1 ohio department of aging 2006 medicare prescription drug coverage speaker team joyce aldridge...

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Ohio Department of Aging

2006 Medicare Prescription Drug

CoverageSpeaker team

Joyce Aldridge (419) 382-7060 ext 29Arlene Conaway (330) 896-9172 ext 3010Patricia Palmer (513) 721-1025 ext 657Gary Panek (614) 466-3583

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Today's presentation will introduce to you the new Medicare Prescription Drug Coverage that begins in Jan.

Please follow along as we discuss this program and note the items that may affect you.

Feel free to ask questions.

Welcome!

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Medicare Modernization Act

(MMA)

Enacted by Congress in 2003 Medicare-approved drug

discount card 2004-05 Medicare prescription drug

insurance benefit starts Jan. 1, 2006 Replaces Medicare-approved drug

discounts cards

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Golden Buckeye Card

Yes, continueto use

No, Medicare-approved drug card program will end

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Medicare Prescription Drug Coverage (Part D)

Optional coverage for any person that has Medicare Part A and/or B

Insurance provided by private companies approved by Medicare

Pay monthly premium for benefit Premium will vary by plan and benefits

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Drug Plan Differences

Understand specific plan information Coverage available, monthly

premiums Plan deductibles, co-pays and

limits of coverage Participating pharmacies List of drugs covered by the

plan (formulary)

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“Model” Coverage

Monthly insurance premium Estimated at $32 per month Does not count as out-of-pocket

expense

$250 annual deductible each Jan. 1 Co-insurance

Senior pays 25% of drug costs Co-insurance limit of $2,000 ($500 paid

by senior/$1,500 paid by insurance)

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“Model” Coverage

Coverage gap (“donut hole”) Senior pays all of next $2,850 in

drug expenses ($3,600 total)

“Catastrophic” coverage Once senior has paid $3,600 out

of pocket in year, senior then pays 5% of drug cost, insurance pays 95%

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Medicare Prescription Drug Coverage-

Formulary Minimum of two drugs in each drug

category, except all drugs covered for

Antidepressant Antipsychotic Anticonvulsant Anticancer Immunosuppressant HIV/AIDS

Benzodiazepines and barbiturates not covered in base plan by law

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Late Enrollment Penalty

Penalty of additional 1 percent per month ($ .322) added to premium

No maximum on penalty If don’t enroll by May 15, 2006,

must wait until next open enrollment period (Nov. 15 – Dec. 31, 2006) 7 percent late penalty ($2.25) 12 percent late penalty (~$4.00)

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Enrollment Choices Based on Current

Coverage

Options and choices will vary based on the type of Medicare and prescription coverage you now have

Select a plan or make changes by May 15 (you have 6 months to make a decision and avoid penalty)

Coverage is effective the 1st day of the month following enrollment (but not before Jan. 1)

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If You Have Medicare Only

No current drug coverage

Options

1. Refer to “Medicare & You” book from Medicare

2. You may select an insurance program that is right for you

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If You Receive VAHealth Care Benefits

If VA meets your needs, continue VA coverage

No penalty to change in future Consider Medicare coverage if:

Qualify for extra help (lower co-pays) Nursing home care is not covered by

VA VA services are not convenient for you

Options

1. Refer to “Medicare & You” book

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Creditable Coverage

Coverage is creditable if the value of the coverage equals or exceeds the value of the standard Medicare prescription drug coverage

Any plan with current drug coverage must determine if present benefit is creditable and notify beneficiary by Nov. 15, 2005

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If You Have Current Medigap/Supplement

Policy

You will receive a notice by Nov. 15 from your Medigap provider with specific information about the future of current coverage and available choices

Options1. Review options outlined in letter2. Obtain OSHIIP book explaining plans3. Make decision to continue existing coverage or select new coverage

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If You Have Coverage From Former Employer

or Union

You will receive a notice by Nov. 15 from your Plan Administrator with specific information about the future of current coverage and available choices

Options1. Continue with current coverage2. You may need to select another insurance plan that is right for you

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If you have OPERS,STRS, SERS, OP&F,

HPRS

You will receive notice by Nov. 15 from your Plan Administrator with specific information about the future of current coverage and available choices

OptionsIf your current coverage is creditable, remain in that planIf not, choose a Medicare prescription drug program that best meets your needs.

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If You Have Medicare Advantage or Other Health

Plan

You will receive a notice by Nov. 15 from your current plan provider with specific information about present coverage and available choices

Options1. Continue (or modify) current

coverage2. Select another insurance program

that is right for you

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If You Have Medicaid and

Medicare

You will be notified by ODJFS of options Will be automatically enrolled in a plan

but may select different plan by Dec. 31 Drugs not covered under Medicare will

continue to be paid for by Medicaid Coverage starts Jan. 1, 2006

$0 monthly premium, $0 deductible $1 generic/$3 brand name drug co-pays

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People with Special

Circumstances

Medicaid Spend down Medicare Savings Program (QMB,

SLMB, QI-1)

Supplemental Security Income (SSI)

Long-term care facilities PASSPORT or PACE

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People with Medicaid Spend down

Will receive notification from ODJFS as to specific drug options available

Must re-qualify for drug benefit annually

Program covers drugs only For other Medicaid benefits, there

is no change to current process

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For drug coverage, if spend down requirement is met in any one month from Aug. – Nov., 2005, you will automatically receive drug coverage Jan. 1 – Dec. 31, 2006

Otherwise, beginning after the month when you first meet spend down requirement in 2006, you will be enrolled for drug coverage for the balance of current year

People with Medicaid Spend Down

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People with Medicare Savings Programs (QMB, SLMB, QI-1) or

Supplemental Security Income (SSI)

Will receive a letter from Medicare in early summer explaining changes and options available to you

May select a plan If you don’t choose a plan by May

15, you will be automatically enrolled (tentative) in a plan effective June 1

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People in Long-term Care Facilities

Dual-eligibles (70%) – same benefit as people with Medicaid but $0 co-pays after one full calendar month

Full pay (30%) – same options as people with Medicare Can apply for extra help May choose insurance provider

Find a plan that includes the LTC pharmacy that is providing dispensing services in the facility

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People with PASSPORT or PACE

Dual-eligibles will receive standard Medicare-Medicaid benefit

People 60-65 with disabilities and Medicaid only will continue to receive current Medicaid benefit (no change)

PACE will have no drug co-pays PASSPORT may have drug co-pays

Co-pays will count toward client liability payments

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Extra Help Program

Special program to help lower the high cost of drugs for seniors with modest means Seniors on fixed incomes No price controls on drugs

Need to apply today for extra help

More than 30% of Ohio seniors qualify for this extra help

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Help for People with Limited Income and

Resources

Program helps pay cost of insurance $0 monthly premium $0 deductible Prescription co-pay of

$1-3 generic or $3-5 brand name drug

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Qualifications Monthly income below $1,077

(single) or $1,443 (married and living with spouse)

Resources below $11,500/$23,000 House and car not included Savings, investments, stocks are

included Tremendous benefit for those living on

Social Security alone or that have only a modest income!

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Other Help for Greater Incomes

Special program for people with monthly incomes of$1,078 to $1,196 single, $1,444 to $1,603 couple

Resources below $11,500/$23,000

Benefit Partial premium payment $50 deductible You pay 15% of drug costs

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Significant money can be savedon buying drugs!

Drug company patient assistance programs may end for seniors Old program qualification –

Medicare-eligible New program qualification –

not Medicare-eligible

Why Apply?

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Extra HelpApplication Process

Must apply to receive extra help!! 4 page questionnaire, 16 questions Application form available from

local SSA office, or call 1-800-772-1213

Apply on-line at www.SSA.gov SSA will notify you of approval or

disapproval

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Extra HelpApplication Process

Children, grandchildren and others can assist with completion of application - no need for legal Social Security representative to fill out application form

Encourage others that you know to fill out application

When in doubt, fill it out!

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Extra HelpSelect a Plan

After submitting application for extra help and receiving approval, still need to select a plan

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Choosing a Part D Plan

What do you do next?

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What To Do NextPlan Selection

Process

Write down list of all medications you take including name, dosage strength and quantity

Locate Medicare card Call 1-800-Medicare to order a

report of actual plan costs using your specific drug information (available 24 hrs a day and 7 days a week)

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Review report and select plans with features important to you

Refer to explanations found in “Medicare & You 2006” book from Medicare

Compare top plans and benefits and decide what is best choice for you

What To Do NextPlan Selection

Process

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Don’t feel rushed or pressured to enroll

Complete enrollment materials for selected plan Application form company/agent 1-800-MEDICARE and OSHIIP

can help you enroll over phone Internet

What To Do NextPlan Selection

Process

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Fraud Prevention

Don’t sign anything until you have had a chance to review all options and discuss with those you trust

Protect personal information and Medicare number No door-to-door solicitation No payment over phone or internet

Report suspected fraud (1-800-MEDICARE)

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Consumer Resources –Web-based Information

Tool

Available at www.Medicare.gov Also available by calling 1-800-

MEDICARE Compare different plans and

coverages side-by-side No personal information needed

to get basic information on all plans Authentication of user needed to

customize information or enroll

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Consumer Resources – General

Information www.GoldenBuckeye.com/Medica

reRx/ “Medicare & You 2006” book

1-800-MEDICARE (1-800-633-4227)

24 hours a day, 7 days a week www.Medicare.gov

OSHIIP – Dept. of InsuranceOhio Senior Health Insurance Information Program

1-800-686-1578 M-F, 7:30 am to 5:00 pm

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Benefits Check-Up Free easy to use web site to identify

potential benefits available to seniors and people with disabilities

Local, county, state, national programs More than 1,300 different programs

drugs, heating, rent, meal services, nutrition, legal matters, medical costs, property tax rebates, Veteran’s benefits

Medicare Prescription Drug Program info www.BenefitsCheckUp.org

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Aging Network Resources

www.GoldenBuckeye.com/MedicareRx/ Centers for Medicare & Medicaid Services

www.cms.hhs.gov/partnerships

Access to Benefits Coalition

www.accesstobenefits.org/Helpful%20Resources/Tools%20You%20Can%20Use/default.aspx

SSA Information for Organizationswww.ssa.gov/organizations/medicareoutreach2

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Questions?

Golden Buckeye Program

Available to OH residents 60+ and persons with disabilities (18-59)

Automatically sent on birthday 18,000+ merchants state wide Provides discount drug card

benefit

Golden Buckeye Prescription Drug

Program

Helps people who pay out-of-pocket for prescriptions

24.5% / $12.84 average savings

$28 M direct savings for seniors 2,100+ harmful interactions ID Savings 78% of time Plan will continue in 2006

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Pharmacy Co-payment

“Pharmacies are permitted to waive or reduce cost-sharing amounts provided they do so in an unadvertised, non-routine manner after determining that the beneficiary in question is financially needy or after failing to collect the cost-sharing amount despite reasonable efforts.” (CMS Q&A #5115)

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“Model” Coverage

Insurance plans may provide you a benefit that costs Medicare the same amount it would have paid using the “Model Coverage”