1. Medicare Part D Symposium Thursday, September 1, 2005 Sacramento, CA Cathy Senderling Senior Legislative Advocate, CWDA

2. Overview  Part D Basics  Enrollment Options  How Plans Will Work  Cost Sharing  “Extra Help” Program  Potential Impacts and Issues

3. Part D Basics  Creates new prescription drug coverage program for Medicare  Eliminates state matching funds under Medicaid program  Shifts those funds to the new Medicare program

4. Part D Basics  All Medicare beneficiaries eligible Different rules for different groups  Coverage begins January 1, 2006 Enrollment Nov 15 ’05 to May 15 ’06 Some individuals automatically enrolled  Low-income beneficiaries can receive “Extra Help” (a.k.a. Low Income Subsidy) Different rules for different groups

5. Enrollment Options  Most beneficiaries must choose and enroll in a drug plan to get coverage Prescription drug plans (PDPs) Medicare Advantage plans (MA-PDs) Some employers/unions for retirees  Some will be auto-enrolled in a plan Duals – on Nov 15 ’05 QMB/SLMB/QI-1 – on May 15 ’06

6. Enrollment Options (cont.)  People with Medicare can enroll: Directly with a plan Through a personal representative  Has authority to act on their behalf  I.E., Power of Attorney, Public Guardian By asking others to help them  Spouses, friends, relatives  Caregivers  Advocacy groups

7. Enrollment Options (cont.)  If in Program for All-Inclusive Care for the Elderly, must get coverage from PACE program  Special rules when a person: Permanently moves to another area Enters/leaves a long-term care facility Involuntarily loses coverage or coverage is reduced  Some can choose not to enroll at all, but there are consequences to waiting Increased premiums (1% increase per month) Applies when moving from coverage that is not as good as the Medicare coverage

8. Enrollment Options (cont.)  Dual-Eligibles will be impacted Medicare will now pay for drugs (not Medi-Cal) Can choose a plan or will be automatically enrolled on Nov 15 ’05 Can change plans after autoenrollment Medi-Cal will pay for some non-covered prescription drugs  QMB/SLMB/QI-1 also impacted

9. Enrollment Options (cont.)  If enrolled between Nov 15 ’05 and Dec 31 ’05 – Coverage will begin on Jan 1 ’06  If enrolled between Jan 1 ’06 and May 15 ’06 – Coverage begins on first day of month following the month in which they enroll

10. How Plans Will Work  Must offer a basic drug benefit “Standard” benefit  May offer supplemental benefits “Enhanced” benefits  Can be flexible in benefit design Example: Enhanced benefit might give coverage where it would otherwise not be provided (i.e., reduce out-of-pocket)

11. How Plans Will Work  Requirements Must process applications timely Must notify of acceptance/denial Will track participant deductibles Must have formularies approved by CMS  Marketing to beneficiaries May begin marketing in October ’05 Must follow marketing guidelines

12. Cost Sharing for those >135% FPL  Premiums About $37/month in 2006 Separate from Part B premium Enhanced coverage may cost more  Deductibles $250 annually

13. Cost Sharing for those >135% FPL  Beneficiary Copayment Equals 25% from $250 to $2,250 annually 100% between $2,250 and $5,100 5% starting at $5,100 and thereafter  Coverage Gap Beneficiary pays ALL costs between $2,250 and $5,100 of expenditures Also known as “doughnut hole”

14. Extra Help Program (LIS)  Aimed at those with limited resources Lower co-pays, premiums, deductibles No coverage gap/doughnut hole Must meet both income and asset tests Must live in the United States Must be enrolled in Medicare

15. Extra Help Program (LIS)  Some automatically enrolled by SSA Dual eligibles or “Medi-Medi’s” Medicare Savings Program (QMB/SLMB/QI-1) SSI recipients  Others can apply in-person and on-line Eligibility determined by SSA or state DHS Applications available at county Medi-Cal offices Applications also being mailed out by SSA now Applications available at www.ssa.gov

16. Cost Sharing for those <135% FPL  Premiums None  Deductibles None  Co-Pays $2-$5 for drug costs up to $5,100 None after $5,100 in drug costs

17. Cost Sharing between 135% - 150%  Premiums Sliding Scale  Deductibles $50 annually  Co-Payments 15% for drug costs of $50 to $5,100 $2-$5 after $5,100 of drug costs

18. Cost Sharing for Dual Eligibles  Premiums None  Deductibles None  Co-Payments Under 100% FPL: $1-$3 up to $5,100 Above 100% FPL: $2-$5 up to $5,100 None after $5,100 in drug costs

19. Potential Impacts and Issues  Extra Help application/autoenrollment  Appeal process  Costs to clients and Share of Cost  Potential for changes to formularies  Provider impacts  Impacts across county departments  Interaction with state, federal government, non-profits, advocates

20. Underscore Importance of:  Outreach  Education  Training  Partnerships

21. Questions?