Download SHINE Program

1
2016
SHINE Yearly
Review
Medicare
2




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 credits under Social Security
 Premium charged for beneficiaries who worked less
than 40 quarters


0-29 quarters: $411 a month
30-39 quarters: $226 a month
Medicare Eligibility
3

Medicare at age 65

If worked 10 years (40 credits) 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
Medicare Enrollment Periods
4
• Initial Enrollment Period: Age 65
• Special Enrollment Period: Up to 8 months after
active employment coverage ends
 Can get B with no penalty
• General Enrollment Period: Late/voluntary enrollees
 Jan 1st -March 31st; coverage effective July 1st
Enrolling in Medicare
5

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
 Under 20 employees, Medicare may be primary and need to
enroll in Part B- Must check with employer
 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 12-month period
of delayed enrollment
 Coverage under COBRA does NOT provide a SEP or
protect one from B penalty
Options for Medicare Coverage
6
• 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
7
2016 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
Refer to Medicare Part A and B Benefits & Gaps chart

Medicare Part A Coverage and Out-ofPocket Costs (cont.)
8
• 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
2016 Medicare Part B Coverage and Outof-Pocket Costs
9










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
Medicare Fraud & Abuse
10
• 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
Medicare Updates:
Observation Status
11
Observation Status
•
•
•
•
•
Part A only pays for care in a SNF if the care follows a Part A covered 3
day inpatient stay in a hospital
Does NOT apply to Medicare Advantage Plans
Observation status does NOT meet the Medicare requirement for SNF
coverage
Beneficiaries must resolve any issues regarding observation status
PRIOR to discharge from hospital
 Observation status issues cannot be resolved while in a SNF
The Medicare Advocacy Project continues to work with beneficiaries
who were not covered for SNF stays due to observation status; please
refer potential cases to MAP
Medicare Appeals
12
• 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
Services Not Covered by Medicare
13

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 her/him
liable for bill
FYI: “Welcome to Medicare Exam” and “Annual Wellness
Visit” ARE covered
14
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
Medicare Supplement/Medigap
Insurance (cont.)
15

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 dis-enroll beneficiary from first company
Medicare Advantage Plans
16
(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 copays

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
Medicare Advantage Plans
17
• 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
Types of Medicare Advantage
Plans
18

HMO (Health Maintenance Organization)


PPO (Preferred Provider Organization)


Most restrictive require member to receive care in network
(exception – urgent/emergency care)
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 MassHealth Standard
19
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 (Tufts in 2016)
 Residents of long-term care facilities , including recently
discharged
• Medicare Advantage Disenrollment Period: Jan. 1st – Feb. 14th
 May dis-enroll 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
Medicare Prescription Drug
Program (Part D)
20
• 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)
Enrollment Periods for Part D
21


•
•
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 (Tufts in 2016) , 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
Enrollment Periods for Part D
22
• Can also enroll during:

SEP provided to members of a PDP that will end its
contract with CMS effective January 1st
begins December 8th and ends on the last day of
February
 SEP
• Penalty for late enrollment:


1% of the benchmark (the national base beneficiary
premium) for each month an eligible person did not
enroll and did not have creditable coverage
Penalty is lifetime
2016 Part D Standard Benefit
23
•
•
•
•
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-of-pocket
costs

Refer to Part D Standard Benefit chart for current amounts
Creditable Coverage
24
• 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 days (2
full months) from the 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
Extra Help
(Low Income Subsidy/LIS)
25
• 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 chart for current amounts

Extra Help (cont.)
26

Full Extra Help: 135% of FPL


Partial Extra Help: 150% of FPL


No deductible, low co-pays
Have sliding scale premium, reduced deductible & 15%
co-pays
Assets NOT counted include:



Home
$1,500/person for funeral expenses
Life insurance policies
27
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
MassHealth Standard
28

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; doesn’t 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 chart for current amounts

MassHealth Standard
29
• 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
MassHealth Senior Buy-In: Qualified
Medicare Beneficiary (QMB)
30




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 chart for current amounts
MassHealth Buy-In Programs
(SLMB & QI-1)
31

MassHealth Buy-In (SLMB)


120% FPL
MassHealth Buy-In (QI -1)


135% FPL
Refer to public benefit eligibility chart for current amounts
MassHealth Buy-In Programs
(SLMB & QI-1)
32
• Covers 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
MassHealth Frail Elder Waiver Program
(300% Waiver Program/Spousal Waiver Program)
33

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 chart for current amounts
MassHealth Frail Elder Waiver
Program (cont.)
34

Coverage:

MassHealth Standard


Deemed eligible for LIS


MAY not pay for the Medicare Part B premium
No co-pay for drugs
Increased homecare services
Health Safety Net (HSN)
35

People 65 and over are eligible if:




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


Income no higher than 200% FPL for full HSN benefit
Income between 201-400% for partial HSN benefit
Assets not counted
Partial HSN members do NOT need to meet the MassHealth
deductible before receiving co-pay assistance for drugs
Refer to public benefit eligibility chart for current amounts
Long-Term Care MassHealth
36
• No income eligibility
• Countable assets no higher than $2,000

Countable assets include:
 Savings/checking
accounts
IRA
 Stocks/bonds
 Cash value of a whole life insurance policy
o Term life policy has no cash surrender and is
NOT a countable asset by MH

Long-term Care MassHealth
37

If married, community spouse can retain assets (home
not counted), and may be able to receive portion of SNF
resident’s income if needed (spousal income allowance/
monthly needs allowance).


Refer to public benefit eligibility chart for current amounts
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
CommonHealth
38
• 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
CommonHealth (cont.)
39
• 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
One Care
40





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
Senior Care Options Plan (SCO)
41
• 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
Prescription Advantage
42
• 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
Prescription Advantage (cont.)
43
• Provides help to people in category S5 once PA’s out-ofpocket 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
Eligibility for Prescription Advantage
44
• 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 chart for current
amounts
VA Health Plan
45
• 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
Questions?
46