SHINE Serving the Health Information Needs of Elders

1
SHINEServing the Health Information Needs of
Elders
3 Day Part D Counselor Training
2
Day 1 Topics

• Overview of SHINE
• Original Medicare (Part A B)
• Medicare Supplement Plans (Medigap)
• Medicare Advantage Plans (Part C)
• Other Sources of Supplementing Medicare
• Medicare Part D

3
Day 2 3 Topics

• Day 2
• Medicare Part D Continued
• Part D and MassHealth
• Extra Help
• Medicare Savings Programs
• Prescription Advantage
• Forms
• Case Examples
• Day 3 Medicare.gov website (hands-on training)

4
SHINE Overview

• Began in 1985 as a pilot program. In 1992,
  SHINE became available statewide with federal
  funding assistance.
• Network of 600 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.
• Objective is to provide elders with access to
  accurate, unbiased health insurance information

5
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 public benefit programs and provide
  assistance with the application process
• Help with claims and billing problems
• Start appeals and explain grievance procedures

6
SHINE Part D Enrollment Counselor

• Assist Medicare beneficiaries in understanding
  their Health Insurance Options
• Assist beneficiaries by comparing the cost and
  benefits of the programs available to them.
• Screen beneficiaries for Prescription Advantage,
  Medicare Savings Programs, and Extra Help
• Provide enrollment assistance into these programs
• This training is designed to help you handle
  basic matters. Clients
• who are seeking assistance beyond basic inquiries
  should be
• referred to a Certified SHINE Counselor.

7
Medicare Parts A BOriginal Medicare
8
Medicare Overview

• Medicare is a health insurance program for
• People 65 years of age and older (not
  necessarily full retirement age)
• People under age 65 with disabilities
  (deemed disabled by Social Security for at
  least 24 months)
• People with End Stage Renal Disease (ESRD)
• People with Amyotrophic Lateral Sclerosis (ALS)
• Note Medicare is NOT Medicaid (which is health
  insurance based on income)

9
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 beneficiarys
  SSN)
• Card lists effective dates
  for Part A and B

10
Original Medicare Parts Premiums

• Part A Hospital Skilled Nursing Care
• (Premium free for most people may purchase if
  insufficient work credits but very expensive)
• Part B Doctors Visits Outpatient Care
• (104.90/month in 2013 for MOST beneficiaries
  with individual incomelt85,000/year)

11
Medicare Part A

• Part A helps cover
• Inpatient care in hospitals
• Inpatient care in a skilled nursing facility
• Hospice care services
• Home health care services
• Medicare does NOT cover Long Term Care

12
Medicare Part B

• Part B helps cover
• Preventive services
• Physician services
• Medical Equipment and Supplies
• Medically-necessary services
• Services or supplies that are needed to diagnose
  to treat your medical condition

13
2013 Gaps in Original Medicare
Part A Hospital deductible 1,184 per benefit period 296/day for extended hospital stays (days 61-90) 148/day for days 21-100 in SNF
Part B Annual deductible 147 20 co-pay for most Part B services Foreign travel

• A benefit period starts the day a beneficiary
  is admitted to the hospital or SNF and ends when
  the beneficiary has not received hospital or SNF
  care for 60 consecutive days

14
Your Medicare Coverage Choices
Start
Step 1 Decide how you want to get your coverage
OR
ORIGINAL MEDICARE
MEDICARE ADVANTAGE PLAN (like an HMO or PPO)
Part B Medical Insurance
Part A Hospital Insurance
Part C Combines Part A, Part B and usually Part D
C
Step 2 Decide if you need a Prescription Drug
Plan
Part D Drug coverage is limited to plan offered
by HMO or PPO.
Part D Stand Alone PDP
Step 3 Decide if you need to add supplemental
medical coverage
End
If you join a Medicare Advantage Plan with drug
coverage (MAPD), you cannot join another drug
plan and you dont need and cannot be sold a
Medigap policy.
Medigap Supplement Core or Supplement 1 plan
HP081111
End
15
Medicare Supplement Plans (Medigaps)

• Sold by private insurance companies with approval
  from the Massachusetts Department of Insurance.
• Only available to people who are enrolled in
  Medicare Part A Part B (must continue to pay
  Part B premium use Medicare Card)
• Pays second to Medicare only after Medicare
  recognizes service as a covered service
• No exclusions for pre-existing conditions (not
  true in all states)
• All Massachusetts Medigap plans have continuous
  open enrollment throughout the year (not true in
  all states)
• Medigap plans do not include prescription drug
  coverage

16
Medigap Plans

• Two Medigap Plans Sold in Massachusetts
• Core - leaves some gaps behind (including
  hospital deductible SNF co-pays), but costs
  less
• Supplement 1 - covers all gaps but costs more
• Both plans allow members to choose their own
  doctors, specialists, and hospitals without
  referrals
• NOTE Some people are covered through older
  policies no longer available to new members (e.g.
  Medex Gold). If you meet someone who has Medex
  Gold refer them to a Certified SHINE Counselor

17
Medigap Plans

• No matter which company a beneficiary selects for
  coverage they will receive the same benefits
• Some Medigap plans offer a discount of up to 15
  to beneficiaries who enroll within 6 months of
  their Medicare Enrollment.
• If an individual switches Medigap companies he or
  she must notify the previous company.
• If an individual leaves a plan that is no longer
  sold they will be unable to return to that plan.

18
Original Medicare vs Medigap
Original Medicare Supplement Core Supplement One
Hospital Deductible 1184 1184 0
Hospital Copayments Days 61-90 296/day Days 91-150 592/day 0 0
SNF Days 21-100 148/day Days 21-100 148/day 0
Part B Deductible 147 147 0
Part B Co-Insurance 20 0 0
19
Medicare Advantage Plans(Medicare Part C)

• Private insurance companies that contract with
  Medicare to provide coverage comparable to
  Original Medicare
• Members must still pay Part B premium
• Plans usually charge an additional premium
  members pay co-pays when receiving services.
• Plans may add additional benefits (e.g. eye
  glasses, hearing aids)
• Plans typically use networks of physicians

20
Medicare Advantage Plans(Medicare Part C)

• Eligibility
• Must have both Part A and Part B
• Must live within plan service area 6 months a
  year
• Must not have ESRD
• Must continue to pay Part B premium
• When to enroll
• Initial Enrollment Period (3 months before, month
  of, 3 months after turning 65)
• New to Medicare Part B (3 months before)
• Annual Enrollment Period (October 15 December
  7)
• Special Enrollment Periods
• Several Different Plan Types
• HMO
• PPO
• PFFS
• SNP

21
HMO - Health Maintenance Organization

• Must choose a Primary Care Physician
• With the exception of urgent or emergency care,
  members must receive all services within the
  plans network
• Need referrals for specialists
• May only join the prescription coverage offered
  by the HMO plan (cannot have a stand alone PDP)
• if plan is a HMO-POS then member is able to
  receive limited services outside of network at a
  higher cost.

22
PPO - Preferred Provider Organization

• Defined network of providers (may not be the same
  as HMO network)
• Plan provides all Medicare benefits whether in or
  out of network
• Usually pay higher co-pays for out-of-network
  services (and may have to meet an annual
  deductible first)
• No referrals needed to see specialists
• May only join the prescription coverage offered
  by the PPO plan (cannot have a stand alone PDP)

23
PFFS - Private Fee-For-Service

• Only available in Berkshire County and Islands
• No defined network no need for referrals
• May use any hospital or doctor across the country
  that accepts the plans terms and conditions of
  payment
• Plan determines how much it will pay providers
  for all services
• Plan may or may not offer Part D coverage
• Members may join a stand alone PDP if selected
  plan does not include prescription coverage

24
SNP - Special Needs Plans

• Only available to certain groups
• Institutionalized (e.g. nursing home) Dually
  Eligible (Medicare/Medicaid)
• Defined network of providers
• Covers all Medicare services AND provides extra
  benefits
• Provides prescription coverage
• Continuous open enrollment

25
Medigap vs. Medicare Advantage
Original Medicare Tufts Basic Rx Blue Cross HMO Supp. One
Premium 104.90 D 44.80 183 182 D
PCP 147 Deductible 20 Co-Insurance 20 15 0
Hospital 1184 Deductible Days 61-90 296/day Days 91-150 592/day Days 1-5 200/day Per visit 150 day 750 max per year 0
SNF Days 21-100 148/day Days 1-20 50/day 50 /day 1000 Max 0
Max None 3,400 3,400 0
26
Medigap vs. Medicare Advantage
Original Medicare Medigap Supplement 1 Medicare Advantage Plan
Higher monthly premium but no co-pays Generally lower premiums but has co-pays
Freedom to choose doctors Generally restricted to network
No referrals necessary May need referrals for specialists
Some routine services not covered (vision, hearing) May include extra benefits (vision, hearing, fitness)
Covered anywhere in US Only emergency or urgent services provided outside certain area
27
Annual Enrollment Period

• Each year Medicare Advantage Plans may change
• benefit structure
• physician network
• formulary
• name
• may leave the market or discontinue
• Members will be notified of plan changes by mail
  in the month of September.

28
Options for Members of Discontinued Plans

• Members may return to Original Medicare and
  purchase a stand-alone drug plan (w or w/o
  Medigap)
• Or may enroll in a new Medicare Advantage Plan
• Important If they do nothing, affected members
  may be returned to Original Medicare WITHOUT drug
  coverage on January 1, 2013.
• Will have the ability to enroll into a plan
  before the end of February, with coverage
  effective the first of the month following the
  enrollment

29
Medicare Advantage Plans and the Affordable Care
Act

• About 25 of seniors are enrolled in Medicare
  Advantage (MA) plans the rest are enrolled in
  traditional Medicare
• On average, Medicare has been paying MA plans
  more (about 14) per person than traditional
  Medicare this extra payment will be gradually
  eliminated (no increased payment in 2011, reduced
  payment in 2012/2013)
• As a result, some MA plans may cut extra
  benefits, increase premiums, or eliminate plans
  over the next few years
• MA plans providing high quality care will receive
  incentive bonus payments

30
Other ways to Supplement Medicare for Certain
Populations

• Retiree Health Plans (group plans)
• Each retiree plan is different
• Refer these clients to a Certified SHINE
  Counselor
• Medicaid/MassHealth (for very low-income)
• Part A and B deductibles and copayments covered
  in full if seeing a MassHealth physician.

31
Medicare Part D
32
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)

33
Your Medicare Coverage Choices
Start
Step 1 Decide how you want to get your coverage
OR
ORIGINAL MEDICARE
MEDICARE ADVANTAGE PLAN (like an HMO or PPO)
Part B Medical Insurance
Part A Hospital Insurance
Part C Combines Part A, Part B and usually Part D
C
Step 2 Decide if you need a Prescription Drug
Plan
Part D Drug coverage is limited to plan offered
by HMO or PPO.
Part D Stand Alone PDP
Step 3 Decide if you need to add supplemental
medical coverage
End
If you join a Medicare Advantage Plan with drug
coverage (MAPD), you cannot join another drug
plan and you dont need and cannot be sold a
Medigap policy.
Medigap Supplement Core or Supplement 1 plan
HP081111
End
34
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 SPAPs (Prescription
  Advantage) and State Medicaid (MassHealth)
  programs that wrap-around coverage

35
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.

36
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)
• Barbiturates (exception Part D covers
  barbiturates used to treat epilepsy, cancers, and
  chronic mental health disorders)
• Drugs used for Erectile Dysfunction (Viagra,
  Cialis, Levitra)
• Drugs that could be covered under Medicare Part A
  and/or Medicare Part B

37
Standard Medicare Part D (2013)
Level Description
Deductible Annual 325 deductible paid by the Beneficiary.
Initial Coverage From 325 to 2,970 (retail cost of drugs) Beneficiary pays 25 of the drug costs and Medicare pays 75
Coverage Gap Donut Hole After 2,970 in costs beneficiary pays 47.5 of brand name drug costs and 79 of generic drug costs until they have spent 4,750 out of pocket.
Catastrophic When true out of pocket (TrOOP) costs reach 4,750 (excluding monthly premium) beneficiary pays 5 of the drug costs and Medicare pays 95.
38
ACA is Closing the Donut Hole!

• In 2013, those in gap will receive 52.5 discount
  on brand-name drugs and 21 discount on generic
  drugs
• Discounts will increase every year until the
  donut hole is closed in 2020

39
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

40
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.

41
Enrollment Periods

• Individuals can only enroll or switch Medicare
  Part D plans during certain time periods
• Initial Enrollment Period (IEP)
• 7 month period surround birth month (3 months
  before , the month of your 65th Birthday, and 3
  months after)
• Annual Election Period (AEP)
• October 15 to December 7
• January 1st effective date
• Medicare Advantage Disenrollment Period (MADP)
• January 1st to February 14th , 2013
• Special Enrollment Periods (SEP)

42
Annual Election Period

• October 15th December 7th
• Every plan changes from year to year they
  change premiums, co-pays, formulary, or can end
  their contract with Medicare
• If an individual elects not to do anything then
  they will remain in that plan for the following
  year

43
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
• Have a lapse in coverage (63 days or more)
• Penalty 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, loss of creditable coverage or
  May 2006, whichever is later
• Penalty is permanent
• Late enrollees may enroll during
• AEP (for coverage effective Jan 1)
• or Special Enrollment Period (SEP) if they are
  eligible

44
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

45
A note about Supplement 2

• Medigap Supplement 2 is no longer sold (as of
  12/31/05)
• Most common Supplement 2 plan is Medex Gold.
• Very high monthly premium
• Provides comprehensive prescription coverage with
  no gaps
• Refer individuals with Medex Gold to a Certified
  SHINE Counselor for assistance.

46
Day 2 Medicare Part D and MassHealth
47
MassHealth and Medicare Part D

• MassHealth (Medicaid) is a state administered
  health care program primarily for low income
  individuals
• Those 65 and older must meet very low income and
  asset levels to qualify
• For those on Medicare, MassHealth provides
  secondary coverage (pays premiums, deductibles,
  co-pays) and provides some additional benefits
• Individuals with MassHealth and Medicare are
  considered Dual Eligible
• MassHealth does not provide drug coverage for
  dual eligibles - individuals must receive primary
  coverage through a Medicare Part D plan
• Dual eligibles will receive assistance with drug
  plan premium and co-pays through federal program
  called the Limited Income Subsidy (LIS) or Extra
  Help
• MassHealth still pays for certain medications
  that Medicare does NOT cover (benzos,
  barbiturates, certain OTC meds)

48
MassHealth and Medicare Part D

• Assisting Dual Eligibles find the best plan for
  them
• Look at stand alone Part D plans. Medical
  copayments are subsidized by MassHealth
• Search for plans with a premium below the
  benchmark. These plans will appear as having a
  0 monthly premium on the Medicare.gov website.
• Since Benzodiazepines and Barbiturates are
  covered by MassHealth directly, you should not
  include them in the plan search on medicare.gov

49
Auto-Enrollment of Duals

• Individuals who have MassHealth and become
  eligible for Medicare are auto-enrolled into the
  Limited Income Newly Eligible Transition Program
  (LI-Net)
• The LI-Net program, administered by Humana,
  provides coverage for individuals for two months.
• LI-Net, CMS, and MassHealth will mail letters to
  an individual during this time encouraging them
  to enroll into a Medicare Part D Plan
• After two months, if a dual-eligible individual
  has not selected a plan on their own they will be
  auto-enrolled into a randomly selected plan below
  the benchmark (so no additional monthly premium)
• BUT, plan may not cover all medications!!!!
• Dual Eligible Individuals can change plans
  monthly (continuous SEP), coverage begins first
  of the following month

50
Some Duals who were Auto-Enrolled will be
switched!

• Individuals who were automatically enrolled into
  a Part D plan may be automatically changed to a
  new plan if the premium of that plan goes above
  the benchmark
• Again, this plan may NOT cover all medications

51
Medicare Savings Programs Extra Help /Limited
Income Subsidy
52
Medicare Savings Programs

• Programs for Medicare beneficiaries to help pay
  for some Medicare co-pays and/or premiums
• QMB-Qualified Medicare Beneficiary - Pays
  Premiums, copayments and deductibles
• SLMB-Specified Low-income Medicare Beneficiary -
  Pays Part B premium only
• QI-Qualifying Individual Pays Part B premium
  only

53
Medicare Savings Programs
Type Income Limit Asset Limit Benefits
QMB 100 FPL 7,080 (I), 10,620 (C) Pays Part A B premiums, co-insurance, and deductibles
SLMB 120 FPL 7,080 (I), 10,620 (C) Pays Part B premiums
QI 135 FPL 7,080 (I), 10,620 (C) Pays Part B premiums
54
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

55
Eligibility

• To be eligible for Extra Help in 2013
• Income below 150 FPL
• (FPL changes each spring)
• Resources (assets) must be below
• 13,300 for an individual
• 26,580 for a couple

56
Levels of Extra Help

• Full Extra Help
• Income Below 135 FPL AND Assets below 8,580 /
  13,620
• Full premium assistance
• 2.65 for generics \ 6.60 for brands
• Partial Extra Help
• If income below 150 FPL
• Reduced premiums (sliding scale between 25
  -75 assistance dependent upon income)
• Reduced deductible (66), 15 copayments

57
LIS Eligibility

• Resources counted
• Bank accounts (checking, savings, CDs)
• Stock, bonds, savings bonds, mutual funds, IRAs
• Cash at any other financial institution or at
  home
• Real estate other than a primary home
• Resources not counted
• Primary home, car
• Property one needs for self-support, such as a
  rental property
• Burial spaces owned by a beneficiary
• Personal belongings
• Cash value of life insurance

58
Applying for Extra Help

• Individuals may be deemed eligible for Extra Help
  and do not have to apply to receive benefits.
• MassHealth/ Medicare beneficiaries (Dual
  Eligible)
• SSI recipients
• Medicare Savings Program enrollees (QMB / SLMB /
  QI)
• Otherwise individuals need to apply
• Complete an application online www.ssa.gov/prescri
  ptionhelp
• Call SSA at 1-800-772-1213 to request a paper
  application or to complete an application over
  the phone
• Visit a local SSA office

59
If found eligible for Extra Help

• Eligible for the entire calendar year
• Effective date is typically back-dated to the
  date the application was received
• Subsidy information will be sent to current
  Medicare Part D plan

60
Prescription Advantage
61
Prescription Advantage

• Massachusetts State Pharmacy Assistance 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)

62
Primary Coverage (for those without Medicare)

• No monthly premium
• If under the age 65 and receiving SSDI income
  must below 188 FPL (Category S2) , otherwise no
  income guidelines.
• Sliding scale, based on income, for copayments,
  quarterly deductibles, and out-of-pocket limits

63
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
• 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

64
How Extra Help and Prescription Advantage Lower
costs
Smart D Rx Plan Saver 2013 No Help PA S2 Partial Extra Help PA S1 Full Extra Help
Premium 32.40 32.40 Reduced Reduced 0
Deductible 325 325 66 7/ 18 0
Generics 0 0 15 15/ 7 2.65
Brands 35 35 15 15/18 6.60
Non-preferred 85 85 15 15/18 6.60
Cov Gap Generics 79 7 15 15/ 7 2.65
Cov Gap Brands 47.5 18 15 15/18 6.60
Benzodiazepines Full cost 7/18 Full Cost 7/18 Full Cost
65
2013 Program Guidelines for Individuals
MSP QMB
MSP SLMB / QI
Single 978 7,080
Full Extra Help
Single 1,313 7,080
Partial Extra Help
Single 1,313 8,580
Prescription Advantage (S4)
A B deductibles and copays Part B Premium
Automatic Full Extra Help
Single 1,457 13,300
Part B Premium Automatic Full Extra Help
Single 2,873 no asset test
Part D Premium Deductible paid for Copays
no more than 6.60
Part D Premium, Deductible,
Copays, reduced
Help in coverage gap





66
2013 Program Guidelines for Couples
MSP QMB
MSP SLMB / QI
Couples 1,313 10,620
Full Extra Help
Couples 1,765 10,620
Partial Extra Help
Couples 1,765 13,620
Prescription Advantage (S4)
A B deductibles and copays Part B Premium
Automatic Full Extra Help
Couples 1,959 26,580
Part B Premium Automatic Full Extra Help
Couples 3,878 no asset test
Part D Premium Deductible paid for Copays
no more than 6.60
Part D Premium, Deductible,
Copays, reduced
Help in coverage gap and Benzos





67
Refer To SHINE

• This training is designed to help you handle
  basic matters.
• If clients are seeking assistance beyond basic
  inquiries you are to refer to a Certified SHINE
  Counselor for assistance.