Download Social Security

SHINE Counselor
2013 Recertification Exam
Review
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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 qtrs. under SS. Premium charged for
beneficiaries who worked less than 40 ($243/mo for 30-39 quarters;
$441/mo for 0-29 quarters for Part A in 2013)
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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) and
spouse* meets above
– *Does not apply to same-sex marriage spouse
• Medicare under age 65
– If receiving Social Security Disability for 24 months
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Medicare Enrollment Periods
• Initial Enrollment Period – age 65
• Special Enrollment Period – up to 8 months
after active employment coverage ends for
Part B and up to 2 months after creditable
coverage ends for Part D (no penalties!)
• General Enrollment Period – late/voluntary
enrollees – Jan 1-March 31 coverage effective
on July 1
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Enrolling in Medicare
• Initial Enrollment Period – seven-month window
– Date coverage begins determined by date of enrollment
– Coverage delayed if enrolled in last 4 months of window
• If continuing to work (client or spouse*) and covered by
employee plan may take Part A and delay Part B
– Must enroll in Part B within 8 months of end of active employment to
avoid penalty – Special Enrollment Period
– Penalty of 10% of current premium** for every 12-month period of
delayed enrollment
* Exception if in a same-sex marriage due to DOMA
**Coverage under COBRA does not provide a SEP or protect one from B
penalty
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Options for Medicare Coverage
• Original/Traditional Medicare
– Part A (Hospital) Part B (Medical)
– Freedom of choice, gaps in coverage
• Medicare Advantage Plan
– May have network restrictions
– Co-pays, may be higher costs for out-of-network
service
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Medicare Part A Coverage and
Out-of-Pocket Costs - 2013
• Inpatient Hospital Care
– $1,184 deductible per benefit period (days 1-60)
• Benefit Periods are renewable – must be out of a hospital/facility
for 60 days – unlimited # in lifetime
– $296/day copayment for days 61-90
– $592/day copayment for days 91-150
• Skilled Nursing Facility (SNF)
– Medicare pays in full days 1-20, (must enter SNF within 30 days of a 3day hospital stay*) beneficiary pays $148.00/day co-pay for days 21100
• 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
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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;
renewable
• Blood
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Medicare Part B Coverage and
Out-of-Pocket Costs – 2013
• Doctor, lab and X-ray services
• Ambulance
• Durable Medical equipment
– Note: DME not required to accept assignment
•
•
•
•
•
•
Home Health Care, Blood
Other outpatient services
Some medications covered under Part B
Standard Pt B premium $104.90
Annual deductible $147
After deductible, 20% co-insurance for most Part B services
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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
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Medicare Appeals
• Beneficiaries can contest a hospital discharge
through MassPro (Mass Quality Improvement
Organization)
• MAP (Medicare Advocacy Project) can help with
most appeals
• Medicare Summary Notice includes info on:
– Why Medicare did not pay
– How to appeal
– Timeline for appeal
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Services Not Covered by Medicare
• Routine Care (Note: Welcome to Medicare and
Annual Wellness Visits are covered)
– Eye exams/glasses, foot care, hearing exams/hearing aids
• 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
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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 ESRD
• Can be offered through employer retiree group
coverage or non-group plan
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Medicare Supplement/Medigap
Insurance
• Currently 7 companies selling Medigap, all have continuous
open enrollment – all offer Core and Supplement 1
– Core – less costly doesn’t cover all gaps (some have “add on” of
foreign travel)
– Supplement 1 – covers all gaps and has “add on” of foreign travel
• Note: Both plans will cover co-insurance for any medications covered by
Part B (after annual deductible is met in Core plan)
• Note: Enrolling in Medigap with new company does not
automatically disenroll bene from first company
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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 Part B premium)
• Plans not required to sell to beneficiaries with ESRD
• Plans may add additional benefits – charge premiums and copays
• If bene enrolling in an MA plan wants Part D coverage, must
take it with the MA plan. If joins stand-alone Pt. D plan, will
be disenrolled from MA
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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 companies
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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, often at higher cost
• SNP – Special Needs Plan – including SCOs for dual
eligible (have Medicare and MassHealth)
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Enrollment Periods for Medicare
Advantage
• 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 the year
Extra Help and MassHealth members have continuous SEP
Five-star SEP – can enroll in 5-star plan if available
Residents of a long term care facility, including those recently
discharged
– 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 bene was in an MA plan without drug coverage –
cannot use the MADP to switch to another MA plan
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Medicare Prescription Drug Plans
(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 (MAPDs)
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Enrollment Periods for Part D
• Enrollment period for initially eligible mirrors the seven-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 October 15 – December 7 (If member is
switching plans, simply enrolls in new plan)
– During a 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)
– Nursing home residents (private pay & Medicaid) entitled to monthly SEP
– 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
– During MADP (Medicare Advantage Disenrollment Period) can return to
original Medicare and join a stand-alone PDP
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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 1 – SEP begins
December 8 and ends on the last day of February
• Penalty for late enrollment:
– 1% of National Base Premium for each month did not
enroll and did not have creditable coverage
– Penalty is lifetime
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Part D Standard Benefit in 2013
• $325 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 $2970
– Under Affordable Care Act will receive 52.5% discount on brands and
21% discount on generics for 2013
• Catastrophic Coverage begins when out-of-pocket costs hit
$4750
– Note: Plan premium does not count toward out-of-pocket costs
• As of 1/1/13 plans will cover benzodiazepines and
barbiturates
• Barbs only covered for treatment of epilepsy, cancers, and chronic
mental health disorders
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Creditable Coverage
• Coverage as good as Medicare Part D
– Many retiree plans and COBRA provide creditable
prescription coverage
– Important to be aware that bene 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
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LIS (Limited/Low Income Subsidy)
AKA Extra Help
• Helps with costs of Part D plan whether beneficiary is
in PDP or MAPD
• Apply via Social Security – paper app. or on line
• Must meet income and eligibility
– Income no higher than 150%FPL
• $1,417/mo. I - $1,912/mo. C
– Assets no higher than:
• $13,300 – Individual
• $26,580 – Couple
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LIS (continued)
• Partial Extra Help:
– Have $66 deductible & 15% co-insurance
• Assets not counted include:
– Home
– $1,500/person for funeral expenses
– Life insurance policies
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Beneficiaries Automatically
Eligible for LIS
• Beneficiaries are “deemed” eligible if:
– Have Medicare and MassHealth – AKA “Dual Eligible”
– Enrolled in a MassHealth Buy-In Program
– On SSI
• LIS members can switch Part D plans monthly
– Note: Institutionalized bene can change plans monthly
also
– If lose LIS at end of year, have three-month SEP
that ends March 31
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MassHealth Standard
• People 65 and over eligible if meet income/asset
requirements
– Income: 100% FPL: $951/mo (individual), $1,281*/mo
(couple)
– Assets $2,000 (individual) , $3,000 (couple)
• Wraps around Medicare – covers premiums,
deductibles, co-insurance and additional benefits
such as adult day health, medical transportation,
eyeglasses, hearing, OTC generic drugs
*Note: Massachusetts recognizes same-sex marriage so MassHealth will
count gross combined income and assets for same-sex couples
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MassHealth Standard (cont.)
• MassHealth members are deemed eligible for
LIS; no LIS application necessary
• If lose MH still remain eligible for LIS for
remainder of year
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MassHealth Senior Buy-In AKA Qualified
Medicare Beneficiary (QMB)
• People 65 and over eligible if meet income/asset
requirements
– Income: 100% FPL - $951/mo (individual) , $1,281/mo
(couple)
– Assets: $7,080 (individual) , $10,620 (couple)
• Covers Medicare A & B premiums, deductibles & coinsurance
• Deemed eligible for LIS
• Need to complete SMBR application
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MassHealth Buy-In Programs
• MassHealth Buy-In (AKA QI 1)
– Income: 135% FPL - $1,277/mo (individual),
$1,723/mo (couple)
– Assets: $7,080 (individual), $10,620 (couple)
• MassHealth Buy-In (AKA SLMB)
– Income: 120% FPL - $1,137/mo (individual),
$1,533/mo (couple)
– Assets: $7,080 (individual), $10,620 (couple)
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MassHealth Buy-In Programs
(cont.)
• Both Buy-In programs cover Part B premium
only
• Members deemed eligible for LIS
• Need to complete MassHealth Buy-In (MHBI1) application for SLMB or QI1
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MassHealth Frail Elder Program
(AKA 300% Waiver Program/Spousal Waiver Program)
• People 60 and over eligible if:
– Income no higher than $2,130/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
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MassHealth Frail Elder Program
(cont.)
• Coverage:
– MassHealth Standard
– Deemed eligible for LIS
– Increased homecare services
Note: May not pay Medicare Part B premium
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Health Safety Net
• People 65 and over are eligible if:
– Income no higher than 200% FPL (for full HSN benefit –
201-400% for partial HSN)
– Assets not counted
• Covers Part A deductible or hospital co-pays in MA
plan if eligible for full HSN
• 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
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Long-Term Care Medicaid
• No income eligibility – member pays all but
$72.80/month (PNA) of income to NH
• Countable assets no higher than $2,000
• If married, at home spouse can retain $113,640 in
cash assets, (home not counted) and may be able to
receive portion of NH resident’s income if needed
(spousal income allowance or monthly maintenance
needs allowance)
• 5 year look back on transfers of income and assets
– Transfers of income and/or assets for less than fair market
value during look back period may result in a
disqualification period
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MassHealth CommonHealth
• People under 65 with a disability are eligible
if:
– Income higher than 133% FPL (no maximum limit,
assets not counted)
AND
– Meet one-time only deductible or meet 40
hour/month work requirement
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MassHealth CommonHealth
(cont.)
• CommonHealth only available to people over 65 who
can document a disability and work 40 hours/month
• No Asset test for over 65 for CommonHealth
• Provides comprehensive coverage
• If have Medicare and MassHealth, deemed eligible
for LIS
– Not automatically eligible for MassHealth Buy-in, must
meet those income and asset requirements
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Prescription Advantage
• 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” (S1) with co-pays
immediately – no deductible
• Provides help with co-pays to categories S2-S4 once
hit donut hole of plan (retail costs hit $2,970)
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Prescription Advantage (cont.)
• Provides help with co-pays to category S5 once hit
PA’s out-of-pocket spending limit 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
• Can be primary Rx coverage if not on Medicare
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Eligibility for Prescription
Advantage (PA)
• Medicare beneficiaries 65 and older with annual
gross incomes no higher than:
 Single $55,850 – ($4,655/month)
 Married $75,650 – ($6,305/month)
 Note: MassHealth members not eligible
• Medicare beneficiaries under 65 must have income
at or below 188% FPL (S2 Category)
• 65 and over not eligible for Medicare may have PA as
primary drug plan
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VA Health Plan
• Provides health care to veterans only
• VA Rx coverage considered creditable
• Can also enroll in Part D but not required
– Note: 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
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Commonwealth Care
• Coverage offered through Massachusetts Health
Connector to Mass residents who are:
– Adults (19+) with gross household income at or less than
300% FPL
– US citizen/national, qualified alien, alien with special
status
– Uninsured or:
• Insured under COBRA
• Paying full market non-group premium
• In waiting period for employer coverage
Note: Medicare beneficiaries with premium-free Part A are not
eligible
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Commonwealth Choice
• Private health insurance for adults who are
Mass residents
• No Income eligibility
• Offers small employers option to purchase
through the Connector
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Accountable Care Organizations ACOs
• ACOs are not HMOs
• Doctors, hospitals, providers coordinate care
through an ACO
• Beneficiaries whose doctor participates can still see
any provider who accepts Medicare
• Beneficiaries may choose to have personal
information removed from info Medicare shares
with doctor
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The End – Yeah!
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