Day 6

1
Day 6 7Public Benefits
2
Review
3
Medicare

• For people 65 and under 65 with a disability
• 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 called 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

4
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
• General Enrollment Period (GEP) Jan 1st March
  31st of each year
• July 1st effective date

5
Delaying Part B Enrollment

• Individuals may choose to have just Medicare Part
  A while they are ACTIVELY working or are 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 (there is no 8 month period for retiree
  coverage)
• If the 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

6
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

7
Medicare

• Pays for reasonable and medically necessary
  services
• There are coverage gaps in Medicare including
• Part A in-patient hospital deductible
• Part A daily co-payment for in-patient hospital
  days 61-90
• Part A daily co-payment for in-patient hospital
  days 91-150
• Part A daily co-payment for SNF days 21-100
• Part B annual deductible
• Part B co-insurance (usually 20)
• First three pints of blood
• Coverage outside the United States

8
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
9
Medigap vs.Medicare Advantage
Original Medicare Medigap Supplement 1 Medicare Advantage Plan
Higher premiums but no co-pays Generally lower premiums but has co-pays
Freedom to choose doctors May be 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 Emergency services ONLY outside service area
10
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
• Part D is voluntary, but eligible beneficiaries
  who do not enroll may be subject to a penalty
• Must have creditable coverage to avoid penalty

11
Part D Enrollment

• Initial Mimics Part B 7 month period
• Open Oct 15th Dec 7th, coverage effective Jan
  1st
• Special Refer to SEP chart for applicable
  situations
• MADP Jan 1st Feb 14th
• Late Penalty is 1 of the national base
  beneficiary premium for EACH MONTH the
  beneficiary
• Did not enroll in a Medicare PDP when they were
  first eligible AND
• Had no prescription drug coverage OR
• Had coverage that was not considered creditable
  OR
• Had a lapse in creditable coverage of 2 full
  months (63 days)

12
Part D Formulary

• The prescription benefit includes a list of
  covered drugs and this list is called the
  formulary
• If the insurer is very selective about which
  drugs are to be covered, then it is sometimes
  referred to as a closed formulary. If the
  formulary is open to all drugs but places drugs
  into different cost sharing categories or
  tiers, it is referred to as an open formulary
• Each plan must meet formulary standards. The
  formulary must include and cover certain drugs or
  certain classes of drugs. Medicare has
  established a category of excluded drugs

13
Extra Help

• Federal assistance program to help low-income and
  low-asset Medicare beneficiaries with costs
  related to Medicare Part D
• Extra Help subsidizes
• Premiums
• Deductibles
• Copayments
• Coverage Gap Donut Hole
• Late Enrollment Penalty
• Does NOT subsidize non-formulary or excluded
  medications
• Apply through Social Security Administration

14
Prescription Advantage

• Massachusetts State Pharmacy Assistance Program
  (SPAP)
• Provides secondary coverage for those with
  Medicare or other creditable drug coverage
  (i.e. retiree plan)
• Provides primary prescription coverage for those
  who dont qualify for Medicare
• Benefits are based on a sliding income scale
  only no asset limit!
• Level of assistance provided is determined by
  gross income
• Different income limits for under 65 and 65 and
  over
• Members are provided a SEP (one extra time each
  year outside of open enrollment to enroll or
  switch plans)

15
Public Benefits
16
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

17
Supplemental Security Income (SSI)

• Federal income supplement program funded by
  general tax revenues to help aged, blind, and
  people with disabilities who have little or no
  income
• Needs based program
• Provides cash to meet basic needs for food,
  clothing, shelter
• Different income supplements for various living
  arrangements
• Apply through Social Security office
• Automatic enrollment into MassHealth

18
MassHealth

• Medicaid National public health insurance
  program
• MassHealth Massachusetts Medicaid program
• Public health insurance program for low- to
  medium-income residents of Massachusetts
• Administered by state Medicaid agencies within
  broad parameters established by federal
  regulations
• Overseen by the Centers for Medicare Medicaid
  Services (CMS)

19
SHINE and MassHealth

• SHINE focus is on MassHealth ONLY AS IT RELATES
  TO MEDICARE BENEFICIARIES
• Benefit programs and eligibility criteria may
  differ for individuals who are not entitled to
  Medicare

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Dual-Eligible

• Medicare beneficiaries who are enrolled in
  MassHealth Standard are referred to as
  dual-eligible
• Dual-eligibles can receive assistance paying for
  Medicare premiums, deductibles, co-insurance, and
  co-pays
• Dual-eligibles receive the many MassHealth
  covered services that Medicare beneficiaries
  typically do not receive

21
Dual-Eligible's and Part D

• Dual-eligibles MUST enroll into a Medicare Part D
  plan
• If beneficiary does not enroll into a plan within
  60 days, they will be auto-assigned to a plan
• Best to avoid this Auto-assigned plan may not be
  lowest cost and formulary may not list all of
  beneficiaries drugs
• Dual-eligibles automatically deemed eligible
  for Full Extra Help, regardless of income and
  assets

22
Dual-eligible's and Part D, cont.

• MassHealth will cover a drug that Medicare does
  not pay for
• Will NOT cover a drug that Medicare does pay for
  but is not listed on the beneficiaries plan
  formulary
• MassHealth is always the payer of last resort
• Will NOT provide primary prescription drug
  coverage for dual-eligible's
• Dual-eligibles not yet enrolled into Part D may
  receive their prescription drugs at the Extra
  Help co-pay amounts by using the Limited Income
  Newly Eligible Transition Program (LINET)

23
Limited Income Newly Eligible Transition Program
(LINET)

• Provides immediate prescription drug coverage for
  people with Medicare who are at the pharmacy
  counter and qualify for Extra Help, but arent
  yet enrolled in a Medicare drug plan
• Also covers prescriptions that eligible people
  filled within the last 30 days
• Covers all Part D covered drugs No prior
  authorization or network pharmacy restrictions
  during the time period covered by this program
• Will be charged the reduced co-payment based on
  the level of Extra Help they are eligible for
• Program administered by Humana

24
MassHealth Standard Eligibility

• Determining eligibility for MassHealth is a
  complex process
• SHINE may screen for potential eligibility,
  educate clients about MassHealth benefits, assist
  in the application process
• Should not guarantee eligibility this decision
  should be left to MassHealth
• Must be a Massachusetts resident
• Defined as someone living in Massachusetts and
  intends to stay
• Different eligibility requirements for applicants
  age 65 and older and those under age 65

25
Financial Eligibility 65

• For married couples living together, eligibility
  usually based on the combined income and assets
  of both members of the couple
• Must meet both income and asset guidelines in
  order to qualify for MassHealth Standard
• Income eligibility Countable income at or below
  100 of the Federal Poverty Level (FPL)
• Asset eligibility 2,000 or less in countable
  assets (3,000 for a couple)
• To determine income
• Take gross countable income and subtract 2
  deductions Unearned income disregard and Earned
  income disregard

26
Income Disregards

• Unearned income disregard is a 20 deduction from
  the households total countable unearned income.
  Married couples receive only one 20 deduction
  from their combined countable income
• Earned income disregard is calculated by
  subtracting 65 from the individuals gross
  earned income, and dividing the remainder by 2.
  Married couples in which both people are working
  will both receive separate earned income
  disregards
• All disregards already calculated in the Pink
  Sheet (Eligibility Guidelines for
  Health/Prescription-Related Public Benefits
  Programs)

27
IncomeCountable VS. Non-Countable

• Countable Income

• Non-countable Income

• Social Security benefits
• Railroad Retirement benefits
• Pensions
• Earned income
• Rental income
• Federal veteran pensions disability
  compensation
• Interest income

• Cash assistance from SSI or the Department of
  Transitional Assistance (DTA)
• Income-in-kind (e.g., gifts)
• Income from a reverse mortgage
• Veterans Aid Attendance benefits
• Chapter 115 benefits for veterans

28
AssetsCountable VS. Non-Countable

• Countable Assets

• Non-countable Assets

• Bank accounts
• Whole life insurance policies, when total face
  value of all policies is over 1,500
• Individual retirement accounts (IRA)
• Stocks and bonds
• Second homes/cars
• RVs/Boats

• Primary residence and 1 car
• Personal belongings home furnishings
• Term life insurance policies
• Whole life insurance policies with total face
  value 1,500 or less
• Burial plot
• 1,500 burial-only account
• Irrevocable burial contract

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(No Transcript)
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Financial Eligibility Under Age 65

• NO asset limits
• Income limit is 133 of the FPL
• Earned income disregard and unearned income
  disregard not used
• Modified Adjusted Gross Income (MAGI) used
  instead of gross income
• Applicant receives an income deduction equivalent
  to 5 of the FPL
• MAGI already calculated in the Pink sheet

31
Examples of MassHealth Covered Services

• In/Out-patient hospital services
• Emergency hospital services
• Skilled nursing facility
• Home health care
• Case management services
• Clinic services
• Diagnostic services
• Dental services
• Programs for all-inclusive care for the elderly
  (PACE)
• Personal care services (PCA)

• Hospice care
• Medical Transportation
• Occupational therapy
• Optometrist services
• Physical therapy
• Podiatrist services
• Preventative services
• Private duty nursing
• Prosthetic/orthotic devices
• Psychologist services
• Rehabilitative services
• Respite care

32
Applying For MassHealth

• Best for the individual, spouse, family member to
  complete the application counselors can assist
  when needed
• 2 application types
• Application for Health Coverage and Help Paying
  Costs (ACA-2)
• In general used by applicants under age 65
• Application for Health Coverage for Seniors and
  People Needing Long-Term-Care Services (SACA-2)
• For applicants 65 and older
• Pink sheet indicates which application is used
  for each MassHealth program

33
Application Processing

• Applications sent to and processed at the Central
  Processing Unit or MassHealth Enrollment Centers
  (MEC)
• If an application is received and requires
  further verification, applicant will receive a
  Request for Information with a deadline by which
  to return the needed documentation
• Retroactive Coverage
• Applicants age 65 and older can receive
  retroactive coverage up to 3 full calendar months
  prior to the date of application
• Applicants under age 65 can receive retroactive
  coverage beginning 10 days prior to the date of
  application
• Does not apply to MassHealth Senior Buy-in

34
Payment For Services

• MassHealth is always the payer of last resort
• Any other insurance plan, including Medicare or
  employer-based health plans, must pay first
  before MassHealth will pay.

35
Special MassHealth Programs

• In addition to the MassHealth Standard benefits
  and eligibility criterion just discussed, there
  are several MassHealth programs that provide
  various levels of benefits for individuals who
  meet specialized eligibility guidelines
• These programs act like Medicare Supplements
  (Supplement 1), covering co-pays and deductibles
  and offering additional benefits

36
Medicare Savings Programs MassHealth Senior
Buy-In

• Federally referred to as the Qualified Medicare
  Beneficiary (QMB)
• Eligibility
• Be entitled to Medicare
• Income at or below 100 of the FPL
• Assets at or below the designated limits (change
  yearly)
• Benefits
• Payment of Medicare Part A B premiums
• Payment of deductibles and co-pays
• Deemed eligible for Full Extra Help

37
Medicare Savings ProgramsMassHealth Buy-In

• Federally referred to as Specified Low-income
  Medicare Beneficiary (SLMB) and Qualified
  Individual 1 (QI-1)
• QI-1 subject to periodic federal funding
  appropriation
• Eligibility for SLMB and QI-1
• Be entitled to Medicare
• Have income at or below QI-1 135 of the FPL
• SLMB120 of the FPL
• Assets at or below the designated limits (change
  yearly)
• Benefits
• Payment of Medicare Part B premium
• Deemed eligible for Full Extra Help

38
Buy-In ForPart B Late Enrollees

• Late enrollees for Medicare Part B who qualify
  for the Senior Buy-in (QMB) or Buy-in (SLMB/QI-1)
  may enroll in Part B outside of the General
  Enrollment Period
• The effective date of Part B coverage would not
  be earlier than the Buy-in start date
• The individuals late enrollment penalty will be
  paid for by MassHealth

39
Caretaker Relative

• Eligibility
• Must meet the definition of a caretaker relative
  Adult of any age who is primary caregiver for a
  child (can be related to the child by blood,
  adoption, marriage, or be the spouse/ex-spouse of
  one of these relatives). Must live in same home
  as the child and neither of the childs parents
  can be living in the home
• Must have income at or below 133 of the FPL
• Benefits
• Eligible individuals will receive MassHealth
  Standard benefits
• Payment of Medicare Part A B premiums,
  deductibles and co-pays
• Deemed eligible for Full Extra Help

40
CommonHealth

• Eligibility
• Must have a disability
• Must be ineligible for MassHealth Standard
• Must currently be working at least 40 hours per
  month, or currently working and worked at least
  240 hours in the past 6 months
• MassHealth flexible on what work is
• Must be paid work cannot be volunteer
• Individuals under age 65 can waive the work
  requirement if they meet a one-time deductible
• NO financial eligibility requirements
• Individuals with incomes above 150 of the FPL
  will pay a monthly premium relative to their
  income

41
CommonHealth, cont

• Benefits provided
• Benefits similar to MassHealth Standard including
  payment for Part A and B co-payments and
  deductibles
• Deemed eligible for Full Extra Help
• Benefits NOT provided
• Skilled nursing facility care
• Automatic payment for Part B premium
• Individuals must separately meet the
  qualifications for Buy-in in order for MassHealth
  to pay premiums

42
Frail Elder Waiver

• Allows elders eligible for nursing home care who
  want to remain at home to get the services
  supports to be able to live safely
• Eligibility
• Be age 60 or older
• Be clinically eligible for nursing home care
  receive services from the ASAPs home care
  program
• Have income at or below 300 of the Federal SSI
  Rate
• Have assets at or below 2,000
• Only counts the income assets of the applicant
  even if married any assets over 2,000 limit
  allowed to be transferred to non-applying spouse

43
Frail Elder Waiver, cont

• Benefits
• Payment of Medicare Part A B deductibles and
  co-pays
• Deemed eligible for Full Extra Help
• No co-pays for prescription drugs
• Supportive services (ex. Personal care,
  homemaking, meals)
• To Apply
• To apply the individual should be referred to
  their local Aging Service Access Point (ASAP)
• ASAP staff will evaluate the applicant for
  clinical eligibility

44
Health Safety Net (HSN)

• Pays for medically necessary services at
  Massachusetts community health centers (CHCs) and
  hospitals
• 2 levels of eligibility Full and Partial
• Eligibility
• Must be a Massachusetts resident
• Non-residents may receive emergency or urgent
  care only
• Full Health Safety Net
• Income must be at or below 200 of FPL
• Partial Health Safety Net
• Income must be above 200 but at or below 400 of
  FPL
• Individual will be assessed an annual deductible

45
Health Safety Net, cont.

• Benefits
• Low co-pay prescription coverage
• Prescription must be filled at a HSN pharmacy
• Will pay for allowed services not covered by
  Medicare, as well as Medicare co-pays,
  coinsurance, and deductibles
• Services must be delivered/ billed through a
  hospital or community health center that has an
  HSN program
• Can pay for services up to 6 months prior to
  approval
• HSN is NOT considered creditable coverage for
  Medicare Part D therefore use of the HSN pharmacy
  benefit does not protect a beneficiary from the
  Part D late enrollment penalty

46
Senior Care Options (SCO)

• Combines MassHealth Standard coverage with social
  support services and coordinated care to help
  individuals maintain their health and live in the
  community
• Eligibility
• Be 65 or older
• Qualify for MassHealth Standard
• Live in a designated service area of a SCO plan
• NOT be diagnosed with End Stage Renal Disease
• NOT be an inpatient in a chronic rehabilitation
  hospital

47
SCO, cont.

• Benefits
• No co-pays or deductibles
• Coordination of health care
• Prescription drugs without a co-pay
• Comprehensive dental, including dentures
• Transportation
• Specialized geriatric support services
• Adult day care
• 24 hour access to medical support
• Home care services
• Family caregiver support
•  

48
One Care

• Managed care option that provides all Medicare
  MassHealth services along with additional care
  coordination and support services to
  dual-eligible individuals with disabilities
• Members can only receive covered services through
  plans network of contracted providers
• One Care is not available in all counties
• Eligibility
• Be age 21-64
• Have Medicare Parts A B
• Have MassHealth Standard or CommonHealth
• Cannot also be enrolled in SCO, PACE, Frail
  Elder Waiver, or other MassHealth waiver program

49
One Care, cont.

• Benefits
• All guaranteed Medicare and MassHealth benefits
  as well as
• No premiums, deductibles, or co-pays
• Services coordination by an interdisciplinary
  care team
• Part D Coverage and no co-pays for prescription
  drugs
• Enhanced behavioral health and substance abuse
  services
• Long-term support
• Home modification
• Comprehensive dental
• Hearing aids
• Transportation

50
Program Of All-Inclusive Care For The Elderly
(PACE)

• Provides community based care services to
  people age 55 who would otherwise require
  nursing home level of care
• Team of health care professionals provide
  integrated care plan to keep individual safe at
  home
• Eligibility
• Be age 55 or older
• Be clinically eligible for nursing home care
• Income at or below 300 of the Federal SSI Rate,
  assets at or below 2,000
• Live in the service area of a PACE organization
• PACE is not available in all regions of the state

51
PACE, cont.

• Benefits
• No premiums, deductibles or co-pays for
  dual-eligible's Medicare only beneficiaries will
  have monthly premium
• Provides all services covered by Medicare and
  MassHealth Standard
• Provides functional, social, and psychological
  services to help individuals safely remain in
  their homes
• Part D coverage through the PACE plan

52
MassHealth Personal Care Attendant (PCA) Program

• Program that helps people with long-term
  disabilities live independently at home by giving
  member funds to hire a personal care attendant
  (PCA) to help with activities of daily living
  (ADLs)
• Eligibility
• Be age 65 or older
• Have a permanent and long-lasting disability
• Must need assistance with at least 2 ADLs
• ADL examples Dressing, eating, bathing, walking
• Income at or below 133 of the FPL
• Assets at or below 2,000 for an individual or
  3,000 for a couple

53
Long Term Care (LTC) MassHealth

• Pays the nursing home the difference between the
  patient private paid amount and Medicaid
  established rate for nursing home care. Requires
  clinical eligibility.
• Financial Eligibility
• No income limit applicant just must have monthly
  income insufficient to pay for nursing home costs
• To prevent impoverishment of community spouse,
  spouse may be able to keep some of applicants
  income, called the monthly maintenance needs
  allowance
• Assets limited to 2,000
• Community spouse allowed to keep all assets (not
  counting the primary residence) up to a certain
  amount

54
Review

1. What does dual-eligible mean?
2. What are the different types of MassHealth
   applications and which application is used for
   which MassHealth program?
3. What MassHealth programs are specifically for
   individuals with a disability?
4. What is Health Safety Net and what does it
   provide?
5. What benefits are available from One Care?

55
Case Study 1Anna Stetick

• Anna 73 year old retired widow lives in senior
  housing
• Income Social Security 1250/month (Net)
• Assets 3300 in her checking account, 9,000 in
  savings
• Anna tells you that she moved here from Florida
  one month ago. She was in a MA plan in Florida
  and knows she needs to pick a plan in
  Massachusetts. She also knows she will lose her
  Part D coverage with the Florida plan and was
  told she cant enroll in a plan in Massachusetts
  until open enrollment and will have a penalty.
  She wants to know if she can get on MassHealth to
  pay for her prescriptions.
• How would you help her?

56
Case Study 2Robin Hood

• Robin 76 years old single, retired, living in
  senior housing
• Income Social Security 1,133/month (Net)
• Assets 2500 in savings, 1000 in checking, car
  valued at 4000. He has a life insurance policy
  with a face value of 10,000 and a cash surrender
  value of 1200
• Insurance Medicare A B effective 3/1/03 and
  currently enrolled in the BCBS PPO plan
• A friend told Mr. Hood to talk to a SHINE
  counselor about getting on MassHealth.
• How would you help him?

57
Case Study 3Donna Wannago

• Donna 77 year old retired widow who lives in
  senior housing
• Income Social Security 816/month (Net)
• Assets 1500 in savings, 200 in checking, life
  insurance policy with a face value of 1200, car
  valued at 4000
• Insurance Medicare A B effective 1/22/02
  Medex Bronze
• Donna signed up for a Part D plan during open
  enrollment although she wasnt taking any drugs
  at that time. She said she she chose the least
  expensive plan. She is worried about paying the
  Part D premium along with her Medigap . Her
  doctor just put her on medication and she doesnt
  know how she will be able to pay for it during
  the gap in coverage under Part D.
• How would you help her?

58
Case Study 4Polly Gimmee

• Polly meets with you on May 10th. She tells you
  she is 64 and has been on MassHealth due to a
  disability for the past 19 months. She says she
  is turning 65 in July and will be enrolled in
  Medicare effective July 1st. She will be
  receiving a Social Security check in the amount
  of 1102. A friend told her that her MassHealth
  might change when she turns 65. She is worried
  about her health care coverage if MassHealth does
  change particularly because she takes several
  medications and has no other income or assets to
  use to pay for them. She wants to know if its
  true that MassHealth might not continue to cover
  her.
• How would you help her?

59
Case Study 5Mel Kontent

• Mel meets with you at the SHINE office. He is
  very confused about the Medicare Prescription
  Drug Program. He tell you he takes several
  medications and gets some coverage through his
  Medicare Advantage HMO plan and that he used to
  get additional coverage through Prescription
  Advantage. He did fill out the application for
  Extra Help that Prescription Advantage told him
  to complete, but he received a letter that he was
  denied. He tells you he cannot afford his co-pays
  for his drugs since he lost his Prescription
  Advantage.
• How would you help him?

60
Case Study 6Martin Eyz

• Mr. Eyz retired at age 65 and is collecting
  Social Security. He has Medicare and Medex
  Bronze. He takes no medications and never signed
  up for Part D. Mr. Eyes recently took a part-time
  job at the local Whypaymore to supplement his
  income. He lives in senior housing, so his rent
  is affordable. Mr. Eyes tells you that he is
  having a difficult time paying for his health
  insurance and was told by a friend that he should
  apply for MassHealth which would cover his
  medical expenses. Mr. Eyes tells you that he gets
  750/month from Social Security and 300/month
  from his job at Whypaymore. He has 600 in a
  checking account and 1,400 in a CD.
• Is he eligible for MassHealth?

61
Case Study 7Arthur Ritis

• Arthur calls for assistance. He received an
  Eligibility Review Form (ERV) from MassHealth to
  complete. He doesnt understand why he received
  the form since he is not on MassHealth. He had
  applied in the past but was denied because he was
  over income (1596.40/month). He tells you he is
  homebound and called because he cannot come in
  for an appointment.
• How would you help him?

62
Case Study 8Ben Hurr

• Ben is 57 years old. He has been on Medicare A
  B since January. He was on a few inexpensive
  medications that he was filling at Wal-mart at
  little cost. His meds are changing and he now has
  a few expensive brands. His income is
  1,900/month, and he has partial Health Safety
  Net. An advocate at the community center
  suggested he see a doctor at the community health
  center in a nearby town so that he can fill his
  prescriptions at the health center. She told him
  he can sign up for Part D at the next Open
  Enrollment Period.
• What additional information would you provide?

63
Case Study 9Charlie Horse

• Charlie meets with you for help with his
  prescription coverage. He is in a Blue Cross PPO
  Medicare Advantage plan with prescription
  coverage. He takes several medications, one of
  which, Procrit, is quite expensive. His plan has
  been covering it, but he will be in the donut
  hole soon and is concerned because he cant
  afford to pay the full price for his drug. He
  tells you he used to be in Prescription Advantage
  but that ended in January. He says his monthly
  income of 1,585 makes him ineligible for any
  benefit programs. He is not a veteran.
• How would you help him?

64
Case Study 10May B. Poor

• May will be 65 and retiring in 2 months and will
  not have retiree coverage available through her
  former employer. She just heard about Medicare
  Part D. She only takes 1 drug now and doesnt
  really want coverage. However, she heard she will
  pay a penalty if she enrolls at a later date
  should her drugs increase, as she believes they
  might. She is concerned about the monthly premium
  along with the premium for health insurance. She
  states that her only income will be Social
  Security and the amount shell receive will be
  1,120/month. She tells you her savings are
  minimal and she has no other assets other than
  her home and a car. She wants to know if there is
  any way she can cut down on her health care costs
  or avoid taking Part D as she feels the
  additional premium will put her over the edge.
• How would you help her?

65
Public Benefits Quiz

• List the MassHealth Buy-In programs and the
  benefits they provide.
• To be eligible for MassHealth an individual
  cannot own a home.
• True or False
• When determining an individuals eligibility for
  Supplemental Security Income (SSI), their living
  arrangements are considered.
• True or False
• If a Medicare beneficiary has MassHealth, do
  they need to purchase a Medicare Supplement or
  join a Medicare Advantage Plan?
• Yes or No
• Why?

66
Public Benefits Quiz, cont.

• What are the major differences between MassHealth
  for individuals under 65 and those 65 and over?
• What resources are counted in the asset test for
  people over 65 who apply for MassHealth while
  living in the community?
• An individual whose assets are too high for
  MassHealth Standard can spend down assets in
  order to qualify on medical expenses only.
• True or False