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Medicare Part D

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by

Betty Brickhouse

on 5 October 2012

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Transcript of Medicare Part D

Medicare Part D How Medicare Part D works:
a brief overview Voluntary insurance that Medicare
beneficiaries can purchase to help
cover the costs of prescription drugs Only offered by private
insurance companies Beneficiaries are responsible
for deductibles, monthly premiums
and copayments Involves a large coverage gap known as the
"donut hole", where you continue paying
monthly premiums but are also required
to cover substantial costs for your prescriptions You may join a stand alone Part D plan and continue
to receive medical coverage through Original Medicare
or join a private insurance Medicare Advantage Plan, which provides all of your Medicare benefits, including prescription drug coverage Fine Print Voluntary....but You must have part A and/or part B Medicare After initial enrollment period (7 month period surround the month your Medicare begins) you may only enroll during the AEP Oct 15- Dec 7 (with some exceptions) There is a penalty of 1% of the average premium per month (.31 in 2012) that you were eligible for part D but were not enrolled in a part D plan and did not have “creditable coverage” from an employer.(with some exceptions) Only private insurance companies can offer Part D plans (with LOTS of rules...)

30 plans available in Virginia, tightly regulated•



Formularies:



"tiers" of drugs, which determine how much you will pay for each drug .
All plans must cover at least two drugs from each therapeutic class of drugs. In addition, plans must cover a number of drugs in certain classes:
antidepressants;antipsychotics; anticonvulsants; antiretrovirals; anticancer drugs; and immunosuppressants . Beginning in 2013 barbiturates (for epilepsy, cancer, chronic mental disorders) and benzodiazepines will be covered. deductibles, monthly premiums and copayments •plans may not impose a higher deductible ($325 in 2013) or require a higher out-of-pocket limit ($4,750 in 2013) than required by the standard benefit.
•The monthly premiums will average about $30 per month in 2013 (or an annual total of about $360).
•The deductible for 2013 is $325 per year.
•The beneficiary then pays 25 percent of the cost of the next $2,970 in qualified drug expenses (in other words, $742.50 in out-of-pocket costs). list of covered drugs, including both brand-name and generic drugs. •you may request an exception:
if you are using a drug that isn't on your plan's formulary, or
if your doctor prescribes a drug not on the formulary because she believes the drugs on the formulary will not work for you or
for many plan coverage rules: copayment tiers, prior authorization requirements, "step therapy" requirements and dose restrictions • "utilization management tools:"


•CMS requires the plans to post their utilization management rules on their websites by mid-November.

•Prior authorization: A requirement to contact the plan to obtain permission before a prescription is filled. Most often, you must ask your doctor to contact the plan.

•Step therapy: A requirement to try a lower-cost drug before a more expensive one is approved for coverage.

Quantity limit: A limit on the quantity of drugs that can be dispensed at one time. Frequently, this is less than a month's supply. Donut Hole •Next, the beneficiary falls into what is known as the "donut hole" or coverage gap.





In 2013, beneficiaries pay 47.5 percent of the cost of brand-name drugs and 79 percent of the cost of generic drugs .
The Affordable Care Act phases out the donut hole completely by 2020. As a result, beneficiaries will pay a smaller and smaller percentage of the costs for brand-name and generic drugs each year .





•Once total spending for the beneficiary and the plan equals $6,733.75, catastrophic coverage begins
beneficiary pays either five percent of qualified costs, or a copayment of $2.65 for a generic or preferred drug and $6.60 for other drugs, whichever is greater, for the remainder of the year. Original Medicare and Medicare Advantage plan •Two ways to get a Part D plan. Original Medicare Part A Hospitalization and Part B Medical. Or Advantage plan, which is medical, hospitalization and Part D in a package administered by a private health insurer.



Fast Facts About Medicare
Number of People Receiving Medicare (2010):
Total Medicare beneficiaries
• Aged
• Disabled47.5 million
• 39.6 million
• 7.9 million
Part A (Hospital Insurance, HI) beneficiaries
• Aged
• Disabled47.1 million
• 39.2 million
• 7.9 million
Part B (Supplementary Medical Insurance, SMI) beneficiaries
• Aged
• Disabled43.8 million
• 36.7 million
• 7.1 million
Part C (Medicare Advantage) beneficiaries11.7 million
Part D (Prescription Drug Benefit) beneficiaries34.5 million
Medicare Eligibility:
Individuals ages 65 and over, who are eligible for Social Security payments
Individuals under 65 with a disability, who receive Social Security cash payments
People of all ages with end-stage renal disease
Average Benefit per Enrollee (2010):
Total: $11,762
Part A: $5,187
Part B: $4,786
Part D: $1,789 Fast Facts About Medicare
Number of People Receiving Medicare (2010):
Total Medicare beneficiaries 47. 5 million
• Aged 39.6 million
• Disabled 7.9 million
Part A beneficiaries 47.1 million
• Aged 39.2 million
• Disabled 7.9 million


Part B beneficiaries 43.8 million
• Aged 36.7 million
• Disabled 7.1 million

Part C (Medicare Advantage) beneficiaries11.7 million

Part D (Prescription Drug Benefit) beneficiaries34.5 million

Medicare Eligibility:
Individuals ages 65 and over, who are eligible for Social Security payments
Individuals under 65 with a disability, who receive Social Security cash payments
People of all ages with end-stage renal disease



Average Benefit per Enrollee (2010):
Total: $11,762
Part A: $5,187
Part B: $4,786
Part D: $1,789 Fast Facts About Medicare
Number of People Receiving Medicare (2010):
Total Medicare beneficiaries 47. 5 million • Aged 39.6 million
• Disabled 7.9 million
Part A beneficiaries 47.1 million
• Aged 39.2million
• Disabled 7.9million Part B beneficiaries 43.8 million • Aged 36.7 million • Disabled 7.1 million Part C (Medicare Advantage) 11.7 million Part D (Prescription Drug Benefit) 34.5 million Medicare Eligibility:Individuals ages 65 and over, who are eligible for Social Security paymentsIndividuals under 65 with a disability, who receive Social Security cash paymentsPeople of all ages with end-stage renal diseaseAverage Benefit per Enrollee (2010):Total: $11,762Part A: $5,187Part B: $4,786Part D: $1,789 utilization management tools Formularies Exceptions Benefit per Enrollee (2010):Total: $11,762
Part A: $5,187
Part B: $4,786
Part D: $1,789 Extra Help

Administered through Social Security, Extra Help (or LIS, low income subsidy) is designed to make prescription medications affordable to low income beneficiaries. For people with incomes between 136% and 149% of poverty level there is a sliding benefit:

• 25% premium subsidy and 15% copay after $63 deductible 146-149% ($1315-1361 per month)
• 50% premium subsidy and 15% copay $63 deductible 141-145% ($1270-1316 per month)
• 75% premium subsidy and 15% copay $63 deductible 136-140% ($1225-1270 per month)
• Full premium subsidy, $2.65 generic or $6.60 brand copay 135% and under ($1224)
• All with assets below $13070
• Under $722 a month 80% of poverty is Medicaid eligible or “dual eligible” Extra Help LI Net
Limited Income Newly Eligible Transition Program
Administered by Human
temporary program which covers prescription drugs for people who are newly eligible for Extra Help, but not yet enrolled in a part D prescription drug plan.
LI NET Program provides retroactive coverage for new LIS and dual eligibles.
individuals are covered by the LI NET Program temporarily while Medicare enrolls them into a standard Medicare Part D plan for the future.
Under the LI NET Program, Humana will not reverse claims to pharmacies for beneficiaries who could not be confirmed as eligible for either Medicaid or extra help. Instead, Humana will send a notice to the affected individuals (an “Evidence of Eligibility” letter), requesting that they either provide proof that they qualify for Medicaid or extra help, or reimburse the LI NET Program for the costs of the claim(s). How to determine eligibility for LINET: Any of the following items are considered acceptable forms of evidence to establish the beneficiary’s eligibility for Extra Help or LIS:
Any documentation provided by the state showing Medicaid status in effect any month after June of the previous calendar year
A letter from Social Security Administration (SSA) showing that the individual receives Supplemental Security Income (SSI)
For individuals who are not deemed eligible but who apply for, and are awarded, the LIS by the Social Security Administration, a copy of one of the following letters will suffice as verification of the individual’s eligibility for the LIS:
SSA award letter or notice of change. And that, my friends is
Full transcript