shine s erving the h ealth i nsurance n eeds of e veryone on medicare n.
Skip this Video
Download Presentation
SHINE S erving the H ealth I nsurance N eeds of E veryone on Medicare

Loading in 2 Seconds...

play fullscreen
1 / 43

SHINE S erving the H ealth I nsurance N eeds of E veryone on Medicare - PowerPoint PPT Presentation

  • Uploaded on

SHINE S erving the H ealth I nsurance N eeds of E veryone on Medicare. 3 Day Part D Counselor Training. Day 1 Topics. Overview of SHINE Original Medicare (Part A & B) Medicare Supplement Plans (Medigap) Medicare Advantage Plans (Part C) Other Sources of Supplementing Medicare

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'SHINE S erving the H ealth I nsurance N eeds of E veryone on Medicare' - lark

Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
shine s erving the h ealth i nsurance n eeds of e veryone on medicare

SHINEServing the Health Insurance Needs of Everyoneon Medicare

3 Day Part D Counselor Training

day 1 topics
Day 1 Topics

Overview of SHINE

Original Medicare (Part A & B)

Medicare Supplement Plans (Medigap)

Medicare Advantage Plans (Part C)

Other Sources of Supplementing Medicare

Medicare Part D

Extra Help

Prescription Advantage

day 2 3 topics
Day 2 & 3 Topics

Day 2

Review of Medicare Basics (Day 1)

Review Extra Help

Review Prescription Advantage

Medicare Plan Finder Demo

Day 3 website (hands-on training)

certified shine counselors
Certified SHINE Counselors
  • Explain Medicare Part A, B, C and D benefits and gaps
  • Compare health insurance and prescription drug plan options, costs and benefits
  • Screen for public benefit programs and provide assistance with the application process
  • Help with claims and billing problems
  • Start appeals and explain grievance procedures
shine part d enrollment counselors
SHINE Part D Enrollment Counselors
  • Assist beneficiaries by comparing the cost and benefits of the programs available to them.
  • Screen beneficiaries for Extra Help and Prescription Advantage
  • Provide enrollment assistance into these programs
  • Complete a client contact form after each appointment

This training is designed to help you handle basic matters.

medicare overview
Medicare Overview

Medicare is a health insurance program for

People 65 years of age and older (not necessarily full retirement age)

People under age 65 with disabilities

(deemed “disabled” by Social Security for at least 24 months)

People under age 65 and have ALS or ESRD

Note: Medicare is NOT Medicaid (which is health insurance for very low income population)

medicare card
Medicare Card
  • Each Medicare Claim Number is unique to a beneficiary
  • The Number is made up of a Social Security Number and Letter (not necessarily the beneficiary’s SSN)
  • Card lists effective dates for Part A and B
  • The information on this card helps counselors perform accurate drug plan searches
original medicare parts premiums
Original Medicare Parts & Premiums

Part A – Hospital & Skilled Nursing Care

(Premium free for most people)

Part B – Doctors’ Visits & Outpatient Care

(Monthly premium, may change annually – increased premium for those with income over $85,000/year)


Your Medicare Coverage Choices


Step 1: Decide how you want to get your coverage




(like an HMO or PPO)

Part B



Part A



Part C

Combines Part A, Part B

and usually Part D


Step 2: Decide if you need a Prescription Drug Plan

Part D

Drug coverage is limited to plan

offered by HMO or PPO.

Part D

Stand Alone PDP

Step 3: Decide if you need to add

supplemental medical coverage


If you join a Medicare Advantage

Plan with drug coverage (MAPD), you cannot

join another drug plan and you don’t need and

cannot be sold a Medigap policy.


Supplement Core or

Supplement 1 plan



medicare supplement plans medigaps
Medicare Supplement Plans (Medigaps)

Sold by private insurance companies

People must be enrolled in Medicare Part A & Part B

Pays second to Medicare only after Medicare recognizes service as a “covered” service

All Massachusetts Medigap plans have continuous open enrollment throughout the year (not true in all states)

Medigap plans do not include prescription drug coverage

There are two types of Medigap policies currently sold in Massachusetts: Core and Supplement 1. Core pays for Medicare A + B co-pays and Supplement 1 pays A + B deductibles and co-pays.

Supplement 2 is a type of Medigap policy no longer sold. Supplement 2 is very expensive and includes prescription coverage. If you encounter someone with this policy please refer them to a SHINE Counselor. The most common Supplement 2 policy is called Medex Gold and was a BCBS product.

medicare advantage plans aka medicare part c medicare health plans
Medicare Advantage Plans(aka Medicare Part C, Medicare Health Plans)

Private insurance companies that contract with Medicare to provide coverage comparable to “Original” Medicare

Medicare Advantage Plans combine Medicare A, B, and Part D benefits into one plan.

Members must have Medicare Part A and B to enroll

Members must still pay Part B premium

Plans usually charge an additional premium & members pay co-pays when receiving services

Plans may add additional benefits (e.g. routine physicals, eye glasses, hearing aids)

Plans typically use networks of physicians

Most common types of Medicare Advantage Plans are HMO’s and PPO’s

types of medicare advantage plans
Types of Medicare Advantage Plans

HMO - Health Maintenance Organization

With the exception of urgent or emergency care, members must receive all services within the plan’s network

Primary Care Physician required and referrals needed to see specialists

May only join the prescription coverage offered by the HMO plan

PPO - Preferred Provider Organization

PPO’s have a defined network of providers with the option of seeing providers outside the network. Care sought out-of-network usually results in higher copays and deductibles.

May only join the prescription coverage offered by the PPO plan

annual enrollment period
Annual Enrollment Period

Each year Medicare Advantage Plans may change

benefit structure

physician network



may leave the market or discontinue

Members will be notified of plan changes by mail in the month

of September.

other ways to supplement medicare
Other ways to Supplement Medicare

Beware of:

Retiree Health Plans (group plans)

Each retiree plan is different

Veterans Administration

Medicaid/MassHealth (for very low-income)

medicare and masshealth
Medicare and MassHealth

A beneficiary who has Medicare and MassHealth is referred to as “Dual Eligible”.

For hospital and medical services, Medicare always pays Primary and MassHealth pays Secondary as long as the provider accepts MassHealth.

Dual eligibles who want drug coverage must get it through a Medicare Part D plan. MassHealth will help pay for some medications not covered by Part D (i.e. OTC medications).

Dual eligibles qualify for reduced Part D premiums, deductibles, and drug co-pays.

overview of medicare part d
Overview of Medicare Part D
  • Voluntary, but may be subject to penalty
  • Provides outpatient prescription drugs
  • People with Part A and/or Part B are eligible
  • Coverage for Part D is provided by:
    • Prescription Drug Plans (PDPs) also known as stand alone plans
    • Medicare Advantage Prescription Drug Plans (MA-PDs)
examples of part d excluded drugs
Examples of Part D Excluded Drugs
  • Drugs for anorexia, weight loss or weight gain
  • Drugs for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Non-prescription drugs (over the counter)
      • Barbiturates (exception: Part D covers barbiturates used to treat epilepsy, cancers, and chronic mental health disorders)
  • Drugs used for Erectile Dysfunction (Viagra, Cialis, Levitra)
  • Drugs that could be covered under Medicare Part A and/or Medicare Part B
not all part d plans are made equal
Not all Part D Plans are made equal!
  • PDPs and MA-PDs may vary based on:
    • Benefit Design
    • Monthly Premium
    • Deductible
    • Co-payments
    • Formulary
    • Drug Prices
    • Drug Restrictions
    • Pharmacy Network
aca is closing the donut hole
ACA is Closing the Donut Hole!

Each year, the co-payment percentage for generics and brand names will decrease.

By 2020, these percentages will match those in the Initial Coverage Period and the donut hole will be eliminated.

how to enroll into medicare part d
How to Enroll Into Medicare Part D
  • Review plan options
    • Plan Finder Tool on Medicare Website
    • Determine PDP plan vs. MA-PD plan
    • Consider cost, coverage, quality, and convenience
    • Be aware of preferred pharmacies
    • Avoid drug restrictions
      • Step Therapy - May require member try an alternative med first
      • Prior Authorizations - Requires doctor’s approval
      • Quantity Limitations - Limits how much medication can be dispensed to a patient within a specific time period.
  • Contact plan directly or call 1-800-Medicare
    • Enrollment can take place on the phone, online, or through a mailed in paper application.
annual election period open enrollment
Annual Election Period“Open Enrollment”
  • October 15th – December 7th. All changes are effective January 1st.
  • Every plan changes from year to year: they change premiums, co-pays, formulary, or can end their contract with Medicare
  • If an individual elects not to do anything then they will remain in that plan for the following year
late enrollment penalty
Late Enrollment Penalty

If an individual does not enroll when first eligible for Part D, they may pay a penalty if they:

  • Have no coverage or have coverage that is not “creditable”
  • Have a lapse in coverage (63 days or more)

Penalty is charged once an individual enrolls in a Part D plan

  • 1% of the benchmark premium* for each month an individual went without creditable coverage since becoming eligible for Medicare, losing creditable coverage or May 2006, whichever is later.
  • Penalty is for life.
  • National Benchmark premium for 2013 is $31.17

Late enrollees may enroll during:

  • AEP (for coverage effective Jan 1)
  • Special Enrollment Period (SEP), if they are eligible. (There are many SEPs, please refer to your PDP/MA-PD Special Enrollment Period Chart)
late enrollment penalty example
Late Enrollment Penalty Example

John enrolled in Original Medicare when he turned 65 but did not pick up Part D because he was not taking medication at the time. He is now 70 and enrolls in a Part D plan during open enrollment because his doctor prescribed him 2 medications. Upon enrolling in his Part D plan he was notified of the Late Enrollment Penalty (LEP) he must pay for failing to sign up when he was first eligible.

5 years without coverage = 60 months

1% of 2013 benchmark $31.17 = .31

60 months x .31 = $18.60 Monthly LEP

John is responsible to pay the LEP every month in addition to his regular Part D premium.

This penalty increases slightly each year with the increase in the benchmark premium.

creditable coverage
Creditable Coverage
  • Prescription drug coverage as good or better than standard Part D
  • All Medicare beneficiaries (including those who are still working) must have creditable coverage to avoid a 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
  • Examples of creditable coverage include: Veterans, COBRA, and most Employer Group Health Plans.

Savings Programs Can Help!

Decide how you want to get your coverage and apply for assistance




(like an HMO or PPO)

Part B



Part A



Part C

Combines Part A, Part B

and usually Part D


Step 2: Decide if you need a Prescription Drug Plan

Part D

Drug coverage is limited to plan

offered by HMO or PPO.

Part D

Stand Alone PDP




Work With Stand Alone Plans AND Drug Coverage offered with a Medicare Advantage.


extra help low income subsidy lis
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 D.
  • Extra Help subsidizes:
    • Premiums
    • Deductibles
    • Copayments
    • Coverage Gap “Donut Hole”
    • Late Enrollment Penalty
    • Does not subsidize non-formulary or excluded medications
  • Apply through Social Security Administration
  • Medicare beneficiaries who qualify for MassHealth will receive Full Extra Help automatically.
levels of extra help lis
Levels of Extra Help (LIS)
  • Full Extra Help

If income below 135% FPL AND resources (assets) below $8,580 (individual) and $13,620 (couple)

    • Full premium assistance with no deductible
    • Low, capped co-payments
  • Partial Extra Help

If income below 150% FPL AND resources (assets) below $13,300 (individual) and $26,580 (couple)

    • Reduced premiums (sliding scale – between 25% -75% assistance dependent upon income)
    • Reduced deductible and 15% copayments
extra help lis eligibility
Extra Help (LIS) Eligibility
  • Resources counted:
    • Bank accounts (checking, savings, CDs)
    • Stock, bonds, savings bonds, mutual funds, IRAs
    • Real estate other than a primary home
  • Resources not counted:
    • Primary home, car
    • Property one needs for self-support, such as a rental property
    • Burial spaces owned by a beneficiary
    • Personal belongings
    • Life Insurance Policies
applying for extra help lis
Applying for Extra Help (LIS)
  • To apply:
    • Complete an application online
    • Call SSA at 1-800-772-1213 to complete an application over the phone
    • Visit a local SSA office
prescription advantage
Prescription Advantage
  • Massachusetts’ State Pharmacy Assistance Program (SPAP)
  • Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i.e. retiree plan)
  • Benefits are based on a sliding income scale only – no asset limit!
  • Different income limits for under 65 vs. 65 and over
applying for prescription advantage
Applying for Prescription Advantage
  • To apply:
    • Call Prescription Advantage at 1-800-243-4636 and Press 2 to complete an application over the phone
    • Member can complete a paper application available at your counseling site.
prescription advantage for those with medicare or creditable plan
Prescription Advantage for those with Medicare or “Creditable Plan”
  • Helps pay for drugs in the gap (for most members)
  • Those with higher incomes may have to pay a $200 annual fee for limited benefits
  • To receive co-pay assistance, all medications must be covered by the primary drug plan
  • Members are provided a Special Enrollment Period (SEP) (one extra time each year outside of open enrollment to enroll or switch plans)
  • Prescription Advantage does not pay Part D late enrollment penalty
part d counselor training
Part D Counselor Training

Day 2: ReviewQuestions

  • What is Medicare Part D and how is it offered?
  • Who is eligible?
  • What is creditable coverage?
  • How is the late enrollment penalty calculated?
  • When is the Annual Election “Open Enrollment” Period?
  • When does the coverage gap or “donut hole” begin?
  • What programs are available to reduce drug costs?
case study 1 phil harmonic
Case Study 1Phil Harmonic

Phil Harmonic comes to see you in October because he needs help reviewing his drug plan for 2014. He tells you he enrolled in a Medicare Part D Plan when he turned 65. He currently takes generic medications and is in a low premium plan; however, his doctor recently informed him that he will be starting a brand name medication in January. Phil is worried that he may enter the donut hole in with this new medication but he’s not sure. He tells you he is single and has a gross monthly income of $1,300. He also has $5,000 in a checking account and owns a life insurance policy.

What information will you need to assist Phil with a drug plan search?

When is Phil able to change his drug plan?

What would you tell Phil about the donut hole?

What subsidy programs may Phil qualify for and how would he apply?

case study 2 bart ender
Case Study 2Bart Ender

Bart comes to see you during Medicare Open Enrollment. He is 70 years old, has Original Medicare, a Part D plan and tells you he just got a letter from Social Security informing him he’s been approved for Extra Help. Bart explains that he has been paying very high copays for several of his brand name medications this year and a friend of his helped him apply for Extra Help on the Social Security website. He mentions to you that he enrolled into Medicare Part D late and has also been paying a penalty. He wants to know how this Extra Help program will lower his costs.

How could you figure out what level of Extra Help Bart has?

How would Extra Help reduce his drug costs?

Would Extra Help pay his Late Enrollment Penalty?

Now that Bart has Extra Help, how often can he change his Part D plan?

How else would you assist Bart?

case study 3 pat e cake
Case Study 3Pat E. Cake

Pat E. Cake meets with you on November 20th. She says she belongs to a Medicare Advantage Plan (HMO). She tells you the prescription drug plan built into her Medicare Advantage plan costs more than she wants to pay, so she has decided to enroll in a Part D plan the offered to her by the agent she met at CVS.

What will happen if Pat enrolls in this Part D plan?

If Pat wants to explore other Medicare coverage options how would you help her?

If Pat makes a change to her coverage now, when will the change take effect?

case study 4 lucy and ricky
Case Study 4Lucy and Ricky

Lucy and Ricky come into the SHINE office on December 1, 2013. They want to know if there is still time to review their drug plan options for next year. They both have Medicare, a Medigap Supplement 1 Plan and a Part D plan. Ricky explains that Lucy was supposed to make an appointment to see the SHINE counselor weeks ago but forgot. In fact, she has been forgetting so much that the doctor has put her on a new brand name medication which is starting to help. Ricky explains that the only issue now is that the medication is very expensive. The couple’s monthly income is $3,700/month and they have $50,000 in assets. Lucy also wants to know why her new over the counter supplement “Vitameatavegamin” is not covered by Medicare Part D.

Why should Lucy and Ricky review their drug plan for 2014?

Do they still have time to make a change?

Would they qualify for any assistance programs?

Should Lucy’s OTC medication be covered?