10) Medicare

what is the cost of medications for patients with dual coverage?

$1.20 for covered generic $3.60 for covered brand Medi-Cal will pay for Medicare premiums, deductibles, copays/coinsurances, drugs during the coverage gap & catastrophic coverage (pt pays $0)

TOTAL costs from $______ to $_____ represent the Donut Hole, or "coverage gap"

$3310 to $7062.50 equal to $4850 in OOP spending

According to the CMS, what is the max deductible a plan can have?

$360

Coinsurance represents the window from $____ to $____

$360 to $3310 - the patient is responsible for 25% of additional drug costs --> 25% of $2950 ($3310-$36) = $737.50 Plan: 75% of $2950 = $2212.50

before catastrophic coverage kicks in, beneficiarie's total drug costs (patient + plan) must reach $_____

$7062.50

SNF vs. LTC

Skilled Nursing Facility (SNF) you need a higher level of care. SKILLED nursing activity ○ Ex. Learning how to walk again Long-Term Care Facility: custodial care (basic things) ○ Ex like brushing teeth, bathing, etc

Tiered Co-Payment

Tier 1: Generics (lowest cost) Tier 2: Preferred Brand-Name Meds (medium cost) Tier 3: Non-preferred Brands (high cost) Specialty Tier (Tier 4): Unique, high-cost drugs (highest cost)

Cosinsurance definition

a % of the drug's cost that the patient must pay 25% coinsurance payment for plan covered drugs after the annual deductible is met - up to the next $2950 (from $360 to $3310) in covered drug expenses

what does Medicare NOT cover?

hearing aids eyeglasses dental care acupuncture chiropractic care long-term care at home or in a nursing home, when the care you need is primarily personal care services/custodial care Health care outside the US cosmetic surgery

Medicare Prescription Drug, Improvement, and Modernization Act

AKA Medicare Moderniztion Act (MMA) Signed into Law on 12/8/2003 Most sweeping legislation affecting Medicare Benefits since its inception in 1965 Administered by Centers for Medicare & Medicaid Services (CMS) Choose and *enroll* in a private plan approved by Medicare Helps pay for *prescription* drugs

Hep B RIsk Categories *Medicare Part B will cover Hep B vaccines only for pts at medium tohigh risk

intermediate risk groups: - staff in institutions for the mentally handicapped - workers in health care professions who have frequent contact with blood/blood-derived body fluids during routine work high risk: - ESRD - hemophilia - clients of institutions for the mentally handicapped - those who live in the same household as a HBV carrier - homosexual men - illicit injectable drug abusers - diabetes

What is Medicare?

Federal health insurance program created in 1965 Covers 55+ million Americans Medicare benefits were estimated at $519 billion in 2013, accounting for 16% of the federal budget Provides coverage and plays a vital role in ensuring the health of beneficiaries by covering many important health care services

HMO vs PPO vs PFFS Health care from any doctor or hospital?

HMO: No. you must get your care from the providers in the plan's network PPO: Yes; but out-of-network providers cost more PFFS: Yes

HMO vs PPO vs PFFS Need to choose primary care doctor? (gate-keeper)

HMO: YES PPO: NO PFFS: NO

HMO vs PPO vs PFFS Rx Drug Coverage?

HMO: if you want Rx drug coverage (and it is available), must get it from the plan PPO: same as HMO PFFS: sometimes

Medicare Advantage Plan Types

HMOs, PPOs, Private FFS (fee for service)

eligibility for Medi-Cal

must be california resident (proof of residency) AND limited income and resources (eligibility is based on FPL - federal poverty threshold)

What other supplies and vaccines does Part D cover?

often includes supplies associated with injection of insulin Coverage of vaccine and administration costs all drug plans must include all commercially available vaccines - exception: those vaccines covered under Part B - still paying co-pay with Part D unlike Part B

What is covered by Medicare Part A for hospice care?

patient has nominal co-pay - no more than $5 Covered: - all items/services needed for sx control and pain relief (including drugs); anything except drugs that are curative in nature - medical/nursing/social services - homemaker/aide services - spiritual and grief counseling (for family) - respite care

What type of coverage does Medicare Part A provide?

pays for *inpatient* care in hospitals* - hospital stays - Skilled nursing facilities (different than long term care facilities!!) - home health (e.g. nursing visits, infusing services) - hospice

What is a premium?

set $ amount that the patient pays each month to the drug plan sponsor - depends on plan selection, residential location, income, and if they receive governmental assistance

Medicare Part B VS Part D

some drugs/drug categories may be covered by either part B or Part D depending on the situation Drug Classes where such uncertainty exists: - insulin - vaccines - immunosuppressants - oral anti-cancer drugs - oral anti-emetic drugs - erythropoietin

Medicare Part D

started January 1, 2006 *Self-enrollment* into Part D voluntary, choose to enroll - penalty assessed if a patient does not enroll when eligible and chooses to enroll later offers generic AND brand prescription drug coverage

Dual-Eligible Beneficiaries

those who qualify for both Medicare and Medical benefits = "dual-eligible" or "medi-medi"

In the co-insurance phase, patients pay ____% of drug costs

25%

Each drug plan sponsor can offer a maximum of ____ plans

3

In the phase 3 of the Part D Standard Benefit, the "coverage gap", patients pay ___% of brand name drug costs, and ___% of generic drug costs

45% brand 58% generic

In "catastrophic coverage" patients pay ___% of the *covered* drug cost over $7062.50 OR $____ for generic, $____ for brand

5% OR nominal co-pay: 1. $2.95 for generic 2. $7.40 brand WHATEVER IS MORE

What are the 4 parts of Medicare?

A. Hospital Coverage B. Outpatient Medical Coverage (doctor visits) C. Medicare Advantage (A + B +/- D = C) - everything that is covered by Part A and everything covered in part B, with/without part D D. Prescription Drug Coverage

What is Medi-Cal?

California's name for the federal Medicaid program - public health insurance program which provides needed health care services for those with limited economic means (income/resources) - jointly funded by federal and state government - many patients receive both medicare and medical --> must qualify for each separately --> "dual eligibles" or "medi-medi's"

Medicare Part B VS Part D Coverage Category: Immunosuppressants Scenario: drug used for immunosuppressive therapy in a beneficiary that received a transplant from a medicare-approved facility

Community Pharmacy Setting Billing: Part B- Medicare Covered Transplant Part D- for all other situations

Medicare Part B VS Part D Coverage Category: Oral Chemotherapy agents used in Cancer Treatment Scenario: oral chemotherapy drugs for which there is an infusible version of the drug

Community Pharmacy Setting Billing: Part B- for cancer treatment Part D- for all other indications

Medicare Part B VS Part D Coverage Category: Erythropoietin Scenario: Treatment of anemia for a person with ESRD (End-Stage Renal Disease) who is on dialysis

Community Pharmacy Setting Billing: Part B: Treatment of anemia for beneficiaries with chronic renal failure undergoing dialysis Part D: for all other situations e.g. 1. patients with HIV (AZT have anemia as result of HIV) 2. anemia that results from pts receiving cancer tx

Medicare Part B VS Part D Scenario: prophylactic vaccines

Community pharmacy setting billing: Part B- flu, pneumococcal, Hep B (med-high risk) Part D- for all other vaccines

Medicare Part B VS Part D Scenario: Beneficiary would like to fill their insulin

Community pharmacy setting billing: Part B- only gives insulin when administered with an insulin pump Part D- all other situations

Hospice

Covered by medicare part A - doctor certifies that you are terminally ill and have ≤6 months to live if your illness runs its normal course goal of hospice care: make pt. as comfortable as possible; paliative not curative care!

What does Medi-Cal Cover?

Medically necessary health care - physician visits - x-rays and lab tests - hospital and nursing home care - home health care - *some dental care* (not covered in Medicare...this is why dual coverage = less gaps in coverage) - prosthetic/orthopedic devices - *eyeglasses and hearing aids* - medical equipment - ambulance services - hospice care - drugs

What drugs fall on the medicare "excluded" list?

--> they can cover these drugs, but in return they charge higher monthly premium: Weight-loss or weight-gain Fertility Promotion Cosmetic Purposes Erectile Dysfunction used for treatment of sexual dysfunction Products for Cough/Cold Sx relief Rx vitamins/minerals (except prenatal, niacin, and fluoride preparations) *OTC DRUGS* - never covered!

what are the 6 therapeutic categories all Medicare Part D plans must cover all drugs within?

1. Antidepressants 2. Anticonvulsants 3. Antipsychotics 4. Antiretrovirals 5. Antineoplastic 6. Immunosuppressants

2 ways to get prescription drug coverage (Part D) through Medicare

1. Medicare Advantage Prescription Drug Plan (MA-PD) - wraps hospital/medical and prescription coverage together - varies by county- each county has only certain plans available - each company may have several different plans - must have Part A AND Part B 2. A stand-alone prescription drug plan (PDP) added to traditional Medicare - varies by region (23 plans available) - some are also national plans - Must have Part A AND/OR Part B --> CAN NEVER HAVE BOTH 1 AND 2

Medi-Cal Benefits Identification Cared (BIC) - what is on it?

ID No. Name DATE OF BIRTH (different from Medicare card) Issue Date

Medicare VS Medi-Cal - Funding

Medicare: - federally funded insurance for those 65+, renal failure, disabled, ALS or exposed to environmental hazard Medical: - federal and state funded Medical insurance for people with limited income/resources

Medicare VS Medi-Cal - Administration

Medicare: federally administered Medical: state administered

What are examples of preventative services?

NO COST TO PATIENT - not even copay BMD Cardiovascular Depression Screening Diabetes Screenings Eye Exams (eye glasses not covered; eye exams only covered for pts w/ diabetes or at other high risk of glaucoma) Mammograms Pap Test/Pelvic Exam Prostate Screening Smoking Cessation Vaccinations (flu, pneumococcal, *medium to high risk* hep B) ...and more

What pieces of information are found on the Medicare Beneficiary Card?

Name of Beneficiary Medicare Claim Number Sex Medicare Part A/Part B (NOT C OR B) Effective Date

What drugs does Medicare Part D cover?

Part D plans have minimum formulary requirements Each plan will have its own formulary - *however each formulary must include all therapeutic classes of drugs* - *must cover a minimum of two agents from each drug class* - the two drug minimum must be met through the provision of *two chemically distinct drugs* Plans must have an authorization process for non-formulary medications All plans should cover all or substantially all drugs in 6 therapeutic categories ○ Antidepressants ○ Anticonvulsants ○ Antipsychotics ○ Antiretrovirals ○ Antineoplastic ○ Immunosuppressants --> There are some exceptions If drugs comes in tablets and capsules...don't have to cover both. Paxil comes in paxil IR and CR. So you don't have to cover both forms. Hence why its "substantially all"

Medicare VS Medi-Cal - Primary payers

When combined with Medi-Cal, Medicare is the primary payer for drugs Medi-Cal is only the primary payer of drugs when it's by itself

What type of coverage does Medicare Part C provide?

aka Medicare Advantage Plans - *Private insurance companies* approved by Medicare provide this coverage - must cover at least all services provided by Medicare Parts A and B - often offer added services (vision, dental, hearing, chiropractic, wellness programs) These plans offer combined coverage of Part A, Part B, and in most cases, Part D benefits and roll them into one A+B+/-D=C IMPORTANT NOTE: if you belong to a Medicare Advantage Plan, and the plan offer rx drug coverage, you must get your drug coverage through the plan.

What is a deductible?

amount that must be spent on drugs by the patient before coverage begins

What is Medicare Standard Coverage?

at minimum, plan sponsors must offer a plan that is equivalent ("actuarially equivalent") to the "standard benefit plan". this includes: - monthly premium - yearly deductible - co-insurance (or co-pays) - coverage gap - catastrophic coverage

respite care

benefit of Medicare in which you can get inpatient care from hospice if your usual caregiver (e.g. family member) needs a rest

Medicare Part B VS Part D Coverage Category: Oral Anti-Emetic Drugs Scenario: Oral Anti-Nausea Drugs Used in Cancer Treatment as replacement for IV anti-emetic drugs before, at, or within 48 hours of chemotherapy

community pharmacy setting billing: Part B: within 48 hours of receiving chemo Part D: for all other situations

What type of coverage does Medicare Part B provide?

covers *outpatient* medical services - physician visits - outpatient care - Durable Medical Equipment - preventative services - certain drugs*

What are examples of Durable Medical Equipment? (DME)

diabetes supplies (blood glucose monitors, test strips, lancets, insulin - if used w/ external pump) - syringes would go to Part D! prosthetic/orthotic items oxygen wheelchairs walkers nebulizers

Who is eligible for Medicare?

you are eligible for Medicare if you are *a citizen of the US or have been a legal resident for at least 5 years* AND one or more of the following: - 65+ y/o - permanently disabled (blind, permanently paraplegic, brain injury, etc.) - End-stage renal disease (ESRD) ○ Undergoing dialysis treatment or receiving kidney transplant - Amyotrophic lateral sclerosis (ALS) ~ leugaric's disease. ○ Progressive neurodegenerative disease affecting the cells of your brain ○ Die w/in 3 years of having this disease due to respiratory collapse. Therefore waiting period is shorter to qualify! - Exposed to environmental health hazards (~100k people) ○ As a result of that exposure you have developed some health related complication (place has to be emergency declaration)

which drugs are "excluded" by Part D, but covered by Medi-Cal?

○ Symptomatic Relief (phenergan Dm, phenergen codeine) ○ Vitamins / Minerals - Vitamin B 12, folic acid ○ OTC Drugs - No OTC drugs covered in Medicare (no matter what); but Medical might cover ASA, APAP, antifungals, etc.