Kate Schilling December 2020 Basic structure of Part D costs2021 Monthly premium Annual deductible up to 445 Initial coverage limit 4130 Out of pocket threshold 6550 Coverage gap phase 25 copays ID: 1001789
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1. OEP Clean-Up & Moving ForwardKate SchillingDecember 2020
2. Basic structure of Part D costs--2021Monthly premiumAnnual deductible (up to $445)Initial coverage limit ($4,130)Out of pocket threshold ($6,550)Coverage gap phase –25% copaysCatastrophic coverage –5% copay
3. ESRD & Advantage plans –new for 2021!People with End Stage Renal Disease (ESRD) can enroll in a Medicare Advantage plan during OEP to start January 1An Advantage plan replaces Original Medicare A & BAdvantage plans are private health plans with HMO or PPOCompare pros/cons of Medicare Advantage plan versus Medicare supplement (networks?)
4. Senior Savings Model plans—new for 2021!A month’s supply of insulin is $35Not all plans offer this benefitIn WI, 9 Part D plans and 6 Adv plans w/drug coverage offer ithttps://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-help-others/Open-Enrollment-Outreach-and-Media-Materials#insulinhttps://innovation.cms.gov/innovation-models/part-d-savings-modelhttps://innovation.cms.gov/files/x/partd-seniordav-ndclist.pdf
5. Part D vs Part B drugs Oral anti-cancer meds (depends)Anti-rejection meds (depends whether on Medicare at time of transplant)Shots given into muscle tissue or IV (given by nurse)Vaccines—shingles is Part D; flu is Part B; COVID = Part B
6. Medicare Part DPart D does not cover: Over the counter medsOff-label usageDrugs not approved by FDACosmetic, weight loss, fertility, ED medsOTC cold & flu meds (watch for Rx cough meds)Meds used with hospice
7. Examples of potential problemsNo drug coverage at pharmacy in JanuaryEnrollment into wrong planMapped into plan with larger premiumPlan does not cover all of client’s meds Step therapy, exception, or prior auth required
8. Immediate need for meds:Transition fillShort-term fixFirst 90 days after enrollment into plan (or after formulary change)Does apply to mid-year plan changesApplies even if did not change plans during AEPPart D plan must cover 30 day supply of drug, even if not on formulary (90 days if LTC institution)Does NOT apply to new drugs during course of the year.
9. Immediate need for meds:Transition fill: Works at pharmacy to cover 1 month of meds If does not automatic, request a transition fill at pharmacyNOTICE mailed to client: this is one-time fix, notice of rights, options.
10. Immediate need for meds:LINET: Allows dual eligibles and LIS beneficiaries immediate access to drug coverage. Most pharmacies are familiar with it. Temporary Part D plan with no formulary restrictions. May need to utilize BAE to show entitlement.
11. Immediate need for meds:LINET will NOT work for clients who:opt-outed of Part D auto-enrollment through 800-Medicareare enrolled in Advantage plan without drug coverageare enrolled in a Part D plan already (and may not know it)are enrolled in private health insurance with Rx coverage
12. Immediate need for meds:LINET troubleshooting:Opt back in with Part D thru 800-MedicareAsk plan, Medicare, and then Region V for retroactive disenrollment from Adv plan (if ok with client)Retroactive enrollment into Adv plan w/ Rx coverageCall Medicare SHIP # to determine if enrolled in Part D Consult HR to determine effect on enrolling in Part D with employer coverage in place.
13. LINET—contact infoLINET help desk 1-800-783-1307 1-800-SHIP counselors LINET line: 1-866-934-2019LINET fax 1-877-210-5592LINET urgent fax: 1-502-580-6644 (< 2 days of meds)
14. Best available evidence (BAE)Use BAE to show a Part D plan that a person is a dual eligible or LIS eligible and should have lower copaysPart D plan should update records quickly, offer a refund if appropriateUse Forward Health printout, letter of Medicaid eligibility, CARES screenshot, etc. for documentationFax documentation to Part D plan and ask them to update client’s fileFile a CTM complaint if plan does not recognize
15. Other solutions for Rx coveragePrior authorizationStep therapyQuantity limitsRequest exceptionSwitch medSwitch Part D plan
16. Prior authorizationBefore the plan will cover a particular drug, your doctor must first show the plan you have a medically-necessary need for that particular drug. Contact the plan about its prior authorization requirements, and talk to dr. Forms available on plan website.
17. Step therapyTry a less-expensive drug that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. If you have already tried the less-expensive drug and it didn’t work, dr can help request an exception.
18. Quantity limits For safety and cost reasons, plans may limit the amount of drugs they cover over a certain period of time. If because of medical condition, a quantity limit isn’t medically appropriate, dr can contact the plan to ask for an exception. If the plan approves the request, the quantity limit will not apply.
19. Request exception“Drug is not on the formulary, but please cover this drug for me due to medical necessity.”This drug is absolutely necessary for my health, I must keep taking it. Tried step therapy and it didn’t work.Forms available on plan website.Most of the rationale is provided by dr.
20. Switch medGeneric medication available? Therapeutically equivalent drug? *Client must consult with doctor
21. Switch Part D plan using a SEPSEPWhat you can doTime FrameLIS or dual eligibleAdd/drop/change PDP or MAPDOnce per quarter, first 3 quarters of yearRecent loss of other coverageEnroll in PDP or MAPD63 days from loss of coverageDisenroll from Part D to enroll in other creditable coverage (VA)Drop PDP or MAPDAnytimeSPAP SEP (SeniorCare 2b & 3)Enroll in or change PDP or MAPDOnce per calendar year Med Advantage OEPDrop or switch Adv plan, enroll in stand alone PDPJanuary 1 – March 31Institutional SEPAdd/drop/change PDP or MAPDOngoing5 Star SEPEnroll into 5 star PDP or MAPD planOnce Dec 8, 2020 – November 30, 2021
22. SEP: LIS or dual eligible entitlementOnce per quarter SEP—only first 3 quarters of the yearNot during 4th quarter of yearRelated SEPs:New to Medicaid (w/n first 3 months)Auto-enrolled into PDP, not a good fit
23. SEP: Recent loss of coverageLoss of other creditable coverage within 63 daysLose employer coverageLose Medicaid Lose Tricare/ChampvaMedicare Advantage plan with drug coverage ended 12/31*
24. Medicare Part D SEP’s Related to SeniorCareLevels 2b & 3 onlyAny level of SrCare
25. SEP to Enroll In Other Creditable CoverageOnly a disenrollment OUT of Part D planDoes NOT get client into new Part D planClient may leave Part D in favor of SeniorCare, VA, etcApplies to ANY level of SeniorCare (not just 2b and 3).Disenrollment effective first of the month following request.
26. SPAP SEPState Pharmaceutical Assistance Program (SPAP) SeniorCare (levels 2b & 3 only)Chronic Disease Programs
27. SPAP SEP cont’dOnce per year opportunityEnroll in PDP or MA-PDWill allow a person to get OUT of a current Part D plan and INTO a new Part D plan. (Use SPAP SEP to enroll in new plan, should automatically drop old plan.) Sometime people enroll in SeniorCare for exactly this purpose.
28. Medicare Adv plan OEPJanuary 1, 2021 through March 31, 2021Can SWITCH or DROP Advantage plan and return to Original MedicareNo reason neededAnyone can drop Adv plan during this timeMust be enrolled in an Adv plan as of 1/1/21 to use this OEPCOORDINATING SEP to obtain drug coverage: SEP to get into standalone Part D plan. Get SEP even if Adv plan leaving did not have drug coverage. PFFS plans must keep same drug plan (no SEP)
29. SEP: institutionalized personOngoing, monthly SEPNeed not be on MedicaidInstitution includes:SNFNHIntermediate Care FacilityPsychiatric hospitalLong-term care hospital or swing-bed hospitalNOT apply to assisted living facility
30. SEP: 5 Star Performance Rated PlanEnroll INTO a 5 star planDoes not matter if coming from Original Medicare or Adv planOnce per year--Dec. 8, 2020 through November 30, 2021.
31. SEP: Low performing planApplies to Part D and Adv plans with less than 3 starsNotices sent to participants October & FebruaryUse SEP once per yearMust show how impacted by poor performance of plan
32. Other SEP’s may pertain if client:MovedQuit job/retiredReleased from jailRecently left SNFJust moved back to US after living abroadConsult with BSSA if need assistance finding SEP
33. Misc. pointsClients on LIS due to eligibility for QMB/SLMB/SLMB+ must be in a Part D plan. SeniorCare will not work without Part D. SHIP counselor error is easily fixed. Talk to BSSA. When in doubt, call BSSA. Region V is fixer of last resort. Call plan & Medicare first, consult with BSSA. (Put “urgent need for meds” in subject line if urgent.)Review cases with Oct, Nov & Dec birthdays—turning 65—IEP & OEP2 enrollments (2020, 2021)SilverScript Smart Rx has $7.30 monthly premiumNOT a low-cost plan!COVID vaccine will be covered under Part B, not Part D
34. Medicare Part B
35. Medicare Part B--General Enrollment PeriodMust enroll between January 1-March 31Part B coverage will begin July 1Late enrollment penalty will applyCoordinating Part D SEP = April, May, June!NOTES:If eligible for QMB, SLMB or SLMB+, do not use GEP. If active employment 8 month Part B SEP. Do not use GEP. Loss of Medicaid mid-year must use GEP to get Part B.