3 Medicare For people 65+ and under 65 with a disability 4 parts of MedicarePart A: Hospital InsurancePart B: Medical InsurancePart C: Medicare Advantage PlansPart D: Prescription Drug CoveragePart A & B called Original MedicareAutomatic enrollment if getting SS benefits, must enroll if notPremiums always for Part B, only for A if not enough creditsNot comprehensive coverage, has coverage gapsOut-of-pocket costs for A & B change yearly- see chart
4 Three Enrollment Periods Initial Enrollment Period (IEP): 7 months surrounding 65th birthday month (month earlier if birthday on 1st of month)Date of enrollment determines effective date of MedicareSpecial Enrollment Period (SEP): 8 months following loss of coverage from “active” employmentGeneral Enrollment Period (GEP): Jan 1st – March 31st of each yearJuly 1st effective date
5 Delaying Part B Enrollment Adults over age 65 may choose to have just Medicare Part A while they are ACTIVELY working or are covered under a spouse who is ACTIVELY workingOnce ACTIVE employment coverage has ended, must take Part B coverage within 8 months to avoid a penalty (there is no 8 month period for retiree coverage)If the employer has <20 employees or <100 employees if the beneficiary has a disability, then the individual may need Part B because Medicare should pay first and Employer Group Health Plan (EGHP) secondBeneficiaries should confirm with their employer if Part B is needed
6 Late Enrollment Penalty Penalty for Part A: Capped at 10% of premium and goes away after penalized for twice the length of time the person delayed enrollmentFor voluntary enrollees (paying for A) who don’t enroll in Part A when initially eligiblePenalty for Part B: 10% of premium for each full 12 month period the individual delayed enrollmentPenalty for Part B not capped and is a lifetime penalty except:Under 65 beneficiaries with a penalty will have the penalty removed and will have a “clean slate” when they turn 65
7 Medicare Pays for reasonable and medically necessary services There are coverage gaps in Medicare including:Part A in-patient hospital deductiblePart A daily co-payment for in-patient hospital days 61-90Part A daily co-payment for in-patient hospital daysPart A daily co-payment for SNF daysPart B annual deductiblePart B co-insurance (usually 20%)First three pints of bloodCoverage outside the United States
8 Two Options For Supplementing Medicare MEDICARE ADVANTAGE PLAN Step 1: Decide how you want to get your coverageORIGINAL MEDICAREMEDICARE ADVANTAGE PLANORPART AHospitalInsurancePART BMedicalInsurancePART CCombines Part A, Part Band usually Part D&Step 2: Decide if you need a Prescription Drug PlanPART DStand Alone PDPPART DIncluded in Part CStep 3: Decide if you need to add supplemental medical coverageENDIf you join a Medicare Advantage Plan with drug coverage (MAPD), you cannot join another drug plan and you don’t need and cannot be sold a Medigap policyMEDIGAPSupplement Core orSupplement 1 plan
9 Medigap vs. Medicare Advantage Original Medicare +Medigap Supplement 1Medicare Advantage PlanHigher premiums but no co-paysGenerally lower premiums but has co-paysFreedom to choose doctorsMay be restricted to networkNo referrals necessaryMay need referrals for specialistsSome routine services not covered (vision, hearing)May include extra benefits (vision, hearing, fitness)Covered anywhere in USEmergency services ONLY outside service area
10 Part D Must have Part A and/or Part B to be eligible 2 ways to get prescription coverage:1. Medicare Prescription Drug Plans (PDPs); also known as stand alone plans2. Medicare Advantage (Part C) Plans with drug coveragePart D is voluntary, but eligible beneficiaries who do not enroll may be subject to a penaltyMust have “creditable coverage” to avoid penalty
11 Part D Enrollment Initial: Mimics Part B 7 month period Open: Oct 15th – Dec 7th, coverage effective Jan 1stSpecial: Refer to SEP chart for applicable situationsMAPD: Jan 1st – Feb 14thLate: Penalty is 1% of the national base beneficiary premium for EACH MONTH the beneficiary:Did not enroll in a Medicare PDP when they were first eligible AND:Had no prescription drug coverage ORHad coverage that was not considered “creditable ORHad a lapse in creditable coverage of 2 full months (63 days)
12 Part D FormularyThe prescription benefit includes a list of “covered drugs” and this list is called the “formulary”If the insurer is very selective about which drugs are to be covered, then it is sometimes referred to as a “closed formulary”. If the formulary is open to all drugs but places drugs into different cost sharing categories or “tiers”, it is referred to as an “open formulary”Each plan must meet formulary standards. The formulary must include and cover certain drugs or certain classes of drugs. Medicare has established a category of excluded drugs
13 Extra HelpFederal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part DExtra Help subsidizes:PremiumsDeductiblesCopaymentsCoverage Gap “Donut Hole”Late Enrollment PenaltyDoes NOT subsidize non-formulary or excluded medicationsApply through Social Security Administration
14 Prescription Advantage Massachusetts’ State Pharmacy Assistance Program (SPAP)Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i.e. retiree plan)Provides primary prescription coverage for those who don’t qualify for MedicareBenefits are based on a sliding income scale only– no asset limit!Level of assistance provided is determined by gross incomeDifferent income limits for under 65 and 65 and overMembers are provided a SEP (one extra time each year outside of open enrollment to enroll or switch plans)
16 SHINE and Public Benefits SHINE counselors screen individuals for potential eligibility for health/prescription-related public benefit programs, provide education about the benefits, and may assist in the application processCounselors do not guarantee that an individual will be eligible for these programs; this decision can only be made by the benefit program
17 Supplemental Security Income (SSI) Federal income supplement program funded by general tax revenues to help aged, blind, and people with disabilities who have little or no incomeNeeds based programProvides cash to meet basic needs for food, clothing, & shelterDifferent income supplements for various living arrangementsApply through Social Security officeAutomatic enrollment into MassHealth
18 MassHealth Medicaid= National public health insurance program MassHealth= Massachusetts Medicaid programPublic health insurance program for low- to medium-income residents of MassachusettsAdministered by state Medicaid agencies within broad parameters established by federal regulationsOverseen by the Centers for Medicare & Medicaid Services (CMS)
19 SHINE and MassHealthSHINE focus is on MassHealth ONLY AS IT RELATES TO MEDICARE BENEFICIARIESBenefit programs and eligibility criteria may differ for individuals who are not entitled to Medicare
20 Dual-EligibleMedicare beneficiaries who are enrolled in MassHealth Standard are referred to as dual-eligibleDual-eligibles can receive assistance paying for Medicare premiums, deductibles, co-insurance, and co-paysDual-eligibles receive the many MassHealth covered services that Medicare beneficiaries typically do not receive
21 Dual-Eligible's and Part D Dual-eligibles MUST enroll into a Medicare Part D planIf beneficiary does not enroll into a plan within 60 days, they will be auto-assigned to a planBest to avoid this: Auto-assigned plan may not be lowest cost and formulary may not list all of beneficiaries drugsDual-eligibles automatically “deemed eligible” for Full Extra Help, regardless of income and assets
22 dual-eligible's and Part D, cont. MassHealth will cover a drug that Medicare does not pay forWill NOT cover a drug that Medicare does pay for but is not listed on the beneficiaries plan formularyMassHealth is always the payer of last resortWill NOT provide primary prescription drug coverage for dual-eligible'sDual-eligibles not yet enrolled into Part D may receive their prescription drugs at the Extra Help co-pay amounts by using the Limited Income Newly Eligible Transition Program (LINET)
23 Limited Income Newly Eligible Transition Program (LINET) Provides immediate prescription drug coverage for people with Medicare who are at the pharmacy counter and qualify for Extra Help, but aren’t yet enrolled in a Medicare drug planAlso covers prescriptions that eligible people filled within the last 30 daysCovers all Part D covered drugs; No prior authorization or network pharmacy restrictions during the time period covered by this programWill be charged the reduced co-payment based on the level of Extra Help they are eligible forProgram administered by Humana
24 MassHealth Standard Eligibility Determining eligibility for MassHealth is a complex processSHINE may screen for potential eligibility, educate clients about MassHealth benefits, assist in the application processShould not guarantee eligibility; this decision should be left to MassHealthDifferent eligibility requirements for applicants age 65 and older and those under age 65
25 Financial Eligibility 65+ For married couples living together, eligibility usually based on the combined income and assets of both members of the coupleMust meet both income and asset guidelines in order to qualify for MassHealth StandardIncome eligibility: Countable income at or below 100% of the Federal Poverty Level (FPL)Asset eligibility: $2,000 or less in countable assets ($3,000 for a couple)To determine income:Take gross countable income and subtract 2 deductions: Unearned income disregard and Earned income disregard
26 Income DisregardsUnearned income disregard is a $20 deduction from the household’s total countable unearned income. Married couples receive only one $20 deduction from their combined countable incomeEarned income disregard is calculated by subtracting $65 from the individual’s gross earned income, and dividing the remainder by 2. Married couples in which both people are working will both receive separate earned income disregardsAll disregards already calculated in the charts provided to SHINE counselors
27 Income: Countable VS. Non-Countable Countable IncomeNon-countable IncomeSocial Security benefitsRailroad Retirement benefitsPensionsEarned incomeRental incomeFederal veteran pensions & disability compensationInterest incomeCash assistance from SSI or the Department of Transitional Assistance (DTA)Income-in-kind (e.g., gifts)Income from a reverse mortgageVeterans’ Aid & Attendance benefitsChapter 115 benefits for veterans
28 Assets: Countable VS. Non-Countable Countable AssetsNon-countable AssetsBank accountsWhole life insurance policies, when total face value of all policies is over $1,500Individual retirement accounts (IRA)Stocks and bondsSecond homes/carsRVs/BoatsPrimary residence and 1 carPersonal belongings & home furnishingsTerm life insurance policiesWhole life insurance policies with total face value $1,500 or lessBurial plot$1,500 burial-only accountIrrevocable burial contract
30 Financial Eligibility Under Age 65 NO asset limitsIncome limit is 133% of the FPLEarned income disregard and unearned income disregard not usedModified Adjusted Gross Income (MAGI) used instead of gross incomeApplicant receives an income deduction equivalent to 5% of the FPLMAGI already calculated in the charts provided to SHINE counselors
31 Examples of MassHealth Covered Services In/Out-patient hospital servicesEmergency hospital servicesSkilled nursing facilityHome health careCase management servicesClinic servicesDiagnostic servicesDental servicesPrograms for all-inclusive care for the elderly (PACE)Personal care services (PCA)Hospice careMedical TransportationOccupational therapyOptometrist servicesPhysical therapyPodiatrist servicesPreventative servicesPrivate duty nursingProsthetic/orthotic devicesPsychologist servicesRehabilitative servicesRespite care
32 Applying For MassHealth Best for the individual, spouse, family member to complete the application; counselors can assist when needed2 application types:Application for Health Coverage and Help Paying Costs (ACA-2)In general used by applicants under age 65Application for Health Coverage for Seniors and People Needing Long-Term-Care Services (SACA-2)For applicants 65 and older
33 Application Processing Applications sent to and processed at the Central Processing Unit or MassHealth Enrollment Centers (MEC)If an application is received and requires further verification, applicant will receive a Request for Information with a deadline by which to return the needed documentationRetroactive Coverage:Applicants age 65 and older can receive retroactive coverage up to 3 full calendar months prior to the date of applicationApplicants under age 65 can receive retroactive coverage beginning 10 days prior to the date of applicationDoes not apply to MassHealth Senior Buy-in
34 Special MassHealth Programs In addition to the MassHealth Standard benefits and eligibility criterion just discussed, there are several MassHealth programs that provide various levels of benefits for individuals who meet specialized eligibility guidelinesThese programs act like Medicare Supplements (Supplement 1), covering co-pays and deductibles and offering additional benefits
35 Medicare Savings Programs: MassHealth Senior Buy-In Federally referred to as the Qualified Medicare Beneficiary (QMB)EligibilityBe entitled to MedicareIncome at or below 100% of the FPLAssets at or below the designated limits (change yearly)BenefitsPayment of Medicare Part A & B premiumsPayment of deductibles and co-paysDeemed eligible for Full Extra Help
36 Medicare Savings Programs: MassHealth Buy-In Federally referred to as Specified Low-income Medicare Beneficiary (SLMB) and Qualified Individual 1 (QI-1)*QI-1 subject to periodic federal funding appropriationEligibility for SLMB and QI-1Be entitled to MedicareHave income at or below: QI-1= 135% of the FPLSLMB=120% of the FPLAssets at or below the designated limits (change yearly)BenefitsPayment of Medicare Part B premiumDeemed eligible for Full Extra Help
37 Buy-In For Part B Late Enrollees Late enrollees for Medicare Part B who qualify for the Senior Buy-in (QMB) or Buy-in (SLMB/QI-1) may enroll in Part B outside of the General Enrollment PeriodThe effective date of Part B coverage would not be earlier than the Buy-in start dateThe individual’s late enrollment penalty will be paid for by MassHealth
38 Caretaker Relative Eligibility Benefits Must meet the definition of a caretaker relative: Adult of any age who is primary caregiver for a child (can be related to the child by blood, adoption, marriage, or be the spouse/ex-spouse of one of these relatives). Must live in same home as the child and neither of the child’s parents can be living in the homeMust have income at or below 133% of the FPLBenefitsEligible individuals will receive MassHealth Standard benefitsPayment of Medicare Part A & B premiums, deductibles and co-paysDeemed eligible for Full Extra Help
39 CommonHealth Eligibility Must have a disability Must be ineligible for MassHealth StandardMust currently be working at least 40 hours per month, or currently working and worked at least 240 hours in the past 6 monthsMassHealth flexible on what “work” isIndividuals under age 65 can waive the work requirement if they meet a one-time deductibleNO financial eligibility requirementsIndividuals with incomes above 150% of the FPL will pay a monthly premium relative to their income
40 CommonHealth, cont Benefits provided Benefits NOT provided Benefits similar to MassHealth Standard including payment for Part A and B co-payments and deductiblesDeemed eligibile for Full Extra HelpBenefits NOT providedSkilled nursing facility careAutomatic payment for Part B premiumIndividuals must separately meet the qualifications for Buy-in in order for MassHealth to pay premiums
41 Frail Elder WaiverAllows elders eligible for nursing home care who want to remain at home to get the services & supports to be able to live safelyEligibilityBe age 60 or olderBe clinically eligible for nursing home care & receive services from the ASAP’s home care programHave income at or below 300% of the Federal SSI RateHave assets at or below $2,000Only counts the income & assets of the applicant even if married; any assets over $2,000 limit allowed to be transferred to non-applying spouse
42 Frail Elder Waiver, cont BenefitsPayment of Medicare Part A & B deductibles and co-paysDeemed eligible for Full Extra HelpNo co-pays for prescription drugsSupportive services (ex. Personal care, homemaking, meals)To ApplyTo apply the individual should be referred to their local Aging Service Access Point (ASAP)ASAP staff will evaluate the applicant for clinical eligibility
43 Health Safety Net (HSN) Pays for medically necessary services at Massachusetts community health centers (CHCs) and hospitals2 levels of eligibility: Full and PartialEligibilityMust be a Massachusetts residentNon-residents may receive emergency or urgent care onlyFull Health Safety NetIncome must be at or below 200% of FPLPartial Health Safety NetIncome must be above 200% but at or below 400% of FPLIndividual will be assessed an annual deductible
44 Health Safety Net, cont. Benefits Low co-pay prescription coverage Prescription must be filled at a HSN pharmacyWill pay for allowed services not covered by Medicare, as well as Medicare co-pays, coinsurance, and deductiblesServices must be delivered/ billed through a hospital or community health center that has an HSN programCan pay for services up to 6 months prior to approvalHSN is NOT considered “creditable coverage” for Medicare Part D therefore use of the HSN pharmacy benefit does not protect a beneficiary from the Part D late enrollment penalty
45 One CareManaged care option that provides all Medicare & MassHealth services along with additional care coordination and support services to dual-eligible individuals with disabilitiesMembers can only receive covered services through plan’s network of contracted providersOne Care is not available in all countiesEligibilityBe age 21-64Have Medicare Parts A & BHave MassHealth Standard or CommonHealthCannot also be enrolled in SCO, PACE, Frail Elder Waiver, or other MassHealth waiver program
46 One Care, cont.BenefitsAll guaranteed Medicare and MassHealth benefits as well as:No premiums, deductibles, or co-paysServices coordination by an interdisciplinary care teamPart D Coverage and no co-pays for prescription drugsEnhanced behavioral health and substance abuse servicesLong-term supportHome modificationComprehensive dentalHearing aidsTransportation
47 Program Of All-Inclusive Care For The Elderly (PACE) Provides community based care & services to people age 55+ who would otherwise require nursing home level of careTeam of health care professionals provide integrated care plan to keep individual safe at homeEligibilityBe age 55 or olderBe clinically eligible for nursing home careIncome at or below 300% of the Federal SSI Rate, assets at or below $2,000PACE uses the same financial & clinical eligibility as Frail Elder WaiverLive in the service area of a PACE organization
48 PACE, cont.BenefitsNo premiums, deductibles or co-pays for dual-eligible's; Medicare only beneficiaries will have monthly premiumProvides all services covered by Medicare and MassHealth StandardProvides functional, social, and psychological services to help individuals safely remain in their homesPart D coverage through the PACE plan
49 MassHealth Personal Care Attendant (PCA) Program Program that helps people with long-term disabilities live independently at home by giving member funds to hire a personal care attendant (PCA) to help with activities of daily living (ADL’s)EligibilityBe age 65 or olderHave a permanent and long-lasting disabilityMust need assistance with at least 2 ADL’sADL examples: Dressing, eating, bathing, walkingIncome at or below 133% of the FPLAssets at or below $2,000 for an individual or $3,000 for a couple
50 Senior Care Options (SCO) Combines MassHealth Standard coverage with social support services and coordinated care to help individuals maintain their health and live in the communityEligibilityBe 65 or olderQualify for MassHealth Standard (can’t have 6 month deductible)Live in a designated service area of a SCO planNOT be diagnosed with End Stage Renal DiseaseNOT be an inpatient in a chronic rehabilitation hospital
51 Long Term Care (LTC) MassHealth Pays the nursing home the difference between the patient private paid amount and Medicaid established rate for nursing home care. Requires clinical eligibility.Financial EligibilityNo income limit; applicant just must have monthly income insufficient to pay for nursing home costsTo prevent impoverishment of community spouse, spouse may be able to keep some of applicants income, called the monthly maintenance needs allowanceAssets limited to $2,000Community spouse allowed to keep all assets (not counting the primary residence) up to a certain amount
52 Public Benefits QuizList the MassHealth Buy-In programs and the benefits they provide.To be eligible for MassHealth an individual cannot own a home.True or FalseWhen determining an individual’s eligibility for Supplemental Security Income (SSI), their living arrangements are considered.If a Medicare beneficiary has MassHealth, do they need to purchase a Medicare Supplement or join a Medicare Advantage Plan?Yes or NoWhy?
53 Public Benefits Quiz, cont. What are the major differences between MassHealth for individuals under 65 and those 65 and over?What resources are counted in the asset test for people over 65 who apply for MassHealth while living in the community?An individual whose assets are too high for MassHealth Standard can spend down assets in order to qualify on medical expenses only.True or False
54 Case Study 1: Anna Stetick Anna: 73 year old retired widow lives in senior housingIncome: Social Security $1250/month (Net)Assets: $3300 in her checking account, $9,000 in savingsAnna tells you that she moved here from Florida one month ago. She was in a MA plan in Florida and knows she needs to pick a plan in Massachusetts. She also knows she will lose her Part D coverage with the Florida plan and was told she can’t enroll in a plan in Massachusetts until open enrollment and will have a penalty. She wants to know if she can get on MassHealth to pay for her prescriptions.How would you help her?
55 Case Study: 2 Robin HoodRobin: 76 years old single, retired, living in senior housingIncome: Social Security: $1,133/month (Net)Assets: $2500 in savings, $1000 in checking, car valued at $4000. He has a life insurance policy with a face value of $10,000 and a cash surrender value of $1200Insurance: Medicare A & B effective 3/1/03 and currently enrolled in the BCBS PPO planA friend told Mr. Hood to talk to a SHINE counselor about getting on MassHealth.How would you help him?
56 Case Study: 3 Donna Wannago Donna: 77 year old retired widow who lives in senior housingIncome: Social Security $816/month (Net)Assets: $1500 in savings, $200 in checking, life insurance policy with a face value of $1200, car valued at $4000Insurance: Medicare A & B effective 1/22/02 & Medex BronzeDonna signed up for a Part D plan during open enrollment although she wasn’t taking any drugs at that time. She said she she chose the least expensive plan. She is worried about paying the Part D premium along with her Medigap . Her doctor just put her on medication and she doesn’t know how she will be able to pay for it during the gap in coverage under Part D.How would you help her?
57 Case Study 4: Polly Gimmee Polly meets with you on May 10th. She tells you she is 64 and has been on MassHealth due to a disability for the past 19 months. She says she is turning 65 in July and will be enrolled in Medicare effective July 1st. She will be receiving a Social Security check in the amount of $1102. A friend told her that her MassHealth might change when she turns 65. She is worried about her health care coverage if MassHealth does change particularly because she takes several medications and has no other income or assets to use to pay for them. She wants to know if it’s true that MassHealth might not continue to cover her.How would you help her?
58 Case Study 5: Mel Kontent Mel meets with you at the SHINE office. He is very confused about the Medicare Prescription Drug Program. He tell you he takes several medications and gets some coverage through his Medicare Advantage HMO plan and that he used to get additional coverage through Prescription Advantage. He did fill out the application for Extra Help that Prescription Advantage told him to complete, but he received a letter that he was denied. He tells you he cannot afford his co-pays for his drugs since he lost his Prescription Advantage.How would you help him?
59 Case Study 6: Martin EyzMr. Eyz retired at age 65 and is collecting Social Security. He has Medicare and Medex Bronze. He takes no medications and never signed up for Part D. Mr. Eyes recently took a part-time job at the local Whypaymore to supplement his income. He lives in senior housing, so his rent is affordable. Mr. Eyes tells you that he is having a difficult time paying for his health insurance and was told by a friend that he should apply for MassHealth which would cover his medical expenses. Mr. Eyes tells you that he gets $750/month from Social Security and $300/month from his job at Whypaymore. He has $600 in a checking account and $1,400 in a CD.Is he eligible for MassHealth?
60 Case Study 7: Arthur Ritis Arthur calls for assistance. He received an Eligibility Review Form (ERV) from MassHealth to complete. He doesn’t understand why he received the form since he is not on MassHealth. He had applied in the past but was denied because he was over income ($ /month). He tells you he is homebound and called because he cannot come in for an appointment.How would you help him?
61 Case Study 8: Ben HurrBen is 57 years old. He has been on Medicare A & B since January. He was on a few inexpensive medications that he was filling at Wal-mart at little cost. His meds are changing and he now has a few expensive brands. His income is $1,900/month, and he has partial Health Safety Net. An advocate at the community center suggested he see a doctor at the community health center in a nearby town so that he can fill his prescriptions at the health center. She told him he can sign up for Part D at the next Open Enrollment Period.What additional information would you provide?
62 Case Study 9: Charlie Horse Charlie meets with you for help with his prescription coverage. He is in a Blue Cross PPO Medicare Advantage plan with prescription coverage. He takes several medications, one of which, Procrit, is quite expensive. His plan has been covering it, but he will be in the donut hole soon and is concerned because he can’t afford to pay the full price for his drug. He tells you he used to be in Prescription Advantage but that ended in January. He says his monthly income of $1,585 makes him ineligible for any benefit programs. He is not a veteran.How would you help him?
63 Case Study 10: May B. Poor How would you help her? May will be 65 and retiring in 2 months and will not have retiree coverage available through her former employer. She just heard about Medicare Part D. She only takes 1 drug now and doesn’t really want coverage. However, she heard she will pay a penalty if she enrolls at a later date should her drugs increase, as she believes they might. She is concerned about the monthly premium along with the premium for health insurance. She states that her only income will be Social Security and the amount she’ll receive will be $1,120/month. She tells you her savings are minimal and she has no other assets other than her home and a car. She wants to know if there is any way she can cut down on her health care costs or avoid taking Part D as she feels the additional premium will put her over the edge.How would you help her?
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