What s New with Medicare in 2015

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1 November 2014 What s New with Medicare in 2015 Audio Portion: Web Portion: Code:

2 What we ll cover today 2015 Medicare cost sharing Part D in 2015 What s the big deal about AEP? Low-income Subsidy (LIS)/Extra Help program 3 R s- Redeem, Redetermination, and Reassignment Limited Income Newly Eligible Transition Program (LINET) Best Available Evidence Important dates and mailings to track Medicare Advantage in 2015 Quality and Star Ratings NEW Case-by-case MA network Special Enrollment Period (SEP) 2

3 Part A Hospital Insurance Costs 2015 Beneficiary pays 2014 Beneficiary pays Hospital Deductible $1,260/benefit period $1,216/benefit period Hospital Copayment Skilled Nursing Facility Copayment Part A Premiums (if any) $315/day for days $304/day for days $630/day for days $608/day for days $157.50/day for days $152/day for days $407/month for those with fewer than 30 quarters of Medicarecovered employment $224/month for those with quarters of Medicare-covered employment $426 $234 3

4 Part B Medical Insurance Costs 2015 Beneficiary pays 2014 Beneficiary pays Annual Deductible $147 $147 Part B Premium for those with incomes below $85,000 if single, $170,000 if married Most Part B covered services, including doctors visits, outpatient therapy, durable medical equipment, and outpatient mental health services: $104.90/month 20% of amount Medicare approves $104.90/month 20% of amount Medicare approves NCOA s 2015 Part A & B costs chart (English only) 4

5 2015 Costs in Multiple Languages! LINK CMS 2015 Part A & B costs translated 5

6 Part D 6

7 Part D Monthly Premium IRMAA Income-related Monthly Adjustment Amount (IRMAA) Based on income above a certain limit Fewer than 5 percent pay a higher premium Uses same thresholds used to compute IRMAA for the Part B premium Income as reported on your IRS tax return from 2 years ago Required to pay if you have Part D coverage Withheld from SSA or RRB benefits check Failure to pay may result in disenrollment 7

8 2015 IRMAA If Your Yearly Income in 2013 was In 2015 You Pay File Individual Tax File Joint Tax Return Return $85,000 or less $170,000 or less Your Plan Premium (YPP) $85, $107,000 $170, $214,000 YPP + $12.30* $107, $160,000 $214, $320,000 YPP + $31.80* $160, $214,000 $320, $428,000 YPP + $51.30* Above $214,000 Above $428,000 YPP + $70.80* *per month IRMAA is adjusted each year, as it is calculated from the annual beneficiary base premium. 8

9 2014/2015 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% 9

10 2015 Part D Landscape Fewer PDPs but still an average of 30 PDP choices 70 new PDPs 168 Consolidations: ex. Cinga-HealthSpring result of Cigna purchasing HealthSpring PDP and rebranding their plans 238 PDPs exited: ex. Anthem Wellpoint (Medicare Rx Rewards), HealthMarkets, AmeriHealth, Emblem Health Of 10 PDPs with highest enrollments 6 will increase premiums by $10 or more 3 will decrease premiums by $10 or more Source: Kaiser Family Foundation Medicare Part D: A First Look at Plan Offerings 10

11 11

12 2015 Part D Landscape 87% of PDPs have Preferred Pharmacy networks Most PDPs will use 5 tier formulary More PDPs change brand-name drug cost sharing from copayments to co-insurance Slight increase utilization management like prior authorization and quantity limits* Fewer LIS $0 premium benchmark plans than in 2014 Sources: Kaiser Family Foundation Medicare Part D: A First Look at Plan Offerings *Avalere Part D Formulary Data Reveals Continued Cost Shift to Coinsurance by plans 12

13 13

14 Improved Coverage in the Coverage Gap Year What You Pay for Covered Brand-Name Drugs in the Coverage Gap What You Pay for Covered Generic Drugs in the Coverage Gap % 72% % 65% % 58% % 51% % 44% % 37% % 25% 14

15 2015 Medicare Part D Coverage Gap/Doughnut Hole 15

16 2015 Gap Discount Ingredients Brand Name Percentage Counts to TrOOP? Generic Drug Percentage Counts to TrOOP? Manufacturer discount 50% Yes NA NA Plan pays 5% No 35% No Beneficiary pays 45% Yes 65% Yes Learn more: NCOA Coverage Gap Tip Sheet 16

17 True Out-of-Pocket (TrOOP) Costs Expenses that count toward your out of pocket threshold ($4,700 in 2015) After threshold you get catastrophic coverage You pay only small copayment or coinsurance for covered drugs Plan Explanation of Benefits (EOB) shows TrOOP costs to date TrOOP transfers if you switch plans mid-year 17

18 What Payments Count Toward TrOOP? Payments That Count Payments made by you, your family members, or friends Qualified State Pharmacy Assistance Programs Medicare s Extra Help Most charities (not if established or run by employer/union) Indian Health Service AIDS Drug Assistance Programs The discount you get on covered brand-name drugs in the coverage gap Payments That Don t Count Your monthly plan premium Share of the drug cost paid by your Medicare drug plan Group Health Plans (including employer/union retiree coverage) Government-funded programs (including Medicaid, TRICARE, VA) Patient Assistance Programs Other third-party payment arrangements Other types of insurance The discount you get on covered generic drugs in the coverage gap 18

19 AEP/OEP Choices Part C & D Plans Shop and compare plans Enroll or disenroll Switch to another plan Medicare Supplemental Policy (Medigap) Can apply to change any time during the year, not limited to AEP/OEP Outside Medigap Open Enrollment and Guarantee Issue may be subject to medical underwriting and therefore charged more or denied a policy 19

20 Preferred Pharmacy 20

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24 Lower Drug Costs 24

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26 Extra Help 26

27 Three R s of Extra Help NCOA Redeeming, Redetermination and Reassignment Tip Sheet 27

28 LIS Redeeming and Redetermination Redeeming for LIS List from State Medicaid covered Jul.-Dec. all on the list are redeemed for LIS the following year No notice from CMS Redetermination 1. Initial- applied and awarded between May-Apr. with a reported or suspected change in circumstance receive a form in Aug./Sept. 2. Cyclical- random sample receive a form in Aug./Sept. 3. Subsidy Changing- marriage, divorce, separation, annulment, or death of spouse 28

29 LIS Plan Reassignment Newly Eligible Full Extra Help/LIS are autoenrolled in low-income benchmark plans with $0 premium Reassignment when a plan is no longer a benchmark plan Receive blue notification letter in Oct./Nov. and again mid-dec. Choosers are not reassigned but receive tan letter about premium due 29

30 CMS and SSA mailings- CMS version CMS s Guide to CMS, SSA & Plan 2014/

31 CMS and SSA mailings- NCOA version NCOA s Guide to Mailings and Key Events in 2015 Page 3 contains a one page color coded chart with links to model notices (Spanish too) Detailed explanation of the mailer and actions the beneficiaries need to take 31

32 LINET Limited Income Newly Eligible Transition For those with no Part D and Awarded Extra Help Administered by Humana Stay in up to 6 months $0 premium Enroll at pharmacy with Best Available Evidence 32

33 Best Available Evidence (BAE) Don t have BAE? Then call the plan. Required Proof varies based on location Long-term Care Facility Home and Community Based Services Medicaid Recipient Including MSP and SSI deemed for Extra Help Applied and Awarded for Extra Help (LINET folks) Award letter, notice of change, notice of planned action 33

34 BAE Timing hours to correct subsidy status Plan will override cost-sharing Need an override per prescription If CMS system does not update in days, plan submits a correction request to CMS Regional Office 34

35 Medicare Advantage (MA) 35

36 2015 Medicare Advantage (MA) Landscape Medicare Advantage (MA) average premium submitted by health plans for 2015 was $33.90 (up $2.94 from 2014) CMS estimates the actual MA average premium will increase by only $1.30 as more people enroll in lower cost plans 61 percent of people with Medicare will not have a premium increase More MA plans will offer supplemental benefits (like dental and vision) 36 36

37 ACA and MA Payments to private Medicare Advantage (MA) Plans tied to plans quality of coverage More high-quality plans were available in 2015 than in 2014 More beneficiaries enrolled in higher quality plans MA Plans MA contracts with 4 or more stars 38% Around 40% MA enrollees in plans with 4 or more stars 52% Around 60% 37

38 MA Quality Approximately 60% of MA Enrollees are in 4 or 5 star plans 11 MA-PD and 2 MA only contracts have 5 star ratings Fewer low-performing plans Average star rating is higher 3.86 in 2014 to 3.92 in 2015 Source: Avalere CMS Report Shows Medicare Advantage Plan Performance and Quality Continue to Improve 38 38

39 5-Star Special Enrollment Period (SEP) Use Medicare Plan Finder tool at medicare.gov to see quality and performance ratings Star ratings given once a year, assigned in October of the past year Use 5-star SEP to switch to any 5-star plan one time December 8 - November 30 of following year Coverage starts first day of month after enrolled Be careful not to switch from Part D coverage to no Part D 39

40 Low-performer (LP) Termination CMS delayed termination of consistently low-performing plans (LPPs) until effective December 31, 2015 If plan receives Part C or Part D summary score of less than 3 stars for three consecutive years Plans will be identified when plan ratings data is released in early October 2015 LPPs currently have icon on Medicare Plan Finder Affected beneficiaries will have an opportunity to join a new plan 40

41 Consistent Poor Performer Notices CMA mails twice: late Oct/early Nov. and Feb. Directs beneficiaries to call Medicare and SHIP Sample notice available CMS NMTP Monthly Webinar Archive 11/4/14 materials 41

42 LP Special Enrollment Period (SEP) SEP for those in LP Plans One-time change after Jan. 1 Must enroll in a plan with 3 stars or more Call Medicare to change Prospective = no retroactive changes Can move to Original Medicare and enroll in Part D 42

43 MA Provider Network Changes MA Plans choose their provider networks and may make network changes at any time Must notify CMS at least 90 days prior to significant provider network changes for no cause Must notify beneficiaries at least 30 days prior to termination who see affected providers 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 43

44 MA Plan Network Change SEP Recent significant mid-year changes caused problems for beneficiaries and prompted CMS to reexamine current guidance Effective 1/1/2015, a Special Enrollment Period for significant mid-year network changes. CMS will make SEP decisions case-by-case. CMS will provide guidance in two weeks Specific criteria to qualify. CMS will post the beneficiary proof items required on CMS website. NCOA s Summary of 2015 Part C & D Final Rule 44

45 Articles of Interest How are Seniors Choosing and Changing Health Insurance Plans? Findings from Focus Groups with Medicare Beneficiaries; Kaiser Family Foundation, May To Switch or Not to Switch: Are Medicare Beneficiaries Switching Drug Plans To Save Money?; Kaiser Family Foundation, Oct. 13, 2013 From 2006 to 2010, average of 13% of Part D enrollees voluntarily switched plans and 46% of them reduced their premium by at least 5% compared to 8% that did not switch Seniors Opinions About Medicare Prescription Drug Coverage; survey conducted for Medicare Today by KRC Research, September 2013 Only 10 percent of respondents beneficiaries with stand-alone or Medicare Advantage prescription drug coverage (N=901) have ever gone to the Medicare Plan Finder for information to help in comparing Medicare health or prescription drug plans. Only 11 percent of respondents ever contacted their state health insurance assistance program. 63 percent of respondents did not know that there are Medicare counselors in their state who can be called or visited to get help in comparing Medicare plans. 45

46 Articles of Interest The Vast Majority of Medicare Part D Beneficiaries Still Don t Choose the Cheapest Plans That Meet Their Medication Needs; Chao Zhou and Yuting Zhang; Health Affairs, October 2012 Only 5.2 percent of the beneficiaries in the study sample chose the least expensive plan available in their region and avoided overspending in The mean overspending was $368, and the median was $331. Approximately 22 percent of beneficiaries could save at least $500 a year by switching to the cheapest plan available, given their current drug portfolios. A key policy concern about the Part D program design is whether beneficiaries generally choose the least expensive plan that satisfies their medication needs, given the large number of plan options What s Behind the Door: Consumers Difficulties Selecting Health Plans; Lynn Quincy; Consumers Union, January 2012 Trusted data must be presented in a way that is usable for consumers. When consumers are faced with a cognitively difficult task, they look for short-cuts to help them get through the task. 46

47 Contact Us Melissa Simpson: Visit us online at: Locate a SHIP for local Medicare help 47

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