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SHINE 3 Day Part D Counselor Training


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Title: SHINE 3 Day Part D Counselor Training

SHINE 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
  • Extra Help
  • Prescription Advantage

Day 2 3 Topics
  • Day 2
  • Review of Medicare Basics (Day 1)
  • Review Extra Help
  • Review Prescription Advantage
  • Medicare Plan Finder Demo
  • Day 3
  • website (hands-on training)

  • SHINE Serving the Health Insurance Needs of
  • Started in Massachusetts 1985
  • Partially federally funded since 1992
  • Part of national SHIP State Health Insurance
    Assistance Programs

Certified SHINE Counselors
  • Explain Medicare Part A, B, C and D benefits and
  • Compare health insurance and prescription drug
    plan options, costs 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 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
  • The 3 day Part D Counselor Training is designed
    to help you handle BASIC matters

Medicare Parts A B Original Medicare Supplem
ents (Part C Medigaps)
  • Enacted into law 1965, Title XVIII of the Social
    Security Act Effective July 1st , 1966
  • Entitlement program
  • Federal health insurance program for
  • Individuals over age 65
  • Not necessarily full retirement age
  • Individuals under age 65 with a disability
  • Deemed disabled by Social Security for at least
    24 months
  • Never intended to cover 100 of healthcare costs
  • NOT a comprehensive health insurance program

  • Medicare only pays for services which are
    reasonable and medically necessary for the
    treatment and diagnosis of an accident or illness
  • Even when medically necessary, there are gaps
    in Medicare coverage and the beneficiary must pay
    a portion of the medical expenses

  • 4 parts of Medicare
  • Part A Hospital Insurance
  • Part B Medical Insurance
  • Part C Medicare Advantage Plans
  • Part D Prescription Drug Coverage
  • Part A B called Original Medicare

Medicare Card
  • Each Medicare Claim Number is unique to the
  • The number is made up of a Social Security Number
    and letter which is not necessarily the
    beneficiarys SSN
  • Card lists effective dates for Part A Part B

Medicare Claim . Letter attached to the claim
indicates how the individual qualifies for
Part A B Effective Dates
Original Medicare Parts Premiums
  • Part A Hospital Skilled Nursing Care
  • Premium free for most people
  • Part B Doctors Visits Outpatient Care
  • EVERYONE pays Part B premium
  • Monthly premium that may change annually
  • Premium based on income with an increased premium
    for those with income over 85,000/year

Coverage Gaps in Medicare
  • There are coverage gaps in Medicare including
  • Part A in-patient hospital deductible
  • Part A daily co-payment for in-patient hospital
    days 61-90
  • Part A daily co-payment for in-patient hospital
    days 91-150
  • Part A daily co-payment for SNF days 21-100
  • Part B annual deductible
  • Part B co-insurance (usually 20)
  • First three pints of blood
  • Coverage outside the United States

Two Options For Supplementing Medicare
Step 1 Decide how you want to get your coverage
PART B Medical Insurance
PART A Hospital Insurance
PART C Combines Part A, Part B and usually Part D

Step 2 Decide if you need a Prescription Drug
PART D Stand Alone PDP
PART D Included in Part C
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 dont need and cannot be sold a
Medigap policy
MEDIGAP Supplement Core or Supplement 1 plan
Medicare Supplement Plans (Medigaps)
  • Sold by private insurance companies
  • People must be enrolled in Medicare Part A Part
  • Pays second to Medicare only after Medicare
    recognizes service as a covered service
  • All Massachusetts Medigap plans have continuous
    open enrollment throughout the year (not true in
    all states)
  • Medigap plans DO NOT include prescription drug

Massachusetts Medigap Plans
  • There are two types of Medigap policies currently
    sold in Massachusetts
  • Core Pays for Medicare A B co-pays
  • Supplement 1 Pays A B co-pays deductibles
  • Supplement 2 Type of Medigap policy no longer
  • Very expensive plan, includes prescription
  • Most common Supplement 2 policy is called Medex
    Gold and was a BCBS product
  • If you encounter someone with this policy please
    refer them to a SHINE Counselor

Medicare Advantage Plans
  • Also referred to as Part C, MA plan, Medicare
    Health Plans
  • Private insurance companies that contract with
    Medicare to provide coverage comparable to
    Original Medicare
  • Members must have Medicare Part A B to enroll
  • Must still pay Part B premium
  • Medicare Advantage Plans combine Medicare A, B,
    and Part D benefits into one plan
  • Plans usually charge an additional premium
    members pay co-pays when receiving services
  • Plans may add additional benefits (e.g. routine
    physicals, eye glasses, hearing aids)
  • Plans typically use networks of physicians
  • Most common types of Medicare Advantage Plans are
    HMOs and PPOs

Types of Medicare Advantage Plans
  • HMO - Health Maintenance Organization
  • With the exception of urgent or emergency care,
    members must receive all services within the
    plans network
  • Primary Care Physician required and referrals
    needed to see specialists
  • May ONLY join the prescription coverage offered
    by HMO plan
  • PPO - Preferred Provider Organization
  • PPOs have a defined network of providers with
    the option of seeing providers outside the
  • Care sought out-of-network usually results in
    higher co-pays deductibles
  • May ONLY join the prescription coverage offered
    by PPO plan

Medigap vs. Medicare Advantage
Original Medicare Medigap Supplement 1 Medicare Advantage Plan
Higher premiums but no co-pays Generally lower premiums but has co-pays
Freedom to choose doctors May be 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 Emergency services ONLY outside service area
Other ways to supplement Medicare
  • Retiree Health Plans (group plans)
  • Each retiree plan is different
  • Veterans Administration
  • Medicaid/MassHealth (for very low-income)

Medicare and MassHealth
  • 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 (ex. OTC medications)
  • Dual eligibles qualify for reduced Part D
    premiums, deductibles, and drug co-pays

Medicare Part D
Part D Overview
  • Medicare offers prescription drug coverage to
    everyone with Medicare
  • Beneficiaries with Part A and/or Part B are
  • 2 ways to get prescription coverage
  • 1. Medicare Prescription Drug Plans (PDPs) also
    known as stand alone plans
  • 2. Medicare Advantage Plans with drug coverage
  • Part D is voluntary, but eligible beneficiaries
    who do not enroll may be subject to a penalty
  • Provides outpatient prescription drugs

  • The prescription benefit includes a list of
    covered drugs and this list is called the
  • If the insurer is very selective about which
    drugs are to be covered, then it is sometimes
    referred to as a closed formulary. If the
    formulary is open to all drugs but places drugs
    into different cost sharing categories or
    tiers, it is referred to as an open formulary
  • Each plan must meet formulary standards. The
    formulary must include and cover certain drugs or
    certain classes of drugs. Medicare has
    established a category of excluded drugs

Examples of Part D Excluded Drugs
  • Drugs for anorexia, weight loss or weight gain
  • Drugs for the symptomatic relief of cough and
  • Prescription vitamins and mineral products,
    except prenatal vitamins and fluoride
  • Non-prescription drugs (over the counter)
  • Drugs that could be covered under Medicare Part A
    and/or Medicare Part B

Appeals to Formulary
  • Beneficiaries can take the following steps when a
    drug they are taking is not covered under the
  • Ask their prescriber if she/he meets prior
    authorization or step therapy requirements or if
    there are generic, over-the-counter or less
    expensive brand name drugs
  • Request an coverage determination (including an
    exception) that the plan cover the drug
  • Try to find a SEP that they are eligible for in
    order to switch Part D plans to one that has a
    formulary that covers all of the beneficiaries

Not all Part D Plans are made equal!
  • PDPs and MA-PDs may vary based on
  • Benefit Design
  • Monthly Premium
  • Deductible
  • Co-payments
  • Formulary
  • Drug Prices
  • Drug Restrictions
  • Pharmacy Network

2014 Standard Medicare Part D
Level Description
Deductible Annual deductible paid by the Beneficiary 310.00 max
Initial Coverage After deductible, beneficiary pays 25 of the drug costs and Medicare pays 75 Initial coverage limit is 2,850
Coverage Gap Donut Hole Begins once initial coverage limit is reached Beneficiary pays percentage of the cost for brand name (47.5) and generic drugs (72) Beneficiarys out of pocket reaches 4,550 catastrophic
Catastrophic Begins when catastrophic limit is reached Beneficiary pays 5 of the drug costs and Medicare pays 95
ACA Closing the Coverage Gap
  • The Affordable Care Act reduces the costs to
    beneficiaries who reach the coverage gap.
    Effective January 2011 beneficiaries receive
    discounts on both brand and generic drugs in the
    gap. These discounts will increase each year
    until the coverage gap is eliminated in 2020

Enrolling into Part D
  • Review plan options
  • Plan Finder Tool on
  • Determine PDP plan vs. MA-PD plan
  • Consider cost, coverage, quality, and convenience
  • Try to avoid drug restrictions using
  • Step Therapy
  • Prior Authorizations
  • Quantity Limitations
  • Contact plan directly or call 1-800-Medicare
  • Enrollment can take place on the phone, online,
    or through a mailed in paper application

Open Enrollment Period
  • October 15th to December 7th Coverage effective
    January 1st
  • During this period beneficiaries can
  • Join a plan for the first time (If late enrollee,
    would be subject to late enrollment penalty)
  • Switch plans (including changing MA plans)
  • Drop a plan
  • To switch a plan
  • Simply enroll in new plan. No need to cancel old
    Medicare drug plan as the coverage will end when
    the new drug plan begins

Late Enrollment
  • If a Medicare beneficiary does not join a
    Medicare Prescription Drug Plan when first
    eligible and didnt have other creditable
    prescription drug coverage that met Medicares
    minimum standards, they could incur a late
    enrollment penalty
  • All Medicare beneficiaries (including those who
    are still working) must have creditable coverage
    to avoid the late enrollment penalty

Creditable Coverage
  • Coverage that is at least as good as Medicare
    Part D
  • Protects a beneficiary from the Part D penalty
  • Employer or retiree coverage, union coverage, VA
    coverage Need proof of coverage to avoid penalty
  • Beneficiaries still working
  • Benefits administrator has information about
    whether the employer coverage is creditable
  • Beneficiaries should be encouraged to ask the
    benefits administrator about their creditable
    coverage status if they have not been notified

Late Enrollment Penalty
  • Penalty is 1 of the national base beneficiary
    premium for EACH MONTH the beneficiary
  • Did not enroll in a Medicare PDP when they were
    first eligible AND
  • Had no prescription drug coverage
  • OR
  • Had coverage that was not considered creditable
  • OR
  • Had a lapse in creditable coverage of 2 full
    months (63 days)

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
  • 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

Supplement 2 (aka Medex Gold)
  • Considered creditable coverage
  • No penalty if beneficiary eventually joins a Part
    D plan
  • Beneficiary can join during a Part D plan during
    the Open Enrollment Period or if they qualify for
    a Special Enrollment Period
  • Dis-enrolling from the plan is not in of itself a

Extra Help / Limited Income Subsidy Prescripti
on Advantage
Savings Programs Can Help!
Step 1 Decide how you want to get your coverage
and apply for assistance
PART B Medical Insurance
PART A Hospital Insurance
PART C Combines Part A, Part B and usually Part D
Step 2 Decide if you need a Prescription Drug
Plan (PDP)
PART D Drug coverage is limited to plan offered
by HMO or PPO
PART D Stand Alone PDP
stand alone plans AND drug coverage offered with
Medicare Advantage plan
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
  • Extra Help subsidizes
  • Premiums
  • Deductibles
  • Co-payments
  • Coverage Gap Donut Hole
  • Late Enrollment Penalty
  • Does NOT subsidize non-formulary or excluded
  • Apply through Social Security Administration

2 Levels of Extra Help
  • Full Extra Help
  • 135 of the Federal Poverty Level (FPL) and asset
  • Full premium assistance with no deductible
  • Low, capped co-payments. Could be 0 for some
    generics at any level
  • Partial Extra Help
  • 150 of the FPL and asset limits
  • Reduced premiums (sliding scale between 25
    -75 assistance dependent upon income)
  • Reduced deductible and 15 copayments

Extra Help Eligibility
  • Resources counted
  • Bank accounts (checking, savings, CDs)
  • Stock, bonds, savings bonds, mutual funds, IRAs
  • Real estate other than a primary home
  • Resources not counted
  • Primary home, car
  • Property one needs for self-support, such as a
    rental property (rent payments are considered as
  • Burial spaces owned by a beneficiary
  • Personal belongings

Dual Eligibles
  • Medicare beneficiaries who are also enrolled in
    Medicaid/MassHealth, Supplemental Security Income
    (SSI) or a Medicare Savings Program/MassHealth
    Buy-in) are known as dual eligibles
  • These beneficiaries do not have to apply for
    Extra Help as they are deemed eligible and will
    be enrolled automatically

Applying for Extra Help (LIS)
  • To apply
  • Complete an application online
  • Call SSA at 1-800-772-1213 to complete an
    application over the phone
  • Visit a local SSA office

Prescription Advantage
  • Massachusetts State Pharmacy Assistance Program
  • Provides secondary coverage for those with
    Medicare or other creditable drug coverage
    (i.e. retiree plan)
  • Benefits are based on a sliding income scale only
    no asset limit!
  • Level of assistance provided is determined by
    gross income
  • Different income limits for under 65 and 65 and

Benefits for Individuals on Medicare or With
Creditable Coverage
  • Helps pay for drugs in the gap (for most members)
  • May help pay all or part of the Medicare
    prescription drug plan's drug co-pays
  • All medications must be covered by primary plan
  • Those in top income category (S5) must pay 200
    annual fee for limited benefits
  • Members are provided a SEP (one extra time each
    year outside of open enrollment to enroll or
    switch plans)
  • Prescription Advantage does NOT pay the late
    enrollment penalty fee

Benefits for Individuals not on Medicare
  • Offers members who do not qualify for Medicare,
    primary prescription drug coverage
  • Coverage has no monthly premium
  • Depending on income, members will pay a co-pay
    for prescription drugs and will have an annual
    out-of-pocket spending limit and quarterly
    deductible. Once annual out-of-pocket limit is
    reached, Prescription Advantage will cover drug
    co-pays for the remainder of the plan year
  • Members are provided a SEP (one extra time each
    year outside of open enrollment to enroll or
    switch plans)

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

  • 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 Open Enrollment Period?
  • When does the coverage gap or donut hole begin?
  • What programs are available to reduce drug costs?

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 hes
    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.
  • 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?

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 hes
    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.
  • 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?

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.
  • What will happen if Pat enrolls in this Part D
  • 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?

Case Study 4 Lucy and Ricky
  • Lucy and Ricky come into the SHINE office on
    December 1st . 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 couples
    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.
  • Why should Lucy and Ricky review their drug plan
    for the next year?
  • Do they still have time to make a change?
  • Would they qualify for any assistance programs?
  • Should Lucys OTC medication be covered?