Transcript Medicare Part D and Low-Income Subsidy Program

2015 SHINE
Certification Review
Medicare Part A & B
“Original Medicare”
Medicare Overview
Medicare is a health insurance program for:
 People 65 years of age and older
(not necessarily full retirement age)
 People under age 65 with disabilities
(deemed “disabled” by Social Security for at least 24
months)
 People under age 65 and have ALS or ESRD
Note: Medicare is NOT Medicaid (which is health insurance
for very low income population)
Medicare Eligibility

Individuals 65 and older
• Entitled to receive Social Security Benefits and
contributed to the Medicare Tax
• Entitled to receive Railroad Retirement Act retiree
benefits
• Be a spouse, ex spouse (marriage lasted at least
10 years), widow or widower (age 65 and over) of
a person who qualifies for Social Security or
Medicare Benefits
Medicare Eligibility

Individuals can qualify for Medicare through a
spouse if the spouse is:
• Aged 62 and over and
• Worked 10 years (40 quarters)
• Contributed to Medicare Tax
Medicare Eligibility

Individuals under age 65
• Receiving Social Security Disability Insurance
(SSDI) for 24 months
• End-Stage Renal Disease (ESRD)
• Amyotrophic Lateral Sclerosis (ALS)
Medicare Parts & Premiums
• Part A & B: “Original Medicare”
• Part A: Hospital & Skilled Nursing Care
 Premium free for most people – may purchase if
insufficient work credits but very expensive)
• Part B: Doctors’ Visits & Outpatient Care
 $104.90/month in 2015 for beneficiaries with individual
income <$85,000/year)
Medicare Agencies

Beneficiaries must enroll through Social Security
Administration (SSA) for Medicare Benefits
• If already receiving Social Security before turning 65, enrollment
into Part A and Part B is automatic
• If not already receiving Social Security benefits an individual must
contact Social Security (in-person, online, or phone) to enroll
into Medicare



Initial Enrollment Period is the 3 months before, the month of, and
3 months after, an individuals 65th birthday.
May delay enrolling into Social Security Benefits
Medicare is administered by The Centers for Medicare
& Medicaid Services (CMS)
Delayed Enrollment

May enroll into Medicare Part A anytime once eligible
• Most people enroll in Part A when they turn 65 since it is
usually premium free
Special
Enrollment Period for Part B
•People may delay enrollment without penalty if covered
through active employment by themselves or spouse
 Will have a 8 month Special Enrollment Period when
active employment ends otherwise may have to pay a
penalty.
 COBRA does not qualify as “active” employment and
does NOT protect an individual from the Part B late
enrollment penalty
Delayed Enrollment- Part B
General
Enrollment Period for Part B
•January 1st – March 31st
•Coverage effective July 1st
Part
B Penalty for delayed enrollment
• Increased premium of 10% for each 12 months of delayed
enrollment
•Lifetime
•Increases with increases in premium
Medicare Part A

Part A helps cover:
• Inpatient care in hospitals
• Inpatient care in a skilled nursing facility
• Hospice care services
• Home health care services
 Medicare does NOT cover Long Term Care
Medicare Part A

Inpatient care in hospital
• Medically necessary

Costs
• 90 Renewable days
Days 1-60: Deductible
 Days 61-90: Copays

• 60 non-renewable days

Covered Services
• Room, nursing, testing, supplies, operating room
Medicare Part A

Skilled Nursing Care
• Daily skilled care medically necessary
• Prior hospital stay of 3 days or more
• Admitted to SNF within 30 days of discharge

Costs
• 100 Renewable days
Day 1-20: No costs
 Days 21- 100: Daily copay

Medicare Part A

Home Health Care
• Physician must authorize
• Beneficiary must be “homebound”
• Need for skilled care on a part-time or intermittent basis

Costs
• Medicare covers 100% for all covered services

Covered services
• Skilled care, therapy, medical supplies,
• care by home health aides (bathing, changing, dressing)
Medicare Part A

Hospice
• Physician must certify patient is terminally ill (6 months)
• Patient has elected Hospice care
• May be provided in home, facility, hospital or nursing home

Costs
• Medicare covers 100% of most services
• Beneficiary only pays small copayment for drugs and respite
care
Medicare Part B

Part B helps cover:
• Physician services
• Out-patient hospital services
• Preventive services
• Medical Equipment and Supplies
• Ambulance
• Medically-necessary services

Services or supplies that are needed to diagnose to
treat your medical condition
Medicare Part B
Preventive Benefits

ACA provides access to many free preventive benefits
• Mammograms
• Some pap smear and pelvic exams
• Colorectal Screenings
• Diabetes Self-Management Training/Tests
• Bone Mass Measurements
• Prostate Cancer Screening
• Depression screening
• Obesity screening and counseling
• Alcohol misuse screening and counseling
• Annual Wellness Visit
 Update individual’s medical & family history
 Record height, weight, body mass index, blood pressure and other
routine measurements
 Provide personal health advice and coordinate appropriate
referrals and health education
Medicare Part B
Preventive Benefits

Most preventive services are not subject to
• Deductible
• 20% copayments

Free Annual Wellness Visit
• NOT a physical exam
• Services provided beyond scope of AWV may be
subject to deductible and/or copayments
Medicare Part B

Physician services
• No network or referral needed
• After annual deductible, 20% copayment
Medicare approved amount
 Accepting Assignment – accepting the Medicare
approved amount as payment in full


Ban on balance billing

In other states there an excess charges of 15% is
allowable for physicians not accepting assignment
Medicare Part B
 Medical Equipment and Supplies
• Supplier not required to accept assignment
• No ban on balance billing
 Ambulance
• Medicare will not pay for ambulance used
as routine transportation
“Gaps” in Original Medicare
Part A
Part B

Hospital deductible per benefit period*

Daily co-pay for extended hospital stays (days 61-90)

Daily co-pay for days 21-100 in SNF

Annual deductible

20% co-pay for most Part B services

Routine physical, hearing, vision, dental

Foreign travel
* A “benefit period” starts the day a beneficiary is admitted to the hospital or SNF
and ends when the beneficiary has not received hospital or SNF care for 60
consecutive days
Medicare Part C:
Medicare Advantage
& Medigap Plans
Supplementing Medicare
Medicare
Advantage Plan
Original Medicare
+
Part D
Stand Alone Plan
+
Optional “Replacement”
OR…
(Provides Original Medicare
benefits plus extra routine and
preventive benefits)
Optional “add-on”
HMO (Health Maint. Org.)
PPO (Pref’d Provider Org.)
PFFS (Private Fee For Service)
SNP (Special Needs Plan)
(Picks up where Original
Medicare leaves off)
Generally includes Part D
drug coverage
Medigap Policy
Medicare Supplements
(Medigap)

Sold by private insurance companies

Only available to people who are enrolled in Medicare
Part A & Part B (continue to pay Part B premium & use
Medicare Card)

Pays second to Medicare only after Medicare
recognizes service as a “covered” service.

Continuous open enrollment in Massachusetts

Medigap plans DO NOT include prescription drug
coverage
Medigap Plans
 Two Medigap Plans Sold in Massachusetts
 Core: Leaves some gaps behind (including hospital
deductible & SNF co-pays), but costs less
 Supplement 1: Covers all gaps – but costs more
 Both plans allow members to choose their own
doctors, specialists, and hospitals without referrals
NOTE: Some people are covered through older policies no
longer available to new members (e.g. “Medex Gold”)
Medigap Plans
 No matter which company a beneficiary selects for
coverage they will receive the same benefits
 Some Medigap plans offer a discount of up to 15% to
beneficiaries who enroll within 6 months of their
Medicare Enrollment
 If an individual switches Medigap companies he or she
must notify the previous company
 If an individual leaves a plan that is no longer sold they
will be unable to return to that plan
Medicare Advantage Plans
(Medicare Part C)

Private plans contract with Medicare to provide
coverage comparable to “Original” Medicare

Plans may add additional benefits (e.g. dental check
ups, vision screening, eye glasses, hearing aids)

Plans usually charge additional premium & co-pays

Members must still pay Part B premium

Plans use networks of physicians
Medicare Advantage Plans
(Medicare Part C)

Eligibility
• Must have both Part A and Part B
• Must live within plan service area 6 months a year
• Must not have ESRD
• Must continue to pay Part B premium

Different Plan Types
• HMO
• PPO
• PFFS
• SNP
Medicare Advantage Plans

Enrollment/Disenrollment Periods
• Initial Coverage Election Period (ICEP)

7 month period around 65th birthday or if under age 65,
7 month period around first month of eligibility
• Open Enrollment Period (OEP)

October 15th – December 7th
• Special Election Period (SEP)
• Medicare Advantage Disenrollment Period (MADP)

January 1st – February 14th
Medicare Advantage Plans

Enrollment is for the entire calendar year
• Can only disenroll under special circumstances

May enroll online, through the mail or over-the-phone
with plan directly, or 1-800-MEDICARE / Medicare.gov

Do not have to disenroll from previous plan if you are
switching to another Medicare Advantage or Part D plan

If leaving a Medigap plan must contact to disenroll
HMO: Health Maintenance
Organization

Must choose a Primary Care Physician

Must receive all services within the plan’s network

Need referrals for specialists

Out-of-network services will not will not be paid for
by the plan with the exception of urgent or
emergency care

May only join the Part D Plan offered by their HMO
plan
PPO: Preferred Provider
Organization

Defined network of providers (may not be the same as
HMO network)

Plan provides all Medicare benefits whether in or out of
network

Usually pay higher co-pays for out-of-network services (and
may have to meet an annual deductible first)

No referrals needed to see specialists

May only join the Part D Plan offered by the plan
PFFS: Private Fee-ForService

Only available in Berkshire, Dukes and Nantucket
Counties

No defined network – no need for referrals

May use any hospital or doctor across the country that
accepts the plan’s terms and conditions of payment

Plan determines how much it will pay providers for all
services

Plan may or may not offer Part D coverage

Members may join a stand alone PDP if selected plan
does not include prescription coverage
SNP: Special Needs Plans

Only available to certain groups:
•
•
•
Institutionalized (e.g. nursing home)
Dually Eligible (Medicare/Medicaid) aka Senior Care Options (SCO)
People with certain chronic conditions*

Defined network of providers
Covers all Medicare services AND provides extra benefits
Provides Part D Coverage
Continuous open enrollment

No or low monthly premium



* Including heart disease, diabetes, & cardiovascular diseases
Medigap vs. Medicare
Advantage
Original Medicare +
Medigap Supplement 1
Medicare Advantage Plan
Higher monthly premium but
no co-pays
Generally lower premiums but
has co-pays
Freedom to choose doctors
Generally restricted to network
No referrals necessary
May need referrals for specialists
Some routine services not covered
(vision, hearing)
May include extra benefits
(vision, hearing, fitness)
Covered anywhere in US
Only emergency services provided
outside certain area
Important Questions to
Consider!

Do their doctors and hospitals accept the plan?
• If not, might consider PPO but higher out of
pocket expenses

How much are the co-pays? What is the out-ofpocket maximum for the year?
• In general, the lower the monthly premium, the
higher the co-pays for services

Are their medications on the plan’s formulary and
how much do they cost?
• May cost more in Medicare Advantage plan
Other ways to Supplement Medicare
for Certain Populations

Retiree Health Plans (group plans)
• Each retiree plan is different
• Request an outline of benefits to learn about plan

Medicaid/MassHealth (for very low-income)
• Part A and B deductibles and copayments covered in full
if seeing a MassHealth physician.

Veterans Health Care
• Supplements copayments when visiting a VA Physician,
Health Clinic or Hospital
Medicare Part D
Overview of Medicare Part D
 Began January 1, 2006
 Eligible if an individual has Part A OR Part B
 Voluntary
 a late enrollment penalty may apply to those who do not enroll when
first eligible.
 Penalty is 1% per month for each month without creditable coverage
and is permanent.
 Provides outpatient prescription drugs
 Coverage for Part D is provided by:
• Prescription Drug Plans (PDPs) also known as stand alone plans
• Medicare Advantage Prescription Drug Plans (MA-PDs)
Supplementing Medicare
Medicare
Advantage Plan
Original Medicare
+
Part D
Stand Alone Plan
+
Optional “Replacement”
OR…
(Provides Original Medicare
benefits plus extra routine and
preventive benefits)
Optional “add-on”
HMO (Health Maint. Org.)
PPO (Pref’d Provider Org.)
PFFS (Private Fee For Service)
SNP (Special Needs Plan)
(Picks up where Original
Medicare leaves off)
Generally includes Part D
drug coverage
Medigap Policy
Medicare Part D

Enrollment Periods
• Initial Coverage Election Period (ICEP)

7 month period around 65th birthday or if under age 65,
7 month period around first month of eligibility
• Open Enrollment Period (OEP)

October 15th – December 7th
• Special Election Period (SEP)
• Medicare Advantage Disenrollment Period (MADP)

January 1st – February 14th
Special Enrollment Periods

When outside of the Open or Initial Enrollment Period an
individual must meet one of the following criteria to enroll:
•
•
•
•
•
•
•
Loss of creditable prescription drug coverage
Have MassHealth or Extra Help towards the cost of your
medications (Low Income Subsidy) or have recently lost this
assistance.
Have a state pharmacy assistance program (SPAP) such as
Prescription Advantage or have recently lost this assistance.
Moved from one state to another
Move in, live in, or move out of a Long Term Care Facility
Current plan is ending its contract with CMS.
Other situation as deemed by CMS
Once the beneficiary has made a choice the SEP typically ends
Late Enrollment Penalty
Part D
 If an individual does not enroll when first eligible for Part D they may
pay a penalty if they:
 Have no coverage or have coverage but it is not considered
creditable
 Have a lapse in coverage (63 days/2 full months)
 Penalty charged once an individual does join a Part D plan
 A 1% increase in premium for each month an individual went
without creditable coverage since Medicare eligible, loss of
creditable coverage or May 2006, whichever is later.
 Penalty is permanent.
 Unable to enroll into Part D until:
 Annual Medicare Open Enrollment (October 15th – December 7th for
an effective date of January 1st)
 or eligible for a Special Enrollment Period (SEP)
CMS Standards for Part D

CMS sets Standard Benefit Structure but plans may provide
benefits beyond.

Each plan has to cover “all or substantially all” the drugs in
the following classes:
• Antidepressants, Antipsychotic, Anticonvulsant,
Anticancer, Immunosuppressant and HIV/AIDS

Plans must cover at least two drugs in each therapeutic class

Drugs excluded by coverage
• OTC, Vitamins, Select Barbiturates
Part D Coverage
• Deductibles, out-of-pocket limits, and
co-pays during the coverage gap change
yearly
•
Refer to Part D Standard Benefit Chart
How to Enroll Into Medicare
Part D



Review plan options
• Consider cost, coverage, quality, and convenience
• Plan Finder Tool on Medicare.gov
• Seek assistance from SHINE or other agencies
Contact plan directly or call 1-800-Medicare
• Enrollment can take place on the phone, online, or
through a mailed in paper application
Enrollment form will ask for:
• General contact information
• Medicare card information
• Method for premium payment (direct or through
Social Security check)
Open Enrollment Period
 October 15th – December 7th
 Every plan changes from year to year
 Plans can change premiums, copayments,
medications covered, the plan name, and can end
their contract with Medicare
 If an individual elects not to do anything then they will
remain in that plan for the following year
 If an individual wants a different Medicare Advantage
Plan or Medicare Part D plan they simply enroll into the
new plan. The change will take effect January 1st
Supplement 2

Medigap Supplement 2 is no longer sold (as of 12/31/05)
• Most common Supplement 2 plan is Medex Gold
• Very high monthly premium
• Provides comprehensive prescription coverage with no
gaps

If an individual wants to drop the coverage to join Medicare
Part D they must have an SEP or wait until the Annual
Coordinated Election Period October 15th – December 7th

If an individual chooses to leave plan they are unable to rejoin
at any time
Assistance with prescription costs:
MassHealth
Extra Help / Low Income Subsidy
Prescription Advantage
MassHealth and Medicare Part D

Individuals with MassHealth and Medicare are considered “Dual
Eligible”

Since January 1, 2006, MassHealth no longer provides primary
prescription coverage to Medicare beneficiaries.
• MassHealth remains to pay for certain classes of medications
directly since Medicare does not cover them. These drug classes are:




Certain Over the Counter Medications (Ibuprofen & acetaminophen)
Most prescription vitamins and minerals
Prescription drugs used for - anorexia, weight loss or weight gain;
fertility; cosmetic purposes or hair growth; relief of symptoms of colds
Dual Eligible individuals must receive primary coverage through a
Medicare Part D plan
Auto-Enrollment of Duals

Individuals who have MassHealth and become eligible for
Medicare are auto-enrolled into the Limited Income Newly
Eligible Transition Program (LI-Net) (this process began on
1/1/2010)
• The LI-Net program, administered by Humana, provides
coverage for individuals for two months.
• After two months, if a dual-eligible individual has not
selected a plan on their own they will be auto-enrolled
into a randomly selected plan below the benchmark.
 $0 Monthly Premium
 Plan may not cover all medications
• Dual Eligible Individuals can change plans monthly
(continuous SEP), coverage begins first of the following
month
Extra Help / Low Income Subsidy

Extra Help, also knows as a Low Income Subsidy, is a federal
assistance program to help low-income and low-asset Medicare
beneficiaries with costs related to Medicare Part D

Individuals with MassHealth assistance are Automatically eligible
for this program and do not need to apply

Auto-Assignment (Li-Net) and Re-assignment (plan changes in the
fall) processes are also used for those who qualify for Extra Help

Extra Help subsidizes:
• Premiums, Deductibles, Copayments, Coverage Gap
• Late Enrollment Penalty
• Does not subsidize non-formulary or excluded medications
Eligibility

To be eligible for Extra Help in 2015:
• Income below 150% FPL
-$20 monthly unearned income applied. Further allowances are
made for any earned income
(The federal poverty level changes each spring)
• Resources (assets) below limit
(Resource levels are determined each year)

Refer to public benefit eligibility charts for premium,
deductible, and co-pay amounts

To apply visit www.ssa.gov/prescriptionhelp
Applying for Extra Help

If found eligible for Extra Help:
• Eligible for the entire calendar year
• Effective date is typically back-dated to the date
the application was received.
• Subsidy information will be sent to current
Medicare Part D plan.
• Information sent to MassHealth to review
eligibility for Medicare Savings Programs
Prescription Advantage

Massachusetts’ State Pharmaceutical Assistance Program
(SPAP)

Provides secondary coverage for those with Medicare or other
“creditable” drug coverage (i.e. retiree plan)

Provides primary coverage for individuals who are NOT eligible
for Medicare

Benefits are based on a sliding income scale only – no asset
limit!

Different income limits for under 65 vs. 65 and over

Dual eligibles can NOT join (but those with LIS or MSP can join)
Primary Coverage
(for those without Medicare)
 No monthly premium
 If under the age 65 and receiving SSDI income must
below 188% FPL , otherwise no income guidelines
 Sliding scale, based on income, for copayments,
quarterly deductibles, and out-of-pocket limits
For those with Medicare
or “Creditable Plan”

Helps pay for drugs in the gap (for most members)

Those in top income category (S5) must pay $200
annual fee for limited benefits

All medications must be covered by primary plan

Members are provided a SEP (one extra time each
year outside of open enrollment to enroll or switch
plans)

Prescription Advantage does not pay late enrollment
penalty fee
Special Enrollment Period

Prescription Advantage members are provided an SEP
• One SEP allowed each year to enroll or switch plans
• Examples:
 Switch to a lower costing plan
 Re-enroll into a plan after disenrollment because of
non-payment (considered an involuntary
disenrollment).
 Enroll into plan for the first time
 Prescription Advantage does NOT pay for the late
enrollment penalty fee
Other Ways to
Lower Prescription Costs

Patient Assistance Programs

Copay Assistance Foundations

Mail Order

Generic Pricing Programs

Alternative medications
MCPHS Pharmacy Outreach
Program

Pharmacy Outreach Program of the Massachusetts College of
Pharmacy and Health Sciences in Worcester

Partially funded by the Executive Office of Elder Affairs

Toll Free number 1-866-633-1617

Pharmacist and Case Managers available
• Part D Reviews
• Screen for financial assistance programs
• Provide recommendations for alternative medications
• Review for drug interactions
Public Benefits
Supplemental Security Income (SSI)

Raises income to standard of living income level

SSI recipients auto enrolled in MassHealth & LIS

Must meet income/asset limits

Must also be aged 65+ OR blind or disabled

Beneficiaries enroll through the SSA
MassHealth Standard

Provides a full range of medical benefits
• Including inpatient, outpatient, skilled nursing care,
and prescription coverage

Provides secondary coverage for Medicare
Beneficiaries
• Medicare Part A & B premiums, deductibles &
coinsurance
• Deemed eligible for Extra Help – can pay for Medicare
Part D premium, deductible, and reduce copays for
medications
MassHealth Standard Eligibility
Eligibility for 65+ years old; not institutionalized
Income limit
Asset
limit
Individual
100% FPL
$2,000
Couple
100% FPL
$3,000
• $20 unearned income disregard applied
•Higher income disregard for earned income
MassHealth for Caretaker
Relatives
Provides
MassHealth Standard benefits
Caretaker relative: an
adult relative living in the same
home with a child under 19 whose parents are not
present in the home; who is related to the child by:
• Blood
• Adoption
• Marriage (or is the spouse or former spouse of
those relatives)
MassHealth for Caretaker
Relatives

Income limit increases to 133% FPL
• No income disregards applied

No asset limit

To apply, ACA-3 form, regardless of applicant
age
MassHealth for Caretaker
Relatives Case Study

Susan, 67, is raising her granddaughter,
Amelia, 13. Susan has been struggling with
her prescription costs and is wondering if any
assistance is available to her. Her income
from social security is $1,500 a month and she
has $20,000 is the bank
MassHealth for Caretaker
Relatives Case Study






Susan on her own would be over income and over
assets for MassHealth
Susan is the caretaker relative of a child under 19,
she can complete a Medical Benefit Request (MBR)
There is no asset test
Income is below the 133% FPL for a family of 2
She and Amelia would qualify for MassHealth
Standard
Susan would automatically qualify for Extra Help
CommonHealth

For adults with disabilities whose incomes are too
high to be eligible for MassHealth Standard

No income or asset limits regardless of age but
those 65 and over must meet a work requirement
(40 hours/month to be eligible.

Those under 65 are not required to work but have
a one-time deductible

Sliding scale monthly premium for those with an
income above 150% FPL
CommonHealth Work
Requirement

Must work at least 40 hours/month and have a
statement from their employer as proof.
• Or worked 240 hours in the last six months
“Work” is not clearly defined by MassHealth
 Must be paid something; CANNOT be volunteer


Could include simple tasks such as:
Walking a dog
Babysitting
Stuffing envelopes
Answering phones
CommonHealth

Regardless of age complete a MassHealth ACA-3
form.
• Recommendation: Write CommonHealth on the front of the
application if submitting in a paper form

If approved will receive many of the same benefits
MassHealth Standard members receive
• Inpatient and Outpatient Services
• Transportation services
• Automatically qualify for Extra Help for Part D
• May not qualify for Part B premium assistance
CommonHealth Case Study

Robert is disabled and not working. He has
been on CommonHealth for a year. He is about
to turn 65. He is concerned about his costs
under Medicare. His social security check is
$1,600 a month and he has about $10,000 in
his savings account
CommonHealth Case Study




Once Robert turns 65 he will only be able to maintain
CommonHealth if he is able to work 40 hours /
month.
CommonHealth will assist him with his Medicare Part
A and Part B deductibles and coinsurance
He will automatically qualify for Extra Help with his
prescription Medications.
Since his income is over 150% FPL he will have to pay
a monthly premium for CommonHealth and will have
to pay his Part B premium
Personal Care Attendant (PCA)
Program

For individuals who need assistance with at least two
Activities of Daily Living (ADL’s) such as bathing, dressing,
eating, taking medicines.

Provides beneficiary MassHealth Standard and coverage for
personal care attendant services

Beneficiary hires their own Personal Care Attendant
• Can be a family member or friend, but not:

A spouse

A parent of a child receiving the services

Legally responsible relative
Personal Care Attendant (PCA)
Program

Eligibility
• Beneficiary must have a permanent or chronic
condition
• Requires approval from physician
• Income limit increases to 133% FPL
• Asset limits still $2,000 (individual) and $3,000
(couple)

For 65 and older, complete a SACA-2 and PCA
supplement
PCA Case Study

Diane has been helping her father, Dennis,
around the house since his stroke. She helps
with bathing, dressing, and getting him to and
from the restroom. She knows her father is
over income for MassHealth but is wondering if
there is something else available. Diane’s
father has a monthly income of $1,150 a
month and no assets
PCA Case Study



Dennis would qualify for the PCA program given his
household income of $1,150. The PCA program
would allow him to pay his daughter, Diane, or hire
someone else to assist him at home
By qualifying for the PCA program he will also receive
Part B premium assistance and Extra Help for his
medications
If Dennis has a Medicare Advantage or Medigap policy
he could drop the policy and just have a Medicare
Part D plan
Home and Community Based
Services Waiver (HCBSW)

Also known as “Frail Elder” Waiver

Provides full MassHealth coverage and support services
to frail elders to help them live at home instead of a
nursing home

May include:
Personal Care Services
Housekeeping
Home Health Aide
Companion Service
Skilled Nursing Grocery Shopping
Accessibility Adaptation
Transportation
Wander response system
Transitional Assistance
Respite Care
HCBSW Eligibility

Individual must be 60 years or older

Must meet MassHealth clinical eligibility requirements
for nursing home care (screened by ASAP)

Individual’s monthly income cannot exceed 300% SSI
and assets limited to $2000 (assets in excess of $2000
must be transferred to spouse)
• Spouse’s income and assets are waived in determining
financial eligibility

Complete the SACA-2 form (even if <65 years old)
HCBSW Case Study

Sandy, 71 has been taking care of her husband Jim, 75,
who has Parkinson's Disease. His level of care is more
than Sandy can handle on her own. She is considering
moving her husband to a nursing home but she is
hoping there is a way to keep her husband at home.
She is seeking assistance.

Sandy’s income is $1,300 a month

Jim’s income is $1,800 a month

Combined they have $25,000 in the bank
HCBSW Case Study

Jim may qualify for HCBSW if he meets the clinical
eligibility requirement

Even though Jim and Sandy have a combined income
of $3,100 a month, only Jim’s income is counted

Jim’s assets must be below $2,000 to qualify. Sandy’s
assets would not be counted. In order to qualify for
the program Sandy must have at least $23,000 in
assets transferred to her name only
Health Safety Net Overview



Pays for services at hospitals and community health
centers for eligible Massachusetts residents
To apply, complete MassHealth
• Medical Benefit Request form
• Senior Medical Benefit Request form
No asset guidelines
Monthly Income Limits
Full HSN
Income Limit
200% FPL
Partial HSN
400% FPL
Health Safety Net and
Medicare

Medicare has many “gaps”

Part A deductible
• Per benefit period

Part A co-payments
• Daily co-payments for hospital stays greater than
60 days
Health Safety Net and
Medicare

Can cover all of the Part A deductible and Part
A co-payments if eligible for full HSN

Must first meet HSN deductible if eligible for
partial HSN

Beneficiary could select more affordable
Medicare supplemental coverage if HSN is in
place
Case Example
Judy is hospitalized for 10 days. How much will
she pay if she has:
• Medicare A & B, Medicare Supplement 1
• Medicare A & B, Medicare Supplement Core
• Medicare A & B, Medicare Supplement Core,
Health Safety Net
Word of Caution

If a client is eligible for HSN and is considering
downgrading from a Medigap Supplement 1
plan to a Core plan, be sure to advise them on
the additional benefits included in
Supplement 1
• Foreign travel (only a select number of Core plans
cover foreign travel)
• SNF coinsurance for days 21-100
• Part B annual deductible
Health Safety Net and
Medications

Health Safety Net can also cover medications
• Two general rules for coverage
 Prescription
is being filled at a facility with a
pharmacy that can bill HSN (Typically a hospital
or community health center)
 Prescription is written by a physician at that
same facility
• Deductible is not applicable
Medicare Savings Programs
(MSP)
Programs for Medicare beneficiaries to help pay for some
Medicare co-pays and/or premiums:
QMB-Qualified Medicare Beneficiary
•
Pays Premiums, copayments and deductibles
SLMB-Specified
•
Low-income Medicare Beneficiary
Pays Part B premium only
QI-Qualifying Individual
•
Pays Part B premium only
Medicare Savings Programs
Type
QMB
SLMB
QI
Income Limit
Asset Limit
Benefits
100% FPL
$7,280 (Individual)
$10,930 (Couple)
Pays Part A & B
premiums, coinsurance, and
deductibles
120% FPL
$7,280 (Individual)
$10,930 (Couple)
Pays Part B
premiums
135% FPL
$7,280 (Individual)
$10,930 (Couple)
Pays Part B
premiums
MSP Application Process

To qualify for QMB, must complete a full
MassHealth application

To qualify for SLMB or QI-1, completed either a
full MassHealth application or a MassHealth BuyIn Application

If an individual qualifies they will also be
approved for Full Extra Help with Prescription
Costs
Case Example
David has an income of $1,100 a month and
has $5,000 in the bank

David can complete a MassHealth Buy-In
Application

If approved:
•His Part B premium would be subsidized
•He would also receive Extra Help, reducing his
prescription premium, deductible, and copays
One Care
Type of Medicare Advantage Special Needs
Plan
 Available to individuals with disabilities age
21-64
 Must have Medicare Part A & B, plus
MassHealth Standard or CommonHealth
 Only available in specific service areas
 Provides coordinated care

One Care

Services include:
• No co-pays for prescription drugs
• Enhanced behavioral health and substance abuse services
• Long-term support
• Crisis stabilization
• Day programs
• Home modification
• Comprehensive dental
• Hearing aids
• Transportation
Medicare Appeals, Fraud
and Abuse
Medicare Appeals

Beneficiaries have the right to a fair/efficient process for
appealing decisions about healthcare payment or services

Expedited appeals available in most situations

Under Part D rules, beneficiaries have a right to a plan
“Coverage Determination” concerning coverage or cost of
a prescribed drug - this must be issued within 72 hours
(24 hours, if expedited)

All steps in the appeal process have specific time frames
and other requirements – it is very important to be aware
of time limits for appeals
Appealable Events

Medicare denies a request for a health care service,
supply, or prescription

Medicare denies payment for health care that the
beneficiary has already received

Medicare stops covering services that the beneficiary
is already receiving

Medicare pays a different amount than the
beneficiary believes it should
The Medicare Advocacy Project
(MAP)

Provides advice/free legal representation to
Massachusetts Medicare beneficiaries

Serves elders and persons with disabilities who are
enrolled in either Original Medicare or a Medicare
Advantage Plan

Offers public education and training on Medicare
issues, including updates on changes in the
Medicare program
Examples of Problems
Referred to MAP









Durable medical equipment coverage
Skilled nursing facility care coverage denials
Early hospital discharges
Ambulance transportation
Physician’s services denials
Access to Medicare covered home health care
Drug coverage exceptions and appeals
Disputed Low Income Subsidy Determinations
Premium penalties
Fraud and Abuse in
Medicare and Medicaid

Health Care Fraud: Intentional deceptions or
misrepresentation a person knowingly makes that
could result in improper payment to a provider or
unnecessary delivery of services to a beneficiary.

Health Care Abuse: Unintentional incidents or
practices of health care providers that are
inconsistent with sound business practice, and that
result in improper payments by Medicare to a
medical provider.
How Medicare Beneficiaries
can Protect Themselves

Be aware of bills for services never received

Review medical statements to verify that services
being billed for seem appropriate

Never accept unsolicited deliveries or services

Guard Medicare and/or Medicaid card numbers like
a credit card number
The End!