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Are You Prepared to Counsel Your Medicare Patients on Part D Drug Benefits
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Sue U. Malone As November 15 approaches you can expect to start hearing from your Medicare patients seeking advice on how to proceed in selecting Medicare’s new prescription drug coverage (Part D). The initial enrollment period runs from November 15 through May 15, 2006. However, if an enrollee signs up by December 31, coverage will commence on January 1. For the first time an outpatient prescription drug benefit is being offered to all Medicare beneficiaries, designed to lower the cost of prescription drugs for most senior and disabled Medicare beneficiaries. This new benefit presents a wide, and potentially confusing, array of new options to California’s four million Medicare beneficiaries, the largest and most diverse Medicare population of any state. Under the standard Medicare drug benefit, a minimum of two drugs in each of 146 therapeutic classes must be covered by participating insurance plans. For this standard coverage, beneficiaries in 2006 will pay a premium, which will vary by plan, but is estimated to average $37 per month nationally. In addition, annually there is a $250 deductible; a 25 percent cost-sharing, up to an initial coverage limit of $2,250 in total drug spending; 100 percent of a beneficiary’s costs covered from $2,250 to $5,100 in total drug spending, and 5 percent cost sharing thereafter. Beneficiaries must enroll in a private Medicare insurance plan. There are two types of drug plans: stand-alone prescription drug plans for beneficiaries who remain in the Medicare fee-for-service delivery system, and Medicare Advantage managed care plans that will provide all services covered by Medicare including drug coverage. Medicare Advantage plans enroll 32 percent of Medicare beneficiaries in California. The Medicare drug plans will be required to offer enrollees the standard benefit, but to confuse the situation, they may offer an actuarially equivalent benefit with modified cost-sharing. For example, plans may require higher cost-sharing with a small gap in coverage; or, they may charge tiered copayments in lieu of percentage cost-sharing. Drug plans may also offer more comprehensive coverage with higher premiums. In addition, the plans will establish formularies subject to federal approval, which will limit the specific drugs covered. In most cases, participation in the drug benefit is voluntary, except for dual-eligibles (Medi-Medi) where participation is mandatory if the beneficiary is to continue receiving drug coverage. Medicare will no long pay for Medicaid expenditures for prescription drugs except for drugs excluded from the Medicare drug benefit. As detailed last month, the Health Plan of San Mateo has received authorization from CMS to implement Care Advantage, a benefit plan only for the Medi-Medi population. To date, Medicare has approved 19 health plans to offer drug coverage to Northern California’s Medicare beneficiaries. Those offering Medicare Advantage are Kaiser Permanente, Secure Horizons, Blue Cross, and Health Net. The companies offering the stand-alone Medicare Prescription Drug Plans are Blue Shield, Prescription Pathway, Blue Cross, SilverScript, CIGNA, RxAmerica, YOURxPLAN (Medco), AdvantraRx (Coventry), Health Net, United American Insurance, Community Care Rx (MemberHealth), Aetna Life, United HealthCare, Humana, SierraRx, PacifCare Life, Unicare, and WellCare. For a list of the prescription drug plans available and the costs associated with each plan, look on the Web at www.medicare.gov or call the SMCMA and we will fax or mail you a copy. I hope this brief summary will assist you in responding to your Medicare patients when they seek your advice about the new Medicare drug program. It is rather complex, so good luck.
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