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

+

+

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