Rob Godwin

A new year and enrollment cycle for Medicare Part D beneficiaries is upon us. With that comes revised formularies and plan offerings from the Prescription Drug Plans (PDPs). For the frail elderly skilled nursing facility (SNF) resident, whose family may or may not be close by, and whose medical conditions may impair their cognition, navigating Medicare Part D can be a daunting task. In many cases, nursing home staff is on the front lines assisting beneficiaries with Medicare part D education and information.

Most beneficiaries who reside in long-term care facilities are dually eligible for Medicaid and Medicare (commonly known as ‘duals’) and may qualify for the low-income subsidy (LIS).  These LIS ‘duals’ have no co-pay and no premium if they choose or are assigned a qualified LIS Medicare Part D plan by the Centers for Medicare and Medicare Services (CMS).

Medicare D formularies are intended to offer drug benefits to a wide array of Medicare beneficiaries in many varied settings and levels of medical care. Beneficiaries may reside at home, in a continuing care retirement community, an assisted living facility, in a skilled nursing facility or anything in-between. Each beneficiary has a different level of medical and medicinal needs.

Broad formulary option

The medication needs of a skilled nursing facility resident may be vastly different from a community-dwelling senior. Facilities can assist SNF beneficiaries by matching the drug regimen to a broad Medicare Part D plan formulary. Many beneficiaries’ drug regimens will change as their medical conditions change throughout the SNF stay. With a broad formulary, beneficiaries can achieve good coverage with low barriers to changes in drug therapy.

Some of the Medicare Part D formularies, through various product restrictions, may inhibit a SNF beneficiary from readily obtaining a prescription. Product restrictions, particularly for SNF beneficiaries, add additional barriers and lead to delays of care while adding an administrative burden on already over-burdened healthcare professionals. LIS plan choice should be based on formulary coverage, restrictions, plan parameters, and the processes that plans employ.

Talk to the pharmacist

Pharmacists are well-suited to assist nursing home staff by evaluating the complexities of the Medicare Part D drug formularies. To aid SNFs in understanding the difference between the 2009 & 2010 LIS plans that will be available, pharmacists can evaluate beneficiaries’ drug regimens and may offer suggestions as to the breadth of coverage with the least restrictive formularies.

Facility staff can be of great help to residents during open enrollment by being aware of the various communications that may come from CMS. Various colored letters may arrive at the SNF or may be brought to the SNF by resident’s families. CMS has sent letters to each beneficiary that are on blue paper (Re-Assignment Notice) or tan paper (LIS Chooser Notice) regarding his/her assigned category. The CMS letter discusses the 2010 choices for the beneficiary.

The impact of these notifications is that any LIS beneficiary (a ‘dual’) enrolled in a 2009 LIS plan may need to consider another plan for 2010 year or be willing to pay premiums. Those who were “choosers” in 2009 will again need to choose to enroll in a new plan for 2010 or they will be randomly assigned to a different LIS plan for 2010 by CMS. It’s important to note that SNF LIS beneficiaries can change their LIS Medicare Part D plan monthly, if desired, in order to better align their changing drug regimens with an optimal plan formulary.      

As in previous years, appropriate plan choices can be made by working closely with the families and beneficiaries to help them understand which plans have broad formulary coverage and align with the beneficiaries’ needs.  Enrolling in those plans would provide the LIS beneficiary with the best formulary coverage and lowest potential facility costs.

State variation

LIS plan options will vary greatly between states. Many of these plans remain as LIS plans in most states or were added to new states. For example, Alabama will lose several plans, leaving four PDP plans available to choose from. Arizona will be adding six new PDP plans, but Texas is losing six. Florida will continue to have five PDP plan options, but two of the original five have changed.

Suggested action steps:

1. Review a resident’s current Medicare Part D plan. Use the resident’s plan card to definitely determine the plan. Ensure that the resident is not enrolled in an MAPD (managed care) plan.  Changing someone in an MAPD plan could result in loss of medical coverage.

2. Look for the residents’ enrollment cards or the blue or tan letters. If you do not have the resident’s information to determine whether the resident was a “chooser,” or was “auto-assigned,” educate him/her on enrolling in a better plan to prevent further auto assignment or a potential premium bill.

3. Utilize the Web site to assist the resident or responsible party in selecting the best plan that meets their needs.

4. Assist the resident or responsible party in enrolling into a plan that fits their needs. 

Remember, residents in long-term care facilities may elect to change plans at any time.  Open enrollment for all beneficiaries began Nov. 15. CMS has advised that all enrollment changes be completed by early December to allow sufficient time to become effective by Jan.1. 

Rob Godwin is vice president of clinical program development at PharMerica, a major institutional pharmacy services company in the U.S. PharMerica serves patients in nursing centers, assisted living facilities, hospitals and other long-term care settings. The company is based in Louisville, KY, and operates institutional pharmacies in 41 states.