Day 1 SHINE Program Certification Training

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Day 1SHINE ProgramCertification Training
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SHINEServing the Health Insurance Needs of
Everyone(on Medicare)

• Started in Massachusetts 1985
• Part of national SHIP State Health Insurance
  Assistance Programs

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Program Structure

• Executive Office of Elder Affairs
• State SHINE Director Cindy Phillips
• Assistant Director Barbara Deveau
• Field Operations Manager/Trainingng Coordinator
  Annie Toth
• Program Coordinator TBD
• 14 Regional Programs throughout the state
• Based at ASAPS and/or Councils on Aging
• Regional Director and staff
• Counselors at local sites

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Goal

• Ensure that Medicare beneficiaries have access to
  accurate, unbiased information regarding health
  insurance and health care options
• Educate beneficiaries about available benefit
  programs
• Advocate on behalf of beneficiaries to ensure
  they receive benefits to which they are entitled

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SHINE Counselors

• Assist beneficiaries and their families in
  understanding Medicare coverage options and
  MassHealth programs and benefits
• Screen for public benefit programs and assist
  with applications
• Advocate with and for beneficiaries to resolve
  issues with Medicare, MassHealth and other
  insurance-related programs

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Training

• Certification training
• Mentoring
• Monthly training meetings
• October Review and training for Medicares
  annual Open Enrollment
• Recertification review every spring

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Counselor Support

• Regional Office
• Regional Program Colleagues
• SHINE Counselor Website
• shinecounselor.800ageinfo.com
• Common Resources
• SHINE newsletter The Beacon

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Medicare Part A Part B
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Medicare

• Federal health insurance program for
• Individuals age 65 and over
• Individuals under age 65 with a disability
• Never intended to cover 100 of healthcare costs
• Provides coverage for services which are
  reasonable and medically necessary for the
  treatment and diagnosis of an illness or injury

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Eligibility

• Age 65
• U.S citizen/lawfully permitted resident for 5
  years
• Earned 40 credits under Social Security (10
  years)
• Be spouse or ex-spouse (marriage lasted at least
  10 years)
• Under Age 65
• On SSDI for 24 months
• Individuals with ESRD (End Stage Renal Disease)
• Individuals with ALS (Amyotrophic Lateral
  Sclerosis Lou Gehrigs Disease)
• FYI Increase in age for full Social Security
  benefits does NOT affect Medicare

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Enrolling in Medicare

• Enrollment through Social Security
• Medicare administered by CMS
• Need to contact SS to enroll in Medicare if not
  yet collecting SS benefits
• Can delay enrolling in Part B if individual or
  spouse still working and covered under employer
  group health plan
• Once coverage ends under active employment, have
  8 months to enroll in B without a penalty
• Note The 8-month special enrollment period
  rules do not apply if employment or Employer
  Group Health Plan (EGHP) coverage ends during the
  Initial Enrollment Period

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Enrollment Types

• Standard Age 65 not collecting Social Security
• Contact SS to enroll or enroll online
• 7-month window (Initial Enrollment Period)
• Automatic Already receiving SS or on SSDI
• On SS receive enrollment notice 3 mos. Before
  65
• On SSDI eligible on month 25 of receiving SSDI
  receive notice approximately 3 mos. prior
• Voluntary Not eligible for premium-free Part A

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Enrollment Periods

• Initial Enrollment Period (IEP) 7 months
  surrounding 65th birthday month (month earlier if
  birthday on 1st of month)
• Date of enrollment determines effective date of
  Medicare
• Special Enrollment Period (SEP) 8 months
  following loss of coverage from active
  employment (individuals or spouses) COBRA
  coverage is not active coverage
• General Enrollment Period (GEP) Jan 1st Mar
  31st of each year (Voluntary and late enrollees)
  
• July 1st effective date

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Initial Enrollment Period When Coverage Starts
If beneficiary enrolls in this month of IEP Medicare Part A B Coverage Starts
1 The month beneficiary becomes eligible for Medicare
2 The month beneficiary becomes eligible for Medicare
3 The month beneficiary becomes eligible for Medicare
4 Folowing month after beneficiary enrolls
5 Two months after beneficiary enrolls
6 Three months after beneficiary enrolls
7 Three months after beneficiary enrolls
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Special Enrollment PeriodDelaying Part B

• Beneficiaries may choose just Medicare Part A
  while ACTIVELY working or covered under a spouse
  who is ACTIVELY working
• Note If delay Part B and no coverage under
  active employment, could only enroll during
  General Enrollment Period and would be subject
  to late enrollment penalty
• Once ACTIVE employment coverage has ended, must
  take Part B coverage within 8 months to avoid a
  penalty
• If employer has lt20 employees or lt100 employees
  if beneficiary has a disability, then the
  individual may need Part B because Medicare
  should pay first and Employer Group Health Plan
  (EGHP) second
• Beneficiaries should confirm with their employer
  if Part B is needed

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Initial Enrollment Example

• Mr. Kaplan is turning 65 on August 29th. His
  first opportunity to enroll in Medicare based on
  his age (not disability) is May 1st . His
  initial enrollment period lasts until November
  30th. The month he enrolls determines the
  effective date of coverage

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Special Enrollment Example

• Mrs. White continued working after age 65 and was
  covered by an employer-related group medical
  plan. She chose to enroll in Part A when she
  turned 65 (because she does not have to pay a
  premium) but delayed Part B enrollment. Her
  Special Enrollment Period will be the 8 month
  period following the month she is no longer
  covered by her employers plan or her employment
  ends, whichever comes first

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Consolidated Omnibus Budget Reconciliation Act
(COBRA)

• When employment and/or EGHP ends, individual can
  elect COBRA coverage which continues health
  coverage through employers plan (in most cases
  for only 18 months) and probably at a higher cost
• If elect COBRA, should NOT wait until COBRA ends
  to enroll in Medicare or will pay a late
  enrollment penalty and will have to wait until
  the next General Enrollment Period to enroll
• Must sign up for B within the first 8 months (SEP
  after ACTIVE work) of COBRA to avoid penalty
• Should enroll in Part B because Medicare pays
  first and COBRA pays second
• COBRA may not provide coverage if individual does
  not have Medicare

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Medicare Premiums

• Individuals or their spouses who have paid into
  the Medicare Program and worked at least 40
  quarters DO NOT pay a Part A premium referred
  to as Premium-free Part A
• Everyone pays a Part B premium
• Benefit programs are available to pay the premium
  for eligible beneficiaries
• Part B premiums are deducted from the Social
  Security check
• If not collecting Social Security, beneficiary
  will be billed every 3 months
• If collecting a federal pension and not SS, Part
  B premiums can be deducted from pension
• Part A B premiums may change annually

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Part A and B Premiums

• Part A
• People who dont qualify for premium-free
  Medicare may enroll voluntarily (during Generla
  Enroll and pay a monthly premium for Parts A B
• Part A Premiums
• See Current Medicare Premiums Chart
• Part B
• Premiums based on annual income (past 2 years tax
  returns)
• Increases with higher income
• See Current Medicare Premiums Chart

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Late Enrollment Penalty

• Penalty for Part A Capped at 10 of premium
  and goes away after penalized for twice the
  length of time the person delayed enrollment
• Only for voluntary enrollees (paying for A) who
  dont enroll in Part A when initially eligible
• Penalty for Part B 10 of premium for each full
  12 month period the individual delayed enrollment
• Penalty for Part B not capped and is a lifetime
  penalty except
• Under 65 beneficiaries with a penalty will have
  the penalty removed and will have a clean slate
  when they turn 65

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Late/General Enrollment Example

• Mr. Santos retires at age 65 and declines
  Medicare Part B. At age 70, Mr. Santos wants to
  purchase Part B. He must wait until the General
  Enrollment Period (January 1st - March 31st ) for
  coverage that begins the following July. Mr.
  Santos will have a 50 penalty added to his Part
  B premium (10 for each 12 month period he
  delayed Part B enrollment)

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Example of Part B Penalty for Mr. Santos
ENROLLMENT YEAR MONTHLY PREMIUM PENALTY (10 penalty per year times the number of years enrollment was delayed, 5 for Mr. Santos)50 TOTAL PART B COST FOR MR. SANTOS
  Year 1   104.90   (104.90 x 50)52.45   157.35
Year 2 106.00 (106.00 x 50)53.00 159.00
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Four Parts of Medicare

• FYI Part A B called Original Medicare

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Original Medicare

• Health care insurance run by the federal
  government
• Provides Part A and/or Part B coverage
• See any doctor or hospital that accepts Medicare
• Beneficiary pays
• Part B premium (Part A is usually premium free)
• Deductibles, coinsurance, or copayments
• Can join a Part D plan to add drug coverage

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Medicare Part A(Hospital Insurance)
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Medicare Part A (Hospital Insurance)

• Part A Covers
• Inpatient hospital care
• Care in a skilled nursing facility (SNF)
• Home health care
• Hospice care
• Blood
• See Part A Benefits and Gaps for current costs

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Inpatient Hospital Coverage

• Covered days in a hospital
• 90 renewable days
• Medicare pays 100 for days 1-60 in a benefit
  period AFTER beneficiary pays Part A deductible
• Daily co-payment for days 61-90 in a benefit
  period
• 60 non-renewable days
• Daily co-payment for days 91-150 (lifetime
  reserve days)

• A benefit period is a period of time that
  Medicare pays for a persons care in a hospital
  or SNF. It begins when a beneficiary goes into
  the hospital and ends when she/he has been out of
  the hospital or skilled nursing facility for 60
  consecutive days

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Inpatient Hospital Coverage

• Inpatient hospital coverage requirements
• Doctor determines it is medically necessary
• Care requires being in a hospital
• Hospital participates with Medicare
• Utilization Review Committee of the hospital
  approves the stay

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Inpatient Hospital Covered Services

• Some services covered during a hospital stay
• Semi-private room and all meals
• Special care units
• General nursing services
• Drugs administered in the hospital
• Lab tests
• Radiology services
• See manual for complete list

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Inpatient Hospital Services NOT Covered

• Services NOT covered during a hospital stay
• Physician services (Covered under Part B)
• Personal convenience items
• Private room (unless medically necessary)
• First three pints of blood
• Private duty nursing

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Hospital Coverage

• Other hospital coverage
• Care in a psychiatric hospital
• 190 lifetime days for Inpatient care
• Care in a foreign hospital
• Medicare usually does NOT pay for care outside
  the United States
• Medicare MAY pay for qualified care in a Mexican
  or Canadian hospital under special conditions

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Skilled Nursing Facility (SNF) Coverage

• Must be a Medicare participating facility
• Physician must certify that patients needs and
  receives daily skilled care from RN or therapist
• Prior Inpatient hospital stay of 3 days or more
  (72 hours as an admitted patient)
• An overnight stay doesnt always mean an
  Inpatient day (can be observation day)
• Break in skilled care that lasts more than 30
  days will require a new 3 day hospital stay to
  qualify for additional SNF care
• Admitted to SNF within 30 days of discharge from
  hospital

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SNF Covered Days

• 100 renewable days
• Days 1-20 Medicare pays 100 in a benefit period
• Days 21 100 Daily co-payment
• See Medicare Part A Benefits and Gaps

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SNF Coverage

• Services covered
• Semi-private room
• Meals (including special diets)
• Nursing Rehabilitation services
• Drugs furnished by the SNF
• Use of medical equipment and supplies
• Services not covered
• Physician services
• Private room (unless required)
• Personal convenience items

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Medicare Part A Benefit Period Example

• Benefit period Example 1
• Mr. Jones has Medicare A B. He is
  hospitalized as an Inpatient on January 5th and
  remains in the hospital until January 12th. Mr.
  Jones has used 8 of his hospital days in the
  benefit period. (Day of discharge does not
  count.) Mr. Jones has 82 hospital days left in
  the benefit period
• How much would Mr. Jones have to pay for his
  hospital stay?

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Medicare Part A Benefit Period Example

• Benefit period Example 2
• Mr. Jones is discharged from the hospital on
  January 12th and transferred to a SNF where he
  remains until February 9th. Mr. Jones used 28
  days of his SNF benefit. He has 72 days left
• How much would Mr. Jones have to pay for his
  Skilled Nursing Facility care?

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Home Health Benefit

• Home health benefit coverage requirements
• Must need skilled care on intermittent basis
• Home health agency must be Medicare-approved
• Physician must authorize treatment and have
  face-to-face meeting with beneficiary prior to
  start
• Beneficiary must be homebound (see manual)
• Medicare pays 100 for all covered and medically
  necessary home health services (see manual for
  covered services)
• EXCEPTION Medicare pays 80 of durable
  equipment

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Hospice

• Hospice Coverage
• Physician must certify that beneficiary is
  terminally ill and expected to live 6 months or
  less
• Beneficiary has elected to receive comfort and
  pain relief care from Hospice instead of medical
  treatment for cure
• Care is provided by Medicare certified hospice
  program

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Utilization Review Committee

• Reviews patient stays in hospitals and SNFs to
  determine if patient meets Medicare standard for
  needing care in hospital setting
• Each patients doctor must satisfy the
  Utilization Review Committee (URC) that patient
  meets admission criteria and continues to need
  acute hospital level of care
• Has authority to terminate Medicares obligation
  to pay for medical services in hospital or SNF
• Determines patient time of discharge

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Medicare Part A Review

• Review
• What are the two major federal agencies involved
  with the Medicare Program and what is each of
  their roles?
• Who can enroll in Medicare?
• When can someone enroll in Medicare?
• Does someone have to enroll in both parts of
  Medicare (A B)?
• What is a benefit period?

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Medicare Part B (Medical Insurance)
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Medicare Part B (Medical Insurance)

• Physicians Services
• Outpatient hospital services
• Durable medical equipment
• Prosthetics, orthotics, and supplies
• Ambulance
• Home health care (if not Part A)
• Blood (if not Part A)

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Medicare Part B Important Terms

• Medicare approved amount Fee Medicare sets for
  Medicare covered service
• Excess charges Amount owed by beneficiary above
  the Medicare approved amount. In other states,
  there is a limit on excess charges of 15
• Ban on Balanced Billing Massachusetts has a law
  prohibiting excess charges by physicians
• Accepting Assignment Accepting the Medicare
  approved amount as payment in full
• Participating Provider Signing an agreement
  saying provider agrees to accept assignment for
  all beneficiaries in all cases (non-participating
  less important in MA)

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Part B Cost Coverage

• Monthly Part B Standard Premium
• See Medicare Premiums Chart
• Annual Deductible
• See Part B Benefits and Gaps
• Medical/Physician Services (See manual)
• Note No coverage for routine care with the
  exception of the Welcome to Medicare Exam
• and Annual Wellness Visit

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Sample of Medicares Preventive Benefits

• Bone mass density testing
• Annual prostate cancer screening test
• Colorectal cancer screening
• Blood sugar testing equipment and training for
  managing diabetes
• Immunization (flu, pneumonia and hepatitis B)
• Annual Screening Glaucoma Screening for people at
  high risk
• Cardiovascular Screening Blood Tests
• Diabetes Screening Tests
• See Medicare Part B Preventive Services for
  complete list

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Ambulance Coverage

• Medicares coverage for ambulance services is
  limited and generally only covers when transport
  in another vehicle would endanger health
• Medicare does not provide coverage for
  transportation in a chair car

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Durable Medical Equipment (DME)

• Medicare helps pay for DME if
• It is prescribed by a physician
• It is medically necessary
• It fills a medical need (more than convenience)
• It is appropriate for use in the home
• It can be used over and over again

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Durable Medical Equipment

• What Medicare pays for DME
• Medicare pays 80 of Medicare approved amount
• If the supplier accepts assignment, beneficiary
  pays 20
• If supplier does NOT accept assignment,
  beneficiary pays 20 PLUS difference between what
  Medicare approves and supplier charges
• Supplier is required to bill Medicare
• Beneficiary can buy or rent DME

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DMEPOS Competitive Bidding Program

• Program aims to lower payment rates for certain
  medical equipment and supplies through supplier
  competition
• Program available in most counties in
  Massachusetts with the exception of Barnstable,
  Berkshire, Dukes and Nantucket counties
• Original Medicare beneficiary must use Medicare
  contract suppliers for certain competitive bid
  items (ex. hospital beds, wheelchairs, oxygen) in
  order for Medicare to pay
• Beneficiaries enrolled in a Medicare Advantage
  Plan are NOT affected and will continue to use
  suppliers designated by the plan

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DME Counseling Tips

• Encourage clients to
• Make sure the physician fills out a Certificate
  of Medical Necessity
• Ask the supplier if they accept Medicare
  assignment
• If the item is on the DMEPOS list, make sure it
  is ordered from a DMEPOS supplier
• Use Medicare.gov to find a DMEPOS-CBP supplier

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Medicare Part B Review

• Review
• What kinds of services does Part B cover?
• What out of pocket expenses does a beneficiary
  have for Part B services?
• What does accepting assignment mean?
• What is a participating provider?
• What are excess charges?
• What is the Ban on Balanced Billing?

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Case Study 1Hal

• Hal will celebrate his 65th birthday in a couple
  of months. He just received his Medicare Initial
  Enrollment Package from the Social Security
  Administration. While he has a general
  understanding of Medicare Part A, Hal doesnt
  feel well informed about Medicare Part B.
• What information would you provide Hal?

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Case Study 2George Bell

• George Bell is a 64 year old man who will soon be
  reaching his 65th birthday. George is so busy
  with a full-time career that his plans for
  retirement are far in the future. George will
  continue employment with a major corporation
  beyond his 65th birthday.
• What should he do about Medicare enrollment and
  his current group health insurance?

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Case Study 3Agnus

• Agnus is 64 years old and has been divorced for
  15 years. Agnus married soon after high school
  and was a full-time homemaker. Until 5 years ago,
  Agnus had never worked outside the home. For the
  past 5 years she has worked for the Red Dye
  Company. She will be retiring in 4 months when
  she turns 65. The benefits administrator of the
  Red Dye Company told Agnus that she will not be
  eligible for Social Security or Medicare since
  she has not worked for a full 10 years.
• Is this true?
• What would you tell Agnus?

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Case Study 4Sam Pan

• Sam calls for assistance with understanding
  Medicare. He tells you he is 59, has been on
  SSDI for 23 months and will be eligible for
  Medicare in a couple of months. From what he
  could figure out, he understands he can sign up
  for Part A but does not need to enroll in Part B
  at this time because he is covered under his
  spouses coverage. His spouse, John, works
  full-time and has excellent coverage for both of
  them through his employer plan. John is 63 and
  plans to retire in 3 years. They will then have
  the option of the companys retiree coverage, so
  Sam plans to pick up Part B at that time. He
  wants confirmation that hes correct in his
  understanding of Medicare.
• What information would you provide to Sam?

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Case Study 5Leann Washington

• Leann Washington lives in Massachusetts. She goes
  to see Dr. Franklin in her town who does not
  accept assignment. Ms. Washington is required to
  pay the entire bill of 150. When she receives
  the Medicare Summary Notice (MSN), she notices
  that the Medicare approved amount is 100. She
  wants to know what the exact amount is that
  Medicare will pay and the amount that is her
  responsibility? She explains that she has already
  met her Part B annual deductible.
• What would Ms. Washington owe if she lived in
  Florida?

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Case Study 6Mrs. Joan Carroll

• Mrs. Carroll called the SHINE office for help on
  June 1st for help with a problem. Mr. Carroll,
  much to his wifes dismay, refused to sign up for
  Medicare Part B when he was initially eligible.
  He is very proud of the fact that he has only
  spent 1,000 for medical care in the last 3
  years. As he repeatedly told his wife, that is
  cheaper than paying the Part B premium for the
  last 3 years.
• Mr. Carroll now needs to have surgery. His wife
  is beginning to realize some of the problems
  involved as a result of an uninformed decision he
  made three years ago.
• List the problems he now will face

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Case Study 7Ruth Rose

• Ruth Rose comes to see you at the SHINE office.
  She says that she will be 65 in 5 months. She
  will continue to work and is covered by her
  employer group plan. She does not want to sign up
  for Medicare. However, her friend Rhoda told her
  that if he does not sign up now, she will not be
  able to get Medicare later.
• What information would you give her?

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Medicare A/B Quiz

• Describe Medicares Enrollment Types
• List the gaps in Medicare Part B coverage
• Mr. Smith comes to see you at the Council on
  Aging (COA) office. He will be retiring soon and
  living on a limited income. His understanding is
  that he can get by with just Medicare AB
  coverage.
• What would you tell him about having Medicare
  AB only?
• What is the current standard monthly premium for
  Medicare Part B?
• Medicare does cover an annual physical True or
  False

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Homework Assignment

• Call Medicare (1-800-633-4227) with the
  following question
• I (or my client) am having day surgery. What is
  my financial obligation/responsibility?