Make Medicare Work Coalition (MMW)

Bulletin Newsletter

July 8, 2016
To view other MMW materials and resources, including past MMW Bulletin newsletters, fact sheets, and recorded webinars, visit our MMW Coalition webpage at

Medicare Updates
Medicare Part D Benefit Structure in 2017
The Centers for Medicare and Medicaid Services (CMS) announced the 2017 Medicare Part D benefit parameters in a notice released in April. Please see the chart below comparing the 2016 to 2017 amounts.
Standard Medicare Part D Benefit Structure
Annual Deductible (varies by plan)
  • The beneficiary usually pays this amount before the plan begins to pay their share for covered drugs
Up to $360
Up to $400
Initial Coverage Limit
  • After paying the deductible (if the plan has one) and until this limit is reached, the beneficiary pays a co-pay for each prescription and the Part D plan pays the rest
  • Count what the beneficiary and the Part D plan pay for formulary drugs to reach this limit
Donut Hole (also called Coverage Gap)
  • Begins once the beneficiary's covered drug expenses reaches the Initial Coverage Limit (ICL)
  • During the Donut Hole, beneficiaries receive discounts on the full price of generic and brand name drugs on the plan's formulary. After the discount is applied to the full price of the drug, the beneficiary pays the remainder.
Discount received on brand name drugs: 55%
Discount received on generic drugs: 42%
Discount received on brand name drugs: 60%
Discount received on generic drugs: 49%
True Out-of-Pocket Threshold (TrOOP)
  • TrOOP is what the beneficiary has paid for formulary drugs out of their own pockets.
  • Note that TrOOP may include costs paid not only by the beneficiary, but also manufacturer discounts received in the donut hole and any amounts paid by the Extra Help program on a beneficiary's behalf.
Once the TrOOP amount is met, the beneficiary enters "Catastrophic Coverage" and pays less for their formulary drugs for the remainder of the calendar
$2.95 for generics or preferred multi-source drugs
$7.40 for all other drugs
$3.30 for generic or preferred multi-source drugs
$8.25 for all other drugs
To view the CMS notice please click here (see page 68).  
Medicare Part D Donut Hole Discounts in 2017 
According to the CMS notice mentioned above, beneficiaries will continue to receive discounts off of the full price of drugs on the plan's formulary during the donut hole. People who enter the donut hole in 2017 will receive a 60% discount on brand name drugs and 49% discount on generic drugs.
The amounts a beneficiary pays in the donut hole for covered drugs count toward TrOOP, which helps the beneficiary move closer to catastrophic coverage. In addition to the amount paid by the beneficiary, the part of the discount that the beneficiary receives from the drug manufacturers for brand name drugs counts toward TrOOP, as well. All other discounts are provided by government subsidies given to the plan and do not count towards TrOOP. (In 2017, drug manufacturers will provide a 50% discount off the full price of brand name drugs, and the government will provide the additional 10% discount for brand name drugs. Government subsidies will be used to provide the entire 49% discount for generic drugs.)
Once a beneficiary reaches catastrophic coverage, their co-pays for drugs decrease drastically. In 2017, catastrophic coverage co-pays will range from $3.30 to $8.25 for a one-month supply per prescription. Unlike Initial Coverage Limits and Donut Hole co-pays, which vary from Part D plan to plan, catastrophic co-pays are the same regardless of which plan a beneficiary is enrolled in.
The discounts that beneficiaries receive in the donut hole will continue to increase through 2020. By 2020, the donut hole will be eliminated, and most beneficiaries will pay 25% for covered drugs once any deductible amount is met and until the TrOOP amount is met.
A snapshot of Donut Hole discounts through 2020
Discounts a beneficiary receives in the Donut Hole for formulary drugs
Brand Name Drugs
Generic Drugs
Medicare Coverage and Travel
Summer is here, and many people with Medicare choose this time of the year to travel. However, they may not fully understand how their Medicare benefits work if they need to use them while away from home. Original Medicare provides coverage to beneficiaries traveling anywhere in the U.S., including
the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa, which are considered part of the U.S. Beneficiaries who are traveling and need to use their Medicare coverage in another state should make certain that providers they seek care from accept Medicare assignment in order to avoid paying more than the Medicare-approved amount for their care.
However, Medicare generally does not provide healthcare coverage to beneficiaries traveling outside of the U.S. except in rare and limited circumstances. Click here for more information on Medicare coverage outside of the U.S.
Beneficiaries with Medicare Advantage plans should carefully review their benefits before traveling, especially if they are traveling outside of the U.S. Individuals with Medicare Advantage (MA) plans should contact their MA plan before traveling to find out how their plan works when traveling within or outside of the U.S., since MA plans work with networks of providers, which usually are based in specific geographic areas. All MA plans work differently, and some plans may provide limited, reduced or no coverage for medical care during travel in the U.S. unless the beneficiary experiences an emergency or urgent care circumstances.  
Beneficiaries with Medigap plans can use their Medigap plan along with their original Medicare coverage anywhere in the U.S. (Note that individuals in Medicare Select plans who are traveling and need non-emergency medical care should make sure that any providers they receive care from are in the Medicare Select plan's network.) Medicare Select plans are a type of Medigap plan that requires the individual to use specific hospitals (and sometimes doctors) except in emergency situations. In return, Medicare Select premiums tend to be lower.
Some Medigap plans (plans C, D, F, G, M and N) provide foreign travel coverage for care received outside of the U.S. in a foreign country. Benefits in these plans pay 80% of actual charges for medically necessary emergency care once a $250 annual deductible is met and as long as the expenses are incurred during the first 60 days of the trip. These plans also have a lifetime maximum benefit of $50,000. To learn more about Medigap plans and traveling outside of the U.S. click here.
For more information on Medicare and traveling, the National Council on Aging has created a useful tip sheet on what beneficiaries need to know before they embark on their summer travels. 
Extra Help Updates
Extra Help Household Size Reminder
The Extra Help program (also called the Low-Income Subsidy or LIS) provides Medicare beneficiaries who qualify assistance in paying for costs associated with their Part D plans, including help with annual deductibles, monthly premiums and drug co-payments. Many counselors and professionals are accustomed to screening older adults and persons with disabilities for this benefit program to help them pay for their drug costs. To qualify for Extra Help, beneficiaries must be eligible for Medicare Part A and/or Part B and meet specific income and asset guidelines.
As a reminder, Extra Help income limits are based on an applicant's household size, which may be larger than just a one or two person family.  To qualify for Extra Help, an individual or married couple's income must be less than 150% of the Federal poverty Level (FPL). Any relatives that live with the beneficiary and who are dependent on the individual or individual's spouse for at least half of their financial support can be included in the household size. In addition, these dependent relatives' income and assets do not count towards the applicant's income to determine eligibility. This means that applicants are allowed higher income limits if they have relatives living with them (for example, grandchildren, adult children or other relatives) that depend on them for half of their financial support.
The Social Security Administration, which handles eligibility and enrollment for the Extra Help program, defines "relative" as some who is related to the applicant by blood, adoption or marriage. If the applicant files taxes, they can refer to the previous year's tax return for their number of dependents if their circumstances have not changed since thy last filed. If they do not file taxes, the applicant can make an estimate of financial support provided to the relative to determine if it is at least half. This includes support provided in the form of food, shelter, utilities, and other contributions to the relative that lives with them. For more information on Extra Help income limits based on household size visit The chart below lists the income limits for Extra Help by household size.
Family Size
Full Extra Help
 2016 income limits
 (Annual income up to 135% FPL)
Partial Extra Help
2016 income limits
(Annual income up to 150% FPL)
Note: Click here to view a chart created by Families USA that lists FPL limits for a household size exceeding 4 members.
Unlike the income limit for Extra Help, the asset limits are based on an individual or married couple only and do not change if an individual has a larger household size. If an Extra Help applicant is married and living together with their spouse, the asset limit for married couples applies regardless of whether one or both members apply for Extra Help. The current asset limits are as follows:
Asset Limit
Full Extra Help
$8,780 - individual
$13,930 - couple
Partial Extra Help
$13,640 - individual
$27,250 - couple

Medicaid  M anaged Care  Updates
MMW Resources on MLTSS
The Managed Long Term Services and Supports (MTLSS) program began in the greater Chicago area on July 1, 2016. The MLTSS program is a mandatory managed care program for dual eligibles in the greater Chicago area who live in long-term care facilities or receive home and community based services through one of five Illinois Medicaid waiver programs. The program requires dual eligibles who have opted out of MMAI and receive long term services and supports (paid for by Medicaid) to enroll into the MTLSS program in order for their long term services and supports (LTSS) to be covered.
The MMW Coalition recently released an updated topical brief on the new MLTSS Program that explains how it works. The brief provides the following information:
What is MLTSS and Who Does It Affect?
  • What is LTSS?
  • What Do MMAI and MLTSS Cover?
  • MLTSS Managed Care Plans
  • MLTSS Enrollment Process
  • Transitioning from MMAI to MLTSS (if someone with LTSS disenrolls from MMAI)
  • Continuity of Care
  • Tips for Helping Consumers Navigate MMAI and MLTSS
  • Resources on MMAI and MLTSS For Professionals and Consumers
Click on the following link to view the brief: MMW Topical Brief on MLTSS In addition to the topical brief, MMW also hosted a webinar in early June on the MTLSS program. L aura Phelan from the Illinois Department of Healthcare & Family Services (HFS) provided an overview of the MMAI program and introduced the new Managed Long Term Services and Supports (MLTSS) program.  The webinar recording and presentation slides are also available at the link above. 
Training Opportunities
MMW Webinar on Chronic Condition Special Needs Plans
The MMW Coalition will be hosting a webinar on July 13
th from 10:00 - 11:30 a.m. CT on  Chronic Condition Special Needs Plans (C-SNPs). The webinar will first provide a brief introduction to C-SNPs, a special type of Medicare Advantage plan available to individuals with certain chronic conditions. During this webinar, representatives from Humana will provide an educational presentation about their C-SNP plan for individuals with cardiovascular disease, chronic heart failure, and diabetes, which is currently available to Medicare beneficiaries in Cook and DuPage Counties. We specifically invited Humana to speak on this webinar because they provide the only C-SNP plan in the greater Chicagoland area, and they are one of only two C-SNP providers in the entire state. At the end of the webinar, Humana and MMW staff will answer questions from audience members about C-SNP plans.
Registration is required for this webinar and there is no charge to attend. You can register at: After you register, you will receive a confirmation link that you may use to attend on the day of the webinar.
Please note: This webinar will not be recorded, so if you wish to attend, you must attend the live session.
2016 CMS National Training Program Workshop
CMS has announced the dates and locations of their 2016 National Training Program Workshops. This is an annual training workshop that CMS hosts every year for professionals who serve people with Medicare to learn and receive updates about Medicare, the Marketplace and other CMS programs.
 A workshop will not be hosted in the Chicago metropolitan area this year. CMS will provide five regional workshops this year that are listed below:
  • Westminster, CO: July 25-26, 2016
  • Kansas City, MO: August 3-4, 2016
  • Atlanta, GA: August 18-19, 2016
  • Seattle, WA: August 23-24, 2016
  • Syracuse, NY: August 30-31, 2016
There is no charge to attend the training, but registration is required and is on a first come, first serve basis. To register and for additional information, please visit

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