Day 1 SHINE Program Certification Training

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Day 1SHINE ProgramCertification Training
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Welcome!

• SHINE Serving the Health Insurance Needs of
  Everyone..on Medicare
• Started in Massachusetts 1985
• Partially federally funded since 1992
• Part of national SHIP State Health Insurance
  Assistance Programs

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State Organization

• Executive Office of Elder Affairs
• State SHINE Director Cindy Phillips
• Assistant State Director Barbara Deveau
• State Field Operations Manager/Training
  Coordinator Annie Toth
• State Program Coordinator

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Regional Organization

• Regional SHINE Office
• Regional SHINE Director
• SHINE Program Assistant

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Overall Goal

• To ensure that Medicare beneficiaries have access
  to accurate, unbiased information regarding
  health insurance and health care options
• To help people help themselves

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Examples Of What We Do

• Assist people in understanding their Medicare and
  MassHealth rights and benefits
• Educate people about all of their health
  insurance options
• Screen for public benefits (State and Federal)
• Assist with applications
• Resolve problems with insurances Medicare,
  MassHealth

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Training

• Certification training
• Mentoring
• Monthly training meetings
• October Review and training for Medicares
  annual Open Enrollment
• Recertification review every spring

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Were Here To Support You

• Regional Office Staff
• Director
• Assistant Director
• SHINE Counselor Website
• shinecounselor.800ageinfo.com
• Common Resources
• SHINE newsletter The Beacon

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Medicare Part A Part B
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Medicare

• Federal health insurance program for
• Individuals age 65 and over
• Individuals under age 65 with a disability
• Enacted into law 1965, Title XVIII of the Social
  Security Act Effective July 1st , 1966
• Entitlement program
• Never intended to cover 100 of healthcare costs
• NOT a comprehensive health insurance program

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Medicare

• Medicare only pays for services which are
  reasonable and medically necessary for the
  treatment and diagnosis of an accident or illness
• Even when medically necessary, there are gaps
  in Medicare coverage and the beneficiary must pay
  a portion of the medical expenses

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Federal Agencies Involved With Medicare
  Department of Health and Human Services (DHHS) Administers Medicare through its divisions, CMS and SSA     Department of Health and Human Services (DHHS) Administers Medicare through its divisions, CMS and SSA  
Centers for Medicare Medicaid Services (CMS) Determines policy Budgets for Medicare Issues regulations Sets provider fees Establishes agreements with contractors Social Security Administration (SSA) Processes Medicare applications Issues Medicare cards Provides public information Determines entitlement to Medicare benefits  
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Medicare Card

• Each Medicare Claim Number is unique to the
  beneficiary
• The number has nine digits and a letter
• Card lists effective dates for Part A Part B

Medicare Claim . Letter attached to the claim
indicates how the individual qualifies for
Medicare
Part A B Effective Dates
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Four Parts of Medicare

• FYI Part A B called Original Medicare

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Original Medicare

• Health care option run by the federal government
• Provides Part A and/or Part B coverage
• See any doctor or hospital that accepts Medicare
• Beneficiary pays
• Part B premium (Part A is usually premium free)
• Deductibles, coinsurance, or copayments
• Can join a Part D plan to add drug coverage

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Eligibility 65

• Age 65
• Must be U.S citizen/lawfully permitted resident
  for 5 years
• For premium-free Part A (entitled to Medicare),
  must qualify under ONE of the following 3
  conditions
• Be entitled to receive Social Security benefits
  and contributed to the Medicare Tax (having
  earned 40 credits from about 10 years of work)
• Be entitled to receive Railroad Retirement Act
  retiree benefits
• Be a spouse or ex-spouse (marriage lasted at
  least 10 years), widow or widower (age 65) of a
  person who qualifies for Social Security or
  Medicare benefits
• FYI Increase in age for full Social Security
  benefits does NOT affect Medicare

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Eligibility Under 65

• Under 65
• Individuals of any age entitled to Social
  Security (SSDI) or Railroad Retirement Disability
  Insurance benefits for 24 months
• Individuals with ESRD (End Stage Renal Disease)
• Individuals with ALS (Amyotrophic Lateral
  Sclerosis, aka Lou Gehrigs Disease)

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Enrolling In Medicare

• Social Security processes Medicare applications
• Common myth that Medicare will know when a person
  turns 65. This is NOT TRUE, unless the person is
  already receiving Social Security benefits
• A person must notify Social Security of their
  intent to enroll in Medicare
• Medicare and Social Security are two entirely
  separate entitlement programs

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Medicare Premiums

• Individuals or their spouses who have paid into
  the Medicare Program and worked at least 40
  credits DO NOT pay a Part A premium
• This is called premium-free Part A
• Most people pay a Part B premium
• Benefit programs available to pay for the premium
  for low-income beneficiaries
• Part B premiums are often deducted from the
  Social Security check
• If not collecting Social Security, will be billed
  every 3 months
• Part A B premiums may change annually

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2015 Part A and B Premiums

• Part A
• People who dont qualify for premium-free
  Medicare may enroll voluntarily and pay a monthly
  premium for Parts A B
• Part A Premiums
• 0-29 work credits See Medicare Part A
  Benefits
• 30-39 work credits and Gaps chart
• Part B
• Premiums based on annual income (past 2 years tax
  returns)
• Standard amount Ind lt 85,000 married lt
  170,000 104.90/month
• Increases with higher income

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Three Enrollment Types

• Automatic Enrollment
• Standard Enrollment
• Voluntary Enrollment

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Automatic Enrollment

• For individuals already receiving Social Security
  benefits
• Beneficiary receives automatic enrollment notice
  3 months before 65th birthday month (4 months
  before if birthday on 1st of month - Medicare
  begins 1st of month prior to birthday month)
• Individuals with a disability become eligible 24
  months after Social Security Disability payments
  began and receive notice about 3 months before
  25th month of disability benefits
• Individual must sign and return card if she/he
  does NOT want Part B

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Standard Enrollment

• Individuals not yet collecting Social Security
  benefits prior to age 65 MUST NOTIFY Social
  Security of intent to enroll in Medicare
  (enrollment is NOT automatic)
• Initial Enrollment Period (IEP) 7 month period
  encompassing the full 3 months preceding persons
  65th birthday, month of 65th birthday, and the
  full 3 months following the 65th birthday (month
  earlier if birthday on 1st of month)
• Must sign up during the first 3 months of IEP to
  get Part B coverage effective 1st of birthday
  month
• If individual waits to sign up until last four
  months of IEP, Part B start date will be delayed

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Voluntary Enrollment

• For individuals who dont have sufficient Social
  Security work credits (40 credits/10 yrs)
• Can purchase Part A
• Must be an American citizen OR an alien lawfully
  admitted for permanent residence and resided in
  US for 5 consecutive years
• Can purchase Part A AND Part B OR Part B only
• CANNOT have Part A alone as a voluntary enrollee
• Having Part B only does NOT meet the minimum
  essential coverage requirement under the
  Affordable Care Act and beneficiary may have to
  pay a penalty

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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 (individuals or spouses)
• General Enrollment Period (GEP) Jan 1st Mar
  31st of each year
• July 1st effective date

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Initial Enrollment Period
Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th
JAN FEB MAR APR MAY JUNE JULY AUG SEP SEP OCT OCT NOV DEC
If you enroll during If you enroll during If you enroll during 3 months before the birthday month 3 months before the birthday month 3 months before the birthday month Month of birthday   3 months after the birthday month 3 months after the birthday month 3 months after the birthday month 3 months after the birthday month 3 months after the birthday month    
MEDICARE STARTS MEDICARE STARTS MEDICARE STARTS JULY 1 JULY 1 JULY 1 AUG 1 OCT 1 OCT 1 DEC 1 DEC 1 JAN 1    
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Initial Enrollment Period When Coverage Starts
If beneficiary enrolls in this month of IEP Medicare Part A B Coverage Starts
1 The month beneficiary becomes eligible for Medicare
2 The month beneficiary becomes eligible for Medicare
3 The month beneficiary becomes eligible for Medicare
4 Following month after beneficiary enrolls
5 Two months after beneficiary enrolls
6 Three months after beneficiary enrolls
7 Three months after beneficiary enrolls
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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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Consolidated Omnibus Budget Reconciliation Act
(COBRA)

• When employment and/or EGHP ends, individual can
  elect COBRA coverage which continues health
  coverage through employers plan (in most cases
  for only 18 months) and probably at a higher cost
• If elect COBRA, should NOT wait until COBRA ends
  to enroll in Medicare or will pay a late
  enrollment penalty and will have to wait until
  the next General Enrollment Period to enroll
• Must sign up for B within the first 8 months (SEP
  after ACTIVE work) of COBRA to avoid penalty
• Should enroll in Part B because Medicare pays
  first and COBRA pays second
• COBRA may not provide coverage if individual does
  not have Medicare

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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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General Enrollment Example

• Mr. Santos retires at age 65 and declines
  Medicare Part B. At age 70, Mr. Santos wants to
  purchase Part B. He must wait until the General
  Enrollment Period (January 1st - March 31st ) for
  coverage that begins the following July. Mr.
  Santos will have a 50 penalty added to his Part
  B premium (10 for each 12 month period he
  delayed Part B enrollment)

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Example of Part B Penalty for Mr. Santos
ENROLLMENT YEAR MONTHLY PREMIUM PENALTY (10 penalty per year times the number of years enrollment was delayed, 5 for Mr. Santos)50 TOTAL PART B COST FOR MR. SANTOS
  Year 1   104.90   (104.90 x 50)52.45   157.35
Year 2 106.00 (106.00 x 50)53.00 159.00
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Initial Enrollment Example

• Mr. Kaplan is turning 65 on August 29th. His
  first opportunity to enroll in Medicare based on
  his age (not disability) is May 1st . His
  initial enrollment period lasts until November
  30th. The month he enrolls determines the
  effective date of coverage

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Special Enrollment Example

• Mrs. White continued working after age 65 and was
  covered by an employer-related group medical
  plan. She chose to enroll in Part A when she
  turned 65 (because she does not have to pay a
  premium) but delayed Part B enrollment. Her
  Special Enrollment Period will be the 8 month
  period following the month she is no longer
  covered by her employers plan or her employment
  ends, whichever comes first

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Medicare Part A(Hospital Insurance)
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Medicare Part A (Hospital Insurance)

• Part A Covers
• Inpatient hospital care
• Care in a skilled nursing facility (SNF)
• Home health care
• Hospice care
• Blood

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2015 Part A Out-of-Pocket Costs

• Inpatient hospital care
• Days 1-60 See Medicare Part A Benefits and
  Gaps
• Days 61-90
• Days 91-150 (Lifetime Reserve Days)
• All additional days All costs
• Skilled Nursing Facility care
• Days 1-20 Nothing
• Days 21-100 See Medicare part A Benefits and
  Gaps
• Durable Medical Equipment
• 20 of approved amount
• Hospice Care
• Small co-pays for inpatient respite care and
  drugs
• Home Health Care
• Nothing

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Inpatient Hospital Coverage

• Covered days in a hospital
• 90 renewable days
• Medicare pays 100 for days 1-60 in a benefit
  period AFTER beneficiary pays Part A deductible
• Daily co-payment for days 61-90 in a benefit
  period
• 60 non-renewable days
• Daily co-payment for days 91-150 (lifetime
  reserve days)

• A benefit period is a period of time that
  Medicare pays for a persons care in a hospital
  or SNF. It begins when a beneficiary goes into
  the hospital and ends when she/he has been out of
  the hospital or skilled nursing facility for 60
  consecutive days

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Inpatient Hospital Coverage

• Inpatient hospital coverage requirements
• Doctor determines it is medically necessary
• Care requires being in a hospital
• Hospital participates with Medicare
• Utilization Review Committee of the hospital
  approves the stay

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Inpatient Hospital Covered Services

• Services covered during a hospital stay
• Semi-private room and all meals
• Special care units
• General nursing services
• Drugs administered in the hospital
• Lab tests
• Radiology services

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Inpatient Hospital Covered Services, cont.

• Services covered during a hospital stay
• Medical supplies (casts, surgical dressings)
• Operating and recovery rooms
• Rehabilitation services (physical therapy)
• Use of appliances (wheelchairs)
• Blood transfusion (after first 3 pints)

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Inpatient Hospital Services NOT Covered

• Services NOT covered during a hospital stay
• Physician services (Part B)
• Personal convenience items
• Private room (unless medically necessary)
• First three pints of blood
• Private duty nursing

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Hospital Coverage

• Other hospital coverage
• Care in a psychiatric hospital
• 190 lifetime days for Inpatient care
• Care in a foreign hospital
• Medicare usually does NOT pay for care outside
  the United States
• Medicare MAY pay for qualified care in a Mexican
  or Canadian hospital under special conditions

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Skilled Nursing Facility (SNF) Coverage

• Must be a Medicare participating facility
• Physician must certify that patients needs and
  receives daily skilled care from RN or therapist
• Prior Inpatient hospital stay of 3 days or more
  (72 hours as an admitted patient)
• An overnight stay doesnt always mean an
  Inpatient day (can be observation day)
• Break in skilled care that lasts more than 30
  days will require a new 3 day hospital stay to
  qualify for additional SNF care
• Admitted to SNF within 30 days of discharge from
  hospital

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SNF Covered Days

• 100 renewable days
• Days 1-20 Medicare pays 100 in a
  benefit period
• Except convenience items
• Days 21 100 Daily co-payment

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SNF Covered Services

• Services covered in a SNF
• Semi-private room
• All meals (including special diets)
• General nursing services
• Rehabilitation services
• Drugs furnished by the SNF during the stay
• Use of medical equipment and supplies

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SNF Services NOT Covered

• Services NOT covered in a SNF
• Physician services (Part B)
• Personal convenience items
• Private room (unless medically necessary)

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Medicare Part A Benefit Period Example

• Benefit period Example 1
• Mr. Jones is hospitalized as an Inpatient on
  January 5th and remains in the hospital until
  January 12th. Mr. Jones has used 8 of his
  hospital days in the benefit period. (Day of
  discharge counts.) Mr. Jones has 82 hospital
  days left in the benefit period
• How much would Mr. Jones have to pay for his
  hospital stay?

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Medicare Part A Benefit Period Example

• Benefit period Example 2
• Mr. Jones is discharged from the hospital on
  January 12th and transferred to a SNF where he
  remains until February 9th. Mr. Jones used 29
  days of his SNF benefit. He has 71 days left
• How much would Mr. Jones have to pay for his
  Skilled Nursing Facility care?

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Home Health Benefit

• Home health benefit coverage requirements
• Must need skilled care on intermittent basis
• Home health agency must be Medicare-approved
• Physician must authorize treatment and have
  face-to-face meeting with beneficiary prior to
  start
• Beneficiary must be homebound (see next slide)
• Medicare pays 100 for all covered and medically
  necessary home health services
• EXCEPTION Medicare pays 80 of durable
  equipment

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Homebound

• Homebound means normally unable to leave home or
  that leaving home is a major effort and must
• Require a supportive device, or
• Use of special transportation, or
• Require the assistance of another person
• Can leave home, but it must be infrequent and for
  a short time.
• Examples Leave to get medical care (may include
  adult day care), attend a religious service, get
  a haircut

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Home Health Benefit Covered Services

• Services covered by home health benefit
• Skilled nursing care
• Physical, occupational, or speech therapy
• Medical social services (dietary counseling)
• Care by home health aide (bathing, changing
  dressing)
• Medical supplies
• Equipment (20 co-insurance)

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Home Health Benefit Services NOT covered

• Services NOT covered by home health benefit
• Prescription drugs
• Homemaker services
• Home delivered meals (Meals on Wheels)
• Personal care services in the absence of skilled
  care

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Hospice

• Hospice Coverage
• Physician must certify that beneficiary is
  terminally ill and expected to live 6 months or
  less
• Beneficiary has elected to receive comfort and
  pain relief care from Hospice instead of medical
  treatment for cure
• Care is provided by Medicare certified hospice
  program

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Hospice, cont.

• Covered benefit period for Hospice Care
• Two 90-day periods
• Then unlimited 60-day periods
• Face-to-face meeting with doctor required
• While receiving Hospice Care
• Medicare pays 100 of most services
• Beneficiary only pays small co-pays (5 or less)
  for outpatient drugs and respite care
• Hospice covers all drugs related to hospice care
• All Part D drugs for hospice patients require
  prior authorization to ensure Part D is not
  covering hospice drugs

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Blood

• Coverage of blood
• Medicare pays 100 after the first 3 pints of
  blood
• The 3 pint blood deductible can be met under Part
  A or Part B
• Wont have to pay for it or replace blood if
  hospital gets it free from a blood bank

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Utilization Review Committee

• Reviews patient stays in hospitals and SNFs to
  determine if patient meets Medicare standard for
  needing care in hospital setting
• Each patients doctor must satisfy the
  Utilization Review Committee (URC) that patient
  meets admission criteria and continues to need
  acute hospital level of care
• Has authority to terminate Medicares obligation
  to pay for medical services in hospital or SNF
• Determines patient time of discharge

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Hospital Discharge

• Discharge Plan
• Beneficiaries should be an active part of their
  discharge plan
• Beneficiary should be given written discharge
  plan at least 24 hours prior to discharge
• Beneficiary signs plan to acknowledge receipt
  (Signature does not mean beneficiary agrees the
  plan is appropriate)
• If unsatisfied with plan, the beneficiary can
  appeal
• Beneficiary should ask for written Notice of
  Non-Coverage and appeal if appropriate to Dept.
  of Public Health

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Medicare Part A Review

• Review
• What are the two major federal agencies involved
  with the Medicare Program and what is each of
  their roles?
• Who can enroll in Medicare?
• When can someone enroll in Medicare?
• Does someone have to enroll in both parts of
  Medicare (A B)?
• What is a benefit period?

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Medicare Part B (Medical Insurance)
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Medicare Part B (Medical Insurance)

• Physicians Services
• Outpatient hospital services
• Durable medical equipment
• Prosthetics, orthotics, and supplies
• Ambulance
• Home health care (if not Part A)
• Blood (if not Part A)

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Medicare Part B Important Terms

• Medicare approved amount Fee Medicare sets for
  Medicare covered service
• Excess charges Amount owed by beneficiary above
  the Medicare approved amount. In other states,
  there is a limit on excess charges of 15
• Ban on Balanced Billing Massachusetts has a law
  prohibiting excess charges by physicians
• Accepting Assignment Accepting the Medicare
  approved amount as payment in full
• Participating Provider Signing an agreement
  saying you agree to accept assignment for all
  beneficiaries in all cases (non-participating
  less important in MA)

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2015 Part B Out-of-Pocket Costs

• Monthly Part B Standard Premium
• 104.90/month
• Premiums based on modified adjusted gross income
  for an individual those with higher annual
  incomes pay higher Part B premiums
• Annual Deductible
• 147

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2015 Part B Out-of-Pocket Costs, cont.

• After the yearly deductible is met, beneficiary
  pays
• Doctor office visits 20 co-payment
• Diagnostic tests Nothing
• Outpatient therapy 20 co-payment
• Outpatient mental health 20 co-payment
• DME 20 co-payment PLUS balance on bill
• DME is sole area in which the provider can bill
  over and above the Medicare-approved amount
  (Balance Billing)
• Emergency Ambulance 20 co-payment
• Outpatient Hospital Services Fixed amount
  determined by Medicare

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Physician Services

• Physicians services covered
• Exams
• DOES NOT include routine annual physicals
• Welcome to Medicare Exam
• 1x only exam within first 12 months of joining
  Part B
• Annual Wellness Visit
• Discussion with doctor to develop prevention plan
  to improve health, routine measurements height,
  weight, blood pressure
• Medical and surgical procedures, anesthesia,
  diagnostic tests and procedures
• Radiology and pathology services (in or out of
  the hospital)

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Physician Services, cont.

• Physicians services covered, cont.
• Drugs that cannot be self administered
• Blood transfusions
• Second opinion about recommended surgery
• Physicians services which may be partially
  covered
• Chiropractors services
• Podiatrists services
• Optometrists services
• Dentists services

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Physician Services

• Physicians services NOT covered
• Most routine physical exams and tests related to
  such exams
• Most routine foot care (covered for individuals
  with diabetes)
• Exams for the fitting of hearing aids
• Exams for eyeglasses (except cataract related)
• Most routine dental care or false teeth

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Physician Services

• Physicians services NOT covered, cont.
• Acupuncture
• Cosmetic surgery (unless related to a
  degenerative disease or accident)
• Experimental medical procedures
• Any other service not considered by Medicare to
  be medically reasonable or necessary

69
Sample of Medicares Preventive Benefits

• Bone mass density testing
• Annual prostate cancer screening test
• Colorectal cancer screening
• Blood sugar testing equipment and training for
  managing diabetes
• Immunization (flu, pneumonia and hepatitis B)
• Annual Screening Glaucoma Screening for people at
  high risk
• Cardiovascular Screening Blood Tests
• Diabetes Screening Tests

70
Outpatient Services

• Outpatient hospital services
• Partial hospitalization services, day surgery,
  radiology, stitches, cast application
• Clinical diagnostic lab services
• Orthotics, prosthetics, take home surgical
  dressings
• Chronic dialysis
• Outpatient rehab services (physical therapy,
  speech therapy, pathology, occupational therapy)

71
Outpatient Mental Health Services

• Medicare covers treatment by following providers
• Doctor, clinical psychologist, clinical social
  worker, clinical nurse specialist, nurse
  practitioner, physicians assistant
• Medicare covers Outpatient mental health services
  at the following settings
• Clinic, doctors office, other therapists
  office, Outpatient hospital department (partial
  hospitalization), community mental health centers
  
• Partial Hospitalization
• Structured program of active treatment more
  intense than care in a therapists or doctors
  office

72
Ambulance Coverage

• Medicare covers ambulance service when transport
  in another vehicle would endanger health
• Will pay for transport from home to hospital/SNF
  or from hospital/SNF to home
• Medicare will NOT pay for ambulance used as
  routine transportation

73
Durable Medical Equipment (DME)

• Medicare helps pay for DME if
• It is prescribed by a physician
• It is medically necessary
• It fills a medical need (more than convenience)
• It is appropriate for use in the home
• It can be used over and over again

74
Durable Medical Equipment

• What Medicare pays for DME
• Medicare pays 80 of Medicare approved amount
• If the supplier accepts assignment, beneficiary
  pays 20
• If supplier does NOT accept assignment,
  beneficiary pays 20 PLUS difference between what
  Medicare approves and supplier charges
• Supplier is required to bill Medicare
• Beneficiary can buy or rent DME

75
DME Counseling Tips

• Encourage clients to
• Make sure the physician fills out a Certificate
  of Medical Necessity
• Ask the supplier if they accept Medicare
  assignment
• If the item is on the DMEPOS list, make sure it
  is ordered from a DMEPOS supplier
• Use Medicare.gov to find a DMEPOS-CBP supplier

76
Medicare Part B Review

• Review
• What kinds of services does Part B cover?
• What out of pocket expenses does a beneficiary
  have for Part B services?
• What does accepting assignment mean?
• What is a participating provider?
• What are excess charges?
• What is the Ban on Balanced Billing?