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Illinois Cares Rx Elimination:
What you Need to Know and
How to Help Your Clients
Make Medicare Work Coalition
(MMW)
• Co-led by AgeOptions, Health & Disability Advocates,
and Progress Center for Independent Living
• Outreach, training, and advocacy on health care issues
affecting older adults and people with disabilities,
with a focus on vulnerable/at risk populations
• Training for professionals who assist clients in
accessing health care services and supports
• Began to educate consumers and professionals about
Part D
What We Will Cover Today
• Background: Illinois Cares Rx
Elimination
• Options for Clients Losing Illinois Cares
Rx Coverage
• Medicaid Spenddown
Background: Illinois Cares Rx
Elimination
SB2840
• Senate Budget Bill for FY2013
(begins July 1, 2012)
• Passed House and Senate 5/24/2012
• Governor signed 6/14/2012
• Included many cuts and changes to Medicaid
and other programs
ICRx Elimination
• Illinois Cares Rx program will end for everyone
July 1, 2012
• People with ICRx coverage will receive a letter
from the Department of Healthcare and
Family Services (HFS)
– Began mailing Tuesday, June 12
– Referral to 1-800 Medicare, Senior Health
Insurance Program (SHIP) and Senior Health
Assistance Program (SHAP) agencies for assistance
ICRx Elimination
• Effective July 1, 2012, individuals will be
responsible for:
– Part D plan’s monthly premium
– Annual deductible (any portion that has not already
been paid by ICRx and the member this year)
– Part D plan’s applicable co-pays by tier (the amount
the plan charges)
– Costs during the “donut hole”
• After 7/1/12, discount received will be 50% off of brand
names and 14% off generics
ICRx Elimination
• People on Medicare and ICRx will have a
Special Enrollment Period (SEP) to change
their Medicare Part D plan. This SEP will run
from June 1, 2012 to August 31, 2012.
People With ICRx and Extra Help
• People with FULL Extra Help will NOT be
affected!
• Important to find out if a client has Full or
Partial Extra Help
– Can do this by:
• visiting www.medicare.gov and do a personalized
plan search
• calling 1-800-Medicare or Social Security at
(800)772-1213
People With ICRx and Extra Help
• People with Extra Help may have to start paying
partial premiums, higher co-pays/coinsurance
– If in AARP Medicare Rx Preferred - $4 monthly premium
• AARP Preferred is $4 above the Extra Help benchmark amount
• ICRx was paying the $4 for ICRx members also in Extra Help
• Extra Help benchmark is $30.23 in 2012
– ICRx members with partial Extra Help and an ICRx
coordinating plan may have pay a higher premium and up
to 15% coinsurance for drugs since ICRx will no longer pay
the difference
People With ICRx and Extra Help
• People with Extra Help may have to start paying full
price for Medicare excluded drugs, such as
benzodiazepines and barbiturates.
• Illinois Cares Rx was assisting with any medication
on the Medicaid formulary.
• Once Illinois Cares Rx disappears, there will be no
assistance with the costs of these drugs by Extra
Help because Extra Help does not cover them.
• If the person still has current Medicaid eligibility for
a given month, Medicaid will pick up the costs of
those Medicare excluded drugs for the month.
Options for Clients Losing Illinois
Cares Rx Coverage
Immediate Assistance
• If possible, have client obtain a prescription
for a 3-month supply of his/her drugs from
doctor and fill before July 1 – before ICRx is
eliminated
• Ask doctor for drug samples
Immediate Assistance
• Review drug list with doctor to determine if it’s
possible to switch to a generic or less expensive
drug
• Consider switching to a mail order option though
the Part D plan
– Mail order is sometimes less expensive
– Check with plan to find out if mail order is available
• All four of the ICRx coordinating stand-alone plans offer
mail order in 2012
Screen Clients for Extra Help
• Full Extra Help:
– Income
• $1,257/month (individual) OR $1,702/month (couple)
– Assets:
• $8,440 (individual) OR $13,410 (couple)
• Note: asset requirements above include $1,500 prepaid burial
plan
• No monthly Part D premium
– If in a basic Part D plan at or below the Extra Help benchmark
amount
• Benchmark in 2012 is $30.23
• No deductible
• Low co-pays
– $1.10/$2.60 for generics or $3.30/$6.50 for brand names
Screen Clients for Extra Help
• Partial Extra Help:
– Income:
• $1,396/month (individual) OR $1,891/month (couple)
– Assets:
• $13,070 (individual) or $26,120 (couple) –
• Note: asset requirements above include $1,500 prepaid
burial plan
• Sliding Scale premium
• Deductible : $0-$65
• Co-pays of $2.60/$6.50 or 15% coinsurance
• Can apply online at www.ssa.gov or
www.benefitscheckup.org
Other Options
• Charities
– Assistance paying for drugs prescribed for specific
diseases or conditions
– Assistance based on availability of funds
• Co-Pay Assistance Programs
– Many of these programs require you have other
insurance and will help pay for the co-pay not covered
by insurance
– MMW Co-pay Assistance Chart:
http://www.ageoptions.org/whatWeDo/documents/C
haritiesPAPsDiscountCards6-6-12.pdf
Drug Discount Cards
• Drug Discount Cards
– Cannot be used with other insurance
– Anyone can use the card
– Can use for drugs not covered by plan or if in the
donut hole and the discount is greater
– Print and ready to use
– Use at participating pharmacies
• http://www.needymeds.org/drugcard/index.htm
• http://www.easydrugcard.com/
Patient Assistance Program
• Patient Assistance Programs (PAP’s)
– Programs offered through drug manufacturers
– Low cost or free drugs
– Each program has different set of rules and
eligibility criteria
– Find out if a program for a specific drug is
available by visiting www.rxassist.org or
www.needymeds.org.
HIV/AIDS and ADAP
• People with HIV/AIDS can use the Aids Drug
Assistance Program (ADAP) to get help paying for
their HIV/AIDS medications
• Should enroll in the ADAP as soon as possible to
help transition from ICRx to ADAP
• Visit
http://www.idph.state.il.us/health/aids/adap.htm
to apply online or call Phone (217) 782-4977 for
more information
Loss of ICRx Special Enrollment Period
• People on Medicare will receive a special
enrollment period (SEP) to switch to a Part D
plan that is more affordable and better suits
their drug needs
• Remember they can also switch during annual
enrollment period (October 15 - December 7
of each year) with a January 1, 2013 effective
date
Medicaid Spenddown
Dual Eligibles
• Automatically eligible for Full Extra Help
• Defined as those that are enrolled in Medicare
and Medicaid in at least ONE relevant month.
• If you are enrolled in Medicaid in JanuaryJune, you get Full Extra Help for the rest of the
year.
• If you are enrolled in Medicaid in JulyDecember, you get Full Extra Help for the
current year and next year
How Do You Get Medicaid Eligibility in
Illinois (AABD Medicaid)?
• 65 or Older or under 65 and meet definition of
disability
• With no spenddown, countable income limit
of 100% of FPL and countable asset limit of
$2000 individual/$3.
• With spenddown, must incur or pay qualified
medical expenses down to the countable
income or asset limit.
Countable Income
• Take $25 general income disregard and count
rest of unearned.
• Net employment income minus:
– $25 deduction if not used on unearned
– Earned income deduction: first $20 of earnings and ½ of
the next $60
– Mileage to work 19 cents/mile
– Lunch: between $3 - $9 month depending
– Special Tools or Uniforms
– Day care cost up to $160/ mo per child or $128 if working
part time
– Special Work Expenses – like IRWE
Spenddown Calculation Example
Mary is single, living with MS, and receives a
Social Security Disability check of $1500. She
lives in her own home and only has about $900
in the bank. She has no other assets. She
applies for Medicaid. She will be found eligible
for AABD with a spenddown of approximately
$544.
$1500 gross unearned income-$25 disregard$931 (100%FPL) = $544.
How Does Mary Meet this $544
Spenddown?
• Incur $544 in allowable medical expenses
• Spend $544 in allowable medical expenses
• Pay $544 to the state of Illinois
• All three above
What are Allowable Medical Expenses
(Non-Exhaustive List)?
• DRS Home Services or Community Care
Program
• Medicare premiums (if not on QMB, SLIB QI-1)
• Medicare co-pays and deductibles
• Medical expense covered by Medicaid or
recognized under state law
• Over the counter drugs and items ordered by
a doctor (gauzes, aspirin, mouthwash, etc.)
Whose Medical Expenses?
• Your own
• Your husband or wife
• Your children under 18 who are living with you
What Unpaid Medical Bills Can Be
Used?
• It does not matter when the medical care or
supplies were given for an unpaid bill.
• The unpaid bill must be dated no earlier than
the 6th month before the month you use it.
• For example, bill dated in January can be used
for any month January through July.
What Paid Medical Bills Can Be Used?
• Receipt can show that bill is paid.
• Paid bill can be used in month paid or for 6
months after you pay it.
• Again, if you paid it in January, it can be used
for any month January through July.
• DHS automatically considers Medicare
premiums paid.
What Must Receipt or Bill Show?
•
•
•
•
•
•
Type of medical care, drugs or supplies
Who gave the care
Who got the care
The date the care was given
The cost
The date of the bill or receipt
What is Pay In Spenddown?
• Allows enrollee to simply pay the spenddown
amount or do a combination of bills/receipts
and pay the difference.
• Send enrollment form into Springfield.
• Given statement that you return with
payment.
What Month is Chosen for Medicaid
Eligibility?
• Right now, potential enrollees want it to be effective
in July or later if solely using this for Full Extra Help
eligibility.
• If a person does not state preference, he/she is given
eligibility in the month in first month in which
receipts and bills meet the spenddown amount.
• Enrollee must tell them if they want eligibility the
next month…….so if a person goes in right now and
meets spenddown, they should tell them they want
eligibility for July.
Why is this So Important Now?
• Without Illinois Cares Rx, a percentage of
enrollees will be choosing between paying for
food and medicine.
• These are the exact same clients that could
possibly enroll in Medicaid and receive Full
Extra Help.
• If we get them enrolled effective in July or
later, they are “covered” through 2013!
Back to Mary……..
• Let’s say Mary comes into your office on June
25 and says she is going stop taking her
medication because she simply cannot afford
it.
• First, have her get a 3 month supply now!
• Next, Mary could qualify for Medicaid for July.
• She has paid Medicare premiums January-July
of $699.30 that all can be used to meet her
spenddown in July of $544.
Some Things to Remember
• You need to tell them to count the Medicare
premiums.
• If you say nothing, they will give Medicaid for
the month of application. Because of this, it
is probably easiest to go in July so there is no
confusion.
• Submit bills with the application so
spenddown can be met. Otherwise, it will sit
until you do.
What are the Down Sides?
• Medicaid applications are not processed in
real time. They are supposed to take 45-60
days, can be longer.
• Establishing Medicaid eligibility requires
completing application, and where applicable,
having proper receipts etc.
• Medicaid eligibility to Full Extra Help does not
happen in real time.
Don’t Forget….Best Evidence Rule
• Use to get Plan to charge Full Extra Help co-pay
when not showing up as such in system.
• Step 1: Gather evidence of Medicaid status (or
other Extra Help documentation).
• Step 2: Submit Evidence to Plan (call and find
out how they want this)
• Step 3: Ask Plan for assistance in confirming if
necessary.
One Last Time with Mary
• Mary has met spenddown and goes to fill her
meds……
• No such luck. They are telling her she owes
$1500.
• Mary (or her support) should contact the plan
about submitting her Medicaid card as proof
of eligibility for Extra Help.
Final Review of Steps
• 3 month supply now.
• Medicaid spenddown application and all
documentation submitted in July or later for
July or later.
• Best Evidence Rule ready for first trip to
pharmacy.
• Don’t forget that this will have to be done in
the second half of 2013 too!
Tips for Filing a Medicaid
Application with Spenddown
• Get to know your local DHS Office Managers and
Secretaries.
– Local offices hold Community Quality Council (CQC)
Meetings – it is a good idea to attend these meetings and
get to know your local office staff. Upcoming CQC meetings
at the suburban Cook County DHS offices are as follows:
• Wednesday, June 20, 2012, 9:30-12:00pm- West Suburban DHS
Office, 2701 West Lake Street, Melrose Park, Illinois
• Wednesday, July 25, 2012, 9:30-12:00pm - South Suburban DHS
Office, 3301 Wireton Road, Blue Island, Illinois
• Wednesday, July 25, 2012, 2:00-4:00pm- Northern DHS Office,
8020 St. Louis Avenue, Skokie, Illinois
Tips for Filing a Medicaid
Application with Spenddown
• A Medicaid Medical benefits application (2378B) will
not be approved unless you provide enough
documentation of medical expenses to meet
spenddown for 1 month.
• Do not try and contact your local DHS office on a
Monday or at the beginning of the month.
• Ask your local DHS office for their preferred method
of receiving documentation. Ask if they would like
you to address all documents to a specific person or
area.
Tips for Filing a Medicaid
Application with Spenddown
• If you are going to apply on-line make sure your
application is flawless.
• If you do an on-line Medicaid application, make sure
you fax or scan/email all required documents to the
local office. Mention that you have just completed
an online application and that these are the
supportive documents. Make sure all documents
submitted with an application have the clients SS#
clearly marked on all pages.
Tips for Filing a Medicaid
Application with Spenddown
• If your clients go to the DHS office make sure they
sign into the VIS System. (Visitor’s Information
System) This way DHS will have a record that they
were in the office and cannot deny receiving
documents.
• Some of the local offices have gone to a system
called Case Banking, which means that clients will
not have an assigned case worker but a team. The
office managers serve as contact points for clients.
Links – Applying for Medicaid
• You can apply for Medicaid using HFS Form number
2378B. Here is a link to that form:
http://www.dhs.state.il.us/OneNetLibrary/27897/docum
ents/Forms/IL444-2378B.pdf
• The online application is on the Department of
Human Services (DHS) website here:
http://fspp.dhs.state.il.us/register/wb/wbHomePre.do
Thank You!
Please submit Questions using our ICRx Q&A Survey
Monkey link, which will be shared after the webinar.