Sticky Scenarios: Help Your Clients with Common …...June 2, 2016 Sticky Scenarios: Help Your Clients with Common (But Challenging) Medicare Issues Audio Portion: Use computer or

1

Improving the lives of 10 million older adults by 2020 © 2016 National Council on Aging

June 2, 2016

Sticky Scenarios: Help Your Clients with Common

(But Challenging) Medicare Issues

Audio Portion: Use computer or dial 1-866-740-1260 using your phone

Web Portion: www.ReadyTalk.com Code: 4796976

2


Agenda

Scenario: Federal employee health benefits and Medicare

Scenario: When IRMAA applies Scenario: Returning to the U.S. after living

overseas Scenario: Switching Medigap Scenario: Helping with the donut hole Scenario: Hospital observation status

3


Scenario: FEBHP and/or Medicare?

Gwen is 67 years old and plans to retire in August. She thinks she can keep her Federal Employee Health Benefits Plan but it’s expensive. She heard from a friend that had to pay a penalty for not joining Medicare at the right time. Will she owe a penalty? And, her sister has a plan that replaced Medicare that she really likes that only costs $20 a month. Gwen wants to know what she should do and what choices she has. What do you advise?

4


Special Enrollment Period for EGHP Coverage

Get Medicare Part A & B within 8 months of losing EGHP regardless of employer size

Get Part D coverage within 63 days of losing EGHP Late enrollment penalty can be assessed

• If EGHP has <20 employees (aged) • If EGHP has <100 employees (disabled) • Penalty is 10% of the Part B premium per year

5


Special Enrollment Period for EGHP Coverage

Since Gwen has FEHBP and her employer size is greater than 20, she won’t owe a penalty if she enrolls in Medicare with a start date of Sept. 2016 – May 2017, after August retirement. If she wants Part D coverage, she has a 63 day SEP to join Part D from the date she loses her EGHP, basically within September or October.

6


How To Help Gwen

Potential coverage overview of each choice: Always join Part A? Keep her FEHBP plan with drug coverage Join Medicare B and keep FEHBP (with drug

coverage) as a secondary policy Join Medicare B & D, and buy a Medigap policy Join Medicare A & B and get a replacement plan

(Medicare Advantage Part C)

7


FEHBP or Medicare?

FEHBP additional benefits may include: • Dental or vision offered in some FEHBP

options • Care outside the U.S.

Medicare A & B

• FEHBP outpatient cost-sharing amounts • Covers some DMEPOS and home health that

may not be covered by all FEHBP options

8


FEHBP and Part A Only (not Part B)

Enroll in Part A (even if still working) • FEHBP pays secondary to Part A and covers

deductibles, copays, and coinsurance FEHBP includes drug coverage

• Don’t need Part D Decline Part B

• Owe FEHBP outpatient cost-sharing amounts • Don’t owe Part B premium • Owe late enrollment penalty if enroll in Part B late

9


Medicare A & B Primary with FEHBP

Medicare Part A & B = primary FEHBP = secondary and drug coverage

• FEHBP pays all Medicare A & B deductibles, copays and coinsurance

• Some FEHBPs waive deductibles, copays, and coinsurance

• FEHBP includes drug coverage so don’t have to join Part D

Two premiums = Part B + FEHBP • Can be expensive • Can change FEHBP plans, shop for lower premium

10


Medicare Advantage Part C Plan

Potentially least expensive option for premium • Usage costs (varies by individual and plan)

Rejoin during FEHBP Open Enrollment later • If SUSPEND FEHBP (don’t cancel it because unlikely

to get it back) • No late enrollment penalty because have Part B

Enroll in MA Plan • Must join Part A & B to get MA • Get MA with drug coverage • Check benefits and networks carefully

11


Resources for Gwen’s Scenario

• Office of Personnel Management (OPM) • Medicare and FEHBP Coordination FAQs • Medicare and FEHBP booklet • Medicare and FEHBP Fast Facts Tip Sheet

• A Closer Look: Medicare for Federal Employees and Retirees: https://www.ncoa.org/wp-content/uploads/medicare-for-federal-employees-and-retirees.pdf

https://www.opm.gov/healthcare-insurance/healthcare/medicare/coordination-of-medicare-and-fehb-benefits/

https://www.opm.gov/healthcare-insurance/healthcare/medicare/75-12-final.pdf

https://www.opm.gov/healthcare-insurance/fastfacts/fehbmedicare.pdf

https://www.ncoa.org/wp-content/uploads/medicare-for-federal-employees-and-retirees.pdf



12


Scenario: When IRMAA Applies

Charlene is a freelance graphic designer who is about to turn 65 in August & enroll in Medicare. She currently buys a high deductible private insurance plan through the Marketplace.

Charlene’s income fluctuates wildly depending on her workload. In 2013 & 2014, she earned $125,000; in the past year and a half she’s only brought in roughly $55,000. She has been told that because of IRMAA rules, she’s going to have to pay $243.60 for her Part B premiums, and is confused. What do you advise?

13


Income Related Monthly Adjustment Amount (IRMAA)

IRMAA amount is based on modified adjusted gross income as reported on your IRS tax return from 2 years prior (so for 2016, it would be 2014 income)

Pay higher premiums for Medicare Parts B & D, based on income level • Up to $389.80/month for Part B in 2016 • Up to $72.90/month + plan premium for Part D

Paid to Medicare directly, not the plan

Redetermination of IRMAA should happen automatically by SSA as long as the individual files a tax return

14


How to Help Charlene

Have Charlene gather current income documentation Contact Social Security to submit documentation and

request a new decision • New IRMAA decisions also may apply to people who:

Got married, divorced, or widowed Stopped work or reduced work hours Lost income-producing property because of disaster/other

uncontrollable event Experienced a scheduled cessation, termination, or

reorganization of an employer’s pension plan Received a settlement from an employer or former employer

because of the employer’s closure, bankruptcy, or reorganization

15


How to Help Charlene (cont.)

In Charlene’s case, documentation should suffice for new decision

If it does not, she can still file an appeal • Must complete SSA form Request for Reconsideration

(SSA-561): https://www.ssa.gov/forms/ssa-561.html An appeal is not required for anyone meeting the situations on

the previous slide—simply request a new decision

If she thinks IRS submitted incorrect income to SSA, Charlene must contact the IRS to correct that information

https://www.ssa.gov/forms/ssa-561.html

16


Related Resources: IRMAA

Medicare Premiums: Rules for Higher Income Beneficiaries: https://www.ssa.gov/pubs/EN-05-10536.pdf

Medicare Annual Verification Notices FAQ: https://www.ssa.gov/pubs/EN-05-10507.pdf

What You Can Do If You Think Your Medicare Income-Related Premium is Incorrect: https://www.ssa.gov/pubs/EN-05-10125.pdf

SSA IRMAA Regulations (POMS): • https://secure.ssa.gov/poms.nsf/lnx/060112000 • https://secure.ssa.gov/poms.nsf/lnx/0601101035

https://www.ssa.gov/pubs/EN-05-10536.pdf




https://secure.ssa.gov/poms.nsf/lnx/060112000

https://secure.ssa.gov/poms.nsf/lnx/0601101035

17


Scenario: Returning to the U.S. after Living Overseas

Todd is 76 years old and lives and works in Canada. His wife died last year and he’s decided to return to the U.S. to live with his daughter and grandchildren in Crane, Texas. He has a rare cancer called GIST. He spoke to his oncologist about the move and was advised to find providers ASAP. Todd doesn’t have Medicare because he works and has national coverage in Canada. He needs help finding providers and sorting out his options. He calls 1-800-MEDICARE and is routed to the Texas SHIP office. What do you advise?

18


How To Help Todd

SSA and Medicare eligibility and enrollment Search for providers on www.medicare.gov Late enrollment penalties apply? Plan comparison

• Medicare vs. Medicare Advantage • Medigap Does he get a Medigap OEP?

• Part D Any special medication for GIST?

http://www.medicare.gov/

19


SSA Benefit Eligibility Rules

SSA benefit eligibility rules • He worked in the U.S. and contributed to SSA for 20

years prior to moving to Canada • Apply online at www.ssa.gov

http://www.ssa.gov/

20


Medicare Eligibility Rules

65 or older, Drawing SSA Disability Income for 24 months, Diagnosed with End Stage Renal Disease (ESRD) or Lou

Gehrig’s disease (ALS), If owe a Part A premium, must also be:

• U.S. resident, • U.S. Citizen OR lawfully admitted as a permanent resident for 5

years

21


Medicare Late Enrollment Penalties Apply?

Does Todd owe a penalty for not signing up at age 65? • Working with foreign government’s national

health coverage No late enrollment penalty SEP for 8 months to join Part A & B SEP for 63 days to join Part D

• What documentation will he need to provide? Evidence of employment Proof of national health coverage

22


Find Medicare Providers

www.medicare.gov search to Find A Provider • By zip code • By type of provider (specialist, DMEPOS, etc.)


23


Medicare Providers - Specialist

Nearest board certified GIST Specialist • 350 mi away in Dallas, TX • Yuke Arriaga

24


25


Considerations for Part D Plans

Total cost of plan= deductible, medication, premium • Maybe $0 deductible since joining late in year

Pharmacy network Formulary

• Check for medication restrictions/utilization management Prior authorization Step Therapy Quantity limits

26


Considerations for MA Plans

MA Networks • Provider accepting new patients? • Is the GIST specialist in-network? If not, how

much will out-of-network visits cost? • How soon can he get an appointment?

Prior Authorization for services MA Part D coverage

• Expensive GIST medicine covered? • Donut Hole • Restrictions/utilization management

27


Considerations for a Medigap Plan

Does he qualify for a Medigap Open Enrollment Period? • Yes, first joining Part B after age 65 • Join any Medigap regardless of health

• See any provider that accepts Medicare Assignment Pays after Medicare Can he afford Medigap?

• TX price range www.medicare.gov or www.naic.org • What will medications cost? • Part B = $121.80 a month • Other monthly living expenses?


http://www.naic.org/state_web_map.htm

28


Related Resources: Citizens Overseas

NCOA LIS and MSP Eligibility Page • Income and asset charts • Federal Poverty Level Guidelines

SSA POMS • Part B Eligibility and Enrollment Residing Abroad • Part A & B Enrollment SEP • Definitions for SEP and Lack of Part B Late

Enrollment Penalty www.medicare.gov

• Provider locator • Plan Finder

https://www.ncoa.org/news/ncoa-news/center-for-benefits-news/updated-benefits-eligibility-2016/

https://secure.ssa.gov/apps10/poms.nsf/lnx/0600805005







29


Scenario: Switching Medigap

Rosa retired at age 65 in 2009, and signed up for Original Medicare, a Part D plan, and Medigap Policy J. Recently, with the onset of a new chronic condition, her medical costs have significantly increased, and so too have her premiums for Part D & Medigap. She’s heard from friends that they have Medigap Policy F and like it, and so she thinks she wants to switch to this policy. What do you advise?

30


Signing Up for/Switching Medigap

Medigap Open Enrollment • 6-month window after person first enrolls in Part B (age 65+) • Person can purchase any Medigap policy • Cannot be denied coverage due to health conditions (though

may face prior existing condition waiting period if she did not have adequate coverage previously)

Guaranteed issue rights/periods • Company must cover pre-existing conditions, and cannot

charge more because of current/past health problems • Under federal law, get these rights during 63-day window after

7 circumstances; not all policies may be available State laws may expand Open Enrollment/guaranteed

issue rights

31


Medigap Policies

Policy J was a fairly comprehensive policy that was sold prior to June 2010 • Still exists for policyholders, but does not accept new

enrollees, so will eventually be phased out Policy F is probably most comparable to Policy J

in terms of coverage

32


How to Help Rosa

Gather information about Rosa’s costs across Original Medicare, Part D, and Medigap

Screen Rosa for benefits that may cover some of these costs--i.e., Medicaid, MSPs, LIS

Visit your state insurance department website to find out your state’s rules on guaranteed issue rights, and to download the Medigap cost comparison guide • Find link to your state website at



33


How to Help Rosa (cont.)

Let’s say Rosa lives in a state that does not offer any guaranteed issue/expanded Open Enrollment beyond what’s federally legislated • May inquire with different companies about costs (including

cost structure) and coverage of Rosa’s chronic condition; they still have ability to deny coverage/refuse to sell policy to Rosa

• If she decides to apply to get a new policy, she should not cancel her Policy J until she receives confirmation of enrollment into new policy

Alternatively, see if Rosa can help cut costs elsewhere through Part D shopping and BenefitsCheckUp®

34


Related Resources: Medigap

Medigap Open Enrollment: https://www.ncoa.org/resources/medigap-open-enrollment-period/

Choosing a Medigap Policy: https://www.medicare.gov/pubs/pdf/02110.pdf

Explanation of federal guaranteed issue rights: https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights-scenarios.html

https://www.ncoa.org/resources/medigap-open-enrollment-period/

https://www.ncoa.org/resources/medigap-open-enrollment-period/

https://www.medicare.gov/pubs/pdf/02110.pdf

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights-scenarios.html



35


Scenario: Help in the Donut Hole

Randall schedules a Part D comparison appointment for help during the Open Enrollment Period (Oct. 15 – Dec. 7). He has three chronic conditions: diabetes, Alzheimer's, and chronic obstructive pulmonary disorder (COPD). He lives in Farmington, MO with zip code 63640. He went into the donut hole in April last year and didn’t get out until August. He brings his medication list to the appointment: Levemir insulin, Namenda XR, and Spiriva.

36


How To Help Randall

Compare Part D Plans Screen for Extra Help Check for SPAP Manufacturer programs Samples from provider

37


Coverage Gap/Donut Hole Illustration

Insert graphic

FULL cost of drug = Bene pays + plan pays What plan paid no longer

counts. What counts to get out of the donut hole:

1. bene pays out-of-pocket 2. 50% drug manufacturer

brand discount

38


39


Randall’s lowest cost 2016 plan

40


Randall’s Monthly Drug Costs – Lowest Cost Plan in 2016

Donut Hole

Catastrophic

41


Screen for Extra Help

Randall’s finances: $1,240 deposited from SSA Gross income: $1,344.90 = $1,240 + $104.90

(Part B premium) $400 checking account $5,600 savings account

42


43


Example of Randall with FULL

Extra Help

44


Screen for Medicare Savings Program

Randall’s finances: $1,240 deposited from SSA Gross income: $1,344.90 = $1,240 + $104.90

(Part B premium) $400 checking account $5,600 savings account

Randall owns property with his brother (not primary residence)

45


State Pharmaceutical Assistance Programs (SPAPs) Find an SPAP

• Search www.medicare.gov for SPAP • Benefits and eligibility vary by state


46


47


Manufacturer Prescription Assistance Programs (PAP)

Benefits and eligibility vary by drug maker • Program details • Often online/paper application forms

Find a PAP • www.needymeds.org • www.rxassist.org • www.pparx.org • www.medicare.gov PAP page

http://www.needymeds.org/

http://www.rxassist.org/

http://www.pparx.org/

https://www.medicare.gov/pharmaceutical-assistance-program/

48


Randall: Provider Samples

Talk to the doctor/provider • Drug representatives may provide samples • Provider is likely unaware of out-of-pocket drug

costs

49


Scenario: Hospital Observation Status

Gus, 76, has a fall in the middle of the night and is taken to the hospital. The next morning, the doctor informs him that he might need surgery on both shoulders to repair the injuries that occurred during the fall. Gus is concerned that he will need extensive rehab after the surgery, and has heard that he was admitted to the hospital under “observation status.” What do you advise?

50


About Observation Status

Observation status is covered as outpatient service (i.e., by Part B)

Remember: For Medicare to cover skilled nursing care, a person must have qualifying hospital stay of 3 days as an inpatient (covered by Part A)

Effective August 6, 2016, the NOTICE Act requires that hospitals provide written and oral notice, within 36 hours, to patients who are in observation or other outpatient status for more than 24 hours • Hospitals also must use new standardized Medicare

Outpatient Observation Notice (MOON) (CMS accepting comments on draft notice until 6/17)

51


About Observation Status: Drug Coverage

Part B covers limited drugs administered to hospital outpatients (mostly injectable/infusion)

Self-administered drugs may be paid for by Part D if: • Drug is on the plan formulary • Not routinely filled at out-of-network (hospital) pharmacy • In-network pharmacy network was impractical at time

Unless hospital is in-network pharmacy, people may be billed up-front and have to get reimbursed by Part D

How Medicare Covers Self-Administered Drugs in Hospital Outpatient Settings: https://www.medicare.gov/Pubs/pdf/11333.pdf

https://www.medicare.gov/Pubs/pdf/11333.pdf

52


How to Help Gus

The best case scenario is to help him at time of hospitalization… If Gus is still in the hospital:

• Seek the doctor’s/primary care physician’s help to have him admitted as an inpatient If hospital has geriatric care manager, may want to enlist help Need to outline risk factors and full conditions Explain why inpatient status is “medically necessary” or why

inpatient services are required • After Aug. 6, if Gus was in the hospital for more than 24

hours under observation status, he would get a MOON

53


How to Help Gus (cont.)

This is really a long shot… If Gus is no longer in the hospital and requires SNF

care: • May face having to pay bill up front • File a double-barreled appeal—try to make claim that

treatment received is usually only given to hospital inpatients Appeal using instructions in Medicare Summary Notice Appeal seeking reimbursement of SNF charges

54


Related Resources: Hospital Observation

Are You a Hospital Inpatient or Outpatient? https://www.medicare.gov/Pubs/pdf/11435.pdf

Center for Medicare Advocacy: http://www.medicareadvocacy.org/medicare-info/observation-status/

Medicare Rights Center national telephone helpline: 1-800-333-4114

https://www.medicare.gov/Pubs/pdf/11435.pdf

http://www.medicareadvocacy.org/medicare-info/observation-status/

http://www.medicareadvocacy.org/medicare-info/observation-status/

55


Contact Us

Melissa Simpson [email protected] Brandy Bauer: [email protected]

Visit us online at:

www.ncoa.org www.ncoa.org/centerforbenefits www.mymedicarematters.org

www.facebook.com/NCOAging www.twitter.com/NCOAging

mailto:[email protected]

mailto:[email protected]

http://www.ncoa.org/

http://www.ncoa.org/centerforbenefits

http://www.twitter.com/NCOAging

Documents

Sticky Scenarios: Help Your Clients with Common …...June 2, 2016 Sticky Scenarios: Help Your Clients with Common (But Challenging) Medicare Issues Audio Portion: Use computer or