1. health and fitness
2. drugs

SHINE
Serving the Health
Insurance Needs of Everyone
Topics
 Part 1: Overview for SHINE and Medicare
 Part 2: Medicare Part D
 Part 3: Medicare Assistance Programs
 Part 4: Medicare.gov
SHINE Overview

Began in 1985 as a pilot program, in 1992 SHINE became available
statewide with federal funding assistance

Objective is to provide elders with access to accurate, unbiased
health insurance information

Network of 500+ volunteer counselors trained and certified by Elder
Affairs to provide information, counseling and assistance regarding
health insurance and benefits

SHINE Counselors are available at many Senior Centers, Councils on
Aging (COA), Area Agencies on Aging, and Aging Services Access
Points (ASAP), Community hospitals and many other communitybased sites
SHINE Counselors

Explain Medicare Part A, B, C and D benefits and gaps

Compare health insurance and prescription drug plans
options, cost and benefits

Screen for Prescription Advantage, Medicare Savings
Programs, and Extra Help

Provide assistance with the application process

Help with claims and billing problems

Start appeals and explain grievance procedures

Know how to solve problems and ask the right questions
SHINE Part D Enrollment
Specialist
 Assist SHINE counselors by using tools on
medicare.gov to get data into and get reporting
from medicare.gov
 Assist counselors by comparing the cost and
benefits of the programs available for clients
 This training is designed to help you handle basic
matters; clients who are seeking assistance beyond
basic inquiries should be referred to a SHINE
Counselor
Open Enrollment Period
 October 15th – December 7th
 Every plan changes from year to year
 Plans change premiums, co-pays, drug
formulary, and can end their contract with
Medicare
 If an individual elects not to do anything
then they will remain in their current plan
for the following year
Medicare Overview
Medicare is a health insurance program for:
 People 65 years of age and older
• This is not necessarily full retirement age
 People under age 65 with disabilities
• Deemed “disabled” by Social Security for at least
24 months
 Note:
Medicare is NOT Medicaid: Medicaid is health
insurance for very low income population and is called
MassHealth in Massachusetts
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
Part A and B
for
Medicare Advantage Plans
(MA-PD, Medicare Part C)
 Eligibility
• Must have both Part A & Part B
• Must live within plan service area 6 months a year
• Must not have ESRD (end stage renal disease)
• Must continue to pay Part B premium
 Characteristics
Other Options for Drug
Coverage

Retiree Benefits (former employer
benefits)

Veterans Benefits

MassHealth (Medicaid) & other related
programs
Medicare Part D
Overview of Medicare Part D
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Began January 1, 2006
Voluntary
Provides outpatient prescription drugs
All Medicare beneficiaries 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)
Prescription Drug Plan Options
Original Medicare
Medicare
Advantage Plan
+
Part D stand alone
plan (PDP)
+
Medigap Policy
Optional “add-on”
Or other supplemental
medical coverage
OR
For prescription coverage
an individual must choose
the Part D coverage
offered by their Medicare
Advantage Plan (MA-PD)
Medicare Part D Plans

All plans, MA-PD and PDPs must meet CMS
standards
• Cost structure
• Formulary (drugs covered)
• Pharmacy Access

May also offer supplemental benefits

Must coordinate benefits with SPAP’s (Prescription
Advantage) and State Medicaid (MassHealth)
programs that wrap-around coverage
Formulary Standards

Each plan has to cover “all or substantially all” the drugs in
the following classes:
• Antidepressants
• Antipsychotic
• Anticonvulsant
• Anticancer
• Immunosuppressant and
• HIV/AIDS

Plans must cover at least two drugs in each therapeutic
class

Plans may change their formularies during the year
however must provide 60 days notice to each member
taking the medication in question
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)

Drugs used for Erectile Dysfunction (Viagra, Cialis, Levitra)

Drugs that may be covered under Medicare Part A and/or
Medicare Part B
Standard Medicare Part D
(2015)
Level
Deductible
Description
Annual $320 deductible paid by the Beneficiary.
Initial Coverage From $320 to $2960 (retail cost of drugs)
Beneficiary pays 25% of the drug costs and Medicare
pays 75%
Coverage Gap
“Donut Hole”
After $2, 960 in costs beneficiary pays 45% of brand
name drug costs and 65% of generic drug costs until they
have spent $4,700 out of pocket.
Catastrophic
When true out of pocket (TrOOP) costs reach $4,700
(excluding monthly premium) beneficiary pays 5% of the
drug costs and Medicare pays 95%.
Not All Part D Plans Are Made
Equal!

PDPs and MA-PDs may vary based on:
• Benefit Design
• Monthly Premium
• Deductible
• Coinsurance
• Formulary
• Drug Prices
• Service Area
How to Enroll Into Medicare
Part D

Review plan options
• Plan Finder Tool on Medicare.gov
• Determine Stand Alone Part D plan vs. Medicare Advantage
Plan
• Consider cost, coverage, quality, and convenience
• Avoid drug restrictions
 Step Therapy
 Prior Authorizations

Contact plan directly or call 1-800-Medicare
• Enrollment can take place on the phone, online, or through
a mailed in paper application
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 but it is not considered
creditable
 Penalty may be charged once an individual does join a Part D
plan
• A 1% increase in premium for each month an individual
went without creditable coverage since Medicare eligible
 Penalty is 1% increase in premium based on a national
standard base premium.
 Penalty is permanent
Creditable Coverage

Prescription drug coverage at least as good as standard
Part D

All Medicare beneficiaries (including those who are still
working) must have creditable coverage to avoid 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
Medicare
Assistance
Programs
Assistance Programs May Help
 LIS aka “Extra Help”
• Assists with Part D premiums and co-pays – apply
thorough Social Security
 Prescription Advantage
• Help with drug costs when in the coverage gap
 There are additional options that your SHINE
Counselor will be aware of
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

Administered by CMS and the Social Security Administration
Prescription Advantage

Massachusetts’ State PharmaceuticalAssistance Program
(SPAP)

Provides secondary coverage for those with Medicare or other
“creditable” drug coverage (i.e. retiree plan)

Provides primary coverage for individuals who are NOT eligible
for Medicare

Benefits are based on a sliding income scale only – No asset
limit!

Different income limits for under 65 vs. 65 and over

Dual eligibles can NOT join (but those with LIS or MSP can join)
Prescription Advantage For those with
Medicare or “Creditable Plan”

Helps pay for drugs in the gap (for most members)

Those in top income category (S5) must pay $200 annual fee
for limited benefits

All medications must be covered by primary plan

Benzodiazepines (xanax, lorazepam, valium, etc) are covered
right away

Members are provided a SEP (one extra time each year outside
of open enrollment to enroll or switch plans)

Prescription Advantage does not pay late enrollment penalty
fee
Medicare.gov
Plan Finder
What is the Meidcare.gov Part-D
Plan Finder?
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A tool on Medicare.gov which helps you to find the drug plan
that best fits the clients personal data and formulary
It should only be used with the clients personal data and
formulary
It has all plans available within a zip code
Pharmacy and clients formulary impact results
Supported formularies vary by plan
Coverage for Part D is provided by:
• Prescription Drug Plans (PDPs) also known as stand alone
plans
• Medicare Advantage Prescription Drug Plans (MA-PDs)
Using the Medicare
Drug Plan Enrollment
Form
Using the Medicare
Drug Plan Enrollment
Form Continued
How to use the Medicare.gov
Plan Finder
To effectively use the medicare.gov Plan Finder you need to do a
personalized search and need the information noted below
1.
2.
3.
4.
5.
Last Name
DOB (date of birth)
Zip Code
Medicare Claim Number
Effective Date for A or B
A personal search will provide accurate and data about the client
including their current status and “Extra Help” supports
Doing a search on Medicare.gov
Results and
importance
of a
Personal
Search
Using the
Medicare
Plan Finder
Part D Case Study
Terry Torial - Case Facts/Assumptions:
Meeting in person. Wants help with Rx drug Costs.
Signed up for PartD during initial open enrolment
she did not take drugs at that time. Now she does
take Lipitor, Fosamax, Synthroid, and Ativan
paying out of pocket. SS income $1,050. Assets
45,000. She does not appear frail.
Part D Case Study
Part D Case Study