Medicare Updates. Illinois Department on Aging Senior Health Insurance Program (SHIP)

Transcription

1 Medicare 2015 Updates Governor s Conference on Aging & Disability Session W2, Wednesday December 10, 2014 Illinois Department on Aging Senior Health Insurance Program (SHIP) Aging.SHIP@illinois.gov

2 Senior Health Insurance Program Established in 1988 What is SHIP Free Medicare Counseling Program Sponsored by the State of Illinois o Illinois Department on Aging Do not sell or solicit insurance Dedicated to educating people with Medicare SHIP trains volunteer counselors throughout Illinois Provide one-on-one counseling o With Medicare Beneficiaries, family members and caregivers Enroll beneficiaries into various Medicare programs o Medicare Prescription Drug Coverage, SSA Extra Help, etc. Through community based sites

3 Two different ways to get Medicare Note: If choosing an HMO or PPO, you must get your Part D prescription drugs from that plan (not stand alone Part D)

4 We just completed: Annual Open Enrollment Period for Parts C and D October 15 th December 7 th each year Join, switch, or drop Medicare Part C or Part D plans Plan effective January 1

5 Upcoming: More upcoming Enrollment Periods for some beneficiaries GEP General Enrollment Period MADP Medicare Advantage Disenrollment Period

6 General Enrollment Period (GEP) If an individual is required to purchase Part A and did not enroll, and/or does not enroll in Part B during their IEP, they may use this GEP Begins January 1 and ends March 31 of every year Coverage effective date is July 1 of same year Penalties for late enrollment usually apply

7 Medicare Advantage Disenrollment Period (MADP) Jan 1 st Feb 14 th of each year Period when a beneficiary can drop their Medicare Advantage (MA) plan and go back to original Medicare only. Receive an SEP to get a Part D plan

8 Special Enrollment Period (SEP) Specific and designated circumstances that allow Medicare beneficiaries to enroll, drop or change coverage outside of normal enrollment periods Examples: Gained or lost Medicaid, left active employer group health insurance, have MA plan and moved out of service area, became eligible for Extra Help program, etc.

9 Part A Cost Changes in 2015

10 2015 PART A - INPATIENT HOSPITAL STAYS For each benefit period You Pay (2015) Days 1-60 Days Days $1,260 deductible Increase from $1216 $315 per day Increase from $304 $630 per day (60 lifetime reserve days) Increase from $608 All days after 150 All Costs

11 2015 Part A - Skilled Nursing Facility Care For each benefit period in 2015 You Pay Days 1-20 $0 Days All days after 100 $ per day Increase from $ All Costs

12 2015 Part B Costs ** No changes ** Part B Annual Deductible - $ Part B Monthly Premium - $ (Income below $85K) Medicare Part B pays 80% of an approved amount The beneficiary pays 20% If provider accepts assignment he/she can collect only the approved amount on a service.

13 2015 Medigap ** Only change is the Plan F high deductible option **

14 Medicare Part D Coverage by private companies contracted with Medicare to provide prescription drug coverage Available to anyone enrolled in Medicare Part A and/or Part B Coverage offered: Stand-alone Prescription Drug Plan (PDP), or As part of a Medicare Advantage Plan (MA-PD)

15 Medicare Part D Covered Drugs Generics & brand name Available only by prescription Approved by the FDA Used and sold in the U.S. Used for medically-accepted indication

16 Medicare Part D Part D National Base Monthly Premium The benchmark premium for 2015 is $33.13 Increased from $32.42 Used in calculating Part D Penalty for late enrollment If you do not enroll when first eligible for Part D, o if you eventually do choose to enroll, o you will pay a 1% per month penalty of the benchmark premium for as long as you stay on Part D.

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18 Standard Part D Drug Coverage and Cost Benefit for Part D base monthly premium is $33.13

19 Improved Coverage in the Coverage Gap (Donut Hole)

20 True Out-of-Pocket (TrOOP) Costs Expenses that count toward your out of pocket threshold to get out of the coverage gap ($4,700 in 2015) After threshold you get catastrophic coverage You pay only small copayment or coinsurance for covered drugs Explanation of Benefits (EOB) shows TrOOP costs to date (you don t have to calculate) TrOOP transfers if you switch plans mid-year

21 Part D Monthly Premium and Income-Related Monthly Adjustment (IRMA) IRMA added to Part D premium

22 Medicare Part D Landscape (Nationwide)

23 Formularies & Tiers Change Formulary: A list of prescription drugs covered by the plan Tier: May have tiers that cost different amounts Tier Structure Example Tier You Pay Prescription Drugs Covered 1 Lowest copayment Most generics 2 Medium copayment Preferred, brand name 3 High copayment Non-preferred, brand name Specialty Highest copayment or coinsurance Unique, very high cost

24 Formulary Changes Plans may only change categories and classes at beginning of each plan year o A drug may be classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition May make maintenance changes during year Such as replacing brand-name drug with new generic Plan usually must notify you 60 days before changes You may be able to use drug until end of calendar year May ask for exception if other drugs don t work Plans may remove drugs withdrawn from market without 60-day notification

25 Preferred Pharmacies Over 70% of stand alone Part D plans offer preferred pharmacy (lower) cost sharing Must use a subset of pharmacies in a plan s network to get lower costs There is a concern that all beneficiaries may not have meaningful or convenient access to preferred pharmacies CMS is studying beneficiary access to preferred cost sharing Based on the results, CMS may set standards for network adequacy

26 Strategy to Combat Prescription Fraud and Abuse Key provisions in the 2015 final rule policy for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP) Requires prescribers of Part D Drugs to enroll in Medicare Permit revocation of Medicare enrollment for abusive prescribing practices and patterns Allow Part D sponsors ability to request/collect information directly from pharmacy benefit managers Require MA Plans and Part D sponsors to report and return identified Medicare overpayments

27 Medicare Part D

28 Low Performing Plans CMS had planned to terminate consistently lowperforming plans (LPPs) effective December 31, 2014 If plan receives Part C or Part D summary score of less than 3 stars for three consecutive years This had been pushed back until December 2015 LPPs shown with icon on Medicare Plan Finder

29 Medicare Advantage (MA) Plans (Such as HMO or PPO) MA Plans choose their provider networks and may make network changes at any time If making changes, MA Plans must continue to Provide all Medicare-covered services Meet access, availability and timely notice standards Ensure continuity of care for enrollees Recent significant mid-year changes caused problems for beneficiaries and prompted CMS to reexamine current guidance

30 Medicare Advantage Changes Beginning in 2015 Plans must notify CMS at least 90-days prior to significant provider network changes for no cause Affected enrollees may be eligible for an SEP Notice to beneficiaries Plans must provide enrollees at least 30 days advance notice of significant network changes New language in ANOC/EOC will explain enrollee rights related to mid-year provider network changes

31 Quality of Service

32 What Is Extra Help? Program to help people pay for Medicare prescription drug costs Also called the Low-Income Subsidy For people with limited income and resources Resources: savings, investments & real estate Married & living together = $26,860 Single = $13,440 Excludes home, vehicles, personal property, life insurance, burial No coverage gap or late enrollment penalty if you qualify Continuous Special Enrollment Period Income levels are based upon Federal Poverty Level (FPL) 2015 FPL not released as of this date

33 Qualifying for Extra Help You automatically qualify for Extra Help if you get Full Medicaid coverage Supplemental Security Income (SSI) Medicare Savings Program o Help from Medicaid paying your Part B premium, etc. All others must apply Online at socialsecurity.gov Call Social Security (SSA) at (TTY ) o Ask for Application for Help With Medicare Prescription Drug Plan Costs (SSA-1020) Contact your state Medicaid agency

34 Extra Help Income and Resource Limits 2015 FPL not released as of this date; 2015 Part D amounts are updated

35 Appendix A: Standard Drug Benefit Benefit Parameters Deductible $310 $320 Initial Coverage Limit $2,850 $2,960 Out of Pocket (OOP) Threshold $4,550 $4,700 Total Covered Drug Spending at OOP Threshold $6, $7, Minimum Cost-Sharing in Catastrophic Coverage $2.55/$6.35 $2.65/$6.60 Extra Help Copayments Institutionalized $0 $0 Receiving Home and Community-Based Services $0 $0 Up to or at 100% Federal Poverty Level (FPL) $1.20/$3.60 $1.20/$3.60 Full Extra Help up to 135% FPL $2.55/$6.35 $2.60/$6.60 Partial Extra Help (Deductible/Cost-Sharing) $63/15% $66/15%

36 Appendix B: 2015 Medicare Drug Plan Costs If You Automatically Qualify for Extra Help If you have Medicare and Your monthly premium Your yearly deductible Your cost per prescription at the pharmacy (until $4,550) Your cost per prescription at the pharmacy (after $4,550*) Full Medicaid coverage for each full month you live in an institution, like a nursing home $0 $0 $0 $0 Full Medicaid coverage and have a yearly income at or below 100% FPL Full Medicaid coverage and have a yearly income above 100% FPL Help from Medicaid paying your Medicare Part B premiums (Medicare Savings Program Participant, QMB-only, SLMB only or QI) $0 $0 Up to $1.20 Generic/preferred drugs: $3.60 Brand-name drugs: $0 $0 Up to $2.60 Generic/preferred drugs: $6.60 Brand-name drugs: $0 $0 Up to $2.60 Generic/preferred drugs: $6.60 Brand-name drugs: $0 $0 $0 Supplemental Security Income $0 $0 Up to $2.60 Generic/preferred drugs: $6.60 Brand-name drugs: $0 Note: There are plans you can join and pay no premium. There are other plans where you will have to pay part of the premium even when you automatically qualify for Extra Help. Tell you plan you qualify for Extra Help and ask how much you will pay for your monthly premium. Your cost per prescription generally decreases once the amount you pay and Medicare pays as the Extra Help reach $4.700 per year. The cost sharing, income levels, and resources listed are for 2014 and can increase each year. Income levels are higher if you live in Alaska or Hawaii, or you or your spouse pays at least half of the living expenses of dependent family members who live with you, or you work.

37 Appendix C: 2015 Medicare Drug Plan Costs If You Apply and Qualify for Extra Help If you have Medicare with a yearly income and resources of Single Income below $15, Resources up to $8,660 Married Income below $21, Resources up to $13,750 Your monthly premium Your yearly deductible Your cost per prescription at the pharmacy (until $4,700) $0 $0 Up to $2.60 Generic/preferred $6.60 Brand-name drugs Your cost per prescription at the pharmacy (after $4,700*) $0 Single Income below $15, Resources between $8,660 $13,440 Single Income: (135%-140% FPL) $15, $16,338 Resources up to $13,440 Married Income below $21, Resources between $13,750 $26,860 Married Income: (135%-140% FPL) $21, $22,022 Resources up to $26,860 $0 $66 up to 15% of the cost of each prescription 25% $66 up to 15% of the cost of each prescription Up to $2.60 Generic/preferred $6.60 Brand-name drugs: Up to $2.60 Generic/preferred $6.60 Brand-name drugs: Single Income: (140%-145% FPL) $16,338 $16, Resources up to $13,440 Married Income: (140%-145% FPL) $22,022 $22, Resources up to $26,860 50% $66 up to 15% of the cost of each prescription Up to $2.60 Generic/preferred $6.60 Brand-name drugs: Single Income: (145%-150% FPL) $16, $17,505 Resources up to $13,440 Married Income: (145%-150% FPL) $22, $23,595 Resources up to $26,860 75% $66 up to 15% of the cost of each prescription Up to $2.60 Generic/preferred $6.60 Brand-name drugs: