SHINEServing the Health

Information Needs of Elders

3 Day Part D Counselor Training

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

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)

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

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

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. Clientswho are seeking assistance beyond basic inquiries should bereferred to a Certified SHINE Counselor.

Medicare Parts A & B“Original Medicare”

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)

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

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 income<$85,000/year)

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

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

2013 “Gaps” in Original Medicare

* 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

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

Your Medicare Coverage ChoicesStart

Step 1: Decide how you want to get your coverage

Part AHospital

Insurance

Part BMedical

Insurance CPart C

Combines Part A, Part B and usually Part D

ORIGINAL MEDICARE MEDICARE ADVANTAGE PLAN(like an HMO or PPO)

Step 2: Decide if you need a Prescription Drug Plan

OR

Part D Stand Alone PDP

Part DDrug coverage is limited to plan

offered by HMO or PPO.

Step 3: Decide if you need to addsupplemental medical coverage

MedigapSupplement Core or Supplement 1 plan

End

End

If you join a Medicare AdvantagePlan with drug coverage (MAPD), you cannotjoin another drug plan and you don’t need andcannot be sold a Medigap policy.

HP081111

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

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

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.

Original Medicare vs Medigap

Original Medicare Supplement Core

Supplement One

Hospital Deductible

$1184 $1184 $0

Hospital Copayments

Days 61-90 $296/dayDays 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 BCo-Insurance

20% $0 $0

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

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

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 plan’s 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.

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)

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 plan’s 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

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

Medigap vs. Medicare Advantage

Original Medicare Tufts Basic Rx

Blue Cross HMO

Supp. One

Premium $104.90 + D + $44.80 + $183 $182 +DPCP $147 Deductible

20% Co-Insurance$20 $15 $0

Hospital $1184 DeductibleDays 61-90 $296/dayDays 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

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

Medigap vs. Medicare Advantage

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.

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

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

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.

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)

Your Medicare Coverage ChoicesStart

Step 1: Decide how you want to get your coverage

Part AHospital

Insurance

Part BMedical

Insurance CPart C

Combines Part A, Part B and usually Part D

ORIGINAL MEDICARE MEDICARE ADVANTAGE PLAN(like an HMO or PPO)

Step 2: Decide if you need a Prescription Drug Plan

OR

Part D Stand Alone PDP

Part DDrug coverage is limited to plan

offered by HMO or PPO.

Step 3: Decide if you need to addsupplemental medical coverage

MedigapSupplement Core or Supplement 1 plan

End

End

If you join a Medicare AdvantagePlan with drug coverage (MAPD), you cannotjoin another drug plan and you don’t need andcannot be sold a Medigap policy.

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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

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) 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

Standard Medicare Part D (2013)

Level DescriptionDeductible 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%.

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

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.

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)

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

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 permanentLate enrollees may enroll during:

AEP (for coverage effective Jan 1) or Special Enrollment Period (SEP) if they are eligible

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

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.

Day 2: Medicare Part D and MassHealth

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 (benzo’s, barbiturates, certain OTC meds)

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

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

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

Medicare Savings Programs & Extra Help /

Limited Income Subsidy

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

Medicare Savings Programs

Type Income Limit Asset Limit Benefits

QMB 100% FPL7,080 (I),

10,620 (C)

Pays Part A & B premiums, co-insurance, and

deductibles

SLMB 120% FPL7,080 (I),

10,620 (C)Pays Part B premiums

QI 135% FPL7,080 (I),

10,620 (C)Pays Part B premiums

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

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

Levels of Extra Help

Full Extra HelpIncome Below 135% FPL AND Assets below $8,580 / $13,620• Full premium assistance• $2.65 for generics \ $6.60 for brands

Partial Extra HelpIf income below 150% FPL• Reduced premiums (sliding scale – between 25% -75%

assistance dependent upon income)• Reduced deductible ($66), 15% copayments

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

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/prescriptionhelp • 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

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

Prescription Advantage

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)

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

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

How Extra Help and Prescription Advantage Lower costs

Smart D Rx Plan Saver 2013

No Help PA S2 PartialExtra 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

2013 Program Guidelines for Individuals

MSP: QMB MSP:

SLMB / QI Full Extra Help Partial Extra

Help Prescription Advantage (S4)

Part B Premium

Automatic Full Extra

Help

Part D Premium & Deductible

paid for

Copays no more than

$6.60

Part D

Premium, Deductible,

Copays, reduced

Help in coverage gap

A & B deductibles and copays

Part B Premium

Automatic Full Extra

Help

Single: $978 $7,080 Single:

$1,313 $8,580

Single: $1,457 $13,300

Single: $2,873 no asset test

Single: $1,313 $7,080

2013 Program Guidelines for Couples

MSP: QMB MSP:

SLMB / QI Full Extra Help Partial Extra

Help Prescription Advantage (S4)

Part B Premium

Automatic Full Extra

Help

Part D Premium & Deductible

paid for

Copays no more than

$6.60

Part D

Premium, Deductible,

Copays, reduced

Help in coverage gap and Benzos

A & B deductibles and copays

Part B Premium

Automatic Full Extra

Help

Couples: $1,313 $10,620 Couples:

$1,765 $13,620

Couples: $1,959 $26,580

Couples: $3,878 no asset test

Couples: $1,765 $10,620

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.