shine s erving the h ealth i nsurance n eeds of e veryone
TRANSCRIPT
SHINEServing the Health
Insurance Needs of Everyone
Topics
Part 1: Overview for SHINE and Medicare
Part 2: Medicare Part D
Part 3: Medicare Assistance Programs
Part 4: Medicare.gov
SHINE Overview Began in 1985 as a pilot program, in 1992 SHINE became available
statewide with federal funding assistance
Objective is to provide elders with access to accurate, unbiased health insurance information
Network of 500+ volunteer counselors trained and certified by Elder Affairs to provide information, counseling and assistance regarding health insurance and benefits
SHINE Counselors are available at many Senior Centers, Councils on Aging (COA), Area Agencies on Aging, and Aging Services Access Points (ASAP), Community hospitals and many other community-based sites
SHINE Counselors Explain Medicare Part A, B, C and D benefits and gaps
Compare health insurance and prescription drug plans options, cost and benefits
Screen for Prescription Advantage, Medicare Savings Programs, and Extra Help
Provide assistance with the application process
Help with claims and billing problems
Start appeals and explain grievance procedures
Know how to solve problems and ask the right questions
SHINE Part D Enrollment Specialist
Assist SHINE counselors by using tools on medicare.gov to get data into and get reporting from medicare.gov
Assist counselors by comparing the cost and benefits of the programs available for clients
This training is designed to help you handle basic matters; clients who are seeking assistance beyond basic inquiries should be referred to a SHINE Counselor
Open Enrollment Period
October 15th – December 7th
Every plan changes from year to year Plans change premiums, co-pays, drug formulary,
and can end their contract with Medicare
If an individual elects not to do anything then they will remain in their current plan for the following year
Medicare OverviewMedicare is a health insurance program for:
People 65 years of age and older • This is not necessarily full retirement age
People under age 65 with disabilities • Deemed “disabled” by Social Security for at least 24
monthsNote: Medicare is NOT Medicaid: Medicaid is health insurance
for very low income population and is called MassHealth in Massachusetts
Medicare Card Each Medicare Claim Number is unique to a
beneficiary
The Number is made up of a Social Security Number and Letter (not necessarily the beneficiary’s SSN)
Card lists effective dates for Part A and B
Medicare Advantage Plans(MA-PD, Medicare Part C)
Eligibility• Must have both Part A & Part B• Must live within plan service area 6 months a year• Must not have ESRD (end stage renal disease)• Must continue to pay Part B premium
Characteristics
Other Options for Drug Coverage
Retiree Benefits (former employer benefits)
Veterans Benefits
MassHealth (Medicaid) & other related programs
Medicare Part D
Overview of Medicare Part D
Began January 1, 2006 Voluntary Provides outpatient prescription drugs All Medicare beneficiaries are eligible Coverage for Part D is provided by:
• Prescription Drug Plans (PDPs) also known as stand alone plans
• Medicare Advantage Prescription Drug Plans (MA-PDs)
Prescription Drug Plan Options
Original Medicare
Part D stand alone plan (PDP)
MedicareAdvantage Plan
For prescription coveragean individual must choose
the Part D coverageoffered by their MedicareAdvantage Plan (MA-PD)
Medigap PolicyOptional “add-on”
Or other supplementalmedical coverage
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OR
Medicare Part D Plans All plans, MA-PD and PDPs must meet CMS standards
• Cost structure• Formulary (drugs covered)• Pharmacy Access
May also offer supplemental benefits
Must coordinate benefits with SPAP’s (Prescription Advantage) and State Medicaid (MassHealth) programs that wrap-around coverage
Formulary Standards Each plan has to cover “all or substantially all” the drugs in
the following classes:• Antidepressants• Antipsychotic• Anticonvulsant• Anticancer• Immunosuppressant and• HIV/AIDS
Plans must cover at least two drugs in each therapeutic class Plans may change their formularies during the year however
must provide 60 days notice to each member taking the medication in question
Examples of Part D Excluded Drugs
Drugs for anorexia, weight loss or weight gain
Drugs for the symptomatic relief of cough and colds
Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Non-prescription drugs (over the counter)
Drugs used for Erectile Dysfunction (Viagra, Cialis, Levitra)
Drugs that may be covered under Medicare Part A and/or Medicare Part B
Standard Medicare Part D (2015)
Level DescriptionDeductible Annual $320 deductible paid by the Beneficiary.
Initial Coverage From $320 to $2960 (retail cost of drugs)
Beneficiary pays 25% of the drug costs and Medicare pays 75%
Coverage Gap“Donut Hole”
After $2, 960 in costs beneficiary pays 45% of brand name drug costs and 65% of generic drug costs until they have spent $4,700 out of pocket.
Catastrophic When true out of pocket (TrOOP) costs reach $4,700 (excluding monthly premium) beneficiary pays 5% of the drug costs and Medicare pays 95%.
Not All Part D Plans Are Made Equal!
PDPs and MA-PDs may vary based on:• Benefit Design• Monthly Premium• Deductible• Coinsurance• Formulary• Drug Prices• Service Area
How to Enroll Into Medicare Part D
Review plan options• Plan Finder Tool on Medicare.gov• Determine Stand Alone Part D plan vs. Medicare Advantage Plan• Consider cost, coverage, quality, and convenience• Avoid drug restrictions
Step Therapy Prior Authorizations
Contact plan directly or call 1-800-Medicare• Enrollment can take place on the phone, online, or through a
mailed in paper application
Late Enrollment Penalty If an individual does not enroll when first eligible for Part D they may
pay a penalty if they:• Have no coverage or have coverage but it is not considered
creditable
Penalty may be charged once an individual does join a Part D plan• A 1% increase in premium for each month an individual went
without creditable coverage since Medicare eligible Penalty is 1% increase in premium based on a national standard
base premium. Penalty is permanent
Creditable Coverage Prescription drug coverage at least as good as standard Part D
All Medicare beneficiaries (including those who are still working) must have creditable coverage to avoid late enrollment penalty
Benefits administrator has information about whether the coverage is creditable
Beneficiaries should be encouraged to ask the benefits administrator if they have not been notified about creditable coverage status
Medicare Assistance Programs
Assistance Programs May Help LIS aka “Extra Help”
• Assists with Part D premiums and co-pays – apply thorough Social Security
Prescription Advantage
• Help with drug costs when in the coverage gap
There are additional options that your SHINE Counselor will be aware of
Extra Help/Low Income Subsidy (LIS)
Extra Help is a federal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part D.
Extra Help subsidizes:• Premiums• Deductibles• Copayments• Coverage Gap “Donut Hole” • Late Enrollment Penalty• Does not subsidize non-formulary or excluded medications
Administered by CMS and the Social Security Administration
Prescription Advantage Massachusetts’ State PharmaceuticalAssistance Program
(SPAP)
Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i.e. retiree plan)
Provides primary coverage for individuals who are NOT eligible for Medicare
Benefits are based on a sliding income scale only – No asset limit!
Different income limits for under 65 vs. 65 and over
Dual eligibles can NOT join (but those with LIS or MSP can join)
Prescription Advantage For those with Medicare or “Creditable Plan”
Helps pay for drugs in the gap (for most members)
Those in top income category (S5) must pay $200 annual fee for limited benefits
All medications must be covered by primary plan
Benzodiazepines (xanax, lorazepam, valium, etc) are covered right away
Members are provided a SEP (one extra time each year outside of open enrollment to enroll or switch plans)
Prescription Advantage does not pay late enrollment penalty fee
Medicare.gov Plan Finder
What is the Meidcare.gov Part-D Plan Finder?
A tool on Medicare.gov which helps you to find the drug plan that best fits the clients personal data and formulary
It should only be used with the clients personal data and formulary It has all plans available within a zip code Pharmacy and clients formulary impact results Supported formularies vary by plan Coverage for Part D is provided by:
• Prescription Drug Plans (PDPs) also known as stand alone plans• Medicare Advantage Prescription Drug Plans (MA-PDs)
Using the Medicare Drug Plan Enrollment
Form
Using the Medicare Drug Plan Enrollment
Form Continued
How to use the Medicare.gov Plan Finder
1. Last Name 2. DOB (date of birth)3. Zip Code 4. Medicare Claim
Number5. Effective Date for A or B
To effectively use the medicare.gov Plan Finder you need to do a personalized search and need the information noted below
A personal search will provide accurate and data about the client including their current status and “Extra Help” supports
Doing a search on Medicare.gov
Results and importance of a Personal Search
Using the Medicare
Plan Finder
Part D Case Study
Terry Torial - Case Facts/Assumptions:
Meeting in person. Wants help with Rx drug Costs. Signed up for PartD during initial open enrolment she did not take drugs at that time. Now she does take Lipitor, Fosamax, Synthroid, and Ativan paying out of pocket. SS income $1,050. Assets 45,000. She does not appear frail.
Part D Case Study
Part D Case Study