Download Medicare Part D and Low-Income Subsidy Program

SHINE
Serving the Health
Insurance Needs of Everyone
on Medicare
3 Day
Part D Counselor Training
Day 1 Topics
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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
Extra Help
Prescription Advantage
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Day 2 & 3 Topics
Day 2
 Review of Medicare Basics (Day 1)
 Review Extra Help
 Review Prescription Advantage
 Medicare Plan Finder Demo
Day 3
 Medicare.gov website (hands-on training)
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Certified SHINE Counselors
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Explain Medicare Part A, B, C and D benefits and gaps
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Compare health insurance and prescription drug plan options,
costs and benefits
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Screen for public benefit programs and provide assistance with
the application process
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Help with claims and billing problems
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Start appeals and explain grievance procedures
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SHINE Part D Enrollment Counselors
 Assist beneficiaries by comparing the cost and benefits
of the programs available to them.
 Screen beneficiaries for Extra Help and Prescription
Advantage
 Provide enrollment assistance into these programs
 Complete a client contact form after each appointment
This training is designed to help you handle basic matters.
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Medicare Parts A & B
“Original Medicare”
&
Supplements (Part C and Medigaps)
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 under age 65 and have ALS or ESRD
Note: Medicare is NOT Medicaid (which is health
insurance for very low income population)
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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
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The information on this card helps
counselors perform accurate drug plan searches
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Original Medicare Parts & Premiums
Part A – Hospital & Skilled Nursing Care
(Premium free for most people)
Part B – Doctors’ Visits & Outpatient Care
(Monthly premium, may change annually – increased
premium for those with income over $85,000/year)
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“Gaps” in Original Medicare
Part A
Part B
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Hospital deductible
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Daily co-pay for extended hospital stays (days 61-90)
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Daily co-pay for days 21-100 in SNF
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Annual deductible
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20% co-pay for most Part B services
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Your Medicare Coverage Choices
Start
Step 1: Decide how you want to get your coverage
ORIGINAL MEDICARE
Part B
Medical
Insurance
Part A
Hospital
Insurance
OR
MEDICARE ADVANTAGE PLAN
(like an HMO or PPO)
Part C
Combines Part
C A, Part B
and usually Part D
Step 2: Decide if you need a Prescription Drug Plan
Part D
Stand Alone PDP
Step 3: Decide if you need to add
supplemental medical coverage
Medigap
Supplement Core or
Supplement 1 plan
Part D
Drug coverage is limited to plan
offered by HMO or PPO.
End
If you join a Medicare Advantage
Plan with drug coverage (MAPD), you cannot
join another drug plan and you don’t need and
cannot be sold a Medigap policy.
HP081111
End
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Medicare Supplement Plans (Medigaps)
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Sold by private insurance companies
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People must be enrolled in Medicare Part A & Part B
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Pays second to Medicare only after Medicare recognizes service as a “covered” service
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All Massachusetts Medigap plans have continuous open enrollment throughout the year
(not true in all states)
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Medigap plans do not include prescription drug coverage
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There are two types of Medigap policies currently sold in Massachusetts:
Core and Supplement 1.
Core pays for Medicare A + B co-pays and Supplement 1 pays A + B deductibles and
co-pays.
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Supplement 2 is a type of Medigap policy no longer sold. Supplement 2 is very
expensive and includes prescription coverage. If you encounter someone with this
policy please refer them to a SHINE Counselor. The most common Supplement 2
policy is called Medex Gold and was a BCBS product.
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Medicare Advantage Plans
(aka Medicare Part C, Medicare Health Plans)
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Private insurance companies that contract with Medicare to provide coverage
comparable to “Original” Medicare
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Medicare Advantage Plans combine Medicare A, B, and Part D benefits into one plan.
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Members must have Medicare Part A and B to enroll
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Members must still pay Part B premium
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Plans usually charge an additional premium & members pay co-pays when receiving
services
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Plans may add additional benefits (e.g. routine physicals, eye glasses, hearing aids)
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Plans typically use networks of physicians
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Most common types of Medicare Advantage Plans are HMO’s and PPO’s
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Types of Medicare Advantage Plans
HMO - Health Maintenance Organization
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With the exception of urgent or emergency care, members must receive
all services within the plan’s network
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Primary Care Physician required and referrals needed to see specialists
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May only join the prescription coverage offered by the HMO plan
PPO - Preferred Provider Organization
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PPO’s have a defined network of providers with the option of seeing
providers outside the network. Care sought out-of-network usually
results in higher copays and deductibles.
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May only join the prescription coverage offered by the PPO plan
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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
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Annual Enrollment Period
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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.
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Other ways to Supplement Medicare
Beware of:
 Retiree Health Plans (group plans)
• Each retiree plan is different
 Veterans Administration
 Medicaid/MassHealth (for very low-income)
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Medicare and MassHealth
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A beneficiary who has Medicare and MassHealth is
referred to as “Dual Eligible”.
For hospital and medical services, Medicare always pays
Primary and MassHealth pays Secondary as long as the
provider accepts MassHealth.
Dual eligibles who want drug coverage must get it
through a Medicare Part D plan. MassHealth will help
pay for some medications not covered by Part D (i.e.
OTC medications).
Dual eligibles qualify for reduced Part D premiums,
deductibles, and drug co-pays.
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Medicare Part D
Overview of Medicare Part D
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Voluntary, but may be subject to penalty
Provides outpatient prescription drugs
People with Part A and/or Part B 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)
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Examples of Part D Excluded Drugs
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Drugs for anorexia, weight loss or weight gain
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Drugs for the symptomatic relief of cough and colds
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Prescription vitamins and mineral products, except prenatal
vitamins and fluoride preparations
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Non-prescription drugs (over the counter)
Barbiturates (exception: Part D covers barbiturates used to
treat epilepsy, cancers, and chronic mental health disorders)
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Drugs used for Erectile Dysfunction (Viagra, Cialis, Levitra)
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Drugs that could be covered under Medicare Part A and/or
Medicare Part B
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Not all Part D Plans are made equal!
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PDPs and MA-PDs may vary based on:
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Benefit Design
Monthly Premium
Deductible
Co-payments
Formulary
Drug Prices
Drug Restrictions
Pharmacy Network
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2013 Medicare Part D Basic Structure
4 Phases of Coverage
Deductible
Description
1st Phase requires member
to pay the full cost of
drugs.* Not all drug plans
have a deductible phase.
Member Pays
PaysPays
Plan Pays
0-$325 depending on plan
Nothing
No more than 25% of the
retail cost for generic and
brand
75%
47.5% of retail cost for
brand
52.5% of retail cost for
brand
79% of retail cost for
generic
21% of retail cost for generic
*Some plans provide coverage for
generics during the deductible
Initial Coverage
Period (ICL)
2nd Phase requires member
to pay a fixed co-pay or
co-insurance.
Coverage Gap
(Donut Hole)
3rd Phase begins when the
retail value of drugs
purchased reaches $2,970.
Member will pay higher
coinsurances for
medications.
Catastrophic
4th Phase begins when out
of pocket spending reaches
$4,750.
The $4,750 represents
everything the MEMBER
PAID during Phases 1, 2,
and 3 plus what the PLAN
PAID for brand names
during Phase 3
5% of retail cost for brand
and generic
No more than $2.65 for
generic
95%
No more than $6.60 for
brand
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ACA is Closing the Donut Hole!
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Each year, the co-payment percentage for generics
and brand names will decrease.
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By 2020, these percentages will match those in the
Initial Coverage Period and the donut hole will be
eliminated.
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How to Enroll Into Medicare Part D
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Review plan options
• Plan Finder Tool on Medicare Website www.medicare.gov
• Determine PDP plan vs. MA-PD plan
• Consider cost, coverage, quality, and convenience
• Be aware of preferred pharmacies
• Avoid drug restrictions
 Step Therapy - May require member try an alternative med first
 Prior Authorizations - Requires doctor’s approval
 Quantity Limitations - Limits how much medication can be
dispensed to a patient within a specific time period.
Contact plan directly or call 1-800-Medicare
• Enrollment can take place on the phone, online, or through a mailed in
paper application.
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Annual Election Period
“Open Enrollment”
 October 15th – December 7th.
All changes are effective January 1st.
 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
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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 that is not “creditable”
 Have a lapse in coverage (63 days or more)
Penalty is charged once an individual enrolls in a Part D plan
 1% of the benchmark premium* for each month an individual went without
creditable coverage since becoming eligible for Medicare, losing creditable
coverage or May 2006, whichever is later.
 Penalty is for life.
 National Benchmark premium for 2013 is $31.17
Late enrollees may enroll during:
 AEP (for coverage effective Jan 1)
 Special Enrollment Period (SEP), if they are eligible.
(There are many SEPs, please refer to your PDP/MA-PD Special Enrollment
Period Chart)
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Late Enrollment Penalty Example
John enrolled in Original Medicare when he turned 65 but did not pick up Part
D because he was not taking medication at the time. He is now 70 and enrolls
in a Part D plan during open enrollment because his doctor prescribed him 2
medications. Upon enrolling in his Part D plan he was notified of the Late
Enrollment Penalty (LEP) he must pay for failing to sign up when he was first
eligible.
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5 years without coverage = 60 months
1% of 2013 benchmark $31.17 = .31
60 months x .31 = $18.60 Monthly LEP
John is responsible to pay the LEP every month in addition to his regular Part D
premium.
This penalty increases slightly each year with the increase in the benchmark
premium.
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Creditable Coverage
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Prescription drug coverage as good or better than standard Part D
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All Medicare beneficiaries (including those who are still working) must have
creditable coverage to avoid a late enrollment penalty
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Benefits administrator has information about whether the coverage is creditable
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Beneficiaries should be encouraged to ask the benefits administrator if they
have not been notified about creditable coverage status
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Examples of creditable coverage include: Veterans, COBRA, and most
Employer Group Health Plans.
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Extra Help /
Limited Income Subsidy
&
Prescription Advantage
Savings Programs Can Help!
Decide how you want to get your coverage and apply for assistance
ORIGINAL MEDICARE
Part A
Hospital
Insurance
OR
MEDICARE ADVANTAGE PLAN
Part B
Medical
Insurance
(like an HMO or PPO)
Part C
Combines Part
C A, Part B
and usually Part D
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
EXTRA HELP
&
PRESCRIPTION ADVANTAGE
Work With Stand Alone Plans
AND Drug Coverage offered with
a Medicare Advantage.
HP081111
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Extra Help/Low Income Subsidy (LIS)
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Extra Help is a federal assistance program to help low-income and low-asset
Medicare beneficiaries with costs related to Medicare Part D.
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Extra Help subsidizes:
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Premiums
Deductibles
Copayments
Coverage Gap “Donut Hole”
Late Enrollment Penalty
Does not subsidize non-formulary or excluded medications
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Apply through Social Security Administration
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Medicare beneficiaries who qualify for MassHealth will receive Full Extra Help
automatically.
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Levels of Extra Help (LIS)
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Full Extra Help
If income below 135% FPL AND resources (assets) below
$8,580 (individual) and $13,620 (couple)
• Full premium assistance with no deductible
• Low, capped co-payments
Partial Extra Help
If income below 150% FPL AND resources (assets) below
$13,300 (individual) and $26,580 (couple)
• Reduced premiums (sliding scale – between 25% -75%
assistance dependent upon income)
• Reduced deductible and 15% copayments
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Extra Help (LIS) Eligibility
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Resources counted:
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Bank accounts (checking, savings, CDs)
Stock, bonds, savings bonds, mutual funds, IRAs
Real estate other than a primary home
Resources not counted:
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Primary home, car
Property one needs for self-support, such as a rental
property
Burial spaces owned by a beneficiary
Personal belongings
Life Insurance Policies
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Applying for Extra Help (LIS)
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To apply:
• Complete an application online
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•
www.ssa.gov/extrahelp
Call SSA at 1-800-772-1213 to complete an
application over the phone
Visit a local SSA office
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Prescription Advantage
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Massachusetts’ State Pharmacy Assistance Program
(SPAP)
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Provides secondary coverage for those with Medicare
or other “creditable” drug coverage (i.e. retiree plan)
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Benefits are based on a sliding income scale only – no
asset limit!
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Different income limits for under 65 vs. 65 and over
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Applying for Prescription Advantage

To apply:
• Call Prescription Advantage at 1-800-243-4636
•
and Press 2 to complete an application over the
phone
Member can complete a paper application
available at your counseling site.
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Prescription Advantage for those with
Medicare or “Creditable Plan”
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Helps pay for drugs in the gap (for most members)
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Those with higher incomes may have to pay a $200 annual
fee for limited benefits
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To receive co-pay assistance, all medications must be
covered by the primary drug plan
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Members are provided a Special Enrollment Period (SEP)
(one extra time each year outside of open enrollment to
enroll or switch plans)
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Prescription Advantage does not pay Part D late enrollment
penalty
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Part D Counselor Training
Day 2: Review Questions
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What is Medicare Part D and how is it offered?
Who is eligible?
What is creditable coverage?
How is the late enrollment penalty calculated?
When is the Annual Election “Open Enrollment” Period?
When does the coverage gap or “donut hole” begin?
What programs are available to reduce drug costs?
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Case Study 1
Phil Harmonic
Phil Harmonic comes to see you in October because he needs help reviewing
his drug plan for 2014. He tells you he enrolled in a Medicare Part D Plan when
he turned 65. He currently takes generic medications and is in a low premium
plan; however, his doctor recently informed him that he will be starting a brand
name medication in January. Phil is worried that he may enter the donut hole in
with this new medication but he’s not sure. He tells you he is single and has a
gross monthly income of $1,300. He also has $5,000 in a checking account and
owns a life insurance policy.
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What information will you need to assist Phil with a drug plan search?
When is Phil able to change his drug plan?
What would you tell Phil about the donut hole?
What subsidy programs may Phil qualify for and how would he apply?
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Case Study 2
Bart Ender
Bart comes to see you during Medicare Open Enrollment. He is 70 years old,
has Original Medicare, a Part D plan and tells you he just got a letter from
Social Security informing him he’s been approved for Extra Help. Bart explains
that he has been paying very high copays for several of his brand name
medications this year and a friend of his helped him apply for Extra Help on the
Social Security website. He mentions to you that he enrolled into Medicare Part
D late and has also been paying a penalty. He wants to know how this Extra
Help program will lower his costs.
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How could you figure out what level of Extra Help Bart has?
How would Extra Help reduce his drug costs?
Would Extra Help pay his Late Enrollment Penalty?
Now that Bart has Extra Help, how often can he change his Part D plan?
How else would you assist Bart?
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Case Study 3
Pat E. Cake
Pat E. Cake meets with you on November 20th. She says she belongs to a
Medicare Advantage Plan (HMO). She tells you the prescription drug plan built
into her Medicare Advantage plan costs more than she wants to pay, so she
has decided to enroll in a Part D plan the offered to her by the agent she met at
CVS.
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What will happen if Pat enrolls in this Part D plan?
If Pat wants to explore other Medicare coverage options how would you
help her?
If Pat makes a change to her coverage now, when will the change take
effect?
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Case Study 4
Lucy and Ricky
Lucy and Ricky come into the SHINE office on December 1, 2013. They want to know if
there is still time to review their drug plan options for next year. They both have
Medicare, a Medigap Supplement 1 Plan and a Part D plan. Ricky explains that Lucy was
supposed to make an appointment to see the SHINE counselor weeks ago but forgot. In
fact, she has been forgetting so much that the doctor has put her on a new brand name
medication which is starting to help. Ricky explains that the only issue now is that the
medication is very expensive. The couple’s monthly income is $3,700/month and they
have $50,000 in assets. Lucy also wants to know why her new over the counter
supplement “Vitameatavegamin” is not covered by Medicare Part D.
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Why should Lucy and Ricky review their drug plan for 2014?
Do they still have time to make a change?
Would they qualify for any assistance programs?
Should Lucy’s OTC medication be covered?
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