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SHINE Serving the Health Insurance Needs of Everyone


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Title: SHINE Serving the Health Insurance Needs of Everyone

SHINE Serving the Health Insurance Needs of
  • Part 1 Overview for SHINE and Medicare
  • Part 2 Medicare Part D
  • Part 3 Medicare Assistance Programs
  • Part 4

SHINE Overview
  • Began in 1985 as a pilot program, in 1992 SHINE
    became available statewide with federal funding
  • Objective is to provide elders with access to
    accurate, unbiased health insurance information
  • Network of 500 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

SHINE Counselors
  • Explain Medicare Part A, B, C and D benefits and
  • Compare health insurance and prescription drug
    plans options, cost and benefits
  • Screen for Prescription Advantage, Medicare
    Savings Programs, and Extra Help
  • Provide assistance with the application process
  • Help with claims and billing problems
  • Start appeals and explain grievance procedures
  • Know how to solve problems and ask the right

SHINE Part D Enrollment Specialist
  • Assist SHINE counselors by using tools on to get data into and get reporting
  • Assist counselors by comparing the cost and
    benefits of the programs available for clients
  • This training is designed to help you handle
    basic matters clients who are seeking assistance
    beyond basic inquiries should be referred to a
    SHINE Counselor

Open Enrollment Period
  • October 15th December 7th
  • Every plan changes from year to year
  • Plans change premiums, co-pays, drug formulary,
    and can end their contract with Medicare
  • If an individual elects not to do anything then
    they will remain in their current plan for the
    following year

Medicare Overview
  • Medicare is a health insurance program for
  • People 65 years of age and older
  • This is not necessarily full retirement age
  • People under age 65 with disabilities
  • Deemed disabled by Social Security for at least
    24 months
  • Note Medicare is NOT Medicaid Medicaid is
    health insurance for very low income population
    and is called MassHealth in Massachusetts

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

(No Transcript)
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 2016 for those protected under
    hold harmless provision
  • 121.80/month for those not protected

Medicare Advantage Plans (MA-PD, Medicare Part C)
  • Eligibility
  • Must have both Part A Part B
  • Must live within plan service area 6 months a
  • Must not have ESRD (end stage renal disease)
  • Must continue to pay Part B premium
  • Characteristics

Other Options for Drug Coverage
  • Retiree Benefits (former employer benefits)
  • Veterans Benefits
  • MassHealth (Medicaid) other related programs

Medicare Part D
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

Prescription Drug Plan Options
  • Original Medicare

Medicare Advantage Plan For prescription
coverage an individual must choose the Part D
coverage offered by their Medicare Advantage Plan

Part D stand alone plan (PDP)

Medigap Policy Optional add-on Or other
supplemental medical coverage
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

Formulary Standards
  • Each plan has to cover all or substantially all
    the drugs in the following classes
  • Antidepressants
  • Antipsychotic
  • Anticonvulsant
  • Anticancer
  • Immunosuppressant and
  • 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

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 may be covered under Medicare Part A
    and/or Medicare Part B

2016 Standard Medicare Part D
Level Description
Deductible Annual 360 deductible paid by the Beneficiary.
Initial Coverage From 360 to 3,310 (retail cost of drugs) Beneficiary pays 25 of the drug costs and Medicare pays 75
Coverage Gap Donut Hole After 3,310in costs beneficiary pays 45 of brand name drug costs and 65 of generic drug costs until they have spent 4,850 out of pocket.
Catastrophic When true out of pocket (TrOOP) costs reach 4,850 (excluding monthly premium) beneficiary pays 5 of the drug costs and Medicare pays 95.
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

How to Enroll Into Medicare Part D
  • Review plan options
  • Plan Finder Tool on
  • 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

Late Enrollment Penalty
  • If an individual does not enroll when first
    eligible for Part D they may pay a penalty if
  • Have no coverage or have coverage but it is not
    considered creditable
  • Penalty may be 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
  • Penalty is 1 increase in premium based on a
    national standard base premium.
  • Penalty is permanent

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

Medicare Assistance Programs
Assistance Programs May Help
  • LIS aka Extra Help
  • Assists with Part D premiums and co-pays apply
    thorough Social Security
  • Prescription Advantage
  • Help with drug costs when in the coverage gap
  • There are additional options that your SHINE
    Counselor will be aware of

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
  • Copayments
  • Coverage Gap Donut Hole
  • Late Enrollment Penalty
  • Does not subsidize non-formulary or excluded
  • Administered by CMS and the Social Security

Prescription Advantage
  • Massachusetts State PharmaceuticalAssistance
    Program (SPAP)
  • Provides secondary coverage for those with
    Medicare or other creditable drug coverage
    (i.e. retiree plan)
  • Provides primary coverage for individuals who are
    NOT eligible for Medicare
  • Benefits are based on a sliding income scale only
    No asset limit!
  • Different income limits for under 65 vs. 65 and
  • Dual eligibles can NOT join (but those with LIS
    or MSP can join)

Prescription Advantage for those with Medicare or
a Creditable Plan
  • Helps pay for drugs in the gap (for most members)
  • Those in top income category (S5) must pay 200
    annual fee for limited benefits
  • All medications must be covered by primary plan
  • Benzodiazepines (xanax, lorazepam, valium, etc)
    are covered right away
  • Members are provided a SEP (one extra time each
    year outside of open enrollment to enroll or
    switch plans)
  • Prescription Advantage does not pay late
    enrollment penalty fee

29 Plan Finder
What is the Part-D Plan Finder?
  • A tool on which helps you to find
    the drug plan that best fits the clients personal
    data and formulary
  • It should only be used with the clients personal
    data and formulary
  • It has all plans available within a zip code
  • Pharmacy and clients formulary impact results
  • Supported formularies vary by plan
  • Coverage for Part D is provided by
  • Prescription Drug Plans (PDPs) also known as
    stand alone plans
  • Medicare Advantage Prescription Drug Plans

Using the Medicare Drug Plan Enrollment Form
Using the Medicare Drug Plan Enrollment Form
Drug Name (as written on bottle) Drug Strength/Dose per Day Example 50 mg/1x a day

How to use the Plan Finder
To effectively use the Plan Finder
you need to do a personalized search and need
the information noted below
  • Last Name
  • DOB (date of birth)
  • Zip Code
  • Medicare Claim Number
  • Effective Date for A or B

A personal search will provide accurate and data
about the client including their current status
and Extra Help supports
Doing a search on
Results and importance of a Personal Search
Using the Medicare Plan Finder
Part D Case Study
Terry Torial - Case Facts/Assumptions Meeting
in person. Wants help with Rx drug Costs.
Signed up for PartD during initial open enrolment
she did not take drugs at that time. Now she
does take Lipitor, Fosamax, Synthroid, and Ativan
paying out of pocket. SS income 1,050. Assets
45,000. She does not appear frail.
Part D Case Study
Part D Case Study