DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD, CGPSeniorPharmAssist

Webinar #1Webinar #9

Medicare 101

Jessica Visco, PharmD, BCGPClinical PharmacistSenior PharmAssist

Disclosures No commercial support has influenced the planning of the

educational objectives and content of the activity. Any

commercial support will be used for events that are not CE

related.

There is no endorsement of any product by DUHS

associated with the session.

No influential financial relationships have been disclosed by

planners or presenters which would influence the planning of

the activity. If any arise, an announcement will be made at

the beginning of the session.

This program is supported by a Geriatric Workforce Enhancement Program (GWEP) grant (U1QHP28708) from the U.S. Bureau of Health Professions Health Resources and Services Administration (HRSA).

Objectives

Explain the basics of Medicare; A B C D

Explain the difference between Original

Medicare and Medicare Advantage products

Describe the 2018 Medicare-approved drug

benefit

Share local, state and federal resources that

help with Medicare Part D

Case

Ms. Ford is a 76 year old woman

History of diabetes, hypertension, arthritis,

seasonal allergies

Lives alone in Durham; daughter lives close

by

Been living independently for the last 5 years

Fell down the steps and injured her hip

Being evaluated for a possible hip fracture

Case

Ms. Ford has:

Original Medicare

Medicare Supplement

Medicare Part D plan

How does Medicare A, B, C and D work?

What is Medicare?

Federally sponsored individual health plan providing coverage for medically necessary procedures and service

Health Insurance for people 65 and older

Under 65 with certain permanent disabilities

Any age with End Stage Renal Disease

ALS (amyotrophic lateral sclerosis – Lou Gehrig’s disease)

Your Medicare Coverage Choices

Part A – Hospital Insurance Coverage

• Part A – Hospital Insurance helps cover

• Inpatient hospital care

• Inpatient skilled nursing facility care

• Blood (inpatient)

• Certain inpatient non-religious, non-medical health

care in approved religious non-medical institutions

• Home health care

• Hospice care

Part B – Medical Insurance Coverage

• Part B – Medical Insurance helps cover

• Doctors’ services

• Outpatient medical and surgical services, supplies

• Clinical lab tests

• Durable medical equipment

• Diabetic testing supplies

• Preventive services

What does Original Medicare not cover?

Prescription medications

Routine dental care

Routine vision care and eyeglasses

Hearing aids

Foreign travel

Cosmetic procedures and treatments

Long Term Care

Medicare Secondary Medical Coverage

Commercially available Medicare supplements

(Medigap policies) “fit” the coverage gaps of

traditional Medicare: pays A and B cost-sharing for

Medicare approved services

Other types of secondary coverage include

Medicaid or Employer health plans

Note: Medicare beneficiaries only have guarantee

issue rights to an affordable supplement when new

to Medicare and in a few select other situations

Provider Choices with Medicare

Participating - accept “assignment” – 100% of what

traditional Medicare “allows”

Non-participating – do not accept Medicare assignment –

allowed to charge 15% above Medicare assigned

charges; person usually pays up-front and Medicare

reimburses him/her

Opt-out – don’t file with Medicare and can charge

whatever they want

Accept traditional Medicare but not any or all of the

replacement plans - Medicare Advantage

2003 Medicare Modernization Act

Replaced existing Medicare + Choice

program with a new program called

Medicare Advantage program

Part B premiums would increase for higher

income beneficiaries

Added a voluntary drug benefit (Part D) that

began January 1, 2006

Medicare Part C –

Medicare Advantage Plans

• Health plan options approved by Medicare• Another way to get your Medicare coverage

• Still part of the Medicare Program

• Run by private companies

• Medicare pays the plan an amount• For each member’s care

• May have to use network providers

• Types of plans available may vary

Medicare Part C

Medicare Advantage Plans

If you join a Medicare Advantage (MA) Plan

Still in Medicare with all rights and protections

Still get those services covered by Part A and Part B

But the MA Plan covers those services instead

May have different cost-sharing

May choose a plan that includes extra benefits

Such as vision or dental offered at the plan’s expense (not covered by Medicare)

May have a premium

Ms. Ford

Ms. Ford is admitted to the hospital for a hip

replacement

Discharged to skilled nursing facility after 4 day

admission

Then discharged home with home health

Requires:

PT

Walker

Diabetes testing supplies

Observation vs admitted and SNF coverage

Part A – What You Pay

Part B – What You Pay

http://www.medicare.gov

DME Suppliers

https://www.medicare.gov/supplierdirectory/search.html

DME Suppliers

DME Suppliers

How They Work

A voluntary benefit; with late enrollment penalties

It is administered by private companies as “insurance model”

with cost-sharing requirements

Medicare beneficiaries with limited incomes and resources

may qualify for “extra help” or a low income subsidy via the

Social Security Administration

Medicare Part D

Everyone who has Medicare Part A or B (regardless of

income) can choose a Medicare prescription drug plan

Medicare Part D

NOT reflected in Medicare website:

Penalty clock - not having “creditable coverage”

when eligible; if June 2006 - (1% of national base

premium); $35.02/month X 139 months =

$48.70/,month); penalty is gathered by Part D plan

and transferred to CMS

Income-Related Medicare Adjustment Amount

(IRMAA) - $85k/single or $170k/couple or higher –

pay higher Part D premiums via your SS check (like

B)

Medicare Beneficiaries’ Out-of-Pocket Drug

Spending Under Medicare Rx Benefit, 2018

Deductible $405

Coverage

Gap

Catastrophic

Coverage

Partial

Coverage

up to Limit

$3,750

$8,418

25%

• 65% discount on

covered BRAND Rxs

• 56% discount on

covered GENERIC Rxs

Beneficiary

Out-of-Pocket

Spending

Part D plan pays

75%

Part D Plan pays

15% & Medicare

pays 80%5%

Medicare Drug Benefit

Annual Adjustments for Standard Benefit

Benefit Parameters 2017 2018

Deductible $400 $405

Initial Coverage Limit $3,700 $3,750

Out-of-Pocket Threshold $4,950 $5,000

“Full” LIS Copayments

Institutionalized $0 $0

Up to or at 100% FPL $0 or

$1.20/$3.70

$0 or

$1.25/$3.70

Other Full LIS $3.30/$8.25 $3.35/$8.35

“Full” Low Income Subsidy (LIS)

or “Extra Help”

Medicare beneficiaries with limited incomes and

resources receive additional help:

135% federal poverty level (FPL) and below

• $16,281/single or $21,924/couple

• Liquid assets less than $8,890/S or $14,090/C (includes

$1,500 per person for burial expenses)

Pay $1.25-8.35/Rx for “formulary meds” in 2018

No monthly premiums, deductibles, or “donut holes”/

coverage gap

“Partial” Low Income Subsidy (LIS)

or “Extra Help”

Medicare beneficiaries with limited incomes and resources

receive additional help:

< or = 150% FPL

• $18,090/single or $24,360/couple

• Liquid assets less than $13,820 or $27,600 (includes

$1,500 per person for burial expenses)

Sliding scale monthly premiums (25-75%)

$83 annual deductible in 2018

15% co-payments – for “formulary medications” but no official

“donut holes”/coverage gap

PDP Plans: “Considerable Discretion”

Formularies; TrOOP – “true” out-of-pocket

Medicines not on formulary are full cost without a limit on

expenditures, unless individual successfully appeals to have it

covered

Utilization Management tools - prior authorization, step

therapy & quantity limits

Tiered cost sharing – 4-6 levels – generic/brand preferred

and non-preferred and specialty tier

Exceptions and appeals processes – begins with Coverage

Determination Request Form

Pharmacy co-branding - preferred, network/standard “retail

cost-sharing”, and non-network; mail order can be MORE

expensive

Medication Requirements

Federal law requires plans to include at least two drugs from each class of drug category on their formulary

All or “substantially all” of the medications for the following conditions must be covered (can still be $$$) by Medicare drug plans, including: Anti-depressants

Anti-psychotics

Anti-convulsants

Chemotherapeutic agents

Anti-retrovirals

Immunosuppressants

Medicare Excluded Classes

Benzodiazepines and some barbiturates – now covered

Drugs for:

Anorexia Fertility

Weight loss Hair growth

Weight gain Cosmetic purposes

Symptomatic relief of coughs and colds

Prescription vitamins and mineral products; OTCs

Medications intended for sexual or erectile dysfunction

Drugs covered by Medicare Part A or B

Outpatient drugs requiring monitoring by manufacturer

“Enhanced Plans” can cover some of these products but does not count towards TrOOP

Steps to Choosing a Plan

CMS website: - www.medicare.gov

Medicare “Find Health and Drug Plans” – can see

annual costs via different plans after entering meds,

dosages, zip code; pharmacy

Must enter a pharmacy

Critical to also view “utilization management” tools

Can see if MTM program available

LI NET

Limited Income Newly Eligible Transition Program

– Humana/Argus/Relay Health

Allows individuals with partial or full LIS to receive

immediate Rx coverage at the point-of-sale if not

already enrolled into a Part D plan.

Can be retroactive – if “full dual”

Temporary coverage - open formulary, no

utilization management restrictions, or pharmacy

networks

Transition Fill

AKA “first-fill” policy of CMS (NOT related to income)

1. Time to get on another medication

2. File an exception request

3. For those with LIS – enroll in a different plan

Automatic override

If a new plan or current plan drops your medication or places utilization management restrictions; when experience a change in level of care (home to SNF, etc.)

Plan must provide a 30 day supply (unless a lesser amt. is prescribed) of an ongoing medication within the first 90 days of the plan membership

Transition Fill

Doesn’t include “excluded Part D drugs,” but does cover

non-formulary drugs & those subject to ST and PA

Plans must give written notice within 3 days of transition fill

Part D sponsors may need to extend transition periods on a

case-by-case basis

LTC – 31 day supply and honor multiple 31 day fills while

exception is being processed; Jan 2013 - SNF has 14-day

short-cycle on brand-name meds and controlled

substances

Ms. Ford – insurance coverage

Ms. Ford has

Traditional Medicare

Medicare supplement

Part D plan

Her gross monthly income $1809

Difficulty paying for her medicines

Wants to learn more about Original

Medicare/supplements vs Medicare Advantage plans

Senior PharmAssist We help any Durham Medicare beneficiary (any age/income) REVIEW &

UNDERSTAND their Medicare hospital, medical and drug insurance

choices.

We CHECK to see if you might be eligible for help

We CONNECT Durham Seniors to other community resources and

programs to help them stay as healthy and independent as possible for as

long as possible.

Through Medication Reviews, we EDUCATE Durham seniors (60 & older)

about the most economical, safe and effective medicines.

Durham seniors with gross monthly income up to $2010 single/$2707

couple may qualify for our PRESCRIPTION CARD PROGRAM ($2 & $5

monthly co-pays for drugs we cover).

Open Enrollment

October 15-December 7

Durham County SHIIP site

Senior PharmAssist

406 Rigsbee Avenue

Suite 201

Durham, NC 27701

919-688-4772

Call for screening and appointments

Call Medicare

1-800-Medicare (1-800-633-4227)

Seniors Health Insurance Information Program (SHIIP)

1-855-408-1212

Where can I get help?

Seniors Health Insurance Information Program (SHIIP) 1-855-408-1212

Social Security 1-800-772-1213 www.socialsecurity.gov

Medicare 1-800-633-4227 or www.medicare.gov

Employer health benefits administrator

Medicaid – Local county Social Services

Senior PharmAssist 919-688-4772

Questions???

Continuing Education Credits• 1 hour of CE credit is being offered for this

webinar.

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