Transcript SHINE Program

2015 SHINE
Recertification
Revie w
1
Medicare




Part A: Hospital Insurance *
Part B: Medical Insurance
Part C: Medicare Advantage Plans (HMO, PPO, SNP)
Part D: Prescription Drug Coverage
*Premium-free if worked 40 quarters under Social
Security
• Premium charged for beneficiaries who
worked less than 40 quarters
• Full cost (worked less than 30 qtrs.) for Part
A in 2015 $426 ($234 if worked 30-39 qtrs.)
2
Medicare Eligibility

Medicare at age 65

If worked 10 years (40 qtrs.) under Social Security
and paid into Medicare Tax
 Or married (or divorced and marriage lasted 10 years)
can enroll into Medicare as long as:
Spouse/Ex-Spouse (includes same-sex spouses) is at
least age 62 with sufficient quarters to qualify for
Medicare

Medicare under age 65
 If meet Social Security disability for 24 months
3
Medicare Enrollment
Periods

Initial Enrollment Period: Age 65

Special Enrollment Period: Up to 8 months
after active employment coverage ends (can get Bno penalty)

General Enrollment Period: Late/voluntary
enrollees
 Jan 1st -March 31st; coverage effective July 1st
4
Enrolling in Medicare

Initial Enrollment Period: 7 month window
 Date coverage begins is determined by the date of
enrollment
 Enrollment is delayed if you wait until after birthday
month

If continue employment (client or spouse) with health
coverage beyond 65, may take Part A and delay Part B
 Must enroll in Part B within 8 months of end of active
employment to avoid penalty= SEP
 Penalty of 10% of current premium for every 12month period of delayed enrollment
 Coverage under COBRA does NOT provide a SEP
or protect one from B penalty
5
Options for Medicare
Coverage

Original/Traditional Medicare
 Part A (Hospital) Part B (Medical)
 Freedom of choice
 Gaps in coverage

Medicare Advantage Plan (Part C)
 May have network restrictions
 Co-pays
 May be higher costs for out-of-network service
6
2015 Medicare Part A Coverage
and Out-of-Pocket Costs
Inpatient Hospital Care
 Deductible per benefit period
 Benefit Periods: Renewable (unlimited # of periods in
lifetime), but must be out of a hospital/facility for 60 days
 Skilled Nursing Facility (SNF)
 Medicare pays in full days 1-20, (must enter SNF within 30
days of a 3-day hospital stay) beneficiary pays co-pay for
days 21-100
SNF benefit period is also renewable; must be out of SNF
for 60 days
May not be required for MA members
 Medicare does NOT provide coverage for long-term
custodial care
7
 Refer to Medicare Part A and B Benefits & Gaps chart

Medicare Part A Coverage and
Out-of-Pocket Costs (cont.)

Home Health Care
 Physician ordered
 Patient homebound &
 Requires intermittent/part-time skilled care
 No co-pay for home health

Hospice Care
 Have life expectancy of six months or less

Blood
8
2015 Medicare Part B Coverage
and Out-of-Pocket Costs









Doctor, lab and X-ray services
Ambulance
Durable Medical equipment
Home Health Care, Blood
Other outpatient services
Some medications covered under Part B
Standard premium
Annual deductible
20% co-insurance for most Part B services
 Refer to Medicare Part A and B Benefits & Gaps
chart for current amounts
9
Medicare Fraud &
Abuse

Fraud
 Intentional deception or misrepresentation
an individual makes that results in
unauthorized benefit/payment

Abuse
 Unintentional practice or procedure which
may result in provider receiving payment for
services
10
Medicare Appeals

Livanta (Beneficiary and Family Centered Care
Quality Improvement Organization)
 Handles Part A hospital appeals

MAP (Medicare Advocacy Project)
 Can help with most other appeals; Parts B, C, &D

Medicare Summary Notice includes info on:
 Why Medicare did not pay
 How to appeal
 Timeline for appeal
11
Services Not Covered
by Medicare

Routine Care
 Eye exams/glasses, foot care, hearing
exams/hearing aids
 Medical care outside the USA
 Dental care/dentures
FYI: Beneficiary may be asked to sign an ABN
(Advance Beneficiary Notice) which would make
him/her liable for bill
 FYI: “Welcome to Medicare Exam” and “Annual
Wellness Visit” ARE covered
12
Medicare Supplemental
Coverage (Medigap)

Designed to supplement/fill the gaps of original
Medicare

Pays second to Medicare for Medicare covered
services with added services offered by plan

Must have A & B to join a Medigap

Under 65: CANNOT have End Stage Renal Disease

Can be offered through employer retiree group
coverage or non-group plan
13
Medicare Supplement/Medigap
Insurance (cont.)

Currently 7 companies selling Medigap, all have
continuous open enrollment; all offer Core and
Supplement 1
 Core: Less costly, doesn’t cover all gaps including Part
A hospital deductible and SNF co-pay (some have
“add on” of foreign travel)
 Supplement 1: Covers all gaps and all have “add on”
of foreign travel
 FYI: Both plans will cover Medicare co-insurance for
any medications covered by Part B (after meet annual
deductible in Core plan – all doctors/providers accept
both plans)
• Enrolling in Medigap with new company DOES NOT
automatically disenroll beneficiary from first company
14
Medicare Advantage
Plans (Part C)

Contract with CMS to provide members all their Medicare
benefits

Must have A & B to join Part C and live in plan’s service
area
 MA members still required to pay the Part B premium

Plans not required to sell to beneficiaries with ESRD

Plans may add additional benefits – charge premiums and
co-pays

If a beneficiary enrolling in an MA HMO/PPO plan wants
Part D coverage, they MUST take it with the plan
 Not required if beneficiary is enrolled in a PFFS
 If joins stand-alone Part D plan, will be dropped from MA
15
Medicare Advantage
Plans (cont.)

May also administer group plans for
employers of active workers and retirees
 Employer group managed care plans are NOT
the same as Medicare Advantage plans even
though they may have the same or similar
names and are offered by the same company
16
Types of Medicare
Advantage Plans

HMO (Health Maintenance Organization)
 Most restrictive require member to receive care in
network (exception – urgent/emergency care)

PPO (Preferred Provider Organization)
 Allow member to go out of network usually at
higher cost

SNP (Special Needs Plan)
 Including Senior Care Options which is a plan for
dual eligible 65 and over who have Medicare and
MassHealth Standard or only MassHealthStandard
17
Enrollment Periods for
Medicare Advantage
Initial Coverage Election Period (Age 65=7 month period)
 Open Enrollment Period: Oct. 15th-Dec. 7th
 Special Enrollment Period
 PA members eligible to make one change any time through
year
 Extra Help and MassHealth members have continuous SEP
 Five-star SEP – can enroll in 5-star plan if available
 Residents of long-term care facilities , including recently
discharged
• Medicare Advantage Disenrollment Period: Jan. 1st – Feb. 14th
 May disenroll from MA and return to original Medicare and
pick up a Part D plan even if beneficiary was in an MA plan
without drug coverage
 Cannot use the MADP to switch to another MA plan

18
Medicare Prescription
Drug Program (Part D)

Provides outpatient prescription drug
coverage to Medicare beneficiaries

CMS contracts with private companies to
provide coverage including:
 Prescription Drug Plans (PDPs)
 Medicare Advantage Prescription Drug Plans
(MA-PDs)
19
Enrollment Periods for Part D

Enrollment period for initially eligible mirrors the 7 month window
for A & B
 Can enroll in Part D if have either Medicare Part A or Part B

Can also enroll during:
 Annual Open Enrollment Period of Oct. 15th – Dec. 7th (If
member is switching plans, simply enrolls in new plan)
 Special Enrollment Period if meet eligibility requirements
Involuntary loss of creditable coverage for instance [60 days to
enroll], PA member, 5-star, Extra Help, MassHealth)
 Medicare Advantage Disenrollment Period: Jan 1st –Feb. 14th
Can return to original Medicare and join a stand-alone PDP
Nursing home residents entitled to monthly SEP
Circumstances that DO NOT provide a SEP
 Change in plan’s formulary
 Dropping from Medex Gold (Sup 2) to Bronze (Sup 1)
 Having creditable coverage under the VA
20
•
•
Enrollment Periods for
Part D (cont.)

Can also enroll during:
 SEP provided to members of a PDP that will
end its contract with CMS effective January 1st
SEP begins December 8th and ends on the last day
of February

Penalty for late enrollment:
◦ 1% of National Base Beneficiary Premium for
each month an eligible person did not enroll
and did not have creditable coverage
◦ Penalty is lifetime
21
2015 Part D Standard
Benefit

Deductible

Co-pays during initial coverage period or until hit
coverage gap

Coverage Gap/Donut Hole when retail costs (includes
what plan and member pay) hit out-of-pocket threshold
 Under Affordable Care Act, receives different discounts
on generics and brands

Catastrophic Coverage begins when beneficiary reaches
TROOP
 FYI: Plan premium DOES NOT count toward out-ofpocket costs

Refer to Part D Standard Benefit chart for current
amounts
22
Creditable Coverage

Coverage as good as Medicare Part D
 Many retiree plans and COBRA provide creditable
prescription coverage
 Important to be aware that beneficiary has only 63
(2 full months) days from end of creditable
coverage to enroll in Part D
 Coverage with the VA Health Plan IS creditable

All Medicare beneficiaries (including those still
working) must have creditable coverage to avoid the
late enrollment penalty
 Beneficiaries must keep letter from
employer/retiree plan stating creditable coverage
23
Extra Help
(Low Income Subsidy)

Helps with costs of Part D plan whether
beneficiary is in PDP or MAPD

Apply via Social Security
 Paper application or online

Must meet financial eligibility
 Income limits
 Asset limits
 Refer to public benefit eligibility
current amounts
charts for
24
Extra Help (cont.)

Full Extra Help: 135% of FPL
 No deductible, low co-pays

Partial Extra Help: 150% of FPL
 Have sliding scale premium, reduced
deductible & 15% co-insurance

Assets NOT counted include:
 Home
 $1,500/person for funeral expenses
 Life insurance policies
25
Beneficiaries Automatically
Eligible for Extra Help

Beneficiaries are “deemed” eligible if:
 Have Medicare and MassHealth Standard or
CommonHealth (“Dual Eligible”)
 Enrolled in a MassHealth Buy-In Program
 On SSI

LIS members can switch Part D plans monthly
◦ FYI: Institutionalized beneficiary can also change plans
monthly
◦ If lose LIS at end of year, have 3 month SEP that ends
March 31st
26
MassHealth Standard

People 65 +: Eligible if meet income/asset requirements
 Income limit: 100% FPL
 Asset limits: $2,000 (individual), $3,000 (couple)
Includes savings/checking, IRA, stocks/bonds, cash
value of whole life insurance
MH counts combined income/assets for a married
couple; does’nt count the combined income for
unmarried, living together

People under age 65 eligible if meet income
requirements
 NO asset requirements
 Income limit: 133% FPL
 Refer to public benefit eligibility charts for current
amounts
27
MassHealth Standard
(cont.)
Wraps around Medicare
 Covers premiums, deductibles, co-insurance and
additional benefits such as adult day health, medical
transportation, eyeglasses, hearing, OTC generic drugs
 MassHealth Standard members are deemed eligible for
LIS
 Medicare reviews MassHealth enrollment data in July of
each year
 If a MassHealth member loses MH before July, she/he
will have LIS until Dec. 31st of that year
 If a member loses MH after July, she/he will remain on
LIS until Dec. 31st of following year
28

MassHealth Senior Buy-In: Qualified
Medicare Beneficiary (QMB)





People 65 and over eligible if meet income/asset
requirements
Covers Medicare A & B premiums, deductibles & coinsurance
Deemed eligible for LIS
Need to complete MassHealth Senior (SACA-2)
application
Refer to public benefit eligibility charts for current
amounts
29
MassHealth Buy-In Programs
(SLMB & QI-1)

MassHealth Buy-In (SLMB)
 120% FPL

MassHealth Buy-In (QI -1)
 135% FPL
 Refer to public benefit eligibility charts for
current amounts
30
MassHealth Buy-In Programs
(SLMB & QI-1)

Cover Part B premium only

Members deemed eligible for LIS

To apply:
 Can complete MassHealth Buy-In (MHBI-1)
application for SLMB or QI-1
 Or can complete a senior MH application
[SACA-2] to screen/apply for other programs
such as HSN
31
MassHealth Frail Elder Waiver Program (300%
Waiver Program/Spousal Waiver Program)

People 60 and over eligible if:
 Income no higher than 300% of the SSI rate
 Assets in applicant’s name $2,000 or less
Will waive income/assets of spouse
 Meet clinical eligibility
Screening done by ASAP Coordination of Care Unit
 Receiving homecare (ASAP) service
 Refer to public benefit eligibility
charts for
current amounts
32
MassHealth Frail Elder
Waiver Program (cont.)

Coverage:
 MassHealth Standard
May not pay Medicare Part B premium
 Deemed eligible for LIS
No co-pay for drugs
 Increased homecare services
33
Health Safety Net
(HSN)

People 65 and over are eligible if:
 Income no higher than 200% FPL for full HSN benefit
 Income between 201-400% for partial HSN benefit
 Assets not counted

Covers Part A deductible or hospital co-pays in MA
plan if eligible for full HSN
 Does NOT cover care in a SNF

Can receive care and Rx coverage at Community
Health Centers and hospitals
 Partial HSN members do NOT need to meet the MassHealth
deductible before receiving co-pay assistance for drugs

Refer to public benefit eligibility charts for current amounts
34
Long-Term Care
MassHealth
No income eligibility
 Member pays all but $72.80/month (Personal
Needs Allowance) of income to SNF
 Countable assets no higher than $2,000
 Countable assets include:
Savings/checking accounts
 IRA
Stocks/bonds
Cash value of a whole life insurance policy
oTerm life policy has no cash surrender and is
NOT a countable asset by MH

35
Long-term Care
MassHealth (cont.)

If married, community spouse can retain $117,240
in countable assets (home not counted), and may
be able to receive portion of SNF resident’s income
if needed (spousal income allowance/ monthly
needs allowance)

5 year look back at transfers of income/assets
 Transfers of assets for less than fair market value
during look-back period may result in a
disqualification period
36
CommonHealth
MassHealth program
 People under 65 with a disability are eligible
if:

 Income above 133% FPL, no limit
 Working 40 hours a month, or
 Meet a one-time deductible
 No asset test for any MH program for under 65
(exception – Frail Elder Waiver)
37
CommonHealth (cont.)

CommonHealth ONLY available to people 65
and over who can document a disability and
work 40 hours a month

No Asset test for over 65 for CommonHealth

Provides comprehensive coverage

If have Medicare and MassHealth, deemed
eligible for LIS
 Must meet income/asset eligibility for Buy-in in order
for MassHealth to pay Part B premium
38
One Care
Managed care plan for dual-eligible (have Medicare and
MassHealth Standard or CommonHealth) individuals
between the ages of 21-64
 Receive health care through plan’s network of providers
 Receive Part D coverage through plan
 Can opt in/out at any time; change takes effect on first of
following month
 Some additional coverage benefits:
 No monthly premium
 No co-pays for drugs
 Enhanced behavioral health services
 Comprehensive dental

39
Senior Care Options
Plan (SCO)





Managed care plan for individuals age 65 and over who have
MassHealth Standard and Medicare or just MassHealth
Standard
Receive health care through plan’s network of providers
Receive Part D coverage through plan
Can opt in/out at any time – change takes effect on first of
following month
Some additional coverage benefits:
 No monthly premium
 No co-pays for drugs
 Comprehensive dental
40
Prescription Advantage

Acts as secondary payer to Part D plan or other
creditable coverage

Don’t need Part D to enroll but no benefit until
have Part D

No cost to join for most income categories (S0-S4)

Provides help to LIS “partials” (S1) with co-pays
immediately; no deductible

Provides help with co-pays to categories S2-S4
once hit donut hole of plan
41
Prescription Advantage
(cont.)

Provides help to people in category S5 once PA’s
out-of-pocket spending limit is reached, as PA
member

Provides all members a SEP to join or switch Part D
plan (once per year) outside of Part D open
enrollment

Do NOT need to be enrolled in Part D to join PA

Requires applicants who are income/asset eligible
for LIS to apply for that program

Can be primary Rx coverage if not on Medicare
42
Eligibility for Prescription
Advantage

Medicare beneficiaries 65 and older with annual
gross incomes no higher than 500% FPL
 MassHealth members NOT eligible

Under 65/Medicare with a disability must meet
income of 188% FPL (S2 Category)

65 and over not entitled to Medicare may have PA
as primary drug plan
 Refer to public benefit eligibility
current amounts
charts for
43
VA Health Plan

Provides health care to veterans only

VA Rx coverage considered creditable

Can also enroll in Pt. D but not required
 Would need a SEP to join outside of OEP

Medicare enrolled vet can receive care either
from VA or Medicare
 CANNOT receive care under both at same time

Good idea to have coverage outside of VA for
emergency
44
The End – Yeah!
45