantage or other Medicare health plan with prescription drug coverage.
When you meet Kate who has Medicare and Medigap, it is important to inform her that Medigap is not considered creditable drug coverage. It is important for her to enroll in a PDP to prevent future penalties. She can choose to keep her Medigap plan without drug coverage, and enroll into a PDP. She cannot have Medigap drug coverage and Part D. Alternately, she can drop her Medigap plan and join a Medicare Advantage or other Medicare health plan with prescription drug coverage.

15. Case Study - 7
Jill is a Medicare beneficiary with Medicare Advantage plan. She asks about Medicare Part D benefit.
What are important things we can tell her?
She can choose to keep her MA plan and enroll into a PDP from her MA insurance company or other company.
She can switch to a MA-PD plan from MA plan from same or different company if she wants all in one package.
She can switch to the Original Medicare plan and enroll into a PDP
If she does not enroll into a PDP or switch to a MA-PD plan to have creditable coverage, she may incur penalties on later enrollment.
Jill who has Medicare Advantage can choose to keep her MA plan and add a PDP from her MA insurance company or other company. Alternately, she can switch to a MA-PD plan from her current MA plan from same or different company if she wants all in one package. She can switch to the Original Medicare plan and enroll into a PDP. If she does not enroll into a PDP or switch to a MA-PD plan to have creditable coverage, she may incur penalties on later enrollment.

16. References
All Part D cases reviewed here developed by the presenter. The guidance is based on information of CMS fact sheets from website.
This slide gives details on how the cases discussed in this module were developed.

17. (JS: UNLESS YOU HAVE PERMISSION FROM CARTOON AUTHOR TO USE CARTOON, I SUGGEST YOU DELETE THEM AND JUST PUT IN A TEXT SLIDE THAT HIGHLIGHTS THE POINTS YOU MAKE BELOW)
LET’S REVIEW WHAT WE HAVE COVERED. The first module included information on Original Medicare, Medicare Supplement Insurance/Medigap, Medicare Advantage and other Medicare Health Plans, as well as Medicaid and Medicare Savings Programs. The key points will help you educate beneficiaries about the basics of Medicare.
The second module described the new Medicare Prescription drug coverage and resources to help you educate yourself and beneficiaries on enrollment decisions and to keep abreast with the continuous changes with Medicare Part D.
This concluding module was on Medicare Part D cases, to help you guide and direct beneficiaries in various scenarios.
To complete the question for credit for this module, please close out of this module, and advance to the question in blackboard, then answer the question and review the answer. Also to receive credit, please complete the evaluation that follows the question.
I thank you for your attention and hope you will play a major role in the coming months on helping educate beneficiaries make informed decisions. When you work with Medicare beneficiaries now or in the future, please feel free to contact me for any further questions or clarifications.
Add question from word document on Module 3