Day 8 Other Health Insurance Options

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Day 8Other Health Insurance Options
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Review
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Medicare

• 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 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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Two Options For Supplementing Medicare
Step 1 Decide how you want to get your coverage
ORIGINAL MEDICARE
MEDICARE ADVANTAGE PLAN
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 cant join another drug
plan and you dont need and cant be sold a
Medigap policy
MEDIGAP Supplement Core or Supplement 1 plan
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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 (MA-PDs)
• 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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Public Benefits

• SSI
• Federal income supplement program funded by
  general tax revenues to help aged, blind, and
  people with disabilities who have little or no
  income
• Provides cash to meet basic needs for food,
  clothing, shelter
• MassHealth (Medicaid)
• Public health insurance program for low- to
  medium-income residents of Massachusetts
• SHINE focus on MassHealth only as it relates to
  Medicare beneficiaries

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Public Benefits

• Dual-eligibles
• Medicare beneficiaries who are also enrolled in
  MassHealth Standard
• Can receive help paying for Medicare premiums,
  deductibles, co-insurance, and co-pays
• Automatically deemed eligible for Full Extra
  Help

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MassHealth

• MassHealth
• Different eligibility requirements for under 65
  and 65
• 65 100 FPL, asset limits
• Under 65 133 FPL, no asset limits
• 2 application types
• ACA-2 (Application for Health Coverage and Help
  Paying Costs)
• In general used by applicants under age 65
• SACA-2 (Application for Health Coverage for
  Seniors and People Needing Long-Term-Care
  Services)
• For applicants 65

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Public BenefitsSpecial MassHealth Programs

• Medicare Savings Programs (Buy-In)
• QMB, SLMB, QI-1 (refer to chart for guidelines)
• Helps with Part B premiums, may help with
  deductibles/co-insurance
• Frail Elder Waiver
• Must be 60, meet clinical requirements
• Services provided to keep frail people at home
• CommonHealth
• Must have disability and be working 40 hrs/month
• NO financial requirements

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Special MassHealth Programs

• Health Safety Net (HSN)
• Pays for medically necessary services at
  Massachusetts community health centers (CHCs) and
  hospitals
• 400 FPL, no asset test
• Caretaker Relative
• Parent/caretaker of any age of child under 19 in
  same home
• Income 133 of FPL
• One Care
• For dual-eligibles age 21-64
• Managed care option providing MH standard
  benefits plus additional benefits (dental, care
  coordination, transportation)

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Other Health Insurance Options
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Employer Group Health Plans (EGHP)

• Employers with 20 or more employees must offer
  Medicare beneficiaries who continue to work (and
  their spouses) the same choice of health plans
  offered to employees under age 65
• Medicare beneficiaries covered by an EGHP for
  active employees may delay enrollment into
  Medicare Part B without penalty
• EGHP is the primary payer and Medicare is
  secondary for Part A covered services for active
  employees, EXCEPT
• Medicare is the primary payer for active
  employees who work for an employer with fewer
  than 20 employees or fewer than 100 if
  beneficiary has a disability
• In these situations, beneficiary must have both
  Medicare Parts A B to be fully covered

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Employer Group Retiree Plan

• Most retiree plans coordinate with Medicare
• Retiree plans may also cover additional benefits
  such as unlimited drug coverage
• Important for beneficiaries to carefully review
  benefits booklet to compare the benefits offered
  by the retiree insurance and Medicare benefits to
  ensure they have adequate coverage
• Beneficiaries should not cancel retiree coverage
  without careful consideration of the benefits
• Coverage under a retiree health insurance does
  NOT prevent the Part B penalty (not ACTIVE
  employment)

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Consolidated Omnibus Budget Reconciliation Act
(COBRA)

• Federal law that requires continuation coverage
  to be offered to covered employees,
  former/current spouses, and dependent children
  when group health coverage would otherwise be
  lost due to certain specific events
• Employers with 20 or more employees must offer
  COBRA
• Individuals have 60 days to choose COBRA coverage
  and may have to pay for the coverage
• Minimum coverage period is 18 months
• Max for spouse/dependent children is 36 months
• Coverage under COBRA does NOT prevent the Part B
  penalty (not ACTIVE employment)

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Workers Compensation

• Insurance that employers are required to purchase
  to cover employees who get sick or injured on the
  job
• For employees covered under Medicare, workers
  compensation insurance pays first
• Medicare is the primary payer for Medicare
  covered services NOT covered by workers
  compensation
• If workers compensation does not pay the health
  care bill within 120 days, Medicare may then make
  a conditional payment

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Veterans Health Administration

• Uniform Benefits Package
• Standard health benefit plan available to all
  veterans
• Eligibility
• All honorably discharged veterans who meet the
  eligibility criteria are eligible for health care
  and in most instances must be enrolled in the VA
  health care system to receive benefits
• Apply at any VA health care facility/benefits
  office at any time
• Cost
• No monthly premium
• Co-pays required when services are received
• Co-pay amount based on the veterans eligibility
  rating

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Veterans Health Administration, cont.

• Uniform Benefits Package Benefits
• Primary and preventive care
• Comprehensive inpatient and outpatient services
• Pharmacy services provided free to certain
  eligible veterans or for a small co-pay
• Veterans can enroll in a Medicare Part D plan
  along with their VA Health Plan prescription
  benefit
• VA drug benefit IS considered creditable coverage
  so beneficiaries are NOT required to enroll in
  Part D

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TRICARE

• Managed health care program for Active Duty,
  Activated Guard and Reserves, Retired members of
  the uniformed services, their families, and
  survivors
• Eligibility
• Be entitled to Medicare Part A and enrolled in
  Part B
• Be a Medicare eligible retiree (including
  Reserve/Guard retirees) and
• Drawing retired pay, OR
• Veterans disability regardless of age, OR
• Be a qualifying family member or survivor, AND
• Certain category of un-remarried former spouse

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TRICARE, cont.

• Benefits 
• All Medicare covered benefits
• All TRICARE covered benefits 
• TRICARE coordinates benefits with Medicare
• Medicare will pay first for all Medicare covered
  services and TRICARE will be secondary payer
• TRICARE will pay all co-pays and deductibles
• Prescription Coverage
• TRICARE IS considered creditable coverage so
  beneficiaries are NOT required to enroll in Part
  D

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TRICARE For Life (TFL)

• Type of TRICARE supplement plan provided
  automatically to all those in TRICARE who have
  Medicare Parts A and B
• Pays the out-of-pocket costs for services covered
  under Medicare
• Beneficiaries have access to TRICARE benefits not
  covered under Medicare, such as the prescription
  drug benefit
• There is no premium but beneficiaries HAVE to be
  enrolled in Medicare Part B and pay their Part B
  premium

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CHAMPVA

• VA Civilian Health and Medical Program which
  helps pay for medical care for dependents and
  survivors of veterans
• Individuals eligible for TRICARE are NOT eligible
  for CHAMPVA
• CHAMPVA For Life (CFL)
• Extension of CHAMPVA benefits to certain
  individuals 65
• Most people covered by both CFL and Medicare do
  not need additional insurance
• CHAMPVA drug benefits more comprehensive than any
  Part D plan
• If a beneficiary enrolls into Part D , CHAMPVA
  coverage becomes secondary
• CHAMPVA IS considered creditable coverage so
  beneficiaries are NOT required to enroll in Part D

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Case Study 1Hal O. Jenn

• Hal calls you to find out what he should do about
  the Medicare Prescription Drug Program. He has a
  Supplement 1 Medigap insurance and gets his
  prescriptions from the VA. His friend told him
  that since he didnt join a Part D plan, he
  should join Prescription Advantage to cover the
  drugs that the VA might not cover. Hal tells you
  that his monthly income is 1500, and he cant
  afford another premium.
• How would you help him?

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Case Study 2Jen R. Ate

• Jen calls you at the SHINE office. Her company is
  downsizing and she will be laid off at the end of
  the month. She is 64 and will turn 65 in 6
  months. She understands that she can remain on
  COBRA for 18 months and then sign up for
  Medicare. She takes several expensive medications
  and wants to stay on COBRA as shes heard the
  Medicare Prescription Drug Program doesnt cover
  all drugs.
• How would you help her?

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Case Study 3Kara Sell

• Kara Sell calls to inquire about her Medicare
  coverage for foreign travel. She tells you she is
  new to Medicare and is not sure what it covers.
  She explains that she is planning a trip to
  Europe and wants to know if her Medicare will
  cover her if she gets sick.
• How would you help her?

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Case Study 4Kim O. Know

• Kim is married. She and her spouse are finding it
  hard to keep up with their expenses. She wonders
  if there is any way to cut down on their health
  care costs. She tells you that they are both on
  Tufts Medicare Preferred HMO Prime with
  prescription coverage with a premium of about
  150/month each. During the process of gathering
  the information you need, she tells you that they
  each get Social Security and their combined
  income is 1878/month. They live in their own
  home have some savings but no income other than
  Social Security.
• How would you help her?

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Case Study 5Herb O. Side

• Herb is 67 years old and will be retiring in a
  few months. He has been fully covered by his
  employer coverage and never applied for Medicare.
  He knows he can have COBRA for a period of time
  after he retires. He plans on traveling a great
  deal for a couple of years after retirement and
  is glad hell continue to have the comprehensive
  coverage COBRA provides. Herb is nervous about
  Medicare and doesnt think the coverage will be
  as good as what hes had through the employer
  plan. His health is good although he takes
  several brand medications which he knows would be
  costly without his insurance. He tells you his
  income after retirement will be just under
  30,000/year.
• How would you help him?

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Case Study 6Tom E. Gunn

• Tom has a question about his Medicare HMO Blue
  Plus Rx plan. He was hospitalized last month in
  his local hospital. He received a bill that he
  owes for his hospital stay. He called the
  hospital but was referred to Blue Cross. The
  customer service rep at Blue Cross told him he is
  responsible for the bill. He thinks its
  incorrect. He tells you he already finds it
  difficult to meet his monthly expenses on his
  Social Security check of 1500 without additional
  surprise bills.
• How would you help him?

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Case Study 7Paul Loot

• Paul and his wife, Sally, meet with you on March
  10th to discuss their insurance. They were both
  covered under his employer plan. He is 67 and has
  Medicare Part A only. He was just laid off from
  his job but the employer will pay for COBRA for
  both of them until the end of the year. Sally
  will turn 65 in February and pay for COBRA
  herself for January.
• What questions would you ask Paul Sally?
• What information would you review with them?
• What materials would you give them?
• Would you refer them to any other agency? If so,
  which one(s)?
• What phone calls, if any, would you make on their
  behalf?
• What follow-up, if any, is required in this case?

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Case Study 8Perry Winkle

• Perry calls you for help with his Part D
  coverage. He tells you he is enrolled in a
  Medicare Advantage plan. He joined a plan that
  provides coverage for generics in the gap even
  though it is more expensive, as most of his drugs
  are generic. He wants to join another plan. He
  tells you his monthly income is a Social Security
  check of 1530. He lives in his own home and
  cant afford additional costs for medication.
• How would you help him?

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Case Study 9Sam Antics

• Sam calls you to get information about Medicare
  for himself and his wife. Sam will turn 65 in 2
  months and will be retiring. He tells you that
  his retirement income of Social Security and a
  pension will be 4,500/month. He has already
  signed up for Medicare AB, a Medicare supplement
  plan and a Part D plan. His wife is 61 and never
  worked outside the home. He recently heard that
  she can get Medicare under his benefit. He wants
  to know if she can join when he becomes eligible.
  If not, he wants to know what her options are for
  health insurance coverage.
• How would you help him?

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Case Study 10Hank R. Chiff

• Hank meets with you at the SHINE office. He is
  very upset over what hes heard about the
  Medicare drug program. He is a veteran and
  currently gets his medication through the VA
  Health Plan. A friend told him that he should
  have joined the Medicare drug program during the
  first enrollment period and that he will now have
  to pay a penalty to join. He tells you that his
  only income is his Social Security check of
  1050/month. He explains that he owns his home
  and a car and has dipped into his savings
  (currently approximately 15,000) at times to
  help pay his living expenses and his Medigap
  premium of over 180/month.
• How would you help him?