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Medicare Part B and D: Impact in the Transplant Population and Transplant Centers

Medicare Part B and D: Impact in the Transplant Population and Transplant Centers. Kristin Fox-Smith, BS, MPA University of Utah Pharmacy Administration. Topics For Discussion. Eligibility and Enrollment for Transplant Medicare Advantage Plans Dual Eligible Enrollment

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Medicare Part B and D: Impact in the Transplant Population and Transplant Centers

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  1. Medicare Part B and D: Impact in the Transplant Population and Transplant Centers Kristin Fox-Smith, BS, MPA University of Utah Pharmacy Administration

  2. Topics For Discussion • Eligibility and Enrollment for Transplant • Medicare Advantage Plans • Dual Eligible Enrollment • Limited Income Subsidy and Extra Help • Medicare Part B vs. Medicare Part D • Legality/Compliance Issues for Medicare Part D • Donut Hole/Coverage Gap • Options for Assistance During Gap • Changes for 2008 and Beyond

  3. Medicare Overview

  4. Eligibility and Enrollment for Medicare Part D • Must be eligible to Medicare Part A and/or enrolled in Part B • Reside in plan’s service area • Enroll in Medicare drug plan, higher premium for delay in enrollment • Initial enrollment: Nov 15, 2005 – May 15, 2006 • Enrollment 2006 and beyond: Nov 15 – Dec 31

  5. Eligibility for Medicare Covered Transplant Patients • Medicare eligibility for kidney transplant patients is automatic for 36 months following transplant • Medicare eligibility for heart, lung, liver, and pancreas transplant patients is NOT automatic. Patients must be over age 65 and/or disabled to be eligible for Medicare benefits • If a patient qualifies for Medicare only because they have end-stage renal disease, the Medicare coverage will end 36 months after the transplant and the patient won't qualify for the extension unless they regain eligibility at a later time

  6. Coverage Guidelines for Immunosuppressive Medications • Effective for all immunosuppressive drugs furnished on or after December 21, 2000, there is no longer any time limit for immunosuppressive drugs following transplantation – previously 36 months • This policy applies to all Medicare beneficiaries who meet all of the other program requirements for coverage under this benefit • Transplant patients with ESRD only will be eligible for Medicare, including Part D for 36 months • Transplant patients with Medicare can keep Medicare and Part D indefinitely if they have Medicare due to age or disability

  7. Medicare Coverage Continued • Although Part D formularies must only have 2 drugs per class, they must have “all or essentially all” immunosuppressants • Covered under Part B if patient meets criteria • Covered under Part D if on formulary and patient does not meet Part B criteria

  8. Medicare Advantage PlansMedicare Part C • Medicare Advantage (MA) • Medicare Advantage + Part D (MA-PD) • In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act was changed to pay Medicare Advantage plans more than is paid under traditional Medicare • Average increase in payment to MA plans is 12%, can be as high as 50% • Medicare Advantage enrollment increased by more than 40 percent between December 2005 and May 2007. As of May 2007, one in five beneficiaries were enrolled in a Medicare Advantage plan

  9. Medicare Advantage Cons: • Network restriction • Once you enroll in a Medicare Advantage plan, you no longer have health coverage through Medicare • Medicare pays the insurance company a pre-negotiated monthly rate as long as beneficiary is enrolled • Leaves many gaps in coverage – doctor visits, hospital visits, skilled nursing care, emergency services • Physicians are restricted by plan with the level of care they can provide, are forced to abide by plans network and level of treatment

  10. Medicare Advantage and ESRD If you develop ESRD while enrolled in an MA plan, you can continue your coverage in that MA plan. However, if you have ESRD and you are not already enrolled in a Medicare Advantage plan, you can not enroll in one, and insurance companies do NOT have to sell you a Medigap policy when you go on Medicare

  11. Special Enrollment Period • Permanent move out of the plan service area • Individual entering, residing in, or leaving a long-term care facility - $0 co-pays for patients accessing this benefit • Involuntary loss, reduction, or non-notification of coverage as good or better than Medicare • Other exceptional circumstances • Dual eligibles – continued enrollment, all year long!

  12. New to Medicare • All individual’s newly entitled to Medicare are given a 7 month initial enrollment period for Part D: • 3 months before month of eligibility – Coverage begins on date eligible • Month of eligibility – Coverage begins the first of the following month • 3 months after month of eligibility – Coverage begins first of the month after month of application

  13. Eligibility for Extra Help • Income • Below 150% Federal poverty level • $1,148.63 per month for an individual* or • $1,540.13 per month for a married couple* • Based on family size • Resources • Up to $11,500 (individual) • Up to $23,000 (married couple living together) • Includes $1,500/person funeral or burial expenses • Counts savings and stocks • Does not count home the person lives in *Higher amounts for Alaska and Hawaii -Not available in the U.S. territories

  14. Extra Help

  15. What Limited Income Subsidy Really Means • Individuals eligible for Limited Income Subsidy (LIS) are approved by Social Security, but must be enrolled by Center for Medicare and Medicaid Services (CMS) • LIS verification MUST be provided to the Part D plan that the patient is signed up with, pharmacy can NOT make these changes, and has no power to override them!

  16. Medicare Prescription Drug Coverage • Prescription drugs, biologicals, insulin • Medical supplies associated with injection of insulin • When a drug is not FDA approved for an indication but it has clinical literature to support its use • Vaccines not covered by Part B • A drug plan may not cover all drugs • Brand name and generic drugs will be in each formulary

  17. Formulary Review • Plan formulary must be developed by a Pharmacy and Therapeutics Committee • Formulary must include at least 2 drugs in each therapeutic category and class of covered drugs and in certain categories, must contain “all or substantially all the medications” • Antiretrovirals • Antineoplastics • Immunosuppressants • Antidepressants • Antipsychotics • Anticonvulsants

  18. Excluded Drugs • Drugs for • Anorexia, weight loss, or weight gain • Fertility • Cosmetic purposes or hair growth • Symptomatic relief of cough and colds • Prescription vitamins and mineral products • Except prenatal vitamins and fluoride preparations • Non-prescription drugs • Barbiturates • Benzodiazepines

  19. Medicare Part B Versus Medicare PrescriptionDrug Coverage • There WILL still be Part A and Part B drugs • Part A drugs • Drugs bundled together with hospital payment • Part B drugs • 1. Drugs delivered in MD office • 2. Drugs delivered in by medical equipment • 3. Few outpatient chemo and immunosupp’s • 4. Hospital outpatient drugs billed separately • 5. ESRD drugs (i.e. EPO)

  20. Medicare Parts B and D Coverage Issues • In retail, home infusion, and long-term care settings, access to Medicare benefit remains the same • Medicare Part B covers medications for patients who received Medicare covered transplants • Medicare Part D covers medications for patients who did not receive a Medicare covered transplant, and for patients who are outside their 36 month coverage window

  21. Solutions to Medicare Part B vs. D Problems • Implementation of mandatory note on all immunosuppressive prescriptions “Medicare Part B covered drug” • This will force the pharmacy to look at the prescription and verify if they are a Medicare Part B supplier • If prescription is filled by NON Medicare Part B supplier, responsibility falls back on pharmacy, not patient, in event of audit or retraction

  22. Status Report • Of the 5 million Americans with Medicare who have not yet enrolled in Medicare Part D, over 3 million are expected to meet low-income criteria, and will be eligible to sign up without penalty through the end of the year • 2008 enrollment begins soon – November 15 – December 31, 2007 is open enrollment • Importance of choosing Medicare plan that has broadest formulary coverage

  23. Medicare Part D “Donut Hole” • The standard statutory Part D drug benefit provides for drug coverage for formulary drugs up to an initial coverage limit of $2400 • Upon reaching this coverage limit, beneficiaries fall into the Donut Hole, and become responsible for the full cost of their formulary medications • Beneficiaries do not get out of this coverage gap until they incur $3850 in out-of-pocket costs for drugs on their Part D formulary • Also responsible for the full costs of non-formulary and non-covered drugs • The deductible, initial coverage limit, and out-of-pocket threshold has increased yearly since Medicare Part D inception

  24. Donut Hole • In 2007, 13 states offer no Part D plans providing coverage during the donut hole • The number of seniors without access to donut hole coverage was 375,000 in 2006, jumped to 6.6 million by July 2007 • Sierra Rx Plus, offering brand name coverage during coverage gap in 2007 (only plan available in the West for brand coverage) reported a $3 million loss in January • By February, Sierra announced that brand coverage would not be offered for 2008 (all three plans) • Humana was only plan to offer this unlimited coverage in 2006, did not offer for 2007

  25. Options During the Coverage Gap • $4 generic prescription initiative – started with WalMart in 2006, 331 generics included, this model now adopted at hundreds of retail pharmacies (Target, Kmart) • Of the 10 most prescribed drugs in the United States, only Amoxicillin is available on the $4 plan • 4 of the top 20 prescribed medications are included in this $4 plan • Multiple strengths of drugs on plan are also $4

  26. Coverage Gap Options • Most manufacturers do NOT disclose income guidelines for patient assistance, but average income for household of 1 is $32,000 and household of 2 is $45,000 • Must prove patient’s inability to pay out-of-pocket expenses • Coverage IS available for patients with commercial or Medicare Part D coverage!

  27. Options During the Coverage Gap • Important that patient continue to use Medicare Part D card! • Plan’s negotiated prices are generally lower than retail, result in patient savings • Money spent on covered drugs counts towards True Out-Of-Pocket (TrOOP) • Part D plan will track spending, and monitor when coverage gap ends, reinstating pharmacy benefits

  28. Patient Assistance Opportunities • Abbott (Gengraf) – allows assistance for any insured or non-insured patient, Medicare Part D covered as well. Income guidelines not disclosed, approximately $45,000 annually • Astellas (Prograf) – allows assistance for any insured or non-insured patient, Medicare Part D covered as well. Income guidelines also approximately $45,000 annually • Novartis (Neoral/Myfortic) – does not allow insured patients, commercial or Medicare. Income guidelines approximately $45,000 annually

  29. Patient Assistance Opportunities • Pfizer (Vfend) – allows for Medicare Part D recipients who have reached their doughnut hole to receive free drug, does allow assistance for commercial/private insured. Pfizer does allow “hardship” appeal for insured patients with no ability to pay for drug. Income guideline for household of one is $20,420, household of two is $27,380 • Roche (Cellcept) – allows assistance for insured or non-insured patient, Medicare Part D included. Income guidelines approximately $45,000 annually • Wyeth (Rapamune) – does not allow coverage for insured patients with exception of Medicare Part D patients in doughnut hole. Income guidelines approximately $45,000 annually

  30. HealthWell Foundation • The HealthWell Foundation® takes into account an individual's financial, medical, and insurance situation when determining who is eligible for assistance • Financial criteria are based on multiples of the federal poverty level, which takes into account a family’s size. Families with incomes up to four times the federal poverty level may qualify. The Foundation also considers the cost of living in a particular city or state • The Foundation asks for the patient's diagnosis, which must be verified by a physician signature, and the patient must receive treatment dispensed in the United States • Individuals covered by private insurance, employer-sponsored plans, Medicare or Medicaid may be eligible

  31. HealthWell Foundation • When enrolled, the Foundation allocates each patient a grant for full or partial assistance for up to 12 months. Patients then submit invoices or receipts to receive monetary awards. The foundation typically sends awards directly to the insurer, pharmacy, physician, or other provider. However, in some cases it may send awards directly to patients to reimburse them for expenses they must pay themselves • The HealthWell Foundation does not restrict the medications that patients use as long as the medication is approved by the Food and Drug Administration and falls within a funded area. The Foundation also does not restrict the provider or pharmacy that the patient selects

  32. HealthWell Foundation • The Foundation is able to help patients receiving treatments for selected diseases • Immunosuppressive treatment for solid organ transplant recipients is covered disease • Cellcept, Gengraf, Myfortic, Neoral, and Prograf are all covered by the Foundation • University has been able to receive assistance for 18 patients, average benefit per year $16,000

  33. HealthWell Foundation • For more information, please visit our Frequently Asked Questions (FAQ) page, or contact us at • The HealthWell Foundation®P.O. Box 4133 Gaithersburg, MD 20878 • info@healthwellfoundation.org • 1-800-675-8416 • 9:30 am to 5:00 pm EST • Monday through Friday • Fax: (800) 282-7692 • The HealthWell Foundation is closed on Federal holidays. For a list of holidays, go to http://www.opm.gov/fedhol.

  34. Patient Services Incorporated • Patient Services Incorporated (PSI) is a non-profit organization primarily dedicated to providing health insurance premium assistance, pharmacy co-payment assistance and co-payment waiver assistance for persons with specific expensive chronic illnesses. • Established in February 1989, PSI has developed into a national organization serving 50 states. Its services are made possible through private/corporate donations and grants. Families requiring assistance in the purchasing/maintaining of COBRAs, high risk insurance pools, conversion policies and open enrollment health insurance plans are given

  35. Patient Services Incorporated • Ask anyone to name their most valuable possessions and surely "health" will be rated among the top answers. But for persons affected by expensive chronic medical disorders, "health" becomes an unaffordable luxury instead of a dire necessity. Disorders affecting the blood, lungs, kidneys, nervous or digestive systems are oftentimes treatable, but the annual expense of routine treatment can range from $30,000--$150,000. This translates into annual out-of-pocket co-pay expenses ranging from $6,000 to $10,000--an amount equivalent to a year's rent or mortgage payments. High risk insurance premiums ranging from $3,600 to $17,000 per year can compound that figure and realistically a family's annual out-of-pocket healthcare costs may range from $9,600 to $27,000 per year.

  36. Patient Services Incorporated • PSI provides the following programs which will complement any established and existing "patient assistance program". According to the particular chronic illness or medical disorder, PSI can provide one of the following services:Premium Assistance Program • Cobra Payments • High-risk Payments • Open-enrollment Payments • Guaranteed Issue Payments • Full Assistance or Share-of-Cost   Copayment Assistance Program

  37. Patient Services Incorporated • Full Assistance or Share-of-Cost • Spend down Assistance Financial Hardship Waiver Program • Determine eligibility for Copayment Waiver • Determine eligibility for Compassionate Product • Coverage is available for solid organ transplant anti-rejection therapy

  38. Patient Services Incorporated • Telephone: 800-366-7741 Fax: 804-744-5407 Email: uneedpsi@uneedpsi.org Patient Services Inc.P.O. Box 1602Midlothian, VA 23113

  39. Changes on the Horizon • CMS will NOT be looking at changing Medicare Part B and Medicare Part D covered drugs until 2008 at the earliest • Patients will continue to have two deductibles and two co-insurance and co-pay structures • Deductibles and co-pays must not be waived, this is an illegal practice and CMS can revoke a pharmacies ability to dispense medications for Medicare programs

  40. Successes at the University of Utah • Patients are given detailed information about Medicare Part B coverage and the importance of using a Medicare Part B supplier • University of Utah contacts patients each month, one week before refills are due, reminding them to refill their medications • Mail-order system in place, all medications are sent by 2nd day Federal Express – at no charge to patients

  41. Successes at the University of Utah • Discharge process in place – all patients are counseled regarding their individualized pharmacy benefit prior to discharge • Discharge medications are provided by the University of Utah • Medicare application assistance is provided by social work, financial counselors, and pharmacy department

  42. Successes at the University of Utah • 89% of all patients receiving a transplant at the University of Utah continue to use our pharmacy services • Compliance and customer service satisfaction are high, as patients are assisted through the “maze” of Medicare and commercial drug coverage by knowledgeable pharmacy staff • Patients transplanted at other institutions and outside the state have found their way to the University pharmacy system as a result of seamless process for patients

  43. Successes at the University of Utah • All primary and secondary billing handled by the pharmacy, patients are removed from this process • Medicare coverage is tracked by patient from time of discharge, and patients are notified prior to Medicare ending • If sufficient coverage is not in place, patient assistance and financial hardship paperwork is started PRIOR to Medicare ending

  44. Contact Information • Kristin Fox-Smith – Pharmacy Billing Manager, University of Utah • Kristin.fox@hsc.utah.edu

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