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SHINE Counselor 2013 Recertification Exam Review

SHINE Counselor 2013 Recertification Exam Review. Medicare. Part A* – Hospital Insurance Part B – Medical Insurance Part C – Medicare Advantage Plans HMO, PPO, SNP Part D – Prescription Drug Coverage

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SHINE Counselor 2013 Recertification Exam Review

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  1. SHINE Counselor2013 Recertification ExamReview

  2. 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)

  3. 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

  4. 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

  5. Enrolling in Medicare • Initial EnrollmentPeriod – 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

  6. 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

  7. 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 3-day hospital stay*) beneficiary pays $148.00/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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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 co-pays • 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

  16. 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

  17. 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)

  18. 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 – cannotuse the MADP toswitch to another MA plan

  19. 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 (MA-PDs)

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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 & co-insurance • Deemed eligible for LIS • Need to complete SMBR application

  30. 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)

  31. 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 (MHBI-1) application for SLMB or QI1

  32. 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

  33. MassHealth Frail Elder Program (cont.) • Coverage: • MassHealth Standard • Deemed eligible for LIS • Increased homecare services Note: May not pay Medicare Part B premium

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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)

  39. 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 Notneed to be enrolled in Part D to join PA • Can be primary Rx coverage if not on Medicare

  40. 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

  41. 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

  42. 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

  43. Commonwealth Choice • Private health insurance for adults who are Mass residents • No Income eligibility • Offers small employers option to purchase through the Connector

  44. 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

  45. The End – Yeah!

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