open enrollment ppt

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Transcript open enrollment ppt

SHINE Counselor
Fall Training
Preparing for Open Enrollment
Medicare Updates
 Observation Status
• Does NOT apply to Medicare Advantage Plans
• Does NOT meet the Medicare requirement for SNF
Beneficiaries must resolve any issues regarding
observation status PRIOR to discharge from a hospital
 Observation status issues cannot be resolved while in a
• 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 2
Counseling Same-Sex Spouses
CMS and SSA view same-sex spouses the same
as opposite- sex spouses
Laws have changed, some issues are still being
worked out
Anyone eligible for benefits should apply
Medicare Plans
Choosing a Medigap
No change in number of plans offering
New premiums
BC/BS lowest cost for CORE and Supplement 1
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
Blue Cross/Blue Shield
MA Plans
 Existing Plans
• Premium increases: HMO Blue Plus Rx & PPO Blue Plus Rx
• Hospital Co-pays higher
• Increases in lab, high tech imaging & outpatient services
• Available in all counties except Dukes & Nantucket,
 For PPO’s
Check to see if providers will accept plan (if not, may be
subject to filing claims and paying a higher rate)
 Dental can be purchased by anyone over 65
Fallon Senior Plans
Existing Plans
• Super Saver Rx premium staying at $0
• Preferred pharmacies: CVS, Target, Walmart
• Premium increases for all other plans
• Inpatient hospital and skilled nursing costs changing
• Higher co-pays for out-of-network care
• Not all services covered out-of-network
• Out of Pocket max. higher on most plans
Harvard Pilgrim
Two Plans: Stride HMO Value Rx and Stride
Value Rx Plus
 New Plan=Stride HMO Value Rx
• Available in Bristol, Norfolk, Suffolk, and Worcester
counties only
• $46 premium, $3,400 annual out-of-pocket
Health New England
Changes in Existing Plans
• Premium increases in most plans
Service area remains Berkshire, Franklin, Hampden,
and Hampshire counties
Hartford County Connecticut in network
Baystate Medical Center in network
Tufts Medicare Preferred
Existing Plans
• Premium and co-pay increases for most plans
• $0 premium plan
• Out of pocket $3400
Existing Plans
• AARP Complete Choice Regional PPO
 Still
available in every county
 Premium and out-of-network co-insurance increased
HMO plans going to PCP based model with referrals
No referrals needed in PPO
Split deductible in tiers 3-4
New HMO Plans
• AARP Medicare Complete new to Bristol County
Special Needs Plans
Types of Special Needs Plans
• Dual- Eligible (Medicare and Medicaid)
• Institutional (Must reside in LTC Facility)
Network Health is now called Tufts Health PlanNetwork Health
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 at hospital or
Community Health Center
Does NOT pay for SNF costs
Part D Standard Benefit
* In 2015, after $2,960 in retail costs, the beneficiary pays 45% of brand
name drug costs and 65% of generic drug costs until total out-of-pocket
costs equal $4,700
Extra Help (LIS)
5 PDP plans with $0 premium for LIS members:
• Aetna Medicare Rx Saver
• AARP MedicareRx Saver Plus
• Humana Preferred Rx Plan
• WellCare Classic
• Silverscript Choice
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 early
LIS Choosers
Members who chose to be in their current plan (not
• Will be notified if the plan’s premium goes above
the benchmark
• Will be given a list of plans available for $0
• Will not be automatically reassigned
CMS will mail out TAN letters in early November
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
Discontinued PDP Plans
Terminated plans offering NO auto-assignment,
SEP available until end of February:
• HealthMarkets Value Rx
• Unicare MedicareRx Rewards Standard
Plans auto-assigning members to new plans:
• AARP MedicareRx Enhanced
• First Health Part D Essentials
• Cigna-HealthSpring Rx-Reg 2
• Silverscript Choice
• SmartD Rx Plus
Auto-Assignment for
Discontinued PDP Plans
2014 Discontinued Plan
2015 Auto-Assignment
AARP MedicareRX Enhanced
AARP MedicareRx Preferred
First Health Part D Essentials
First Health Part D Value Plus
Cigna-HealthSpring Rx-Reg 2
Cigna-HealthSpring Rx Secure
Silverscript Choice
SilverScript Choice
(Basic plan renamed Choice)
SmartD Rx Plus
SmartD Rx Saver
New PDP for 2015
United American Essential
27 plans available in 2015
• Down from 33 in 2014
Same Plan, New Name
2014 Name
Cigna Medicare Rx Secure
Cigna Medicare Rx SecureMax
2015 New Name
Cigna Medicare Secure-Xtr
Cigna-HealthSpring Rx Secure
Cigna-HealthSpring Rx SecureMax
Cigna-HealthSpring Rx SecureXtra
Aetna CVS/pharmacy
Aetna Medicare Rx Saver
SilverScript Basic
SilverScript Choice
Sanctioned Plans
Smart D Rx Saver
• Plans remain under CMS sanction
• Beneficiaries currently enrolled should not be
affected by the sanctions
• Must do personalized search to compare plans
with 2015 options
Preferred Pharmacy Pricing
Many PDPs continue to offer preferred cost sharing
at select pharmacies in 2015
• Refer to updated Preferred Pharmacy Chart
Pricing can vary dramatically between pharmacies
• Important for beneficiaries to do 2 pharmacy
comparisons for preferred pharmacy pricing
SEPs Available After
December 7th
 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 1/1/2015
• SEP Until March 31st
 5 Star Plan SEP
 Low Performing Medicare Plan
• Call 1-800-Medicare
 Medicare Advantage Disenrollment Period
• Jan 1st – Feb 14th
5 Star SEP
2015 plan star ratings will be available on
around October 19th
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
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
Medicare Plan Finder
Updates and Tips
for Open Enrollment Home Page Update
3 green buttons replace the 2 yellow buttons. The blue button that took
the user to the MyMedicare login page has been removed- users can go to
MyMedicare through the link at the top right corner
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
Pharmacy selection is important
Check for Prescription Advantage eligibility
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
• S5: $200 enrollment fee; may be worth it for some
1x yearly SEP available to ALL categories
Online application now available
Suppressed vs. Sanctioned
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
Sanctioned drug plans
• Have failed to remain in compliance with CMS
standards and practices
• These plans WON’T appear in the Plan Finder
My Current Profile Box
Displays dates for
Current Coverage
and Current
If possible, always
do a Personalized
Add, Change or Remove Drug Doses
Buttons added to drug list section of Plan
Comparison and Plan Details pages on drug costs &
coverage tab
page after
Add, change
dose, remove
drugs at this tab
rather than going
back to beginning
Pharmacy Language Updates
The previous
pharmacy status
“Network” has
been changed to
“Standard CostSharing”
The old pharmacy
status “PreferredNetwork” has been
changed to
“Preferred CostSharing”
Retail or Mail Order
Enter month
quantity at retail
(default) when
Don’t forget you
can customize
your report when
Email Functionality Removed
Removed due to security issues
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
Remember to Click on Watermark
When Enrolling Beneficiaries
Click here
Enter your
SHINE office
phone number
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
Print Confirmation page on Plan Finder with “Ctrl P”
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
One Care Updates
One Care:
Medicare + MassHealth
NOT available in all counties
Health insurance plan combines Medicare and Medicaid
payments and services like a SCO but with additional
For dual-eligibles between the aged 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
One Care Updates
Entering second year of three year
demonstration project
 8/28/14 - Final mailing sent out
 As of 9/1/14 - 17,739 enrolled statewide out
of 95,140 eligible
 One Care on Medicare website may not
always be accurate
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. Select Medicare Health Plans with Drug
2. In the left column, click the + by “Select
Special Needs
Plans” to display4 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
One Care Plans
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.
Helpful One Care Websites
One Care Plans
 Commonwealth Care Alliance
• Contact: 1-866-610-2273,
 Fallon Total Care
• Contact: 1-800-879-0852,
 Tufts Health Plan-Network Health
• Contact: 1-855-393-3154,
Medicare and the
Frequently Asked Questions
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
• It is designed to help people who don’t have any health
• Medicare is NOT part of the Health Insurance
The Health Connector is Massachusetts' health insurance
Marketplace Open Enrollment is from November 15th 2014 53
February 15th 2015
What is the message to Medicare beneficiaries
who have questions about how the Marketplace
affects them?
Medicare isn’t part of the Health Insurance
Medicare beneficiaries DO NOT NEED TO DO
ANYTHING about the Marketplace
Can a Medicare beneficiary purchase a standalone dental plan through the Individual
Yes. In Massachusetts everyone can purchase
a dental plan through the Marketplace
Where can individuals go for help
with the Marketplace?
SHINE counselors receiving calls about the
Marketplace should refer individuals to their
local Navigator or Certified Application
Counselor (CAC)
 Massachusetts Health Connector
• (877) 623-6765