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SHINE Counselor Fall Training
Preparing for Open Enrollment
Medicare UpdatesObservation Status
• Does NOT apply to Medicare Advantage Plans• Does NOT meet the Medicare requirement for SNF
coverage• Beneficiaries must resolve any issues regarding
observation status PRIOR to discharge from a hospital Observation status issues cannot be resolved while in a
SNF
• The Medicare Advocacy Project continues to work with beneficiaries who were not covered for SNF stays due to observation status; please refer potential cases to MAP
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Counseling Same-Sex Spouses
CMS and SSA view same-sex spouses the same as opposite- sex spouses
Laws have changed, some issues are still being worked out
Anyone eligible for benefits should apply
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2015 Medicare Plans
Choosing a Medigap
No change in number of plans offering Medigaps
New premiums
BC/BS lowest cost for CORE and Supplement 1
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Choosing a Medicare Advantage Plan
Check if doctors take plan and if drugs covered (use plan finder)
Compare premiums, co-pays, deductibles, and annual out-of-pocket maximums
Cannot enroll in an MA plan (HMO, PPO) and a stand-alone PDP• Selection of PDP will result in disenrollment from MA plan
New MA enrollment will result in automatic disenrollment from prior MA or PDP plan
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Blue Cross/Blue Shield MA Plans
Existing Plans• Premium increases: HMO Blue Plus Rx & PPO Blue Plus Rx• Hospital Co-pays higher• Increases in lab, high tech imaging & outpatient services• Available in all counties except Dukes & Nantucket,
Berkshires For PPO’s
• Check to see if providers will accept plan (if not, may be subject to filing claims and paying a higher rate)
Dental can be purchased by anyone over 65 7
Fallon Senior Plans
Existing Plans• Super Saver Rx premium staying at $0• Preferred pharmacies: CVS, Target, Walmart• Premium increases for all other plans • Inpatient hospital and skilled nursing costs changing• Higher co-pays for out-of-network care• Not all services covered out-of-network• Out of Pocket max. higher on most plans
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Harvard Pilgrim Two Plans: Stride HMO Value Rx and Stride
Value Rx Plus New Plan=Stride HMO Value Rx
• Available in Bristol, Norfolk, Suffolk, and Worcester counties only
• $46 premium, $3,400 annual out-of-pocket maximum
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Health New England
Changes in Existing Plans
• Premium increases in most plans
Service area remains Berkshire, Franklin, Hampden, and Hampshire counties
Hartford County Connecticut in network
Baystate Medical Center in network
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Tufts Medicare Preferred Existing Plans
• Premium and co-pay increases for most plans• $0 premium plan• Out of pocket $3400
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UnitedHealthCare Existing Plans
• AARP Complete Choice Regional PPO Still available in every county Premium and out-of-network co-insurance increased
HMO plans going to PCP based model with referrals required
No referrals needed in PPO Split deductible in tiers 3-4 New HMO Plans
• AARP Medicare Complete new to Bristol County12
Special Needs Plans Types of Special Needs Plans
• Dual- Eligible (Medicare and Medicaid)• Institutional (Must reside in LTC Facility)
Network Health is now called Tufts Health Plan-Network Health
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Health Safety Net Reminders Income 0-200% FPL – extensive benefits Income at 200-400% FPL partial assistance Could provide additional hospital coverage for
individuals enrolled in Original Medicare, Core Medigap, or Medicare Advantage
May pay for medical services at hospital or Community Health Center
Does NOT pay for SNF costs
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Part D Standard Benefit
* In 2015, after $2,960 in retail costs, the beneficiary pays 45% of brand name drug costs and 65% of generic drug costs until total out-of-pocket costs equal $4,700 15
Extra Help (LIS)
5 PDP plans with $0 premium for LIS members:
• Aetna Medicare Rx Saver• AARP MedicareRx Saver Plus• Humana Preferred Rx Plan• WellCare Classic• Silverscript Choice
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LIS Member Reassignment CMS will first attempt to transfer to other plans
below benchmark within same organization as member’s current plan
If none available, CMS will randomly reassign to plan offered by another organization
CMS will start making reassignments in mid-October
Affected members will be sent a BLUE letter in early November
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LIS Choosers Members who chose to be in their current plan (not
auto-enrolled):
• Will be notified if the plan’s premium goes above the benchmark
• Will be given a list of plans available for $0 premium
• Will not be automatically reassigned
CMS will mail out TAN letters in early November18
Discontinued PDP Plans Members of discontinued plans received
notification by October 2nd
Notification explains options:• List of alternative Medicare Advantage or
Prescription Drug Plans and phone numbers• Information on Original Medicare, Medigap, Extra
Help, and Medicaid• Contact information for Medicare & SHINE
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Discontinued PDP Plans Terminated plans offering NO auto-assignment,
SEP available until end of February:• HealthMarkets Value Rx• Unicare MedicareRx Rewards Standard
Plans auto-assigning members to new plans:• AARP MedicareRx Enhanced • First Health Part D Essentials• Cigna-HealthSpring Rx-Reg 2• Silverscript Choice• SmartD Rx Plus
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Auto-Assignment for Discontinued PDP Plans
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2014 Discontinued Plan 2015 Auto-Assignment
AARP MedicareRX Enhanced AARP MedicareRx Preferred
First Health Part D Essentials First Health Part D Value Plus
Cigna-HealthSpring Rx-Reg 2 Cigna-HealthSpring Rx Secure
Silverscript Choice SilverScript Choice (Basic plan renamed Choice)
SmartD Rx Plus SmartD Rx Saver
New PDP for 2015
United American Essential
27 plans available in 2015• Down from 33 in 2014
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Same Plan, New Name2014 Name 2015 New Name
Cigna Medicare Rx Secure Cigna-HealthSpring Rx SecureCigna Medicare Rx Secure-Max
Cigna-HealthSpring Rx Secure-Max
Cigna Medicare Secure-XtrCigna-HealthSpring Rx Secure-Xtra
Aetna CVS/pharmacy Aetna Medicare Rx Saver
SilverScript Basic SilverScript Choice
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Sanctioned Plans Smart D Rx Saver
• Plans remain under CMS sanction• Beneficiaries currently enrolled should not be
affected by the sanctions• Must do personalized search to compare plans
with 2015 options
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Preferred Pharmacy Pricing
Many PDPs continue to offer preferred pricing at select pharmacies in 2015• Refer to updated Preferred Pharmacy Chart
Pricing can vary dramatically between pharmacies• Important for beneficiaries to do 2 pharmacy
comparisons for preferred pharmacy pricing options
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SEPs Available After December 7th
Plan is terminating• Special Enrollment Period (SEP): Dec 8th – Feb 28th
Prescription Advantage members• One SEP each calendar year • If used in December, counted for 2015 SEP
Extra Help beneficiaries and dual-eligibles• Continuous SEP
Loss of Extra Help on 1/1/2015• SEP Until March 31st
5 Star Plan SEP Low Performing Medicare Plan
• Call 1-800-Medicare Medicare Advantage Disenrollment Period
• Jan 1st – Feb 14th 26
5 Star SEP
2015 plan star ratings will be available on Medicare.gov around October 19th
Ratings based on:• Customer service, complaints & member experience• Drug pricing and patient safety• Health screenings and management of chronic conditions
SEP December 8th– November 30th • Allows beneficiary to enroll or switch into 5 star plan
One time each year If Medicare Advantage plan, must meet eligibility criteria to enroll
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Medicare Advantage Disenrollment Period (MADP)
Beneficiaries can disenroll from Medicare Advantage plan and return to Original Medicare from January 1st - February 14th
Does not allow beneficiaries to switch to another MA Plan or switch from Original Medicare to a MA Plan
Beneficiaries who switch to Original Medicare will have a SEP to join a PDP from Jan 1st – Feb 14th
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Medicare Plan FinderUpdates and Tips
for Open Enrollment
Medicare.gov Home Page Update
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3 green buttons replace the 2 yellow buttons. The blue button that took the user to the MyMedicare login page has been removed- users can go to
MyMedicare through the link at the top right corner
Choosing a PDP or MA-PD
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Do a personalized search• If alerted that website is not secure when attempting
personalized search; Ask beneficiary if they feel comfortable to continue
despite alert If not, consider doing a general search
Enter drugs accurately
Pharmacy selection is important
Check for Prescription Advantage eligibility
Prescription Advantage Prescription Advantage Categories
• S1: Most beneficial for those in it• S2-S4: Helps when beneficiaries hit the
donut hole; provides fixed low co-pays• S5: $200 enrollment fee; may be worth it for some
1x yearly SEP available to ALL categories
Online application now available• www.prescriptionadvantagema.org
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Suppressed vs. Sanctioned Plans
Suppressed drug plans • Have submitted inaccurate drug pricing to CMS• These plans appear at the bottom of the Results
Page of the Plan Finder and do not display accurate costs
Sanctioned drug plans • Have failed to remain in compliance with CMS
standards and practices• These plans WON’T appear in the Plan Finder
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My Current Profile Box
Displays dates for Current Coverage
and Current Subsidy.
If possible, always do a Personalized
Search.
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Add, Change or Remove Drug Doses______________________________________________________________________
Buttons added to drug list section of Plan Comparison and Plan Details pages on drug costs & coverage tab
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Add, change dose, remove drugs at this tab rather than going back to beginning
Refresh page after making changes
Pharmacy Language Updates
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The old pharmacy status “Preferred-
Network” has been changed to
“Preferred Cost-Sharing”
The previous pharmacy status “Network” has
been changed to “Standard Cost-
Sharing”
Retail or Mail Order
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Enter month quantity at retail
pharmacy (default) when
possible
Printable Plan
Report
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Don’t forget you can customize
your report when printing
Email Functionality Removed
Removed due to security issues
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Improved Enrollment Safeguard
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Occasionally, when an enrollment is submitted, the confirmation page is not
displayed because an error occurred. This pop up window will inform you if the application was in fact received by
Medicare and will indicate the enrollment confirmation number
Remember to Click on Watermark When Enrolling Beneficiaries
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Click here on
Watermark
Enter your SHINE office
phone number here
Remember!
Always use Plan Finder unless client takes no drugs! Write down Drug ID and Password after entering first
drug (in case system goes down) Check plans for Restrictions (Prior Authorization,
Quantity Limits, Step Therapy) Use Medicare Plan Finder Guide in your folder to
ensure you are following all the necessary steps when performing drug plan searches
Print Confirmation page on Plan Finder with “Ctrl P” keys
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Medicare Improvements for Patients and Providers Act (MIPPA)
Screen beneficiaries for:• Extra Help• Medicare Savings Programs (Buy-In Programs)• Prescription Advantage
Remind beneficiaries about:• Preventive benefits offered by Medicare Part B
MIPPA Brochure available on SHINE counselor website 44
One Care Updates
One Care: Medicare + MassHealth
NOT available in all counties Health insurance plan combines Medicare and Medicaid
payments and services like a SCO but with additional features
For dual-eligibles between the aged of 21-64 Person-centered model providing full range of acute,
behavioral health, and long term supports and services Designed to coordinate care and provide higher quality,
more cost-effective care with improved health outcomes46
One Care Updates
Entering second year of three year demonstration project
8/28/14 - Final mailing sent out As of 9/1/14 - 17,739 enrolled statewide out
of 95,140 eligible One Care on Medicare website may not
always be accurate
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Role of SHINE Counselor Assist eligible beneficiaries to understand One Care,
review choices, check provider networks, check drug formularies and describe the enrollment process• Same process as for Medicare Advantage
Complete the client contact form, including new data fields, as required by CMS
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How to Search One Care Plans Step 4 of 4: Refine Your Plan Results
1
2
3
4
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1. Select Medicare Health Plans with Drug Coverage
2. In the left column, click the + by “Select Special Needs
Plans” to display available options
3. Check the first box that says “plans for people who are
eligible for both Medicare and Medicaid”
4. Click Update Plan Results and Continue to Plan Results
One Care Plans
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One Care Plans will indicate (Medicare – Medicaid) next to the plan name. This
designation should help you distinguish from other types of SNPs such as SCO Plans.
Helpful One Care Websites
One Care Plans Commonwealth Care Alliance
• Contact: 1-866-610-2273, www.commonwealthonecare.org
Fallon Total Care• Contact: 1-800-879-0852, www.fallontotalcare.org
Tufts Health Plan-Network Health• Contact: 1-855-393-3154, www.chooseunify.com
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Medicare and the Marketplace
Frequently Asked Questions
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What is the Marketplace? The Marketplace is a state price comparison website for
subsidized health insurance where individuals, families, and small businesses can shop for health insurance plans• It is designed to help people who don’t have any health
coverage• Medicare is NOT part of the Health Insurance Marketplace
The Health Connector is Massachusetts' health insurance Marketplace
Marketplace Open Enrollment is from November 15th 2014 -February 15th 2015
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What is the message to Medicare beneficiaries who have questions about how the Marketplace
affects them?
Medicare isn’t part of the Health Insurance Marketplace
Medicare beneficiaries DO NOT NEED TO DO ANYTHING about the Marketplace
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Can a Medicare beneficiary purchase a stand-alone dental plan through the Individual
Marketplace?
Yes. In Massachusetts everyone can purchase a dental plan through the Marketplace
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Where can individuals go for help with the Marketplace?
SHINE counselors receiving calls about the Marketplace should refer individuals to their local Navigator or Certified Application Counselor (CAC)
Massachusetts Health Connector• www.mahealthconnector.org• (877) 623-6765
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Questions
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