Other Health Insurance Options

1. Other Health Insurance Options

2. Review

3. Medicare • 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= 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. 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

5. 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 (MA-PD’s) • Part D is voluntary, but eligible beneficiaries who do not enroll may be subject to a penalty • Must have “creditable coverage” to avoid penalty

6. 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

7. Public Benefits • SSI: • Federal income supplement program funded by general tax revenues to help aged, blind, and people with disabilities who have little or no income • Provides cash to meet basic needs for food, clothing, & shelter • MassHealth (Medicaid) • Public health insurance program for low- to medium-income residents of Massachusetts • SHINE focus on MassHealth only as it relates to Medicare beneficiaries

8. Public Benefits • Dual-eligibles • Medicare beneficiaries who are also enrolled in MassHealth Standard • Can receive help paying for Medicare premiums, deductibles, co-insurance, and co-pays • Automatically “deemed eligible” for Full Extra Help

9. MassHealth Standard • MassHealth Standard • Different eligibility requirements for under 65 and 65+ • 65+: 100% FPL, asset limits • Under 65: 133% FPL, no asset limits • 2 application types: • ACA-3 (Application for Health Coverage and Help Paying Costs) • In general used by applicants under age 65 • SACA-2 (Application for Health Coverage for Seniors and People Needing Long-Term-Care Services) • For applicants 65+

10. Public Benefits:Special MassHealth Programs • Medicare Savings Programs (Buy-In) • QMB, SLMB, QI-1 (refer to pink sheet for guidelines) • Helps with Part B premiums, may help with deductibles/co-insurance • Frail Elder Waiver • Must be 60+, meet clinical requirements • Services provided to keep frail people at home • CommonHealth • Must have disability and be working 40+ hrs/month • Under 65 can waive work requirement if meet one-time deductible • NO financial requirements

11. Special MassHealth Programs • Health Safety Net (HSN) • Pays for medically necessary services at Massachusetts community health centers (CHCs) and hospitals • 400% FPL, no asset test • Caretaker Relative • Parent/caretaker of any age of child under 19 in same home • Income 133% of FPL • One Care • For dual-eligibles age 21-64 • Managed care option providing MH standard benefits plus additional benefits (dental, care coordination, transportation)

12. Other Health Insurance Options

13. Employer Group Health Plans (EGHP) • Employers with 20 or more employees (100+ for beneficiaries with disability) must offer Medicare beneficiaries who continue to work (and their spouses) the same choice of health plans offered to employees under age 65 • Medicare beneficiaries covered by an EGHP for active employees may delay enrollment into Medicare Part B without penalty • EGHP is the primary payer and Medicare is secondary for covered services for active employees, EXCEPT… • Medicare may be primary payer for active employees who work for an employer with fewer than 20 employees or fewer than 100 if beneficiary has a disability • Beneficiary needs to check with employer whether they must have both Medicare Parts A & B to be fully covered

14. Employer Group Retiree Plan Most retiree plans coordinate with Medicare Retiree plans may also cover additional benefits such as unlimited drug coverage Important for beneficiaries to carefully review benefits booklet to compare the benefits offered by the retiree insurance and Medicare benefits to ensure they have adequate coverage Beneficiaries should not cancel retiree coverage without careful consideration of the benefits Coverage under a retiree health insurance does NOTprevent the Part B penalty (not ACTIVE employment)

15. Consolidated Omnibus Budget Reconciliation Act (COBRA) • Federal law that requires continuation coverage to be offered to covered employees, former/current spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events • Employers with 20 or more employees must offer COBRA • Individuals have 60 days to choose COBRA coverage and may have to pay for the coverage • Minimum coverage period is 18 months • Max for spouse/dependent children is 36 months

16. COBRA & Medicare • Coverage under COBRA does NOT prevent the Part B penalty (not ACTIVE employment) • Medicare is usually the primary payer and COBRA is secondary • Individual must check with employer to determine whether she/he needs to have Medicare for COBRA to provide coverage • If on COBRA when individual becomes eligible for Medicare, individual loses COBRA coverage • Generally, COBRA drug coverage is “creditable” so when COBRA coverage ends there is a 2 month (63 day) SEP for enrolling into a PDP without penalty

17. Workers’ Compensation • Insurance that employers are required to purchase to cover employees who get sick or injured on the job • For employee’s covered under Medicare, workers’ compensation insurance pays first • Medicare is the primary payer for Medicare covered services NOT covered by worker’s compensation • If worker’s compensation does not pay the health care bill within 120 days, Medicare may then make a conditional payment

18. Veteran’s Health Administration • Health Benefits Package • Comprehensive health benefit plan available to all veterans • Enrollment • All honorably discharged veterans who meet the eligibility criteria must be enrolled in the VA health care system to receive benefits • Apply at any VA health care facility/benefits office at any time • Cost • No monthly premium • Co-pays required when services are received • Co-pay amount based on the veteran’s eligibility rating

19. Veteran’s Health Administration, cont. • Benefits • Primary and preventive care • Comprehensive inpatient and outpatient services • Pharmacy services provided free to certain eligible veterans or for a small co-pay • Veterans can enroll in a Medicare Part D plan along with their VA Health Plan prescription benefit • VA drug benefit ISconsidered creditable coverage so beneficiaries are NOT required to enroll in Part D

20. TRICARE For Life (TFL) • Health care program serving Uniformed Service members, retirees and their families worldwide • Provided automatically to all in TRICARE who have Medicare Parts A & B • Eligibility • Be entitled to Medicare Part A and enrolled in Part B • Be a Medicare eligible retiree (including Reserve/Guard retirees) and: • Drawing retired pay, OR • Veteran’s disability regardless of age, OR • Be a qualifying family member or survivor, AND • Certain category of un-remarried former spouse

21. TRICARE For Life (TFL), cont. Pays the out-of-pocket costs for services covered under Medicare Beneficiaries have access to TRICARE benefits not covered under Medicare, such as the prescription drug benefit There is no premium but beneficiaries HAVE to be enrolled in Medicare Part B and pay their Part B premium Drug coverage is creditable so beneficiaries are not required to enroll in Part D

22. CHAMPVA • VA Civilian Health and Medical Program which helps pay for medical care for dependents and survivors of veterans • Individuals eligible for TRICARE are NOTeligible for CHAMPVA • CHAMPVA For Life (CFL) • Extension of CHAMPVA benefits to certain individuals 65 + • Most people covered by both CFL and Medicare do not need additional insurance • CHAMPVA drug benefits more comprehensive than any Part D plan • If a beneficiary enrolls into Part D , CHAMPVA coverage becomes secondary • CHAMPVA IS considered creditable coverage so beneficiaries are NOT required to enroll in Part D

23. Massachusetts Health Connector • The Health Connector is a state price comparison website for subsidized health insurance where individuals, families, and small businesses can shop for health & dental insurance plans • It is designed to help people who don’t have any health coverage • Medicare is NOT part of the Health Insurance Marketplace • It is illegal for the Connector to sell a Medicare beneficiary a health plan • In Massachusetts everyone (including Medicare beneficiaries) can purchase a dental plan through the Connector

24. Where can individuals go for help with the Connector? • SHINE counselors should refer individuals to their local Navigator or Certified Application Counselor (CAC) or provide the contact information below • Massachusetts Health Connector • betterhealthconnector.com • (877) 623-6765

25. Review When is Medicare the primary payer for beneficiaries who are actively employed? Does an individual with retiree health insurance coverage need to be concerned about the Part B penalty? Having COBRA will protect a beneficiary from the Part B penalty. True False What is the VA Health Benefits Package and what benefits does it provide? Which VA programs provide prescription coverage that is creditable?