SHARP Changes for 2014

Transcription

1 SHARP Changes for 2014 Lisa Turpen RN Assistant Administrator/SHARP Manager 1 IRS status of the SHARP plan In 2013 the IRS made changes relating to group health plans and the SHARP plan is no longer considered a retirement only plan. The impact of this change is found in two areas for SHARP The ACA (Affordable Care Act) HIPAA (Health Insurance Portability and Accountability) The non-medicare eligible dependents are the group impacted by these Acts. 2 Changes for the Medicare eligible retiree The ACA (Affordable Card Act 2010) has added some benefits for the Medicare eligible retiree. Medicare eligible retirees enrolled in the SHARP Base or MCx Options are impacted in the following way. Preventive Care Services list: Medicare and SHARP payment equals 100% for these covered services Physical Exam every year Blood Cholesterol test every year Complete Blood Count every year Fecal Occult Blood test every year Flexible Sigmoidoscopy every 3 years Prostate Specific Antigen (PSA) every year Routine Colonoscopy every 10 years Thyroid Function test every year 3 1

2 Preventive Care (continued) Urinalysis every year Fasting Blood Glucose Test every 3 years Abdominal Aortic Aneurysm screening 1 between 65 and 75 years of age Routine GYN Exam, Pap Smear Mammogram Bone Density testing every 2 years beginning at age 65 The complete list will be noted in the 2014 SHARP document. You may also review the preventive care list for Medicare at 4 HIPAA Portability Rules The HIPAA (Health Insurance Portability And Accountability- 1996) group health plan portability rules have now brought a few changes to the SHARP benefits. No lifetime limit on essential health benefits SHARP removed lifetime limits to benefits in 2011 No pre-existing clause (Pre-Medicare/Non-Medicare)if member has not had lapse in healthcare coverage of more than 63 days. Medicare eligible retiree/spouse have not had the pre-existing clause ever applied No limit on medical necessary genetic testing (as defined by the ACA) SHARP has included this in the plan since 2013 Mental Health Parity Coverage of services that are part of a clinical trial External Appeal Process Healthcare claim processing now includes a third party appeal 5 Dependent Eligibility change SHARP must comply with a portion of the Affordable Care Act(ACA) effective January 1, The dependent child age may enroll in SHARP. The SHARP committee has a vote on the 2014 costs Nov. 21, No lifetime limits on essential medical benefits. SHARP must also comply with ACA rules for the spouse of a retiree. The Non-Joint & Survivor spouse (married after retirement) may enroll in SHARP benefits. Spouse employer benefits are required to be primary The Earned Credit Does Not apply to the Non-Joint & Survivor spouse enrollment. 6 2

3 SHARP Rx Option SHARP Drug Spend 2012 In 2012 the SHARP Rx Option had a drug spend of $17,611,529 SHARP accessed additional federal retiree drug subsidies of $3.6 million to help offset the total drug spend. Total drug spend of a little over $13 million 93% of enrollees utilize the Rx benefit There was a 3.4% increase in the Specialty Drug classification in Drugs for high cost disease processes In 2012 for the SHARP Rx Option the generic fill rate was 78.9%. The home delivery utilization was 82.2%. The formulary compliance rate was 96.5% 8 Plan change for 2014 The Adventist Retirement Board has approved a change in the SHARP Rx Option for the Medicare eligible retiree and/or spouse. The SHARP Rx Option enrolled retiree/spouse will be moved to a new prescription drug program effective This is not an open enrollment to join the SHARP Rx Option. 9 3

4 Plan Change for 2014 Effective the SHARP Rx Option will become a two part benefit. 1. Express Scripts Medicare (PDP): all age 65 members Required enrollment in Medicare Part A and Part B 2. Express Scripts: Pre-Medicare/Non-Medicare member and age 65 new retiree/spouse while awaiting approval for enrollment in Express Scripts Medicare (PDP). 10 Express Scripts Medicare (PDP) + Wrapa Medicare D plan All age 65 retirees/spouses will be required to have Medicare Part A and Medicare Part B to participate in the SHARP Rx Option. The retiree/spouse currently enrolled in the SHARP Rx Option does not need to complete a new enrollment form for SHARP will automatically move you to the new plan. The retiree will not enroll in Medicare D on their own. The retiree will not pay a base Medicare D premium to Social Security. SHARP pays the base Medicare D premium for the approved member The retiree will pay CMS (Centers for Medicare and Medicaid Services) any High Income penalty Tax return of single $85,000/year or family $170,000/year 11 New Retiree Enrollment At retirement the retiree/spouse will decide whether or not to enroll in the SHARP Rx Option. The retiree/spouse must be enrolled in Medicare Part A and Medicare Part B. Retiree/spouse Do Not enroll in Medicare Part D If the retiree opts to enroll in SHARP Rx he/she will be automatically enrolled in the Express Scripts Medicare D program by completing the SHARP enrollment form. 12 4

5 What is Medicare D with a Wrap? The core of the new program is the CMS (Centers for Medicare and Medicaid Services) approved Medicare D drugs. In addition SHARP has provided a Wrap formulary. The wrap consists of drugs which are found on the national formulary that SHARP currently uses but which are not on the Medicare D formulary. The wrap drugs do not apply to the Medicare D coverage stages There will be three levels of benefit: Generic drugs Brand drugs Non-preferred/non-formulary drugs As with all prescription drug formularies there may be some drugs which are not covered. FDA rules do apply. 13 Express Scripts Medicare (PDP) How does it works? Initial Coverage Stage: You will pay the copayment until your total yearly Medicare D drug costs (what you and the plan pay) reach $2850. Coverage Gap Stage: You will continue to pay the copayment until your yearly out-of-pocket Medicare D drug costs (what you and the 50% manufacturer payment) reach $4550. Catastrophic Coverage Stage: After the $4550 limit is reached for Medicare D drugs you will pay the greater of 5% coinsurance or: A $2.55 copayment for covered generic drugs A $6.35 copayment for all other drugs 14 What is the Coverage Gap Yearly Out-of- Pocket limit? Brand drugs in the Coverage Gap of a Medicare D program include a manufacturer discount of 50%. The amount the retiree/spouse pays in copayment and the amount discounted by the manufacturer count toward your true out-of-pocket costs in the Coverage Gap. ($2850 -$4550) SHARP pays the remainder. SHARP s payment does not count toward the retiree/spouse yearly out-of-pocket limit. Generic drugs in the Coverage Gap of a Medicare D program include a retiree/spouse copay. SHARP pays the remaining price of the drug. The amount SHARP pays for generic drugs in the Coverage Gap does not count toward the retiree/spouse yearly out-of-pocket limit. ($2850 -$4550) 15 5

6 Cost Containment Rules CMS (Center for Medicare and Medicaid Service) stipulates all cost containment rules that apply under the Express Scripts Medicare (PDP) program. Prior Authorization Step Therapy Quantity limits Participating Retail Pharmacies Medication Therapy Management must be offered to the member but participation is not required. In 2014 the Retail Refill Allowance rule is removed. CMS requires that a member be allowed up to fill a prescription to a 90 day supply at retail. Walgreens will be a participating pharmacy in SHARP RX Three Tier copay Retail : 30, 60 & 90 day supply $12 generic $24 brand $40 non-preferred/nonformulary 60 day supply is 2 times the above noted copay 90 day supply is 3 times the above noted copay Mail order: 90 day supply $29 generic $58 brand $90 non-preferred/nonformulary 17 Upcoming Mailings in 2013 Express Scripts mailing to participating retirees/spouses. The Pre-notification letter was mailed Retiree/spouse have 21 days to respond if they wish to opt out. CMS requires the opt out opportunity. SHARP will not offer any other type of prescription option. If the retiree opts out they will need to find prescription drug coverage on the open market. SHARP will not assist with open market premiums the retiree may incur. December of 2013 each SHARP Rx Option participating retiree/spouse will receive the Welcome Kit from Express Scripts. The kit will include the evidence of coverage letter, program formulary, drug list and ID cards. 18 6

7 Yearly Rx Option Notice The Express Scripts Medicare (PDP) currently enrolled retiree/spouse will receive an opt out notice yearly (annual notice of change/anoc). The member is not required to make a change The member who wants to continue in the SHARP Rx Option is not required to sign anything. If the retiree/spouse opts out of Express Scripts Medicare (PDP) there will be no other prescription drug plan offered by SHARP. 19 Express Scripts Pre-Medicare/Non-Medicare The Pre-Medicare/Non-Medicare eligible retiree, spouse or eligible dependent child who enrolls in the SHARP Rx Option will remain on the current national formulary. The cost containment rules in place will continue to apply. The new Three Tier Copay will apply (see slide 17) The Retail Refill Allowance rule is removed effective Up to a 90 day supply may be purchased as retail. Walgreens will be a participating pharmacy in New SHARP ID Cards 2014 The retiree/spouse will now have three ID cards for healthcare. Medicare Part A and Part B card (primary medical benefits) or Pre-Medicare/Non-Medicare the Blue Cross card SHARP ID card (if covered by the SHARP Base, MCx or DVH Options) Express Scripts card (if covered by the SHARP Rx Option) Each member will have their own card. The SHARP ID card will have: NAD logo and Supplemental Healthcare Adventist Retirement Plan Adventist Risk Management, Inc. The Express Scripts ID card will have the Express Scripts and NAD logo and prescription information only. 21 7

8 SHARP Customer Service SHARP (Eligibility) Main Phone Number: Monday Thursday 8 a.m. 5 p.m. Eastern Time SHARP@nad.adventist.org Express Scripts Medicare Customer Service: (opens ) ARM/SHARP Claims and Benefits Customer Service: