Medicare Advantage Plan
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Transcript Medicare Advantage Plan
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2015
SHINE
Recertification
Review
Medicare
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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 quarters under Social
Security
Premium charged for beneficiaries who worked less
than 40 quarters
0-29 quarters: $407 a month
30-39 quarters: $224 a month
Medicare Eligibility
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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/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
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• 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
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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
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• 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
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2015 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.)
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• 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
2015 Medicare Part B Coverage and Outof-Pocket Costs
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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 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
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• 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
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Observation Status
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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
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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; 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
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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
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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 End Stage Renal Disease
• Can be offered through employer retiree group
coverage or non-group plan
Medicare Supplement/Medigap
Insurance (cont.)
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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)
FYI: BCBS offering another plan option in 2015 called Medex
Choice; a Medicare Select Plan (hybrid between Medigap and
MA Plan)
• Enrolling in Medigap with new company DOES NOT
automatically dis-enroll beneficiary from first company
Medicare Advantage Plans
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(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
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• 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
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Types of Medicare Advantage
Plans
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
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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 if available
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)
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• 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
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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, 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
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• 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
2015 Part D Standard Benefit
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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
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• 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)
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• 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 charts for current amounts
Extra Help (cont.)
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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
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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
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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 charts for current amounts
MassHealth Standard
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• 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)
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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 charts for current amounts
MassHealth Buy-In Programs
(SLMB & QI-1)
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MassHealth Buy-In (SLMB)
120% FPL
MassHealth Buy-In (QI -1)
135% FPL
Refer to public benefit eligibility charts for current amounts
MassHealth Buy-In Programs
(SLMB & QI-1)
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• 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)
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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 charts for current amounts
MassHealth Frail Elder Waiver
Program (cont.)
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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)
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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 charts for current amounts
Long-Term Care MassHealth
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• No income eligibility
Member pays all but $72.80/month (Personal Needs
Allowance) of income to SNF
• 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
NOT a countable asset by MH
is
Long-term Care MassHealth
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If married, community 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)
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
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• 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.)
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• 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
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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
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)
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• 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
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• 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.)
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• 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
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• 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 charts for current
amounts
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
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
The End – Yeah!
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