Day 6

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Day 6 7Public Benefits
2
Review
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Medicare

• For people 65 and under 65 with a disability
• 4 parts of Medicare
• Part A Hospital Insurance
• Part B Medical Insurance
• Part C Medicare Advantage Plans
• Part D Prescription Drug Coverage
• Part A B called Original Medicare
• Automatic enrollment if getting SS benefits, must
  enroll if not
• Premiums always for Part B, only for A if not
  enough credits
• Not comprehensive coverage, has coverage gaps
• Out-of-pocket costs for A B change yearly- see
  chart

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Three Enrollment Periods

• Initial Enrollment Period (IEP) 7 months
  surrounding 65th birthday month (month earlier if
  birthday on 1st of month)
• Date of enrollment determines effective date of
  Medicare
• Special Enrollment Period (SEP) 8 months
  following loss of coverage from active
  employment
• General Enrollment Period (GEP) Jan 1st March
  31st of each year
• July 1st effective date

5
Delaying Part B Enrollment

• Beneficiaries may choose to have just Medicare
  Part A while ACTIVELY working or covered under a
  spouse who is ACTIVELY working
• Once ACTIVE employment coverage has ended, must
  take Part B coverage within 8 months to avoid a
  penalty
• If employer has lt20 employees or lt100 employees
  if the beneficiary has a disability, then the
  individual may need Part B because Medicare
  should pay first and Employer Group Health Plan
  (EGHP) second
• Beneficiaries should confirm with their employer
  if Part B is needed

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Late Enrollment Penalty

• Penalty for Part A Capped at 10 of premium
  and goes away after penalized for twice the
  length of time the person delayed enrollment
• Only for voluntary enrollees (paying for A) who
  dont enroll in Part A when initially eligible
• Penalty for Part B 10 of premium for each full
  12 month period the individual delayed enrollment
• Penalty for Part B not capped and is a lifetime
  penalty except
• Under 65 beneficiaries with a penalty will have
  the penalty removed and will have a clean slate
  when they turn 65

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Medicare

• Pays for reasonable and medically necessary
  services
• There are coverage gaps in Medicare including
• Part A in-patient hospital deductible
• Part A daily co-payment for in-patient hospital
  days 61-90
• Part A daily co-payment for in-patient hospital
  days 91-150
• Part A daily co-payment for SNF days 21-100
• Part B annual deductible
• Part B co-insurance (usually 20)
• First three pints of blood
• Coverage outside the United States

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Two Options For Supplementing Medicare
Step 1 Decide how you want to get your coverage
MEDICARE ADVANTAGE PLAN
ORIGINAL MEDICARE
OR
PART B Medical Insurance
PART A Hospital Insurance
PART C Combines Part A, Part B and usually Part D

Step 2 Decide if you need a Prescription Drug
Plan
PART D Stand Alone PDP
PART D Included in Part C
Step 3 Decide if you need to add supplemental
medical coverage
END If you join a Medicare Advantage Plan with
drug coverage (MAPD), you cannot join another
drug plan and you dont need and cannot be sold a
Medigap policy
MEDIGAP Supplement Core or Supplement 1 plan
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Medigap vs.Medicare Advantage
Original Medicare Medigap Supplement 1 Medicare Advantage Plan
Higher premiums but no co-pays Generally lower premiums but has co-pays
Freedom to choose doctors May be 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 Emergency services ONLY outside service area
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Part D

• Must have Part A and/or Part B to be eligible
• 2 ways to get prescription coverage
• 1. Medicare Prescription Drug Plans (PDPs) also
  known as stand alone plans
• 2. Medicare Advantage (Part C) Plans with drug
  coverage
• Part D is voluntary, but eligible beneficiaries
  who do not enroll may be subject to a penalty
• Must have creditable coverage to avoid penalty

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Part D Enrollment

• Initial Mimics Part B 7 month period
• Open Oct 15th Dec 7th, coverage effective Jan
  1st
• Special Refer to SEP chart for applicable
  situations
• MADP Jan 1st Feb 14th
• Late Penalty is 1 of the benchmark (the
  national base beneficiary premium) for EACH MONTH
  the beneficiary
• Did not enroll in Part D when they were first
  eligible AND
• Had no prescription drug coverage OR
• Had coverage that was not considered creditable
  OR
• Had a lapse in creditable coverage of 2 full
  months (63 days)

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Part D Formulary

• The prescription benefit includes a list of
  covered drugs and this list is called the
  formulary
• If the insurer is very selective about which
  drugs are to be covered, then it is sometimes
  referred to as a closed formulary. If the
  formulary is open to all drugs but places drugs
  into different cost sharing categories or
  tiers, it is referred to as an open formulary
• Each plan must meet formulary standards. The
  formulary must include and cover certain drugs or
  certain classes of drugs. Medicare has
  established a category of excluded drugs

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Extra Help

• Federal assistance program to help low-income and
  low-asset Medicare beneficiaries with costs
  related to Medicare Part D
• Extra Help subsidizes
• Premiums
• Deductibles
• Copayments
• Coverage Gap Donut Hole
• Late Enrollment Penalty
• Does NOT subsidize non-formulary or excluded
  medications
• Apply through Social Security Administration

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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 prescription coverage for those
  who dont qualify for Medicare
• Benefits are based on a sliding income scale
  only no asset limit!
• Level of assistance provided is determined by
  gross income
• Different income limits for under 65 and 65 and
  over
• Members are provided a SEP (one extra time each
  year outside of open enrollment to enroll or
  switch plans)

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Public Benefits
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SHINE and Public Benefits

• SHINE counselors screen individuals for potential
  eligibility for health/prescription-related
  public benefit programs, provide education about
  the benefits, and may assist in the application
  process
• Counselors do not guarantee that an individual
  will be eligible for these programs this
  decision can only be made by the benefit program

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Supplemental Security Income (SSI)

• Federal income supplement program funded by
  general tax revenues to help aged, blind, and
  people with disabilities who have little or no
  income
• Needs based program
• Provides cash to meet basic needs for food,
  clothing, shelter
• Different income supplements for various living
  arrangements
• Apply through Social Security office
• Automatic enrollment into MassHealth

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MassHealth

• Medicaid National public health insurance
  program
• MassHealth Massachusetts Medicaid program
• Public health insurance program for low- to
  medium-income residents of Massachusetts
• Administered by state Medicaid agencies within
  broad parameters established by federal
  regulations
• Overseen by the Centers for Medicare Medicaid
  Services (CMS)

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SHINE and MassHealth

• SHINE focus is on MassHealth ONLY AS IT RELATES
  TO MEDICARE BENEFICIARIES
• Benefit programs and eligibility criteria may
  differ for individuals who are not entitled to
  Medicare

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Dual-Eligible

• Medicare beneficiaries who are enrolled in
  MassHealth Standard are referred to as
  dual-eligible
• Dual-eligibles can receive assistance paying for
  Medicare premiums, deductibles, co-insurance, and
  co-pays
• Dual-eligibles receive the many MassHealth
  covered services that Medicare beneficiaries
  typically do not receive

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Dual-Eligible's and Part D

• Dual-eligibles MUST enroll into a Medicare Part D
  plan
• If beneficiary does not enroll into a plan within
  60 days, they will be auto-assigned to a plan
• Best to avoid this Auto-assigned plan may not be
  lowest cost and formulary may not list all of
  beneficiaries drugs
• Dual-eligibles automatically deemed eligible
  for Full Extra Help, regardless of income and
  assets

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Dual-eligible's and Part D, cont.

• MassHealth will cover a drug that Medicare does
  not pay for
• Will NOT cover a drug that Medicare does pay for
  but is not listed on the beneficiaries plan
  formulary
• MassHealth is always the payer of last resort
• Will NOT provide primary prescription drug
  coverage for dual-eligible's
• Dual-eligibles not yet enrolled into Part D may
  receive their prescription drugs at the Extra
  Help co-pay amounts by using the Limited Income
  Newly Eligible Transition Program (LINET)

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Limited Income Newly Eligible Transition Program
(LINET)

• Provides immediate prescription drug coverage for
  people with Medicare who are at the pharmacy
  counter and qualify for Extra Help, but arent
  yet enrolled in a Medicare drug plan
• Also covers prescriptions that eligible people
  filled within the last 30 days
• Covers all Part D covered drugs No prior
  authorization or network pharmacy restrictions
  during the time period covered by this program
• Will be charged the reduced co-payment based on
  the level of Extra Help they are eligible for
• Program administered by Humana

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MassHealth Standard Eligibility

• Determining eligibility for MassHealth is a
  complex process
• SHINE may screen for potential eligibility,
  educate clients about MassHealth benefits, assist
  in the application process
• Should not guarantee eligibility this decision
  should be left to MassHealth
• Must be a Massachusetts resident
• Defined as someone living in Massachusetts and
  intends to stay
• Different eligibility requirements for applicants
  age 65 and older and those under age 65

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Financial Eligibility 65

• For married couples living together, eligibility
  usually based on the combined income and assets
  of both members of the couple
• Must meet both income and asset guidelines in
  order to qualify for MassHealth Standard
• Income eligibility Countable income at or below
  100 of the Federal Poverty Level (FPL)
• Asset eligibility 2,000 or less in countable
  assets (3,000 for a couple)
• To determine income
• Take gross countable income and subtract 2
  deductions Unearned income disregard and Earned
  income disregard

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Income Disregards

• Unearned income disregard is a 20 deduction from
  the households total countable unearned income.
  Married couples receive only one 20 deduction
  from their combined countable income
• Earned income disregard is calculated by
  subtracting 65 from the individuals gross
  earned income, and dividing the remainder by 2.
  Married couples in which both people are working
  will both receive separate earned income
  disregards
• Disregards already calculated in the Pink Sheet
  (Eligibility Guidelines for Health/Prescription-Re
  lated Public Benefits Programs)

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IncomeCountable VS. Non-Countable

• Countable Income

• Non-countable Income

• Social Security benefits
• Railroad Retirement benefits
• Pensions
• Earned income
• Rental income
• Federal veteran pensions disability
  compensation
• Interest income

• Cash assistance from SSI or the Department of
  Transitional Assistance (DTA)
• Income-in-kind (e.g., gifts)
• Income from a reverse mortgage
• Veterans Aid Attendance benefits
• Chapter 115 benefits for veterans

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AssetsCountable VS. Non-Countable

• Countable Assets

• Non-countable Assets

• Bank accounts
• Whole life insurance policies, when total face
  value of all policies is over 1,500
• Individual retirement accounts (IRA)
• Stocks and bonds
• Second homes/cars
• RVs/Boats

• Primary residence and 1 car
• Personal belongings home furnishings
• Term life insurance policies
• Whole life insurance policies with total face
  value 1,500 or less
• Burial plot
• 1,500 burial-only account
• Irrevocable burial contract

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Financial Eligibility Under Age 65

• NO asset limits
• Income limit is 133 of the FPL
• Earned income disregard and unearned income
  disregard not used
• Modified Adjusted Gross Income (MAGI) used
  instead of gross income
• Applicant receives an income disregard
  equivalent to 5 of the FPL
• 5 FPL disregard already calculated in the Pink
  sheet

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Examples of MassHealth Covered Services

• In/Out-patient hospital services
• Emergency hospital services
• Skilled nursing facility
• Home health care
• Case management services
• Clinic services
• Diagnostic services
• Dental services
• Programs for all-inclusive care for the elderly
  (PACE)
• Personal care services (PCA)

• Hospice care
• Medical Transportation
• Occupational therapy
• Optometrist services
• Physical therapy
• Podiatrist services
• Preventative services
• Private duty nursing
• Prosthetic/orthotic devices
• Psychologist services
• Rehabilitative services
• Respite care

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Applying For MassHealth

• Best for the individual, spouse, family member to
  complete the application counselors can assist
  when needed
• 2 application types
• Application for Health Coverage and Help Paying
  Costs (ACA-3)
• In general used by applicants under age 65
• Application for Health Coverage for Seniors and
  People Needing Long-Term-Care Services (SACA-2)
• For applicants 65 and older
• Pink sheet indicates which application is used
  for each MassHealth program

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Application Processing

• Applications sent to and processed at the Central
  Processing Unit or MassHealth Enrollment Centers
  (MEC)
• If an application is received and requires
  further verification, applicant will receive a
  Request for Information with a deadline by which
  to return the needed documentation
• Retroactive Coverage
• Applicants age 65 and older can receive
  retroactive coverage up to 3 full calendar months
  prior to the date of application
• Applicants under age 65 can receive retroactive
  coverage beginning 10 days prior to the date of
  application
• Does not apply to MassHealth Senior Buy-in

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Payment For Services

• MassHealth is always the payer of last resort
• Any other insurance plan, including Medicare or
  employer-based health plans, must pay first
  before MassHealth will pay.

35
Special MassHealth Programs

• In addition to the MassHealth Standard benefits
  and eligibility criteria just discussed, there
  are several MassHealth programs that provide
  various levels of benefits for individuals who
  meet specialized eligibility guidelines
• These programs act like Medicare Supplements
  (Supplement 1), covering co-pays and deductibles
  and offering additional benefits

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Medicare Savings Programs MassHealth Senior
Buy-In

• Federally referred to as the Qualified Medicare
  Beneficiary (QMB)
• Eligibility
• Be entitled to Medicare
• Income at or below 100 of the FPL
• Assets at or below the designated limits (change
  yearly)
• Benefits
• Payment of Medicare Part A B premiums
• Payment of deductibles and co-pays
• Deemed eligible for Full Extra Help

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Medicare Savings ProgramsMassHealth Buy-In

• Federally referred to as Specified Low-income
  Medicare Beneficiary (SLMB) and Qualified
  Individual 1 (QI-1)
• QI-1 subject to periodic federal funding
  appropriation
• Eligibility for SLMB and QI-1
• Be entitled to Medicare
• Have income at or below QI-1 135 of the FPL
• SLMB120 of the FPL
• Assets at or below the designated limits (change
  yearly)
• Benefits
• Payment of Medicare Part B premium
• Deemed eligible for Full Extra Help

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Buy-In ForPart B Late Enrollees

• Late enrollees for Medicare Part B who qualify
  for the Senior Buy-in (QMB) or Buy-in (SLMB/QI-1)
  may enroll in Part B outside of the General
  Enrollment Period
• The effective date of Part B coverage would not
  be earlier than the Buy-in start date
• The individuals late enrollment penalty will be
  paid for by MassHealth

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Caretaker Relative

• Eligibility
• Must meet the definition of a caretaker relative
  Adult of any age who is primary caregiver for a
  child (can be related to the child by blood,
  adoption, marriage, or be the spouse/ex-spouse of
  one of these relatives). Must live in same home
  as the child and neither of the childs parents
  can be living in the home
• Must have income at or below 133 of the FPL
• Benefits
• Eligible individuals will receive MassHealth
  Standard benefits
• Payment of Medicare Part A B premiums,
  deductibles and co-pays
• Deemed eligible for Full Extra Help

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CommonHealth

• Eligibility
• Must have a disability
• Must be ineligible for MassHealth Standard
• Must currently be working at least 40 hours per
  month, or currently working and worked at least
  240 hours in the past 6 months
• MassHealth flexible on what work is
• Must be paid work cannot be volunteer
• Individuals under age 65 can waive the work
  requirement if they meet a one-time deductible
• NO financial eligibility requirements
• Individuals with incomes above 150 of the FPL
  will pay a monthly premium relative to their
  income

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CommonHealth, cont

• Benefits provided
• Benefits similar to MassHealth Standard including
  payment for Part A and B co-payments and
  deductibles
• Deemed eligible for Full Extra Help
• Benefit NOT provided
• Automatic payment for Part B premium
• Individuals must separately meet the
  qualifications for Buy-in in order for MassHealth
  to pay premiums

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Frail Elder Waiver

• Allows elders eligible for nursing home care who
  want to remain at home to get the services
  supports to be able to live safely
• Eligibility
• Be age 60 or older
• Be clinically eligible for nursing home care
  receive services from the ASAPs home care
  program
• Have income at or below 300 of the Federal SSI
  Rate
• Have assets at or below 2,000
• Only counts the income assets of the applicant
  even if married any assets over 2,000 limit
  allowed to be transferred to non-applying spouse

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Frail Elder Waiver, cont

• Benefits
• Payment of Medicare Part A B deductibles and
  co-pays
• Deemed eligible for Full Extra Help
• No co-pays for prescription drugs
• Supportive services (ex. Personal care,
  homemaking, meals)
• To Apply
• To apply the individual should be referred to
  their local Aging Service Access Point (ASAP)
• ASAP staff will evaluate the applicant for
  clinical eligibility

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Health Safety Net (HSN)

• Pays for medically necessary services at
  Massachusetts community health centers (CHCs) and
  hospitals
• 2 levels of eligibility Full and Partial
• Eligibility
• Must be a Massachusetts resident
• Non-residents may receive emergency or urgent
  care only
• Full Health Safety Net
• Income must be at or below 200 of FPL
• Partial Health Safety Net
• Income must be above 200 but at or below 400 of
  FPL
• Individual will be assessed an annual deductible

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Health Safety Net, cont.

• Benefits
• Low co-pay prescription coverage
• Prescription must be filled at a HSN pharmacy
• Will pay for allowed services not covered by
  Medicare, as well as Medicare co-pays,
  coinsurance, and deductibles
• Services must be delivered/ billed through a
  hospital or community health center that has an
  HSN program
• Can pay for services up to 6 months prior to
  approval
• HSN is NOT considered creditable coverage for
  Medicare Part D therefore use of the HSN pharmacy
  benefit does not protect a beneficiary from the
  Part D late enrollment penalty

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Senior Care Options (SCO)

• Combines MassHealth Standard coverage with social
  support services and coordinated care to help
  individuals maintain their health and live in the
  community
• Eligibility
• Be 65 or older
• Qualify for MassHealth Standard
• Live in a designated service area of a SCO plan
• NOT be diagnosed with End Stage Renal Disease
• NOT be an inpatient in a chronic rehabilitation
  hospital

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SCO, cont.

• Benefits
• No co-pays or deductibles
• Coordination of health care
• Prescription drugs without a co-pay
• Comprehensive dental, including dentures
• Transportation
• Specialized geriatric support services
• Adult day care
• 24 hour access to medical support
• Home care services
• Family caregiver support
•  

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One Care

• Managed care option that provides all Medicare
  MassHealth services along with additional care
  coordination and support services to
  dual-eligible individuals with disabilities
• Members can only receive covered services through
  plans network of contracted providers
• One Care is not available in all counties
• Eligibility
• Be age 21-64
• Have Medicare Parts A B
• Have MassHealth Standard or CommonHealth
• Cannot also be enrolled in SCO, PACE, Frail
  Elder Waiver, or other MassHealth waiver program

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One Care, cont.

• Benefits
• All guaranteed Medicare and MassHealth benefits
  as well as
• No premiums, deductibles, or co-pays
• Services coordination by an interdisciplinary
  care team
• Part D Coverage and no co-pays for prescription
  drugs
• Enhanced behavioral health and substance abuse
  services
• Long-term support
• Home modification
• Comprehensive dental
• Hearing aids
• Transportation

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Program Of All-Inclusive Care For The Elderly
(PACE)

• Provides community based care services to
  people age 55 who would otherwise require
  nursing home level of care
• Team of health care professionals provide
  integrated care plan to keep individual safe at
  home
• Eligibility
• Be age 55 or older
• Be clinically eligible for nursing home care
• Income at or below 300 of the Federal SSI Rate,
  assets at or below 2,000
• Live in the service area of a PACE organization
• PACE is not available in all regions of the state

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PACE, cont.

• Benefits
• No premiums, deductibles or co-pays for
  dual-eligible's Medicare only beneficiaries will
  have monthly premium
• Provides all services covered by Medicare and
  MassHealth Standard
• Provides functional, social, and psychological
  services to help individuals safely remain in
  their homes
• Part D coverage through the PACE plan

52
MassHealth Personal Care Attendant (PCA) Program

• Program that helps people with long-term
  disabilities live independently at home by giving
  member funds to hire a personal care attendant
  (PCA) to help with activities of daily living
  (ADLs)
• Eligibility
• Be age 65 or older
• Have a permanent and long-lasting disability
• Must need assistance with at least 2 ADLs
• ADL examples Dressing, eating, bathing, walking
• Income at or below 133 of the FPL
• Assets at or below 2,000 for an individual or
  3,000 for a couple

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Long Term Care (LTC) MassHealth

• Pays the nursing home the difference between the
  patient private paid amount and Medicaid
  established rate for nursing home care. Requires
  clinical eligibility.
• Financial Eligibility
• No income limit applicant just must have monthly
  income insufficient to pay for nursing home costs
• To prevent impoverishment of community spouse,
  spouse may be able to keep some of applicants
  income, called the monthly maintenance needs
  allowance
• Assets limited to 2,000
• Community spouse allowed to keep all assets (not
  counting the primary residence) up to a certain
  amount

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Review

1. What does dual-eligible mean?
2. What are the different types of MassHealth
   applications and which application is used for
   which MassHealth program?
3. What MassHealth programs are specifically for
   individuals with a disability?
4. What is Health Safety Net and what does it
   provide?
5. What benefits are available from One Care?