Only one enrollment box can be checked in the CTS

1. ✓ Medicare Part D or ✓ Medicare Advantage MA-PD.
2. CANNOT SELECT BOTH

What is it?

The Guiding an Improved Dementia Experience (GUIDE) Model is a voluntary nationwide model test that aims to support people with dementia and their unpaid caregivers. The model began on July 1, 2024, and will run for eight years.
GUIDE is designed to attract a range of Medicare Part-B enrolled providers and practitioners with the expertise and capabilities to establish a Dementia Care Program (DCP).
The GUIDE Model focuses on

• comprehensive, coordinated dementia care
• aims to improve quality of life for people with dementia,
• reduce strain on their unpaid caregivers
• enable people with dementia to remain in their homes and communities.
• It will achieve these goals through Medicare Part B payments for a comprehensive package of care coordination and care management, caregiver education and support, and respite services.

What does it cover?

• The GUIDE Model sets a standard approach to care that requires the following:
  • 24/7 access to a support line,
  • caregiver training, education, and support services
  • standard approach will allow people with dementia to remain safely in their homes for longer by preventing or delaying nursing home placement and improve quality of life for both people with dementia and their unpaid caregivers.  

How does Medicare pay for the GUIDE service?

• GUIDE’s alternative payment methodology covers a more comprehensive set of services than existing care codes, is less burdensome to bill, and allows for payment for care delivery by members of the care team who are otherwise not eligible to bill for Medicare services.
• MONTHLY DEMENTIA CARE MANAGEMENT PAYMENT(DCMP) The DCMP is a per beneficiary per month care management payment that covers care management, care coordination, and caregiver education and support services to beneficiaries and caregivers. The DCMP will offer participants more flexibility to deliver personalized dementia care through a payment model that is predictable for providers.
• PAYMENT FOR RESPITE SERVICES GUIDE will provide up to $2,500 per year for respite services for qualified beneficiaries. Payment for respite services enables caregivers to keep a person with dementia at home and out of a nursing facility longer.
• ONE-TIME INFRASTRUCTURE PAYMENT FOR SAFETY NET PROVIDERS GUIDE will provide a one-time, lump sum infrastructure payment of $75,000 to safety net providers in the new program track in the first year. This payment will support program development activities and build organizational capabilities.
• PERFORMANCE BASED PAYMENT ADJUSTMENT The performance-based adjustment (PBA) will increase or decrease participants’ monthly DCMPs, depending on how they perform on model metrics. The PBA will be applied as an ongoing percentage adjustment to the model’s DCMP.
• HEALTH EQUITY ADJUSTMENT A Health Equity Adjustment (HEA) will be applied to the DCMP to provide better support and resourcing for outreach and service to underserved populations

How to people get enrolled in the GUIDE service?

• Patients must be enrolled in Original Medicare Parts A and B and meet other eligibility requirements.
• Visit with a doctor or care team participating in GUIDE and get a comprehensive assessment of their health needs.
• At the end of the visit, a doctor or a care team member will submit a form to CMS.
• If eligible for GUIDE, they will get more information about next steps from the care team.

Who are the Minnesota providers that participate?

• Harmonic Medical Group of MN, Moorhead
• KNWM, Alexandria
• Bluestone Physician Services, Stillwater
• Minneapolis Clinic of Neurology
• LifeSpark Medical Group, St Louis Park

• Level 1: $4.90 for generic/preferred multi-source drugs, and $12.15 for other drugs 
  • QMB, SLMB and QI pay this copay amount

• Level 2: $1.60 for generic/preferred multi-source drugs, and $4.80 for other drugs             
  • Full dual eligibles pay this copay amount

• Level 3: $0 for both generic/preferred multi-source and other drugs
  • Beneficiaries residing in skilled nursing facility, assisted living, and home and community-based services do not pay any copays

What's the Medicare Prescription Payment Plan? - Medicare fact sheet

The Medicare Prescription Payment Plan is entirely voluntary. 
There’s no cost to participate in the Medicare Prescription Payment Plan. 
Opting into the MPPP does not save money or decrease prescription drug costs.
All Medicare Advantage and Medicare Part D stand-alone plans must offer the MPPP option. 
To get the MPPP, the beneficiary must opt in by contacting their plan.

If the beneficiary selects this payment option:

If the person opts in in January, the beneficiary will pay the MPPP payment over the 12-month period. However, if the person opts in mid-year, they will pay the MPPP payment over the remaining months (e.g., if the person opts in in June, they will pay the MPPP payment over the remaining 6 months of the year). 

The MPPP payment does not include the Part D premium.

The beneficiary will not pay the pharmacy for their prescription medications. This includes mail order and specialty pharmacies. The beneficiary will continue to pick up their prescription medications from the pharmacy.

The beneficiary will get a bill from their drug plan to pay for their prescription drugs which is an amount calculated across the 12 month period. These amounts will vary based on the drug costs. Once the drug costs reach $2,000, payments will end.

The beneficiary’s monthly bill is based on:

What the beneficiary would have paid for prescriptions they get.

The beneficiary’s previous month’s balance, divided by the number of months left in the year.  For this reason amounts can and do change.

All plans use the same formula to calculate the monthly payments.

Payments might change every month, so the beneficiary may not know what the exact bill will be ahead of time:

Future payments might increase when a new prescription is filled or when refilling an existing prescription because as new out-of-pocket costs get added to their monthly payment, there are fewer months left in the year to spread out the remaining payments.

When a person can enroll in MPPP: 

In order to have drug costs paid across the 12-month period, Medicare beneficiaries who want to opt into the MPPP, should do it during OEP so it takes effect on 1/1/2025. A beneficiary can opt into the MPPP anytime during the 12 month period. Beneficiaries can voluntarily choose to end their participation in the Medicare Prescription Payment Plan at any time during the year.

Methods to opt into the MPPP:

Telephone: Call their Part D or Medicare Advantage plan directly.

Paper Request: Fill out a paper election request form from their plan.

Online: Elect this option through their plan’s website.

Note: If a patient opts into the program during the plan year, it may take their Part D or Medicare Advantage plan up to 24 hours to process the election.

  What if a person misses their MPPP payment? 

If a beneficiary misses payments, their Part D plan can involuntarily remove them from the program. If a beneficiary fails to pay the amount they are billed by the Part D sponsor, their participation in the program may be terminated following a required two-month grace period.

However, their Part D drug coverage will continue as long as they continue to pay their plan premiums.

Regardless, if a beneficiary is removed from the program due to missed payments or the beneficiary decides to voluntarily leave the program, they are still responsible for paying their Part D plan any remaining balances owed under the program. There will be no interest or fees for late payments.

Calculation examples to determine MPPP amounts.
MPPP Wizard - The Wizard questions for the MPPP are found at the bottom of the page.

 Medicare.gov - Minnesota Prescription Payment Plan Wizard example: 

*If you right click the screen and select print, then choose print to Adobe PDF, you can save the information. This seems easier than taking screenshots. 

1. Some staff are getting questions where agents are encouraging a switch to MAPD since there’s a medigap OEP coming in August. 
   1. The new Medigap OEP does NOT start until 8/1/2026. It was originally going to take effect on 8/1/2025 but it has been delayed per Commerce.
   2. Is it guaranteed?  Yes it will be on 8/1/2026
   3. How do we discuss this option?
      1. Inform callers that this DOES NOT begin until 8/1/2026.
      2.  Unfortunately, agents are giving wrong information. These agents should be reported to Commerce so Commerce can educate them on the correct info.
      3. What happens if you are on MAPD and want to get into the Medigap in August 2026 – how is the PDP managed?
         1. Since Medigaps cannot cover drugs (except for Part B drugs), they would need to enroll in a separate PDP if they want drug coverage.

Many people have complained that drug prices in the Medicare Plan Finder tool seem lower during OEP but go up in January, making them look artificially low when people are deciding their coverage for the next year. Part D sponsors submit drug pricing and pharmacy network information to CMS on a biweekly basis for posting on the Medicare Plan Finder tool.

Starting in the first quarter of 2025, CMS will watch Part D sponsors' drug prices closely. They will look for big price increases between the Medicare Annual Enrollment Period in the last quarter of the year before the contract year starts, and the first three quarters of the contract year (Q1, Q2, and Q3). CMS expects to keep monitoring prices beyond 2025.

• Disability Hub MN
  • Toll free at 866-333-2466 or your preferred relay service
  • Online at disabilityhubmn.org
  • Office hours are Monday through Friday, 8:30 a.m. to 5 p.m.
• Senior Linkage Line
  • Senior LinkAge Line at 800-333-2433
  • https://mn.gov/senior-linkage-line
  • Office hours are Monday - Friday from 8:00 a.m. to 4:30 p.m.

There are two managed care programs for seniors.

• Minnesota Senior Care Plus (MSC+)
  • Mandatory managed care program for people 65+
    • MA services are covered by the health plan.
      • Can change plans by returning their AHPS notice or completing a phone-in change request.
    • If dual eligible for MA and Medicare, Medicare services are covered by FFS or original Medicare.
      • Can enroll in MSHO by calling the health plan they wish to enroll in.
• Minnesota Senior Health Options (MSHO)
  • Voluntary managed care program for people 65+ who opt-in
    • MA services plus Medicare Part A, B and D prescription drugs are covered by the health plan.
      • Can change MSHO plans by calling the health plan they wish to enroll in.
      • Can change to MSC+ by contacting their current health plan.

AHPS notice for Seniors

• Specific instructions, deadlines, and contact information are on each notice depending on the program the person is enrolled in.
• Enrollees can call Senior Linkage Line if they have questions about MSHO.
• If they do not want to change, they do not have to do anything. –except in Kanabec.
• One Plan notices will be going to Seniors in Kanabec County.
  • Seniors on Blue Plus who do not want to make a change do not have to do anything.
  • Seniors who were on SCHA will be enrolled into Blue Plus MSC+ unless they call Blue Plus to enroll in MSHO.

​

​The current quarterly SEP available to all dually eligible individuals and LIS-only individuals, which allowed individuals to switch, or in certain circumstances, disenroll from a Medicare Advantage plan is eliminated as of January 1, 2025.

1. NEW SEPS FOR 2025
   1. There is a new monthly SEP for all dually eligible individuals and LIS-only individuals to
      • disenroll from a Medicare Advantage plan with prescription coverage (Medicare Advantage Prescription Drug plan, or MAPD plan), return to Original Medicare; and
      • enroll in a standalone prescription drug plan (as of January 1, 2025).

• • There is a new monthly SEP for all dually eligible individuals and LIS-only individuals to change standalone Prescription Drug Plan enrollment (as of January 1, 2025).
  • CMS created a new SEP for dually eligible individuals and LIS-only individuals to make changes to their MAPD and Prescription Drug Plan enrollment on a monthly basis, one time per month.
    • This SEP allows individuals to switch to a different standalone prescription drug plan or disenroll from a Medicare Advantage plan into Original Medicare and enroll in a standalone prescription drug plan.
    • While individuals can use this SEP to return to Original Medicare and enroll in a standalone Prescription Drug Plan on a monthly basis, the SEP cannot be used to enroll into another Medicare Advantage plan. This new monthly SEP is effective January 1, 2025.
  • There is a new monthly SEP for full-benefit dually eligible individuals to enroll into integrated and aligned D-SNPs (as of January 1, 2025).
  • All other SEPs remain the same.

Who is impacted by the new SEPs? 
All dually eligible individuals and people receiving LIS or Extra Help. 

New Integrated Special Enrollment Period

• To facilitate enrollment into integrated Medicare Advantage plans, there is a new SEP for full-benefit dually eligible individuals known as the Integrated SEP.
  • Starting January 1, 2025, full-benefit dually eligible individuals can choose to enroll into, or switch between, integrated D-SNPs on a monthly basis. This SEP is limited and can only be used by full-benefit dual eligible individuals to enroll into integrated plans to align enrollment between their Medicare and Medicaid plans.  
  • In Minnesota, the integrated plans are MSHO plans and integrated SNBC plans
• This SEP can be used to enroll into:
  • (1) A Fully Integrated Dually Eligible Special Needs Plan (FIDE SNP);
    • All Minnesota SNPs are FIDE Plans
      • These are plans that have full integration of Medicare and Medical Assistance benefits
      • FIDE SNPs fully integrate care for dually eligible beneficiaries under a single managed care organization
      • They must have a contract with the state Medicaid agency.
        • Must include coverage of primary, acute, and long-term services and supports benefits.
        • FIDE SNPs must also cover behavioral health benefits unless the state carves behavioral health out of the capitation rate. 
  • (2) A Highly Integrated Dually Eligible Special Needs Plan (HIDE SNP); or
  • (3) A D-SNP that is an Applicable Integrated Plan (AIP).
• This SEP is not available to enroll into
  • (1) A Coordination Only D-SNP that is also not an AIP  (not available in MN)or
  • (2) A standard Medicare Advantage plan
  • This SEP is limited to full-benefit dually eligible individuals with access to an integrated, aligned plan.
  • LIS-only individuals, partial-benefit dually eligible individuals, and Medicare-only individuals cannot use this SEP. 

Restrictions

• Individuals with LIS, but who are not also enrolled in Medicaid (Medicare Savings Program), will no longer be allowed to switch Medicare Advantage plans on a quarterly basis. 
• They must wait until Open Enrollment, an initial enrollment period, or meet the requirements for one of the other SEP options available.

Special Needs BasicCare

• SNBC is a voluntary managed care program for people with disabilities. There are two options within SNBC.
  • Non-Integrated SNBC Program (MA37)
    • MA services are covered by the health plan.
      • Can change plans or opt out of SNBC and return to Fee for Service (FFS) by returning their AHPS notice or by calling the Disability Hub MN.
    • If dual eligible for MA and Medicare, Medicare services are covered by FFS or original Medicare.
      • Can enroll in Integrated SNBC by calling the health plan they wish to enroll in.
  • Integrated SNBC (I-SNBC) Program (MA 17)
    • MA services plus Medicare Part A, B and D prescription drugs are covered by the health plan.
      • Can change Integrated plans by calling the plan they wish to enroll in.
      • Can call the Senior Linkage Line to pick a Part D plan which will change them to FFS.

AHPS Notices for SNBC

• Specific instructions, deadlines, and contact information are on each notice depending on the program the person is enrolled in.
• If an enrollee has questions about SNBC health plan choices or if they want to know if SNBC is right for them, refer them to the Disability Hub MN.
• Enrollees can call their health plan if they have questions about the clinics or primary care providers available.
• If they do not want to change, they do not need to do anything.

When to mark which options in activities in CTS
Select all topics of what was discussed/covered during the call.
Only select enrollment if enrollment into a PDP or MA-PD is actually done.
Make sure to select what type of enrollment was done – PDP or MA-PD. If this activity is completed, then cost savings/information must be recorded.