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SHINE Counselor Fall Training Preparing for Open Enrollment.

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Presentation on theme: "SHINE Counselor Fall Training Preparing for Open Enrollment."— Presentation transcript:

1 SHINE Counselor Fall Training Preparing for Open Enrollment

2 Medicare Updates  Observation 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 2

3 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 3

4 2015 Medicare Plans

5 Choosing a Medigap No change in number of plans offering Medigaps New premiums BC/BS lowest cost for CORE and Supplement 1 5

6 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 6

7 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

8 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 8

9 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 9

10 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 10

11 Tufts Medicare Preferred Existing Plans Premium and co-pay increases for most plans $0 premium plan Out of pocket $

12 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 Count y 12

13 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 13

14 Health Safety Net Reminders Income 0-200% FPL – extensive benefits Income at % 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 14

15 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

16 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 16

17 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 17

18 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 November 18

19 Discontinued PDP Plans Members of discontinued plans received notification by October 2 nd 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 19

20 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 20

21 Auto-Assignment for Discontinued PDP Plans Discontinued Plan2015 Auto-Assignment AARP MedicareRX EnhancedAARP MedicareRx Preferred First Health Part D EssentialsFirst Health Part D Value Plus Cigna-HealthSpring Rx-Reg 2Cigna-HealthSpring Rx Secure Silverscript ChoiceSilverScript Choice (Basic plan renamed Choice) SmartD Rx PlusSmartD Rx Saver

22 New PDP for 2015 United American Essential 27 plans available in 2015 Down from 33 in

23 Same Plan, New Name 2014 Name2015 New Name Cigna Medicare Rx SecureCigna-HealthSpring Rx Secure Cigna Medicare Rx Secure- Max Cigna-HealthSpring Rx Secure- Max Cigna Medicare Secure-Xtr Cigna-HealthSpring Rx Secure- Xtra Aetna CVS/pharmacyAetna Medicare Rx Saver SilverScript BasicSilverScript Choice 23

24 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 24

25 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 25

26 SEPs Available After December 7 th  Plan is terminating Special Enrollment Period (SEP): Dec 8 th – Feb 28 th  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 31 st  5 Star Plan SEP  Low Performing Medicare Plan Call Medicare  Medicare Advantage Disenrollment Period Jan 1 st – Feb 14 th 26

27 5 Star SEP 2015 plan star ratings will be available on Medicare.gov around October 19 th Ratings based on: Customer service, complaints & member experience Drug pricing and patient safety Health screenings and management of chronic conditions SEP December 8 th – November 30 th Allows beneficiary to enroll or switch into 5 star plan  One time each year  If Medicare Advantage plan, must meet eligibility criteria to enroll 27

28 Medicare Advantage Disenrollment Period (MADP) Beneficiaries can disenroll from Medicare Advantage plan and return to Original Medicare from January 1 st - February 14 th 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 1 st – Feb 14 th 28

29 Medicare Plan Finder Updates and Tips for Open Enrollment

30 Medicare.gov Home Page Update 30 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

31 Choosing a PDP or MA-PD 31 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

32 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 32

33 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 33

34 My Current Profile Box Displays dates for Current Coverage and Current Subsidy. If possible, always do a Personalized Search. Displays dates for Current Coverage and Current Subsidy. If possible, always do a Personalized Search. 34

35 Add, Change or Remove Drug Doses ______________________________________________________________________ Buttons added to drug list section of Plan Comparison and Plan Details pages on drug costs & coverage tab 35 Add, change dose, remove drugs at this tab rather than going back to beginning Refresh page after making changes

36 Pharmacy Language Updates 36 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”

37 Retail or Mail Order 37 Enter month quantity at retail pharmacy (default) when possible

38 Printable Plan Report 38

39 39 Don’t forget you can customize your report when printing

40 Functionality Removed Removed due to security issues 40

41 Improved Enrollment Safeguard 41 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

42 Remember to Click on Watermark When Enrolling Beneficiaries 42 Click here on Watermark Enter your SHINE office phone number here

43 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 43

44 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

45 One Care Updates

46 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 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 outcomes 46

47 One Care Updates Entering second year of three year demonstration project 8/28/14 - Final mailing sent out As of 9/1/ ,739 enrolled statewide out of 95,140 eligible One Care on Medicare website may not always be accurate 47

48 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 48

49 How to Search One Care Plans Step 4 of 4: Refine Your Plan Results 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 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

50 One Care Plans 50 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.

51 Helpful One Care Websites One Care Plans  Commonwealth Care Alliance Contact: ,  Fallon Total Care Contact: ,  Tufts Health Plan-Network Health Contact: , 51

52 Medicare and the Marketplace Frequently Asked Questions 52

53 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 15 th February 15 th

54 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 54

55 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 55

56 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 (877)

57 Questions 57


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