Download SHINE Program

SHINE Program
Recert Review
April/May 2016
1
Medicare

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Part A* – Hospital Insurance
Part B** – Medical Insurance
Part C – Medicare Advantage Plans

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HMO, PPO, SNP (SCOs)
Part D – Prescription Drug Coverage
*Premium cost for Part A based on quarters worked/credits earned.
Premium-free if worked 40 qtrs. under SS. Premium charged for beneficiaries
who worked less than 40 qtrs. (worked 0-29 qtrs.) full cost – for Part A in
2016 $411 ($226 if worked 30-39 qtrs.) See 2016 Medicare Part A
Benefits and Gaps
**Premium for Part B indexed per income – See 2016 Medicare
Premiums chart
2
Medicare Eligibility

Medicare at age 65

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If worked 10 years (40 qtrs.) under Social Security
and/or paid into Medicare Tax
Or married (or divorced and marriage lasted 10 years)
can enroll into Medicare as long as:

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Spouse* (or ex spouse) is at least age 62 with sufficient
quarters/credits to qualify for Medicare
Medicare under age 65

If meet Social Security disability for 24 months or
diagnosed with ESRD or ALS
*Including same-sex marriage spouse
3
Medicare Enrollment Periods
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Initial Enrollment Period – age 65
Special Enrollment Period – up to 8
months after active employment coverage
ends (can get B – no penalty)
General Enrollment Period –
late/voluntary enrollees – Jan 1-March 31
coverage effective on July 1
4
Enrolling in Medicare

Initial Enrollment Period – seven-month window
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Must contact Social Security to enroll – not automatically enrolled at 65
Date coverage begins determined by date of enrollment
Enrollment delayed if wait till after birthday month
If continue employment (client or spouse) with health
coverage beyond 65, may take Pt. A, delay Part B and
remain on EGHP – (can pick up B at any time as long as
covered by employer plan)


Must enroll in Part B within 8 months of end of active employment
or EGHP to avoid penalty – Special Enrollment Period (Note: Can
drop Part B later if return to work with employer coverage)
Penalty of 10% of current premium* for every 12-month period of
delayed enrollment
*Coverage under
penalty
COBRA does not provide a SEP or protect one from B
5
Delaying Medicare Enrollment

Can delay Medicare enrollment without a penalty if
covered because of active employment (client or
spouse). If client wants to delay should:
 Check with employer to see if coverage will change at
65
 Review employer outline of coverage with Medicare
options to compare costs and coverage
Note: If entitled to Medicare and employer has less
than 20 employees, Medicare would be primary
6
Options for Medicare Coverage

Original/Traditional Medicare
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Part A (Hospital) Part B (Medical)
Freedom of choice, gaps in coverage
Medicare Advantage Plan (MA)
(Note: MA is Medicare Not Medicare
Supplement/Medigap)


May have network restrictions
Co-pays, may be higher costs for out-of-network
7
service
Medicare Part A Coverage and
Out-of-Pocket Costs - 2016


Inpatient Hospital Care
 $1,288 deductible per benefit period
 Benefit Periods are renewable – must be out of a
hospital/facility for 60 days – unlimited # in lifetime
Skilled Nursing Facility (SNF)
 Medicare pays in full days 1-20, (must enter SNF within
30 days of a 3-day hospital stay* - not observation)
beneficiary pays $161.00/day co-pay for days 21-100
 SNF benefit period is also renewable – must be out of
SNF for 60 days
 Medicare does not provide coverage for long-term
custodial care
*May not be required for MA members
See 2016 Medicare Part A Benefits and Gaps
8
Medicare Part A Coverage and
Out-of-Pocket Costs (cont.)
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Home Health Care
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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
9
Medicare Part B Coverage and
Out-of-Pocket Costs – 2016
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Doctor, lab and X-ray services
Ambulance
Durable Medical equipment
Home Health Care, Blood
Other outpatient services
Some medications covered under Part B
Standard Pt B premium $121.80*
Annual deductible $166.00
20% co-insurance for most Part B services
See 2016 Medicare Part B Benefits and Gaps
*Note:
See 2016 Medicare Premiums sheet for premium cost for
higher income beneficiaries
10
Medicare Fraud & Abuse

Fraud

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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
11
Medicare Appeals

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Livanta (Beneficiary and Family Centered Care
Quality Improvement Organization) handles Part A
hospital appeals
MAP (Medicare Advocacy Project) can help with
most other appeals–Pt. B, Pt. C, Pt. D
Medicare Summary Notice includes info on:

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Why Medicare did not pay
How to appeal
Timeline for appeal
12
Services Not Covered by
Medicare
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Routine Care (Note: Welcome to Medicare
and Annual Wellness Visit are covered)

Eye exams/glasses, foot care, hearing
exams/hearing aids
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Note: Beneficiary may be asked to sign an ABN
(Advance Beneficiary Notice) which would make him/her
liable for bill
Medical care outside the USA
Dental care/dentures
13
Medicare Supplemental
Coverage (Medigap)
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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
Medigap companies are not required to sell to
beneficiaries under age 65 with ESRD
Can be offered through employer retiree group
coverage or non-group plan
Note: Medicare Supplement/Medigap is Not Medicare.
Medigap is private insurance a beneficiary can purchase to fill
the gaps in their coverage under original Medicare.
14
Medicare Supplement/Medigap
Insurance (cont.)
7 companies, all have continuous open enrollment* – all offer Core &
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
 Note: Both plans cover Medicare co-insurance for any medications
covered by Part B (after meet annual deductible in Core – all
doctors/providers accept both plans)
 Medex Choice – offered by BCBS only
 Similar* to Bronze only if use BC HMO “Blue Choice” network
PCP
 Similar* to Core if use BC HMO Blue network PCP
 No coverage (only Medicare) if PCP out of BC HMO Blue network
* Cannot purchase Rider – no foreign travel
Note: Enrolling in Medigap with new company does not
automatically disenroll beneficiary from first company
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15
Employer Retiree Options
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Employer Retiree Options
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Beneficiaries who have employer retiree
benefits such as:
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GIC (state/municipal retirees)
Federal Blue Cross/Blue Shield

These plans usually provide very comprehensive coverage
Clients should be referred back to their plan
administrator or Human Resource department
with questions
16
Medicare Advantage Plans
(Part C)

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Contract with CMS to provide members their Medicare benefits
Must have A & B* to join Part C and live in plan’s service
area (MA members still required to pay Pt. B premium)
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*Can join an MA during the Initial Coverage Election Period – 3 months
before, month of, 3 months after eligibility for both A & B. (Late
enrollee into Part B who is enrolling during General Enrollment Period
[January 1 – March 31] can enroll in MA plan April 1 – June 30 with
coverage effective on July 1.)
Coverage for urgent or emergency care only out of area
Not required to sell to beneficiaries with ESRD
If beneficiary enrolling in an MA plan wants Part D coverage,
must take it with the MA HMO/PPO plan. (Unless the
beneficiary is enrolled in a PFFS.) If joins stand-alone Pt. D
plan, will be dropped from MA
17
Types of Medicare Advantage
Plans
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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 SCOs
(for dual eligible 65 and over who have
Medicare and MassHealth Standard or only
MassHealthStandard)
18
Enrollment Periods for
Medicare Advantage
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Initial Coverage Election Period (Age 65: seven-month period)
Open Enrollment Period – 10/15 - 12/7
Special Enrollment Period
PA members eligible to make one change any time through year
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Extra Help and MassHealth members have continuous SEP

Five-star SEP – can enroll in 5-star plan (or switch within 5-star plan)

SEP65 – individuals who join an MA plan during the initial enrollment period
at their 65th birthday can disenroll any time during first 12 months of their
enrollment into an MA plan (Trial), return to original Medicare and join a Pt.D

Residents of long-term care facilities, including recently discharged

Move into or out of plan area (from one state to another)

Medicare Advantage Disenrollment Period – 1/1 – 2/14 – 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
Note: A late enrollee into Part B (enroll during General Open
Enrollment Period) can enroll in an MA plan from April 1-June 30 with
coverage effective on July 1.
19

Medicare Prescription Drug
Program (Part D)

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Provides outpatient prescription drug
coverage to Medicare beneficiaries
CMS contracts with private companies
to provide coverage including:
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Prescription Drug Plans (PDPs)
Medicare Advantage Prescription Drug
Plans (MA-PDs)
20
Enrollment Periods for Part D
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Enrollment period for initially eligible mirrors the seven-month window
for A & B
 Can enroll in stand-alone Part D (PDP) if have either Medicare Part
A or Part B
 Can enroll in Medicare Advantage with Part D (MAPD) only if have
both A & B
Can also enroll during:
 Open Enrollment Period of October 15 – December 7 (If
member is switching plans, simply enrolls in new plan)
 Special Enrollment Period if meet eligibility requirements
(involuntary loss of creditable coverage [such as EGHP for instance]
creditable Rx coverage under COBRA ending, move out of or into plan
service area [60 days to enroll], PA member, 5-star, Extra Help,
MassHealth)
 Medicare Advantage Disenrollment Period (MAPD) – 1/12/14) can return to original Medicare and join a stand-alone PDP
21
Enrollment Periods for Part D
(cont.)
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Nursing home residents (private pay & Medicaid) entitled
to monthly SEP
Medicare Advantage Disenrollment Period (1/1-2/14)
 Can return to original Medicare and join a stand-alone
PDP
Note:
 Change in plan’s formulary does not provide a SEP
 Dropping from Medex Gold (Sup 2) to Bronze (Sup 1)
does not provide a SEP
 Having creditable coverage under the VA does not
provide a SEP
22
Enrollment Periods for Part D
(cont.)

Can also enroll during:
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SEP provided to members of a PDP that will end
its contract with CMS effective January 1 – SEP
begins December 8 and ends on the last day of
February
Penalty for late enrollment:
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1% of National Base Premium for each month did
not enroll and did not have creditable coverage
Penalty is lifetime
23
Part D Standard Benefit in
2016
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$360 Deductible
Co-pays/co-insurance during initial coverage period or until
hit coverage gap
Coverage Gap/Donut Hole when retail costs (includes
what plan and member pay) hit $3,310
 Under Affordable Care Act will pay 45% for brands and
58% for generics in 2016
Catastrophic Coverage begins when total costs (includes
amount plan and member pay and 50% manufacturer’s
discount) hit $4,850
 Note: Plan premium does not count toward out-ofpocket costs
24
Creditable Coverage
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Coverage as good as Medicare Part D
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Many retiree plans and COBRA provide creditable
prescription coverage
Important to be aware that beneficiary has only 60
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
25
LIS (Limited/Low Income
Subsidy) AKA Extra Help
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Helps with costs of Part D plan whether beneficiary
is in PDP or MA-PD*
Provides SEP to join/switch Part D plan
Eliminates late-enrollment penalty
Must meet income/asset and eligibility:
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Income no higher than:
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150% FPL=$1,505**/mo. Individual
$2,023**/mo. Couple
Assets: $13,640 Individual - $27,250 Couple
*Note:
LIS will subsidize the premium in stand-alone Part D
basic plan or the portion of the MA-PD plan that covers Part D
premium
**Amounts include $20 disregard
See MassHealth/LIS Programs–2016 or Eligibility Guidelines for PB Programs
26
LIS (continued)
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Full Extra Help:
 $0 premium (basic plan), no deductible, co-pays:
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100% FPL - $1.20 generics, $3.60 brands
135% FPL - $2.95 generics, $7.40 for brands
Partial Extra Help: (150% FPL)
 Have sliding scale premium, $74 deductible & 15% coinsurance
Assets not counted include:
 Home
 $1,500/person for funeral expenses
 Life insurance policies
27
Beneficiaries Automatically
Eligible for LIS
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Beneficiaries are “deemed” eligible if:
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Have Medicare and MassHealth Standard or
CommonHealth – AKA “Dual Eligible”
Enrolled in a MassHealth Buy-In Program
On SSI
Note: Institutionalized beneficiary can also
change plans monthly whether private pay (nonLIS) or on LTC Medicaid
If lose LIS at end of year, have three-month SEP that
ends March 31
Note: If lose MH before July, will have LIS until end of the current calendar year (12/31)
If lose MH after July, will remain on LIS until 12/31 of following year
See Slide #31 for detail
28
Medicare and
The Health Connector (HC)
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How the Health Connector works with Medicare:
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A Health Connector member can remain on the HC plan
when become eligible for premium-free Medicare Part
A* – will not be required to take A and/or B – however:
Will lose premium subsidy or tax credits
Will be subject to Part B late enrollment penalty if delay
enrolling in Part B

If delay Part B, would only be able to enroll during the GEP –
January 1–March 31 – with coverage effective July 1
*If required to pay for Part A, would not be required to enroll and
would still receive premium subsidy
29
MassHealth Standard
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People 65 and over eligible if:
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Income: 100% FPL=$1,010*/mo. Individual
$1,355*/mo. Couple
Assets $2,000 Individual - $3,000 Couple and include:
 Savings/checking, IRA, stocks/bonds, cash value of whole life
insurance
*MH counts combined income/assets for a married couple –
does not count combined income for unmarried, living
together
Wraps around Medicare – covers premiums, deductibles, coinsurance and additional benefits such as adult day health,
medical transportation, eyeglasses, hearing, OTC generic
drugs and eligible to join a SCO (Over 65 on
CommonHealth cannot join a SCO)
*Amounts include $20 disregard
30
MassHealth Standard (cont.)

MassHealth Standard members are
deemed eligible for LIS

Note: Medicare reviews MassHealth
enrollment data in July of each year. If a
MassHealth member loses MH before
July, he/she will have LIS for the
remainder of the year (until 12/31). If a
member loses MH after July, he/she will
remain on LIS until December 31 of
following year.
31
MassHealth Senior Buy-In AKA
Medicare Savings Program (MSP)
Qualified Medicare Beneficiary (QMB)
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MassHealth Senior Buy-In Eligibility:
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Income: 100% FPL=$1,010*/mo. Individual
$1,355*/mo. Couple
Assets: $7,280 Individual – $10,930 Couple
Covers Medicare A & B premiums, deductibles & coinsurance
Deemed eligible for LIS
Need to complete MassHealth SACA-2 application
*Amounts include $20 disregard
32
MassHealth Buy-In Programs
Medicare Savings Program (MSP)
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MassHealth Buy-In (AKA QI 1)
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Income: 135% FPL=$1,357*/mo. Individual
$1,823*/mo. Couple
Assets: $7,280 Individual - $10,930 Couple
MassHealth Buy-In (AKA SLMB)
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Income: 120% FPL= $1,208*/mo. Individual
$1,622*/mo. Couple
Assets: $7,280 Individual – $10,930 Couple
Note: Buy-In programs pay the late enrollment penalty and enrollment
into Part B is effective immediately with Buy-In eligibility.
*Amounts include $20 disregard
33
MassHealth Buy-In Programs
Medicare Savings Program (MSP)
(cont.)
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Both Buy-In programs cover Part B
premium only
Members deemed eligible for LIS
Can complete MassHealth Buy-In (MHBI-1)
application for SLMB or QI1 (or senior MH
application [SACA-2] to screen/apply for
other programs such as HSN)
34
MassHealth Frail Elder Waiver/AKA
Home and Community-Based Waiver/
Spousal Waiver Program
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People 60 and over eligible if:
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Income no higher than $2,199/mo (300% SSI)
Assets in applicant’s name $2,000 or less
Note: Will waive income/assets of spouse
Meet clinical eligibility (screening done by
ASAP Coordination of Care Unit)
Receiving homecare (ASAP) service
35
MassHealth Frail Elder Waiver
Program (cont.)
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Coverage:
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MassHealth Standard
Deemed eligible for LIS
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No co-pay for drugs
Increased homecare services
Note: May not pay Medicare Part B premium
Need to Complete SACA-2 application
36
MassHealth Health
Safety Net

Medicare beneficiaries 65 and over are eligible if:
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Income no higher than 200% FPL for full HSN benefit:
 $1,962 – Individual/$2,655 – Couple
Between 200-400% for partial HSN benefit (would have
to meet a deductible* with MassHealth first)
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 MassHealth
deductible before receiving co-pay assistance for drugs
Need to complete SACA-2 application
37
Long-Term Care
MassHealth/Medicaid
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No income eligibility – member pays all but $72.80/month
(PNA – Personal Needs Allowance) of income to NH
Must meet clinical eligibility
Countable* assets no higher than $2,000
 Includes:
 Savings/checking accounts
 IRA
 Stocks/bonds
 Cash value of a whole life* insurance policy
 Not have a disqualifying transfer of assets
*Note: Term life policy has no cash surrender
and not a countable asset by MH
38
Long-term Care
MassHealth/Medicaid (cont.)

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If married, at home spouse can retain $119,220 in
countable assets (home not counted), and may be
able to receive portion of NH resident’s income if
needed (spousal income allowance/ monthly needs
allowance)
Five-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
Note: Complete SACA-2 & Long-Term Care Supplement
39
MassHealth CommonHealth: Under 65
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People under 65 with a disability eligible if:

Not eligible for MassHealth Standard
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Income over 138% FPL (MAGI) - $1,367-Indiv./$1,843-Couple
No asset test for any MH program for under 65 (exception: Frail
Elder Waiver)
No income cap in these situations:
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Eligible for MH Standard if income 138% FPL [MAGI] or less
Work at least 40 hours/month or
Meet one-time deductible/spend-down
May have premium for CommonHealth if income over 150% FPL
May not pay Part B premium if do not meet eligibility for Buy-In
Need to complete MassHealth ACA-3 application
Note: Receive coverage similar to MH Standard
40
MassHealth CommonHealth Over 65

People over 65 with a disability only eligible if:

Not eligible for MassHealth Standard
 Work 40 hours/month – no income cap
 No Asset test for over 65 for CommonHealth
 With Medicare & CommonHealth, deemed eligible for LIS
 May not pay Part B premium if do not meet income
eligibility for Buy-In Program (140% MAGI)
 May have premium for CommonHealth if income over
150% FPL
Need to complete MassHealth ACA-3 application

Note: Receive coverage similar to MH Standard
41
One Care
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One Care
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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

Providers who accept MassHealth must be in the network of a One Care plan –
providers may accept MassHealth but not One Care

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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:

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No monthly premium
No co-pays for drugs
Vision care
Comprehensive dental
42
Senior Care Options Plan
(SCO)
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Managed care plan for individuals age 65 and over who
have MassHealth Standard and Medicare or just
MassHealth Standard – Not eligible to join SCO if on
CommonHealth
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:

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No monthly premium
No co-pays for drugs
Comprehensive dental
43
Prescription Advantage
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Acts as secondary payer to Part D plan
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” (150% FPL)
immediately – Would be Category S1
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Helps with co-pays during the $74 deductible period
Instead of 15% co-insurance, would pay no more than
$7.00 for generics or $18.00 for brands
Provides help with co-pays to categories S2-S4
once hit donut hole of plan (retail costs hit $3,310)
44
Prescription Advantage (cont.)


Provides help with co-pays to category S5 once hit PA’s
out-of-pocket spending limit as PA member ($3,530)
Provides members a SEP to join or switch Part D plan
(once per year) outside of open enrollment

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Can
Can
Can
Can
switch from MA-PD plan to stand-alone PDP
switch from one MA-PD plan to another MA-PD plan
switch from stand-alone PDP to an MA-PD plan
switch from one stand-alone PDP to another stand-alone PDP
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
45
Eligibility for Prescription
Advantage (PA)

Medicare beneficiaries 65 and older with annual
gross incomes no higher than:



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
Single $59,400 – ($4,950/month)
Married $80,100 – ($6,675/month)
Note: MassHealth members are not eligible
Under 65/Medicare with disability must meet
income of 188% FPL $1,861/mo – Individual
$2,510/mo – Couple (S2 Category)
65 and over not entitled to Medicare may have PA
as primary drug plan
Note: Assets not counted
46
VA Health Plan
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

Provides health care to veterans only
VA Rx coverage considered creditable
Can also enroll in Pt. D but not required



Note: Would need a SEP (such as Prescription
Advantage) to join outside of Open Enrollment
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
47
Client Contact Form



All sections of CC form need to be completed
All programs/plans discussed should be checked
Any information/assistance about benefit programs (MH
Buy-In, MassHealth, Prescription Advantage, etc.) which
enabled client to access a program either with you or on
his/her own should be recorded in the Potential Financial
Assistance Provided section of the form


Note: Clients eligible for a Buy-In Program would have
income under 150% and below LIS Asset Limits (See Client
Monthly Income/Client Assets category on Client Contact Form)
CC forms should be sent to the regional office on the first of
the following month
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SHINE Program
Policies/Procedures



Maintain client confidentiality – share client
information with SHINE staff only and in a private
setting
Avoid conflict of interest – no financial interest by
counselor or family member in company that
provides/sells drug coverage or health insurance
Provide information to empower clients to make
their own choices about health insurance
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The End – Yeah!
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