Medicare and Benefits
Update
2014
Legal Aid of the Bluegrass
SHIP PROGRAM
Medicare & Benefits Updates- 2014
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ACA
Medicare Part A & B
Medicare Part C & D
Money Saving Benefits
THE ACA
The ACA and Health Insurance
Marketplaces
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ACA created marketplaces for uninsured
individuals and insured individuals with high
premiums to purchase health insurance
Insurance sold under the marketplace offered
by private companies
Kentucky’s marketplace is called kynect
(kynect.ky.gov)
Over 600,000 Kentuckians are uninsured
The ACA and Health Insurance
Marketplaces

Insurance plans will be placed into categories based
on level of coverage
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Bronze, silver, gold and platinum
Individuals can compare the coverage and determine
which type is best for them
Assistance in the way of tax credits and cost sharing
reductions are available to people to reduce the cost
of premiums

To determine approximate credit and premium amounts
visit, http://kff.org/interactive/subsidy-calculator/
The ACA and Medicaid
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Governor Beshear
expanded Medicaid to
include anyone with
income of 138% fpl or
below
Over 300,000
Kentuckians will be
eligible for Medicaid
benefits under the
expansion
Family
Size
Monthly
Income
1
$1,321
2
$1,784
3
$2,247
4
$2,710
The ACA and health care
marketplaces
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Enrollment begins October 1 and ends March
31 for the first year
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October 15 to December 7 in 2014 and beyond
Coverage is effective January 1 if enrollment
happens prior to December 15
People on Medicare are not allowed to
participate in the marketplace
Medicare Part A &
Part B
Outpatient Mental Health
Care
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After Part B deductible
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For visits to diagnose condition
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Beneficiaries pay 20% of Medicare-approved
amount
For outpatient treatment (such as
psychotherapy)
In this Year
Beneficiaries Pay
2013
35%
2014
20%
National Mail Order Program for
Diabetic Testing Supplies
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Effective July 1, 2013
Includes all parts of the United States including
US Territories
To find a supplier, visit
http://www.medicare.gov/supplierdirectory/sea
rch.html
Outpatient vs Inpatient
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Must be formally admitted to be considered
inpatient
Outpatient services include
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Emergency Room visits
Observation services at a hospital- including over
night stays at the hospital
Outpatient surgery
Lab tests and X-rays
Outpatient vs Inpatient
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Always ask for inpatient or outpatient status if
in the hospital for more than a few hours
Outpatient status will affect admission to a
skilled nursing facility
Medicare Part C & D
Standard Part D
Benefit Parameters
Benefit Parameters
2013
2014
Deductible
$325
$310
Initial Coverage Limit
$2970
$2850
Out-of-Pocket Threshold
$4750
$3605
Total Covered Drug Spending at OOP
Threshold
$6954.52
$6455
Minimum Cost Sharing in Catastrophic
Coverage
$2.65/$6.60
$2.55/$6.35
Extra Help Copayments
2013
2014
Institutionalized
$0
$0
Receiving Home & Community Based Ser.
$0
$0
Up to or at 100% FPL
$1.15/$3.50
$1.20/$3.60
Full Extra Help
$2.65/$6.60
$2.55/$6.35
Partial Extra Help (deductible/cost-sharing)
$66/15%
$63/15%
Part D Coverage Gap
Discount Program
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If beneficiaries reach the coverage gap in 2014
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52.5% discount on covered brand-name drugs
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50% paid by drug manufacturer will still apply to getting out of
the donut hole
2.5% paid by Part D plan will not count toward TrOOP
28% discount on covered generic drugs
Dispensing fees are not subject to the 52.5% discount
Additional savings in coverage gap each year

Until 2020
Improved Coverage in the Coverage Gap
Year
What Beneficiaries Pay for Brand
Name Drugs in the Coverage Gap
What Beneficiaries Pay for
Generic Drugs in the Coverage
Gap
2013
47.5%
79%
2014
47.5%
72%
2015
45%
65%
2016
45%
58%
2017
40%
51%
2018
35%
44%
2019
30%
37%
2020
25%
25%
Landscape of Plans
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100% of people with Medicare have access to a Medicare Advantage plan
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100% of people with Part D have access to a plan with lower premium than
what they paid in 2013
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38% of people with Medicare Part D get Extra Help (also called the lowincome subsidy, or LIS)
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$12.60 is the lowest monthly premium for a prescription drug plan
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13 PDPs have a premium of $0 for people who qualify for Extra Help
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340,165 people in Kentucky with Original Medicare took advantage of at
least one free preventive service through August 2013
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People with Medicare in Kentucky have saved $141,019,279 on
prescription drugs in the Medicare Part D donut hole as a result of the
Affordable Care Act.
Landscape of Plans (PDP)
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New Plans
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Transamerica MedicareRx
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Symphonix
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Humana Walmart Rx
Cigna Secure-Xtra
EnvisionRxPlus Gold
Humana Complete
Name Changes
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Rite Aid Value Rx
Value Rx
Plans That Are Leaving
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Choice
Classic
2013 Humana Walmart-Preferred Rx plan will be called Humana Preferred Rx Plan
Cigna Plan One now Cigna Secure
Cigna Plan Two now Cigna Secure-Max
Cigna has purchased HealthSpring and will rename the HealthSpring plan to CignaHealthSpring Rx
Reader’s Digest plan will change to HealthMarkets Value Rx
SmartD Rx (purchased by Express Scripts) and SilverScript are still under CMS
sanction and were not included in Medicare Part D landscape data
Landscape of Plans (PDP), cont’d
Statistic
2014
Change from 2013 to
2014
Total Number of Part D
Drug Plans
30
-2
# of Enhanced Plans
15
-2
# of Basic Plans
15
0
# of $0 Deductible Plans 14
-1
Lowest Cost PDP Plan
$12.60*
-$2.40
Lowest Premium for $0
Deductible Plan
$20.90**
-$8.20
Number of LIS $0
Premium Plans
13
2
*Lowest Premium PDP for 2014: Humana Walmart Rx Plan
**Lowest Premium $0 Deductible PDP for 2014: WellCare Classic
Premium Changes for Persons
Staying in their Current PDP
Statistic
2014
Change from
2013 to 2014
Number of Plans with Premium
Decrease
10
0
Number of Plans with No Premium
Change
0
0
Number of Plans with Premium
Increase
14
-7
% of People with Premium Increase
73%
-9%
Weighted Average Increase for People
with a Premium Increase
$5.26
$1.55
Landscape of Plans (MA)
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New Plans
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Anthem Senior Advantage Complete HMO
HumanaChoice H6609-(078-081)
Plans That Are Leaving
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Anthem Medicare Preferred Select PPO
2013 non-regional HumanaChoice plans
Today’s Options plans
Landscape of Plans (SNP)
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Minimal changes
WellCare Access HMO-SNP for dual eligible
individuals has expanded its covered counties
2013 Calendar Highlights
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Late September- CMS mails the Medicare & You
handbook
September 30- Plans must provide Annual Notice of
Change/Evidence of Coverage to members
October 1- Plans begin marketing
October 1- 2014 plan data to be displayed on the
Medicare Plan Finder
Mid-October- plan ratings updated on MPF
October 15-Open Enrollment beings
December 7- Open Enrollment ends
January 1- 2014 plan benefit period begins
Low-Performing Medicare
Advantage and Drug Plans
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Plans that receive average Part C or D
summary rating of less than 3-stars for 3 years
in a row
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Indicates organization’s substantial failure to
comply with its Medicare contract
Ratings are on Medicare Plan Finder Tool
Medicare & You does not have full, updated
ratings
Low-Performing Medicare
Advantage Plans
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Changes for low-performing plans in 2013
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No online enrollment for low-performing plans
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Enrolled beneficiaries may use Special Enrollment
Period to move to a higher quality plan
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Must contact plan directly to enroll
Will receive mailing from CMS
CMS has option to terminate low-performing
contracts starting in 2015
High Performing Medicare
Drug Plans
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5 Star Special Enrollment Period
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Plans rated 5 Stars are indicated with a yellow
triangle with a star and the number 5 located in
the center
SEP begins December 8 each year
Beneficiaries can enroll into a 5 Star rated plan
up until Nov. 30 of the following year
Only allowed one enrollment during the SEP
SEP is extended to individuals currently enrolled
into a 5 Star plan
Marketing Guidelines During
Medicare Open Enrollment
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Plans must disclose plan information,
including changes at least twice a year
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At time of enrollment
Annual Notice of Change
Marketing Guidelines During
Medicare Open Enrollment
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Plans can
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Offer gifts costing no more than $15 to potential
enrollees (could include light snack)
Call existing members regarding enrollment into a
plan
Call beneficiaries that requested a phone call
Schedule in home appointments with beneficiaries
during a sales event
Sell non-health related products if the beneficiary
contacts the plan and requests that information
Marketing Guidelines During
Medicare Open Enrollment
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Plans CANNOT
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Conduct door-to-door solicitation
Make outbound marketing calls (cold calling)
Call beneficiaries to confirm receipt of mailed
information
Approach beneficiaries in common areas (parking
lots, hallways, lobbies, sidewalks, etc.)
Call or visit beneficiaries that attended sales events
unless express permission is given by the
beneficiary
Marketing Guidelines During
Medicare Open Enrollment
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Plans CANNOT
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Cross sell other non-health related insurance
products during a MA or Part D sales
activity/presentation (annuities, life insurance, etc.)
Notices from CMS and SSA
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September
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Social Security Notice to Review Eligibility for LIS
Plan Annual Notice of Change/Evidence of
Coverage
Plan LIS Rider-from plan telling how much they get
in 2014 towards Part D premium, deductibles and
co-payments
Creditable Coverage letters from Employer/Union
plans
Loss of Deemed Status Notice-from SSA stating
they are no longer eligible for LIS
Medicare & You handbooks
Notices from CMS and SSA
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October
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Plan Non-Renewal Notices
Change in Extra Help Co-Payment Notice- from
SSA on orange paper explaining copayments levels
will change in 2014
Reassignment Notices-Plan Termination-on blue
paper explaining that plan is terminating and they
will be reassigned to a new plan
Reassignment Notice-Premium Increase-on blue
paper explaining that will be re-assigned to a new
plan due to the increase in their current plan
premium which is above the benchmark
Notices from CMS and SSA
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October
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MA Reassignment Notice-on blue paper explaining
that the MA plan is terminating and they will be reassigned to a Medicare drug plan for 2014
November
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LIS Choosers Notice-on tan paper explaining if they
chose a Plan on their own that the plan’s premium
has increased above the benchmark and they will
pay a portion of the premium
Notices from CMS and SSA
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November
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Non-Renewal Reminder Notice- reminds people who
do not get LIS that the plan is terminating
Social Security Income Related Adjustment Amount
Notice- tell higher income beneficiaries about the
higher Part B and Part D premium adjustments
Social Security LIS Redetermination Decision
Notice-informing beneficiaries of their LIS award for
2014
Social Security LIS and MSP Outreach Noticeinforms individuals of these two benefits
Notices from CMS and SSA
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December
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January
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Social Security Benefit Rate Change Notice- tells people about benefit
payment changes due to cost of living increases, premium withholdings,
etc.
Reassign Formulary Notice- on blue paper informing individuals who get
LIS and were affected by reassignment which of the Part D drugs they
took in 2013 will be covered in their new 2014 Medicare plan
CMS Non-Renewal Action Notice- reminds people who do not get LIS
and whose plan terminated to join a new drug plan
February
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Consistent Poor Performer Notice- Informs people that they’re enrolled in
a plan that has been identified as a consistent poor performer and
encourages them to explore other plan options in their area
Changes to Plan Finder Tool
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Session timeout redirects to Medicare.gov
Estimated annual costs rounded to nearest $10 instead
of $50
30, 60, 90 day supply info on drug benefit summary
pop-up
Medication Therapy Management tab instead of link
Show estimated full cost the plan charges Medicare
January 2014 – Will show costs for the rest of the
year ONLY
Money Saving Benefits
Extra Help With Drug Costs
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Sometimes called Low Income Subsidy (LIS)
People with lowest income and resources
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Those with slightly higher income and
resources
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Pay no premiums or deductibles
Have small or no copayments
Have a reduced deductible
Pay a little more out of pocket
No coverage gap for people who qualify for LIS
Extra Help in 2013
Group 1
Group 2
Group 3
Premium
$0
$0
Deductible
$325/year
Coinsurance up
to $4,750 out
of pocket
Catastrophic
coverage
$0
$0
Sliding scale
based on
income
$65
$1.15/$3.50
copay
$2.65/$6.60
copay
Up to 15%
coinsurance
$0
$0
$2.65/$6.60
copay
Medicare Savings Programs
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Help from Medicaid to pay Medicare
premiums
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For people with limited income and resources
May also pay Medicare deductibles and
coinsurance
Programs include
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Qualified Medicare Beneficiary (QMB)
Specified Low-income Medicare Beneficiary (SLMB)
Qualifying Individual (QI)
Medicare Savings Programs
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Provides payment for Part A and Part B
premiums and deductibles and co-insurance
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QMB
SLMB
QI
Eligibility for QMB
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Provides assistance with Part B premium and
offers additional insurance
Income not exceeding 100% FPL
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$978 individual
$1313 couple
Resources
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$7,080 for an individual
$10,620 for married couple
Eligibility for SLMB
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Benefit is limited to payment of Part B
premiums only
Income not higher than 120% FPL
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$1169 individual
$1571 couple
Resources
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$7,080 for an individual
$10,620 for married couple
Eligibility for QI
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Benefit limited payment of Part B premiums
Cannot be otherwise eligible for Medicaid
Income not higher than 135% FPL
 $1313 Individual
 $1765 couple
Resources
 $7,080 for an individual
 $10,620 for married couple
SNAP Benefits
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Supplemental Nutrition Assistance Program
(SNAP)
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Federally funded program to assist with purchasing
food
Must have resources (assets) below $3250 if age
65 or older or disabled (some exclusions including
the home and its contents, personal property and
vehicles)
Income requirements based on household size
Deductions to income such as medical expenses
are allowed
SNAP- Income Guidelines
Household Size
1
Gross Income for Elder or
Disabled Person
$1498
2
$2023
3
$2548
4
$3074
5
$3599