Other Health Insurance Options

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Other 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
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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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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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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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 Standard

• MassHealth Standard
• Different eligibility requirements for under 65
  and 65
• 65 100 FPL, asset limits
• Under 65 133 FPL, no asset limits
• 2 application types
• ACA-3 (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 pink sheet 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
• Under 65 can waive work requirement if meet
  one-time deductible
• 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 (100 for
  beneficiaries with disability) 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 covered services for active
  employees, EXCEPT
• Medicare may be primary payer for active
  employees who work for an employer with fewer
  than 20 employees or fewer than 100 if
  beneficiary has a disability
• Beneficiary needs to check with employer whether
  they 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

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COBRA Medicare

• Coverage under COBRA does NOT prevent the Part B
  penalty (not ACTIVE employment)
• Medicare is usually the primary payer and COBRA
  is secondary
• Individual must check with employer to determine
  whether she/he needs to have Medicare for COBRA
  to provide coverage
• If on COBRA when individual becomes eligible for
  Medicare, individual loses COBRA coverage
• Generally, COBRA drug coverage is creditable so
  when COBRA coverage ends there is a 2 month (63
  day) SEP for enrolling into a PDP without penalty

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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

• Health Benefits Package
• Comprehensive health benefit plan available to
  all veterans
• Enrollment
• All honorably discharged veterans who meet the
  eligibility criteria 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.

• 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 For Life (TFL)

• Health care program serving Uniformed Service
  members, retirees and their families worldwide
• Provided automatically to all in TRICARE who
  have Medicare Parts A B
• 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 For Life (TFL), cont.

• 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
• Drug coverage is creditable so beneficiaries are
  not required to enroll in Part D

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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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Massachusetts Health Connector

• The Health Connector is a state price comparison
  website for subsidized health insurance where
  individuals, families, and small businesses can
  shop for health dental insurance plans
• It is designed to help people who dont have any
  health coverage
• Medicare is NOT part of the Health Insurance
  Marketplace
• It is illegal for the Connector to sell a
  Medicare beneficiary a health plan
• In Massachusetts everyone (including Medicare
  beneficiaries) can purchase a dental plan
  through the Connector

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Where can individuals go for help with the
Connector?

• SHINE counselors should refer individuals to
  their local Navigator or Certified Application
  Counselor (CAC) or provide the contact
  information below
• Massachusetts Health Connector
• betterhealthconnector.com
• [phone]

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Review

• When is Medicare the primary payer for
  beneficiaries who are actively employed?
• Does an individual with retiree health insurance
  coverage need to be concerned about the Part B
  penalty?
• Having COBRA will protect a beneficiary from the
  Part B penalty.
• True False
• What is the VA Health Benefits Package and what
  benefits does it provide?
• Which VA programs provide prescription coverage
  that is creditable?