Health Benefits University

1. Health Benefits University LOCATION

2. Agenda • What is SHINE? What is Medicare? • How does a person get Medicare? • What does Medicare cover? • What about additional coverage? • Medicare Advocacy Project • Prescription Advantage • What public assistance benefits are available?

3. What is SHINE?

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

5. What does a SHINE Counselor do? • Provides free, and 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

6. What is Medicare?

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

8. Parts of Medicare Part A Hospital coverage Inpatient hospital and skilled nursing care (rehab.) Part B Medical coverage Outpatient doctor visits and other services Part D Prescription drug coverage Parts A & B are often referred to as “Original Medicare”

9. Medicare Eligibility Age 65+: Entitled to Social Security and paid Medicare Tax (for 40 credits/quarters), or Entitled to Railroad Retirement Act retiree benefits, or Be a spouse or ex-spouse* of someone who qualifies for Social Security or Medicare *To qualify for Medicare through an ex-spouse, the marriage must have lasted at least 10 years

10. Medicare Eligibility Under 65: Entitled to Social Security Disability Insurance (SSDI) for 24 months, or Entitled to SSDI and have ALS, ESRD, or certain other disabilities

12. Medicare Enrollment Periods • Individuals may only enroll into Medicare at prescribed times—called Enrollment Periods • Four types of Enrollment Periods • Initial Enrollment Period (IEP) • General Enrollment Period (GEP) • Open Enrollment Period (OEP) • Special Enrollment Period (SEP)

13. Initial Enrollment Period Can enroll in Parts A, B, C, and D Seven month window around the month in which a person becomes entitled to Medicare If 65+, one’s IEP is the 7 month window around the month he/she turns 65 If under 65, one’s IEP is the 7 month window around the 25th month of SSDI entitlement The month in which one enrolls determines the coverage start date

14. Initial Enrollment Period

15. General Enrollment Period Can enroll into Part B January 1 – March 31, every year Coverage begins July 1

16. Open Enrollment Period Can enroll or disenroll from Parts C and D Can change from one plan to another October 15 – December 7, every year Coverage starts the following January 1

17. Special Enrollment Periods Can enroll, disenroll, or change Parts C or D Part B Special Enrollment Period when leaving active employment Must be triggered by qualifying events or circumstances Can occur anytime throughout the year due to the circumstance of the event

18. Common Parts C & D Special Enrollment Periods

19. Enrollment Periods

20. Late Enrollment Penalties A surcharge may be applied to Medicare premiums if a beneficiary did not enroll during the prescribed enrollment period, called a Late Enrollment Penalty (LEP) Penalties apply to Part B & D and for Part A voluntary enrollees (not premium free)

21. Part B Special Enrollment Period Can delay enrollment into Part B without a late enrollment penalty if actively working (or spouse is actively working) and covered by an employer group health plan If employer group health plan ends, the beneficiary must enroll into Part B within 8 months in order to avoid the LEP

22. Employer Group Health Plan • If continue employment (client or spouse) with health coverage beyond 65, may take Part A and delay Part B • Under 20 employees, Medicare may be primary and need to enroll in Part B: Must check with employer • Must enroll in Part B within 8 months of end of active employment to avoid penalty= SEP • Penalty of 10% of current premium for every 12-month period of delayed enrollment • Coverage under COBRA does NOT provide a SEP or protect one from B penalty

23. Part D Late Enrollment Penalty Assessed if beneficiary does not enroll in Part D during Initial Enrollment Period Amount is based on the length of time the person went without Part D Equals 1% of the current Part D National Base Premium for every month the person could have had Part D but did not enroll Lifetime penalty—is added to the person’s Part D premium for the rest of his/her life

24. Waiving the Part D Penalty A person can delay enrollment into Part Dwithout a late enrollment penalty if she 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

25. What does Medicare Cover?

26. 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

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

28. Part B Coverage Physician services Outpatient therapies Outpatient hospital services Medical equipment and supplies Ambulance Preventive service

29. Part B Preventive Services • Mammograms • Some pap smear and pelvic exams • Colorectal screenings • Diabetes self-management training/tests • Bone mass measurements • Prostate cancer screening • Depression screening • Obesity screening and counseling • Alcohol misuse and counseling • Annual Wellness Visit • Update individual’s medical and family history • Record height, weight, BMI, blood pressure, and other routine measurements • Provide personal health advice and coordinate appropriate referrals and health education

30. Part B Preventive Services • Most preventive services are not subject to • Deductible • 20% co-insurance • Free Annual Wellness Visit • Not a physical exam • Services provided beyond scope of this visit may be subject to deductible and/or co-insurance

31. Part D Coverage • Began January 1, 2006 • 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)

32. Part D Coverage • Each plan must follow a standard benefit structure set forth by Medicare • Costs vary by Part D plan • Premiums • Deductibles • Co-pays • Coverage varies by Part D plan • Formularies • Drug restrictions

33. Part D Standard Benefit A beneficiary advances into the next coverage phase when his/her drug costs reach certain limits. These limits change annually. Due to the Affordable Care Act, the coverage gap is gradually being eliminated. By 2020, the coverage gap will not exist.

35. What additional coverage is available?

36. 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

37. Medicare Choices 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)

38. 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

39. 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 • Handout: Medicare Supplement (Medigap) Plans, Massachusetts

40. Medicare Choices 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 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 usually charge additional premiums and copays May be restricted to networks and require referrals

42. 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

43. Medicare Advantage Plan Types Health Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) Private Fee-For-Service (PFFS) Special Needs Plans (SNP)

44. Medicare AdvantageEnrollment & Disenrollment • Initial Enrollment Period • Open Enrollment Period • Special Enrollment Period • Medicare Advantage Disenrollment Period • January 1 – February 14 • Can disenroll from an MA plan and revert to Original Medicare

45. Important Questions to Consider • Do doctors and hospitals accept the plan? • How much are the copays? What is the out-of-pocket maximum for the year? • In general, the lower the monthly premium, the higher the copays • Are medications on the plan’s formulary and how much do they cost • May cost more in Medicare Advantage plan

46. Medigap vs. Medicare Advantage

47. 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

48. SHINE HBU Medicare Advocacy Project (MAP)

49. What Does MAP Do? Provides advice/free legal representation to Massachusetts Medicare beneficiaries Serves elders and persons with disabilities who are enrolled in either original Medicare, a Medicare Advantage Plan or a Medicare Prescription Drug Plan Offers public education and training on Medicare issues, including updates on changes in the Medicare program Works on pertinent systemic issues

50. Medicare Advocacy Project • MAP helps with • Medicare A, B, C and D coverage issues • Medicare onset dates and premium penalties • MAP's “bias” is insuring that Massachusetts beneficiaries receive all the Medicare and Medicare-related health coverage to which they are entitled