Day 8 Other Health Insurance Options

1. Day 8Other 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-2 (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 • 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 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 Part A covered services for active employees, EXCEPT… • Medicare is the primary payer for active employees who work for an employer with fewer than 20 employees or fewer than 100 if beneficiary has a disability • In these situations, beneficiary 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 • Coverage under COBRA does NOT prevent the Part B penalty (not ACTIVE employment)

16. 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

17. Veteran’s Health Administration • Uniform Benefits Package • Standard health benefit plan available to all veterans • Eligibility • All honorably discharged veterans who meet the eligibility criteria are eligible for health care and in most instances 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

18. Veteran’s Health Administration, cont. • Uniform Benefits Package 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

19. TRICARE • Managed health care program for Active Duty, Activated Guard and Reserves, Retired members of the uniformed services, their families, and survivors • 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

20. TRICARE, cont. • Benefits  • All Medicare covered benefits • All TRICARE covered benefits  • TRICARE coordinates benefits with Medicare • Medicare will pay first for all Medicare covered services and TRICARE will be secondary payer • TRICARE will pay all co-pays and deductibles • Prescription Coverage • TRICARE IS considered creditable coverage so beneficiaries are NOT required to enroll in Part D

21. TRICARE For Life (TFL) Type of TRICARE supplement plan provided automatically to all those in TRICARE who have Medicare Parts A and B 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

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. 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 Uniform Benefits Package and what benefits does it provide? Which VA programs provide prescription coverage that is creditable?

24. Case Study 1:Hal O. Jenn • Hal calls you to find out what he should do about the Medicare Prescription Drug Program. He has a Supplement 1 Medigap insurance and gets his prescriptions from the VA. His friend told him that since he didn’t join a Part D plan, he should join Prescription Advantage to cover the drugs that the VA might not cover. Hal tells you that his monthly income is $1500, and he can’t afford another premium. • How would you help him?

25. Case Study 2:Jen R. Ate • Jen calls you at the SHINE office. Her company is downsizing and she will be laid off at the end of the month. She is 64 and will turn 65 in 6 months. She understands that she can remain on COBRA for 18 months and then sign up for Medicare. She takes several expensive medications and wants to stay on COBRA as she’s heard the Medicare Prescription Drug Program doesn’t cover all drugs. • How would you help her?

26. Case Study 3:Kara Sell • Kara Sell calls to inquire about her Medicare coverage for foreign travel. She tells you she is new to Medicare and is not sure what it covers. She explains that she is planning a trip to Europe and wants to know if her Medicare will cover her if she gets sick. • How would you help her?

27. Case Study 4:Kim O. Know • Kim is married. She and her spouse are finding it hard to keep up with their expenses. She wonders if there is any way to cut down on their health care costs. She tells you that they are both on Tufts Medicare Preferred HMO Prime with prescription coverage with a premium of about $150/month each. During the process of gathering the information you need, she tells you that they each get Social Security and their combined income is $1878/month. They live in their own home; have some savings but no income other than Social Security. • How would you help her?

28. Case Study 5:Herb O. Side • Herb is 67 years old and will be retiring in a few months. He has been fully covered by his employer coverage and never applied for Medicare. He knows he can have COBRA for a period of time after he retires. He plans on traveling a great deal for a couple of years after retirement and is glad he’ll continue to have the comprehensive coverage COBRA provides. Herb is nervous about Medicare and doesn’t think the coverage will be as good as what he’s had through the employer plan. His health is good although he takes several brand medications which he knows would be costly without his insurance. He tells you his income after retirement will be just under $30,000/year. • How would you help him?

29. Case Study 6:Tom E. Gunn • Tom has a question about his Medicare HMO Blue Plus Rx plan. He was hospitalized last month in his local hospital. He received a bill that he owes for his hospital stay. He called the hospital but was referred to Blue Cross. The customer service rep at Blue Cross told him he is responsible for the bill. He thinks it’s incorrect. He tells you he already finds it difficult to meet his monthly expenses on his Social Security check of $1500 without additional surprise bills. • How would you help him?

30. Case Study 7:Paul Loot • Paul and his wife, Sally, meet with you on March 10th to discuss their insurance. They were both covered under his employer plan. He is 67 and has Medicare Part A only. He was just laid off from his job but the employer will pay for COBRA for both of them until the end of the year. Sally will turn 65 in February and pay for COBRA herself for January. • What questions would you ask Paul & Sally? • What information would you review with them? • What materials would you give them? • Would you refer them to any other agency? If so, which one(s)? • What phone calls, if any, would you make on their behalf? • What follow-up, if any, is required in this case?

31. Case Study 8:Perry Winkle • Perry calls you for help with his Part D coverage. He tells you he is enrolled in a Medicare Advantage plan. He joined a plan that provides coverage for generics in the gap even though it is more expensive, as most of his drugs are generic. He wants to join another plan. He tells you his monthly income is a Social Security check of $1530. He lives in his own home and can’t afford additional costs for medication. • How would you help him?

32. Case Study 9:Sam Antics • Sam calls you to get information about Medicare for himself and his wife. Sam will turn 65 in 2 months and will be retiring. He tells you that his retirement income of Social Security and a pension will be $4,500/month. He has already signed up for Medicare A+B, a Medicare supplement plan and a Part D plan. His wife is 61 and never worked outside the home. He recently heard that she can get Medicare under his benefit. He wants to know if she can join when he becomes eligible. If not, he wants to know what her options are for health insurance coverage. • How would you help him?

33. Case Study 10:Hank R. Chiff • Hank meets with you at the SHINE office. He is very upset over what he’s heard about the Medicare drug program. He is a veteran and currently gets his medication through the VA Health Plan. A friend told him that he should have joined the Medicare drug program during the first enrollment period and that he will now have to pay a penalty to join. He tells you that his only income is his Social Security check of $1050/month. He explains that he owns his home and a car and has dipped into his savings (currently approximately $15,000) at times to help pay his living expenses and his Medigap premium of over $180/month. • How would you help him?