SHINE Program Certification Training

1. SHINE ProgramCertification Training

2. 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

3. State Organization • Executive Office of Elder Affairs • State SHINE Director: Cindy Phillips • Assistant State Director: • State Field Operations Manager/Training Coordinator: Annie Toth • State Program Coordinator: Jessica Gutierrez-Dutra

4. Regional Organization Regional SHINE Office: Regional SHINE Director: SHINE Program Assistant:

5. 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

6. 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

7. Training Certification training Mentoring Monthly training meetings October: Review and training for Medicare’s annual Open Enrollment Recertification review every spring

8. We’re Here To Support You • Regional Office Staff • Director: name and phone number • Assistant Director: name and phone number • SHINE Counselor Website • shinecounselor.800ageinfo.com • Common Resources • SHINE newsletter: The Beacon

9. Medicare Part A & Part B

10. Medicare • Federal health insurance program for: • Individuals over age 65 • 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

11. Medicare Medicare only pays for services which are reasonable and medically necessaryfor 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

12. Federal Agencies Involved With Medicare

13. Medicare Card Medicare Claim #. Letter attached to the claim # indicates how the individual qualifies for Medicare Part A & B Effective Dates 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

14. Four Parts of Medicare • Part A: Hospital Insurance • Part B: Medical Insurance • Part C: Medicare Advantage Plans • Part D: Prescription Drug Coverage • FYI: Part A & B called “Original Medicare”

15. Eligibility: 65+ • Age 65 + • Must be a citizen/lawfully permitted resident for 5 years AND • 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

16. 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 Gehrig’s Disease”)

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

18. Medicare Premiums • Individuals or their spouses who have paid into the Medicare Program and worked at least 40 quarters DO NOT pay a Part A premium • This is called premium-free Part A • EVERYONE pays a Part B premium • 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

19. 2014 Part A and B Premiums • Part A • People that don’t qualify for premium-free Medicare may enroll voluntarily and pay a monthly premium for Parts A & B • Part A Premiums • 0-29 work quarters= $426/month • 30-39 work quarters= $234/month • Part B • Premiums based on annual income (past 2 years tax returns) • Part B Premiums • Ind < $85,000 & married < $170,000= $104.90/month • Increases with higher income

20. Three Enrollment Types Automatic Enrollment Standard Enrollment Voluntary Enrollment

21. 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 receive notice 24 months after Social Security Disability payments began Individual must sign and return card if she/he does NOT want Part B

22. 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 person’s 65th birthday, the month of the 65th birthday, and the full 3 months following the 65th birthday • 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

23. Voluntary Enrollment • For individuals who don’t have sufficient Social Security work credits (40 quarters/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

24. 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 – Mar 31st of each year • July 1st effective date

25. Initial Enrollment Period

26. Initial Enrollment Period: When Part B Starts

27. Delaying Part B Enrollment • Adults over age 65 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 <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

28. Consolidated Omnibus Budget Reconciliation Act (COBRA) • When employment and/or EGHP ends, individual can elect COBRA coverage which continues health coverage through employer’s 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 Part B 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

29. 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 • 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

30. 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

31. 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 employer’s plan or her employment ends, whichever comes first

32. 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)

33. Medicare Part A(Hospital Insurance)

34. Medicare Part A (Hospital Insurance) • Part A Covers: • Inpatient hospital care • Care in a skilled nursing facility (SNF) • Home health care • Hospice care • Blood

35. In-patient Hospital Coverage • In-patienthospital 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

36. In-Patient Hospital Coverage • A benefit period is a period of time that Medicare pays for a person’s 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 • 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)

37. In-Patient 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

38. In-Patient 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)

39. In-Patient 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

40. Hospital Coverage • Other hospital coverage • Care in a psychiatric hospital • 190 lifetime days for in-patient care • Care in a foreign hospital • Medicare usually does NOT pay for care outside the United States • MedicareMAYpay for qualified care in a Mexican or Canadian hospital under special conditions

41. 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 in-patient hospital stay of 3 days or more (72 hours as an admitted patient) • An overnight stay doesn’t always mean an in-patient 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

42. 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

43. 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

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

45. 2014 Part A Out-of-Pocket Costs • Inpatient hospital care • Days 1-60: $1216 deductible (per benefit period) • Days 61-90: $304 per day • Days 91-150 (Lifetime Reserve Days): $608 per day • All additional days: All costs • Skilled Nursing Facility care • Days 1-20: Nothing • Days 21-100: $152 per day • Durable Medical Equipment • 20% of approved amount • Hospice Care • Small co-pays for inpatient respite care and drugs • Home Health Care • Nothing

46. Medicare Part A: Benefit Period Example • Benefit period Example 1: Mr. Jones is hospitalized as an in-patient 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?

47. 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?

48. 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

49. 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

50. 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)