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SHINE Program

Learn about Medicare enrollment periods, eligibility criteria, coverage options, and potential penalties for delaying enrollment. Understand how the Health Connector works with Medicare and the availability of equitable relief.

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SHINE Program

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  1. SHINE Program Recert Review April 2018

  2. Medicare • Part A* – Hospital Insurance • Part B** – Medical Insurance • Part C – Medicare Advantage Plans • HMO, PPO, SNP (SCOs) • Part D** – Prescription Drug Coverage *Premium cost for Part A based on credits earned. Premium-free if earned 40 credits under Social Security/Medicare. Premium charged for beneficiaries with less than 40 credits: (0-29 credits) full cost – for Part A in 2018 $422 ($232 if 30-39 credits) See 2018 Medicare Part A Benefits and Gaps **Premium for Part B & Part D indexed per income (IRMAA-Income Related Monthly Adjustment Amount) – See 2018 Medicare Premiums chart

  3. Medicare Eligibility • Medicare at age 65 • If worked 10 years (40 credits) under Social Security and/or paid into Medicare Tax • Or married (or divorced and marriage lasted 10 years) can enroll into Medicare at age 65 as long as: • Spouse* (or ex spouse) is at least age 62 with sufficient credits to qualify for Medicare • Medicare under age 65 • If meet Social Security disability for 24 months or diagnosed with ESRD or ALS *Including same-sex marriage spouse

  4. Medicare Enrollment Periods • Initial Enrollment Period (IEP) – age 65 • Special Enrollment Period (SEP)* – up to 8 months after current employment coverage (EGHP) ends or coverage under the EGHP ends (can get B–no penalty – can start 1st of following month) • General Enrollment Period(GEP) – late/voluntary enrollees – Jan 1-March 31 – coverage effective on July 1 *Exception: The IEPsupersedes the eight-month SEP if a client is still within his/her seven-month window when enrolling

  5. Enrolling in Medicare • Initial EnrollmentPeriod – seven-month window • Must contact Social Security to enroll – not automatically enrolled at 65 • If collect Social Security prior to age 65, will be automatically enrolled at 65 • Date coverage begins determined by date of enrollment • Enrollment delayed if wait till after birthday month • If continue employment • Client/spouse with Employer Group Health Coverage (EGHP) beyond 65 may take Part A, delay Part B and remain on EGHP – can pick up B at any time [if beyond 7-month IEP] as long as have been covered by EGHP • Must enroll in Part B within 8 months of end of current employment or end of EGHP* to avoid penalty – Special Enrollment Period (Note: Can drop Part B later if return to work with employer coverage) • Penalty of 10% of current premium for every 12-month period of delayed enrollment Note: Coverage under COBRA does notprovide a SEP or protect one from Part B penalty Living outside the US does not provide a SEP or protect from B penalty *See POMS Handout

  6. Enrolling in Medicare and Health Savings Account (HSA) • Enrollment Exception with HSA • People with Medicare are not allowed to contribute money into an HSA • If continue to contribute, will receive a tax penalty from the IRS • Medicare Part A will be retroactive for up to 6 months (as long as person was eligible during the 6 months), so contributions to the HSA must stop 6 months prior to when the person signs up for Medicare* *See HSA Handout Note: Individuals contributing to an HSA should speak with their Human Resource department and tax consultant

  7. Delaying Medicare Enrollment • Can delay Medicare enrollment without a penalty if covered under EGHP* because of current employment (client or spouse). If client wants to delay should: • Check with employer to see if coverage will change at 65 • Review employer outline of coverage with Medicare options to compare costs and coverage Note: If entitled to Medicare and employer has less than 20 employees (less than 100 if on Medicare because of disability), Medicare would be primary *Note: Individual may be offered a severance package that can include continued current employment status and coverage under the EGHP which would provide an 8-month SEP when coverage ends

  8. Medicare and the Health Connector • How the Health Connector works with Medicare: • A Health Connector member can remain on the HC plan when become eligible for premium-free Medicare Part A* – will not be required to take A and/or B – however: • Will lose premium subsidy or tax credits and may have to pay back for tax credits • Will be subject to Part B late enrollment penalty** if delay enrolling in Part B • If delay Part B, would only be able to enroll during the General Enrollment Period – January 1-March 31 – with coverage effective July 1** *If required to pay for Part A, would not be required to enroll, could remain on Connector plan and continue to receive premium subsidy **See Slide #9 re: Equitable Relief for Connector members

  9. Health Connector and Equitable Relief • CMS has allowed a SEP scheduled to end Sept. 30, 2018 for Marketplace (Health Connector is Mass. Marketplace) plan members who did not enroll in Part B when initially eligible either at age 65 or on becoming eligible due to disability* • This SEP provides Part B coverage which can begin the month the individual enrolls with no penalty and/or remove prior penalty • Documentation of Marketplace/Connector coverage can include: • IRS Form 1095-A • Health Connector premium notices • Receipts of premium payments • Other documentation that clearly shows individual was enrolled in a Health Connector plan See Equitable Relief Handout

  10. Options for Medicare Coverage • Original/Traditional Medicare • Part A (Hospital) Part B (Medical) • Freedom of choice, gaps in coverage • Medicare Advantage Plan (MA)* *(Note: MA is the managed care option for Medicare. It is Not Medicare Supplement/Medigap) • May have network restrictions • Co-pays, may be higher costs for out-of-network service

  11. Medicare Part A Coverage and Out-of-Pocket Costs - 2018 • Inpatient Hospital Care • $1,340 deductible per benefit period • Benefit Periods are renewable – must be out of a hospital/facility for 60 days – unlimited # in lifetime • Skilled Nursing Facility (SNF) • Medicare pays in full days 1-20, (must enter SNF within 30 days of 3-day/overnight hospital stay*-not observation) beneficiary pays $167.50/day co-pay for days 21-100 • SNF benefit period is also renewable – must be out of SNF for 60 days • Medicare does not provide coverage for long-term custodial care *May not be required for MA members or some ACO members See 2018 Medicare Part A Benefits and Gaps

  12. Medicare Part A Coverage and Out-of-Pocket Costs (cont.) • Home Health Care • Physician ordered • Patient homebound & • Requires intermittent/part-time skilled care • No co-pay for home health • Hospice Care • Have life expectancy of six months or less • Blood

  13. Medicare Part B Coverage and Out-of-Pocket Costs – 2018 • Doctor, lab and X-ray services • Ambulance • Durable Medical equipment • Home Health Care, Blood • Other outpatient services • Some medications covered under Part B (See Slide #24) • Standard Part B premium $134.00* • Annual deductible $183.00 • 20% co-insurance for most Part B services • Many free preventive services See 2018 Medicare Part B Benefits and Gaps *Note: See 2018 Medicare Premiums chart for premium cost for higher income beneficiaries (IRMAA)

  14. Medicare Fraud & Abuse • Fraud • Intentional deception or misrepresentation an individual makes that results in unauthorized benefit/payment • Abuse • Unintentional practice or procedure which may result in provider receiving payment for services

  15. Medicare Appeals • Livanta (Beneficiary and Family Centered Care Quality Improvement Organization) handles Part A hospital appeals • MAP (Medicare Advocacy Project) can help with most appeals–Part B, Part C, Part D • Medicare Summary Notice includes info on: • Why Medicare did not pay • How to appeal • Timeline for appeal

  16. Services Not Covered by Medicare • Routine Care (Note: Welcome to Medicare and Annual Wellness Visit are covered) • Eye exams/glasses, foot care, hearing exams/hearing aids • Note: Beneficiary may be asked to sign an ABN (Advance Beneficiary Notice) which would make him/her liable for bill • Medical care outside the USA • Dental care/dentures

  17. Medicare Supplemental Coverage (Medigap) • Designed to supplement/fill the gaps of original Medicare • Pays second to Medicare for Medicare covered services with added services offered by plan • Must have A & B to join a Medigap • Under 65 – cannot have Medicare due to ESRD • Medicare supplement can be offered through employer retiree group coverage or non-group plan Note: Medicare Supplement/Medigap is NotMedicare. Medigap is private insurance a beneficiary can purchase to fill the gaps in their coverage under original Medicare.

  18. Medicare Supplement/Medigap Insurance (cont.) • 7 companies, all have continuous open enrollment* – all offer Core & Supplement 1 • Core – less costly, doesn’t cover all gaps including Part A hospital deductible and SNF co-pays (some have “add on” of foreign travel) • Supplement 1 – covers all gaps and provides coverage for foreign travel • Note: Both plans cover Medicare co-insurance for any medications covered by Part B (after meet annual deductible in Core) – allMedicare providers accept both Core and Supplement 1 • Medex Choice – offered by BCBS only • Similar* to Bronze only if use BC HMO “Blue Choice” network PCP • Similar* to Core if use BC HMO Blue network PCP • No coverage (only Medicare) if PCP out of BC HMO Blue network *Cannot purchase Hearing/Vision Rider – no foreign travel Note: Enrolling in Medigap with new company does not automaticallydisenroll beneficiary from first company

  19. Employer Retiree Options • Employer Retiree Options • Beneficiaries who have employer retiree benefits such as: • GIC (state/municipal retirees) • Federal Blue Cross/Blue Shield • These plans usually provide very comprehensive coverage Clients should be referred back to their plan administrator or Human Resource department with questions

  20. Employer Retiree Options (cont.) • Benefits May Also Be Offered: • Through licensed benefits management company/broker such as Aon or Via Benefits (formerly One Exchange) • Retiree is offered a dollar benefit* • Must work with and usually enroll through benefit advisor • SHINE counselors should refer clients back to the benefit advisor and not enroll clients on the Medicare Plan Finder *The dollar benefit is usually only available if client works/enrolls with the benefit advisor

  21. Medicare Advantage Plans (Part C) • Contract with CMS to provide members their Medicare benefits • Must have A & B* to join Part C and live in plan’s service area (MA members still required to pay Part B premium) • *Can join an MA during the Initial Coverage Election Period – 3 months before, month of, 3 months after eligibility for both A & B. (Late enrollee into Part B who is enrolling during General Enrollment Period [January 1 – March 31] can enroll in MA plan April 1 – June 30 with coverage effective on July 1.) • Coverage for urgent or emergency care only out of area • Not required to sell to beneficiaries with Medicare due to ESRD • If beneficiary enrolling in an MA plan wants Part D coverage, musttake it with the MA HMO/PPO plan. (Unless the beneficiary is enrolled in a PFFS.) If joins stand-alone Part D plan, will be dropped from MA

  22. Types of Medicare Advantage Plans • HMO – Health Maintenance Organization – most restrictive require member to receive care in network (exception – urgent/emergency care) • PPO – Preferred Provider Organization – allow member to go out of network usually at higher cost • SNP – Special Needs Plan – Includes: • SCOs (for dual eligible 65 and over who have Medicare and MassHealth Standard or only MassHealth Standard) • One Care (for dual eligible age 19-64 who have MassHealth Standard or CommonHealth)

  23. Enrollment Periods for Medicare Advantage • Initial Coverage Election Period (Age 65: seven-month period) • Open Enrollment Period – 10/15 - 12/7 • Special Enrollment Period • PA members eligible to make one change anytime through year • Extra Help and MassHealth members have continuous SEP • Five-star SEP – can enroll in 5-star plan (or switch within 5-star plan) • SEP65–individuals who join an MA plan during the initial enrollment periodat their 65th birthday can disenroll any time during the first 12 months of their enrollment into an MA plan (Trial), return to original Medicare and join a Pt. D • Residents of long-term care facilities, including recently discharged • Move into or out of plan area • Leaving employer coverage • Medicare Advantage Disenrollment Period (MADP) – 1/1–2/14 – Maydisenroll from MA and return to original Medicare and pick up Pt. D plan even if beneficiary was in an MA plan without drug coverage (would still have penalty if applicable) – cannotuse the MADP toswitchto another MA plan Note: A late enrollee into Part B (enroll during General Open Enrollment Period) can enroll in an MA plan from April 1-June 30 with coverage effective on July 1. See SEP Chart (PDP and MA-PD Special Enrollment Periods) for more SEPs and details

  24. Medicare Prescription Drug Program (Part D) • Provides outpatient prescription drug coverage to Medicare beneficiaries • Note: Some drugs/supplies covered under Part B – diabetic supplies, injec- tions (e.g. antigens) administered in doctor’s office, some chemo Rx, immuno-suppressant Rx after Medicare-covered transplant • CMS contracts with private companies to provide coverage including: • Prescription Drug Plans (PDPs) • Medicare Advantage Prescription Drug Plans (MA-PDs) • Beneficiary pays monthly premium* whether enrolled in a PDP or MA-PD *Note: Higher income categories pay a monthly Part D “Adjustment” (IRMAA) which is deducted from the Social Security check whether enrolled in a stand-alone Part D or in a Medicare Advantage with Part D. IRMAA also pertains to beneficiaries covered by group Part D plans such as GIC See 2018 Medicare Premiums Chart

  25. Enrollment Periods for Part D • Enrollment period for initially eligible mirrors the seven-month window for A & B • Can enroll in stand-alone Part D (PDP) if have either Medicare Part A or Part B • Can enroll in Medicare Advantage with Part D (MA-PD) only if haveboth A & B • Can also enroll during: • Open Enrollment Periodof October 15 – December 7 (If member is switching plans, simply enrolls in new plan) • Special Enrollment Period– if meet eligibility requirements (involuntary loss of creditable coverage [such as EGHP for instance], creditable Rx coverage ending [even if under COBRA], move out of or into plan service area [2 months to enroll], PA member, 5-star, Extra Help, MassHealth) • Note: A MassHealth member who becomes eligible for Medicare will be auto-enrolled into a “Basic”(Pink plans on Part D sheet) Part D plan by Medicare

  26. Enrollment Periods for Part D (cont.) • Nursing home residents (private pay & Medicaid) entitled to monthly SEP • Medicare Advantage Disenrollment Period (1/1-2/14) • Can return to Original Medicare and join a stand-alone PDP • Note: • Change in plan’s formulary does notprovide a SEP • Dropping from Medex Gold (Sup 2)* to Bronze (Sup 1) does not provide a SEP to enroll • Having creditable coverage under the VA* does notprovide a SEP to enroll *Note: Would not have penalty because of creditable coverage, but no SEP

  27. Enrollment Periods for Part D (cont.) • SEP provided to members of a PDP that will end its contract with CMS effective January 1 – SEP begins December 8 and ends on the last day of February • Penalty for late enrollment: • 1% of National Base Premium for each month did not enroll and did not have creditable coverage • Penalty is lifetime Note: A beneficiary who returns to the US after living permanently outside the US would get a 2-month SEP for Part D – No SEP for Part B See SEP Chart (PDP and MA-PD Special Enrollment Periods) for details

  28. Part D Standard Benefit in 2018 • $405 Deductible • Provides coverage for drugs on plan’s formulary • Co-pays/co-insurance during initial coverage period or until hit coverage gap • Coverage Gap/Donut Hole when retail costs(includes what plan and member pay) hit $3,750 • Under Affordable Care Act will pay 35% for brands and 44% for generics in 2018 • Catastrophic Coverage begins when total costs (includes amount plan and member pay and 50% manufacturer’s discount) hit $5,000 • Note: Plan premium and cost of medication not on plan’s formulary do not count toward out-of-pocket costs See 2018 Part D Standard Benefit Chart

  29. Part D Coverage Issues • Drugs must be on plan’s formulary* to be covered • Plans can drop drugs from the formulary* • Cost of drugs can change • Member’s costs can be impacted by pharmacy network • Tier category can change from plan to plan *Note: Member can always ask for an exception if medication is not on formulary or speak with doctor about possible medication change

  30. Creditable Coverage • Coverage as good as Medicare Part D • Many retiree plans and COBRA provide creditable prescription coverage • Important to be aware that beneficiary has only 2 months from end of creditable coverage to enroll in Part D • Coverage with the VA Health Plan is creditable but does not provide a SEP to join outside of the annual OEP • All Medicare beneficiaries (including those still working) must have creditable coverage to avoid the late enrollment penalty • Beneficiaries must keep letter from employer/retiree plan stating creditable coverage

  31. LIS (Limited/Low Income Subsidy) AKA Extra Help • Helps with costs of Part D plan whether beneficiary is in PDP or MA-PD* • Provides SEP to join/switch Part D plan • Eliminates late-enrollment penalty • Must meet income/asset and eligibility: • Income no higher than: • 150% FPL=$1,538**/mo. Individual $2,078**/mo. Couple • Assets: $14,100 Individual - $28,150 Couple *Note: LIS (Not MassHealth) will subsidize the premium in stand-alone Part D basic plan or a portion of the MA-PD plan that covers Part D premium for beneficiary enrolled in MassHealth **Amounts include $20 disregard See MassHealth/LIS Programs–2018 (Green Chart) or Eligibility Guidelines for PB Programs

  32. LIS (continued) • Full Extra Help: • $0 premium (basic plan), no deductible, co-pays: • 100% FPL ($1,032-Ind/$1,392-Cpl.) - $1.25 generics, $3.70 brands • 135% FPL ($1,386-Ind/$1,872-Cpl.) - $3.35 generics, $8.35 brands • Partial Extra Help: 150% FPL ($1,538-Individual/$2,078-Couple) • Have sliding scale premium, $83 deductible & 15% co-insurance • Assets not counted include: • Home • $1,500/person for funeral expenses • Life insurance policies

  33. Automatic Eligibility for LIS/Enrollment SEP/Loss of LIS • Automatic Eligibility for LIS • Beneficiaries are “deemed” (automatically) eligible if: • Have Medicare and MassHealth Standard or CommonHealth – AKA “Dual Eligible” • Enrolled in MassHealthBuy-In Program (QMB, SLMB, QI – AKA MSP) • On SSI • Enrollment SEP • LIS members can change* plans monthly • *Note: Institutionalized beneficiary can also change plans monthly whether private pay (non-LIS) or on LTC Medicaid • Loss of LIS • If lose LIS at end of year, have three-month SEP that ends March 31 Note: If on MassHealth with LIS and lose MH before July, will have LIS until end of the current calendar year (12/31) If lose MH after July, will remain on LIS until 12/31 of the following year See Slide #35 for detail

  34. MassHealth Standard • People 65 and over eligible if: • Income: 100% FPL or less = $1,032*/mo. Individual, $1,392*/mo. Couple** • Assets $2,000 Individual – $3,000 Couple and include: • Savings/checking, IRA, stocks/bonds, cash value of whole life insurance • Coverage: • Wraps around Medicare – covers premiums, deductibles, co-insurance, deemed eligible for LIS, and additional benefits such as adult day health, medical transportation, dental, eyeglasses, hearing, some OTC prescriptions generic drugs and eligible to join a SCO ***************************************************************************************************** • People under 65 with a disability eligible if: • Income: 138% FPL (133% + MAGI 5% income disregard) or less = $1,397/mo. Individual, $1,894/mo. Couple** • No Asset Test for under 65 • Coverage: • Comprehensive coverage including prescription coverage – must use MH providers Note: If become eligible for Medicare will be automatically enrolledby Medicare into “Basic” Part D plan & deemed eligible for LIS – MassHealth may cover some OTC prescription generic Rx *Amounts include $20 disregard **MH counts combined income/assets of married couple – does not count as combined for married not living together or if living with adult family member

  35. MassHealth Standard (cont.) • MassHealth Standard members on Medicare are deemed eligible for LIS • Note: Medicare reviews MassHealth enrollment data in July of each year. If a MassHealth member loses MH before July, he/she will have LIS for the remainder of the year (until 12/31). If a member loses MH after July, he/she will remain on LIS until December 31 of following year.

  36. MassHealth Senior Buy-In AKAMedicare Savings Program (MSP) Qualified Medicare Beneficiary (QMB) • MassHealth Senior Buy-In Eligibility: • Income: 100% FPL = $1,032*/mo. Individual $1,392*/mo. Couple • Assets: $7,560 Individual – $11,340 Couple • Covers Medicare A & B premiums, deductibles & co-insurance • Deemed eligible for LIS • Need to complete MassHealthSACA application *Amounts include $20 disregard

  37. MassHealth Buy-In Programs Medicare Savings Program (MSP) • MassHealth Buy-In (AKA Qualified Individual 1 – QI-1) • Income: 135% FPL = $1,386*/mo. Individual $1,872*/mo. Couple • Assets: $7,560 Individual - $11,340 Couple • MassHealth Buy-In (AKA Specified Low-Income Medicare Beneficiary – SLMB) • Income: 120% FPL= $1,234*/mo. Individual $1,666*/mo. Couple • Assets: $7,560 Individual – $11,340 Couple Note: Buy-In programs pay the Part B premium and late enrollment penalty and allow immediate enrollment into Part B upon eligibility. *Amounts include $20 disregard

  38. MassHealth Buy-In Programs Medicare Savings Program (MSP) (cont.) • Both Buy-In programs (QI 1 & SLMB) cover Part B premium only • Members deemed eligible for full LIS • Can complete MassHealth Buy-In (MHBI) • Should complete SACA application so client will be screened for other programs such as Health Safety Net

  39. MassHealth Frail Elder Waiver/AKA Home and Community-Based Waiver/AKA Spousal Waiver Program • People 60 and over eligible if: • Income no higher than $2,250/mo. (300% SSI) • Assets in applicant’s name $2,000 or less • Note: Will waive income of spouse and waive assets up to $123,600* • Meet clinical eligibility (screening done by ASAP Coordination of Care Unit) • Receiving homecare (ASAP) service *Note: Asset allowance for spouse under FEW same as long-term care Medicaid

  40. MassHealth Frail Elder Waiver/AKA Home and Community-Based Waiver/AKA Spousal Waiver Program (cont.) • Coverage: • MassHealth Standard • Deemed eligible for full LIS • No co-pay for drugs • Increased homecare services • Frail Elder can join a SCO (Senior Care Options) plan because have MH Standard Note: May not pay Medicare Part B premium Need to Complete SACA application

  41. MassHealth Health Safety Net • Medicare beneficiaries 65 and over are eligible if: • Income no higher than 150% FPL for full HSN benefit: • $1,518 –Individual • $2,058 – Couple • Between 151% - 300% for partial HSN benefit (would have to meet a deductible* amount determined by MassHealth first) • Assets not counted • Covers Part A deductible or hospital co-pays in MA plan if eligible for full HSN – does not cover care in a SNF • Covers some services at hospital-based/affiliated (satellite) clinic/center • Can receive care and Rx* coverage at Community Health Centers and hospitals *Partial HSN members do not need to meet MassHealth deductible before receiving co-pay assistance for drugs Need to complete SACA application

  42. Long-Term Care MassHealth/Medicaid • No income eligibility – member pays all but $72.80/month (PNA – Personal Needs Allowance) of income to nursing home • Must meet clinical eligibility • Countable assets no higher than $2,000 • Includes: • Savings/checking accounts • IRA • Stocks/bonds • Cash value of a whole life* insurance policy • Cannot have a disqualifying transfer of assets *Note: Term life policy has no cash surrender and not a countable asset by MH

  43. Long-term Care MassHealth/Medicaid (cont.) • If married, at home spouse can retain $123,600 in countable assets (home not counted), and may be able to receive portion of NH resident’s income if needed (spousal income allowance/monthly needs allowance) • Five-year look back at transfers of income/assets • Transfers of assets for less than fair market value during look-back period may result in a disqualification period Note: Complete SACA application & Long-Term Care Supplement

  44. MassHealth CommonHealthUnder 65 • People under 65 with a disability eligible if: • Not eligible for MassHealth Standard (Eligible for MH Standard if income at 138% FPL [133% + MAGI 5% disregard] = $1,397 – Individual, $1,894 – Couple or less) • Income over 138% FPL $1,397+ – Individual, $1,894+ – Couple • No asset test for any MH program for under 65 (exception: Frail Elder or other waiver program) • No Income cap but requires: • Work at least 40 hours/month OR • Meet one-time deductible/spend-down (can spend down income on any medically-related expense) • If become eligible for Medicare, automatically eligible for LIS/Extra Help and will be auto-enrolled by Medicare into “Basic” (Pink plans) Part D plan • May not pay Part B premium if do not meet income eligibility for Buy-In Program (140% FPL [MAGI] = $1,417-Individual, $1,921-Couple) • May have to pay premium for CommonHealth if income over 150% FPL Note: Receive coverage similar to MH Standard

  45. MassHealth CommonHealth 65 and Over • People 65 and over with a disability*only eligible if: • Work 40 hours/month – no income cap • No Asset test for over 65 for CommonHealth • If have Medicare and CommonHealth, deemed eligible for LIS • May not pay Part B premium if do not meet income eligibility for Buy-In Program (140% [MAGI] = $1,417-Individual, $1,921-Couple) • May have to pay premium for CommonHealth if income over 150% FPL • Not eligible to join a SCO • Need to complete MassHealthACA application *May be required to file MassHealth Disability Supplement for disability determination to be made by MassHealth Note: Receive coverage similar to MH Standard

  46. One Care • One Care • Managed care plan for dual eligible (have Medicare and MassHealth Standard or CommonHealth) individuals between the ages of 21-64* • Receive health care through plan’s network of providers • Providers must be in the network of a One Care plan – providers may accept MassHealth but not One Care • Receive Part D coverage through plan • Can opt in/out at any time – change takes effect on first of following month • Some additional coverage benefits: • No monthly premium • No co-pays for drugs • Vision care • Comprehensive dental *Note: If already on One Care, can remain when turn 65, if eligible

  47. Senior Care Options Plan(SCO) • Managed care plan for individuals age 65 and over who have MassHealth Standard and Medicare or just MassHealth Standard (Frail Elder Waiver client can join SCO) – Not eligible to join SCO if on CommonHealth • Receive health care through plan’s network of providers • Receive Part D coverage through plan • Can opt in/out* at any time – change takes effect on first of following month • Important note: If opt out, must sign up for Part D plan • Some additional coverage benefits: • No monthly premium • No co-pays for drugs • Comprehensive dental

  48. Prescription Advantage (PA) • Acts as secondary payer to Part D plan • Don’t need Part D to enroll but no help until have Part D • MassHealth members not eligible to join PA • No cost to join for categories S0-S4 (income up to 300% FPL) • Provides help to LIS “partials” (150% FPL) immediately– would be Category S1 • Helps with co-pays during the $83 deductible period • Instead of 15% co-insurance, would pay no more than $7.00 for generics or $18.00 for brands • Provides help with co-pays to categories S2-S4 once hit donut hole of plan (retail costs hit $3,750) as a PA member – doesnot provide retroactive coverage for costs incurred in donut hole prior to membership • Only helps with drugs covered on drug plan formulary

  49. Prescription Advantage (cont.) • Provides help with co-pays to category S5once hit PA’s out-of-pocket spending limit($3,620) as PA member • Does not provide help with drugs not covered by Part D plan • Provides members a SEP to join or switch Part D plan (once per year) outside of open enrollment • Can join a Part D plan (PDP) or a Medicare Advantage plan with Part D (MA-PD) • Can switch from MA-PD plan to stand-alone PDP • Can switch from one MA-PD plan to another MA-PD plan • Can switch from stand-alone PDP to an MA-PD plan • Can switchfrom one stand-alone PDP to another stand-alone PDP • Do Not need to be enrolled in Part D to join PA • Requires applicants who are income/asset eligible for LIS to apply for that program • Can be primary Rx coverage only if not eligible for Medicare

  50. Eligibility for Prescription Advantage (PA) • Medicare beneficiaries 65 and older with annual gross incomes no higher than: • Single $60,700 – ($5,058/month) • Married $82,300 – ($6,858/month) • Note: MassHealth members are not eligible • Under 65 Medicare with disability must meet income of 188% FPL $1,902/mo – Individual $2,579/mo – Couple(S2 Category) • 65 and over not eligible for Medicare may have PA as primary drug coverage Note: Assets not counted

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