Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Roy Trudel, CMSO National Eligibility Workers Association 07/12/05.

MMAMedicare Modernization ActPL 108-173 Most sweeping reform since program

inception Incredibly short timeframes to

implementation New partnerships between Medicare and

Medicaid, SSA and States New ground for Medicare – “means

testing!”

MMA

Title I

Medicare Prescription Drug Benefit

Medicare-Approved Drug Discount Card

MMA

We will cover….

A (very brief) mention of the drug card A Part D Overview A look at the Low Income Subsidy State roles and responsibilities

Medicare ApprovedDrug Discount Card

Help for many people with Medicare

REAL discounts on prescription drugs

Voluntary Program

Bridge to Part D Prescription Drug benefit

Medicare ApprovedDrug Discount Card

Enrollment began on May 3, 2004

Discounts began June 1, 2004

Program sunsets on December 31, 2005 (or whenever Part D kicks in…)

So much for the drug card . .

. . . on to Part D!

Part D Medicare Prescription Drug Plans Effective: January 1, 2006 Called “Medicare Prescription Drug

Plans” – MPDPs (v. Part D) Eligibility?

• Must be entitled to Part A or enrolled in Part B

(Have Medicare Card)

Part DMedicare Prescription Drug Plans Enrollment for Part D

• Voluntary

• Medicare beneficiaries who opt for Part D must actively choose a plan

Part DMedicare Prescription Drug Plans

If enrolled in fee-for-service Medicare Receive Part D benefits through a Prescription

Drug Plan (PDP)

If enrolled in Medicare Advantage (MA) Plan Receive Part D benefits through Medicare

Advantage Prescription Drug Plan (MA-PD)

Standard Medicare Drug Benefit

Benefit (Rx costs)Beneficiary

TrOOP

Monthly PremiumAverages

$37/month

Annual Deductible ($0-$250) $250

Initial Rx Benefit ($250-$2,250)$500 (25%

coinsurance)

100% Coinsurance ($2,250-$5,100) $2,850

Catastrophic Benefit Period (>$5100)

Greater of 5% or $2 after $3,600

spent above

Dual Eligibles

Medicare Beneficiaries

Who receive some or all Medicaid Benefits

Full Benefit Dual Eligibles

Medicare beneficiaries

With full (comprehensive) Medicaid benefits

Full Benefit Dual Eligibles Coverage Under Part D

As of January 1, 2006, there will be no Medicaid match available for prescription drugs States provide to full benefit duals

other than “excludable drugs”(weight loss and certain psych drugs) not covered by Medicare

Full Medicaid Benefits

Full BenefitDual EligiblesCoverage under Part D

Critical for States and CMS to help full benefit dual eligibles (FBDE) transition to Part D plan

Good transition to talk about the Low Income Subsidy…..

Low Income Subsidy Assistance

Low-income Medicare beneficiaries

Extra assistance with premium and cost sharing under the new drug benefit.

Low Income Subsidy (LIS)AssistanceFederal Help in Paying

Deductibles Premiums Co-payments Coinsurance

Note – these are forms of “cost sharing”

Low Income Subsidy Assistance

Certain groups (deemed) are automatically eligible for a subsidy.

Low income subsidy “applicants” (undeemed) will have to “apply” and meet an income and asset test.

Eligibility determinations? SSA or the State Medicaid Agency

Low Income Subsidy - Process

Important!

For LIS Beneficiaries, it’s a 2-step process!

1. “Apply” for LIS2. “Enroll” in MPDP

Low Income Subsidy Eligibles – Who are those guys?

Mechanism Subsidy Group Subsidy Category

Deemed by law

FBDEs at or below 100% FPL

Full subsidy eligible – lowest co pays ($1/$3)

FBDEs above 100% FPL

Full subsidy eligible – nominal co pays ($2/$5)

SSI recipients

Deemed by regulation

Medicare Savings Program Groups (QMB,

SLMB, QI)

Must Apply (Undeemed)

“Applicants”

Other non-dual, low-income beneficiaries

May qualify for 1 of 3 groups: 2nd FSE group above, or 2 other “not-full subsidy” groups

Low Income Subsidy for FBDEs

BenefitTrOOP for FBDEs

@/b 100% FPL over 100% FPL

Monthly Premium $0 $0

Annual Deductible $0 $0

Initial Rx Benefit

($0-$5,100)

$1/$3 co pays $2/$5 co pays

Institutionalized pay $0

100% Coinsurance N/A N/A

Catastrophic Benefit Period >$5100

$0 $0

FBDEs are Treated Specially

Certain duals get lower cost-sharing. < 100% FPL lower co-pays $1 to $3 institutionalized no cost sharing

FBDEs auto-assigned to a plan with opportunity to change plans.

LIS for non-FBDEs

Benefit

TrOOP for non-FBDEs

Below 135% FPL & limited resources

Below 135% FPL & higher resources

Below 150% FPL & higher

resources

Mon. Premium $0 $0 Sliding Scale

Annual.Deduct $0 $50 $50

Initial Rx Benefit

$2/$5

co paysMax 15% coinsur.

Max 15% coinsur.

100% Coinsur. N/A N/A N/A

Catastrophic Period >$5100

$0 $2/$5 $2/$5

What is the process for deeming?

States

SSA

Identify FBDEs, MSPs

Some overlap

Identify SSI/Medicare recipients with no Medicaid

Notices sent, “You are eligible!”

Low-Income Subsidy SSA & State Roles

Both States and SSA are required to make low income subsidy eligibility determinations.

Both States and SSA are also required to conduct redeterminations and appeals of denials of eligibility.

Given similar roles, coordination will be necessary.

CountableIncome

Compare to

IncomeStandard

Based on FPL for size of the familyUse SSI rules

When applying for LIS, how is income considered?

CountableResources

Compare to

ResourceStandard

2 types of standard:

Full Subsidy = < 3 x SSI limit ($6k individual, $9k couple)

Other Low-income Subsidy = Alternate standard (<$10k individual, < $20k couple)

When applying for LIS,how are resources counted?

Phased Down State Contributions

States make monthly payments to Medicare for a portion of the drug expenditures for dual eligibles (state contribution).

The contribution will based on a state’s own per capita spending for dual eligibles

By no later than October 15, 2005 and October 15 of each succeeding year, the Secretary will notify the states of their per capita amount

Questions to: [email protected]

Rulemaking Process

Final CMS Rule was published January 28, 2005

Addressed 8,000 comments received on NPRM

SSA’s Proposed Rule on the LIS process published March 4; no Final Rule as of yet.

Wrap-up Part D: State Issues

Low-Income Subsidy Process Coordination Between CMS, SSA &

States Educating beneficiaries Data for Part D phased-down state

contributions Coordination of benefits

Thanks for listening!

Questions?Questions?