SHINEServing the Health Information Needs

of Elders

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 ESRDNote: Medicare is NOT Medicaid (which is health insurance for very low income population)

Medicare Eligibility

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

• Is a member of the opposite sex Under the Federal Defense of Marriage Act, Federal

Agencies can not recognize same-sex marriages

Medicare Eligibility

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 2013 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 at 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

*DOMA excludes Medicare from recognizing same-sex spouses

Delayed Enrollment

General Enrollment Period for Part B•January 1 – March 31•Coverage effective July 1

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

2013 “Gaps” in Original Medicare

* 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

Part A Hospital deductible $1,184 per benefit period*

$296/day for extended hospital stays (days 61-90)

$148/day for days 21-100 in SNF

Part B Annual deductible $147

20% co-pay for most Part B services

Routine physical, hearing, vision, dental

Foreign travel

Medicare Part C (Medicare Advantage Plans)

& Medigap Plans

Supplementing Medicare

Original Medicare

Medigap Policy

Optional “add-on”

(Picks up where Original Medicare leaves off)

Part D

Stand Alone Plan

+

+

OR…

Medicare Advantage Plan

Optional “Replacement”

(Provides Original Medicare benefits plus extra routine and

preventive benefits)

HMO (Health Maint. Org.)PPO (Pref’d Provider Org.)

PFFS (Private Fee For Service)SNP (Special Needs Plan)

Generally includes Part D drug coverage

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 in 2013

Medigap CarriersMedicare

Supplement Core

Medicare Supplement 1

BlueCross BlueShield of Mass $96.38 $183.73

Fallon $100.25 $182.00

Harvard Pilgrim Health Care $100.50 $189.50

Health New England $97.00 $189.00

Humana $137.18 $214.41

Tufts $102.71 $199.70

United HealthCare $122.75 $211.50

Original Medicare vs MedigapOriginal Medicare Supplement

CoreSupplement

One

Premium B + D B + D + $97 B + D + $182

Hospital Deductible

$1184 $1184 $0

Hospital Copayments

Days 61-90 $296/dayDays 91-150 $592/day

$0 $0

SNF Days 21-100 $148/day

Days 21-100 $148/day

$0

Part B Deductible

$147 $147 $0

Part BCo-Insurance

20% $0 $0

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

Several 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 15 – December 7

• Special Election Period (SEP)

• Medicare Advantage Disenrollment Period (MADP) January 1 – February 14

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-For-Service

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 Fallon Super Saver

Tufts Prime Rx

Supp. 1

Premium B + D B + $0 B + $140 B+D +$182

PCP $147 Deductible20% Co-Insurance

$25 $10 $0

Hospital $1184 DeductibleDays 61-90 $296/dayDays 91-150 $592/day

Days 1-5 $355/day

$300 per year

$0

SNF Days 21-100 $148/day

Days 1-20 $65/day

Days 1-20 $20/day

$0

Max None $3,400 $3,400 $0

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 USOnly 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-of-pocket 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)

Prescription Drug Plan Options

Original Medicare

Part D stand alone plan

MedicareAdvantage Plan

For prescription coveragean individual must choose

the Part D coverageoffered by their Medicare

Advantage Plan.

Exception: individuals enrolledin a PFFS plan that does not

provide prescription coveragemay choose a standalone

Part D plan.

Medigap PolicyOptional “add-on”

Or other supplementalmedical coverage

+

+

or

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 15 – December 7

• Special Election Period (SEP)

• Medicare Advantage Disenrollment Period (MADP) January 1 – February 14

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

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 or more)

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

Standard Coverage Levels 2013

Deductible $325

Initial Coverage Limit $2,970

Out-of-Pocket Threshold $4,750*

Catastrophic Cost-Sharing 5% or $2.65 / 6.60

* In 2013, after $2,970 in costs, beneficiary pays 47.5% of brand name drug costs and 89% of generic drug costs until they have spent $4,750 out of pocket. Note, in the gap, the full cost of brand name medications is counted towards TROOP

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 1.

A note about 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:

Select Barbiturates (used to treat cancer, epilepsy or chronic mental health conditions )

Certain Over the Counter Medications (Ibuprofen & acetaminophen)

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 2013:

• 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) must be below:$13,300 for an individual$26,580 for a couple(Resource levels are determined each year)

To apply visit www.ssa.gov/prescriptionhelp

Extra Help and PDPs

LIS Copayments 2013

Institutionalized $0

Up to 100% FPL (Full dual eligible) $1.15/ $3.50

100–135% FPL (Full LIS) $2.65 / $6.60

135–150% FPL (Partial LIS) 15% co-pay

$66 deductible

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 Pharmacy 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 late enrollment penalty fee

How Extra Help and Prescription Advantage Lower costs

Smart D Rx Plan with PA S2

Plan with Partial

Extra Help

Plan with PA S1

Plan with Full Extra Help

Premium $32.40 $32.40 Reduced Reduced $0

Deductible $325 $325 $66 $7 / $18 $0

Generics $0-$20 $0-$20 15% 15% / $7 $2.65

Brands $35-$85 $35-$85 15% 15%/$18 $6.60

Cov Gap Generics 79% $7 15% 15% / $7 $2.65

Cov Gap Brands 47.5% $18 15% 15%/$18 $6.60

Other Ways to Lower Prescription Costs

Patient Assistance Programs Copay Assistance Foundations Mail Order Generic Pricing Programs Alternative medications

MCPHS Pharmacy Outreach Program (MassMedLine)

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

Income limit

Assetlimit

Individual 100% FPL $2,000

Couple 100% FPL $3,000

Eligibility for 65+ years old; not institutionalized

• $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, Medical Benefit Request form,

regardless of applicant age

MassHealth for Caretaker Relatives

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

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 limit for a household of two is $1,720 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 Stuffing envelopesBabysitting Answering phones

CommonHealth

Regardless of age complete a MassHealth MBR. • 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

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

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 SMBR and PCA form

PCA

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

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

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 Respite Care

Wander response system Transitional Assistance

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

($2130/month) 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 Senior Medical Benefit Request form (even if <65 years old)

HCBSW

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

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

Income LimitFull HSN 200% FPL

Partial HSN 400% FPL

Health Safety Net and Medicare

Medicare has many “gaps” Part A deductible:

• $1,184 per benefit period Part A co-payments:

• Days 61-90: $296/day

• Days 91-150: $592/day

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

Coverage Premiums Deductible Total

Supplement 1 $182.00 $0 $182.00

Core $97.00 $1,184 $1,281.00

Core +

Full HSN$97.00 $0 $97.00

Out-of-pocket Hospital Costs

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.

• $3.65/medication• Deductible is not applicable

Medicare Savings Programs

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 Income Limit Asset Limit Benefits

QMB 100% FPL7,080 (I),

10,620 (C)

Pays Part A & B premiums, co-insurance, and

deductibles

SLMB 120% FPL7,080 (I),

10,620 (C)Pays Part B premiums

QI 135% FPL7,080 (I),

10,620 (C)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 Buy-In 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.

Commonwealth Care

Health insurance coverage for uninsured adults

Also for those on COBRA or those paying full non-group premium

Must have income at or below 300% FPL

Premiums and co-pays vary based on income and plan choice

Note: Medicare beneficiaries are not eligible

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

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