Medicare Modernization Act, Part DPrescription Drug Benefit

Presentation for County Program Administrators

September 1, 2005

Part D Provisions

General Policy Those At or Above 150% of FPL

Between 135% and 150% of FPL

Under 135% of FPL

Dual-Eligible

Annual Premium $35 per month ($20 annually)

Sliding Scale None None

Deductible (person pays in full)

$250 $50 None None

Co-payment 25% for drug costs between $250 and $2,250

100% for drug costs between $2,250 and $5,100

15% for drug costs between $50 and $5,100

$2 - $5 co-pays for drug costs up to $5,100

Under 100% FPL: $1 - $3 copays for drug costs up to $5,100

Above 100% FPL: $2 - $5 co-pays for drug costs up to $5,100

No copays for drug costs over $5,100

Doughnut Hole $2,850 gap in coverage

n/a n/a n/a

Catastrophic Coverage for drug costs over $5,100

5% or copays $2-$5 Co-pays of $2-$5 100% covered 100% covered

Timeline: When It All Happens

Date Action

May 31, 2005CMS will begin sending mailings to Dual

Eligibles and Low-Income subsidy eligible beneficiaries

June 20-30, 2005CMS mails letters to Dual Eligibles

explaining the transition to Part D

July 2005CMS launches discussion phase of

message campaign

July 1, 2005SSA and State Medicaid offices can begin

accepting applications for Low-Income subsidies

October 1, 2005Approved Part D plans can begin

marketing to beneficiaries

Timeline: When It All Happens

October 15, 2005

CMS Web Portal of PDPs and MA-PDs itemizing drug benefits goes live.

Oct 27 – Nov 10., 2005

CMS mails auto-enrollment information to Dual Eligibles

November 15, 2005

Enrollment in Part D Drug Plans Begins

January 1, 2006Medicaid Drug Benefit for Dual Eligible

Ends

May 15, 2006 Initial Enrollment Period for Part D Ends

Nov 15 through Dec 31

Annual Coordinated Election Period (beginning in 2007)

II. Impacts

• On Client

• On County Clinicians

• On County Psychiatrists

• On County Budgets

Client Impacts• Client Awareness. Many of county mental health

clients are isolated and do not have the benefit of family members to help them understand and navigate this process.

• Coverage of PDP and/or MA-PD plans. Formularies. CMS guidance indicates that PDPs

and MA/PDs must cover “all or substantially all” medications in six pharmaceutical classes.

Step Therapy. PDPs and/or MA-PDs may require the use of step therapy prior to authorizing the payment of other medications.

Pharmacies May Not Contract with All PDPs or MA/PDs.

Client Impacts• Client Co-pays and Deductibles. Extra Help Low Income Subsidy May Not Cover All the

Costs. For Medi-Medi clients, the transition period is insufficient. Co-payments create an undue hardship Cost control mechanisms may deny access to current

medications (e.g. step therapy) “Bait and switch” - plans offer generous, inclusive

coverage initially and reduce access through subsequent plan amendments.

• Coverage that Follows Client with Transitions to Other Levels of Care.

Transitional Levels of Care. There may be unintended consequences for transfers to other levels of care such as PHFs, IMDs, Jail, Juvenile Hall, etc.

Impact on Clinician

Increased case management. Educating clientsCross-referencing plan coverage with

psychotropic medication needs/prescriptions. If client is not full benefit dual eligible, but is

Medicare eligible, the clinician will need to help these individuals complete the “Extra Help” Low Income Subsidy.

Continuity of Care. Ensuring plan coverage takes place during transitions to other levels of care.

Impact on County Psychiatrists

Formularies:

Tier 1 is lowest cost sharing• Subsequent tiers have higher cost sharing in

ascending order• CMS will review to identify drug categories that

may discourage enrollment of certain people with Medicare by placing drugs in non-preferred tiers.

• Plan must have exceptions procedures for tiered formularies. Psychiatrists will need to know what the exceptions procedures are. And, each plan may have different exceptions procedures.

Impact on County Psychiatrists

• TAR Process. Knowledge and understanding of TAR process and which drugs will fall under the TAR.

• Medication Coverage Six classes (including antidepressants and

antipsychotics). CMS guidance indicates PDPs and MA-PDs are required to cover “all or substantially all” medications.

Other health conditions may actually define consumer choice of PDPs or MA-PDs.

Knowledge of plan benefits and drug coverage.

Impact on County Mental Health• Increase in staff time for case management, both at the

front end (enrollment) and through the Appeals Process.

• Increase in staff time for administrative functions and problem resolution, including fiscal administration, navigating CMS system, and complaint/resolution process.

• Increase in ER visits due to loss of eligibility and/or difficulty in navigating.

• Depending upon county decisions, resources, and feasibility, counties could potentially be in the position of having to pick up a share or shares of cost.

III. Coordination with Inter-county agencies

• County Welfare “Extra Help” Low Income Subsidy. What

directives do county welfare agencies want county mental health to follow in terms of

enrolling clients in the LIS?

III. Coordination with Inter-county agencies

• County Health Care

Who should be the “lead” in ensuring the client’s PDP/MA-PD plan covers all health medication needs and all mental health needs? What kind of protocol makes sense? What happens when a PCP changes a

client’s health care medication and realizes that the medication is not covered under the client’s current PDP or MA-PD and advocates a change in plan for client? How will county mental health know about this change and how will it impact psychotropic script?

County Inter-agency • County Pharmacies

What role will county pharmacies play?