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SHINE Program

SHINE Program. Recert Review April 2014. 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 Program

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  1. SHINE Program Recert Review April 2014

  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 Social Security. Premium charged for beneficiaries who worked less than 40 – full cost (workedless than 30 qtrs.) for Part A in 2014 $426 ($234 if worked 30-39 qtrs.)

  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) can enroll into Medicare as long as: • Spouse* (or ex spouse) is at least age 62 with sufficient quarters to qualify for Medicare • Medicare under age 65 • If meet Social Security disability for 24 months *Including same-sex marriage spouse

  4. Medicare Enrollment Periods • 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

  5. Enrolling in Medicare • Initial EnrollmentPeriod – seven-month window • Date coverage begins determined by date of enrollment • Enrollment delayed if wait until after birthday month • If continue employment (client or spouse) with health coverage beyond 65, may take Pt. A and delay Pt. 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 *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 - 2014 • Inpatient Hospital Care • 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*) beneficiary pays 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 • Refer to Medicare Part A and B Benefits & Gaps chart *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 • Blood

  9. Medicare Part B Coverage and Out-of-Pocket Costs – 2014 • 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

  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 • MassPro (Mass 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: • Why Medicare did not pay • How to appeal • Timeline for appeal

  12. Services Not Covered by Medicare • Routine Care (Note: “Welcome to Medicare Exam” and “Annual Wellness Visit” 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 End Stage Renal Disease • Can be offered through employer retiree group coverage or non-group plan

  14. 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 • Note: 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) *Note: Enrolling in Medigap with new company does not automatically disenroll beneficiary 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 Pt. B premium) • Plans not required to sell to beneficiaries with ESRD • Plans may add additional benefits – charge premiums and co-pays • If beneficiary enrolling in an MA HMO/PPO plan wants Part D coverage, must take it with the plan. (Not required if beneficiary is enrolled in a PFFS.) If joins stand-alone Pt. D plan, will be dropped 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 company

  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 usually at higher cost • SNP – Special Needs Plan – including Senior Care Options (for dual eligible 65 and over who have Medicare and MassHealth Standard or only MassHealthStandard)

  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 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 – 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 – cannotuse the MADP toswitch to another MA plan

  19. 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)

  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 • 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 • During MADP (Medicare Advantage Disenrollment Period – 1/1-2/14) 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 2014 • 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 • Note: Plan premium does not count toward out-of-pocket costs Refer to Part D Standard Benefit chart for current amounts

  23. 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 60 days from end of creditable coverage to enroll in Pt. 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 application or on line • Must meet financial eligibility • Income limits • Asset limits Refer to public benefit eligibility charts for current amounts

  25. LIS (continued) • Partial Extra Help: • Have sliding scale premium, reduced 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 Standard or CommonHealth – AKA “Dual Eligible” • Enrolled in a MassHealth Buy-In Program • On SSI • LIS members can switch Pt. D plans monthly • Note: Institutionalized beneficiary can also change plans monthly • 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 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 not 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

  28. 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 • 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.

  29. MassHealth Senior Buy-In AKA Qualified Medicare Beneficiary (QMB) • People 65 and over eligible if meet income/asset requirements • Covers Medicare A & B premiums, deductibles & co-insurance • Deemed eligible for LIS • Need to complete MassHealth Senior (SACA-2) application Refer to public benefit eligibility charts for current amounts

  30. MassHealth Buy-In Programs • MassHealth Buy-In (AKA QI 1) • Income and asset limits • MassHealth Buy-In (AKA SLMB) • Income and asset limits Refer to public benefit eligibility charts for current amounts

  31. MassHealth Buy-In Programs (cont.) • 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)

  32. MassHealth Frail Elder Waiver Program (AKA 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 • Note: 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

  33. MassHealth Frail Elder Waiver Program (cont.) • Coverage: • MassHealth Standard • Deemed eligible for LIS • No co-pay for drugs • Increased homecare services Note: May not pay Medicare Part B premium

  34. MassHealth Health Safety Net • People 65 and over are eligible if: • Income no higher than 200% FPL for full HSN benefit; 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

  35. Long-Term Care Medicaid • No income eligibility – member pays all but $72.80/month (Personal Needs Allowance) of income to SNF • Countable* assets no higher than $2,000 • Includes: • Savings/checking accounts • IRA • Stocks/bonds • Cash value of a whole life* insurance policy *Note: Term life policy has no cash surrender and not a countable asset by MH

  36. Long-term Care Medicaid (cont.) • If married, at home 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) • 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

  37. MassHealth CommonHealth • People under 65 with a disability are eligible if: • Income above 133% FPL, no limit • Working 40 hours/month, or Meet a one-time deductible • No asset test for any MH program for under 65 (exception – Frail Elder Waiver)

  38. MassHealth CommonHealth (cont.) • CommonHealth only available to people 65 and over 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 • Must meet income/asset eligibility for Buy-in in order for MassHealth to pay Part B premium

  39. One Care • 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

  40. 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

  41. 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

  42. 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 notneed 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

  43. Eligibility for Prescription Advantage (PA) • Medicare beneficiaries 65 and older with annual gross incomes no higher than 500% FPL • Note: 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 charts for current amounts

  44. VA Health Plan • 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 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

  45. The End – Yeah!

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