Transcript Document

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 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 3
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
Medicare

Special Enrollment Period (SEP): 8 months following
loss of coverage from “active” employment

General Enrollment Period (GEP): Jan 1st – March
31st of each year
• July 1st effective date
4
Delaying Part B Enrollment

Beneficiaries may choose to have just Medicare Part A while
ACTIVELY working or 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

If 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
5
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
• Only 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
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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 61-90
 Part A daily co-payment for in-patient hospital days 91-150
 Part A daily co-payment for SNF days 21-100
 Part B annual deductible
 Part B co-insurance (usually 20%)
 First three pints of blood
 Coverage outside the United States
7
Two Options For Supplementing Medicare
Step 1: Decide how you want to get your coverage
MEDICARE ADVANTAGE PLAN
ORIGINAL MEDICARE
PART A
Hospital
Insurance
&
PART B
Medical
Insurance
OR
PART C
Combines Part A, Part B
and usually Part D
Step 2: Decide if you need a Prescription Drug Plan
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
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Medigap policy
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
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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
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Part D Enrollment





Initial: Mimics Part B 7 month period
Open: Oct 15th – Dec 7th, coverage effective Jan 1st
Special: Refer to SEP chart for applicable situations
MADP: Jan 1st – Feb 14th
Late: Penalty is 1% of the benchmark (the national base beneficiary
premium) for EACH MONTH the beneficiary:
• Did not enroll in Part D 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)
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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
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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
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Prescription Advantage

Massachusetts’ State Pharmaceutical 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
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of open enrollment to enroll or switch plans)
Public Benefits
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
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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
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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)
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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
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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
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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
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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)
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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
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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

Must be a Massachusetts resident
• Defined as someone living in Massachusetts and intends
to stay

Different eligibility requirements for applicants age 65 and
older and those under age 65
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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
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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
Disregards already calculated in the Pink Sheet (Eligibility
Guidelines for Health/Prescription-Related Public Benefits Programs)
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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
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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 28
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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 disregard
equivalent to
5% of the FPL
5% FPL disregard already calculated in the Pink sheet
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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
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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-3)
 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
 Pink sheet indicates which application is used for each
MassHealth program
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
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
33
Payment For Services

MassHealth is always the payer of last resort

Any other insurance plan, including Medicare
or employer-based health plans, must pay first
before MassHealth will pay.
34
Special MassHealth Programs

In addition to the MassHealth Standard benefits
and eligibility criteria 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
35
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
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 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
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
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
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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
39
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
 Must be paid work; cannot be volunteer
 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
40
CommonHealth, cont

Benefits provided
• Benefits similar to MassHealth Standard including
payment for Part A and B co-payments and deductibles
• Deemed eligible for Full Extra Help

Benefit NOT provided
• Automatic payment for Part B premium
 Individuals must separately meet the qualifications
for Buy-in in order for MassHealth to pay premiums
41
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 nonapplying spouse
42
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
43
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
44
 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
45
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
• 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
46
SCO, cont.

Benefits
• No co-pays or deductibles
• Coordination of health care
• Prescription drugs without a co-pay
• Comprehensive dental, including dentures
• Transportation
• Specialized geriatric support services
• Adult day care
• 24 hour access to medical support
• Home care services
• Family caregiver support
47
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 21-64
• 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
48
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
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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
• Live in the service area of a PACE organization
PACE is not available in all regions of the state
50
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
51
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

•
•
52
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 53
Review
1. What does “dual-eligible” mean?
2. What are the different types of MassHealth
applications and which application is used for which
MassHealth program?
3. What MassHealth programs are specifically for
individuals with a disability?
4. What is Health Safety Net and what does it provide?
5. What benefits are available from One Care?
54