Medicare Part D:
Outreach and Implementation Challenges for State Medicaid Programs
Trey Berndt, Senior Policy Advisor Project Director for Medicaid Part D Impacts – Texas Office of Health Services
Who is Affected? What Do They Need to Do?
Medicare Eligible Group Full Dual Eligibles
(Medicare & Full Medicaid)
Change
-Medicaid Rx ends -Auto-assigned to Medicare Rx plan in October 2005
Part D Action Needed?
-Evaluate autoassigned plan and formulary -Change plans?
Other Dual Eligibles
(Medicare and Limited Medicaid)
-No Medicaid Rx now -Enroll in plan earlier than auto-assignment -Gain Medicare Rx -Auto-assigned in June 2006 date -Change plans? - Apply for Low Income Subsidy MA-PD -Enroll in Rx Plan -Auto-assigned in June 2006 earlier than autoassignment date? -Gain Medicare Rx -Coverage through PDP or MA-PD -Keep current Rx coverage; or -Enroll in Rx Plan? 2
Low Income Medicare- -Gain Medicare Rx Only -Coverage through PDP or
(135%-150% FPL)
Medicare-Only
(Over 150% FPL)
What Medicaid Drug Coverage Continues for Full Dual Eligibles?
Medicaid continues to pay cost sharing for Medicare Part B covered drugs Texas Medicaid will continue to pay for a few categories of drugs not covered by Medicare Rx (wrap around): • Nonprescription drugs (over-the-counter medications). • Barbiturates • Benzodiazepines • Some products used in symptomatic relief of cough and colds • Some prescription vitamins and mineral products • Some prescribed drugs used for weight gain, anorexia, and weight loss Medicaid cannot pay for a drug whose category is included in Medicare Rx, but not covered by a particular plan’s formulary.
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How Many Texas Medicaid clients are affected? (as of 8/1/05)
Full Dual eligible clients: In nursing facilities In State Schools In community based ICFs/MR Total in institutions Total in the community Total full dual eligibles 56,911 3,455 4,055 64,421 257,095 321,516
Non-Full Dual In nursing facilities 529 Eligible Clients: In state schools 9 In community-based ICFs/MR 20 Total in institutions 558 Comm. Attendant Services 47,334 Other clients (QMB,SLMB,QI-1) 122,863 Total non-full duals 170,755
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Cost Sharing - Low-Income Subsidy Groups
Population Premium & Deductible Cost Sharing Catastrophic coverage
Full and Non-Full Duals (including HCBS waiver clients)
Full Dual eligible clients in institutions
No premium No deductible
Copays of $1-$5 depending on income level and whether generic or brand
No cost sharing
No copay after total drug expenses reach $3,600 in 2006
No cost sharing
No premium No deductible
New low-income subsidy groups: • Up to 135% FPL •135% to 150% FPL
-no premium -no deductible
•$2-$5 cost sharing (generic/brand)
No copay after total drug expenses reach $3,600 in 2006. $2 generic and $5 brand 5
-sliding premium -$50 deductible
• 15% of the cost of the covered drug
The Texas Outreach and Communications Challenge
• 500,000+ in state-related programs affected by change • Three different populations, each affected differently (Full duals, other duals, statefunded) • Language barriers, geography
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Texas Communications Strategy
• Provider Outreach and Education (pharmacists, physicians, long term care providers, etc.)
Briefings for association members Training materials Articles for newsletters Statewide Community Outreach Sessions
• Professional Training
Caseworkers and other front-line staff in all HHS agencies
• Beneficiary Outreach (via Public Relations/Advertising Firm)
Materials • High interest direct mail campaign (“heads up” mailing and plan selection assistance) • Push cards at pharmacy
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Outreach Activity- Three Phases
• Phase 1: Research (Survey and Focus Groups)
May through October • Phase 2: Informing and Awareness July through October Phase 3: Informing Plan Selection November through December
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Phase 1 - Survey Conclusions
Knowledge of the new program is relatively low: 28% of Beneficiaries, and 31% or Caretakers recall seeing, reading or hearing about how the new Medicare Rx assists in paying drug costs.
Clients cannot distinguish between Medicare and Medicaid: While Medicare and Medicaid enjoy strong positive images, only 28% of Beneficiaries can correctly identify each program name with its corresponding population segment. In contrast, 42% of Caretakers can make the correct identification.
Client prefer communication by mail: Eight out of nine respondents prefer to receive more information about Medicare Rx via the mail, while three out of four would like to call 1-800 MEDICARE. Note: nine out of ten respondents would open mail that had the State of Texas seal on it (approximately 2/3rds would definitely open it).
Community events are more attractive to minority respondents than to Anglos, but Full Duals are more apt than Other Dual or Kidney Beneficiaries to want to learn more via a community event. 9
Phase 2: Informing and Awareness (Now thru October)
• High Interest, Direct Mail Campaign to 3 target populations (week of 7/5)
• Statewide Stakeholder Meetings (16 full regional education sessions plus many association trainings) • Special Part D Project Website: www.TexasMedicareRx.org
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Phase 2: Key Messages for Clients
Full duals: Reassure clients that they will have drug coverage in January. They will get more info in the fall. No need to do anything right now.
• Other Duals: Good News - They will have access to a new Medicare drug program in January. They are automatically eligible for the “extra help” or subsidy. • Medicare only clients: If they just have Medicare and want to apply for “extra help” they should contact Social Security for an application. 11
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Phase 3: Informing Plan Selection
• Mailing in early November Info on how to enroll or change plans Info on how to select plan that best meets your needs Individualized Rx Match for Texas Full Duals – Number of Drugs they Take Covered by Texas Subsidized PDPs (14 Plans) • Top 200 Drugs Matched to 14 Plans on Website?
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Implementation Challenge #1:
“Look Up” Function • Plan Assignment “Look Up” for Auto-assigned Full Duals
Many confused full duals in January-March 2006 Mail notice of auto assignment not always reliable Retail pharmacists, long term care pharmacists, facility staff, family, friends, caseworkers will all need to know how to identify assigned plan Formulary match cannot be evaluated until PDP is known Info on “look up” needs to be widely distributed to “helpers”
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Implementation Challenge #2:
Potential Gaps in Coverage? • In January 2006 and Months After, Gap in Coverage for Clients Converting from Medicaid Rx to Medicare Rx?
Potential health risks if clients can’t access coverage Stems from full dual data exchange timing and CMS time needed to auto-assign, enroll, and inform client and plan MMA prohibition on federal matching funds for full duals adds to problem CMS needs to work quickly with states for national solution – appears to be a problem in all states Potential financial risks to states (if states cover “gap” month with 100% state $$ 19
Implementation Challenge #3:
State Facilities – PDP Contracts in Place? • Most States Have Large Mental Health Facilities or Mental Retardation Facilities with Many Full Dual Residents
May use in-house pharmacies In-house pharmacies will now need to bill outside PDPs or MA-PDPs PDP contracts not in place yet in TX and other states; some contracts offered cannot be executed by state government; PDP LTC network adequacy? Significant potential financial risk to states
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Implementation Challenge #4:
Long Term Care Facilities and Auto-assignment
• Auto-assignment good, but makes life complicated in nursing homes Clients auto-assigned into multiple plans, formularies; Is providing LTC pharmacy in all those plans? Multiple pharmacies trying to serve same LTC facility? No retroactive Medicaid Rx starting January ’06 – Clients may be subject to high cost sharing while waiting for dual status (Medicaid eligibility) to process For Medicare clients, facilities need to start ensuring Medicare Part D enrollment, on admission, to avoid months of no Rx coverage 21
Other Issues
• Part B Drugs vs. Part D Drugs – Need more definitive info from CMS; potential for cost shifting to Part B and Medicaid coinsurance for Part B • Coordination of state wrap around coverage – PDPs need to help point claims towards Medicaid for wrap around coverage • Marketing to Full Duals – Potential for beneficiary confusion is significant
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Other Medicare Rx Resources
• http://www.texasmedicarerx.org http://www.cms.hhs.gov/medicarereform/pharmacy/ • http://www.cms.hhs.gov/medicarereform/pdbma/ • http://www.texaspharmacy.org • http://www.txcares.org/medicare/faqs.html • 1-800-Medicare
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