SHINE Counselor
Fall Training
Preparing for Open
Enrollment
Save Time
Remember to Pre-Screen!

Ask beneficiaries if they have:
GIC
Retiree
Federal Blue Cross

Ask beneficiary what insurance coverage they already have:
Do they have Part A and Part B
Ask to see their cards

It is very important to know the current coverage:
• Enrolling in Part D may dis-enroll beneficiary from retiree
plan
2
GIC and Part D

All GIC retirees with a UniCare State Indemnity Plan will
be auto-enrolled into SilverScript for 2016

Early November SilverScript is required by Medicare to
send opt out letters to all being auto-enrolled

DO NOT OPT OUT-Will lose GIC coverage

DO NOT CHANGE PART D PLANS-Will lose GIC coverage
• Refer all GIC retirees back to GIC
 GIC Phone Number: (617) 727-2310
3
Federal Employees Health
Benefits

Open Enrollment period: Nov 9th- Dec 14th

New enrollment type:
• Self + 1: Retiree plus another individual
 Lower cost option
 Must select this option (no automatic
enrollment)

Self and Self + Family types still available
4
Reporting Issues with Part C
and/or Part D

What should be reported (actual examples of complaints)
• PDPs- when medication cost rises a lot or when
beneficiaries are running out of meds and can’t get them
at pharmacy
• When plan member is having billing issues with MA or
PDP
• Plan changed formulary/cost of meds differed from Plan
Finder
• Plan mailed wrong meds and member can’t get ones she
ordered and needs
• MA plan is reducing services that are needed
5
Where To Send Complaints


Complaint Process:
• Fill out Complaint Entry Form (found on Common
Resources)
• Send to RD who will either enter it in computer or send to
state staff to enter
• CMS follows and action is taken quickly
Where Complaints go: Complaints Tracking Module System
(CTM)
• Repository of Part C and Part D complaints that is used to
detect patterns of problems and obtain RAPID resolution
by plans
6
2016
Medicare Plans
Choosing a Medigap

No change in number of plans offering
Medigaps

New premiums

BC/BS lowest cost for CORE and Supplement 1
8
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
9
Blue Cross/Blue Shield
MA Plans
 New Plan
• Medicare HMO Blue FlexRx (HMO-POS)
 Existing Plans
• Premium increases in all plans except SaverRx which
remains a $0 premium plan
• Increase in Part B Meds in all plans but PlusRx HMO
• Increase in hospital co-pays and high tech imaging in
]
all but PlusRx plans
10
Fallon Senior Plans

Existing Plans
• Super Saver Rx premium staying at $0
• Premium increase for plans in Franklin, Hampden,
Hampshire & Worcester counties
• Preferred pharmacies: CVS, Target, Walmart, Big Y,
Shaws/Star Market, Stop & Shop
• Inpatient hospital & skilled nursing costs staying the
same
• Not all services covered out-of-network
11
Harvard Pilgrim

Existing Plans: Stride HMO Value Rx
Stride HMO Value Rx Plus
 Both plans now available in Essex, Middlesex and
Plymouth counties
 Open network, Maine, New Hampshire, Massachusetts

Cost Changes
• $2 Premium increase in both plans
• DME now 20%
• Tier 1 $0 co-pays in both plans
12
Health New England

Freedom (HMO-POS) Plan discontinued
Members will be auto-enrolled into Premium HMO

Existing Plans
• $8 premium increase in all plans

Increase in some DME and diagnostic x-ray costs
Service area remains Berkshire, Franklin, Hampden,
and Hampshire counties
• Hartford County Connecticut in network
13
• Baystate Medical Center in network

•
Tufts Medicare Preferred
 Existing Plans
•No premium changes for all HMO plans
•SaverRx remains a $0 premium plan
•Some increases and decreases in medical
costs
 Primary Care office visits now $10
14
UnitedHealthCare

Existing Plans
• AARP Complete Choice Regional PPO
 Still
available in every county
 $10 premium increase in all counties
• Plan 1 and 2 no premium change
 Expanded
to additional counties
• Hampden County: Medicare Complete plan
replaced by Plan 1 and 2 (members must choose
new plan, no auto-enrollment)
• Open network in New England
15
Part D Standard Benefit
Standard Coverage Levels
2015
2016
$320
$360
Initial Coverage Limit
$2,960
$3,310
“Out-of-pocket” Threshold
$4,700*
$4,850*
Catastrophic Cost-Sharing
5% or
$2.65/$6.60
5% or
$2.95/$7.40
Deductible
* In 2016, after $3,310 in retail costs, the beneficiary pays 45% of brand
name drug costs and 58% of generic drug costs until total out-of-pocket
costs equal $4,850
16
Health Safety Net Reminders


Income 0-200% FPL – extensive benefits
Income at 200-400% FPL partial assistance

Could provide additional hospital coverage for
individuals enrolled in Original Medicare, Core
Medigap, or Medicare Advantage

May pay for medical services or drugs at a hospital or
Community Health Center
• HSN drug coverage is NOT creditable coverage

Does NOT pay for SNF costs
17
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
 Under 65 must meet S2 income category
• S5: $200 enrollment fee; may be worth it for some



1x yearly SEP available to ALL categories
MassHealth beneficiaries not eligible for PA
Online application available
• www.prescriptionadvantagema.org
18
Extra Help (LIS)

6 PDP plans with $0 premium for LIS members:
• Aetna Medicare Rx Saver
• AARP MedicareRx Saver Plus
• Humana Preferred Rx Plan
• WellCare Classic
• Silverscript Choice
• Symphonix Value Rx
19
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 late Oct/early
Nov
• Second BLUE letter sent in December identifying which of
members drugs are on formulary of 2016 reassigned plan
 Info on how to appeal, request exception, file grievance
included
20
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
21
Discontinued PDP Plans

Members of discontinued plans received
notification by October 2nd

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
22
Discontinued PDP Plans

Terminated plans offering NO auto-assignment,
SEP available until end of February:
• Smart D Rx Saver

Plans auto-assigning members to new plans:
• Aetna Rx Premiere  Aetna Rx Saver
• Transamerica Rx Choice  Transamerica Rx Classic
• Cigna Healthspring Secure Max  Cigna Healthspring
Secure-Xtra
23
Auto-Assignment for
Discontinued PDP Plans
2015 Discontinued Plan
2016 Auto-Assignment
Aetna Rx Premiere
Aetna Rx Saver
Transamerica Rx Choice
Transamerica Rx Classic
Cigna Healthspring Secure –Max
Cigna Healthspring SecureXtra
24
New PDPs in 2016

New Company: Symphonix Health

3 new plans
1. Symphonix PrimeSaver Rx
2. Symphonix Value Rx
3. EnvisionRx Plus Clear Choice

26 plans in 2016
• Down from 27 in 2015
25
Sanctioned Plans

United American (S5755)
• Plan remains under CMS sanction
• Beneficiaries currently enrolled should not
be affected by the sanctions
• Plan will not appear on Plan Finder
26
2016 PDP Premiums
Average premiums remain stable at about $53
 Transamerica Medicare Rx Classic premium
change

• 2015 premium:
• 2016 premium:
$34.70
$118.80
242% premium increase
27
Preferred Pharmacy Pricing

Many PDPs continue to offer preferred cost
sharing at select pharmacies in 2016
• 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
28
SEPs Available After
th
December 7
 Plan is terminating
• Special Enrollment Period (SEP): Dec 8th – Feb 28th
 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 1/1/2016
• SEP Until March 31st
 5 Star Plan SEP
 Low Performing Medicare Plan
• Call 1-800-Medicare
 Medicare Advantage Disenrollment Period
• Jan 1st – Feb 14th
29
5 Star SEP

2016 plan star ratings will be available on Medicare.gov in
October

Ratings based on:

•
•
•
Customer service, complaints & member experience
Drug pricing and patient safety
Health screenings and management of chronic conditions
SEP December 8th– November 30th
•
Allows beneficiary to enroll or switch into 5 star plan
 One time each year
 If Medicare Advantage plan, must meet eligibility criteria
to enroll
30
Medicare Advantage
Disenrollment Period (MADP)

Beneficiaries can disenroll from Medicare Advantage
plan and return to Original Medicare from January 1st
- February 14th

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 1st – Feb 14th
31
Medicare Plan Finder
Updates and Tips
for Open Enrollment
Choosing a PDP or MA-PD

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- check with beneficiary or
pharmacy if unclear whether brand or generic
Pharmacy selection is important
Check for Prescription Advantage eligibility
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
34
My Current Profile Box
Displays dates for
Current Coverage
and Current
Subsidy.
If possible, always
do a Personalized
Search.
35
Add/Edit Drugs

In Drug Costs & Coverage tab

Under Drug List section
Add or edit drugs
here rather than
going back to the
beginning
36
Add/Remove Pharmacy


In same Drug Costs & Coverage tab
Under Pharmacy & Mail Order Information section
Click on highlighted
network
pharmacies link
37
Add/Remove Pharmacy Cont.

A new Medicare.gov page opens
Hit Add or Remove
Pharmacy
Hit Close window
when finished
(automatically saves)
38
Add/Remove Pharmacy Cont.

Refresh page to see updated pharmacy

Look inside browser toolbar for the refresh
button, an icon similar to these
39
Retail or Mail Order
Enter month
quantity at retail
pharmacy
(default) when
possible
40
Printable
Plan
Report
41
Don’t forget you
can customize
your report when
printing
42
Remember to Click on Watermark
When Enrolling Beneficiaries
Click here
on
Watermark
Enter your
SHINE office
phone number
here
43
Remember!
Always use Plan Finder unless beneficiary 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 Enrollment Confirmation page on Plan Finder
with “Ctrl P” keys
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
45
One Care Updates
One Care Updates

Fallon Total Care left One Care as of Sept. 30th
•
•

Most members returned to fee for service Medicare &
Medicaid
Some accepted into Tufts, CCA, PACE, SCO
2 providers remaining
• Commonwealth Care Alliance
Temporary moratorium on enrollment
• Tufts Health Plan
 Network Health will accept 500 from Worcester
County and open to Suffolk County

47
Medicare and the
Marketplace
48
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
• 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
• Connector Open Enrollment: Nov 1st 2015 -Jan 31st 2016
49
Message to Medicare Beneficiaries Who Have
Questions About How the Marketplace Affects
Them

Medicare isn’t part of the Health Insurance Marketplace

No one can sell a Medicare beneficiary a Marketplace
plan
• Even if they only have Medicare Part A or Part B
• Except plans through an employer sold through the
Small Business Health Options Program (SHOP) if
they’re an active worker/ dependent of an active
worker

Medicare beneficiaries DO NOT NEED TO DO ANYTHING
about the Marketplace
50
Can you keep a Marketplace
Plan Once Medicare Begins?
If you are:
Currently enrolled in a
Marketplace plan and
become entitled
to Premium-free Part A
Currently enrolled in a
Marketplace plan and
become eligible
to buy Premium Part A
& Part B
Can you keep
Marketplace
Plan after
enrolling in
Medicare?
Are you eligible to continue
receiving tax credits and
reduced
cost-sharing?
Yes
No. Any tax credits the individual
is receiving in the plan will be
discontinued once Part A coverage
begins.
Yes
Yes, if you only enroll in Part B,
(B doesn’t constitute Minimum
Essential Coverage).
No, if you enroll in Premium Part
A.
51

Marketplace
Drug Coverage & Dental
Prescription Drug Coverage:
•
Prescription drug coverage in Marketplace plans is
NOT required to be creditable
 Need to verify creditability with plan or possibly

face a Part D penalty upon enrollment
Dental Coverage:
•
In Massachusetts everyone can purchase a dental
plan through the Marketplace

Dental coverage is NOT subsidized
52
Where Can People Go for Help With
the Marketplace?

SHINE counselors receiving calls about the
Marketplace should refer individuals to their
local Certified Application Counselor (CAC)
 Massachusetts Health Connector
• https://betterhealthconnector.com/
• (877) 623-6765
53
Updates
54
2016 Part B Costs


No COLA expected
Expected increase in Part B premiums for new
enrollees, those with IRMAA & those who deferred
claiming Social Security

Projected 2016 premium: $159.30
• $223 to $509.80 for higher incomes
• 52% premium increase

Projected 2016 deductible: $223
SCREEN for eligibility for Medicare Savings Plans!!

55
Questions
56