medicare prescription drug, improvement, and modernization act of 2003 roy trudel, cmso national...
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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: MMAphasedown@cms.hhs.gov
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?
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