SHINE S erving the H ealth I nformation N eeds of E lders

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 & B“Original 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 beneficiary’s 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 income<$85,000/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 * 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 don’t 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

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 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.

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 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

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

26. Medigap vs. Medicare Advantage

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 don’t 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)

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 (benzo’s, 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