Medicare Open Enrollment Period
October 19, 2016
© AgeOptions 2016. All rights reserved.
Who We Are: MMW Leadership
• AgeOptions
–Area Agency on Aging (AAA) for suburban
Cook County
• Health & Disability Advocates
–Policy and advocacy organization
• Progress Center for Independent Living
–Cross-disability, non-residential – suburban Cook
County
2
What We Do
• Gather and create practical, accessible information
and materials
• Educate Medicare consumers, service providers and
policymakers
• Problem solving – individual and systemic
• Provide training and technical support for
professionals and volunteers
• Advocate for consumer focused laws and policies
• Target underserved groups
• To join the MMW email list, visit
http://www.ageoptions.org/services-andprograms_makemedicarework.html
3
MMW work is supported by grants
from local and regional foundations:
Michael
Reese
Health Trust
Retirement
Research
Foundation
Chicago
Community
Trust
4
Medicare Annual Enrollment Period
• The Annual Enrollment Period (AEP) takes place October
15 to December 7 of each year
– Can make any Medicare Part D plan changes at this time (enroll,
disenroll or switch plans)
– Includes stand alone PDP’s and Medicare Advantage plans
• Part D plans are effective January 1st
• Beneficiaries should have received an Annual Notice of
Change (ANOC) from their Part D plans by October 1st that
lists premium, plan and formulary changes for 2017
5
2017 Medicare Part D Plans
• 2017 Medicare Part D plan information (standalone and Medicare Advantage plans) is
available through the Medicare Plan Finder at
www.Medicare.gov
• 2017 Medicare Part D landscapes are available
at https://www.cms.gov/Medicare/PrescriptionDrugCoverage/PrescriptionDrugCovGenIn/index.html
Part D Costs in 2017
Monthly premium (continue paying all year)
Varies by plan
Yearly deductible (if applicable)
$0 - $400
Initial Coverage Limit (ICL)
• The beneficiary pays a co-pay or co-insurance for
each prescription and the Part D plan pays the rest
Until $3,700
(count what the beneficiary and the plan
pays for formulary drugs)
Donut hole (Coverage Gap)
• During the donut hole a beneficiary receives
discounts on the full price of generic and brand
name formulary drugs
•60% discount on brand name drugs
•49% discount on generics
•
True Out-of-Pocket Threshold (TrOOP)
• TrOOP is the amount the beneficiary has paid for
formulary drugs out of pocket
• Note that TrOOP may include costs paid not only
by the beneficiary, but also manufacturer
discounts, a charity program, or the Extra Help
program
$4,950 = TrOOP
• Once TrOOP is met, the beneficiary
enters Catastrophic Coverage and
pays less for formulary drugs for the
remainder of the calendar year
• Beneficiaries in catastrophic coverage
pay no more than 5% or $3.30/$8.25 for
generics/brand names – whichever
amount is greater
•
Begins once the beneficiary’s covered
drug expenses reach $3,700 ( the
ICL)
The donut hole continues until a
beneficiary meets TrOOP
7
Donut Hole Discounts
• In 2017, people who enter the Part D donut hole will receive
• 60% discount on brand name drugs (50% from the manufacturer and
10% government subsidy)
• 49% discount on generics - entire discount provided to the plan by a
government subsidy
• The 50% manufacturer discount counts towards TrOOP but subsidies
provided by the government do not
• Discounts increase over the next couple of years until 2020 when the donut
hole will be closed
A snapshot of Donut Hole discounts through 2020
Discounts a beneficiary receives in the Donut Hole for formulary
drugs
2016
2017
2018
2019
2020
Brand Name
Drugs
55%
60%
65%
70%
75%
Generic Drugs
42%
49%
56%
63%
75%
Donut Hole – What Counts?
•
To get to the donut hole (begins at $3,700), count the
total cost of the drug – the beneficiary’s co-pay and what
the plan pays
•
To get out of it ($4,950), count what’s paid by:
–
–
–
–
–
•
You, family member or other person for you (your co-pay)
50% manufacturers’ discounts on brand name drugs
Medicare’s Extra Help program (through Social Security)
A charity program
If you find a cheaper price than your plan pays (like a
store discount card), you may send the receipt to your
plan and it will count. Not out of country.
These are called your True Out-of-Pocket (TrOOP) costs
–
Explanation of Benefits (EOB) shows TrOOP costs to date
Donut Hole – What Does NOT Count
• Premiums
• Any payment for a drug that is not on the plan’s
formulary
• Any amounts paid by employer or retiree plan
• Government subsidies given to the plans during
the donut hole
– 49% generic discount and 10% brand name discount
• Drugs purchased outside the U.S.
10
Part D Income Related Monthly
Adjustment Amount (IRMAA)
• Medicare beneficiaries with annual incomes greater than $85,000
($170,000 if married and filing a joint tax return) are required to pay an
extra IRMAA amount each month in addition to their Part D plan premium
• Created in 2010 as a provision of the Affordable Care Act
• Affects less than 5% of Medicare beneficiaries
• The same beneficiaries usually also pay a Part B IRMAA
• SSA notifies beneficiaries who are required to pay an IRMAA amount
• The IRMAA amount is paid to the federal government and not to the Part D
plan
o Deducted from a beneficiary’s Social Security check or billed directly if
the beneficiary is not yet receiving benefits
• Beneficiaries must pay the IRMAA amount or they may be disenrolled from
their Part D plan
2017 Part D IRMAA Amounts
2017 Medicare Part D Income-Related Monthly Adjustment
(IRMAA)
Based on 2015 Income
Beneficiaries who file Beneficiaries who
IRMAA amounts (in
an individual tax
are married and filing addition to the Part D
return
a joint tax return
plan monthly
premium)
$85,000 or less
$170,000 or less
$0
$85,001 – $107,000
$170,001 - $214,000
$13.30
$107,001 - $160,000
$214,001 - $320,000
$34.20
$160,001 – $214,000
$320,001 - $428,000
$55.20
Greater than
$214,000
Greater than
$428,000
$76.20
Part D Late Enrollment Penalty
• Late enrollment penalty if a beneficiary does not
enroll in Part D when first eligible
• If they join later, they pay:
– 1% extra premium each month they were eligible but
did not enroll in a plan (based on the national Part D
base premium which is $35.63 ion 2017)
• Must pay this penalty for as long as they are
enrolled in a Part D plan
• The penalty is waived if a beneficiary is eligible
for Extra Help or has other credible prescription
drug coverage
2017 Stand Alone Part D Plans
in Illinois
• Stand-alone prescription drug plans (PDPs) cover only prescription
drugs
• 21 PDPs available in Illinois (does not include plans under sanction)
• Monthly premiums range from $17.00 - $163.70
• Some plans have a deductible – up to $400
– Plans may cover some drugs that do not apply to the deductible
• 8 $0 deductible plans
• 8 plans offer $0 premiums to beneficiaries with full Extra Help
• 5 plans offer “additional coverage in the gap”
• Co-payment of co-insurance for drugs depend on which “tier” a drug is
on
– Some plans offer tier 1 drugs for $0 or $1
Basic Plans
• 10 basic plans offered in 2017
• Standard Part D benefit structure that is actuarially
equivalent
– Plans can vary the deductible and cost sharing
amounts as long as the benefit remains actuarially
equivalent
• Basic plans are not allowed to offer coverage in
the gap
• Extra Help will help eligible beneficiaries pay the
monthly premium for a Part D plan that is basic
and up to the Extra Help benchmark
– 2017 Extra Help benchmark in Illinois is $28.68
Enhanced Plans
• 11 Enhanced PDPs offered in Illinois in 2017
• Offer a wide range of benefits that may include
–
–
–
–
No deductible
Coverage in the donut hole
Broader list of covered formulary drugs
May also cover drugs that are excluded from Medicare drug coverage
by law (these drugs will not count towards TrOOP)
• Often charge higher premiums and higher cost sharing amounts
than Basic plans
• Monthly premiums are comprised of Basic premium ad an
enhanced benefit portion
• The Extra Help program (also known as Low-Income Subsidy or
LIS) will not pay for the enhanced portion of the benefit even if the
total drug premium is under the benchmark
Medicare Advantage (MA) Plans in 2017
• Managed care plans owned and operated by private companies
• Most MA plans provide health (Part A and Part B) and prescription
(Part D) coverage under one plan
• Medicare Advantage plans with drug coverage included are called
MA-PD plans (MA-only plans do not include drug coverage)
• Different types of MA plans, each with different rules
– HMOs, PPOs, SNPs and PFFS
• Medicare pays the plan a fixed amount each month to provide Part
A, Part B and Part D services (if drug coverage is included) to the
beneficiary
• A beneficiary may have to use doctors, hospitals and other providers
that work with the plan (called a network) in order for a service to be
covered or to pay less
Types of MA Plans Offered in Illinois
• HMO- Must utilize medical providers or hospitals in the
plan’s network for a service to be covered except in an
emergency. You usually also need a referral from your
primary care doctor to visit a specialist.
• HMO POS- HMO plans that may allow you to receive
certain services out of network or without a referral from
a primary care physician (PCP) for a higher co-payment
or co-insurance
• PPO -You pay less if you use providers or hospitals that
belong to the plan’s network, and more for out of
network providers. Usually do not need a referral to see
a specialist.
MA Plan Definitions (cont.)
• Private Fee-For-Service (PFFS) - You can generally go to any
provider or hospital as long as they agree to treat you and
accept the plan’s terms. Plan determines how much it will pay
providers and hospitals and how much you must pay when you
receive care. Some PFFS plans have a network of providers
that agree to always treat members. Other doctors out of
network may decide to not treat you even if you have seen
them before. Always make sure the provider accepts the plan’s
terms and payment prior to receiving services. Usually do not
need a referral to see a specialist
• Special Needs Plans (SNPs)- Provide focused and
specialized health care for specific groups of people including
those who have both Medicare and Medicaid, living a nursing
home or have certain chronic conditions
2017 MA Plans in Illinois
• 881 MA-PD plans offered. Options include:
–
–
–
–
542 local HMOs
183 local PPOs
102 regional PPOs
54 PFFS plans
• Monthly premiums range from $0 - $179.00
• Annual drug deductibles range from $0 - $400
• Maximum Out-of-Pocket (MOOP) amounts range from $2,250
to $6,700 for in-network Part A and Part B medical expenses
(does not include Part D costs)
• Some plans may have an annual health deductible
– Contact plan for additional information
2017 MA Plans in Cook County
• 23 MA-PD plans offered in Cook County. Options
include:
–
–
–
–
16 local HMOs
5 local PPOs
1 regional PPO
1 PFFS plan
• Monthly premiums range from $0 - $179.00
• Annual drug deductibles from $0 - $400
• MOOP amounts range from $2,900 - $6,700
• Some plans may have an annual health deductible
– Contact plan for additional information
2017 Special Needs Plans in Illinois
(SNPs)
• 32 SNPs offered in Illinois
– 21 dual-eligible plans (different than MMAI plans)
– 8 plans for institutionalized individuals
– 3 plans for individuals with chronic or disabling conditions
• One plan for individuals with End Stage Renal Disease (ESRD) requiring
dialysis
• Two plans for cardiovascular disorders, chronic heart failure and diabetes
• In Cook County in 2017, 5 SNPs are offered
– One plan for institutionalized individuals
– 2 plans for dual-eligibles
– 2 plans for individuals with chronic or disabling conditions
• One plan for individuals with ESRD requiting dialysis
• One plan for individuals with cardiovascular disorders, chronic heart
failure and diabetes
5 star rating SEP
• Medicare beneficiaries receive a special
enrollment period (SEP) to switch to a 5-Star Part
D plan if one is available in their area
– Illinois does not have any 5-star plans offered
in 2017
• Limited to one switch per year
• Plan ratings are listed on Medicare.gov
Low Performing Part D Plans and SEP
• Medicare beneficiaries in Part D plans that receive an overall
rating of less than 3 stars for 3 years in a row will be eligible
for a SEP to enroll into a higher quality plan throughout the
year if they wish
– In plans with ratings of “Below Average” or “Poor”
– Can use SEP to switch to a plan with 3 stars or more
• Low performing plans are identified on the Plan Finder with an
icon
• CMS will mail members in consistent low performing plans a
letter in late October encouraging them to compare their plans
to higher rated plans in their area
• Plan changes can be made during the OEP (October 15 December 7) but they also receive a SEP that can be used
throughout the year to switch to a higher rated plan
– Must call 1-800 Medicare to use SEP
Sanctioned Part D Plans
•
CMS sanctions plans when they fail to properly administer the Part C or
Part D benefit
•
Depending on the situation, CMS may decide to take several actions
including imposing fines, suspending marketing and enrollment into the
plan, or terminating the plan’s contract
•
Currently in Illinois, CMS has placed sanctions on the following company
– Cigna-HealthSpring (includes stand-alone PDP and Medicare Advantage plans)
•
As a result on the sanctions placed on Cigna-HealthSpring, the following
has occurred:
– Not allowed to market plans to potential new enrollees
– Enrollment into plans is suspended
– Plan information is suppressed on the Medicare.gov Plan Finder
•
Current members of Cigna-HealthSpring who experience issues obtaining
their prescription drugs should contact 1-800-Medicare if they are unable to
resolve the issue with the plan and to determine if they are eligible for a
special enrollment period to switch to another Part D plan
•
Current members also have the option of remaining in their plan or making
a change during the annual enrollment period that takes place October 15 –
December 7
Letters, Letters Letters!
• CMS is mailing out different letters to individuals
with Part D and Extra Help notifying them about
how their plan or benefits are changing for 2017
• A chart of the different letters including copies,
when they are being mailed and what action the
beneficiary needs to take may be found at:
https://www.cms.gov/Medicare/Prescription-DrugCoverage/LimitedIncomeandResources/index.html
26
Letters, Letters, Letters –
Extra Help
•
Grey letter – loss of deemed status (mailed in September)
•
Tan letter – “choosers” (mailed in early November)
•
Blue letter (1) – plan reassignment due to premium increase /above
benchmark (mailed in late October)
•
Blue letter (2) – reassignment due to plan termination (mailed in late
October)
•
Blue letter (3) – reassignment due to Medicare Advantage plan leaving
the Medicare program (mailed in late October/early November)
•
Orange letter – change in LIS co-payments (mailed in October)
27
2017 Extra Help/Low-Income Subsidy (LIS)
Cost Sharing Amounts
• Full Extra Help
– $0 annual deductible
– Co-pays either $1.20/$3.70 (generics/brand names)
or $3.30/$8.25 (generics/brand names)
• Partial Extra Help
– Annual deductible between $ 0 - $82
– Co-pays of $3.30/$8.25 (generics/brand names) or
15% coinsurance
• Cost sharing amounts depend on the beneficiary’s
income and subsidy level
• 2017 Extra Help income and asset levels will be
announced in early 2017
Medicaid Spenddown and Extra Help
• People with Medicare who meet their Medicaid
spenddown automatically qualify for Extra
Help/LIS
• How long they receive Extra Help depends on
when they meet their spenddown
– Spenddown met at least once between January 1 and
June 30 = qualify for Extra Help for the remainder of
the calendar year
– Spenddown met at least once between July 1 and
December 31 = qualify for Extra Help for the
remainder of the calendar year and the entire next
year
Best Available Evidence Policy
• Best Available Evidence (BAE) is a CMS policy that
can be used when beneficiaries are eligible for LIS but
their LIS eligibility is not yet reflected on the Part D
plan’s files
• CMS requires the Part D plan to issue LIS members
Part D formulary drugs at correct LIS co-pays when
provided with proof of LIS eligibility
• The BAE policy can only be used when a beneficiary
is already enrolled in a Part D plan
30
Best Available Evidence Policy
• If Extra help status is not reflected in a Part D plan’s files, a beneficiary
can show Best Available Evidence (BAE) of Extra Help eligibility to
receive their prescriptions at the correct Extra Help co-pay amounts
• Part D plan must accept one of the following as proof of BAE:
– A copy of the Medicaid award letter
– Medicaid print out, or copy of a state document with the person’s name on
it showing Medicaid legibility during a month after June of the previous
calendar year
– A signed and dated note from the state Medicaid agency that verifies
Medicaid eligibility
– A print out, screen shot or copy of electronic eligibility data
– An Extra Help/LIS award letter
• CMS policy also requires the plan to help the beneficiary collect the
documentation proof if the beneficiary is unable to submit it
• If the plan will not work to resolve the issue or accept BAE,
contact 1-800-Medicare and specifically request to file a complaint
Limited Income Newly Eligible
Transition (LINET) Program
• Provides temporary drug coverage if a beneficiary has
Extra Help and is not enrolled in a Medicare Part D plan
• CMS contracts with Humana to operate LINET
• Acts as temporary Part D coverage until the beneficiary
is enrolled in a PDP by CMS
• Covers all drugs covered under Part D without any prior
authorization or pharmacy restrictions
• Special LINET number for SHIP counselors –
– (866)934-2019
• For more information visit:
– https://www.humana.com/pharmacy/pharmacists/linet
Part D Transition Policy
• For beneficiaries who are new to a Part D plan and find
out within the first 90 days of enrollment that a Part D
drug is not on the formulary or has drug restrictions
such as step therapy or prior authorization
• Plan is required to provide a temporary one-time 30-day
fill during the first 90 days of coverage
• Once a transition fill is supplied by a plan, the plan
notifies the member that it is only a one-time fill
• Gives the member enough time to request a formulary
exception or find an alternate drug on the formulary that
works as well
Part D Transition Policy
Who does the transition policy apply to?
• People new to a Part D plan for the first time
• People who switch Part D plans (anytime during the year)
• Dual-eligibles who were randomly assigned to a Part D plan
• Newly eligible Medicare beneficiaries who switched from over
coverage such as employer or COBRA coverage
• People who experience a change in level of care
-E.g., people who move from a hospital to a skilled nursing
• People residing in long-term care facilities
-eligible to receive a 31-day transition fill (including multiple 31-day fills during the first 90
days of enrollment)
• In some cases, current enrollees affected by a plan’s formulary
change from year to the next
o If the plan did not work with the beneficiary prior to the new contract year to
find another equivalent formulary drug or complete a formulary exception
before the new coverage year began
Other Medicare Updates
Purchasing Medigap Outside of
the Medigap OEP
• Medicare beneficiaries with disabilities under age 65 who
missed their Medigap OEP, may only purchase select
Medigap plans that offer guaranteed issue during certain
times. These plans include
• BCBS of Illinois from October 15 – December 7
• Health Alliance from October 15 – December 7
• Beneficiaries 65 and older can apply for a Medigap plan at
any time of the year but…
– A company is allowed to deny them coverage of charge them
more higher premiums due to a pre-existing condition
– In Illinois, BCBS and Health Alliance will offer guaranteed issue
policies to people 65 and older any time during the year
Medicare General Enrollment Period
• General Enrollment Period – if you did not enroll in Medicare
Part A and/or Part B when you where first eligible
Part A
• If eligible for premium-free Part A, you can enroll at any time
after your initial enrollment period (do not need to wait for the
general enrollment period) and you don’t have to pay a penalty
– Part A coverage can be retroactive for six months from the date you
sign up
• If not eligible for Part A premium-free, you can use the
General Enrollment Period (Jan 1 – March 31) to apply and
Part A coverage begins July 1 of the same year (must also
enroll or be enrolled in Part B)
– Part A late enrollment penalty applies and your premium may increase
by 10%. You pay this penalty for twice the number of years you were
eligible for Part A but did not enroll
– In Illinois, if you are eligible for QMB, you need to enroll in Part A first
and can only do so during the GEP
Medicare Advantage (MA)
Disenrollment Period
• January 1 through February 14 of each year
• Allows people in Medicare Advantage (MA) plans to
disenroll from their MA plan and return to Original Medicare
Part A and Part B
• Individuals who use this disenrollment period:
– receive a SEP to enroll in a stand-alone PDP
– are not allowed to enroll in or switch to another Medicare
Advantage plan
– do not receive guaranteed issue rights to purchase a Medigap
policy
• People who wish to enroll in or switch Medicare Advantage
plans should make changes during the AEP October 15th December 7th
38
Medicare General Enrollment Period
Part B
• Enroll in Part B from January 1 to March 31 of
each year coverage but Part B coverage will
not begin until July 1st of the same year
• Late enrollment penalties usually apply for
Part B
• 10% of the Part B premium for each full 12
months you were eligible but did not enroll.
The penalty is not capped
For more information and resources,
visit our MMW webpage at:
http://www.ageoptions.org/servicesand-programs_MedicareMaterials.html
Thank You!
Georgia Gerdes
Since 1974, AgeOptions
has established a national
reputation for meeting the
needs, wants and
expectations of older adults
in suburban Cook County.
We are recognized as a
leader in developing and
helping to deliver innovative
community-based
resources and options to
the evolving, diverse
communities we serve.
Healthcare Choices Specialist
AgeOptions
[email protected]
(708)383-0258