Health Benefits University

1. Health Benefits University 2016

2. SHINE Serving the Health Insurance Needs of Everyone on Medicare Network of 600 volunteer and working counselors across the Commonwealth SHINE Counselors are certified by the Exec. Office of Elders Affairs, complete extensive training Counselors are available at Councils on Aging, Senior Centers, ASAPs, elder service agencies, and other community-based organizations

3. What does a SHINE Counselor do? • Provides unbiased health insurance counseling to Medicare beneficiaries of all ages and their caregivers • At a local site, on the phone, or via email • Home visits may be available for homebound clients • Assists clients in finding coverage that meets their needs • Answers questions regarding Medicare eligibility, enrollment periods, and benefits • Assists with Medicare appeals and billing issues • Screens for public assistance programs

4. Helpful Insurance Terms • Premium: amount paid monthly to have insurance • Deductible:out-of-pocket amount paid before health insurance begins to cover the cost of health care services • Copayment: set amount consumer pays for each service or item (ex. $20 copay for PCP, $35 for specialist) • Coinsurance: percentage of the cost of the care received after insurance pays (ex. 20% coinsurance)

5. What is Medicare? • Federal health insurance program for: • People 65 years or older • People under 65 with a disability • Medicare is not Medicaid (MassHealth) • Enroll in Medicare with the Social Security Adminstration • Medicare is administered by the Centers for Medicare & Medicaid Services (CMS)

6. What is Medicare?

7. Medicare Eligibility Age 65+: Entitled to Social Security and paid Medicare Tax (for 40 credits/quarters), or Be a spouse (or ex-spouse of 10+ year marriage) of someone who qualifies for Social Security or Medicare Under 65: Entitled to Social Security Disability Insurance (SSDI) for 24 months, or Entitled to SSDI and have ALS, ESRD, or certain other disabilities

8. Enrollment Periods

9. Late Enrollment Penalties • A surcharge/lifetime penalty may be added to Medicare premiums if a beneficiary did not enroll during the prescribed enrollment period • Part B (medical) penalty is 10% of current premium for every 12-month period of delayed enrollment • Must enroll in Part B within 8 months of end of active employment to avoid penalty • Coverage under COBRA does NOT provide a SEP or protect one from B penalty • Part D (drug) penalty is1% of the current Part D National Base Premium for every month the person could have had coverage but did not enroll

10. Avoiding the Part D Penalty A person can delay enrollment into Part Dwithout a late enrollment penalty if s/he has other “creditable drug coverage” “Creditable drug coverage” is any drug coverage, regardless of the source, that is at least as good as Medicare’s drug coverage If creditable drug coverage ends, the beneficiary must enroll into Part D within 2 months in order to avoid the LEP

11. What does Medicare Cover? • Helps to cover a range of inpatient, outpatient, and home care services • Not created to be an individual’s sole source of coverage • Includes out-of-pocket costs: • Premiums • Deductibles • Co-pays and co-insurance

12. Part A Coverage • Inpatient care in hospitals • Inpatient care in a skilled nursing facility • Rehabilitation setting with licensed therapists (PT/OT/Speech) • Hospice care services • Home health care services Note: Medicare does not cover long term care

13. Part B Coverage Physician services Outpatient therapies Outpatient hospital services Medical equipment and supplies Ambulance Lab tests Preventive services such as wellness visits, health screenings, flu/pneumonia shots

14. Part D Coverage • Provides outpatient prescription drug coverage • Eligible to enroll if individual has Part A or B • Voluntary • Late enrollment penalty may apply if no other creditable drug coverage • Delivered by “stand alone” Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MAPDs)

15. Part D Coverage

16. Extra Help/Low Income Subsidy • Federal assistance program to help reduce the cost of Part D plans for beneficiaries with limited resources • Extra Help subsidizes: • Premiums, deductibles, copays, and coverage gap • Late enrollment penalty • Individuals with MassHealth are automatically enrolled • Apply through Social Security Administration

17. Extra Help/Low Income Subsidy See Public Benefits Chart for income limits For those on Extra Help/LIS, benefits/savings worth approximately $4,000/year Recipients have a continuous Special Enrollment Period

18. Prescription Advantage State-sponsored pharmaceutical assistance program Administered by the Massachusetts Executive Office of Elder Affairs Reduces a member’s prescription drug copays associated with Medicare prescription drug coverage or other “creditable” coverage Level of assistance depends on membership category, which is defined by income

19. Prescription Advantage Benefits For lowest income categories, provides immediate copay assistance For those in the middle income categories, copay assistance begins when they reach the coverage gap For the highest income category, copay assistance begins once member’s out-of-pocket costs reach $3,500 Higher income members must also pay a $200 annual enrollment fee All have an annual out-of-pocket spending limit All receive one Special Enrollment Period every calendar year

20. To Apply for Prescription Advantage • Applications can be obtained from your local SHINE counselor, Council on Aging, and Prescription Advantage (PA) Customer Service • Applications can also be done over the phone with a PA customer service representative • Applications can be done online • Phone: 1-800-AGE-INFO, option 2 1-800-243-4636 • Website: www.prescriptionadvantagema.org

21. Pharmacy Outreach Program • Pharmacy Outreach Program of the Massachusetts College of Pharmacy and Health Sciences University • Partially funded by the Executive Office of Elder Affairs • Toll free number 1-866-633-1617 • Website: www.mcphs.edu/pharmacyoutreach • Pharmacists and case managers available to • Conduct Part D reviews • Screen for financial assistance programs • Provide recommendations for alternative medications • Review for drug interactions

23. Additional Coverage Beneficiaries may obtain additional coverage in a number of ways, including: • Medigap plans • Medicare Advantage Plans • MassHealth (Medicaid) • Retiree plans • Veteran or military benefits

24. Supplementing Medicare Medicare Advantage Plan Optional “Replacement” (Provides Original Medicare benefits plus extra routine and preventive benefits) HMO (Health Maint. Org.) PPO (Pref’d Provider Org.) PFFS (Private Fee For Service) SNP (Special Needs Plan) Generally includes Part D drug coverage Original Medicare + Part D Stand Alone Plan OR… + Medigap Policy Optional “add-on” (Picks up where Original Medicare leaves off)

25. Medigap Plans • Sold by private insurance companies • Must have Parts A & B • Continue to pay Part B premium • Pays secondary to Medicare only for Medicare-covered services • Continuous open enrollment in Massachusetts • Do not include prescription drug coverage

26. Medigap Plans • Two types sold in Massachusetts: • Core—does not cover all gaps (such as A & B deductibles, and SNF copays), but costs less • Supplement 1—coversall gaps, but costs more • Both types allow members to see any Medicare provider without referrals

27. Medicare Advantage Plans Also known as Part C Private plans contracted with Medicare to provide coverage comparable to Original Medicare Include Part D coverage (cannot enroll in a separate stand alone Medicare Part D plan) Plans may add benefits (e.g., dental checkups, vision screening, eyeglasses, hearing aids) Plans charge additional premiums and copays May be restricted to networks and require referrals

28. Medicare Advantage Eligibility Must have Parts A & B Must continue to pay Part B premium Must live within the plan’s service area for at least 6 months of the year Cannot have End Stage Renal Disease

29. Medigap vs. Medicare Advantage

30. Other ways to Supplement Medicare • Retiree health plans (group plans) • Each retiree plan is different • Request an outline of benefits to learn about plan • MassHealth/Medicaid (for low-income) • Part A & B deductibles and copays covered in full if seeing MassHealth providers • Veterans health care • Supplements copayments when visiting a VA physician, health clinic, or hospital

31. MassHealth Standard • Provides a full range of medical benefits • Including inpatient, outpatient, skilled nursing care, and prescription drug coverage • Provides secondary coverage for Medicare beneficiaries • Pays Part A & B premiums, deductibles & coinsurance • Deemed eligible for Extra Help – can pay for Medicare Part D premium, deductible, and reduce copays for medications

32. CommonHealth For individuals with disabilities who are not eligible for MassHealth Standard No income or asset limits regardless of age If 65+, must meet a work requirement to be eligible If under 65, can meet the work requirement or a deductible to be eligible Sliding scale monthly premium for those with an income above 150% FPL

33. CommonHealth • Regardless of age, complete ACA-3 form. • Recommendation: Write “CommonHealth” on the front of the application if submitting a paper form • If approved will receive many of the MassHealth Standard benefits • Inpatient and outpatient services • Transportation services • Automatically enrolled in Extra Help

34. Frail Elder Waiver Eligibility • Individual must be 60 years or older • Must meet MassHealth clinical eligibility requirements for nursing home care (screened by ASAP) • Income limit: • 300% of SSI Federal Benefit Rate • Asset limit: • $2,000 • Excess assets can be transferred to a spouse • Spouse’s income and assets are waived in determining financial eligibility • Complete the SACA-2 form (even if under 65 years old)

35. Medicare Savings Programs • Programs that help pay for Medicare cost-sharing • Qualified Medicare Beneficiary (QMB) • Pays Part A & B premiums, copays, and deductibles • Specified Low-income Medicare Beneficiary (SLMB)and Qualifying Individual (QI) • Pays Part B premium only • Part B premium for new enrollees in 2016 = $121.80/month for an individual, prior to 2016, Part B = $104.90/month (no COLA in 2016)

36. MSP Application Process • To qualify for QMB, must complete a full MassHealth application • To qualify for SLMB or QI-1, complete either a full MassHealth application or a MassHealth Buy-In Application • If an individual qualifies they will also be approved for Full Extra Help with Prescription Costs.

37. Example Lucy Jones, age 73 Income -- $1333/year (including Part B which is automatically deducted from her SS check) Assets -- $5,000 in savings account. Lives in her own home (not counted for eligibility). She appears ELIGIBLE for MassHealth Buy-In program (QI-1), should complete MH application, if approved, will automatically receive Extra Help (Full LIS) Potential savings: Buy-In $1,259 + LIS $4,000

38. Health Insurance Marketplace • New benefits and expanded access for individuals without health insurance • Administered by the Connector in Massachusetts • Does not apply to Medicare beneficiaries! • Not eligible for health plans through the Marketplace • Medicare Open Enrollment is still Oct. 15 – Dec. 7

39. One Care: Medicare + MassHealth Health insurance plan which combines Medicare and Medicaid payments and services for consumers aged 21-64 Person-centered model providing the full range of acute, behavioral health, and long term supports and services – including transportation and dental services. Designed to coordinate care and provide higher quality, more cost-effective care with improved health outcomes Individuals enrolled in a SCO, PACE, Frail Elder Waiver or other Home and Community Based Service Waivers are not eligible * A One Care member turning 65 can stay in their One Care plan as long as they remain eligible for MassHealth

40. One Care Plans Two companies offer One Care Plans in select counties: 1) Commonwealth Care Alliance Contact: 1-866-610-2273, www.commonwealthonecare.org 2) TuftsNetwork Health Contact: 1-855-393-3154, www.chooseunify.com Visit the One Care Website: www.mass.gov/masshealth/onecare

41. Where is One Care Available? * One Care is available in Plymouth County except for the following towns: Wareham, E. Wareham, W. Wareham, Lakeville, Marion and Mattapoisett One Care is not available in Barnstable, Berkshire, Bristol, Dukes, and Nantucket Counties.