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Day 1 SHINE Program Certification Training


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Title: Day 1 SHINE Program Certification Training

Day 1SHINE ProgramCertification Training
  • SHINE Serving the Health Insurance Needs of
    Everyone..on Medicare
  • Started in Massachusetts 1985
  • Partially federally funded since 1992
  • Part of national SHIP State Health Insurance
    Assistance Programs

State Organization
  • Executive Office of Elder Affairs
  • State SHINE Director Cindy Phillips
  • Assistant State Director
  • State Field Operations Manager/Training
    Coordinator Annie Toth
  • State Program Coordinator Jessica

Regional Organization
  • Regional SHINE Office
  • Regional SHINE Director
  • SHINE Program Assistant

Overall Goal
  • To ensure that Medicare beneficiaries have access
    to accurate, unbiased information regarding
    health insurance and health care options
  • To help people help themselves

Examples Of What We Do
  • Assist people in understanding their Medicare and
    MassHealth rights and benefits
  • Educate people about all of their health
    insurance options
  • Screen for public benefits (State and Federal)
  • Assist with applications
  • Resolve problems with insurances Medicare,

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

Were Here To Support You
  • Regional Office Staff
  • Director name and phone number
  • Assistant Director name and phone number
  • SHINE Counselor Website
  • Common Resources
  • SHINE newsletter The Beacon

Medicare Part A Part B
  • Federal health insurance program for
  • Individuals age 65 and over
  • Individuals under age 65 with a disability
  • Enacted into law 1965, Title XVIII of the Social
    Security Act Effective July 1st , 1966
  • Entitlement program
  • Never intended to cover 100 of healthcare costs
  • NOT a comprehensive health insurance program

  • Medicare only pays for services which are
    reasonable and medically necessary for the
    treatment and diagnosis of an accident or illness
  • Even when medically necessary, there are gaps
    in Medicare coverage and the beneficiary must pay
    a portion of the medical expenses

Federal Agencies Involved With Medicare
  Department of Health and Human Services (DHHS) Administers Medicare through its divisions, CMS and SSA     Department of Health and Human Services (DHHS) Administers Medicare through its divisions, CMS and SSA  
Centers for Medicare Medicaid Services (CMS) Determines policy Budgets for Medicare Issues regulations Sets provider fees Establishes agreements with contractors Social Security Administration (SSA) Processes Medicare applications Issues Medicare cards Provides public information Determines entitlement to Medicare benefits  
Medicare Card
  • Each Medicare Claim Number is unique to the
  • The number has nine digits and a letter
  • Card lists effective dates for Part A Part B

Medicare Claim . Letter attached to the claim
indicates how the individual qualifies for
Part A B Effective Dates
Four Parts of Medicare
  • FYI Part A B called Original Medicare

Original Medicare
  • Health care option 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

Eligibility 65
  • Age 65
  • Must be U.S citizen/lawfully permitted resident
    for 5 years
  • For premium-free Part A (entitled to Medicare),
    must qualify under ONE of the following 3
  • Be entitled to receive Social Security benefits
    and contributed to the Medicare Tax (having
    earned 40 credits from about 10 years of work)
  • Be entitled to receive Railroad Retirement Act
    retiree benefits
  • Be a spouse or ex-spouse (marriage lasted at
    least 10 years), widow or widower (age 65) of a
    person who qualifies for Social Security or
    Medicare benefits
  • FYI Increase in age for full Social Security
    benefits does NOT affect Medicare

Eligibility Under 65
  • Under 65
  • Individuals of any age entitled to Social
    Security (SSDI) or Railroad Retirement Disability
    Insurance benefits for 24 months
  • Individuals with ESRD (End Stage Renal Disease)
  • Individuals with ALS (Amyotrophic Lateral
    Sclerosis, aka Lou Gehrigs Disease)

Enrolling In Medicare
  • Social Security processes Medicare applications
  • Common myth that Medicare will know when a person
    turns 65. This is NOT TRUE, unless the person is
    already receiving Social Security benefits
  • A person must notify Social Security of their
    intent to enroll in Medicare
  • Medicare and Social Security are two entirely
    separate entitlement programs

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
  • This is called premium-free Part A
  • Most people pay a Part B premium
  • Benefit programs available to pay for the premium
    for low-income beneficiaries
  • Part B premiums are often deducted from the
    Social Security check
  • If not collecting Social Security, will be billed
    every 3 months
  • Part A B premiums may change annually

2014 Part A and B Premiums
  • Part A
  • People who dont qualify for premium-free
    Medicare may enroll voluntarily and pay a monthly
    premium for Parts A B
  • Part A Premiums
  • 0-29 work quarters 426/month
  • 30-39 work quarters 234/month
  • Part B
  • Premiums based on annual income (past 2 years tax
  • Standard amount Ind lt 85,000 married lt
    170,000 104.90/month
  • Increases with higher income

Three Enrollment Types
  • Automatic Enrollment
  • Standard Enrollment
  • Voluntary Enrollment

Automatic Enrollment
  • For individuals already receiving Social Security
  • Beneficiary receives automatic enrollment notice
    3 months before 65th birthday month (4 months
    before if birthday on 1st of month - Medicare
    begins 1st of month prior to birthday month)
  • Individuals with a disability become eligible 24
    months after Social Security Disability payments
    began and receive notice about 3 months before
    25th month of disability benefits
  • Individual must sign and return card if she/he
    does NOT want Part B

Standard Enrollment
  • Individuals not yet collecting Social Security
    benefits prior to age 65 MUST NOTIFY Social
    Security of intent to enroll in Medicare
    (enrollment is NOT automatic)
  • Initial Enrollment Period (IEP) 7 month period
    encompassing the full 3 months preceding persons
    65th birthday, month of 65th birthday, and the
    full 3 months following the 65th birthday (month
    earlier if birthday on 1st of month)
  • Must sign up during the first 3 months of IEP to
    get Part A/B coverage effective 1st of birthday
  • If individual waits to sign up until last four
    months of IEP, Part B start date will be delayed

Voluntary Enrollment
  • For individuals who dont have sufficient Social
    Security work credits (40 quarters/10 yrs)
  • Can purchase Part A
  • Must be an American citizen OR an alien lawfully
    admitted for permanent residence and resided in
    US for 5 consecutive years
  • Can purchase Part A AND Part B OR Part B only
  • CANNOT have Part A alone as a voluntary enrollee
  • Having Part B only does NOT meet the minimum
    essential coverage requirement under the
    Affordable Care Act and beneficiary may have to
    pay a penalty

Three 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
  • Special Enrollment Period (SEP) 8 months
    following loss of coverage from active
    employment (individuals or spouses)
  • General Enrollment Period (GEP) Jan 1st Mar
    31st of each year
  • July 1st effective date

Initial Enrollment Period
Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th Enrollment Period Ex. Birthday is July 4th
If you enroll during If you enroll during If you enroll during 3 months before the birthday month 3 months before the birthday month 3 months before the birthday month Month of birthday   3 months after the birthday month 3 months after the birthday month 3 months after the birthday month 3 months after the birthday month 3 months after the birthday month    
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
Delaying Part B Enrollment
  • Beneficiaries may choose to have just Medicare
    Part A while ACTIVELY working or covered under a
    spouse who is ACTIVELY working
  • Once ACTIVE employment coverage has ended, must
    take Part B coverage within 8 months to avoid a
  • If employer has lt20 employees or lt100 employees
    if the 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

Consolidated Omnibus Budget Reconciliation Act
  • 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

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

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)

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
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

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

Medicare Part A(Hospital Insurance)
Medicare Part A (Hospital Insurance)
  • Part A Covers
  • Inpatient hospital care
  • Care in a skilled nursing facility (SNF)
  • Home health care
  • Hospice care
  • Blood

2014 Part A Out-of-Pocket Costs
  • Inpatient hospital care
  • Days 1-60 1216 deductible (per benefit period)
  • Days 61-90 304 per day
  • Days 91-150 (Lifetime Reserve Days) 608 per
  • All additional days All costs
  • Skilled Nursing Facility care
  • Days 1-20 Nothing
  • Days 21-100 152 per day
  • Durable Medical Equipment
  • 20 of approved amount
  • Hospice Care
  • Small co-pays for inpatient respite care and
  • Home Health Care
  • Nothing

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
  • 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

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

Inpatient Hospital Covered Services
  • 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

Inpatient Hospital Covered Services, cont.
  • Services covered during a hospital stay
  • Medical supplies (casts, surgical dressings)
  • Operating and recovery rooms
  • Rehabilitation services (physical therapy)
  • Use of appliances (wheelchairs)
  • Blood transfusion (after first 3 pints)

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

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

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

SNF Covered Days
  • 100 renewable days
  • Days 1-20 Medicare pays 100 in a
    benefit period
  • Except convenience items
  • Days 21 100 Daily co-payment

SNF Covered Services
  • Services covered in a SNF
  • Semi-private room
  • All meals (including special diets)
  • General nursing services
  • Rehabilitation services
  • Drugs furnished by the SNF during the stay
  • Use of medical equipment and supplies

SNF Services NOT Covered
  • Services NOT covered in a SNF
  • Physician services (Part B)
  • Personal convenience items
  • Private room (unless medically necessary)

Medicare Part A Benefit Period Example
  • Benefit period Example 1
  • Mr. Jones 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 counts.) Mr. Jones has 82 hospital
    days left in the benefit period
  • How much would Mr. Jones have to pay for his
    hospital stay?

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 29
    days of his SNF benefit. He has 71 days left
  • How much would Mr. Jones have to pay for his
    Skilled Nursing Facility care?

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
  • Beneficiary must be homebound (see next slide)
  • Medicare pays 100 for all covered and medically
    necessary home health services
  • EXCEPTION Medicare pays 80 of durable

  • Homebound means normally unable to leave home or
    that leaving home is a major effort and must
  • Require a supportive device, or
  • Use of special transportation, or
  • Require the assistance of another person
  • Can leave home, but it must be infrequent and for
    a short time.
  • Examples Leave to get medical care (may include
    adult day care), attend a religious service, get
    a haircut

Home Health Benefit Covered Services
  • Services covered by home health benefit
  • Skilled nursing care
  • Physical, occupational, or speech therapy
  • Medical social services (dietary counseling)
  • Care by home health aide (bathing, changing
  • Medical supplies
  • Equipment (20 co-insurance)

Home Health Benefit Services NOT covered
  • Services NOT covered by home health benefit
  • Prescription drugs
  • Homemaker services
  • Home delivered meals (Meals on Wheels)
  • Personal care services in the absence of skilled

  • Hospice Coverage
  • Physician must certify that beneficiary is
    terminally ill and expected to live 6 months or
  • 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

Hospice, cont.
  • Covered benefit period for Hospice Care
  • Two 90-day periods
  • Then unlimited 60-day periods
  • Face-to-face meeting with doctor required
  • While receiving Hospice Care
  • Medicare pays 100 of most services
  • Beneficiary only pays small co-pays (5 or less)
    for outpatient drugs and respite care
  • Hospice covers all drugs related to hospice care
  • All Part D drugs for hospice patients require
    prior authorization to ensure Part D is not
    covering hospice drugs

  • Coverage of blood
  • Medicare pays 100 after the first 3 pints of
  • The 3 pint blood deductible can be met under Part
    A or Part B
  • Wont have to pay for it or replace blood if
    hospital gets it free from a blood bank

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

Hospital Discharge
  • Discharge Plan
  • Beneficiaries should be an active part of their
    discharge plan
  • Beneficiary should be given written discharge
    plan at least 24 hours prior to discharge
  • Beneficiary signs plan to acknowledge receipt
    (Signature does not mean beneficiary agrees the
    plan is appropriate)
  • If unsatisfied with plan, the beneficiary can
  • Beneficiary should ask for written Notice of
    Non-Coverage and appeal if appropriate to Dept.
    of Public Health

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?

Medicare Part B (Medical Insurance)
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)

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 you agree to accept assignment for all
    beneficiaries in all cases (non-participating
    less important in MA)

2014 Part B Out-of-Pocket Costs
  • Monthly Part B Standard Premium
  • 104.90/month
  • Premiums based on modified adjusted gross income
    for an individual those with higher annual
    incomes pay higher Part B premiums
  • Annual Deductible
  • 147

2014 Part B Out-of-Pocket Costs, cont.
  • After the yearly deductible is met, beneficiary
  • Doctor office visits 20 co-payment
  • Diagnostic tests Nothing
  • Outpatient therapy 20 co-payment
  • Outpatient mental health 20 co-payment
  • DME 20 co-payment PLUS balance on bill
  • DME is sole area in which the provider can bill
    over and above the Medicare-approved amount
    (Balance Billing)
  • Emergency Ambulance 20 co-payment
  • Outpatient Hospital Services Fixed amount
    determined by Medicare

Physician Services
  • Physicians services covered
  • Exams
  • DOES NOT include routine annual physicals
  • Welcome to Medicare Exam
  • 1x only exam within first 12 months of joining
    Part B
  • Annual Wellness Visit
  • Discussion with doctor to develop prevention plan
    to improve health, routine measurements height,
    weight, blood pressure
  • Medical and surgical procedures, anesthesia,
    diagnostic tests and procedures
  • Radiology and pathology services (in or out of
    the hospital)

Physician Services, cont.
  • Physicians services covered, cont.
  • Drugs that cannot be self administered
  • Blood transfusions
  • Second opinion about recommended surgery
  • Physicians services which may be partially
  • Chiropractors services
  • Podiatrists services
  • Optometrists services
  • Dentists services

Physician Services
  • Physicians services NOT covered
  • Most routine physical exams and tests related to
    such exams
  • Most routine foot care (covered for individuals
    with diabetes)
  • Exams for the fitting of hearing aids
  • Exams for eyeglasses (except cataract related)
  • Most routine dental care or false teeth

Physician Services
  • Physicians services NOT covered, cont.
  • Acupuncture
  • Cosmetic surgery (unless related to a
    degenerative disease or accident)
  • Experimental medical procedures
  • Any other service not considered by Medicare to
    be medically reasonable or necessary

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

Outpatient Services
  • Outpatient hospital services
  • Partial hospitalization services, day surgery,
    radiology, stitches, cast application
  • Clinical diagnostic lab services
  • Orthotics, prosthetics, take home surgical
  • Chronic dialysis
  • Outpatient rehab services (physical therapy,
    speech therapy, pathology, occupational therapy)

Outpatient Mental Health Services
  • Medicare covers treatment by following providers
  • Doctor, clinical psychologist, clinical social
    worker, clinical nurse specialist, nurse
    practitioner, physicians assistant
  • Medicare covers Outpatient mental health services
    at the following settings
  • Clinic, doctors office, other therapists
    office, Outpatient hospital department (partial
    hospitalization), community mental health centers
  • Partial Hospitalization
  • Structured program of active treatment more
    intense than care in a therapists or doctors

Ambulance Coverage
  • Medicare covers ambulance service when transport
    in another vehicle would endanger health
  • Will pay for transport from home to hospital/SNF
    or from hospital/SNF to home
  • Medicare will NOT pay for ambulance used as
    routine transportation

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

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

DMEPOS Competitive Bidding Program
  • Program aims to lower payment rates for certain
    medical equipment and supplies through supplier
  • 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

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

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?

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?

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?

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?

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?

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

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

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?

Medicare A/B Quiz
  • Describe Medicares Enrollment Types
  • Mr. Hoover comes to ask about his mothers
    hospitalization. His mother has been hospitalized
    for 62 days. His mother has no insurance other
    than Medicare.
  • After Medicare pays, what part of the bill is her
  • If she is discharged, but is readmitted 10 days
    later and stays for 10 days, what additional
    amount of money will she owe?
  • If she stays an additional 40 days instead of 10
    days, what additional amount of money will she

Medicare A/B Quiz
  • 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
  • What would you tell him about having Medicare AB
    coverage only?
  • What is the current monthly premium for Medicare
    Part B?
  • Medicare does cover an annual physical True or

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?
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