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Day 6


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Title: Day 6

Day 6 7Public Benefits
  • For people 65 and under 65 with a disability
  • 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 called 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

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
  • General Enrollment Period (GEP) Jan 1st March
    31st of each year
  • July 1st effective date

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

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

  • Pays for reasonable and medically necessary
  • There are coverage gaps in Medicare including
  • Part A in-patient hospital deductible
  • Part A daily co-payment for in-patient hospital
    days 61-90
  • Part A daily co-payment for in-patient hospital
    days 91-150
  • Part A daily co-payment for SNF days 21-100
  • Part B annual deductible
  • Part B co-insurance (usually 20)
  • First three pints of blood
  • Coverage outside the United States

Two Options For Supplementing Medicare
Step 1 Decide how you want to get your coverage
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
PART D Stand Alone PDP
PART D Included in Part C
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 dont need and cannot be sold a
Medigap policy
MEDIGAP Supplement Core or Supplement 1 plan
Medigap vs.Medicare Advantage
Original Medicare Medigap Supplement 1 Medicare Advantage Plan
Higher premiums but no co-pays Generally lower premiums but has co-pays
Freedom to choose doctors May be restricted to network
No referrals necessary May need referrals for specialists
Some routine services not covered (vision, hearing) May include extra benefits (vision, hearing, fitness)
Covered anywhere in US Emergency services ONLY outside service area
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
  • Part D is voluntary, but eligible beneficiaries
    who do not enroll may be subject to a penalty
  • Must have creditable coverage to avoid penalty

Part D Enrollment
  • Initial Mimics Part B 7 month period
  • Open Oct 15th Dec 7th, coverage effective Jan
  • Special Refer to SEP chart for applicable
  • MADP Jan 1st Feb 14th
  • Late Penalty is 1 of the national base
    beneficiary premium for EACH MONTH the
  • Did not enroll in Part D when they were first
    eligible AND
  • Had no prescription drug coverage OR
  • Had coverage that was not considered creditable
  • Had a lapse in creditable coverage of 2 full
    months (63 days)

Part D Formulary
  • The prescription benefit includes a list of
    covered drugs and this list is called the
  • If the insurer is very selective about which
    drugs are to be covered, then it is sometimes
    referred to as a closed formulary. If the
    formulary is open to all drugs but places drugs
    into different cost sharing categories or
    tiers, it is referred to as an open formulary
  • Each plan must meet formulary standards. The
    formulary must include and cover certain drugs or
    certain classes of drugs. Medicare has
    established a category of excluded drugs

Extra Help
  • Federal assistance program to help low-income and
    low-asset Medicare beneficiaries with costs
    related to Medicare Part D
  • Extra Help subsidizes
  • Premiums
  • Deductibles
  • Copayments
  • Coverage Gap Donut Hole
  • Late Enrollment Penalty
  • Does NOT subsidize non-formulary or excluded
  • Apply through Social Security Administration

Prescription Advantage
  • Massachusetts State Pharmaceutical Assistance
    Program (SPAP)
  • Provides secondary coverage for those with
    Medicare or other creditable drug coverage
    (i.e. retiree plan)
  • Provides primary prescription coverage for those
    who dont qualify for Medicare
  • Benefits are based on a sliding income scale
    only no asset limit!
  • Level of assistance provided is determined by
    gross income
  • Different income limits for under 65 and 65 and
  • Members are provided a SEP (one extra time each
    year outside of open enrollment to enroll or
    switch plans)

Public Benefits
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
  • Counselors do not guarantee that an individual
    will be eligible for these programs this
    decision can only be made by the benefit program

Supplemental Security Income (SSI)
  • Federal income supplement program funded by
    general tax revenues to help aged, blind, and
    people with disabilities who have little or no
  • Needs based program
  • Provides cash to meet basic needs for food,
    clothing, shelter
  • Different income supplements for various living
  • Apply through Social Security office
  • Automatic enrollment into MassHealth

  • Medicaid National public health insurance
  • MassHealth Massachusetts Medicaid program
  • Public health insurance program for low- to
    medium-income residents of Massachusetts
  • Administered by state Medicaid agencies within
    broad parameters established by federal
  • Overseen by the Centers for Medicare Medicaid
    Services (CMS)

SHINE and MassHealth
  • SHINE focus is on MassHealth ONLY AS IT RELATES
  • Benefit programs and eligibility criteria may
    differ for individuals who are not entitled to

  • Medicare beneficiaries who are enrolled in
    MassHealth Standard are referred to as
  • Dual-eligibles can receive assistance paying for
    Medicare premiums, deductibles, co-insurance, and
  • Dual-eligibles receive the many MassHealth
    covered services that Medicare beneficiaries
    typically do not receive

Dual-Eligible's and Part D
  • Dual-eligibles MUST enroll into a Medicare Part D
  • If beneficiary does not enroll into a plan within
    60 days, they will be auto-assigned to a plan
  • Best to avoid this Auto-assigned plan may not be
    lowest cost and formulary may not list all of
    beneficiaries drugs
  • Dual-eligibles automatically deemed eligible
    for Full Extra Help, regardless of income and

Dual-eligible's and Part D, cont.
  • MassHealth will cover a drug that Medicare does
    not pay for
  • Will NOT cover a drug that Medicare does pay for
    but is not listed on the beneficiaries plan
  • MassHealth is always the payer of last resort
  • Will NOT provide primary prescription drug
    coverage for dual-eligible's
  • Dual-eligibles not yet enrolled into Part D may
    receive their prescription drugs at the Extra
    Help co-pay amounts by using the Limited Income
    Newly Eligible Transition Program (LINET)

Limited Income Newly Eligible Transition Program
  • Provides immediate prescription drug coverage for
    people with Medicare who are at the pharmacy
    counter and qualify for Extra Help, but arent
    yet enrolled in a Medicare drug plan
  • Also covers prescriptions that eligible people
    filled within the last 30 days
  • Covers all Part D covered drugs No prior
    authorization or network pharmacy restrictions
    during the time period covered by this program
  • Will be charged the reduced co-payment based on
    the level of Extra Help they are eligible for
  • Program administered by Humana

MassHealth Standard Eligibility
  • Determining eligibility for MassHealth is a
    complex process
  • SHINE may screen for potential eligibility,
    educate clients about MassHealth benefits, assist
    in the application process
  • Should not guarantee eligibility this decision
    should be left to MassHealth
  • Must be a Massachusetts resident
  • Defined as someone living in Massachusetts and
    intends to stay
  • Different eligibility requirements for applicants
    age 65 and older and those under age 65

Financial Eligibility 65
  • For married couples living together, eligibility
    usually based on the combined income and assets
    of both members of the couple
  • Must meet both income and asset guidelines in
    order to qualify for MassHealth Standard
  • Income eligibility Countable income at or below
    100 of the Federal Poverty Level (FPL)
  • Asset eligibility 2,000 or less in countable
    assets (3,000 for a couple)
  • To determine income
  • Take gross countable income and subtract 2
    deductions Unearned income disregard and Earned
    income disregard

Income Disregards
  • Unearned income disregard is a 20 deduction from
    the households total countable unearned income.
    Married couples receive only one 20 deduction
    from their combined countable income
  • Earned income disregard is calculated by
    subtracting 65 from the individuals gross
    earned income, and dividing the remainder by 2.
    Married couples in which both people are working
    will both receive separate earned income
  • Disregards already calculated in the Pink Sheet
    (Eligibility Guidelines for Health/Prescription-Re
    lated Public Benefits Programs)

IncomeCountable VS. Non-Countable
  • Countable Income
  • Non-countable Income
  • Social Security benefits
  • Railroad Retirement benefits
  • Pensions
  • Earned income
  • Rental income
  • Federal veteran pensions disability
  • Interest income
  • Cash assistance from SSI or the Department of
    Transitional Assistance (DTA)
  • Income-in-kind (e.g., gifts)
  • Income from a reverse mortgage
  • Veterans Aid Attendance benefits
  • Chapter 115 benefits for veterans

AssetsCountable VS. Non-Countable
  • Countable Assets
  • Non-countable Assets
  • Bank accounts
  • Whole life insurance policies, when total face
    value of all policies is over 1,500
  • Individual retirement accounts (IRA)
  • Stocks and bonds
  • Second homes/cars
  • RVs/Boats
  • Primary residence and 1 car
  • Personal belongings home furnishings
  • Term life insurance policies
  • Whole life insurance policies with total face
    value 1,500 or less
  • Burial plot
  • 1,500 burial-only account
  • Irrevocable burial contract

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Financial Eligibility Under Age 65
  • NO asset limits
  • Income limit is 133 of the FPL
  • Earned income disregard and unearned income
    disregard not used
  • Modified Adjusted Gross Income (MAGI) used
    instead of gross income
  • Applicant receives an income disregard
    equivalent to 5 of the FPL
  • 5 FPL disregard already calculated in the Pink

Examples of MassHealth Covered Services
  • In/Out-patient hospital services
  • Emergency hospital services
  • Skilled nursing facility
  • Home health care
  • Case management services
  • Clinic services
  • Diagnostic services
  • Dental services
  • Programs for all-inclusive care for the elderly
  • Personal care services (PCA)
  • Hospice care
  • Medical Transportation
  • Occupational therapy
  • Optometrist services
  • Physical therapy
  • Podiatrist services
  • Preventative services
  • Private duty nursing
  • Prosthetic/orthotic devices
  • Psychologist services
  • Rehabilitative services
  • Respite care

Applying For MassHealth
  • Best for the individual, spouse, family member to
    complete the application counselors can assist
    when needed
  • 2 application types
  • Application for Health Coverage and Help Paying
    Costs (ACA-2)
  • In general used by applicants under age 65
  • Application for Health Coverage for Seniors and
    People Needing Long-Term-Care Services (SACA-2)
  • For applicants 65 and older
  • Pink sheet indicates which application is used
    for each MassHealth program

Application Processing
  • Applications sent to and processed at the Central
    Processing Unit or MassHealth Enrollment Centers
  • If an application is received and requires
    further verification, applicant will receive a
    Request for Information with a deadline by which
    to return the needed documentation
  • Retroactive Coverage
  • Applicants age 65 and older can receive
    retroactive coverage up to 3 full calendar months
    prior to the date of application
  • Applicants under age 65 can receive retroactive
    coverage beginning 10 days prior to the date of
  • Does not apply to MassHealth Senior Buy-in

Payment For Services
  • MassHealth is always the payer of last resort
  • Any other insurance plan, including Medicare or
    employer-based health plans, must pay first
    before MassHealth will pay.

Special MassHealth Programs
  • In addition to the MassHealth Standard benefits
    and eligibility criteria just discussed, there
    are several MassHealth programs that provide
    various levels of benefits for individuals who
    meet specialized eligibility guidelines
  • These programs act like Medicare Supplements
    (Supplement 1), covering co-pays and deductibles
    and offering additional benefits

Medicare Savings Programs MassHealth Senior
  • Federally referred to as the Qualified Medicare
    Beneficiary (QMB)
  • Eligibility
  • Be entitled to Medicare
  • Income at or below 100 of the FPL
  • Assets at or below the designated limits (change
  • Benefits
  • Payment of Medicare Part A B premiums
  • Payment of deductibles and co-pays
  • Deemed eligible for Full Extra Help

Medicare Savings ProgramsMassHealth Buy-In
  • Federally referred to as Specified Low-income
    Medicare Beneficiary (SLMB) and Qualified
    Individual 1 (QI-1)
  • QI-1 subject to periodic federal funding
  • Eligibility for SLMB and QI-1
  • Be entitled to Medicare
  • Have income at or below QI-1 135 of the FPL
  • SLMB120 of the FPL
  • Assets at or below the designated limits (change
  • Benefits
  • Payment of Medicare Part B premium
  • Deemed eligible for Full Extra Help

Buy-In ForPart B Late Enrollees
  • Late enrollees for Medicare Part B who qualify
    for the Senior Buy-in (QMB) or Buy-in (SLMB/QI-1)
    may enroll in Part B outside of the General
    Enrollment Period
  • The effective date of Part B coverage would not
    be earlier than the Buy-in start date
  • The individuals late enrollment penalty will be
    paid for by MassHealth

Caretaker Relative
  • Eligibility
  • Must meet the definition of a caretaker relative
    Adult of any age who is primary caregiver for a
    child (can be related to the child by blood,
    adoption, marriage, or be the spouse/ex-spouse of
    one of these relatives). Must live in same home
    as the child and neither of the childs parents
    can be living in the home
  • Must have income at or below 133 of the FPL
  • Benefits
  • Eligible individuals will receive MassHealth
    Standard benefits
  • Payment of Medicare Part A B premiums,
    deductibles and co-pays
  • Deemed eligible for Full Extra Help

  • Eligibility
  • Must have a disability
  • Must be ineligible for MassHealth Standard
  • Must currently be working at least 40 hours per
    month, or currently working and worked at least
    240 hours in the past 6 months
  • MassHealth flexible on what work is
  • Must be paid work cannot be volunteer
  • Individuals under age 65 can waive the work
    requirement if they meet a one-time deductible
  • NO financial eligibility requirements
  • Individuals with incomes above 150 of the FPL
    will pay a monthly premium relative to their

CommonHealth, cont
  • Benefits provided
  • Benefits similar to MassHealth Standard including
    payment for Part A and B co-payments and
  • Deemed eligible for Full Extra Help
  • Benefit NOT provided
  • Automatic payment for Part B premium
  • Individuals must separately meet the
    qualifications for Buy-in in order for MassHealth
    to pay premiums

Frail Elder Waiver
  • Allows elders eligible for nursing home care who
    want to remain at home to get the services
    supports to be able to live safely
  • Eligibility
  • Be age 60 or older
  • Be clinically eligible for nursing home care
    receive services from the ASAPs home care
  • Have income at or below 300 of the Federal SSI
  • Have assets at or below 2,000
  • Only counts the income assets of the applicant
    even if married any assets over 2,000 limit
    allowed to be transferred to non-applying spouse

Frail Elder Waiver, cont
  • Benefits
  • Payment of Medicare Part A B deductibles and
  • Deemed eligible for Full Extra Help
  • No co-pays for prescription drugs
  • Supportive services (ex. Personal care,
    homemaking, meals)
  • To Apply
  • To apply the individual should be referred to
    their local Aging Service Access Point (ASAP)
  • ASAP staff will evaluate the applicant for
    clinical eligibility

Health Safety Net (HSN)
  • Pays for medically necessary services at
    Massachusetts community health centers (CHCs) and
  • 2 levels of eligibility Full and Partial
  • Eligibility
  • Must be a Massachusetts resident
  • Non-residents may receive emergency or urgent
    care only
  • Full Health Safety Net
  • Income must be at or below 200 of FPL
  • Partial Health Safety Net
  • Income must be above 200 but at or below 400 of
  • Individual will be assessed an annual deductible

Health Safety Net, cont.
  • Benefits
  • Low co-pay prescription coverage
  • Prescription must be filled at a HSN pharmacy
  • Will pay for allowed services not covered by
    Medicare, as well as Medicare co-pays,
    coinsurance, and deductibles
  • Services must be delivered/ billed through a
    hospital or community health center that has an
    HSN program
  • Can pay for services up to 6 months prior to
  • HSN is NOT considered creditable coverage for
    Medicare Part D therefore use of the HSN pharmacy
    benefit does not protect a beneficiary from the
    Part D late enrollment penalty

Senior Care Options (SCO)
  • Combines MassHealth Standard coverage with social
    support services and coordinated care to help
    individuals maintain their health and live in the
  • Eligibility
  • Be 65 or older
  • Qualify for MassHealth Standard
  • Live in a designated service area of a SCO plan
  • NOT be diagnosed with End Stage Renal Disease
  • NOT be an inpatient in a chronic rehabilitation

SCO, cont.
  • Benefits
  • No co-pays or deductibles
  • Coordination of health care
  • Prescription drugs without a co-pay
  • Comprehensive dental, including dentures
  • Transportation
  • Specialized geriatric support services
  • Adult day care
  • 24 hour access to medical support
  • Home care services
  • Family caregiver support

One Care
  • Managed care option that provides all Medicare
    MassHealth services along with additional care
    coordination and support services to
    dual-eligible individuals with disabilities
  • Members can only receive covered services through
    plans network of contracted providers
  • One Care is not available in all counties
  • Eligibility
  • Be age 21-64
  • Have Medicare Parts A B
  • Have MassHealth Standard or CommonHealth
  • Cannot also be enrolled in SCO, PACE, Frail
    Elder Waiver, or other MassHealth waiver program

One Care, cont.
  • Benefits
  • All guaranteed Medicare and MassHealth benefits
    as well as
  • No premiums, deductibles, or co-pays
  • Services coordination by an interdisciplinary
    care team
  • Part D Coverage and no co-pays for prescription
  • Enhanced behavioral health and substance abuse
  • Long-term support
  • Home modification
  • Comprehensive dental
  • Hearing aids
  • Transportation

Program Of All-Inclusive Care For The Elderly
  • Provides community based care services to
    people age 55 who would otherwise require
    nursing home level of care
  • Team of health care professionals provide
    integrated care plan to keep individual safe at
  • Eligibility
  • Be age 55 or older
  • Be clinically eligible for nursing home care
  • Income at or below 300 of the Federal SSI Rate,
    assets at or below 2,000
  • Live in the service area of a PACE organization
  • PACE is not available in all regions of the state

PACE, cont.
  • Benefits
  • No premiums, deductibles or co-pays for
    dual-eligible's Medicare only beneficiaries will
    have monthly premium
  • Provides all services covered by Medicare and
    MassHealth Standard
  • Provides functional, social, and psychological
    services to help individuals safely remain in
    their homes
  • Part D coverage through the PACE plan

MassHealth Personal Care Attendant (PCA) Program
  • Program that helps people with long-term
    disabilities live independently at home by giving
    member funds to hire a personal care attendant
    (PCA) to help with activities of daily living
  • Eligibility
  • Be age 65 or older
  • Have a permanent and long-lasting disability
  • Must need assistance with at least 2 ADLs
  • ADL examples Dressing, eating, bathing, walking
  • Income at or below 133 of the FPL
  • Assets at or below 2,000 for an individual or
    3,000 for a couple

Long Term Care (LTC) MassHealth
  • Pays the nursing home the difference between the
    patient private paid amount and Medicaid
    established rate for nursing home care. Requires
    clinical eligibility.
  • Financial Eligibility
  • No income limit applicant just must have monthly
    income insufficient to pay for nursing home costs
  • To prevent impoverishment of community spouse,
    spouse may be able to keep some of applicants
    income, called the monthly maintenance needs
  • Assets limited to 2,000
  • Community spouse allowed to keep all assets (not
    counting the primary residence) up to a certain

  1. What does dual-eligible mean?
  2. What are the different types of MassHealth
    applications and which application is used for
    which MassHealth program?
  3. What MassHealth programs are specifically for
    individuals with a disability?
  4. What is Health Safety Net and what does it
  5. What benefits are available from One Care?

Case Study 1Anna Stetick
  • Anna 73 year old retired widow lives in senior
  • Income Social Security 1250/month (Net)
  • Assets 3300 in her checking account, 9,000 in
  • Anna tells you that she moved here from Florida
    one month ago. She was in a MA plan in Florida
    and knows she needs to pick a plan in
    Massachusetts. She also knows she will lose her
    Part D coverage with the Florida plan and was
    told she cant enroll in a plan in Massachusetts
    until open enrollment and will have a penalty.
    She wants to know if she can get on MassHealth to
    pay for her prescriptions.
  • How would you help her?

Case Study 2Robin Hood
  • Robin 76 years old single, retired, living in
    senior housing
  • Income Social Security 1,133/month (Net)
  • Assets 2500 in savings, 1000 in checking, car
    valued at 4000. He has a life insurance policy
    with a face value of 10,000 and a cash surrender
    value of 1200
  • Insurance Medicare A B effective 3/1/03 and
    currently enrolled in the BCBS PPO plan
  • A friend told Mr. Hood to talk to a SHINE
    counselor about getting on MassHealth.
  • How would you help him?

Case Study 3Donna Wannago
  • Donna 77 year old retired widow who lives in
    senior housing
  • Income Social Security 816/month (Net)
  • Assets 1500 in savings, 200 in checking, life
    insurance policy with a face value of 1200, car
    valued at 4000
  • Insurance Medicare A B effective 1/22/02
    Medex Bronze
  • Donna signed up for a Part D plan during open
    enrollment although she wasnt taking any drugs
    at that time. She said she she chose the least
    expensive plan. She is worried about paying the
    Part D premium along with her Medigap . Her
    doctor just put her on medication and she doesnt
    know how she will be able to pay for it during
    the gap in coverage under Part D.
  • How would you help her?

Case Study 4Polly Gimmee
  • Polly meets with you on May 10th. She tells you
    she is 64 and has been on MassHealth due to a
    disability for the past 19 months. She says she
    is turning 65 in July and will be enrolled in
    Medicare effective July 1st. She will be
    receiving a Social Security check in the amount
    of 1102. A friend told her that her MassHealth
    might change when she turns 65. She is worried
    about her health care coverage if MassHealth does
    change particularly because she takes several
    medications and has no other income or assets to
    use to pay for them. She wants to know if its
    true that MassHealth might not continue to cover
  • How would you help her?

Case Study 5Mel Kontent
  • Mel meets with you at the SHINE office. He is
    very confused about the Medicare Prescription
    Drug Program. He tell you he takes several
    medications and gets some coverage through his
    Medicare Advantage HMO plan and that he used to
    get additional coverage through Prescription
    Advantage. He did fill out the application for
    Extra Help that Prescription Advantage told him
    to complete, but he received a letter that he was
    denied. He tells you he cannot afford his co-pays
    for his drugs since he lost his Prescription
  • How would you help him?

Case Study 6Martin Eyz
  • Mr. Eyz retired at age 65 and is collecting
    Social Security. He has Medicare and Medex
    Bronze. He takes no medications and never signed
    up for Part D. Mr. Eyes recently took a part-time
    job at the local Whypaymore to supplement his
    income. He lives in senior housing, so his rent
    is affordable. Mr. Eyes tells you that he is
    having a difficult time paying for his health
    insurance and was told by a friend that he should
    apply for MassHealth which would cover his
    medical expenses. Mr. Eyes tells you that he gets
    750/month from Social Security and 300/month
    from his job at Whypaymore. He has 600 in a
    checking account and 1,400 in a CD.
  • Is he eligible for MassHealth?

Case Study 7Arthur Ritis
  • Arthur calls for assistance. He received an
    Eligibility Review Form (ERV) from MassHealth to
    complete. He doesnt understand why he received
    the form since he is not on MassHealth. He had
    applied in the past but was denied because he was
    over income (1596.40/month). He tells you he is
    homebound and called because he cannot come in
    for an appointment.
  • How would you help him?

Case Study 8Ben Hurr
  • Ben is 57 years old. He has been on Medicare A
    B since January. He was on a few inexpensive
    medications that he was filling at Wal-mart at
    little cost. His meds are changing and he now has
    a few expensive brands. His income is
    1,900/month, and he has partial Health Safety
    Net. An advocate at the community center
    suggested he see a doctor at the community health
    center in a nearby town so that he can fill his
    prescriptions at the health center. She told him
    he can sign up for Part D at the next Open
    Enrollment Period.
  • What additional information would you provide?

Case Study 9Charlie Horse
  • Charlie meets with you for help with his
    prescription coverage. He is in a Blue Cross PPO
    Medicare Advantage plan with prescription
    coverage. He takes several medications, one of
    which, Procrit, is quite expensive. His plan has
    been covering it, but he will be in the donut
    hole soon and is concerned because he cant
    afford to pay the full price for his drug. He
    tells you he used to be in Prescription Advantage
    but that ended in January. He says his monthly
    income of 1,585 makes him ineligible for any
    benefit programs. He is not a veteran.
  • How would you help him?

Case Study 10May B. Poor
  • May will be 65 and retiring in 2 months and will
    not have retiree coverage available through her
    former employer. She just heard about Medicare
    Part D. She only takes 1 drug now and doesnt
    really want coverage. However, she heard she will
    pay a penalty if she enrolls at a later date
    should her drugs increase, as she believes they
    might. She is concerned about the monthly premium
    along with the premium for health insurance. She
    states that her only income will be Social
    Security and the amount shell receive will be
    1,120/month. She tells you her savings are
    minimal and she has no other assets other than
    her home and a car. She wants to know if there is
    any way she can cut down on her health care costs
    or avoid taking Part D as she feels the
    additional premium will put her over the edge.
  • How would you help her?

Public Benefits Quiz
  • List the MassHealth Buy-In programs and the
    benefits they provide.
  • To be eligible for MassHealth an individual
    cannot own a home.
  • True or False
  • When determining an individuals eligibility for
    Supplemental Security Income (SSI), their living
    arrangements are considered.
  • True or False

Public Benefits Quiz, cont.
  • If a Medicare beneficiary has MassHealth, do they
    need to purchase a Medicare Supplement or join a
    Medicare Advantage Plan?
  • Yes or No
  • Why?
  • What are the major differences between MassHealth
    for individuals under 65 and those 65 and over?
  • What resources are counted in the asset test for
    people over 65 who apply for MassHealth while
    living in the community?
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