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					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)

www.ageinfo.com

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 www.800ageinfo.com

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



Professionals

Health Benefits Universities CEUs

Inservices

SHINE Counseling and MassHealth



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

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



Referrals



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
months)



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

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)

Deductible

Plan pays 75%

25% ($630)

Coverage Period

100%

($3,610)

Coverage Gap

Drug plan and Medicare Pay 95%

5%

Catastrophic

Initial Coverage Limit

drug costs = $2,830

Out of Pocket threshold

$4,550

Total Drug Costs =

$6,440

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
beneficiaries.

•

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:

•

Premiums

•

Deductibles

•

Copayments

•

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

Eligibility
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 www.ssa.gov/prescriptionhelp

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
recovery.

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

2009

2010

Individuals

$4,000

$6,600

Couples

$6,000

$9,910

Helpful Options for Elders Buying Prescription Drugs



Medicare HMOs



MassHealth



Save Money at Local Pharmacy –Shop Around



Prescription Advantage



Online Pharmacies and Mail Order Pharmacies



Discount Card Programs



www.needymeds.org
www.massmedline.com

Are there Bilingual SHINE Counselors?

Language

SHINE Counselor Location

Contact

Cantonese, Mandarin

Greater Boston Chinese Golden Age Center

617-357-0226

Haitian Creole

Haitian American Public Health Initiative

617-298-8076

Cape Verdean Creole

Immigrant Assistance Center

508-996-8113

Khmer

Seton Asian Center

978-683-7316

Portuguese

Immigrant Assistance Center

508-996-8113

Russian

Russian Community Association of Mass.

781-593-0100

Spanish

Lawrence Council on Aging
978-794-5886

Vietnamese

Vietnamese American Civic Association

617-288-7344

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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