Welcome to the SHINE Counselor Fall Training Preparing

Welcome to the SHINE Counselor Fall Training “Preparing for Open Enrollment”

Medicare Updates New Medicare Summary Notice • Redesigned Medicare Summary Notices provide clearer language, snapshots of deductible, payment, services, and providers. 2

Medicare Updates Continued Explanation of Benefits for Medicare Advantage Plans Beginning in October 2013, Medicare Advantage plans will be required to send beneficiaries a monthly EOB which will include a description of medical and hospital claims and details for claims processed. Special Needs Plans are not required to send an EOB. 3

Medicare Updates Continued Outpatient Mental Health Effective 2014, a beneficiary will pay 20% of Medicare approved amount for outpatient mental health care after the deductible is met (down from 35% in 2013). Observation Status Beneficiaries should be aware that observation status does not meet the Medicare requirement for SNF coverage. The Medicare Advocacy Project continues to work with beneficiaries who were not covered for SNF stays due to observation status. Please refer potential cases to MAP. 4

2014 Medicare Plans

Choosing a Medigap • No change in number of plans offering Medigaps • New premiums • BC/BS lowest cost for CORE and Supplement 1 Updated Medigap Chart in your packet! 6

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 standalone 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 Updated MA Charts in your packet! 7

Blue Cross/Blue Shield MA Plans Existing Plans • Lower premiums • Medicare HMO Value Rx eliminated $1, 000 deductible • Medicare PPO Plus Rx eliminated $500 out-of-network deductible New Plan • Medicare PPO Saver Rx • Available in all counties except Dukes and Nantucket • $0 premium, $6, 700 annual maximum For PPOs - check to see if providers will accept plan (if not, may be subject to filing claims and paying a higher rate) 8

Fallon Senior Plans Existing Plans • Premium and annual out-of-pocket maximum increases for most plans • Fallon Senior Plan HMO Saver Rx and HMO Saver Enhanced Rx changing to HMO-POS (Worcester and Franklin counties only) • higher co-pays for out-of-network care • not all services covered out-of-network • Transitioned automatically, no re-enrollment required • Reliant Medical Group no longer in network 9

Harvard Pilgrim New Plan • Stride HMO • Available in Bristol, Norfolk, Suffolk, and Worcester counties only • $163 premium, $3, 400 annual out-of-pocket maximum • Offers $25 monthly allowance for over-the-counter products (mail order only) • All Part D drugs included in formulary

Health New England Changes in Existing Plans • Service area remains Berkshire, Franklin, Hampden, and Hampshire counties • Premium increases in all plans New Plan • Health New England Medicare Value HMO, $18 premium 11

Tufts Medicare Preferred Existing Plans • Premium and co-pay increases for most plans • Reliant Medical Group accepting all plans Action Required for some members • Members in Worcester County enrolled in the following plans must re-enroll in same plan to continue coverage for 2014: • Preferred HMO Basic (no Rx) • Value (no Rx) • Prime (no Rx) • Members contact enrollment department to complete short enrollment form over the phone 12

United. Health. Care Existing Plans • AARP Complete Choice Regional PPO • still available in every county • Premium and out-of-network co-insurance increased HMO Name Change (Middlesex and Suffolk counties only) • AARP Medicare. Complete to AARP Medicare. Complete Plan 1 • Premium remains $0, annual out-of-pocket $6, 700 New HMO Plans • AARP Medicare. Complete (Hampden county only), $0 premium • AARP Medicare. Complete Plan 2 (Middlesex and Suffolk only), $45 premium 13

Universal American Existing PFFS Plans • Still in Berkshire, Dukes and Nantucket counties Name changes for Today’s Options Plans 14

Special Needs Plans Types of Special Needs Plans • Dual- Eligible (Medicare and Medicaid) • Institutional (Must reside in LTC Facility) Plan Change • Tufts Health Plan Senior Care Options (SCO) • Dual-eligible • Expanded service area to include all counties except Berkshire, Franklin, Dukes and Nantucket. 15

Health Safety Net Reminders • Income at or below 400% FPL - no asset limit! • Could provide additional hospital coverage for individuals enrolled in Original Medicare, Core Medigap, or Medicare Advantage • May pay for medical services at hospital or Community Health Center • Does not pay for SNF costs 16

Part D Standard Benefit 2013 2014 $325 $310 Initial Coverage Limit $2, 970 $2, 850 Brand copay in gap 47. 5% 79% 72% $4, 750 $4, 550 $2. 65 / $6. 60 or 5% $2. 55 / $6. 35 or 5% Deductible Generic copay in gap Out of Pocket Threshold Catastrophic costs Dual-eligible clients will pay no more than $2. 55 for generics and $6. 35 for brands in 2014. 17

Barbiturates • Medicare will cover barbiturates used for the treatment of any illness • In 2013, Medicare covered barbiturates only for epilepsy, cancer, or chronic mental health conditions (restrictions removed as of 1/1/14) • May require prior authorization • Be sure to enter barbiturates into Plan Finder • Mass. Health will no longer cover barbiturates for people with Medicare 18

LIS 8 PDP plans with $0 premium for LIS members: Aetna CVS/Pharmacy AARP Medicare. Rx Saver Plus Cigna Medicare Rx Secure Health. Markets Value Rx Humana Preferred Rx Plan (formerly Walmart Preferred) • Well. Care Classic • Smart D Rx Saver* • Silverscript Basic * * These plans remain under CMS sanction • • • 19

LIS Member Reassignment CMS randomly reassigns full LIS beneficiaries to new plan if: • Plan is terminating • Plan premium is above the benchmark and the member was auto-enrolled in the plan CMS will mail out blue letters in mid-October 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 • Envision Rx. Plus Gold • Choose new plan • Humana Complete • Automatically enrolled in Humana Enhanced 22

Discontinued PDP Plans • Members of discontinued plans received notification by October 1 st • 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 23

Discontinued PDP Plans • Members of Humana Complete will automatically be transferred, if no selection is made during Open Enrollment • Members of Envision Rx. Plus Gold must select plan or will be without Medicare Prescription Drug Coverage on January 1, 2014 (unless Dual-eligible or LIS) • If they do not select a plan by Dec 7, they will be eligible for a Special Enrollment Period between Dec 8 – Feb 28 24

Same Plan, New Name 2013 Name 2014 New Name Cigna Medicare Rx Plan 1 Cigna Medicare Rx Secure Cigna Medicare Rx Plan 2 Cigna Medicare Rx Secure-Max First Health Part D Premier First Health Part D Essentials Health. Spring Rx Drug Plan-Reg 2 Cigna-Health. Spring Rx-Reg 2 Humana Walmart- Preferred Rx Humana Preferred Rx Reader's Digest Value Rx Health. Markets Value Rx 25

New PDPs for 2014 • • • Cigna Medicare Rx Secure-Xtra Express Scripts Medicare – Choice Humana Walmart Rx Plan Transamerica Medicare. Rx Choice Transamerica Medicare. Rx Classic Updated PDP Charts in your packet!

Sanctioned Plans • • • Silver. Script Choice Silver. Script Basic Silver. Script Plus Smart D Rx Saver Smart D Rx Plus • Plans remain under CMS sanction • Must do personalized search to compare plans with 2014 options

Preferred Pharmacy Pricing • Many PDPs continue to offer preferred pricing at select pharmacies in 2014 • Refer to updated Preferred Pharmacy Chart 28

After December 7 th Plan is terminating • Special Enrollment Period (SEP): Dec 8 – Feb 28 Prescription Advantage members • One SEP each calendar year • If used in December, counted for 2013 SEP Extra Help beneficiaries and dual-eligibles • Continuous SEP Loss of Extra Help on 1/1/2014 • SEP Until March 31 st 5 Star Plan SEP Low Performing Medicare Plan • Call 1 -800 -Medicare Advantage Disenrollment Period • Jan 1 – Feb 14 29

5 Star SEP • 2014 plan ratings available on Medicare. gov website • Ratings based on: • Customer service, complaints & member experience • Drug pricing and patient safety • Health screenings and management of chronic conditions • SEP December 8 – November 30 • 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 1 - February 14 • 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 SEP to join PDP from Jan 1 – Feb 14 31

BC/BS Dental Insurance • New Dental Blue 65 plans offered • Coverage for services in addition to preventive • Contact Member Service 800 -200 -4255

Medicare Plan Finder Updates and Tips for Open Enrollment

Choosing a PDP or MA-PD • Do a Personalized Search • Enter Drugs Accurately • Pharmacy Selection is Important 34

Suppressed vs. Sanctioned Plans • Suppressed drug plans have submitted inaccurate drug pricing to CMS. Online enrollments for suppressed plans remain disabled until the plan submits correct pricing information. These plans appear at the bottom of the Results Page and do not display accurate costs. Example: First Health Drug Plans were suppressed for a several weeks in 2013. • Sanctioned drug plans have failed to remain in compliance with CMS standards and practices. When plans are sanctioned by CMS, all new enrollments are suspended and the plan must work with CMS to address any member issues. Must do personalized search to see plan data. Example: Smart D and Silver Script Plans are currently sanctioned for numerous failures in properly handling member’s prescription drug and enrollment transactions. 35

My Current Profile Box Displays dates for Current Coverage and Current Subsidy. If possible, always do a Personalized Search. 36

Preferred vs. Network Pharmacy Look at this field to see if pharmacy you chose is Preferred, Network, or Out-of. Network for each plan 37

Retail or Mail Order Enter I month quantity at retail pharmacy (default) when possible 38

Printable Plan Report 39

Don’t forget you can customize your report when printing. 40

Email button 41

Improved Enrollment Safeguard Occasionally, when an enrollment is submitted, the confirmation page is not displayed because an error occurred. This pop up window will inform you if the application was in fact received by Medicare and will indicate the enrollment confirmation number. 42

Remember! Always use Plan Finder unless client 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 43

Updates for One Care and DMEPOS Supplier Directory

One Care: Medicare + Mass. Health • Not available in all counties • Health insurance plan combines Medicare and Medicaid payments and services, like a SCO but with additional features • For dual eligibles between age of 21 -64 • Person-centered model providing full range of acute, behavioral health, and long term supports and services • Designed to coordinate care and provide higher quality, more cost-effective care with improved health outcomes

Role of SHINE Counselor • Assist eligible beneficiaries to understand One Care, review choices, check provider networks, check drug formularies and describe the enrollment process (Same process as for Medicare Advantage) • Complete the client contact form, including new data fields, as required by CMS

How to Search One Care Plans Step 4 of 4: Refine Your Plan Results 1 2 4 1. Select Medicare Health Plans with Drug Coverage 3 2. In the left column, click the + by “Select Special Needs Plans” to display available options 3. Check the first box that says “plans for people who are eligible for both Medicare and Medicaid” 4. Click Update Plan Results and Continue to Plan Results 47

One Care Plans will indicate (Medicare – Medicaid) next to the plan name. This designation should help you distinguish from other types of SNPs such as SCO Plans. 48

DMEPOS Supplier Directory www. medicare. gov/supplierdirectory Enter a zip code 49

8 Competitive Bid Categories To find a supplier within the selected zip code, indicate the competitive bid item needed 50

All other DMEPOS items Select this option when searching local retail pharmacies that cover diabetic supplies The directory also allows you to view suppliers carrying non-competitive bid items. 51

Supplier Results Supplier information will be displayed for the selected zip code and item. Sometimes the parent company is listed. You may also select View Manufacturers and Models to get information on specific brands each 52 supplier carries.

Counseling Same- Sex Couples • Supreme Court ruled Defense of Marriage Act (DOMA) unconstitutional in June 2013 • Laws have changed, but rules and regulations have not been released • Anyone eligible for benefits should apply • Stay Tuned! Will provide necessary updates as become available 53

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 54

Health Insurance Marketplace • New benefits and expanded access for individuals without health insurance • Administered by the Connector in Massachusetts • Marketplace Open Enrollment from Oct 1, 2013 - Mar 31, 2014 • Does not apply to Medicare beneficiaries! • Not eligible for health plans through the Marketplace • Medicare Open Enrollment is still Oct. 15 – Dec. 7 • Cannot use the expanded enrollment period to enroll or change Medicare plans • SHINE counselors receiving calls about the Marketplace should refer individuals to their local Navigator or Certified Application Counselor (CAC). Stay tuned to the SHINE website for contact information. 55

Helpful Websites One Care Plans 1) Commonwealth Care Alliance Contact: 1 -866 -610 -2273, www. commonwealthonecare. org 2) Fallon Total Care Contact: 1 -800 -879 -0852, www. fallontotalcare. org 3) Network Health Contact: 1 -855 -393 -3154, www. chooseunify. com Massachusetts Health Connector www. mahealthconnector. org