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SHINE Program
Recert Review
April 2014
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
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 (worked less than
30 qtrs.) for Part A in 2014 $426 ($234 if worked 30-39 qtrs.)
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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)
can enroll into Medicare as long as:

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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
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
 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
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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

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May have network restrictions
Co-pays, may be higher costs for out-ofnetwork service
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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
7
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
8
Medicare Part B Coverage and
Out-of-Pocket Costs – 2014
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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
9
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
10
Medicare Appeals

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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:

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Why Medicare did not pay
How to appeal
Timeline for appeal
11
Services Not Covered by
Medicare

Routine Care (Note: “Welcome to Medicare
Exam” and “Annual Wellness Visit” are
covered)
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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
12
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
Under 65 – cannot have End Stage Renal
Disease
Can be offered through employer retiree
group coverage or non-group plan
13
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

14
Medicare Advantage Plans
(Part C)

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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
15
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
16
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 Senior
Care Options (for dual eligible 65 and over
who have Medicare and MassHealth Standard
or only MassHealthStandard)
17
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
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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 – cannot use the MADP to switch to another MA plan
18
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)
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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 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
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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
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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
21
Part D Standard Benefit in
2014
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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-ofpocket 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 outof-pocket costs
Refer to Part D Standard Benefit chart for current
amounts
22
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 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
23
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 MAPD
Apply via Social Security – paper application
or on line
Must meet financial eligibility
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Income limits
Asset limits
Refer to public benefit eligibility charts for
current amounts
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LIS (continued)
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Partial Extra Help:
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Have sliding scale premium, reduced
deductible & 15% co-insurance
Assets not counted include:
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Home
$1,500/person for funeral expenses
Life insurance policies
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Beneficiaries Automatically
Eligible for LIS

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
LIS members can switch Pt. D plans monthly

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Note: Institutionalized beneficiary can also
change plans monthly
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

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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
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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
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MassHealth Standard (cont.)
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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

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.
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MassHealth Senior Buy-In AKA
Qualified Medicare Beneficiary (QMB)
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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
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MassHealth Buy-In Programs
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MassHealth Buy-In (AKA QI 1)
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Income and asset limits
MassHealth Buy-In (AKA SLMB)

Income and asset limits
Refer to public benefit eligibility charts for current
amounts
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MassHealth Buy-In Programs
(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)
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MassHealth Frail Elder Waiver
Program (AKA 300% Waiver
Program/Spousal Waiver Program)

People 60 and over eligible if:
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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
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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
33
MassHealth Health
Safety Net

People 65 and over are eligible if:
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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

34
Long-Term Care Medicaid

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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
 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
35
Long-term Care Medicaid
(cont.)
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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
36
MassHealth CommonHealth

People under 65 with a disability are eligible
if:
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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)
37
MassHealth CommonHealth
(cont.)
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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
38
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
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
Enhanced behavioral health services
Comprehensive dental
39
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:
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No monthly premium
No co-pays for drugs
Comprehensive dental
40
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 S2S4 once hit donut hole of plan
41
Prescription Advantage (cont.)

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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 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
42
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
43
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

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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
44
The End – Yeah!
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