Case Study - Will E. Nffly

Will calls you for help with getting coverage in a Medicare Advantage plan. He explains that he has Medicare A, B & D and was on the CommonHealth program due to a disability. He received a letter from MassHealth saying he is no longer eligible for CommonHealth as he is over income. He just turned 65, and his gross monthly income is $1,448. Will wants to join a Tufts MA plan. When he called Tufts, he was told he could not join until the annual open enrollment. A case worker at his therapy clinic told him to call SHINE.

How would you help him?

Case Study — Penny Less

Penny Less calls you on August 20th from the home of her mother-in-law (MIL). An insurance broker had just left after meeting with them to tell her MIL about AARP. She still has some questions and remembered a SHINE counselor was helpful with her friend when she was retiring. Her MIL is on BCBS Medex Gold. The broker told her she could switch to an AARP Supplement One plan and save a great deal of money. He told them that because her Gold is creditable coverage, she could drop it and join a Part D plan. She thought this sounded too good to be true and wanted a second opinion.

How would you help her?

  • Loss of MH - SEP to enroll in Tufts MA plan
  • If can work (40 hrs/mo for $1/hr) can remain on CommonHealth and will have lower premium than before because MH is Supplement (secondary payer) to Medicare
  • Work letter to MH
  • If cannot work explain MA-PD vs Medigap and PDP
  • Discuss HSN with MA-PD plan or CORE
  • Plan Finder search
  • PA application (not with CommonHealth)
  • Can change to Supplement One at any time, but no SEP to pick up Part D plan (only during OEP)
  • AARP not cheapest Medigap, change to BCBS Medex Bronze during OEP
  • Check income and assets for LIS, PA
  • If eligible for LIS or PA will have SEP to get PDP, so can to down to Bronze now
  • Plan Finder search

Case Study — Bob Kat

Bob calls you on June 8th to get information about Medicare. He tells you he will be 66 on October 16th and eligible to retire with Social Security. He doesn’t know much about Medicare and isn’t sure what he needs to do to enroll. He tells you he has some health problems and thinks he would like to retire from his job but isn’t sure if that’s a good idea. He has excellent health insurance now with his employer and wonders whether he would be able to have coverage as good under Medicare. He is also concerned about the costs he will incur under Medicare. He’s heard that the Medicare drug program is expensive and doesn’t provide much coverage especially for expensive medications like those he currently takes.

  1. What questions would you ask?
  2. What information would you review with him?
  3. What materials would you send/give to him?
  4. Would you refer him to any other agency? If so, which one(s)?
  5. What phone calls, if any, would you make on his behalf?
  6. What follow-up, if any, is required in this case?
  • Questions: Married? Veteran? Offered retiree plan?
  • Check income and assets for eligibility for Public Benefits (including LIS and PA)
  • In IEP, enroll in Medicare Parts A & B online at SSA, if wants to retire
  • Medicare 101 (MA vs Medigap)
  • Plan Finder search for drug plan
  • Compare costs with EGHP
  • If continue to be employed (company has >20 employees) and covered under EGHP, sign up for Part A online at SSA, but don’t take Part B
  • 8 mos SEP to pick up Part B without penalty when stops being covered by active EGHP
  • Enroll in Part B at SSA (need employer verification form)

Case Study — Sal Manella

Sal meets with you on February 2. He tells you he has been on a Tufts plan with prescription coverage for the last couple of years. He changed to Tufts 2 years ago when his doctor changed to that plan. However, his doctor just informed him that he will no longer take Tufts after March 31 and, in fact, will take no other Medicare Advantage plans. Sal tells you he has great confidence in his doctor as he is convinced that the doctor’s diagnostic skills saved his life in the past. He wants to know what coverage will allow him to stay with his doctor.

How would you help him?

Case Study — Ben There

Ben meets with you on June 1 for help with his prescription costs. He is 72, single, and on Medicare A & B only. He has no other insurance and never joined a Part D plan. His monthly income is $4,600. He is not a veteran. He saw a doctor recently after many years because he was having dizzy spells. Following a series of tests the doctor gave him prescriptions for several brand medications inc1uding one to treat anemia, which will run hundreds of dollars per month.

Ben wants to know what Medicare drug plan he can join to help with this cost.

  • Medigap – CORE and Supplement One
  • Check income and assets for eligibility for Public Benefits (including LIS and PA)
  • Plan Finder search for PDP
  • Since MA-DP can drop Tufts and enroll in Medigap and PDP for March 1
  • Discuss HSN and CORE
  • PA (S5) application
  • $200/yr cost for membership but get SEP to pick up PDP, but no other help
  • Will have penalty
  • Discuss Medigap and PDP vs MA-PD
  • Plan Finder search

Case Study — Carrie Kature

Carrie calls for assistance with her father’s health care and prescription costs. He has Medex Bronze and the VA Health Plan for his meds. However, the VA doesn’t cover one of his drugs. His income is just under $1100/month. She doesn’t know the exact dollar amount of his assets but doesn’t think he has more than $5,000-6,000.

How would you help her?

Case Study — Sal E. Vate

Sal meets with you to see if he is eligible for help from MassHealth. He tells you his gross monthly income is $860, but that $109.00 is taken out for Part B. He lives with his girlfriend in the home she owns. He is 73 and has Medicare A & B only. He never signed up for Part D. His doctor gave him a prescription for Advair, but he can’t afford it. You ask for some additional information and learn that he is a veteran as he served in the National Guard in his 20’s. He tells you he has $1,000 in the bank and a life insurance policy with a face value of $1400.

How would you help him?

  • Full LIS will help with cost of PDP ($0 premium and low co-pays) – application
  • QI1 application to pay for Part B
  • Plan Finder search
  • Discuss HSN and CORE
  • Refer to VA Agent for eligibility for other benefits
  • MH application
  • With MH will get Full LIS and QI1 (no longer have $109.00 taken out for Part B)
  • MH SEP to pick up Part D with no penalty
  • Plan Finder search
  • Refer to VA Agent for check on VA benefits

Case Study — Doug Out

Doug meets with you on June 1st. He is 69 years old, single and lives in his own home. He is retired and has Medicare A & B only. He is not a veteran. Until recently, he was very healthy and saw no reason to purchase additional insurance or join a Medicare drug plan. He is now being treated for a health condition which requires that he take what has turned out to be a couple of very expensive medications.

He inquired with his doctor’s office to see what Medicare plans they accept. He was told that they accept Tufts Medicare Preferred HMO and Blue Cross Medex. After calling Tufts and Blue Cross, he understands that Tufts would be cheaper. He is thinking that the Tufts Medicare Preferred Prime Rx Plus plan would make the most sense as it provides additional prescription coverage.

He explains that his income is $31,000/year and he has assets which he uses to maintain his home. He would like to get coverage for his health care and prescriptions so he does not deplete his assets to cover these expenses.

He wants to check that the Tufts plan is probably the best that he can do.

How would you help him?

  • PA (S4) application
  • PA SEP to get Part D
  • Tufts Prime RX Plus only gives extra coverage in gap for Tiers 1 &2 drugs, so probably not necessary – should consider Tufts Prime Rx
  • Plan Finder search
  • Compare MA-PD to Medigap and PDP

Case Study — Bobbi Sox

Bobbi calls on September 15th for assistance with her brother’s insurance. She explains that her brother, Red, has a disability and was covered under CommonHealth for several years. He turned 65 in May. He enrolled in Medicare Part A but did not pick up Part B because he was covered under CommonHealth. He just received a notice that he would no longer be covered under CommonHealth. His income is $1,300/month.

Bobbi called Medicare to enroll her brother and was told that he could not enroll until the general open enrollment in January. Bobbi heard about the Frail Elder program for her brother and wants to know if this will cover him without Part B.

What information would you give her?

  • If Bobbi can work (40 hrs/mo for $1/hr) , she can remain on CommonHealth and will have a lower premium than before because MH is Supplement (secondary payer) to Medicare
  • Work letter to MH
  • Check assets to see if eligible for Buy-in (Part B immediately with no premium)
  • If cannot work, may be financially eligible (assets?) for FEW if also “nursing home eligible” – evaluation by ASAP
  • If not eligible for either CommonHealth or FEW
  • LIS and QI1 applications (depending on assets)
  • Explain MA-PD vs Medigap and PDP
  • Discuss HSN with MA-PD plan or CORE
  • Plan Finder search
  • PA application, if not eligible for MH programs

Review Day – 20171