Public Benefits For Medicare Beneficiaries Review Medicare n

Public Benefits For Medicare Beneficiaries

Review

Medicare n For people 65+ and under 65 with a disability n 4 parts of Medicare • Part A: Hospital Insurance • Part B: Medical Insurance • Part C: Medicare Advantage Plans • Part D: Prescription Drug Coverage n 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 3

Three Enrollment Periods n Initial Enrollment Period (IEP): 7 months surrounding 65 th birthday month (month earlier if birthday on 1 st of month) • Date of enrollment determines effective date of Medicare n Special Enrollment Period (SEP): 8 months following loss of coverage from “active” employment n General Enrollment Period (GEP): Jan 1 st – March 31 st of each year • July 1 st effective date 4

Delaying Part B Enrollment n Beneficiaries may choose to have just Medicare Part A while ACTIVELY working or covered under a spouse who is ACTIVELY working n Once ACTIVE employment coverage has ended, must take Part B coverage within 8 months to avoid a penalty n If employer has <20 employees or <100 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 5 needed

Late Enrollment Penalty n 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 don’t enroll in Part A when initially eligible n 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: Ø Under 65 beneficiaries with a penalty will have the penalty removed and will have a “clean slate” when 6 they turn 65

Two Options For Supplementing Medicare Step 1: Decide how you want to get your coverage MEDICARE ADVANTAGE PLAN ORIGINAL MEDICARE PART A Hospital Insurance & PART B Medical Insurance OR 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 MEDIGAP Supplement Core or Supplement 1 plan END If you join a Medicare Advantage Plan with drug coverage (MAPD), you cannot join another drug plan and you don’t need and cannot be sold a 7 Medigap policy

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 8

Extra Help/LIS n Federal assistance program to help low-income and low-asset Medicare beneficiaries with costs related to Medicare Part D n Extra Help subsidizes: • Premiums • Deductibles • Copayments • Coverage Gap “Donut Hole” • Late Enrollment Penalty • Does NOT subsidize non-formulary or excluded medications n Apply through Social Security Administration 9

Prescription Advantage n Massachusetts’ State Pharmaceutical Assistance Program (SPAP) n Provides secondary coverage for those with Medicare or other “creditable” drug coverage (i. e. retiree plan) n Provides primary prescription coverage for those who don’t qualify for Medicare n Benefits are based on a sliding income scale only– no asset limit! n Level of assistance provided is determined by gross income n Different income limits for under 65 and over n Members are provided a SEP (one extra time each year outside 10 of open enrollment to enroll or switch plans)

Public Benefits

SHINE and Public Benefits n 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 n Counselors do not guarantee that an individual will be eligible for these programs; this decision can only be made by the benefit program 12

Supplemental Security Income (SSI) n Federal income supplement program funded by general tax revenues to help aged, blind, and people with disabilities who have little or no income n Needs based program n Provides cash to meet basic needs for food, clothing, & shelter n Different income supplements for various living arrangements n Apply through Social Security office n Automatic enrollment into Mass. Health 13

Mass. Health Medicaid= National public health insurance program Mass. Health= Massachusetts Medicaid program n Public health insurance program for low- to mediumincome residents of Massachusetts n Administered by state Medicaid agencies within broad parameters established by federal regulations n Overseen by the Centers for Medicare & Medicaid Services (CMS) 14

SHINE and Mass. Health n SHINE focus is on Mass. Health ONLY AS IT RELATES TO MEDICARE BENEFICIARIES n Benefit programs and eligibility criteria may differ for individuals who are not entitled to Medicare 15

Dual-Eligible n Medicare beneficiaries who are enrolled in Mass. Health Standard are referred to as dual-eligible n Dual-eligibles can receive assistance paying for Medicare premiums, deductibles, co-insurance, and co-pays n Dual-eligibles receive the many Mass. Health covered services that Medicare beneficiaries typically do not receive 16

Dual-Eligibles and Part D n Dual-eligibles MUST enroll into a Medicare Part D plan n 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 n Dual-eligibles automatically “deemed eligible” for Full Extra Help, regardless of income and assets 17

Dual-eligibles and Part D, cont. n Mass. Health 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 n Mass. Health is always the payer of last resort • Will NOT provide primary prescription drug coverage for dual-eligible's n 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) 18

Limited Income Newly Eligible Transition Program (LINET) n Provides immediate prescription drug coverage for people with Medicare who are at the pharmacy counter and qualify for Extra Help, but aren’t yet enrolled in a Medicare drug plan • Also covers prescriptions that eligible people filled within the last 30 days n Covers all Part D covered drugs; No prior authorization or network pharmacy restrictions during the time period covered by this program n Will be charged the reduced co-payment based on the level of Extra Help they are eligible for n Program administered by Humana 19

Mass. Health Standard Eligibility n Determining eligibility for Mass. Health is a complex process n SHINE may screen for potential eligibility, educate clients about Mass. Health benefits, assist in the application process • Should not guarantee eligibility; this decision should be left to Mass. Health n Must be a Massachusetts resident • Defined as someone living in Massachusetts and intends to stay n Different eligibility requirements for applicants age 65 and older and those under age 65 20

Financial Eligibility 65+ n For married couples living together, eligibility usually based on the combined income and assets of both members of the couple n Must meet both income and asset guidelines in order to qualify for Mass. Health Standard • Income eligibility: Countable income at or below 100% of the Federal Poverty Level (FPL) • Asset eligibility: for a couple) n $2, 000 or less in countable assets ($3, 000 To determine income: • Take gross countable income and subtract 2 deductions: Unearned income disregard and Earned income disregard 21

Income Disregards n Unearned income disregard is a $20 deduction from the household’s total countable unearned income. Married couples receive only one $20 deduction from their combined countable income n Earned income disregard is calculated by subtracting $65 from the individual’s gross earned income, and dividing the remainder by 2. Married couples in which both people are working will both receive separate earned income disregards Disregards already calculated in the Public Benefits Chart in Tool Kit 22

Income: Countable VS. Non-Countable Income • Social Security benefits • Railroad Retirement benefits • Pensions • Earned income • Rental income • Federal veteran pensions & disability compensation • Interest income Non-countable 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 23

Assets: Countable VS. 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 Non-countable Assets • • 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 24

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Financial Eligibility Under Age 65 n NO asset limits n Income limit is 133% of the FPL n Earned income disregard and unearned income disregard not used Modified Adjusted Gross Income (MAGI) used instead of gross income n • Applicant receives an income disregard 5% of the FPL equivalent to 5% FPL disregard already calculated in the Public Benefits Chart 26

Examples of Mass. Health 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 27

Applying For Mass. Health n 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-3) Ø In general used by applicants under age 65 • Application for Health Coverage for Seniors and People Needing Long-Term-Care Services (SACA-2) Ø For applicants 65 and older Public Benefits chart indicates which application is used for each Mass. Health program 28 n

Application Processing n n n Applications sent to and processed at the Central Processing Unit or Mass. Health 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 Ø Does not apply to Mass. Health Senior Buy-in 29

Payment For Services n Mass. Health is always the payer of last resort n Any other insurance plan, including Medicare or employer-based health plans, must pay first before Mass. Health will pay. 30

Special Mass. Health Programs n In addition to the Mass. Health Standard benefits and eligibility criteria just discussed, there are several Mass. Health programs that provide various levels of benefits for individuals who meet specialized eligibility guidelines n These programs act like Medicare Supplements (Supplement 1), covering co-pays and deductibles and offering additional benefits 31

Medicare Savings Programs: Mass. Health Senior Buy-In n Federally referred to as the Qualified Medicare Beneficiary (QMB) • Eligibility Ø Be entitled to Medicare Ø Income at or below 100% of the FPL Ø Assets at or below the designated limits (change yearly) • Benefits Ø Ø Ø Payment of Medicare Part A & B premiums Payment of deductibles and co-pays Deemed eligible for Full Extra Help 32

Medicare Savings Programs: Mass. Health Buy-In n 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 Ø Ø Ø Be entitled to Medicare Have income at or below: QI-1= 135% of the FPL SLMB=120% of the FPL Assets at or below the designated limits (change yearly) • Benefits Ø Ø Payment of Medicare Part B premium Deemed eligible for Full Extra Help 33

Buy-In For Part B Late Enrollees n 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 n The effective date of Part B coverage would not be earlier than the Buy-in start date n The individual’s late enrollment penalty will be paid for by Mass. Health 34

Caretaker Relative n Eligibility • Must meet the definition of a caretaker relative: Adult of any age • n 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 child’s parents can be living in the home Must have income at or below 133% of the FPL Benefits • Eligible individuals will receive Mass. Health Standard benefits • Payment of Medicare Part A & B premiums, deductibles and co • pays Deemed eligible for Full Extra Help 35

Common. Health n Eligibility • Must have a disability • Must be ineligible for Mass. Health 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 Ø Mass. Health flexible on what “work” is § Must be paid work; cannot be volunteer Ø Individuals under age 65 can waive the work requirement if they meet a one-time deductible • NO financial eligibility requirements Ø Individuals with incomes above 150% of the FPL will pay a monthly premium relative to their income 36

Common. Health, cont. n Benefits provided • Benefits similar to Mass. Health Standard including payment for Part A and B co-payments and deductibles • Deemed eligible for Full Extra Help n Benefit NOT provided • Automatic payment for Part B premium Ø Individuals must separately meet the qualifications for Buy-in in order for Mass. Health to pay premiums 37

Frail Elder Waiver n 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 ASAP’s 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 nonapplying spouse 38

Frail Elder Waiver, cont. n 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) n To Apply • To apply the individual should be referred to their local Aging Service Access Point (ASAP) Ø ASAP staff will evaluate the applicant for clinical eligibility 39

Health Safety Net (HSN) n n n 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 Ø Non-residents may receive emergency or urgent care only • Full Health Safety Net Ø 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 40 Ø Individual will be assessed an annual deductible Ø

Health Safety Net, cont. n Benefits • Low co-pay prescription coverage Ø 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 Ø 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 41

Senior Care Options (SCO) n Combines Mass. Health Standard coverage with social support services and coordinated care to help individuals maintain their health and live in the community n Eligibility • Be 65 or older • Qualify for Mass. Health 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 42

SCO, cont. n 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 43

One Care n Managed care option that provides all Medicare & Mass. Health services along with additional care coordination and support services to dual-eligible individuals with disabilities • Members can only receive covered services through plan’s network of contracted providers • One Care is not available in all counties n Eligibility • Be age 21 -64 • Have Medicare Parts A & B • Have Mass. Health Standard or Common. Health Ø Cannot also be enrolled in SCO, PACE, Frail Elder Waiver, or other Mass. Health waiver program 44

One Care, cont. n Benefits • All guaranteed Medicare and Mass. Health benefits as well as: Ø Ø Ø Ø Ø 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 45

Program Of All-Inclusive Care For The Elderly (PACE) n 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 n 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 ØPACE is not available in all regions of the state 46

PACE, cont. n Benefits • No premiums, deductibles or co-pays for dualeligible's; Medicare only beneficiaries will have monthly premium • Provides all services covered by Medicare and Mass. Health Standard • Provides functional, social, and psychological services to help individuals safely remain in their homes • Part D coverage through the PACE plan 47

Mass. Health Personal Care Attendant (PCA) Program n 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 (ADL’s) n Eligibility • Be age 65 or older • Have a permanent and long-lasting disability • Must need assistance with at least 2 ADL’s ADL examples: Dressing, eating, bathing, walking • Income at or below 133% of the FPL Ø • Assets at or below $2, 000 for an individual or $3, 000 for a couple 48

Long Term Care (LTC) Mass. Health n Pays the nursing home the difference between the patient private paid amount and Medicaid established rate for nursing home care. Requires clinical eligibility. n Financial Eligibility • No income limit; applicant just must have monthly income insufficient to pay for nursing home costs Ø 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 ØCommunity spouse allowed to keep all assets (not counting the primary residence) up to a certain amount 49

Review 1. What does “dual-eligible” mean? 2. What are the different types of Mass. Health applications and which application is used for which Mass. Health program? 3. What Mass. Health 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? 50