SHINE Program

1. SHINE Program Recert Review April/May 2016

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 quarters worked/credits earned. Premium-free if worked 40 qtrs. under SS. Premium charged for beneficiaries who worked less than 40 qtrs. (worked 0-29 qtrs.) full cost – for Part A in 2016 $411 ($226 if worked 30-39 qtrs.)See 2016 Medicare Part A Benefits and Gaps **Premium for Part B indexed per income – See 2016 Medicare Premiums chart

3. Medicare Eligibility • Medicare at age 65 • If worked 10 years (40 qtrs.) under Social Security and/or paid into Medicare Tax • Or married (or divorced and marriage lasted 10 years) can enroll into Medicare as long as: • Spouse* (or ex spouse) is at least age 62 with sufficient quarters/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 – age 65 • Special Enrollment Period – up to 8 months after active employment coverage ends (can get B – no penalty) • General Enrollment Period – late/voluntary enrollees – Jan 1-March 31 coverage effective on July 1

5. Enrolling in Medicare • Initial EnrollmentPeriod – seven-month window • Must contact Social Security to enroll – not automatically enrolled at 65 • Date coverage begins determined by date of enrollment • Enrollment delayed if wait till after birthday month • If continue employment (client or spouse) with health coverage beyond 65, may take Pt. A, delay Part B and remain on EGHP – (can pick up B at any time as long as covered by employer plan) • Must enroll in Part B within 8 months of end of active employment or EGHP to avoid penalty – SpecialEnrollment 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 *Coverage under COBRAdoes notprovide a SEP or protect one from B penalty

6. Delaying Medicare Enrollment • Can delay Medicare enrollment without a penalty if covered because of active 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, Medicare would be primary

7. 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 Medicare Not Medicare Supplement/Medigap) • May have network restrictions • Co-pays, may be higher costs for out-of-network service

8. Medicare Part A Coverage and Out-of-Pocket Costs - 2016 • Inpatient Hospital Care • $1,288 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 a 3-day hospital stay* - not observation) beneficiary pays $161.00/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 See 2016 Medicare Part A Benefits and Gaps

9. 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

10. Medicare Part B Coverage and Out-of-Pocket Costs – 2016 • Doctor, lab and X-ray services • Ambulance • Durable Medical equipment • Home Health Care, Blood • Other outpatient services • Some medications covered under Part B • Standard Pt B premium $121.80* • Annual deductible $166.00 • 20% co-insurance for most Part B services See 2016 Medicare Part B Benefits and Gaps *Note: See 2016 Medicare Premiums sheet for premium cost for higher income beneficiaries

11. 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

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

13. 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

14. 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 • Medigap companies are not required to sell to beneficiaries under age 65 with ESRD • 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.

15. 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-pay (some have “add on” of foreign travel) • Supplement 1 – covers all gaps and all have “add on” of foreign travel • Note: Both plans cover Medicare co-insurance for any medications covered by Part B (after meet annual deductible in Core – all doctors/providers accept both plans) • 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 Rider – no foreign travel Note: Enrolling in Medigap with new company does not automatically disenroll beneficiary from first company

16. 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

17. 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 Pt. 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 ESRD • If beneficiary enrolling in an MA plan wants Part D coverage, must take it with the MA HMO/PPO plan. (Unless the beneficiary is enrolled in a PFFS.) If joins stand-alone Pt. D plan, will be dropped from MA

18. 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 – including SCOs (for dual eligible 65 and over who have Medicare and MassHealth Standard or only MassHealthStandard)

19. 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 any time 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 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 (from one state to another) • Medicare Advantage Disenrollment Period – 1/1 – 2/14 – Maydisenroll from MA and return to original Medicare and pick up a Part D plan even if beneficiary was in an MA plan without drug coverage – 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.

20. Medicare Prescription Drug Program (Part D) • Provides outpatient prescription drug coverage to Medicare beneficiaries • CMS contracts with private companies to provide coverage including: • Prescription Drug Plans (PDPs) • Medicare Advantage Prescription Drug Plans (MA-PDs)

21. 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 (MAPD) 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 under COBRA ending, move out of or into plan service area [60 days to enroll], PA member, 5-star, Extra Help, MassHealth) • Medicare Advantage Disenrollment Period (MAPD) – 1/1-2/14) can return to original Medicare and join a stand-alone PDP

22. 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 notprovide a SEP • Having creditable coverage under the VA does notprovide a SEP

23. Enrollment Periods for Part D (cont.) • Can also enroll during: • 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

24. Part D Standard Benefit in 2016 • $360 Deductible • 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 $3,310 • Under Affordable Care Act will pay 45% for brands and 58% for generics in 2016 • Catastrophic Coverage begins when total costs (includes amount plan and member pay and 50% manufacturer’s discount) hit $4,850 • Note: Plan premium does not count toward out-of-pocket costs

25. 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 60 days from end of creditable coverage to enroll in Part D • Coverage with the VA Health Plan is creditable • 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

26. 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=$1,505**/mo. Individual $2,023**/mo. Couple • Assets: $13,640 Individual - $27,250 Couple *Note: LIS will subsidize the premium in stand-alone Part D basic plan or the portion of the MA-PD plan that covers Part D premium **Amounts include $20 disregard See MassHealth/LIS Programs–2016 or Eligibility Guidelines for PB Programs

27. LIS (continued) • Full Extra Help: • $0 premium (basic plan), no deductible, co-pays: • 100% FPL - $1.20 generics, $3.60 brands • 135% FPL - $2.95 generics, $7.40 for brands • Partial Extra Help: (150% FPL) • Have sliding scale premium, $74 deductible & 15% co-insurance • Assets not counted include: • Home • $1,500/person for funeral expenses • Life insurance policies

28. Beneficiaries Automatically Eligible for LIS • Beneficiaries are “deemed” eligible if: • Have Medicare and MassHealth Standard or CommonHealth – AKA “Dual Eligible” • Enrolled in a MassHealth Buy-In Program • On SSI • Note: Institutionalized beneficiary can also change plans monthly whether private pay (non-LIS) or on LTC Medicaid • If lose LIS at end of year, have three-month SEP that ends March 31 Note: If 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 following year See Slide #31 for detail

29. Medicare and The Health Connector (HC) • 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 • 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 GEP – January 1–March 31 – with coverage effective July 1 *If required to pay for Part A, would not be required to enroll and would still receive premium subsidy

30. MassHealth Standard • People 65 and over eligible if: • Income: 100% FPL=$1,010*/mo. Individual $1,355*/mo. Couple • Assets $2,000 Individual - $3,000 Couple and include: • Savings/checking, IRA, stocks/bonds, cash value of whole life insurance *MH counts combined income/assets for a married couple – does not count combined income for unmarried, living together • Wraps around Medicare – covers premiums, deductibles, co-insurance and additional benefits such as adult day health, medical transportation, eyeglasses, hearing, OTC generic drugs and eligible to join a SCO (Over 65 on CommonHealth cannot join a SCO) *Amounts include $20 disregard

31. MassHealth Standard (cont.) • MassHealth Standard members 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.

32. MassHealth Senior Buy-In AKAMedicare Savings Program (MSP) Qualified Medicare Beneficiary (QMB) • MassHealth Senior Buy-In Eligibility: • Income: 100% FPL=$1,010*/mo. Individual $1,355*/mo. Couple • Assets: $7,280 Individual – $10,930 Couple • Covers Medicare A & B premiums, deductibles & co-insurance • Deemed eligible for LIS • Need to complete MassHealthSACA-2 application *Amounts include $20 disregard

33. MassHealth Buy-In Programs Medicare Savings Program (MSP) • MassHealth Buy-In (AKA QI 1) • Income: 135% FPL=$1,357*/mo. Individual $1,823*/mo. Couple • Assets: $7,280 Individual - $10,930 Couple • MassHealth Buy-In (AKA SLMB) • Income: 120% FPL= $1,208*/mo. Individual $1,622*/mo. Couple • Assets: $7,280 Individual – $10,930 Couple Note: Buy-In programs pay the late enrollment penalty and enrollment into Part B is effective immediately with Buy-In eligibility. *Amounts include $20 disregard

34. MassHealth Buy-In Programs Medicare Savings Program (MSP) (cont.) • Both Buy-In programs cover Part B premium only • Members deemed eligible for LIS • Can complete MassHealth Buy-In (MHBI-1) application for SLMB or QI1 (or senior MH application [SACA-2] to screen/apply for other programs such as HSN)

35. MassHealth Frail Elder Waiver/AKA Home and Community-Based Waiver/ Spousal Waiver Program • People 60 and over eligible if: • Income no higher than $2,199/mo (300%SSI) • Assets in applicant’s name $2,000 or less • Note: Will waive income/assets of spouse • Meet clinical eligibility (screening done by ASAP Coordination of Care Unit) • Receiving homecare (ASAP) service

36. MassHealth Frail Elder Waiver Program (cont.) • Coverage: • MassHealth Standard • Deemed eligible for LIS • No co-pay for drugs • Increased homecare services Note: May not pay Medicare Part B premium Need to Complete SACA-2 application

37. MassHealth Health Safety Net • Medicare beneficiaries 65 and over are eligible if: • Income no higher than 200% FPL for full HSN benefit: • $1,962 –Individual/$2,655 – Couple Between 200-400% for partial HSN benefit (would have to meet a deductible* with 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 • 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-2 application

38. Long-Term Care MassHealth/Medicaid • No income eligibility – member pays all but $72.80/month (PNA – Personal Needs Allowance) of income to NH • 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 • Not have a disqualifying transfer of assets *Note: Term life policy has no cash surrender and not a countable asset by MH

39. Long-term Care MassHealth/Medicaid (cont.) • If married, at home spouse can retain $119,220 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-2 & Long-Term Care Supplement

40. MassHealth CommonHealth: Under 65 • People under 65 with a disability eligible if: • Not eligible for MassHealth Standard • Eligible for MH Standard if income 138% FPL [MAGI] or less • Income over 138% FPL (MAGI) - $1,367-Indiv./$1,843-Couple • No asset test for any MH program for under 65 (exception: Frail Elder Waiver) • No income cap in these situations: • Work at least 40 hours/month or • Meet one-time deductible/spend-down • May have premium for CommonHealth if income over 150% FPL • May not pay Part B premium if do not meet eligibility for Buy-In Need to complete MassHealth ACA-3 application Note: Receive coverage similar to MH Standard

41. MassHealth CommonHealth Over 65 • People over 65 with a disability only eligible if: • Not eligible for MassHealth Standard • Work 40 hours/month – no income cap • No Asset test for over 65 for CommonHealth • With Medicare & CommonHealth, deemed eligible for LIS • May not pay Part B premium if do not meet income eligibility for Buy-In Program (140% MAGI) • May have premium for CommonHealth if income over 150% FPL • Need to complete MassHealthACA-3 application Note: Receive coverage similar to MH Standard

42. 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 who accept MassHealth 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

43. Senior Care Options Plan(SCO) • Managed care plan for individuals age 65 and over who have MassHealth Standard and Medicare or just MassHealth Standard – 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 • Some additional coverage benefits: • No monthly premium • No co-pays for drugs • Comprehensive dental

44. Prescription Advantage • Acts as secondary payer to Part D plan • Don’t need Part D to enroll but no benefit until have Part D • No cost to join for most income categories (S0-S4) • Provides help to LIS “partials” (150% FPL) immediately– Would be Category S1 • Helps with co-pays during the $74 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 $3,310)

45. Prescription Advantage (cont.) • Provides help with co-pays to category S5once hit PA’s out-of-pocket spending limitas PA member($3,530) • Provides members a SEP to join or switchPart D plan (once per year) outside of open enrollment • 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 if not on Medicare

46. Eligibility for Prescription Advantage (PA) • Medicare beneficiaries 65 and older with annual gross incomes no higher than: • Single $59,400 – ($4,950/month) • Married $80,100 – ($6,675/month) • Note: MassHealth members are not eligible • Under 65/Medicare with disability must meet income of 188% FPL $1,861/mo – Individual $2,510/mo – Couple(S2 Category) • 65 and over not entitled to Medicare may have PA as primary drug plan Note: Assets not counted

47. VA Health Plan • Provides health care to veterans only • VA Rx coverage considered creditable • Can also enroll in Pt. D but not required • Note: Would need a SEP (such as Prescription Advantage) to join outside of Open Enrollment • Medicare enrolled vet can receive care either from VA or Medicare – cannot receive care under both at same time • Good idea to have coverage outside of VA for emergency

48. Client Contact Form • All sections of CC form need to be completed • All programs/plans discussed should be checked • Any information/assistance about benefit programs (MH Buy-In, MassHealth, Prescription Advantage, etc.) which enabled client to access a program either with you or on his/her own should be recorded in the Potential Financial Assistance Provided section of the form • Note: Clients eligible for a Buy-In Program would have income under 150% and below LIS Asset Limits (See Client Monthly Income/Client Assets category on Client Contact Form) • CC forms should be sent to the regional office on the first of the following month

49. SHINE Program Policies/Procedures • Maintain client confidentiality – share client information with SHINE staff only and in a private setting • Avoid conflict of interest – no financial interest by counselor or family member in company that provides/sells drug coverage or health insurance • Provide information to empower clients to make their own choices about health insurance

50. The End – Yeah!