Transcript SSI - Typepad

SHINE Program
Recert Review
April 2014
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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
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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:
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Spouse* (or ex spouse) is at least age 62 with sufficient
quarters to qualify for Medicare
Medicare under age 65
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If meet Social Security disability for 24 months
*Including same-sex marriage spouse
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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
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Enrolling in Medicare

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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
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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
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Inpatient Hospital Care
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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)
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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
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*May not be required for MA members
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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
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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
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Medicare Fraud & Abuse
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Fraud
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Intentional deception or
misrepresentation an individual makes that
results in unauthorized benefit/payment
Abuse
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Unintentional practice or procedure
which may result in provider receiving
payment for services
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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
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Services Not Covered by
Medicare
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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
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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
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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
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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
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Medicare Advantage Plans
(cont.)
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May also administer group plans for
employers of active workers and
retirees
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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
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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)
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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
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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.)
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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
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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
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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
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Beneficiaries must keep letter from employer/retiree
plan stating creditable coverage
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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
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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
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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
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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)
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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)
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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
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MassHealth Health
Safety Net
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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
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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
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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
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MassHealth CommonHealth
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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
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No asset test for any MH program for under 65
(exception – Frail Elder Waiver)
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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
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Must meet income/asset eligibility for Buy-in in
order for MassHealth to pay Part B premium
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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
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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
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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
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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)
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Medicare beneficiaries 65 and older with annual
gross incomes no higher than 500% FPL
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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
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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
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The End – Yeah!
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