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SHINE Health Benefits Counseling and MassHealth Partnering to .rtf


									SHINE Health Benefits Counseling and MassHealth: Partnering to Help Medicare Beneficiaries

Executive Office of Elder Affairs

One Ashburton Place, 5thfloor

Boston, MA 02108

1-800-AGE-INFO (800-243-4636)

Table of Contents

Executive Office of Elder Affairs & MassHealth

SHINE Overview

Medicare Overview (A-D)

Medicare D Overview –Duals and Low Income Subsidy

Medicare Savings Programs aka MassHealth Buy-In

Helpful Options for Elders buying Prescription Drugs

SHINE Contact & Referral Information

Executive Office of Elder Affairs

Established in 1971 to promote independence and well-being of elders and disabled people needing
medical and social supportive services
Network of 11 Aging and Disability Resource Consortia (ADRCs), 23 Area Agencies on Aging (AAAs), 27
Aging Services Access Points (ASAPs), 14 SHINE programs

7 Program areas: Housing & Supportive Housing, Health Care includes MassHealth & SHINE, Home Care,
Caregiver Support, Advocacy, Employment & Training, Meals & Nutrition

Call 1-800-AGE-INFO or

Elder Affairs Intersects with MassHealth

2003 reorganized to administer long term care programs: home health and hospice, Program for All
Inclusive Care (PACE), Senior Care Options (SCO), Adult Day Health, Adult Foster Care and more

Serve Medicare beneficiaries-elders and disabled requiring long term care services

Counselors screen for public benefits and assist with applications as needed

SHINE Overview

Serving the Health Information Needs of Elders-Began in 1985 as pilot program. Statewide in 1992

13 Regional Programs + Greater Boston Chinese Golden Age Center, bilingual counselors

Network of 550+ volunteer counselors trained and certified by Elder Affairs to provide free unbiased,
comprehensive information, counseling and assistance regarding health insurance and benefits.

SHINE Counselors at Senior Centers, town Councils on Aging (COA), elder network agencies, hospitals,
housing, other community organizations

What is a SHINE Counselor?
SHINE counselors are committed volunteers and staff, trained and certified by the Executive Office of
Elder Affairs, in many areas of health insurance, including:

Medicare Part A and Part B

Medigap insurance

Medicare HMO’s

Retiree insurance plans

Long term care insurance

MassHealth (“Medicaid”)

Medicare’s Savings Programs (QMB, SLMB and QI)

Prescription drug programs

Other insurance programs, including free or reduced-fee health care programs

SHINE –Info Sharing & Training for Agencies

Counselors/Enrollment Specialists

12 day training-public benefits to LTCI

3-4 day specialized enrollment training
Yearly recertification

Monthly meetings

Call 1-800-AGE-INFO (1-800-243-4636)

Counsel at senior centers, hospitals,

home visits when needed


Health Benefits Universities CEUs


SHINE Counseling and MassHealth

MassHealth members must choose Medicare D plan for prescription coverage when become Medicare

Medicare Part D

Who pays what and when

Special enrollment periods

Extra Help/ LIS

Counseling: Screening Process/ Eligibility Tool

Medicare Savings Plans –QMB, SLMBI, QI, other MassHealth
Applications-Community, Elder Programs, LTC


Training and info sharing: MHF, Medicare Beneficiary Work Group, SHINE meeting, HBU

Medicare Overview

Medicare is a health insurance program for

People 65 years of age and older (not necessarily full retirement age)

People under age 65 with disabilities (usually deemed “disabled” by Social Security for at least 24

Medicare A (hospital insurance), B (medical insurance), C (managed care plans), D (prescription drug

Medicare Part D Plans

All plans must meet CMS standards


Cost structure


Formulary (drugs covered)


Pharmacy Access
May also offer supplemental benefits

Must coordinate benefits with SPAPs (Prescription Advantage) and State Medicaid (MassHealth)
programs that wrap-around coverage

Since 2006 have been 50+ plans from which to choose

Medicare Part D Plans in 2010for non-LIS Members

100% ($310)


Plan pays 75%

25% ($630)

Coverage Period



Coverage Gap

Drug plan and Medicare Pay 95%



Initial Coverage Limit

drug costs = $2,830

Out of Pocket threshold


Total Drug Costs =


Enrollment Periodsfor non LIS members
Most Individuals can only enroll or switch Medicare Part D plans during certain time periods:

Initial Enrollment Period (IEP)


Three months before , the month of your 65thBirthday, and three months after.

Annual Coordinated Election Period (ACEP)


November 15 to December 31


January 1steffective date


In 2011 this time frame will move to October 15th

to December 7th(Health Care Reform)

SPECIAL ENROLLMENT PERIOD-MassHealth member can switch any time

Annual Coordinated Election Periodfor non LIS

November 15th–December 31stAll Medicare members should evaluate drug list, plans and may want to
change for January 1.

Plans change premiums, co-pays, formulary every years and announce changes by October 31st.

If individual does nothing (and plan is available) then will remain in current plan for the following year.

MassHealth and Medicare Part D
Individuals with MassHealth and Medicare are considered “Dual Eligible”

Since January 1, 2006, MassHealth no longer provides primary prescription coverage to Medicare


MassHealth pays for certain classes of medications directly since Medicare does not cover them.

Benzodiazepines and Barbiturates

Certain Over the Counter Medications eg.Ibuprofen

Dual Eligible individuals must receive primary drug coverage through a Medicare Part D plan

Benchmark-$33.66. Plan free to MassHealth member if has a plan within $2. Otherwise may pay extra.

Auto-Enrollment of Duals

MassHealth members becoming eligible for Medicare are auto-enrolled into Limited Income Newly
Eligible Transition Program (LI-Net) for 2 month

LI-Net, CMS, MassHealth mail letters to member encouraging select and enroll into Medicare Part D Plan


After two months, if a dual-eligible has not selected plan, will be auto-enrolled into randomly selected
plan below the benchmark (average price of regional drug plan), $33.66 in 2010

$0 Monthly Premium

Plan may not cover all medications so may need to change

Dual Eligible Individuals can change plans monthly (continuous SEP), coverage begins first of the
following month.

Extra Help / Low Income Subsidy

Extra Help, or Low Income Subsidy, is federal program to help low-income and low-asset Medicare
beneficiaries with costs related to Medicare Part D.

Extra Help subsidizes:








Coverage Gap “Donut Hole”


Late Enrollment Penalty


Does not subsidize non-formulary or excluded medications

Administered by CMS and the Social Security Administration

Dual Eligibles automatically eligible for Extra Help

To be eligible for Full or Partial Extra Help in 2010:


Income below 150% FPL

$16,265* for an individual

$21,875* for a couple

*$20 unearned income disregard included. Further allowances are made for any earned income

(The federal poverty level usually changes each spring)


Resources (assets) must be below:

$12,510 for an individual

$25,010 for a couple

(Resource levels are determined each year)

$1500 allowed per person for burial expenses

Levels of Extra Help

Full Extra Help

Income Below 135% FPL ANDAssets below $8,100 / $12,910

Individuals with MassHealth, SSI, or QMB, SLMB, QI auto eligible


Full premium assistance


$2.50 for generics \$6.30 for brands

Partial Extra Help
Income below 135% FPL; Assets over $8,100/ $12,910


Eligible for full premium assistance


Reduced deductible ($62), 15% copayments

If income 136% -150% FPL; Assets over


Eligible for reduced premiums (sliding scale –between 25% -75% assistance dependent upon income)


Reduced deductible ($62), 15% copayments

Changes in 2010

MIPPA –Medicare Improvements for Patients and Providers

Cash value of life insurance no longer counted for extra Help


Individuals who were denied extra help in the past received letters to reapply


Individuals who currently qualify for partial help may reapply to see if they now qualify for full help

Eligibility information is passed to MassHealth for MSP Programs screening

Apply on-line

Medicare Savings Programs

Also known as MassHealth Buy-In
QMB –Qualified Medicare Beneficiary


100% FPL


Pays Medicare Part A & B premiums, copayments, and deductibles

SLMB –Specified Low-Income Medicare Beneficiary


120% FPL


Pays Medicare Part B premium only

QI-1 –Qualifying Individual


135% FPL


Pays Medicare Part B premium only

Medicare Savings Programs

The Medicare Improvements for Patients and Providers Act (MIPPA), encompasses significant changes
and opportunities for Medicare beneficiaries, particularly those who are low-income. MIPPA required
states to increase their asset guidelines for Buy-In programs to match Full Extra Help

Under MIPPA –benefits paid by MassHealth for Medicare Savings Plans will be exempt from estate

Individuals apply via paper applications or via Virtual Gateway. If an applicant is applying for Buy-In only,
a shortened Buy-In application, is available for download on the MassHealth website.
Asset Guidelines









Helpful Options for Elders Buying Prescription Drugs

Medicare HMOs


Save Money at Local Pharmacy –Shop Around

Prescription Advantage

Online Pharmacies and Mail Order Pharmacies

Discount Card Programs

Are there Bilingual SHINE Counselors?


SHINE Counselor Location


Cantonese, Mandarin

Greater Boston Chinese Golden Age Center


Haitian Creole

Haitian American Public Health Initiative


Cape Verdean Creole

Immigrant Assistance Center



Seton Asian Center



Immigrant Assistance Center



Russian Community Association of Mass.



Lawrence Council on Aging


Vietnamese American Civic Association


SHINE Contact & Referral Info. for Medicare Beneficiaries

Complicated insurance, drug coverage problem

Need to enroll/change Part D Drug Plan

Lose MassHealth –consider options

Complaints about Drug Plans

Application review/ assistance

1-800-AGE-INFO (1-800-243-4636)

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