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Dear Avisery Members,
We wanted to share two important Medicare Part D updates that may impact Medicare beneficiaries in Illinois. The first update is the termination and sanctions placed on the Clear Spring Health stand-alone Medicare Part D prescription drug plan (PDP) by the Centers of Medicare and Medicaid Services (CMS). The second update involves the limited number of available Part D plan options in 2024 that offer a $0 monthly premium to beneficiaries with full Extra Help.
CMS Terminates Clear Spring Health Insurance Company and
Places Sanctions
CMS recently announced that they will be terminating the Medicare contract for Clear Spring Health’s Medicare PDP effective December 31, 2024, for being a consistent poor performer and receiving less than a 3-star rating for three years in a row. In Illinois, the plan is called Clear Spring Health Value Rx stand-alone Medicare Part D (ID S6946 014). The Medicare Advantage plans offered by Clear Spring Health are not impacted.
In addition to the contract termination, CMS has also imposed sanctions on Clear Spring effective October 20, 2023. This sanction prohibits Clear Spring Health from marketing and enrolling new members into the plan. As a result of these enforcement actions, plan information and drug pricing for the Clear Spring Value Rx PDP has been removed from the Medicare.gov plan finder tool. Clear Spring members should have received an annual notice of change from the plan in late September that summarizes benefit and costs changes for 2024, but members can also contact Clear Spring directly to learn about specific drug cost sharing amounts.
Members currently enrolled in the Clear Spring Health Value Rx PDP may remain in the plan if they choose until the end of 2024. Members in this plan will also receive a notice from CMS alerting them of the plan’s low ratings and of their eligibility for a one-time special enrollment period (SEP) to change plans during the rest of 2023 and all of 2024 to a higher rated plan with at least a three-star rating. Please note that members interested in using this SEP will need to contact 1-800-Medicare.
CMS Clear Spring Health Termination and Sanction notice: https://www.cms.gov/files/document/clear-spring-termination-sanction-10132023.pdf
Fewer $0 Premium Stand-Alone Part D Plans Available in 2024 for Beneficiaries with Extra Help
The Extra Help program (also referred to as the Low-Income Subsidy or LIS) helps Medicare beneficiaries with limited incomes and assets pay for their Medicare Part D plan expenses. Extra Help assists beneficiaries to pay their monthly Part D plan premium, annual drug deductible, and prescription drug co-pays for covered formulary drugs.
CMS will pay the entire monthly Part D plan premium for beneficiaries with full Extra Help if the plan is a basic plan and the monthly premium is at or below a certain premium amount, called the Extra Help benchmark. In Illinois, the Extra Help benchmark premium amount for 2024 is $32.70. This amount is calculated by CMS for each geographic region and changes every year. If an individual with full Extra Help enrolls in an "enhanced" plan instead of a basic plan even if the plan’s premium is below the benchmark, the individual will be responsible for the portion of the plan’s premium that accounts for the “enhanced” portion (for ex., providing extra coverage during the donut hole or a broader formulary). The Medicare.gov Plan Finder will not specify if a plan provides a basic or enhanced benefit, but CMS has released a landscape chart of PDPs in Illinois that lists a plan's benefit type. Click here to access the chart.
In 2024, only two stand-alone Part D plans will be available at a $0 monthly premium to beneficiaries with Extra Help (compared to seven plans offered in 2023). The two plans include WellCare Classic (which offers a $0 monthly premium only to beneficiaries who qualify for Extra Help) and WellCare Value Script (which offers a $0 monthly premium to any Medicare beneficiary who chooses to enroll in the plan). Clear Spring Health PDP is also an Extra Help $0 premium plan, but is currently sanctioned and not accepting new enrollments.
Beneficiaries with Extra Help who are enrolled in any other stand-alone Part D plan in 2024 will be required to pay a portion of the plan's monthly premium since all the other stand-alone Part D plans available are above the benchmark and/or enhanced. The amount of premium they will have to pay will vary by plan. Extra Help will still pay the entire annual drug deductible and provide them with low prescription drug co-pays for drugs on the plan’s formulary regardless of the Medicare Part D plan they are enrolled in (over or under the benchmark).
In some cases, it may be beneficial for beneficiaries with Extra Help to enroll in plan that that does not provide a $0 premium if their drugs are not covered by an Extra Help $0 premium benchmark plan. The www.Medicare.gov Plan Finder tool is the best resource to determine how much of the Part D plan’s premium a beneficiary may be responsible for paying if they enroll in a non-benchmark plan.
As a reminder, Extra Help beneficiaries receive an SEP that allows them to change plans once per calendar quarter, for the first three quarters of the year if they do not change plans during the Medicare Open Enrollment Period. This is useful for beneficiaries who do not realize until 2024 that they are responsible for a portion of the premium or find out a drug is not on the plan’s formulary. It is also important to note that beneficiaries always have the right to request a formulary exception at any time if a specific prescription drug is not covered on a plan’s formulary.
We are aware that this issue limits plan options for Extra Help beneficiaries and may potentially increase their Part D out-of-pocket costs in 2024. The Illinois Senior Health Insurance Program (SHIP) has elevated the issue to CMS and Administration for Community Living (ACL).
As always, if you have any questions, please do not hesitate to contact Avisery at avisery@ageoptions.org or call 708-628-3440.
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