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SHIP/SMP Case Studies

SHIP/SMP Case Studies Dyan Walsh, EAAA, SHIP/SMP Coordinator Maureen Dea, LSE Attorney, Part D Unit Case 1

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SHIP/SMP Case Studies

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  1. SHIP/SMP Case Studies Dyan Walsh, EAAA, SHIP/SMP Coordinator Maureen Dea, LSE Attorney, Part D Unit

  2. Case 1 • A Medicare beneficiary under age 65, had a kidney transplant in February of 2007.  She is still working and has an Employee Group Health Plan.  Knowing that Medicare will become primary after the 30 month coordination period, does she need to have Part B now because she has an EGHP? • What other questions do you need to ask?

  3. Social Security Laws and CMS Publications • Reference Section • 1836 paragraph (1) or (2) • 1837. [42 U.S.C. 1395p] • 1862(b)(1)(A)(v) • 1862(b)(1)(B)(iii) • Reference CMS Publication 10128

  4. Case 2 A Medicare beneficiary enrolled in a Medicare Advantage plan in March of 2008.  After the costs became too high she decided she wanted out of the plan.  She contacted the agency in October of 2008 after she contacted the plan twice, in writing, and was never removed.  A complaint was entered into the CTM system and the beneficiary was denied a disenrollment? Why? What other information do you need?

  5. Case 2 • People who join an MA plan for the first time • When first eligible for Medicare at age 65 • Leave Original Medicare Plan and drop aMedigap policy • Can dis-enroll from MA plan during first 12 months • Join Original Medicare Plan • Have guaranteed issue for Medigap policy

  6. Case 3 • Lucille X, 75, calls you. She is in a Medicare Part D Plan, but cannot afford the co-pays for her 2 brand name drugs. She is not taking this medication due to the cost. • She does not have Maine Care, MSP, LIS, or DEL. • She says her monthly income is $1,844. She is a widow. • How can you help her?

  7. Considering the Options • You check and the income limit for the Medicare Savings program (QI) this year is $1,745 a month. • What can you do? • In some situations you could refer her to Legal Services for the Elderly’s Part D unit and they could try to get a “tiering exception” to drop her costs to a lower tier. • But her 2 medications are on Tier 2, and you cannot get a Tiering exception to drop to a Generic Level (Tier One) • So what can you do?

  8. Getting More Information You ask Lucille if her income is all from Social Security. She say no and tells you that she gets: • $1,104 from Social Security (before Part B is taken out) • $100 a month from an annuity • $640 a month from her house cleaning job. She still works because she needs the money. (She cleans house 10 days a month, $8 an hour for 8 hours a day.)

  9. MSP-Earned Income Disregard • You then remember that the Medicare Savings Program has an earned income disregard for people who work. This disregard is in addition to the regular federal and state disregards. (If she were disabled, she could also deduct work expenses, such as the cost of gasoline.)

  10. What is the Earned Income Disregard? When determining countable income for the Medicare Savings Program, in addition to other disregards, you: • Deduct $65 from an individual’s or couple’s earned income and then • Deduct half the remaining amount of earned income • This disregard must be applied in certain order, see next slides.

  11. Applying the Earned Income Disregard • Lucille’s Unearned Income is $1,104 Social Security and $100 Annuity; her Earned Income is $640, from house cleaning Steps to deduct allowable disregards for a working individual (Must be done in this order.) 1. Combine all gross unearned income $1,104 plus $100 = $1,204 2. Subtract $20 federal disregard: $1204 - $20 = $1,184 (countable unearned income) 3. Combine all gross earned income: $640 • a. Subtract $65 earned income disregard $640 - $65 = $575 • b. Divide remaining income by 2: $575 / 2 = $287.50 (countable earned income) 4. Combine the countable unearned and earned income: $1,184 + 287.50 = $1,471.50 5. Subtract the $55 state disregard. $1, 471.50 - $55 = $1,416.50 • So her countable income is $1,416.50 and she is eligible for the Medicare Savings Program, SLMB benefit (income under 170 % of poverty level or $1,535 in 2009) • She is $62.50 over income for QMB, so she might consider giving up a day of her house cleaning.

  12. Earned Income Disregard for a Married Couple 1. Combine all gross unearned income 2. Subtract $20 federal disregard (This total equals countable unearned income.) 3. Combine all gross earned income • Subtract $65 earned income disregard • Divide remaining earned income by 2 (This equals countable earned income.) 4. Combine countable unearned and earned income 5. Subtract the $80 State disregard. This is their countable income for determining MSP eligibility.

  13. Resources • http://www.cms.hhs.gov/MedicareMangCareEligEnrol/Downloads/2009MAenrollmentguidance.pdf • http://www.ssa.gov/OP_Home/ssact/title18/1862.htm • http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf

  14. For More Information • Maureen Dea LSE’s Part D Appeals Unit 1-877-774-7772 • Dyan Walsh Eastern Area Agency on Aging 1-800-432-7812

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