SHINE Certification Review

1. SHINE Certification Review

2. Medicare Part A & B“Original Medicare”

3. Medicare Overview Medicare is a health insurance program for: People 65 years of age and older (not necessarily full retirement age) People under age 65 with disabilities (deemed “disabled” by Social Security for at least 24 months) People under age 65 and have ALS or ESRD Note: Medicare is NOT Medicaid (which is health insurance for very low income population)

4. Medicare Eligibility • Individuals 65 and older • Entitled to receive Social Security Benefits or contributed to the Medicare Tax • Entitled to receive Railroad Retirement Act retiree benefits • Be a spouse, ex spouse (marriage lasted at least 10 years), widow or widower (age 65 and over) of a person who qualifies for Social Security or Medicare Benefits

5. Medicare Eligibility • Individuals can qualify for Medicare through a spouse if the spouse is: • Aged 62 and over and • Worked 10 years (40 quarters) • Contributed to Medicare Tax

6. Medicare Eligibility • Individuals under age 65 • Receiving Social Security Disability Insurance (SSDI) for 24 months • End-Stage Renal Disease (ESRD) • Amyotrophic Lateral Sclerosis (ALS)

7. Medicare Parts & Premiums Part A & B: “Original Medicare” Part A: Hospital & Skilled Nursing Care Premium free for most people – may purchase if insufficient work credits but very expensive) Part B: Doctors’ Visits & Outpatient Care

8. Medicare Agencies Beneficiaries must enroll through Social Security Administration (SSA) for Medicare Benefits If already receiving Social Security before turning 65, enrollment into Part A and Part B is automatic If not already receiving Social Security benefits an individual must contact Social Security (in-person, online, or phone) to enroll into Medicare Initial Enrollment Period is the 3 months before, the month of, and 3 months after, an individuals 65th birthday. May delay enrolling into Social Security Benefits Medicare is administered by The Centers for Medicare & Medicaid Services (CMS)

9. Delayed Enrollment May enroll into Medicare Part A anytime once eligible Most people enroll in Part A when they turn 65 since it is usually premium free Special Enrollment Period for Part B People may delay enrollment without penalty if covered through active employment by themselves or spouse Will have a 8 month Special Enrollment Period when active employment ends otherwise may have to pay a penalty. COBRA does not qualify as “active” employment and does NOT protect an individual from the Part B late enrollment penalty

10. Delayed Enrollment- Part B General Enrollment Period for Part B January 1st – March 31st Coverage effective July 1st Part B Penalty for delayed enrollment Increased premium of 10% for each 12 months of delayed enrollment Lifetime Increases with increases in premium

11. Medicare Part A • Part A helps cover: • Inpatient care in hospitals • Inpatient care in a skilled nursing facility • Hospice care services • Home health care services • Medicare does NOT cover Long Term Care

12. Medicare Part A Inpatient care in hospital Medically necessary Costs 90 Renewable days Days 1-60: Deductible Days 61-90: Copays 60 non-renewable days Covered Services Room, nursing, testing, supplies, operating room

13. Medicare Part A Skilled Nursing Care Daily skilled care medically necessary Prior hospital stay of 3 days or more Admitted to SNF within 30 days of discharge Costs 100 Renewable days Day 1-20: No costs Days 21- 100: Daily copay

14. Medicare Part A Home Health Care Physician must authorize Beneficiary must be “homebound” Need for skilled care on a part-time or intermittent basis Costs Medicare covers 100% for all covered services Covered services Skilled care, therapy, medical supplies, care by home health aides (bathing, changing, dressing)

15. Medicare Part A Hospice Physician must certify patient is terminally ill (6 months) Patient has elected Hospice care May be provided in home, facility, hospital or nursing home Costs Medicare covers 100% of most services Beneficiary only pays small copayment for drugs and respite care

16. Medicare Part B • Part B helps cover: • Physician services • Out-patient hospital services • Preventive services • Medical Equipment and Supplies • Ambulance • Medically-necessary services • Services or supplies that are needed to diagnose to treat your medical condition

17. Medicare Part B Preventive Benefits ACA provides access to many free preventive benefits Colorectal Screenings Diabetes Self-Management Training/Tests Bone Mass Measurements Prostate Cancer Screening Depression screening Obesity screening and counseling Alcohol misuse screening and counseling Annual Wellness Visit Update individual’s medical & family history Record height, weight, body mass index, blood pressure and other routine measurements Provide personal health advice and coordinate appropriate referrals and health education

18. Medicare Part B Preventive Benefits • Most preventive services are not subject to • Deductible • 20% copayments • Free Annual Wellness Visit • NOT a physical exam • Services provided beyond scope of AWV may be subject to deductible and/or copayments

19. Medicare Part B Physician services No network or referral needed After annual deductible, 20% copayment Medicare approved amount Accepting Assignment – accepting the Medicare approved amount as payment in full Ban on balance billing In other states there an excess charges of 15% is allowable for physicians not accepting assignment

20. Medicare Part B Medical Equipment and Supplies Supplier not required to accept assignment No ban on balance billing Ambulance Medicare will not pay for ambulance used as routine transportation

21. “Gaps” in Original Medicare * A “benefit period” starts the day a beneficiary is admitted to the hospital or SNF and ends when the beneficiary has not received hospital or SNF care for 60 consecutive days

22. Medicare Part C: Medicare Advantage& Medigap Plans

23. 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)

24. Medicare Supplements (Medigap) Sold by private insurance companies Only available to people who are enrolled in Medicare Part A & Part B (continue to pay Part B premium & use Medicare Card) Pays second to Medicare only after Medicare recognizes service as a “covered” service. Continuous open enrollment in Massachusetts Medigap plans DO NOT include prescription drug coverage

25. Medigap Plans • Two Medigap Plans Sold in Massachusetts • Core: Leaves some gaps behind (including hospital deductible & SNF co-pays), but costs less • Supplement 1: Covers all gaps – but costs more • Both plans allow members to choose their own doctors, specialists, and hospitals without referrals NOTE: Some people are covered through older policies no longer available to new members (e.g. “Medex Gold”)

26. Medigap Plans • No matter which company a beneficiary selects for coverage they will receive the same benefits • Some Medigap plans offer a discount of up to 15% to beneficiaries who enroll within 6 months of their Medicare Enrollment • If an individual switches Medigap companies he or she must notify the previous company • If an individual leaves a plan that is no longer sold they will be unable to return to that plan

27. Medicare Advantage Plans(Medicare Part C) Private plans contract with Medicare to provide coverage comparable to “Original” Medicare Plans may add additional benefits (e.g. dental check ups, vision screening, eye glasses, hearing aids) Plans usually charge additional premium & co-pays Members must still pay Part B premium Plans use networks of physicians

28. Medicare Advantage Plans(Medicare Part C) Eligibility Must have both Part A and Part B Must live within plan service area 6 months a year Must not have ESRD Must continue to pay Part B premium Different Plan Types HMO PPO PFFS SNP

29. Medicare Advantage Plans Enrollment/Disenrollment Periods Initial Coverage Election Period (ICEP) 7 month period around 65th birthday or if under age 65, 7 month period around first month of eligibility Open Enrollment Period (OEP) October 15th – December 7th Special Election Period (SEP) Medicare Advantage Disenrollment Period (MADP) January 1st – February 14th

30. Medicare Advantage Plans Enrollment is for the entire calendar year Can only disenroll under special circumstances May enroll online, through the mail or over-the-phone with plan directly, or 1-800-MEDICARE / Medicare.gov Do not have to disenroll from previous plan if you are switching to another Medicare Advantage or Part D plan If leaving a Medigap plan must contact to disenroll

31. HMO: Health Maintenance Organization Must choose a Primary Care Physician Must receive all services within the plan’s network Need referrals for specialists Out-of-network services will not will not be paid for by the plan with the exception of urgent or emergency care May only join the Part D Plan offered by their HMO plan

32. PPO: Preferred Provider Organization Defined network of providers (may not be the same as HMO network) Plan provides all Medicare benefits whether in or out of network Usually pay higher co-pays for out-of-network services (and may have to meet an annual deductible first) No referrals needed to see specialists May only join the Part D Plan offered by the plan

33. PFFS: Private Fee-For-Service Only available in Berkshire, Dukes and Nantucket Counties No defined network – no need for referrals May use any hospital or doctor across the country that accepts the plan’s terms and conditions of payment Plan determines how much it will pay providers for all services Plan may or may not offer Part D coverage Members may join a stand alone PDP if selected plan does not include prescription coverage

34. SNP: Special Needs Plans Only available to certain groups: Institutionalized (e.g. nursing home) Dually Eligible (Medicare/Medicaid) aka Senior Care Options (SCO) People with certain chronic conditions* Defined network of providers Covers all Medicare services AND provides extra benefits Provides Part D Coverage Continuous open enrollment No or low monthly premium * Including heart disease, diabetes, & cardiovascular diseases

35. Medigap vs. Medicare Advantage

36. Important Questions to Consider! • Do their doctors and hospitals accept the plan? • If not, might consider PPO but higher out of pocket expenses • How much are the co-pays? What is the out-of-pocket maximum for the year? • In general, the lower the monthly premium, the higher the co-pays for services • Are their medications on the plan’s formulary and how much do they cost? • May cost more in Medicare Advantage plan

37. Other ways to Supplement Medicare for Certain Populations Retiree Health Plans (group plans) Each retiree plan is different Request an outline of benefits to learn about plan Medicaid/MassHealth (for very low-income) Part A and B deductibles and copayments covered in full if seeing a MassHealth physician

38. Medicare Part D

39. Overview of Medicare Part D • Began January 1, 2006 • Eligible if an individual has Part A OR Part B • Voluntary • a late enrollment penalty may apply to those who do not enroll when first eligible. • Penalty is 1% per month for each month without creditable coverage and is permanent. • Provides outpatient prescription drugs • Coverage for Part D is provided by: • Prescription Drug Plans (PDPs) also known as stand alone plans • Medicare Advantage Prescription Drug Plans (MA-PDs)

40. 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)

41. Medicare Part D Enrollment Periods Initial Coverage Election Period (ICEP) 7 month period around 65th birthday or if under age 65, 7 month period around first month of eligibility Open Enrollment Period (OEP) October 15th – December 7th Special Election Period (SEP) Medicare Advantage Disenrollment Period (MADP) January 1st – February 14th

42. Special Enrollment Periods When outside of the Open or Initial Enrollment Period an individual must meet one of the following criteria to enroll: Loss of creditable prescription drug coverage Have MassHealth or Extra Help towards the cost of your medications (Low Income Subsidy) or have recently lost this assistance. Have a state pharmacy assistance program (SPAP) such as Prescription Advantage or have recently lost this assistance. Moved from one state to another Move in, live in, or move out of a Long Term Care Facility Enroll into a 5 Star plan Once the beneficiary has made a choice the SEP typically ends

43. Late Enrollment PenaltyPart D If an individual does not enroll when first eligible for Part D they may pay a penalty if they: Have no coverage or have coverage but it is not considered creditable Have a lapse in coverage (63 days/2 full months) Penalty charged once an individual does join a Part D plan A 1% increase in premium for each month an individual went without creditable coverage since Medicare eligible, loss of creditable coverage or May 2006, whichever is later. Penalty is permanent. Unable to enroll into Part D until: Annual Medicare Open Enrollment (October 15th – December 7th for an effective date of January 1st) or eligible for a Special Enrollment Period (SEP)

44. CMS Standards for Part D • CMS sets Standard Benefit Structure but plans may provide benefits beyond. • Each plan has to cover “all or substantially all” the drugs in the following classes: • Antidepressants, Antipsychotic, Anticonvulsant, Anticancer, Immunosuppressant and HIV/AIDS • Plans must cover at least two drugs in each therapeutic class • Drugs excluded by coverage • OTC, Vitamins, Select Barbiturates

45. Part D Coverage • Deductibles, out-of-pocket limits, and co-pays during the coverage gap change yearly • Refer to Part D Standard Benefit Chart

46. How to Enroll Into Medicare Part D Review plan options Consider cost, coverage, quality, and convenience Plan Finder Tool on Medicare.gov Seek assistance from SHINE or other agencies Contact plan directly or call 1-800-Medicare Enrollment can take place on the phone, online, or through a mailed in paper application Enrollment form will ask for: General contact information Medicare card information Method for premium payment (direct or through Social Security check)

47. Open Enrollment Period October 15th – December 7th Every plan changes from year to year Plans can change premiums, copayments, tiers, medications covered, the plan name, and can end their contract with Medicare If an individual elects not to do anything then they will remain in that plan for the following year If an individual wants a different Medicare Advantage Plan or Medicare Part D plan they simply enroll into the new plan. The change will take effect January 1st

48. Supplement 2 Medigap Supplement 2 is no longer sold (as of 12/31/05) Most common Supplement 2 plan is Medex Gold Very high monthly premium Provides comprehensive prescription coverage with no gaps If an individual wants to drop the coverage to join Medicare Part D they must have an SEP or wait until the Open Enrollment Period October 15th – December 7th If an individual chooses to leave plan they are unable to rejoin at any time

49. Assistance with prescription costs:MassHealth Extra Help / Low Income Subsidy Prescription Advantage

50. MassHealth and Medicare Part D • Individuals with MassHealth and Medicare are considered “Dual Eligible” • Since January 1, 2006, MassHealth no longer provides primary prescription coverage to Medicare beneficiaries. • MassHealth remains to pay for certain classes of medications directly since Medicare does not cover them. These drug classes are: • Certain Over the Counter Medications (Ibuprofen & acetaminophen) • Most prescription vitamins and minerals • Prescription drugs used for - anorexia, weight loss or weight gain; fertility; cosmetic purposes or hair growth; relief of symptoms of colds • Dual Eligible individuals must receive primary coverage through a Medicare Part D plan