Maximizing the Medicare Drug Discount Card Subsidy Maximizing the Medicare Drug Discount Card Subsidy and Part-D State Implementation Status Update Web-and Part-D State Implementation Status Update Web-

conferenceconference

December 16, 2004 3:30 – 5:00 pm ESTDecember 16, 2004 3:30 – 5:00 pm EST

3:30 – 3:353:30 – 3:35 Dr. Mark McClellanDr. Mark McClellan WelcomeWelcome

3:35 – 3:503:35 – 3:50 Tim Trysla Tim Trysla Moderator, Agenda, Moderator, Agenda, Discount Discount Card Card

3:50 – 4:053:50 – 4:05 Kim Fox Kim Fox State experience with Drug State experience with Drug Card EnrollmentCard Enrollment

4:05-4:204:05-4:20 Michael McMullanMichael McMullan CMS TimelineCMS Timeline

4:20 – 4:354:20 – 4:35 Gale ArdenGale Arden Low Income SubsidyLow Income Subsidy

4:35 –4:504:35 –4:50 Donna BoswellDonna Boswell SPATCSPATC Preliminary Preliminary RecommendationsRecommendations

4:50 – 5:004:50 – 5:00 Any Additional Questions/ Wrap Up Any Additional Questions/ Wrap Up

Dr. Mark McClellanDr. Mark McClellan

WelcomeWelcome

Tim TryslaTim Trysla

AgendaAgenda

Discount CardDiscount Card

Kim FoxKim Fox

State experience with Drug Card State experience with Drug Card EnrollmentEnrollment

Presentation to the Presentation to the National Governors AssociationNational Governors Association

Kimberley Fox, Senior Policy AnalystKimberley Fox, Senior Policy Analyst

Rutgers Center for State Health PolicyRutgers Center for State Health Policy

December 16, 2004December 16, 2004

Maximizing Enrollment in Transitional Assistance: Lessons from Medicare Discount Cards and Other

Low-Income Enrollment Initiatives

AcknowledgementAcknowledgement Presentation based on:Presentation based on: Study of state pharmacy assistance programs funded by Study of state pharmacy assistance programs funded by

The Commonwealth Fund The Commonwealth Fund Telephone interviews in Spring 2004 with 17 states re: Medicare Telephone interviews in Spring 2004 with 17 states re: Medicare

coordination of benefit issues and discount card experience.coordination of benefit issues and discount card experience. Website with more detailed reports: http://www.cshp.rutgers.eduWebsite with more detailed reports: http://www.cshp.rutgers.edu//

Findings from the State Solutions project funded by the Findings from the State Solutions project funded by the Robert Wood Johnson Foundation to maximize Robert Wood Johnson Foundation to maximize enrollment in Medicare Savings Programs enrollment in Medicare Savings Programs (QMB/SLMB/QI1s). (QMB/SLMB/QI1s).

Estimated Percent of SPAP Enrollees Estimated Percent of SPAP Enrollees Eligible for $600 CreditEligible for $600 Credit

Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming.*Includes disabled persons enrolled in state-only program. Enrollees in Illinois’ Senior Care Pharmacy Plus waiver program are ineligible for transitional assistance and the discount card.

0%

20%

40%

60%

80%

100%

Number of States Mandating Enrollment in Number of States Mandating Enrollment in Medicare during Discount Card PeriodMedicare during Discount Card Period

0

2

4

6

8

10

12

14

16

Mandatory Voluntary

Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming.

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s

N=10

States Strategies for Getting SPAP Eligible States Strategies for Getting SPAP Eligible Persons EnrolledPersons Enrolled

Source: Fox, K, Crystal, S. Coordinating Medicare Prescription Drug Benefits with State Pharmacy Assistance Programs. New York, NY; The Commonwealth Fund, publication forthcoming.

0

2

4

6

8

10

12

14

16

Autoenrollment inPreferred Card

FacilitatedEnrollment in

Preferred Card

Autoenrollment inMultiple Cards

VoluntaryEnrollment

# o

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tate

s

State Strategies for Enrolling Members in State Strategies for Enrolling Members in Transitional AssistanceTransitional Assistance

Autoenrollment in Preferred Card (8 states)Autoenrollment in Preferred Card (8 states) Authorized representative statusAuthorized representative status Expedited RFP or Expansion of Existing ContractExpedited RFP or Expansion of Existing Contract Opt-out letters – different methods for response.Opt-out letters – different methods for response. High participation rates in short period.High participation rates in short period. Significant state savings reportedSignificant state savings reported

Autoenrollment in Multiple Cards (1 state)Autoenrollment in Multiple Cards (1 state) Authorized representative statusAuthorized representative status RFI to card sponsors – data sharing agreementRFI to card sponsors – data sharing agreement Opt-out lettersOpt-out letters Start-up delays, file-sharing inconsistenciesStart-up delays, file-sharing inconsistencies High participation rates after 6 months.High participation rates after 6 months. Savings still being determined.Savings still being determined.

State Strategies for Enrolling Members in State Strategies for Enrolling Members in Transitional Assistance (cont.)Transitional Assistance (cont.)

Facilitated Enrollment w/ Preferred Card (1)Facilitated Enrollment w/ Preferred Card (1) Expedited RFP or Expansion of Existing ContractExpedited RFP or Expansion of Existing Contract Pre-populating applicationsPre-populating applications Outcome - ?Outcome - ?

Voluntary Enrollment by Individual Members (6)Voluntary Enrollment by Individual Members (6) Outreach varies.Outreach varies.

Letter to benesLetter to benes Use of SHIPs Use of SHIPs

Outcome – Much lower enrollment rates in states that had data from CMS.Outcome – Much lower enrollment rates in states that had data from CMS. Minimal savings to state.Minimal savings to state. Two states moving to autoenroll or facilitate enrollment due to low Two states moving to autoenroll or facilitate enrollment due to low

enrollment rates. enrollment rates. Many of those enrolled are not using the $600 credit. Many of those enrolled are not using the $600 credit.

Use of Incentives by SPAPs to Use of Incentives by SPAPs to Encourage EnrollmentEncourage Enrollment

State pays all or portion of the 5-10% coinsurance (10 states)State pays all or portion of the 5-10% coinsurance (10 states) Preceded autoenrollment allowance.Preceded autoenrollment allowance. Post autoenrollment maintained to discourage opt-out.Post autoenrollment maintained to discourage opt-out. Outcome – difficult to measure.Outcome – difficult to measure.

Waiving other SPAP requirementsWaiving other SPAP requirements Enrollment feesEnrollment fees Counting $600 toward state deductibleCounting $600 toward state deductible Waiving reapplication for SPAP during discount card period.Waiving reapplication for SPAP during discount card period.

Increasing SPAP BenefitsIncreasing SPAP Benefits Increasing benefit capsIncreasing benefit caps SPAP pays first, discount card used only if state does not paySPAP pays first, discount card used only if state does not pay

Incremental impact of Incentives vs. other approaches unknown.Incremental impact of Incentives vs. other approaches unknown. Most states using incentives were also autoenrolling.Most states using incentives were also autoenrolling.

Lessons from Efforts to Enroll Persons in Lessons from Efforts to Enroll Persons in Medicare Savings ProgramsMedicare Savings Programs

Community-based outreach important Community-based outreach important One-on-one assistance works best, but expensiveOne-on-one assistance works best, but expensive Use of SHIPsUse of SHIPs

Linking outreach/enrollment with other low-income benefit programsLinking outreach/enrollment with other low-income benefit programs Combined outreach for TA, SPAP, and MSPCombined outreach for TA, SPAP, and MSP

Limiting administrative hassles can significantly impact enrollmentLimiting administrative hassles can significantly impact enrollment Simplifying application and renewal processesSimplifying application and renewal processes Modifying eligibility and eliminating documentation requirementsModifying eligibility and eliminating documentation requirements Implications for Part D more than Discount Card/TAImplications for Part D more than Discount Card/TA

Partnerships with Other Trusted Sources HelpfulPartnerships with Other Trusted Sources Helpful Deputization to allow these entities to help fill out applications and submitDeputization to allow these entities to help fill out applications and submit Kiosks at medical clinics. Kiosks at medical clinics.

Mixed success with direct mail Mixed success with direct mail

Summary of Enrollment Lessons Summary of Enrollment Lessons from Discount Cardfrom Discount Card

Autoenrollment the most efficient mode for getting people enrolled. Autoenrollment the most efficient mode for getting people enrolled. Transparent to enrollees.Transparent to enrollees. Nearly 100% of enrollment in transitional assistance is due to SPAP and M+C Nearly 100% of enrollment in transitional assistance is due to SPAP and M+C

autoenrollment.autoenrollment. One application process for card and subsidy minimized burden. One application process for card and subsidy minimized burden.

Will not be the case under Part D – expect even lower enrollment in Will not be the case under Part D – expect even lower enrollment in subsidies. subsidies.

Asset test requirement will also reduce participation in Part D subsidies. Asset test requirement will also reduce participation in Part D subsidies. Left on their own, voluntary enrollment has been extremely low.Left on their own, voluntary enrollment has been extremely low. Voluntary enrollment may be enhanced by offering incentives, but degree Voluntary enrollment may be enhanced by offering incentives, but degree

of impact unknown. of impact unknown.

Michael McMullanMichael McMullan

CMS TimelineCMS Timeline

Gale ArdenGale Arden

Low Income SubsidyLow Income Subsidy

Donna BoswellDonna Boswell

SPATC preliminary recommendationsSPATC preliminary recommendations

State Pharmaceutical State Pharmaceutical Assistance Transition Assistance Transition Commission (SPATC)Commission (SPATC)

Snap Preview of Snap Preview of SPATC RecommendationsSPATC Recommendations

For NGA Part D For NGA Part D Implementation ProjectImplementation Project

December 16, 2004December 16, 2004

SPATC Charter in MMASPATC Charter in MMA

Appointed by the Secretary to develop a proposal to Appointed by the Secretary to develop a proposal to advise the Secretary and the Administrator of CMS on advise the Secretary and the Administrator of CMS on ways to address the unique transitional issues facing ways to address the unique transitional issues facing SPAPs and SPAP participants consistent with the SPAPs and SPAP participants consistent with the following principles:following principles: Protection of the interests of program participants in Protection of the interests of program participants in

a manner that is least disruptive to such participants a manner that is least disruptive to such participants and that includes a single point of contact for and that includes a single point of contact for enrollment and processing of benefits.enrollment and processing of benefits.

Protection of the financial and flexibility interests of Protection of the financial and flexibility interests of States so that States are not financially worse off as States so that States are not financially worse off as a result of the enactment of this title.a result of the enactment of this title.

Principles of Medicare modernization under the MMA.Principles of Medicare modernization under the MMA.

Knowledge Through Knowledge Through ExperienceExperience

SPATC members believe that the SPATC members believe that the experience gained --experience gained -- (1) in administering SPAPs for Medicare (1) in administering SPAPs for Medicare

beneficiaries over the last decade, and beneficiaries over the last decade, and (2) in helping those beneficiaries deal with the (2) in helping those beneficiaries deal with the

Medicare drug discount cards Medicare drug discount cards

should be used to inform the part D should be used to inform the part D implementation and to avoid – if possible-- implementation and to avoid – if possible-- making the same missteps twice!making the same missteps twice!

SPATC ApproachSPATC ApproachFor Tackling Complex IssuesFor Tackling Complex Issues

The problems identified at the first meeting, The problems identified at the first meeting, July 8, 2004, were divided into three groups, July 8, 2004, were divided into three groups, and Commission members each served on and Commission members each served on one of the work groups: one of the work groups: 1) transition of current SPAP beneficiaries: 1) transition of current SPAP beneficiaries:

education, eligibility, and enrollment; education, eligibility, and enrollment; 2) benefit design/coordination of SPAPs with the 2) benefit design/coordination of SPAPs with the

new Part D program; and new Part D program; and 3) issues affecting the infrastructure of providers, 3) issues affecting the infrastructure of providers,

systems, and data collection and management. systems, and data collection and management.

Key Recommendations: 1Key Recommendations: 1

SPAPs should be considered SPAPs should be considered authorized representatives of authorized representatives of their beneficiariestheir beneficiaries for the purposes for the purposes of determining their eligibility for of determining their eligibility for subsidy assistance, enrolling them in subsidy assistance, enrolling them in one or more preferred PDP sponsors, one or more preferred PDP sponsors, and paying their Part D premiums.and paying their Part D premiums.

To provide seamless and comprehensive To provide seamless and comprehensive benefits coordination, benefits coordination, SPAPs should be SPAPs should be allowed to choose preferred part D allowed to choose preferred part D sponsorssponsors on behalf of their enrollees. on behalf of their enrollees. SPAPs know their beneficiaries’ existing SPAPs know their beneficiaries’ existing

medications and can help select part D plan with medications and can help select part D plan with appropriate formulary and cost sharing to assure appropriate formulary and cost sharing to assure that beneficiary’s transition is smooth.that beneficiary’s transition is smooth.

The MMA “anti-discrimination” requirement can The MMA “anti-discrimination” requirement can be met by ensuring that the SPAP provides be met by ensuring that the SPAP provides equivalent subsidy to any of its beneficiaries that equivalent subsidy to any of its beneficiaries that wishes to opt for a different part D plan.wishes to opt for a different part D plan.

Key Recommendations: 2Key Recommendations: 2

The exceptions and appeals process, as The exceptions and appeals process, as proposed in regulations, should be revised-proposed in regulations, should be revised- SPAPs should be given authority to SPAPs should be given authority to

appeal on behalf of beneficiariesappeal on behalf of beneficiaries, since , since the SPAPs are at financial risk for formulary the SPAPs are at financial risk for formulary denials and high tier copays. denials and high tier copays.

The process should provide denial and The process should provide denial and appeal rights notices and make the appeal rights notices and make the process timelines much quickerprocess timelines much quicker for the for the sake of consumer access and protection.sake of consumer access and protection.

Key Recommendations: 3Key Recommendations: 3

CMS should form an advisory CMS should form an advisory committee of SPAP committee of SPAP representatives and other representatives and other stakeholders (like the SPATC)stakeholders (like the SPATC) to to assist and inform them through the assist and inform them through the transition of implementing Part D.transition of implementing Part D.

Key Recommendations: 4Key Recommendations: 4

A Centralized Data System should be A Centralized Data System should be established to facilitate data established to facilitate data exchange through a single entry pointexchange through a single entry point so that all involved parties have access to so that all involved parties have access to timely and accurate data needed –timely and accurate data needed – for the “real-time” coordination of for the “real-time” coordination of

benefits (COB);benefits (COB); For the tracking of TrOOP.For the tracking of TrOOP.

Key Recommendations: 5Key Recommendations: 5

Marketing, enrollment, and Marketing, enrollment, and educational materials should be educational materials should be appropriate to the beneficiary’s appropriate to the beneficiary’s situation, situation, including—including— Information about the availability of SPAP Information about the availability of SPAP

coverage in the State, and coverage in the State, and clear explanations of how the SPAP will clear explanations of how the SPAP will

coordinate prescription benefitscoordinate prescription benefits with part with part D plans in the state.D plans in the state.

Key Recommendations: 6Key Recommendations: 6

CMS should ensure that SPAPs that do not wish CMS should ensure that SPAPs that do not wish to provide to provide fullfull secondary coverage can secondary coverage can supplement the coverage offered by Part D supplement the coverage offered by Part D plan’s coverage by—plan’s coverage by— Paying premiums for standard coveragePaying premiums for standard coverage Paying premiums for enhanced alternative coveragePaying premiums for enhanced alternative coverage Paying a flat fee to reduce cost sharing by eliminating Paying a flat fee to reduce cost sharing by eliminating

the deductible; filling the “donut hole”; or reducing the deductible; filling the “donut hole”; or reducing the coinsurance, like the federal subsidy does for the the coinsurance, like the federal subsidy does for the lowest income beneficiaries, or lowest income beneficiaries, or

Paying cost-sharing for drugs for specific diseases. Paying cost-sharing for drugs for specific diseases.

Key Recommendations: 7Key Recommendations: 7

Additional QuestionsAdditional Questions

Please use the dialog box beside the Please use the dialog box beside the screen to send your questions to the screen to send your questions to the speakers.speakers.