avella medicare b & d education

Medicare B & D EducationChanges for 2014 - 2015

September 20, 2014

Medicare B Overview

3 | Confidential and proprietary

Medicare Drug Coverage Under Part B (Medical Insurance)

Does Medicare cover drugs under Part B?

• Yes, but only a limited number of drugs

• Generally, Part B covers drugs that aren’t usually self-administered

• Coverage is usually limited to drugs given by infusion or injection

Part B covers the following drugs

• Vaccinations

• Durable Medical Equipment (DME)

• Injectable drugs

• Osteoporosis Drugs (if patient or family unable to give injection)

• ESA’s


Medicare Drug Coverage Under Part B (Medical Insurance)

Part B covers the following drugs (cont.)• Blood Clotting Factors

• Immunosuppressive Drugs (transplant patients)

• Oral Anti-Cancer Drugs: If the same drug is available in injectable form

• Capecitabine (Xeloda®)

• Cyclophosphamide (Cytoxan®)

• Temozolomide (Temodar®)

• Busulfan (Myleran®)

• Etoposide (VePesid®)

• Melphalan (Alkeran®)

As new oral anti-cancer drugs become available, Part B may cover them.


Medicare B Authorized to Order

• Treating Physician, MD, or DO

• Physician Assistant

• Meet definition of physician assistant found in Section 1861

(aa)(5)(A) of Social Security Act

• Treating beneficiary for condition for which item is needed

• Practice under supervision of MD or DO

• Has own NPI

• Permitted to perform services in accordance with state law

• Nurse Practitioner or Clinical Nurse Specialist

• Treating beneficiary for condition for which item is needed

• Practicing independently of physician

• Bill Medicare for other covered services using own NPI

• Permitted to do in state where services are rendered

(2014, June) Chapter 3. DME MAC Jurisdiction D Supplier Manual


Medicare B Detailed Written Order Elements

• Beneficiary’s name

• Physician’s name

• Date of the order and the start date, if start date is different from the date of the order

• Detailed description of the item(s)

• Physician signature and signature date• Signature must include physician credentials

• Stamps not allowed

• Item(s) to be dispensed

• Dosage or concentration, if applicable

• Route of administration

• Frequency of use

• Duration of infusion, if applicable

• Number of refills



Medicare B Acceptable Detailed Written

Order

• May be completed by someone other than

physician

• Treating physician must review, sign, and date

• Acceptable orders

• Fax

• Photocopy

• Electronic

• Original pen and ink



Importance of a Valid Script

• Avella is unable to fill a prescription if sufficient

documentation is not received from the provider.

• Payment for the prescription from Medicare would be

lost if an audit request is received.

• Avella could lose their contract with Medicare for not

being in compliance with the documentation

requirements as outlined in the Supplier Manual.

Medicare D Overview


Medicare Drug Coverage Under Part D (Medicare Prescription Drug Coverage)

What drugs are covered under Medicare Part D ?

Medicare offers comprehensive prescription coverage to people with Medicare under Part D. A Part D-covered drug must meet all of these conditions:

• The drug is only available by prescription

• The drug is approved by the FDA

• The drug is used and sold in the United States

• The drug is used for a medically-accepted indication, as defined under the Social Security Act

Medicare drug plans cover generic and brand-name drugs

All Medicare drug plans must generally cover at least 2 drugs in each category of drugs


Medicare Drug Coverage Under Part D (Medicare Prescription Drug Coverage)

Medicare drug plans must also cover all drugs, with a few

exceptions in 6 categories:

• Antidepressants

• Anticonvulsants

• Antipsychotics

• Antiretrovirals

• Immunosuppressants

• Antineoplastics

Does Part D cover vaccinations?

• Yes, except flu and pneumococcal covered under Part B


Drugs Not Covered Under Part D

Part D cannot cover drugs that would be covered under Part A or Part B

The following drugs cannot be included in standard coverage:• Benzodiazepines

• Barbiturates

• Drugs for weight loss or gain

• Drugs for erectile dysfunction

• Drugs for relief of cough and colds

• Non-prescription drugs

• Drugs used for cosmetic purposes or hair growth

• Drugs used to promote fertility

• Prescription vitamins and minerals, except prenatal vitamin and fluoride preparation products


CMS Part D 2015 Standard

Benefit Model Plan Details

Initial Deductible • from $310 in 2014 to $320 in 2015

Initial Coverage Limit

• from $2,850 in 2014 to $2,960 in 2015

Out-of-Pocket Threshold • from $4,550 in 2014 to $4,700 in 2015

Minimum Cost sharing in the Catastrophic Coverage Portion of the Benefit• from the greater of 5% or $2.55 for generic or preferred drug that is a multi-

source drug and the greater of 5% or $6.35 for all other drugs in 2014 to $2.65 for generic or preferred drug and $6.60 for all other drugs

Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees• Same as above for 2015


CMS Part D 2015 Details

• The CMS model plan has a $320 deductible – some plans have no deductible and have “first dollar” coverage

• After the insured has paid the first $320, Medicare will cover 75% of the covered prescription costs up to $2,960 ($1,980) initial coverage limit

• The insured person pays the remaining 25% ($660)

• After the $2,960, the insured person pays 100% of the next $3,720, this is the so called “donut hole” or coverage gap.

• After $4,700 (maximum out-of-pocket cost), Catastrophic Coverage benefits begin.


Important Medicare Part D Dates for 2014-2015

October 15 to December 7, 2014• Annual Coordinated Enrollment Period

• Opportunity to select 2015 Coverage

January 1, 2015 • Medicare Part D Plan becomes effective

January 1 to February 14, 2015• The Dis-enrollment Period takes effect. Members of Medicare

Advantage plans have an opportunity to return to Original Medicare and a Stand-alone Medicare Part D plan. The Open Enrollment Period of prior years (Jan 1st - Mar 31) has been discontinued.


15 Tips to Help with Drug Costs or Survive

a Fall into the “Donut Hole”

1. Apply for extra federal help

2. Determine what your state has to offer

3. Contact the company that makes your medication

4. Contact Partnership for Prescription Assistance

5. Visit those who know

6. Comparison shop

7. Have a talk with your pharmacist (Don’t throw her/him to the curb just

yet)


15 Tips to Help with Drug Costs or Survive a

Fall into the “Doughnut Hole”

8. Tell your doctor that you cannot buy a medication

9. Talk to your doctor about switching to cost-effective drugs

10. Contact your elected officials

11. Get an on-line benefits checkup

12. Apply for assistance from a certified charity

13. Call your Part D insurance provider

14. Hospitals

15. 90 -day supplies save money


Medicare Supplements or Medigap Coverage

• Medicare pays 80% of your doctor and hospital coverage

• You need the supplement to pay the other 20%

• A Medicare supplement policy combined with a Stand Alone Part D plan provides the best coverage along with choice of plans

• The only out of pocket costs are the monthly premium

• You can go to any doctor or hospital in the USA


Benefit Changes 2014-2015

2014 Standard Benefit: 2015 Standard Benefit:

You pay the first $310 (Deductible) You pay the first $320 (Deductible)

You pay 25% of the next $2,540

(25% of $2,850 - $310 = $635)

(Initial Benefit Period)


(25% of $2,960 - $320 = $660)

(Initial Benefit Period)

Donut hole "threshold" = $2,850

That is, what you and the plan have spent ($945 + $1,905 = $2,850)

Donut hole "threshold" = $2,960

That is, what you and the plan have spent ($980 + $1,980 = $2,960)


(The "donut hole")


(The "donut hole")

"Catastrophic coverage" begins after you have spent $4,550 (this is

your total out-of-pocket spending requirement)

($310 + $635 + $3,605 = $4,550)

Or, put another way:

Total spending (you and the plan) for catastrophic coverage = $6,455

($310 + $2,540 + $3,605 = $6,455)

"Catastrophic coverage" begins after you have spent $4,700 (this is

your total out-of-pocket spending requirement)

($320 + $660 + $3,720 = $4,700)

Or, put another way:

Total spending (you and the plan) for catastrophic coverage =

$6,153.75

($320 + $2,640 + $3,720 = $6,680)

Minimum cost sharing in catastrophic benefit period: $2.55 (generic)

and $6.35 (brand)

Minimum cost sharing in catastrophic benefit period: $2.65 (generic)

and $6.60 (brand)

Partial LIS deductible/ cost sharing $63/15% Partial LIS deductible/ cost sharing $66/15%


Getting Out of the Donut Hole

Meeting the Annual True Out-Of-Pocket (TrOOP) Spending

Requirement

• To get past the Donut Hole and into Catastrophic Coverage beneficiaries need to

meet their out-of-pocket (TrOOP) spending requirement, which is $4,500 in 2010.

Only certain costs count toward the true out-of-pocket spending requirement.

Costs that count toward the TrOOP:

• Costs that the beneficiary spent on formulary drugs (or non-formulary drugs that have

been granted an exception by the plan)

• Costs paid by the beneficiary's family, a charity, or a State Pharmaceutical Assistance

Program such as ConnPACE.

Costs that do not count toward the TrOOP:

• Costs paid for non-formulary drugs.

• Cost of drugs purchased outside the United States.

• Costs paid for by other insurance, including ADAP plans (CADAP in Connecticut).

• Premiums paid to the Part D plan.


What Share of Part D Enrollees Reached

the Coverage Gap in 2007?

One quarter (26 percent) had spending high enough to reach the coverage gap. Fifteen percent of these Part D enrollees who reached the coverage gap ultimately had spending high enough to reach catastrophic coverage.

Applying this estimate to the entire population of Part D enrollees, the analysis suggests that about 3.4 million beneficiaries (14 percent of all Part D enrollees) reached the coverage gap and faced the full cost of their prescriptions in 2007.

Age. The share of enrollees with spending high enough to reach the gap increased with age, from 25 percent of Part D enrollees age 65-74 to 33 percent of those age 85 and older. A smaller share of Medicare beneficiaries under age 65 with disabilities reached the gap compared to those age 65 and older.


How soon did Part D Enrollees Reach the

Coverage Gap? How Long did they Stay in the Gap?

Half of all Part D enrollees who had spending high enough to reach the coverage gap in 2007 did so by the end of August.

Only a small share of enrollees who reached the coverage gap in July or later had spending high enough to reach catastrophic coverage before the end of the year; instead, most spent the rest of the year in the coverage gap.

On average, enrollees who reached the coverage gap remained in the gap for just over four months.


Did Part D Enrollees Change their Drug Use when

they Reached the Coverage Gap?

Averaged across Part D enrollees using drugs in one or more of 8 drug classes (PPI, Anti-depressants, anti-diabetic, Osteoporosis, ACEI, Statins, ARB’s, Alzheimer's• 20% of enrollees who reached the coverage gap in 2007 either

stopped taking a medication in that drug class, reduced their medication use (e.g., skipped doses), or switched to a different medication in that class when they reached the gap.

15% stopped taking their medication

5% switched to an alternative drug in that class

1% reduced their medication use.


Accountable Care Organizations

CMS has created regulations under the Affordable Care Act to help healthcare providers better coordinate patient care through Accountable Care Organizations (ACOs).

ACOs aim to incentivize healthcare providers to work together across many care settings – doctor’s offices, long-term care facilities, hospitals etc.• ACOs that reduce health care costs and meet established

performance standards will be rewarded by the Medicare Shared Savings Program.

• Provider participation is completely voluntary.


Accountable Care Organizations

Quality Measures and Performance Scoring Methods• ACOs will be accountable for 33 measures of quality performance

separated into four domains: Patient Experience of Care, Care Coordination/Patient Safety, Preventive Health and At-Risk Population.

• In the first year, the ACOs will be rewarded for reporting on all 33 measures through patient surveys and claims (Pay for reporting)

• In the second year, they are responsible for meeting performance standards in 25 measures (Pay for performance)

• In the third year, ACOs are responsible for all 33 performance standard measures (Pay for performance)

CMS establishes the benchmarks for ACO quality measures prior to the start of each performance year.

Optimizing patient health through a

relentless devotion to clinical excellence.

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