Those who qualify for both Medicare and Medicaid services are known as dual eligibles.  Depending on income and assets, these individuals may be considered either partial or full benefit dual-eligibles.

Multiple studies have found that these individuals suffer from a higher prevalence of physical and mental disabilities. Since January of 2006, three years after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, legislators have placed special attention to these vulnerable populations by requiring that certain Part D plans be automatically assigned to full benefit dual-eligibles as a type of safety net.

These special Part D plans for low-income beneficiaries are known as regional benchmark plans.  The Centers for Medicare and Medicaid services (CMS) designates at the very least one benchmark plan per Medicare region.  A regional benchmark premium is calculated using a weighted average of PDP and MA-PD monthly premiums in a particular region.  Table 1 shows the list of benchmark premiums for every region, from 2006 until 2015.The benchmark plans must be in accordance with two criteria: the monthly premium is equal to or less than the calculated regional benchmark premium; and the plan offers a standard benefit. Unless the person opts out of Part D or actively chooses a specific Part D plan, qualifying dual-eligibles are auto-assigned randomly to a regional benchmark plan.  If their current plan no longer meets the benchmark criteria, they will be reassigned a plan.

For additional, specific regional benchmark information, one may review the downloads and spreadsheets available (here)[]

Pros and Cons of Auto-Assigning a Plan:

The premise of auto-assigning is to ensure that full benefit dual eligibles have a reliable source of prescription drug coverage.  If enrolled in a benchmark plan, the individual does not have to pay a monthly premium.  If enrolled in a non-benchmark plan that has a higher monthly premium by at least de minimis amount ($2.00 as of 2013) or greater than the regional benchmark premium, the plan may charge the individual the difference according to the Affordable Care Act.  If all of the person’s medications are covered by the plan’s formulary, he or she will only have to pay a very small copay.

One unfortunate outcome is that an individual has one or more medication not covered by the plan’s formulary.  In this case, the beneficiary must pay the full cost of the not-covered medication.  This out of pocket price may be very expensive.  In 2013, the Office of the Inspector General performed a study that found that drugs commonly used by dual eligibles are widely included by Part D plan formularies, though with some variation.  The use of utilization management tools (prior authorizations, quantity limits, etc.) in plan formularies varies across the board.  For those situations where a drug is not covered or a utilization tool is in effect, one must investigate his or her options.  If unable to overcome restrictions or pay high out of pocket copays, he or she must either request coverage by the Part D plan or have his or her provider prescribe a therapeutic alternative that is covered by the formulary.  Lastly, he or she may change part D plans to find a more suitable match for his or her needs.

Case Study Involving the Pitfalls of Auto-Assignment: Rajul Patel et al. (2013) analyzed data from six California benchmark plans from 2010.  They wanted to determine the implications of auto-assigning a plan to full benefit dual eligibles. They found that startling low amounts, approximately 34%, of auto-assigned beneficiaries were assigned the lowest cost plan.  They argue that auto-assignment precludes factoring in one’s unique drug profile, causing easily preventable high out of pocket costs.  On average, the estimated annual cost between the benchmark plans varied from $302 to $1223.  Half of the benchmark plans had at least one instance in which they were the highest cost PDP in the entire region. Patel et al. found one shocking example where the difference between the lowest and highest estimated annual cost benchmark plan was over $12,000 dollars for one unfortunate individual.

Essentially, a plan that is auto-assigned to a full benefit dual eligible may not be their best or cheapest option.  Every case must be considered on an individual basis. _ How can iMedicare help?

Our program makes it easy for a pharmacist to review all of the PDP and MAPD plans available to their patient.  Our platform populates relevant plan information specific to an individual’s unique medication profile including but not limited to: monthly premium, estimated annual premium, drug restrictions, and therapeutic alternatives.  In less than one minute, the pharmacist can help find a plan best suited to his or her patient’s needs without any of the guesswork.  In addition, iMedicare provides a user-friendly, side-by-side monthly breakdown comparison of premiums, drug copays, plan restrictions, and therapeutic alternatives between selected plans ( Figure 1 ).  Upon finding a desired plan, one can follow the link “apply/enroll” to the plan application. Dual eligibles may change plans at any time during the year.  If the beneficiary decides to switch plans, the changes will be in effect the following month.  Neglecting to find the best and most affordable plan for the patient may result in medication non-adherence and ultimately, poorer health.  Pharmacists can use iMedicare all year round to help their patients find the best plan for their health - and wallet!