Presentation on theme: "Day 6 & 7 Public Benefits. Review Medicare For people 65+ and under 65 with a disability 4 parts of Medicare Part A: Hospital Insurance Part B: Medical."— Presentation transcript:
Day 6 & 7 Public Benefits
Medicare For people 65+ and under 65 with a disability 4 parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Plans Part D: Prescription Drug Coverage Part A & B called Original Medicare Automatic enrollment if getting SS benefits, must enroll if not Premiums always for Part B, only for A if not enough credits Not comprehensive coverage, has coverage gaps Out-of-pocket costs for A & B change yearly- see chart
Three Enrollment Periods Initial Enrollment Period (IEP): 7 months surrounding 65 th birthday month (month earlier if birthday on 1 st of month) Date of enrollment determines effective date of Medicare Special Enrollment Period (SEP): 8 months following loss of coverage from “active” employment General Enrollment Period (GEP): Jan 1 st – March 31 st of each year July 1 st effective date
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 working Once 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) second Beneficiaries should confirm with their employer if Part B is needed
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 enrollment For voluntary enrollees (paying for A) who don’t enroll in Part A when initially eligible Penalty for Part B: 10% of premium for each full 12 month period the individual delayed enrollment Penalty 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
Medicare Pays for reasonable and medically necessary services There are coverage gaps in Medicare including: Part A in-patient hospital deductible Part A daily co-payment for in-patient hospital days Part A daily co-payment for in-patient hospital days Part A daily co-payment for SNF days Part B annual deductible Part B co-insurance (usually 20%) First three pints of blood Coverage outside the United States
Two Options For Supplementing Medicare Step 1: Decide how you want to get your coverage PART A Hospital Insurance PART B Medical Insurance PART C Combines Part A, Part B and usually Part D ORIGINAL MEDICARE MEDICARE ADVANTAGE PLAN OR PART D Stand Alone PDP PART D Included in Part C Step 3: Decide if you need to add supplemental medical coverage MEDIGAP Supplement Core or Supplement 1 plan END If 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 policy Step 2: Decide if you need a Prescription Drug Plan &
Medigap vs. Medicare Advantage Original Medicare + Medigap Supplement 1 Medicare Advantage Plan Higher premiums but no co-pays Generally lower premiums but has co-pays Freedom to choose doctors May be restricted to network No referrals necessary May need referrals for specialists Some routine services not covered (vision, hearing) May include extra benefits (vision, hearing, fitness) Covered anywhere in US Emergency services ONLY outside service area
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 plans 2. Medicare Advantage (Part C) Plans with drug coverage Part D is voluntary, but eligible beneficiaries who do not enroll may be subject to a penalty Must have “creditable coverage” to avoid penalty
Part D Enrollment Initial: Mimics Part B 7 month period Open: Oct 15 th – Dec 7 th, coverage effective Jan 1 st Special: Refer to SEP chart for applicable situations MAPD: Jan 1 st – Feb 14 th Late: 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 OR Had coverage that was not considered “creditable OR Had a lapse in creditable coverage of 2 full months (63 days)
Part D Formulary The 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
Extra Help Federal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part D Extra Help subsidizes: Premiums Deductibles Copayments Coverage Gap “Donut Hole” Late Enrollment Penalty Does NOT subsidize non-formulary or excluded medications Apply through Social Security Administration
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 Medicare Benefits are based on a sliding income scale only– no asset limit! Level of assistance provided is determined by gross income Different income limits for under 65 and 65 and over Members are provided a SEP (one extra time each year outside of open enrollment to enroll or switch plans)
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 process Counselors do not guarantee that an individual will be eligible for these programs; this decision can only be made by the benefit program
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 income Needs based program Provides cash to meet basic needs for food, clothing, & shelter Different income supplements for various living arrangements Apply through Social Security office Automatic enrollment into MassHealth
MassHealth Medicaid = National public health insurance program MassHealth = Massachusetts Medicaid program Public health insurance program for low- to medium-income residents of Massachusetts Administered by state Medicaid agencies within broad parameters established by federal regulations Overseen by the Centers for Medicare & Medicaid Services (CMS)
SHINE and MassHealth SHINE focus is on MassHealth ONLY AS IT RELATES TO MEDICARE BENEFICIARIES Benefit programs and eligibility criteria may differ for individuals who are not entitled to Medicare
Dual-Eligible Medicare beneficiaries who are enrolled in MassHealth Standard are referred to as dual-eligible Dual-eligibles can receive assistance paying for Medicare premiums, deductibles, co-insurance, and co-pays Dual-eligibles receive the many MassHealth covered services that Medicare beneficiaries typically do not receive
Dual-Eligible's and Part D Dual-eligibles MUST enroll into a Medicare Part D plan If beneficiary does not enroll into a plan within 60 days, they will be auto-assigned to a plan Best to avoid this: Auto-assigned plan may not be lowest cost and formulary may not list all of beneficiaries drugs Dual-eligibles automatically “deemed eligible” for Full Extra Help, regardless of income and assets
dual-eligible's and Part D, cont. MassHealth will cover a drug that Medicare does not pay for Will NOT cover a drug that Medicare does pay for but is not listed on the beneficiaries plan formulary MassHealth is always the payer of last resort Will NOT provide primary prescription drug coverage for dual-eligible's Dual-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)
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 plan Also covers prescriptions that eligible people filled within the last 30 days Covers all Part D covered drugs; No prior authorization or network pharmacy restrictions during the time period covered by this program Will be charged the reduced co-payment based on the level of Extra Help they are eligible for Program administered by Humana
MassHealth Standard Eligibility Determining eligibility for MassHealth is a complex process SHINE may screen for potential eligibility, educate clients about MassHealth benefits, assist in the application process Should not guarantee eligibility; this decision should be left to MassHealth Different eligibility requirements for applicants age 65 and older and those under age 65
Financial Eligibility 65+ For married couples living together, eligibility usually based on the combined income and assets of both members of the couple Must meet both income and asset guidelines in order to qualify for MassHealth Standard Income 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
Income Disregards Unearned 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 income Earned 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 disregards All disregards already calculated in the charts provided to SHINE counselors
Income: Countable VS. Non-Countable Countable Income Social Security benefits Railroad Retirement benefits Pensions Earned income Rental income Federal veteran pensions & disability compensation Interest income Non-countable Income Cash assistance from SSI or the Department of Transitional Assistance (DTA) Income-in-kind (e.g., gifts) Income from a reverse mortgage Veterans’ Aid & Attendance benefits Chapter 115 benefits for veterans
Assets: Countable VS. Non-Countable Countable Assets Bank accounts Whole life insurance policies, when total face value of all policies is over $1,500 Individual retirement accounts (IRA) Stocks and bonds Second homes/cars RVs/Boats Non-countable Assets Primary residence and 1 car Personal belongings & home furnishings Term life insurance policies Whole life insurance policies with total face value $1,500 or less Burial plot $1,500 burial-only account Irrevocable burial contract
Financial Eligibility Under Age 65 NO asset limits Income limit is 133% of the FPL Earned income disregard and unearned income disregard not used Modified Adjusted Gross Income (MAGI) used instead of gross income Applicant receives an income deduction equivalent to 5% of the FPL MAGI already calculated in the charts provided to SHINE counselors
Examples of MassHealth Covered Services In/Out-patient hospital services Emergency hospital services Skilled nursing facility Home health care Case management services Clinic services Diagnostic services Dental services Programs for all-inclusive care for the elderly (PACE) Personal care services (PCA) Hospice care Medical Transportation Occupational therapy Optometrist services Physical therapy Podiatrist services Preventative services Private duty nursing Prosthetic/orthotic devices Psychologist services Rehabilitative services Respite care
Applying For MassHealth Best for the individual, spouse, family member to complete the application; counselors can assist when needed 2 application types: Application for Health Coverage and Help Paying Costs (ACA-2) In general used by applicants under age 65 Application for Health Coverage for Seniors and People Needing Long-Term-Care Services (SACA-2) For applicants 65 and older
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 documentation Retroactive Coverage: Applicants age 65 and older can receive retroactive coverage up to 3 full calendar months prior to the date of application Applicants under age 65 can receive retroactive coverage beginning 10 days prior to the date of application Does not apply to MassHealth Senior Buy-in
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 guidelines These programs act like Medicare Supplements (Supplement 1), covering co-pays and deductibles and offering additional benefits
Medicare Savings Programs: MassHealth Senior Buy-In Federally referred to as the Qualified Medicare Beneficiary (QMB) Eligibility Be entitled to Medicare Income at or below 100% of the FPL Assets at or below the designated limits (change yearly) Benefits Payment of Medicare Part A & B premiums Payment of deductibles and co-pays Deemed eligible for Full Extra Help
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 appropriation Eligibility for SLMB and QI-1 Be entitled to Medicare Have income at or below: QI-1= 135% of the FPL SLMB=120% of the FPL Assets at or below the designated limits (change yearly) Benefits Payment of Medicare Part B premium Deemed eligible for Full Extra Help
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 Period The effective date of Part B coverage would not be earlier than the Buy-in start date The individual’s late enrollment penalty will be paid for by MassHealth
Caretaker Relative Eligibility 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 home Must have income at or below 133% of the FPL Benefits Eligible individuals will receive MassHealth Standard benefits Payment of Medicare Part A & B premiums, deductibles and co- pays Deemed eligible for Full Extra Help
CommonHealth Eligibility Must have a disability Must be ineligible for MassHealth Standard Must currently be working at least 40 hours per month, or currently working and worked at least 240 hours in the past 6 months MassHealth flexible on what “work” is Individuals under age 65 can waive the work requirement if they meet a one-time deductible NO financial eligibility requirements Individuals with incomes above 150% of the FPL will pay a monthly premium relative to their income
CommonHealth, cont Benefits provided Benefits similar to MassHealth Standard including payment for Part A and B co-payments and deductibles Deemed eligibile for Full Extra Help Benefits NOT provided Skilled nursing facility care Automatic payment for Part B premium Individuals must separately meet the qualifications for Buy-in in order for MassHealth to pay premiums
Frail Elder Waiver Allows elders eligible for nursing home care who want to remain at home to get the services & supports to be able to live safely Eligibility Be age 60 or older Be clinically eligible for nursing home care & receive services from the ASAP’s home care program Have income at or below 300% of the Federal SSI Rate Have assets at or below $2,000 Only counts the income & assets of the applicant even if married; any assets over $2,000 limit allowed to be transferred to non- applying spouse
Frail Elder Waiver, cont Benefits Payment of Medicare Part A & B deductibles and co-pays Deemed eligible for Full Extra Help No co-pays for prescription drugs Supportive services (ex. Personal care, homemaking, meals) To Apply To apply the individual should be referred to their local Aging Service Access Point (ASAP) ASAP staff will evaluate the applicant for clinical eligibility
Health Safety Net (HSN) Pays for medically necessary services at Massachusetts community health centers (CHCs) and hospitals 2 levels of eligibility: Full and Partial Eligibility Must be a Massachusetts resident Non-residents may receive emergency or urgent care only Full Health Safety Net Income must be at or below 200% of FPL Partial Health Safety Net Income must be above 200% but at or below 400% of FPL Individual will be assessed an annual deductible
Health Safety Net, cont. Benefits Low co-pay prescription coverage Prescription must be filled at a HSN pharmacy Will pay for allowed services not covered by Medicare, as well as Medicare co-pays, coinsurance, and deductibles Services must be delivered/ billed through a hospital or community health center that has an HSN program Can pay for services up to 6 months prior to approval HSN 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
One Care Managed care option that provides all Medicare & MassHealth services along with additional care coordination and support services to dual-eligible individuals with disabilities Members can only receive covered services through plan’s network of contracted providers One Care is not available in all counties Eligibility Be age Have Medicare Parts A & B Have MassHealth Standard or CommonHealth Cannot also be enrolled in SCO, PACE, Frail Elder Waiver, or other MassHealth waiver program
One Care, cont. Benefits All guaranteed Medicare and MassHealth benefits as well as: No premiums, deductibles, or co-pays Services coordination by an interdisciplinary care team Part D Coverage and no co-pays for prescription drugs Enhanced behavioral health and substance abuse services Long-term support Home modification Comprehensive dental Hearing aids Transportation
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 care Team of health care professionals provide integrated care plan to keep individual safe at home Eligibility Be age 55 or older Be clinically eligible for nursing home care Income at or below 300% of the Federal SSI Rate, assets at or below $2,000 PACE uses the same financial & clinical eligibility as Frail Elder Waiver Live in the service area of a PACE organization
PACE, cont. Benefits No premiums, deductibles or co-pays for dual-eligible's; Medicare only beneficiaries will have monthly premium Provides all services covered by Medicare and MassHealth Standard Provides functional, social, and psychological services to help individuals safely remain in their homes Part D coverage through the PACE plan
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) Eligibility Be age 65 or older Have a permanent and long-lasting disability Must need assistance with at least 2 ADL’s ADL examples: Dressing, eating, bathing, walking Income at or below 133% of the FPL Assets at or below $2,000 for an individual or $3,000 for a couple
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 community Eligibility Be 65 or older Qualify for MassHealth Standard (can’t have 6 month deductible) Live in a designated service area of a SCO plan NOT be diagnosed with End Stage Renal Disease NOT be an inpatient in a chronic rehabilitation hospital
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 Eligibility No income limit; applicant just must have monthly income insufficient to pay for nursing home costs To prevent impoverishment of community spouse, spouse may be able to keep some of applicants income, called the monthly maintenance needs allowance Assets limited to $2,000 Community spouse allowed to keep all assets (not counting the primary residence) up to a certain amount
Public Benefits Quiz 1.List the MassHealth Buy-In programs and the benefits they provide. 2.To be eligible for MassHealth an individual cannot own a home. True or False 1.When determining an individual’s eligibility for Supplemental Security Income (SSI), their living arrangements are considered. True or False 4. If a Medicare beneficiary has MassHealth, do they need to purchase a Medicare Supplement or join a Medicare Advantage Plan? Yes or No Why?
Public Benefits Quiz, cont. 5.What are the major differences between MassHealth for individuals under 65 and those 65 and over? 6.What resources are counted in the asset test for people over 65 who apply for MassHealth while living in the community? 7.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
Case Study 1: Anna Stetick Anna: 73 year old retired widow lives in senior housing Income: Social Security $1250/month (Net) Assets: $3300 in her checking account, $9,000 in savings Anna 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?
Case Study: 2 Robin Hood Robin: 76 years old single, retired, living in senior housing Income: 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 $1200 Insurance: Medicare A & B effective 3/1/03 and currently enrolled in the BCBS PPO plan A friend told Mr. Hood to talk to a SHINE counselor about getting on MassHealth. How would you help him?
Case Study: 3 Donna Wannago Donna: 77 year old retired widow who lives in senior housing Income: Social Security $816/month (Net) Assets: $1500 in savings, $200 in checking, life insurance policy with a face value of $1200, car valued at $4000 Insurance: Medicare A & B effective 1/22/02 & Medex Bronze Donna 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?
Case Study 4: Polly Gimmee Polly meets with you on May 10 th. 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 1 st. 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?
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?
Case Study 6: Martin Eyz Mr. 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 $1,400 in a CD. Is he eligible for MassHealth?
Case Study 7: Arthur Ritis Arthur calls for assistance. He received an Eligibility Review Form (ERV) from MassHealth to complete. He doesn’t understand why he received the form since he is not on MassHealth. He had applied in the past but was denied because he was over income ($ /month). He tells you he is homebound and called because he cannot come in for an appointment. How would you help him?
Case Study 8: Ben Hurr Ben 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?
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?
Case Study 10: May B. Poor 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?