Laura Cheever, M.D., ScM
Deputy Director, Chief Medical Officer
HIV/AIDS Bureau Health Resources and Services Administration
Department of Health and Human Services

• Approximately 60,000-80,000 Medicare beneficiaries with HIV/AIDS
  • Qualify primarily through being on Social Security Disability Income (SSDI) for 2+ years
  • Currently no prescription benefit
• 70-85% also qualify for Medicaid
  • ‘Dually eligible' or ‘dual eligibles'
  • Approximately 50,000-60,000 individuals
  • Medicaid currently provides prescription drug coverage

• Adds a prescription drug benefit to Medicare, known as Medicare Part D
  • Benefit starts January 1, 2006
  • Most Medicare beneficiaries must elect the benefit and choose a plan
  • Dual eligible beneficiaries will be automatically enrolled in Medicare Part D because prescription drug coverage will switch from Medicaid to Medicare January 1
  • Plan formularies must include all antiretrovirals

• Monthly premium (around $32.20 in 2006)
• $250 deductible
• 25% coinsurance from $250 to $2,250*
• 100% of drug costs from $2,251 to $5,100
• Catastrophic coverage: co-pay of 5% or $2/$5 (whichever is greater) after total drug costs reached $5,100 and beneficiary has paid $3,600 in out-of-pocket costs

*Coinsurance is a term used in Medicare Part D that refers to the beneficiary's contribution toward prescription drug costs until the catastrophic coverage level has been reached.

• Most Medicare beneficiaries with HIV/AIDS will qualify for some type of low-income subsidy
• Dual eligibles, Medicare beneficiaries on Supplemental Security Income (SSI) or in a Medicare Savings Program (QMB, SLMB, QI) will automatically be eligible
• Beneficiaries who aren't included in the group above but meet income and asset criteria need to apply to Social Security or Medicaid to qualify for a subsidy
• Subsidy counts toward out-of-pocket costs and reaching catastrophic coverage level

Main Benefit and Low-Income Provisions

charts here

*Cost sharing is $0 if the beneficiary is on Medicaid and institutionalized.

• On SSDI, Medicare and Medicaid (dual eligible)
• SSDI benefit $780/month (less than100% FPL)
• Antiretroviral regimen is efavirenz and FTC/TDF
• Drugs cost $1,300 per month
• Jane pays $6 in co-pays per month for two scripts (income < 100% FPL so $3 brand name co-pay applies) for three months
• By 4 th month, total drug costs of $5,200 exceeds $5,100 catastrophic limit
• No cost to Jane after that
• Jane pays $18 for the year [3 months of $6 co-pay]

• On SSDI, Medicare and small private disability insurance benefit
• Income $1,100 per month (138% FPL)
• Same drug regimen and costs
• Jason pays:
  • About $8 per month in premiums (75% subsidy of $32.20)
  • Month 1: $50 deductible plus $187.50 (15% co-insurance of $1,250 balance)
  • Month 2: $195 coinsurance (15% coinsurance of $1,300)
  • Month 3: $195 coinsurance (total drug costs $3,900)
  • Month 4: $180 coinsurance (on $1200 balance of $5100 total drug cost limit for catastrophic coverage level)
  • Months 5-12: $10 per month ($5 brand name co-pay on two scripts)
• Jason pays $983 for the year [$96 in premiums, $807.50 in deductible and co-insurance, $80 in co-pays]

• 65 years old, HIV positive, aged into Medicare
• Income $1,600 per month (200% FPL)
• Same drug regimen and costs
• Peter pays:
  • $32.20 per month in premiums
  • Month 1: $250 deductible plus $262 (25% coinsurance) towards $1050 balance
  • Month 2: $237 coinsurance (25% of $950 balance to reach $2250 co-insurance limit) plus $350 (balance of $1300 pharmacy cost)
  • Month 3: $1,300 prescription cost (100%) [Peter has now paid $2,399 out-of- pocket towards his drugs]
  • Month 4: $1,201 prescription cost (100% coinsurance for a total of $3,600 in out-of-pocket costs). Total drug costs are also above the $5,100 limit so the catastrophic coverage level has been reached.
  • Months 5-12: $65 per month (5% co-pay)
• Peter pays $$4,506.40 for the year [$386.40 in premiums, $3600 out-of-pocket and $520 in co-pays]

• AIDS Drug Assistance Programs (ADAP), in accordance with State program policy, can pay:
  • Premiums
  • Deductible
  • Coinsurance (15%, 25% and 100%)
  • Co-pays
• ADAP contributions do not count toward the $3,600 in out-of-pocket costs needed to reach the catastrophic coverage level

• June, 2005
  • Dual eligibles will get letters from Medicare telling them they will be auto-enrolled in Medicare Part D
  • Beneficiaries with low incomes may get letters from Social Security about applying for low income subsidies
• You can:
  • Encourage Medicare patients to apply for subsidies
  • Tell dual eligibles to hold onto letters for their records
• October, 2005
  • “Medicare and You” sent to all beneficiaries with plan information
  • Dual eligibles will get letters notifying them of the plan into which they are automatically enrolled
• You can:
  • Encourage Medicare beneficiaries to enroll
  • Tell dual eligibles that they can choose a different plan
  • Refer patients to www.Medicare.gov or 1-800-Medicare
• January 1, 2006
  • Dual eligible beneficiaries will receive drugs through Medicare plan
• You can:
  • Prescribe extra antiretroviral medication to “bridge” transition period so that treatment regimen is uninterrupted
  • Ask about access to medication