Day 6 & 7 Public Benefits

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 • 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 <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 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 don’t 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 Included in Part C PART D Stand Alone PDP 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 don’t need and cannot be sold a Medigap policy MEDIGAP Supplement Core or Supplement 1 plan

9. Medigap vs.Medicare Advantage

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 Part D 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 Pharmaceutical 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 don’t 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

20. 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-eligiblesMUST 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-eligiblesnot 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 aren’t 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 household’s 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 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 Pink Sheet (Eligibility Guidelines for Health/Prescription-Related Public Benefits Programs)

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

28. Assets:Countable VS. Non-Countable Countable Assets 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 • 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

30. 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 disregard equivalent to 5% of the FPL • 5% FPL disregard already calculated in the Pink sheet

31. Examples of MassHealth Covered Services 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 • 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)

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 criteria 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 Programs:MassHealth 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 SLMB=120% 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 individual’s 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 child’s 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 • Benefit NOT provided • 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 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 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 plan’s 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