Medicare Part D Data for Research Minneapolis MAY 15-16, 2013 - PowerPoint PPT Presentation

Introduction to the Use of Medicare Part D Data for Research Minneapolis MAY 15-16, 2013

Educational Objectives of Workshop  Understand the Medicare Part D Program and its benefits  Understand what demographic, useful enrollment and linking information is available in the “new” Master Beneficiary Summary File (the updated Denominator File)  Become acquainted with the processing of Part D event data  Understand the content of the Part D Event File 2

Educational Objectives of Workshop  Understand the content of the Part D Characteristics Files  Understand issues involved with the use of Part D data for research  Understand what special Part D variables have been created for researchers and how they were created 3

Educational Objectives of Workshop  Begin to appreciate the types of research that can be done using the Medicare Part D data  Understand the requirements of the Centers for Medicare and Medicaid Services for obtaining and using Part D data 4

Description of the Medicare Part D Program

Frequently Repeated Acronyms/Names  ResDAC – Research Data Assistance Center  CMS – Centers for Medicare and Medicaid Services  CCW – Chronic Condition Warehouse  Buccaneer Computer Systems and Services  MMA – Medicare Modernization Act  PDP – Stand-alone Prescription Drug Plan – fee- for-service  MA-PD – Medicare Advantage Prescription Drug Plan 6

Frequently Repeated Acronyms/Names  LIS – Low Income Subsidy  TrOOP – True Out of Pocket Spending  ICL – Initial Coverage Limit  PDE – Prescription Drug Event  CCL – Catastrophic Coverage Limit  PDE – Prescription Drug Event  MBSF – Master Beneficiary Summary File 7

Medicare Prescription Drug Program  Implemented in 2006 as part of the Medicare Modernization Act (MMA) of 2003  Part D is based on a competitive model where beneficiaries can voluntarily purchase drug coverage offered by private plans.  Part D plans have flexibility in the design of plan: benefit package (e.g., deductibles/copays, formularies, prior authorization requirements, etc.) Premiums vary by plan. 8

Medicare Prescription Drug Program  Part D enrollment is for a calendar year.  Beneficiaries may choose from multiple plans during annual open enrollment in Oct-Dec of each year  Originally, 6% are plan switchers each year; last 2 years = 13%.  Plans are state or region-based and each beneficiary has 23-38 PDPs from which to choose for 2013  Average base monthly premium in 2013 = 31.17; 2012 = $31.08, down from $32.34 in 2011  Percentage of Medicare beneficiaries enrolled in Part D ˗ 2006 = 54% 2010 = 59% ˗ ˗ 2011 = 60% ˗ 2012 = 65% 9

Medicare Prescription Drug Program  Enrollment in Part D is optional, but a penalty for those without creditable coverage who enroll after age 65.  “Extra Help” available for those who qualify; called Low Income Subsidy (LIS) 10

Medicare Part D Enrollment – 2012 MAPD = Medicare Advantage Prescription Drug PDP = (Fee-for-Service) Prescription Drug Plan Creditable MAPD coverage 24% 26% No creditable coverage 10% PDP 41% 11

Medicare Part D Standard Benefit, 2013 Cata tastr strophic phic Tot otal al drug ug Enrollee ee Pa Pays spend nding ing at Medicar icare e Pa Pays 80% 5% or $2.60- OOP thres OOP hreshold old Plan Pa Pays 15 15% $6.50 co-pa pay TrOOP or CCL L Spendin ending $6,95 ,954.52 4.52 Coverage age Gap ($3,984. 4.52 52) $4,75 ,750 Enrollee ee Pa Pays 47.5% % for brand d name Tot otal al Drug ug drugs, s, and 79% for generic ic drugs $3,051 1 Coverage age Gap Spendin ending TrOOP at ICL Spendin ending $2,9 ,970 70 $986.25 25 Enrollee ee Pa Pays Initi tial al Coverage erage Period od 25% coinsurance 25 25% Plan Pa Pays s 75% Tot otal al Drug ug ($1. 1.983. 83.75) 5) ($661.25) 5) Spendin ending g at TrOOP dedu ductib ctible le Spendin ending Deducti uctible Deducti uctible e ($325) 5) limit $325 325 Enrollee ee Pa Pays 100% $325 325 $0 $0 $0 $0 12 .

True Out-of-Pocket Spending (TrOOP) Not the amount the patient paid – well almost  TrOOP , "True Out of Pocket Costs“: “the beneficiary’s own out -of-pocket spending; that of a family member or official charity; supplemental drug coverage provided through qualifying state pharmacy assistance programs or Part D’s low - income subsidies; and, under CMS’s demonstration authority, supplemental drug coverage paid for with MA rebate dollars.  TROOP amounts are the medication costs that can be used to calculate “beneficiary payments” and are used by CCW/Buccaneer to calculate the benefit phase that each drug fill falls into in the PDE data files. 13

Medicare Part D Standard Benefit, 2013 Cata tastr strophic phic Tot otal al drug ug Enrollee ee Pa Pays spend nding ing at Medicar icare e Pa Pays 80% 5% or $2.60- OOP OOP thres resho hold ld Plan Pa Pays 15 15% $6.50 co-pa pay TrOOP or CCL L Spendin ending $6,95 ,954.52 4.52 Coverage age Gap ($3,984. 4.52 52) $4,75 ,750 Enrollee ee Pa Pays 47.5% % for brand d name Tot otal al Drug ug drugs, s, and 79% for generic ic drugs $3,051 1 Coverage age Gap Spendin ending TrOOP at ICL Spendin ending $2,9 ,970 70 $986.25 25 Enrollee ee Pa Pays Initi tial al Coverage erage Period od 25% coinsurance 25 25% Plan Pa Pays s 75% Tot otal al Drug ug ($1. 1.983. 83.75) 5) ($661.25) 5) Spendin ending g at TrOOP dedu ductib ctible le Spendin ending Deducti uctible Deducti uctible e ($325) 5) limit $325 325 Enrollee ee Pa Pays 100% $325 325 $0 $0 $0 $0 14 .

Medicare Part D Standard Benefit, 2012 Cata tastr strophic phic Tot otal al drug ug Enrollee ee Pa Pays spend nding ing at Medicar icare e Pa Pays 80% 5% or $2.60- OOP thres resho hold ld Plan Pa Pays 15 15% $6.50 co-pa pay TrOOP $6,65 ,657.50 .50 Spendin ending Coverage age Gap ($3,727.50) 0) $4,70 ,700 Enrollee ee Pa Pays 50% for brand d name e Tot otal al Drug ug drugs, s, and 86% for generic ic drugs $3,051 1 Coverage age Gap Spendin ending TrOOP at ICL Spendin ending $2,93 ,930 $972.50 50 Enrollee ee Pa Pays Initi tial al Coverage erage Period od 25% coinsurance 25% 25% Plan Pa Pays s 75% Tot otal al Drug ug ($1. 1.957.50) 0) Spendin ending g at TrOOP dedu ductib ctible le Spendin ending Deducti uctible Deducti uctible e ($310) 0) limit $320 320 Enrollee ee Pa Pays 100% $320 320 $0 $0 $0 $0 15 .

Medicare Part D Standard Benefit Thresholds Benefit Parameters 2006 2008 2010 2011 2012 2013 Deductible $250 $275 $310 $310 $320 $325 Initial Coverage Limit $2,250 $2,510 $2,830 $2,840 $2,930 $2,970 TrOOP threshold at catastrophic coverage limit (CCL) $3,600 $4,050 $4,550 $4,550 $4,700 $4,750 Total covered drug expenditure at CCL $5,100 $5,726.25 $6,440 $6,447.50 $6,657.50 $6,950 16

“Extra Help” – Low Income Subsidy (LIS)  Benefits ˗ Help paying Medicare drug plan’s monthly premium, any yearly deductible, coinsurance, and/or copayments ˗ No coverage gap liability ˗ No late enrollment penalty  Major Effort on the part of CMS and advocacy groups to inform beneficiaries about the Low Income Subsidy available to them to help pay for Part D services. 17

Medicare Part D Enrollment, 2010 No creditable coverage 10% 17% Primary coverage through FEHB, TRICARE, or active worker 14% Covered by employers who receive RDS Other creditable coverage Non-LIS in MA-PD 21% 13% LIS in MA-PD Non-LIS in PDP 3% 4% LIS in PDP 18 17%

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Public Use Files Describing the Drug Plans a.k.a., Landscape Files  Plan Information File  Basic Drugs Formulary File  Excluded Drugs Formulary fFle  Beneficiary Cost File  Geography Locator file  Pharmacy Networks File  Cannot be linked to beneficiary-level files 20

Public Use Files Describing the Plans Some content  Stand-alone PDP or MA-PD (Local or Regional)  Monthly premium amount  Annual deductible amount  Initial coverage limit  Drugs listed on each plan’s formulary and tier placement  Enrollee cost-sharing amounts for each drug tier 21

Public Use Files Describing the Plans Some content  Pharmacy networks for each plan  Information on utilization management for each drug: ˗ quantity limit, ˗ prior authorization required, and ˗ step therapy  Average monthly prices for Part D drugs  To locate and order these files: http://www.cms.gov/Research-Statistics-Data-and- Systems/Files-for- Order/NonIdentifiableDataFiles/PrescriptionDrugPlan FormularyPharmacyNetworkandPricingInformationFil es.html 22

Number of Part D Contracts and Plans 2006 - 2012 23

Patterns of Enrollment in 2009 and 2011 Difference between PDP and MA-PD, not between years 2009 2011 Percent of PDP MA-PD PDP MA-PD beneficiaries with Enhanced (v. basic) 27% 94% 18% 92% benefits Plan has no 48% 94% 43% 91% deductible Plan offers some 7% 64% 15% 54% gap coverage Source: MedPAC analysis of CMS 2008 and 2009 landscape and enrollment data: 24 http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/