2015 SHINE Certification Review

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2015 SHINE Certification Review
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Medicare Part A BOriginal Medicare
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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 ESRD
• Note Medicare is NOT Medicaid (which is health
  insurance for very low income population)

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Medicare Eligibility

• Individuals 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

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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

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Medicare Eligibility

• Individuals under age 65
• Receiving Social Security Disability Insurance
  (SSDI) for 24 months
• End-Stage Renal Disease (ESRD)
• Amyotrophic Lateral Sclerosis (ALS)

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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 2015 for beneficiaries with
  individual income lt85,000/year)

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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)

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Delayed Enrollment

• May enroll into Medicare Part A 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

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Delayed Enrollment- Part B

• General Enrollment Period for Part B
• January 1st March 31st
• Coverage effective July 1st
• Part B Penalty for delayed enrollment
• Increased premium of 10 for each 12 months of
  delayed enrollment
• Lifetime
• Increases with increases in premium

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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

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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

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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

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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)

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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

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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

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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 individuals 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

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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

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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

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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

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Gaps in Original Medicare
Part A Hospital deductible per benefit period Daily co-pay for extended hospital stays (days 61-90) Daily co-pay for days 21-100 in SNF
Part B Annual deductible 20 co-pay for most Part B services Routine physical, hearing, vision, dental Foreign travel

• 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

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Medicare Part C Medicare Advantage Medigap
Plans
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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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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

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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)

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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

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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

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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
• Different Plan Types
• HMO
• PPO
• PFFS
• SNP

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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 15th December 7th
• Special Election Period (SEP)
• Medicare Advantage Disenrollment Period (MADP)
• January 1st February 14th

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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

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HMO Health Maintenance Organization

• Must choose a Primary Care Physician
• Must receive all services within the plans
  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

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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

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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 plans 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

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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
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• 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 US Only emergency services provided outside certain area
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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 plans formulary and
  how much do they cost?
• May cost more in Medicare Advantage plan

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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

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Medicare Part D
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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)

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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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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 15th December 7th
• Special Election Period (SEP)
• Medicare Advantage Disenrollment Period (MADP)
• January 1st February 14th

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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

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Late Enrollment PenaltyPart D

• 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/2 full months)
• 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)

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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

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Part D Coverage

• Deductibles, out-of-pocket limits, and co-pays
  during the coverage gap change yearly
• Refer to Part D Standard Benefit Chart

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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)

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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 1st

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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

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Assistance with prescription costsMassHealth
Extra Help / Low Income Subsidy Prescription
Advantage
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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
• Certain Over the Counter Medications (Ibuprofen
  acetaminophen)
• Most prescription vitamins and minerals
• Prescription drugs used for - anorexia, weight
  loss or weight gain fertility cosmetic purposes
  or hair growth relief of symptoms of colds
• Dual Eligible individuals must receive primary
  coverage through a Medicare Part D plan

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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

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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

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Eligibility

• To be eligible for Extra Help in 2015
• 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) below limit
• (Resource levels are determined each year)
• Refer to public benefit eligibility charts for
  premium, deductible, and co-pay amounts
• To apply visit www.ssa.gov/prescriptionhelp

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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

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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 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)

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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

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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

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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 for the late
  enrollment penalty fee

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Other Ways to Lower Prescription Costs

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

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MCPHS Pharmacy Outreach Program

• 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

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Public Benefits
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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

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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

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MassHealth Standard Eligibility
Eligibility for 65 years old not
institutionalized
Income limit Asset limit
Individual 100 FPL 2,000
Couple 100 FPL 3,000

• 20 unearned income disregard applied
• Higher income disregard for earned income

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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)

66
MassHealth for Caretaker Relatives

• Income limit increases to 133 FPL
• No income disregards applied
• No asset limit
• To apply, ACA-3 form, regardless of applicant
  age

67
MassHealth for Caretaker Relatives Case Study

• 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

68
MassHealth for Caretaker Relatives Case Study

• 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 is below the 133 FPL for a family of 2
• She and Amelia would qualify for MassHealth
  Standard
• Susan would automatically qualify for Extra Help

69
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

70
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 envelopes
• Babysitting Answering phones

71
CommonHealth

• Regardless of age complete a MassHealth ACA-3
  form.
• 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

72
CommonHealth Case Study

• 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

73
CommonHealth Case Study

• 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

74
Personal Care Attendant (PCA) Program

• For individuals who need assistance with at least
  two Activities of Daily Living (ADLs) 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

75
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 SACA-2 and PCA
  supplement

76
PCA Case Study

• 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. Dianes father has a
  monthly income of 1,150 a month and no assets

77
PCA Case Study

• 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

78
Home and Community Based Services Waiver (HCBSW)

• 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

79
HCBSW Eligibility

• Individual must be 60 years or older
• Must meet MassHealth clinical eligibility
  requirements for nursing home care (screened by
  ASAP)
• Individuals monthly income cannot exceed 300
  SSI and assets limited to 2000 (assets in excess
  of 2000 must be transferred to spouse)
• Spouses income and assets are waived in
  determining financial eligibility
• Complete the SACA-2 form (even if lt65 years old)

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HCBSW Case Study

• 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.
• Sandys income is 1,300 a month
• Jims income is 1,800 a month
• Combined they have 25,000 in the bank

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HCBSW Case Study

• 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 Jims income is counted
• Jims assets must be below 2,000 to qualify.
  Sandys 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

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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 Limit
Full HSN 200 FPL
Partial HSN 400 FPL
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Health Safety Net and Medicare

• Medicare has many gaps
• Part A deductible
• Per benefit period
• Part A co-payments
• Daily co-payments for hospital stays greater than
  60 days

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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

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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

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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

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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
• Deductible is not applicable

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Medicare Savings Programs (MSP)

• 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

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Medicare Savings Programs
Type Income Limit Asset Limit Benefits
QMB 100 FPL 7,280 (Individual) 10,930 (Couple) Pays Part A B premiums, co-insurance, and deductibles
SLMB 120 FPL 7,280 (Individual) 10,930 (Couple) Pays Part B premiums
QI 135 FPL 7,280 (Individual) 10,930 (Couple) Pays Part B premiums
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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

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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

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One Care

• Type of Medicare Advantage Special Needs Plan
• Available to individuals with disabilities age
  21-64
• Must have Medicare Part A B, plus MassHealth
  Standard or CommonHealth
• Only available in specific service areas
• Provides coordinated care

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One Care

• Services include
• No co-pays for prescription drugs
• Enhanced behavioral health and substance abuse
  services
• Long-term support
• Crisis stabilization
• Day programs
• Home modification
• Comprehensive dental
• Hearing aids
• Transportation

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Medicare Appeals, Fraud and Abuse
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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

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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

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The Medicare Advocacy Project(MAP)

• 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

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Examples of Problems Referred to MAP

• Durable medical equipment coverage
• Skilled nursing facility care coverage denials
• Early hospital discharges
• Ambulance transportation
• Physicians services denials
• Access to Medicare covered home health care
• Drug coverage exceptions and appeals
• Disputed Low Income Subsidy Determinations
• Premium penalties

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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.

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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

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The End!