2016 Medicare Training
for Professionals
Refresher and Updates for the 2016 Plan
Year for Medicare Part D & C Plans and
Medicare Supplements
Housekeeping
• Materials
• Registrants should have received an email with today’s materials. If you did not register and would like a copy of the materials,
please email Ginger Rogers at [email protected]
• Archived Webcast
Today’s Agenda
8:30 – 9 AM Registration
9 – 10 AM Medicare Part D: The Basics – Lisa Clay Foley, DRW 10 – 10:15 AM Break
10:15 – 10:25 AM Plan Finder Problems – Phoebe Hefko, DHS 10:25 – 10:40 AM Wisconsin’s Senior Care
Prescription Drug Assistance Program – (Madison) Kate Schilling, GWAAR
(Milwaukee) Pamela Franke, SeniorLaw 10:40 – Noon Medicare Part D:
Advanced Topics – Ginger Rogers, DRW Noon – 1PM Lunch – on your own
1:00 – 2:00 PM Medicare Advantage Plans – Vicki Buchholz and Jill Helgeson, Medigap Helpline
2:00 – 2:15 PM Break
2:15 – 3:15 PM Medicare Supplement Insurance and Employer Plans - Vicki Buchholz and Jill Helgeson, Medigap Helpline
3:15 PM – 3:30 PM Medicare and the Marketplace - Vicki Buchholz and Jill Helgeson, Medigap Helpline
The Basics
• Overview Medicare Part D
• What are Part D plans? • What are Part D costs?
• What do Part D plans cover?
• Enrollment
• When can you enroll?
• What is the Part D Late Enrollment Penalty?
• What is the Low Income Subsidy?
• How do you choose a plan?
Overview
• What is Medicare Part D?
• What are Part D plans?
• What are Part D costs?
What is Medicare Part D?
• Medicare’s prescription drug program
• Helps subsidize cost of prescription drugs and prescription drug insurance costs
• Began January 1, 2006
• Consists of private “prescription drug plans” or “PDPs”
• Has premiums, co-pays and deductibles
Who is eligible for Part D?
• Beneficiaries must:
• Be entitled to Part A and/or enrolled in Part B,
Creditable Coverage
• Current or past prescription drug coverage
• For example, employer group health plans, retiree plans, Veterans Affairs, TRICARE, the Indian Health Service, and the Federal Employee Health Benefits Program
• Creditable if it pays, on average, as much as Medicare’s standard drug coverage
• Plans inform yearly about whether creditable
What are the drug plans?
• Known as “prescription drug plans” or “PDPs”
• All plans must follow basic cost-sharing structures and include a certain level of coverage in their formularies
Types of Part D Plans
• Two Types:
• Stand-alone prescription drug plan (PDP)
• Prescription drug coverage included as a part of a Medicare Advantage plan (MA-PDP)
Wisconsin Part D Plans
•
In 2016, there are 25 Part D plans available in Wisconsin.
PDP Changes for 2016
• Not available for 2016• Aetna Medicare Rx Premier
• Cigna-HealthSpring Rx Secure-Max
• Transamerica MedicareRx Choice
• SmartD Rx Basic • Name change for 2016
• Cigna-HealthSpring Rx Secure-Xtra to Cigna-HealthSpring Rx Secure-Extra
• Symphonix Premier Rx to Symphonix PrimeSaver Rx
• New Plans for 2016
• Wellcare Classic (low cost)
• Wellcare Extra
• No longer Low Cost for 2016
• AARP Medicare Rx Saver Plus • Sanctioned
• United American-Select
•
What are Part D plan costs?
• Premiums
• All plans have a monthly premium
• In 2016, premiums range from $18.70 - $139.40
• Individuals with an income over $85,000 for an individual or $170,000 for a couple will have a higher Part D premium.
• Called D-IRMAA (Part D Income Related Monthly Adjustment Amount)
2016 Medicare Part D Costs
Medicare Standard Benefit
Deductible No more than $360 Initial Coverage Limit $3,310
Out of Pocket Threshold $4,850 Catastrophic Minimum
Cost-sharing
$2.95 generic drugs
2016 Medicare Part D Costs
Catastrophic
Period
Coverage Gap
Initial Coverage
Period
D
Closing the Coverage Gap
• 2016: The federal subsidy for brand name medications beneficiary cost remains 45% of the total drug cost, and the federal subsidy for generic medications reduces beneficiary cost to 58% of the drug cost
• Each year until 2020, the federal subsidies will increase until the maximum beneficiary cost is 25% for both brand name and
Generic Drug Subsidies in the
Coverage Gap
•
In 2016, beneficiaries will pay 58% of the costs of
generics in the coverage gap.
•
Only that 58% will count towards beneficiaries
Total Out of Pocket Costs
•
Example: A beneficiary paid $5.80 for a generic
drug. The drug cost was $10.00. Because this drug
was a generic, only $5.80 will count towards
Brand Name Discounts in the
Coverage Gap
• These are automatic discounts applied by drug manufacturers to beneficiaries’ drug purchases, i.e., beneficiaries don’t have to do anything to obtain the discount
• What the beneficiary pays and the manufacturer’s discount count as out-of-pocket costs
• What the plan pays toward the drug cost does not count toward out-of-pocket costs
Enhanced Coverage
• For an additional cost, plans may offer “enhanced benefits,” which include benefits that are not required by the laws governing Part D plans
• Examples include Part D excluded drugs such as vitamins
• Costs associated with enhanced benefits do not count towards out of pocket costs used to determine when a beneficiary has met his/her deductible or made it to the coverage gap or to the catastrophic coverage level
What do Part D plans cover?
•
Retail pharmacy prescription drugs
•
Requires a prescription
•
Used for an FDA medically accepted indication
Part D Covered Prescriptions
• Prescription drugs, but plans are allowed to put certain restrictions on coverage.
• Must cover “all or substantially all” drugs in these 6 categories:
• Antidepressant medications
• Antipsychotic drug medications
• Anticonvulsant medications
• Antineoplastic drugs (used by cancer patients)
• Immunosuppressant (used by transplant patients)
• Antiretroviral (used by patients with HIV).
Excluded Drugs
• Excluded drugs:
• Medicare Part B drugs, e.g., outpatient drugs that require durable medical equipment like an external infusion pump
• See CMS Medicare Parts B/C Coverage Issues chart
• “Off label” prescriptions • Drugs not approved by FDA
• Prescription vitamins, weight loss drugs, over-the-counter drugs, drugs for “cosmetic” purposes (e.g., hair loss), erectile
Additional Plan Requirements
• Make sure you have convenient access to retail pharmacies.
• Have a process in place to get medically necessary drugs that are not on the formulary (see Part D appeals, Exceptions ).
• Provide useful information, such as how formularies work, how to save money with generic drugs, and how to navigate the grievance and appeals processes.
Controlling Part D Plan Costs
• Formularies
• “Utilization Management” Tools
• Prior authorization • Quantity limits • Step therapy
• Medication Therapy Management (MTM)
Utilization Management
• Prior Authorization (PA)
• Plan will require a prior authorization before coverage of certain medications. The plan makes the coverage determination.
• Quantity Limits
• Excess amounts from the most common dosage level. This will require a coverage determination.
• Step Therapy
• Try another drug before covering the prescribed medication. Coverage determination is needed to override this requirement.
• Medication Therapy Management
Tiering
• Plans group medications for payment purposes.
• Each tier has separate co-pay amount.
• For example, for each prescription, a plan may charge $5 for Tier 1 drugs, $45 for Tier 2 drugs, $80 for Tier 3 drugs, and 33% of the cost for Tier 4 drugs.
Formulary Exceptions
• Part D plan members have the right to challenge denials of drug coverage
• Plan members can also request exceptions:
• Coverage of a drug that’s not on a formulary;
• Challenge a plan’s PA requirement, step therapy, or quantity limit requirements; or
Denied at the pharmacy?
• Request a “transition fill”
• Contact the prescriber
• Contact the plan to obtain a coverage determination in case the person chooses to pursue a formulary exception
• Explore other plans to see if another plan might provide better coverage, if beneficiary has a SEP or any other enrollment
Enrollment
• When can you enroll?
When can you enroll?
Initial Enrollment Period
• 7-month window
• 3 months before the first month you are eligible (turn 65 or 25th
month you receive SSDI payments), • Month you become eligible, and
• 3 months after the month you become eligible
• What if you receive Medicare retroactively?
Annual Enrollment Period
• Also known as the “Open Enrollment Period”
• October 15th – December 7th
What can you do during the AEP?
•
Sign up for a new PDP
•
Switch PDPs
•
If you have a MA-PDP, you can switch to another
MA-PDP
•
If you have a MA-PDP, you can go to Medicare
Advantage and a stand-alone PDP
•
If you have a MA-PDP, you can go back to Original
Medicare and a standalone PDP
Special Enrollment Period
(SEP)
•
Generally, a SEP gives a beneficiary the ability to
make one election or choice within a period of time
•
Disenrollment
•
Enrollment
Special Enrollment Periods
•
Some examples:
•
Ongoing SEP for those with Extra Help or Low
Income Subsidy (LIS)
•
Moving out of a service area
•
Entering or leaving a long term care facility
•
Loss of creditable prescription drug coverage
•
Enrollment in Part B during Annual Enrollment
Period (Jan–Mar) triggers Part D SEP (April-June)
•
Plan terminated/ not renewed by Medicare
•
Loss of Extra Help or LIS
•
Enrollment in 5-Star Plan
SEP for Non-Renewals
•
Beneficiaries in non-renewed plans can sign up for a plan
during the OEP
•
If beneficiaries have not signed up for a new plan by
December 7, they can sign up for a new plan before the
end of February
AUTO AND FACILITATED
ENROLLMENT
• Full Benefit Dual Eligibles (FBDE) who have not selected a Part D plan will be auto-enrolled in a low cost plan by CMS
• SSI recipients
• Other LIS eligible individuals have facilitated enrollment.
• MSP only
• FBDE Medicaid
• Extra help through SSA
• Auto enrollment is usually effective the first of the month of Medicare eligibility.
• Facilitated enrollment is effective the first of the 2nd month
The Part D Late Enrollment
Penalty
Individuals will be assessed a penalty if:
•
If it has been 63 days or longer since either the
individual’s initial enrollment period ended, or since the
individual was last enrolled in a Part D plan, and the
individual:
What is the Low Income
Subsidy?
• Also known as “LIS” or “Extra Help”
• For low income and low assets individuals
• Provides assistance with premium, deductible and co-payments costs
Who receives LIS?
Three groups of people receive LIS:
1.
Full dual eligibles (full Medicaid card services and
Medicare) automatically have the full subsidy
2.
Medicare Savings Program (MSP) recipients automatically
have the full subsidy
Medicaid/Medicare Dual
Eligibles
•
Provides full LIS
•
Needs-based (SSI or low income/assets)
Low Income Subsidy through
Medicare Savings Programs
•
Also known as “Medicare Buy-ins”
•
QMB, SLMB, SLMB+ and QDWI
•
Provide full LIS
Extra Help through Social Security
•
Provides full or partial LIS
•
Must have assets and income below certain
amounts
•
A few assets are treated more generously by
Social Security than Medicaid
Low Cost Plans and LIS
•
A low cost plan, “benchmark plan,” has a
premium below the benchmark dollar figure for
Wisconsin, and is a “basic” – not “enhanced” –
plan.
LOW COST PLANS
•
De Minimus plans
Full LIS Costs 2016
• Level 1
• Income ≥ 101% of Federal Poverty Level (FPL)
• Cost sharing $2.95 generic / $7.40 Name Brand • Level 2
• Income ≤ 100% FPL
2016 Medicare Part D LIS Costs
Catastrophic Period
Initial Coverage
Period
Co-Pays: Institutionalized: $0 HCBWS: $0$1.20 generics & $3.60 brand names $2.95 generics & $7.40 brand names
Co-pays:
Brand Name: $0 Generics: $0
From January 1, 2016 (or at start date for those who begin Med D
2016 Medicare Part D partial LIS costs
Catastrophic Period
Initial Coverage
Period
Co-insurance no more than 15% for beneficiary
Co-pays:
Brand Name: $7.40 Generics: $2.95
2016 LOW COST PLANS
How do you choose a plan?
•
1-800-MEDICARE will help people over the phone.
•
Call a plan directly.
•
But, the most effective way to choose a plan for
Beneficiaries often fail to choose
the best plan
•
Majority of people do not select the lowest cost Part D
plan.
•
Fewer than 10% of all seniors picked the Part D plan that
was best for them.
•
Fewer than 15% picked one of two lowest cost plans for
them.
•
Even if you look at the cheapest 25% of plans available to
a person in a particular state, only 50% of Medicare
beneficiaries chose one of those plans.
Why revisit plan every year?
• Low premium may not be the lowest cost plan.
• Low deductible may not be the lowest cost plan.
• Generic coverage during coverage gap may not be the lowest cost plan.
• Enhanced coverage may not save you money.
Medicare’s Plan Finder
•
Plan Finder Website
•
CMS’ Plan Finder Toolkit
•
Medicare has a
training site
that looks just like the
real site
Plan Finder Tips
• Always do a personalized search
• Confirm the drug list (if already entered) is accurate
• Note current enrollment status and whether Medicare has identified the client as LIS eligible in “My Current Profile”
• Identify any restrictions in the footnotes on the client’s drugs when reviewing the plan’s coverage
• Enter client’s pharmacies
CMS Notices
•
CMS publishes a list
of its mailings
NOTICES
• Beneficiaries who get Extra Help through Social Security will get an award letter and instructions on what to do.
• Beneficiaries who are found eligible through Medicaid or MSPs who are “deemed” eligible for LIS, will get a PURPLE
letter informing them of this and instructions on what to do.
• Beneficiaries who are not already in a plan when they get the LIS will get a YELLOW or GREEN notice informing them that they will be placed in a part D plan, which plan, and the effective date of that plan.
• These notices will tell the beneficiary how to use the LINET (Limited Income Newly Eligible Transition Program) process to obtain coverage in any uncovered or retroactive period of
REDEEMING NOTICES
• CMS looks at Medicaid data from states in July of every year and uses that data to determine LIS eligibility for the
upcoming year
• Eligible for LIS 2016 - Those who receive Medicaid, even for one month, after the July window, will be deemed eligible for the subsidy for the remainder of 2015 through December 31. 2016. Will NOT receive a letter.
Other Notices – Tan Letters
• Premium Change – TAN Letter
• LIS beneficiaries who originally chose a plan that will no longer be a low-cost plan will stay in that plan and have premiums or increased premiums in 2016, if they do nothing.
Blue Letter
• Individuals Reassigned - BLUE letter
• If Medicare auto-enrolled, Medicare will automatically reassign to a new plan.
• Individuals can supersede this selection and choose their own plan.
Orange Letter
• Co-Pay Change – Orange Letter
PLAN MAILINGS AND
NOTICES
• Every Part D and Medicare Advantage plan member gets an Annual Notice of Change letter from their plan by September 30th
• Explains changes for the coming year
• Plan could have same name but different costs, formulary, and rules
• Different set of plans available every year
Creditable Coverage Notices
• Creditable coverage letter sent by October 15
• Sent by current health insurance plan
• Ex. Employer group health plans retiree plans, Veterans benefits, TRICARE, the Indian Health Service (IHS, and the Federal
Employee Health Benefits Program.
Medicare Plan Finder
Problems
•
Report errors in formularies or costs to the Part D plan.
•
Report technical problems or malfunctions with the online
Medicare plan finder tool at
www.medicare.gov
to:
Phoebe Hefko, Wisconsin SHIP Director
[email protected]
(608) 267-3201
TOPICS
1.LIS and Best Available Evidence
2.Disenrollment for Failure to Pay Premium
3.Good Cause for Reinstatement after Loss of Plan
4.Convenient Access to Retail Pharmacies
5.Exception Requests & Appeals
6.Part A v Part B v Part D
BEST AVAILABLE EVIDENCE
(BAE)
• CMS Policy
• Acceptable BAE
• The state of Wisconsin and BAE
• When to submit
CMS Policy on BAE
• Part D sponsors are required to accept BAE
• Accept different forms of evidence
• Must establish the subsidy status
• Must update their system within 48-72 hours
• Provide access to covered Part D drugs at reduced cost-sharing
ACCEPTABLE BAE
• A copy of a state document that confirms active Medicaid status
• A printout from Forward Health Interchange enrollment file
• A screen shot from CARES showing Medicaid status
• Other state documentation, e.g. notice of decision
The State of Wisconsin
• Sends a file to CMS every month
• Every person who is Medicare/Medicaid eligible
• Information is not always timely
BAE and HCBS
• HCBS zero copays
• The BAE is the functional screen page
• Other evidence, e.g. remittance advice showing Medicaid payment, etc.
• Qualifies if receiving HCBS services since 1/1/12 or currently eligible.
• Challenges in establishing subsidy level for Wisconsin HCBS clients.
Waiver in CARES
• Waiver must show in Forward Health
• May need a F-10110 (formerly 3070) to update CARES
How to Submit BAE
• Call the plan
• Fax
Here is the link for BAE contacts , click on Part D Contacts under Related Links header near bottom of the page:
https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/best_available_evidence_policy.h tml
Practice tip:
Include a cover sheet/memo about your client, outlining FBDE status effective date, a short statement that the state of Wisconsin has not uploaded the information. and any other information you feel that will get the subsidy in place faster
Failure to Pay Premiums
• Plans may take one of these two actions:
• Do nothing, i.e., allow the member to remain enrolled in the PDP • Disenroll after a grace period and proper notice
• May not disenroll members for failure to pay premiums or D-IRMAA if member has requested premiums be withheld from SSA check.
• Disenrollment may occur if premium withhold has been rejected, failed or been unsuccessful, or;
Disenrollment Policy
• Plan must apply policies consistently across all plan members
• LIS is not a protection for failure to pay
• Plan must make a reasonable effort to collect
• Grace period notice must be provided
• Partial payment does not guarantee protection from disenrollment
Grace Period
• A minimum of 2 calendar months
• Begins on the first of month for which the premium is due and unpaid
Reinstatement for Good Cause
• Applies only to involuntary disenrollment for nonpayment of plan premium or D-IRMAA
• Member must request reinstatement within 60 calendar days of disenrollment effective date
Good Cause Criteria
• Serious illness, institutionalization and/or hospitalization
• Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, spouse,
caregiver/authorized representative
• Recent death of spouse, immediate family member or caregiver
• Home severely damaged by fire, natural disaster or other unexpected event
Not considered Good Cause
• Allegations that bills or notices were not received due to unreported change of address, out of town for vacation, visiting family members, etc.
• Authorized representative did not pay timely
• Lack of understanding
• Could not afford to pay premiums during the grace period
Plan Determines Good Cause
• If criteria are met, a favorable determination will be issued when;
• Request is received within 60 calendar days of disenrollment date • Plan gets creditable statement regarding the circumstance
• Obtain affirmation of willingness and ability to pay; and • Amount due is paid within 3 months of disenrollment
• If criteria not met, an unfavorable decision will be issued
• Not appealable
Convenient Access to Retail
Pharmacies
• Preferred cost sharing
• Beneficiaries should have access within a certain mile radius
Preferred Cost Sharing
Pharmacies (PCSP)
• Offer lower cost sharing levels
• Convenient access standard similar to the TriCare standard
• 90% in urban areas have access within 2 miles • 90% in suburban areas have access within 5 miles • 70% in rural areas have access within 15 miles
• There is no access standard for PCSP network
COVERAGE DETERMINATIONS
AND EXCEPTIONS
• Any decision made by the Part D plan regarding
• Receipt of or payment for a prescription medication the member may think is covered
• Tiering or formulary exception request • Amount of copay
• Quantity limit • Step therapy
EXCEPTION REQUEST
• A type of coverage determination
• Tiering exception
• Formulary exception
• Usually granted when a plan determines that a requested medication is medically necessary.
• Prescriber must submit a supporting statement
• Usually granted within 72 hours.
• Expedited requests with supporting prescriber statement is decided within 24 hours.
Transition Fills
• Available first 90 days of enrollment in plan.
• Does have to include medications with utilization requirements
• One time only 30 day fill
• Not for new medications, only existing ongoing medication therapies
RECONSIDERATION AND
APPEALS
• Five levels of appeals
• Redetermination • Reconsideration • ALJ hearing
• MAC review
COORDINATION OF BENEFITS
• Medicaid & Part D coordinate well.
• Part D does mostly coordinate with SeniorCare.
Medicare Drug Coverage
• A v B v C v D is found here
• A v B v D is found here
2016 Changes to the
Requirement for Part D
Prescribers
• Starting no later than January 1, 2016 all Part D prescribing physicians and other medical prescribers must enroll in
Medicare and receive a valid NPI.
• Law does not affect prescribing pharmacists with a valid NPI and allowed to prescribe by their state.
• Law goes into effect June 1, 2016
• If no Medicare enrollment by prescriber, prescription will be rejected by plan.
Observation Stay v 2-Midnight
Inpatient Admission
• They can overlap
• Observation stay – fact sheet
• Beneficiary is not formally admitted to the hospital • Part D may pay for self administered medications • Beneficiary must submit a claim to plan
Miscellaneous
• Incarcerated disenrolled and then re-enrolled by CMS
• Unlawful presence will be involuntarily disenrolled
• Non-preferred generic tier will not be available for 2016
• There will be maximum copay and coinsurance thresholds for plans with 3 or more tiers
• Plans are encouraged to offer $0 or low cost sharing for vaccines. Fact Sheet
• Especially if there is a 5 or 6 tier formulary that includes a
dedicated vaccine only or Select care/Select diabetes tier which includes vaccines.
• LTC facilities cannot involuntarily disenroll beneficiaries
Resources
• DRW Disability Drug Benefit Helpline 1-800-926-4862
• Prescription Drug Helpline 1-855-677-2783
• Medigap Helpline 1-800-242-1060
• 1-800-MEDICARE
• Medicare.gov
• Medicare Publications
• Example: How Medicare Prescription Drug Plans and Medicare
