Medicare Part D - California Alliance for Retired Americans by wulinqing

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									Medicare Part D –
Think “D” for Disaster
The Advocate’s Guide for Organizing
To Improve Medicare Drug Coverage

                 David Grant and Marie Jobling
                     CARA 415-550-0828
This Workshop brought to you by…
California Alliance for Retired Americans
           (CARA) 877-223-6107
         in partnership with the
   Medicare Advocacy Collaborative:
       -   Health Access California
       -   OWL - California
       -   Gray Panthers - California
       -   Congress of California Seniors

This workshop made possible in part by a grant
from The California Wellness Foundation.
           Medicare Part D - Time to
            “Shout Out” an Alarm
• Everywhere folks are talking about Part D
• Mostly, individuals are trying to figure out if it
  will help or hurt them
• We need to raise the “red warning flag”
  about dangers as they unfold.
• We need to “Shout Out” that Medicare Part D
  has too many problems and must to be
  “Reconsidered and Replaced” by Congress
    Overview of Today’s Workshop
• Medicare Part D – The Basics
• Medicare Part D – An Advocate’s Perspective
  - Does Medicare Part D reduce cost & improve
  - Does it simply privatize a major part of Medicare
    by turning over drug coverage to an
    unregulated army of private drug providers
    (while sacrificing the standard benefits
    fundamental to Medicare?)
• CARA’s Call to Action!                           4
Here is a CLUE…
In 2003, when Medicare Part D was
enacted, the Drug Companies…
  • hired 952 lobbyists,
  • spent $141 million on
  • contributed more than
    $30 million to campaigns.
Drug profits rose $182 billion.
Medicare Part D – Working for YOU?

What has been your
experience so far?

    Welcome to Medicare Part D
          “The Basics”
• Coverage began January 1, 2006 for those
• Available for all people with Medicare, but
  impacts particular groups differently
• Drug Benefits provided through Private Plans:
   – Prescription Drug Plans (PDP’s)
   – Medicare Advantage Plans (HMO’s)
• Some Employer and Union Retiree Plans
  receive government subsidies to help prevent
  them from dropping drug coverage.
    How it Works – The Basics
• Monthly premium: minimum of $5.31 to $66.00 per
  month (in California)
• Deductible - $250 per year
• Co-payment - $500 maximum based on drug “costs”
  up to $2,250
• Donut Hole – No coverage for costs from $2,250 to
  $5,100 (but you must keep paying monthly premiums)
• Catastrophic Coverage – After $5,100, it covers 95%
  of drug costs
• Co-pays – generally $2 - $5 for each prescription

     Part D Plans – The Basics
• Plan Choice – 47 “stand alone” plans in addition to
  current HMO plans
• Co-payments, deductibles, pharmacy networks vary
• All mental health drugs, immunosuppressants, AIDS and
  cancer drugs are covered
• In other categories, all drugs are not covered
• Medi-Cal will continue to cover drugs not on Part D
  formulary for Medi-Cal recipients
• Part D Plans can change formulary at any time
• Customer service – up to each plan
• Appeals - up to each plan

  Low Income Subsidy – The Basics
• Three groups “deemed” eligible for full low-income subsidy
  were automatically enrolled January 1, 2006.
   – Dual eligible (Medicare/Medi-Cal)
   – People with SSI
   – People enrolled in Medicare Savings Programs (QMB, SLMB & QI-1)
• Those with incomes OVER this level and UNDER 150% of
  poverty level are eligible but must apply through Social
  Security for this benefit.
   – Single – up to $1197 monthly
   – Couple – up to $1,604 monthly
   – Excess assets may prevent you from getting this benefit.
   First, you must apply for the subsidy, then you must enroll
  in a Part D Plan.
   Enrollment Issues – The Basics
• Dual Eligibles (with both Medicare and Medi-Cal):
   – Were automatically enrolled in a Part D plan January 1, 2006
   – Beneficiaries must determine if chosen plan covers their drugs and
     is accepted at a nearby pharmacy
   – Drugs on the Medi-Cal formulary, but not on the Part D formulary,
     will continue to be paid for by Medi-Cal
   – If you don’t like your plan, you can change as often as monthly
• Medicare Only:
   – Can apply for Low-Income Subsidy
   – Are being encouraged to pick a Part D plan and enroll by May 15,
   – You can only change plans during the annual open enrollment
     period, November 15 through December 31.
   – Beneficiaries pay a 1% of premium penalty each month if you do
     not enroll by May 15, 2006
               Dual Eligibles
• Dual eligibles in long term care facilities
  No premium, no deductible, no co-pays
• Dual eligibles in the community and those in
  Medicare/Medi-Cal Medicare Savings
  Programs (QMB, SLMB, QI-1) or SSI/SSDI
  – No premium or deductible
  – Co-pays: $1 to $5 (per prescription)
  – No “donut hole” of non-coverage
  – No co-pay after $5,100 limit of total cost of
What did the Governor just do?
• Authorized the State to pay for
  medications for those Medi-Medi’s who
  are unable to get their drugs paid for by
• This coverage was only for the period
  January 12 through January 17, 2006.
• Sponsors of this workshop are part of
  efforts with the Legislature to get this
  safety net coverage continued.
Low-income Medicare Beneficiaries
        Not on Medi-Cal
• A two–step process
• Apply for a “low-income subsidy” if income
  and assets are low
  – Single – up to $1,197 monthly
  – Couple – up to $1,604 monthly
  – Assets limits vary
• Choose a prescription drug plan before
  May 15, 2006 and enroll – your subsidy
  should be automatically applied.
       Medicare Beneficiaries with
        Existing Drug Coverage
• Watch out for a letter saying if your current coverage is
  at least as good as Medicare Part D – the term used is
  “creditable” – not all plans are “creditable”.
• These letters could come from:
   – Existing Medi-gap policies
   – Medicare Advantage HMO’s
   – VA and TRICARE
   – Union and Corporate Retiree Benefit Programs
• Covered individuals can still sign up for a Part D plan,
  but may lose their regular drug AND health coverage
  (More on this in the “red flag” section to follow).
• If you have not yet received a letter, or are confused, call
  your health plan.                                         15
  Where You Can Go For Help
• Health Insurance Counseling and Advocacy
  Program (HICAP): Call 1-800-434-0222 to reach
  your local HICAP or go to
• Social Security: 1-800-772-1213 or go to
• Center for Medicare and Medicaid Services
  (CMS): Call 1-800-MEDICARE or go to
• Your CARA Part D Toolkit and at
• Remember, most other sources of information
  are trying to sell you something
Preparing Advocates to
 “Raise the Red Flag”
• Presentations like what you just saw are
  happening all over the state.
• We need to tell the other side of the story - that
  Medicare Part D = Disaster
• We need to be “on guard” against the numerous
  dangerous features of Medicare Part D
• Let’s count the ways that Part D is a Disaster…

      #1 Enrollment =
    Chaos and Confusion

• Enrollment is being pushed too quickly
• Enrollment decisions are too complex
• Too few resources are available to help
• Too little information is available in multiple
  languages and in formats easy for consumers to

  #2 Medi-Cal Enrollment
• On January 1, over 1 million Medi-Cal
  beneficiaries were automatically switched to
  Medicare Part D. Horror stories include:
  – Pharmacies can’t access computer system to process
    claims. When they do, data is not accurate.
  – Phone lines for Medicare and the private plans totally
  – High co-payments and totally different formularies
    mean beneficiaries leave without lifesaving drugs.
  – California and other states must step in to bail out the

#3 - Late Enrollment Penalty
     It Lasts A Lifetime!
• Beneficiaries not automatically enrolled have until May
  15, 2006 to chose a plan.
• After May 15, 2006, if you have not chosen a plan, you
  will pay 1% of the average area premium PER
  MONTH…FOR LIFE as your penalty!
• Example – say the average monthly premium in your
  area is $50 a month. If you wait 12 months to sign up,
  your premium would be $50 + $6 (12% of $50) every
  month or an additional $72 per year forever! If the rate
  goes up, your penalty goes up proportionately. If you
  wait longer, the penalty just keeps growing.

  #4 -Retirees with Current
  Drug Coverage - Beware!
• Retirees with current drug coverage through a
  retiree or employer health plan could lose
  (not just drug coverage) by signing up for
  Medicare Part D.
• Many letters to retirees regarding “creditable
  coverage” do not make this pitfall clear.
• If you mistakenly join Part D, you and your family
  members covered by the retiree plan may not be
  able to get the coverage back.
  #5 The “Donut Hole” – Not
     Such A Sweet Deal
• You get no coverage for costs between $2,250
  and $5,100
• You keep paying premiums but get no benefit
• It is unclear what drug costs will get counted
  toward the $2,250 (i.e. all out of pocket costs or
  only those that show up in the Medicare
• Many factors will make it difficult for individuals
  to reach the other side of the hole ($5,100) and
  to start getting benefits again.

   #6 Choosing a Plan?
Welcome to the Valley of Tiers
• Already complex decisions related to cost and coverage are
  now more difficult because of choices within plans.
• Many plans are organized into different “tiers” based on
  whether you are using generic, preferred, non-preferred, or
  specialty drugs – Higher tier = Higher cost.
• Plans may force you to try cheaper drugs, perhaps with bad
  side effects, before you can get the “higher tier” drug they offer.
• In addition, plans have different costs depending on whether
  you go to a preferred, non-preferred or off-plan pharmacy.
• For example, you could have as 12 different combinations of
  premium and co-payment amounts and the possibility of even
  more confusion if all your drugs are not covered in one plan
• End result – it is virtually impossible to make an informed

     DANGER – With Part D,
     You Could Pay MORE!
•    Annual Premium                     $ 445
•    Annual Deductible                  $ 250
•    Co-payments (varies)               $ 155 - $500
•    Donut hole coverage gap            $ 2,850
•    Additional charges based on
    whether drug is covered,
    pharmacy is in network, etc.   Unknown

• How does this compare with what you pay now?
• How does it compare if you simply bought your drugs
  from Canada or from places like Costco?
• How would it compare if the government could negotiate
  lower drug prices, like those for the VA?            24
  #7-12 More Dangers on
    the Road to Part D
• Persons in special programs for HIV/AIDS, disabled
  children, other groups face even more confusion.
• Many beneficiaries will find this new “benefit” actually
  reduces assistance from other programs like food stamps.
• Beneficiaries in long term care facilities nursing home left to
  fend for themselves in terms of making choices.
• Each plan has its own grievance and appeal process.
  Doctors and patients are forced to deal with multiple,
  differing appeal processes to get needed drugs.
• Beneficiaries will be trapped in plans even if drug
  formularies changes
• Drug plans have little or no oversight from government.

 #13 Unlucky California Will
  Lose Nearly $420 Million
• The federal government will “clawback” $1.4
  billion of the money formerly in Medi-Cal.
• Experts estimate that over-all, California will lose
  more than $250 million in the first year alone.
• Since the State is no longer buying drugs
  directly, it potentially loses all the discounts and
  rebates, an estimated loss of $170 million more.

America Can Do Better
After all that you’ve heard, what do YOU

Will Medicare Part D reduce cost, improve
access, and increase your ability to live a
healthy life?

Together We Can Get A Real
  Prescription Drug Benefit
• CARA has a plan for how to “Reconsider
  and Reform” Medicare Part D,
• Here are at least 4 Ways you can help.
At the national level…
• Take the CARA Medicare Petition and get everyone you
  know to sign it.
• Tell people about the problems with Part D and urge them
  to join the fight for a Real Drug Plan.
• Join the CARA Action Team (CAT) and participate in
  meetings in your area. Call 877-223-6107(toll free) for the
  Team in your area.
• Organize to hold your representative accountable for real
  relief from high drug costs
   – Support HR 3861, the Medicare Informed Choice Act (Stark,
     Schakowsky) to extend the deadline
   – Support HR 752 (Stark, Berry) the Medicare Prescription Drug
     Savings and Choice Act, to create a uniform drug benefit in
     Medicare and require that Medicare negotiate for the best
     possible prices.
• Dial the House & Senate switchboard
• Ask the operator for the first representative you want to reach
• When connected: “Hello, I live in your district and I’m calling to
  ask you to:
   – Support HR 3861, the Medicare Informed Choice Act to
     extend the enrollment period and protect against bad choices.
   – Support HR 752, the Medicare Prescription Drug Savings and
     Choice Act, to create a uniform drug benefit in Medicare and
     require Medicare negotiate for the best prices
   – Reconsider & replace Medicare Part D with real reform that
     saves Medicare and provides relief from high drug prices.”
• Repeat until you have called all 3 of your representatives!
• Call today, call often, get your friends to call too!

• Be part of a team to follow-up on today’s
  – Take what you’ve learned today back to other
    groups you’re involved with
  – Attend local Medicare Part D trainings and
    workshops to help “raise the red flag” about
    problems with Part D.
  – Write a “Letter to the Editor” about the pain
    and confusion Medicare Part D is causing
    (see information in your toolkit).
• Share your experiences and those of people you know
   – “Tell Your Story” form is in the Toolkit to help make
     the issues real to the media and local policymakers.
   – Tell your story today!
   – Collect stories from others tomorrow
   – Host a local “Shout Out” to get the press to cover the
     “dangerous side” of Part D.
• The Tool Kit can help guide you with these and other
• Your local CAT Team can help you organize a “shout-out
  and media” in your area.

At the state level…
• Support State legislation being developed for the 3rd year
  of the statewide OuRx Coalition - Year 3? – Part D!
   – Establish a “wrap-around” benefit to protect “Medi-
   – Provide assistance with co-payments and deductibles
   – Increase funding for consumer counseling and support
   – Demand oversight and regulation of drug plans
• Participate in state hearings on Medicare Part D
• Coordinate “shout-outs” and legislative visits through the
  local CAT’s to participate in your area.

• CARA member groups
• Local senior and disability advocacy groups
• Pharmacists and their organizations
• Non-profit housing providers to seniors and
  persons with disabilities
• Nursing Homes & Residential Care Facilities
• Legal Services Programs
• Paid and family care givers


• Now it’s time to move into action
• Join us as we plan the next steps in your

• And to end on an up-beat note, join us in
  song as we prepare to march and sing our
  way into the history books.
Stay Involved - Join the CARA
      Action Team (CAT)

  The Alameda County CAT meets
  every 2nd Monday, at 10:00 a.m.
   South Berkeley Senior Center
     Ellis at Ashby in Berkeley

  For more information, contact
  Jim Forsyth at 510-581-5169.

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