Health Benefits University

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Health Benefits University

• McCormack Building
• Boston, MA

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SHINE

• Serving the Health Insurance Needs of Everyone on
  Medicare
• Network of 600 volunteer and working counselors
  across the Commonwealth
• SHINE Counselors are certified by the Exec.
  Office of Elders Affairs, complete extensive
  training
• Counselors are available at Councils on Aging,
  Senior Centers, elder service agencies, and other
  community-based organizations

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What does a SHINE Counselor do?

• Provides unbiased health insurance counseling to
  Medicare beneficiaries of all ages and their
  caregivers
• At a local site, on the phone, or via email
• Home visits may be available for homebound
  clients
• Assists clients in finding coverage that meets
  their needs
• Answers questions regarding Medicare eligibility,
  enrollment periods, and benefits
• Assists with Medicare appeals and billing issues
• Screens for public assistance programs

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Helpful Insurance Terms

• Premium amount paid monthly to have insurance
• Deductible out-of-pocket amount paid before
  health insurance begins to cover the cost of
  health care services
• Copayment set amount consumer pays for each
  service or item (ex. 20 copay for PCP, 35 for
  specialist)
• Coinsurance percentage of the cost of the care
  received after insurance pays (ex. 20
  coinsurance)

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What is Medicare?

• Federal health insurance program for
• People 65 years or older
• People under 65 with a disability
• Medicare is not Medicaid (MassHealth)
• Enroll in Medicare with the Social Security
  Adminstration
• Medicare is administered by the Centers for
  Medicare Medicaid Services (CMS)

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What is Medicare?
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Medicare Eligibility

• Age 65
• Entitled to Social Security and paid Medicare Tax
  (for 40 credits/quarters), or
• Be a spouse (or ex-spouse of 10 year marriage)
  of someone who qualifies for Social Security or
  Medicare
• Under 65
• Entitled to Social Security Disability Insurance
  (SSDI) for 24 months, or
• Entitled to SSDI and have ALS, ESRD, or certain
  other disabilities

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Enrollment Periods
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Enrollment Periods
During the One can enroll or change
Initial Enrollment Period A, B, C, D
General Enrollment Period Jan 1. Mar. 31 Coverage begins July 1 A, B
OPEN Enrollment Period Oct. 15 Dec. 7 C, D
Special Enrollment Period B, C, D
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After December 7th

• Plan is terminating
• Special Enrollment Period (SEP) Dec 8 Feb 28
• Prescription Advantage members
• One SEP each calendar year
• Extra Help beneficiaries and dual-eligibles
• Continuous SEP
• Loss of Extra Help on 1/1/2015
• SEP Until March 31st
• Medicare Advantage Disenrollment Period
• Jan 1 Feb 14
• 5 Star Plan SEP 2016 Tufts HMO Medicare
  Advantage Plan
• One SEP each calendar year to enroll in 5 Star
  Plan

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Late Enrollment Penalties

• A surcharge/lifetime penalty may be added to
  Medicare premiums if a beneficiary did not enroll
  during the prescribed enrollment period
• Part B (medical) penalty is 10 of current
  premium for every 12-month period of delayed
  enrollment
• Must enroll in Part B within 8 months of end of
  active employment to avoid penalty
• Coverage under COBRA does NOT provide a SEP or
  protect one from B penalty
• Part D (drug) penalty is 1 of the current Part D
  National Base Premium for every month the person
  could have had coverage but did not enroll

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Avoiding the Part D Penalty

• A person can delay enrollment into Part D without
  a late enrollment penalty if s/he has other
  creditable drug coverage
• Creditable drug coverage is any drug coverage,
  regardless of the source, that is at least as
  good as Medicares drug coverage
• If creditable drug coverage ends, the beneficiary
  must enroll into Part D within 2 months in order
  to avoid the LEP

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What does Medicare Cover?

• Helps to cover a range of inpatient, outpatient,
  and home care services
• Not created to be an individuals sole source of
  coverage
• Includes out-of-pocket costs
• Premiums
• Deductibles
• Co-pays and co-insurance

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Part A Coverage

• Inpatient care in hospitals
• Inpatient care in a skilled nursing facility
• Rehabilitation setting with licensed therapists
  (PT/OT/Speech)
• Hospice care services
• Home health care services
• Note Medicare does not cover long term care

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Part B Coverage

• Physician services
• Outpatient therapies
• Outpatient hospital services
• Medical equipment and supplies
• Ambulance
• Preventive services such as wellness visits,
  health screenings, flu/pneumonia shots

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Part D Coverage

• Provides outpatient prescription drug coverage
• Eligible to enroll if individual has Part A or B
• Voluntary
• Late enrollment penalty may apply if no other
  creditable drug coverage
• Delivered by stand alone Prescription Drug
  Plans (PDPs) or Medicare Advantage Prescription
  Drug Plans (MAPDs)

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Part D Coverage

• Each plan must follow a standard benefit
  structure set forth by Medicare
• Costs vary by Part D plan
• Premiums, deductibles, co-pays
• Coverage varies by Part D plan and formularies
  (drugs that plan covers) change EVERY year

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Part D Coverage
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Extra Help/Low Income Subsidy

• Federal assistance program to help reduce the
  cost of Part D plans for beneficiaries with
  limited resources
• Income and asset limits
• Extra Help subsidizes
• Premiums, deductibles, copays, and coverage gap
• Late enrollment penalty
• Individuals with MassHealth are automatically
  enrolled
• Recipients receive a continuous SEP
• Apply through Social Security Administration

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Prescription Advantage

• State-sponsored pharmaceutical assistance program
• Administered by the Massachusetts Executive
  Office of Elder Affairs
• Reduces a members prescription drug copays
  associated with Medicare prescription drug
  coverage or other creditable coverage
• Level of assistance depends on membership
  category, which is defined by income

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Prescription Advantage Benefits

• For lowest income categories, provides immediate
  copay assistance
• For those in the middle income categories, copay
  assistance begins when they reach the coverage
  gap
• For the highest income category, copay assistance
  begins once members out-of-pocket costs reach
  3,500
• Higher income members must also pay a 200 annual
  enrollment fee
• All have an annual out-of-pocket spending limit
• All receive one Special Enrollment Period every
  calendar year

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To Apply for Prescription Advantage

• Applications can be obtained from your local
  SHINE counselor, Council on Aging, and
  Prescription Advantage (PA) Customer Service
• Applications can also be done over the phone with
  a PA customer service representative
• Applications can be done online
• Phone 1-800-AGE-INFO, option 2
• 1-800-243-4636
• Website www.prescriptionadvantagema.org

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Pharmacy Outreach Program

• Pharmacy Outreach Program of the Massachusetts
  College of Pharmacy and Health Sciences
  University
• Partially funded by the Executive Office of Elder
  Affairs
• Toll free number 1-866-633-1617
• Website www.mcphs.edu/pharmacyoutreach
• Pharmacists and case managers available to
• Conduct Part D reviews
• Screen for financial assistance programs
• Provide recommendations for alternative
  medications
• Review for drug interactions

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Additional Coverage

• Beneficiaries may obtain additional coverage in a
  number of ways, including
• Medigap plans
• Medicare Advantage Plans
• MassHealth (Medicaid)
• Retiree plans
• Veteran or military benefits

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Supplementing Medicare
Medicare Advantage Plan Optional
Replacement (Provides Original Medicare
benefits plus extra routine and preventive
benefits) HMO (Health Maint. Org.) PPO (Prefd
Provider Org.) PFFS (Private Fee For Service) SNP
(Special Needs Plan) Generally includes Part D
drug coverage
Original Medicare

Part D Stand Alone Plan
OR

Medigap Policy Optional add-on (Picks up where
Original Medicare leaves off)
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Medigap Plans

• Sold by private insurance companies
• Must have Parts A B
• Continue to pay Part B premium
• Pays secondary to Medicare only for
  Medicare-covered services
• Continuous open enrollment in Massachusetts
• Do not include prescription drug coverage

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Medigap Plans

• Two types sold in Massachusetts
• Coredoes not cover all gaps (such as A B
  deductibles, and SNF copays), but costs less
• Supplement 1covers all gaps, but costs more
• Both types allow members to see any Medicare
  provider without referrals

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Medicare Advantage Plans

• Also known as Part C
• Private plans contracted with Medicare to provide
  coverage comparable to Original Medicare
• Include Part D coverage (cannot enroll in a
  separate stand alone Medicare Part D plan)
• Plans may add benefits (e.g., dental checkups,
  vision screening, eyeglasses, hearing aids)
• Plans charge additional premiums and copays
• May be restricted to networks and require
  referrals

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Medicare Advantage Eligibility

• Must have Parts A B
• Must continue to pay Part B premium
• Must live within the plans service area for at
  least 6 months of the year
• Cannot have End Stage Renal Disease

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Medigap vs. Medicare Advantage
Original Medicare Supplement 1 Medicare Advantage Plan
Higher monthly premium but no copays Generally lower premiums but has copays
Freedom to choose doctors Generally restricted to networks
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 U.S. Only emergency services provided outside certain area
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Other ways to Supplement Medicare

• Retiree health plans (group plans)
• Each retiree plan is different
• Request an outline of benefits to learn about
  plan
• MassHealth/Medicaid (for low-income)
• Part A B deductibles and copays covered in full
  if seeing MassHealth providers
• Veterans health care
• Supplements copayments when visiting a VA
  physician, health clinic, or hospital

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MassHealth Standard

• Provides a full range of medical benefits
• Including inpatient, outpatient, skilled nursing
  care, and prescription drug coverage
• 
  
• Provides secondary coverage for Medicare
  beneficiaries
• Pays Part A B premiums, deductibles
  coinsurance
• Deemed eligible for Extra Help can pay for
  Medicare Part D premium, deductible, and reduce
  copays for medications

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CommonHealth

• For individuals with disabilities who are not
  eligible for MassHealth Standard
• No income or asset limits regardless of age
• If 65, must meet a work requirement to be
  eligible
• If under 65, can meet the work requirement or a
  deductible to be eligible
• Sliding scale monthly premium for those with an
  income above 150 FPL

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CommonHealth

• Regardless of age, complete ACA-3 form.
• Recommendation Write CommonHealth on the front
  of the application if submitting a paper form
• If approved will receive many of the MassHealth
  Standard benefits
• Inpatient and outpatient services
• Transportation services
• Automatically enrolled in Extra Help

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Frail Elder Waiver Eligibility

• Individual must be 60 years or older
• Must meet MassHealth clinical eligibility
  requirements for nursing home care (screened by
  ASAP)
• Income limit
• 300 of SSI Federal Benefit Rate
• Asset limit
• 2,000
• Excess assets can be transferred to a spouse
• Spouses income and assets are waived in
  determining financial eligibility
• Complete the SACA-2 form (even if under 65 years
  old)

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Medicare Savings Programs

• Programs that help pay for Medicare cost-sharing
• Qualified Medicare Beneficiary (QMB)
• Pays Part A B premiums, copays, and deductibles
• Specified Low-income Medicare Beneficiary
  (SLMB)and Qualifying Individual (QI)
• Pays Part B premium only
• Part B premium for new enrollees in 2016 is
  121.80/month for an individual

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MSP Application Process

• To qualify for QMB, must complete a full
  MassHealth application
• To qualify for SLMB or QI-1, complete 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.

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Health Insurance Marketplace

• New benefits and expanded access for individuals
  without health insurance
• Administered by the Connector in Massachusetts
• Does not apply to Medicare beneficiaries!
• Not eligible for health plans through the
  Marketplace
• Medicare Open Enrollment is still Oct. 15 Dec.
  7

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One Care Medicare MassHealth

• Health insurance plan which combines Medicare and
  Medicaid payments and services for consumers aged
  21-64
• Person-centered model providing the full range of
  acute, behavioral health, and long term supports
  and services including transportation and
  dental services.
• Designed to coordinate care and provide higher
  quality, more cost-effective care with improved
  health outcomes
• Individuals enrolled in a SCO, PACE, Frail Elder
  Waiver or other Home and Community Based Service
  Waivers are not eligible
• A One Care member turning 65 can stay in their
  One Care plan as long as they remain eligible for
  MassHealth

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One Care Plans

• Two companies offer One Care Plans in select
  counties
• 1) Commonwealth Care Alliance
• Contact 1-866-610-2273,
  www.commonwealthonecare.org
• 2) Tufts Network Health
  
  
• Contact 1-855-393-3154,
  www.chooseunify.com
• Visit the One Care Website www.mass.gov/massheal
  th/onecare

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Where is One Care Available?
  Commonwealth Care Alliance Network Health
Essex X    
Franklin X    
Hampden X  
Hampshire X  
Middlesex X    
Norfolk X    
Plymouth X    
Suffolk X   X
Worcester X X
One Care is available in Plymouth County except
for the following towns Wareham, E. Wareham,
W. Wareham, Lakeville, Marion and
Mattapoisett One Care is not available in
Barnstable, Berkshire, Bristol, Dukes, and
Nantucket Counties.
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