The webinar is now online. The following materials are available to reference during the presentation, please print them if desired. The presentation will begin at 4:00 pm EST 1. Handout version of this presentation – for taking notes and jotting down questions as we proceed To download: www.adventistretirement.org, Retiree, Retiree Webinars, SHARP 2014 Changes & Rx Option Webinar 1
SHARP Changes for 2014 Lisa Turpen RN Assistant Administrator/SHARP Manager 2
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. 3
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 4 • Thyroid Function test every year
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 www.medicare.gov 5
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 6 • Healthcare claim processing now includes a third party appeal
Dependent Eligibility change -2014 SHARP must comply with a portion of the Affordable Care Act(ACA) effective January 1, 2014. • The dependent child age 19-26 may enroll in SHARP. • The SHARP committee has a vote on the 2014 costs Nov. 21, 2013. • 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 7 spouse enrollment.
SHARP Rx Option - 2014 8
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 2012. • 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%. 9 The formulary compliance rate was 96.5%
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 1-1- 2014. • This is not an open enrollment to join the SHARP Rx Option. 10
Plan Change for 2014 • Effective 1-1-2014 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). 11
Express Scripts Medicare (PDP) + Wrap- a 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 2014. • 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 12
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. 13
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 14 drugs which are not covered. FDA rules do apply.
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: 15 A $2.55 copayment for covered generic A $6.35 copayment for all other drugs drugs
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) 16
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. 17 • Walgreens will be a participating pharmacy in 2014.
2014 SHARP RX Three Tier copay Retail : 30 , 60 & 90 day supply Mail order: 90 day supply • $12 generic • $29 generic • $24 brand • $58 brand • $40 non-preferred/non- • $90 non-preferred/non- formulary formulary • 60 day supply is 2 times the above noted copay • 90 day supply is 3 times the above noted copay 18
Upcoming Mailings in 2013 • Express Scripts mailing to participating retirees/spouses. • The Pre-notification letter was mailed 11-8-2013. • 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. 19
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