Case Study — Anna Stetick
Anna Stetick
1 Way
Wrongway, MA01212
508-123-0123
DOB: 1/11/41
U.S. Citizen: Yes
Marital Status: Widow
Employment Status: Retired
Income: Social Security $1250/month (Net)
Assets: $3300 in her checking account & $9,000 in savings
Ms. Stetick lives in senior housing
______
Ms. Stetick meets with you at the SHINE office. She tells you that she moved here from Florida one month ago. She was in a Medicare Advantage plan in Florida and knows she needs to pick a plan in Massachusetts. She also understands that she will lose her Part D coverage with the Florida plan and was told she can’t 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?
- SEP for moving to Mass with no penalty
- Partial LIS – LIS application
- Prescription Advantage (category S1) – PA application
- HSN with CORE or MA plan (low premium with high co-pays) – MH application
- Plan Finder search for MA-PD or PDP
Case Study — Frank Furder
Frank Furder
100 Winter Street
Winterville, MA05050
508-050-5050
DOB: 6/17/46
U.S. Citizen: Yes
Marital Status: Single
Employment Status: Retired
Veteran: Yes
Income: Social Security $996/month (Net)
Assets: $2500 in savings, $1200 in checking, car value $4200
Insurance: Medicare A & B effective 6/1/11 & Medex Bronze
Mr. Furder lives in a single family home he owns.
______
Mr. Furder meets with you on May 15th to inquire about whether he should join the Part D program to help with his prescription costs. He didn’t
join when it first started because he didn’t take any drugs at the time. His
doctor put him on three medications several months ago. The doctor has been giving him samples but recently told him he would not be able to continue. A friend told him he gets his medication from Canada and advised Frank to do the same. He wants to know if that would be better than the Part D program.
How would you help him?
- LIS and QI1 applications – SEP to get Part D with no penalty
- LIS helps with drug premium and co-pays, QI1 pays Part B premium
- Plan Finder search (Canadian drugs not SHINE issue)
- Explain Medigap vs MA plan
- Discuss HSN with CORE or MA plan
- Refer to Veterans Agent for Veterans Benefits (may pay for Bronze)
Case Study — Donna Wannago
Donna Wannago
222 Summer Street
Summerville, MA02020
781-202-2020
DOB: 1/22/37
U.S. Citizen: Yes
Marital Status: Widow
Employment Status: Retired
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
Ms. Wannago lives in senior housing.
______
Ms. Wannago meets with you at the COA. She signed up for a Part D plan during open enrollment although she was not taking any medication at
that time. She tells you that she chose the least expensive plan. She is worried about paying the premium for this plan along with her Medigap
plan. Her doctor just put her on medication and she doesn’t know how she
will be able to pay for it during the gap in coverage under Part D.
How would you help her?
- MH application (eligible for Standard and QMB)
- Will be deemed LIS and Part B will be paid
- Can drop Bronze, - with Standard only doctors that take MH, with QMB can use any Medicare doctor
- Plan Finder search
Case Study — Eileen Sideways
Eileen Sideways
300 Spring Sideways
Springville, MA03030
508-303-3030
DOB: 3/10/39
U.S. Citizen: Yes
Marital Status: Single
Employment Status: Retired
Income: Social Security $822/month (Net)
Assets: $3000 in savings, $600 in checking, car valued at $3500. She has
an irrevocable burial account for $1500 and a prepaid funeral plan for $6000.
Insurance: Medicare A & B effective 3/10/04 and Tufts MA.
Ms. Sideways lives in senior housing.
Ms. Sideways meets with you at the SHINE office. She says she is having a hard time paying the premium for Tufts with the addition of the Part D drug portion along with her other bills. She does not want to give up her car but has severely limited her travel due to the price of gas. She wonders if you have any suggestions for cheaper insurance or senior discounts that would help. How would you help her?
- QMB – MH application
- Will be deemed LIS and Part B will be paid
- Can drop Tufts MA - with QMB can use any Medicare doctor
- Plan Finder search for PDP
Case Study - Ben Efit
Ben Efit
404 Fall Lane
Fallville, MA 04040
508-404-4040
DOB: 2/15/46
U.S. Citizen: Yes
Marital Status: Widower
Employment Status: Retired
Income: Social Security — $720/month (Net)
Assets: $1000 in savings, $300 in checking, car valued at $4500. He also has a pre-paid funeral plan for $6,000, an irrevocable burial account for $1500 and a burial plot.
Insurance: Medicare A & B since 2/1/11. He is currently enrolled in a Medicare Advantage plan with the basic Rx benefit.
Mr. Efit lives in senior housing.
______
Mr. Efit comes to see you because his doctor recently put him on additional medication which is very expensive. He is concerned about what he will have to pay during the gap in Part D coverage.
How would you help him?
- Referred to SSA for SSI
- SSI will automatically enroll in MH
- Will be deemed LIS and Part B will be paid
- Can drop MA if doctors take MH, MH will be Supplement
- If not, discuss CORE with MH
- Plan Finder search
Case Study — Rob N. Hood
Rob N. Hood
2 Sherwood Forest Land
Merrymen, MA09090
781-099-0999
DOB: 3/23/38
U. S. Citizen: Yes
Marital Status: Single
Employment Status: Retired
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.
Mr. Hood lives in senior housing
______
A friend told Mr. Hood to talk to a SHINE counselor about getting on MassHealth.
How would you help him?
- Not eligible for MH – income and assets too high
- QI1 application – will pay Part B premium
- LIS application – assist with premium and co-pays
- Plan Finder search to compare PPO vs. Medigap and PDP
Case Study — Polly 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 7/1. 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 it’s true that MassHealth might not continue to cover her.
How would you help her?
- At 65 – her income is too high for MH
- If she can work (40 hrs/mo at $1.00/hr) can pay small premium and get CommonHealth (will pay Part B premium and give Full LIS)
- Explain Medicare 101 with MH as Supplement
- Needs a PDP - Plan Finder search
- If she cannot work, then no MH – will have Medicare and needs a supplement plan
- Will have QI1 and LIS
- Plan Finder search
Case Study Mr. & Mrs Owen Money
Mr. Money meets with you at the SHINE office. Mr. Money receives a Social Security check for $1250 a month and Mrs. Money receives a check for $950 a month. They have a joint savings account with $8500, a CD for $23,000 and $4,000 in a checking account. They own their home and a car.
They both have a Supplement 1 plan with a monthly premium of about $176 each. They joined the Part D plan their friend suggested with the lowest monthly premium. They both take some expensive medication and are now paying 45% of the cost for their meds as they are in the coverage gap.
Mr. Money tells you his wife has dementia and a number of other health problems. He is her primary caregiver with some help from family. He also pays for in-home help from time to time when he is not able to provide it himself.
Mr. Money says he is worried about the cost of their medication and how long he will be able to care for his wife at home if he needs to pay for more in-home services.
- Frail Elder Waiver for wife
- Contact ASAP for Nursing evaluation
- Transfer all but $2,000 of assets into his name
- MH application –personal care services
- Plan Finder search for both of them
- Drugs will be $0 co-pays for her
- PA application for him - will help with co-pays in gap
Mel 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 Advantage.
How would you help him?
- Did he send LIS denial to PA?
- Contact PA to check status of his application
- What category PA? If S5 – $200 yearly premium, no coverage in gap, but SEP to change MA-PD
- If S2-S4 –no premium, assistance in the gap and SEP to change MA-PD
- Plan Finder search to compare cost of drugs in MA-PD and PDP
Case Study – Pearl E Whites
Pearl E. Whites
501 Need Street
Broke, MA 06060
781-066-0666
DOB: 6/19/38
U.S. Citizen: Yes
Marital Status: Widow
Employment Status: Retired
Income: Social Security $910/month (Net)
Assets: $1300 in checking, $200 in savings
Insurance: Medicare A & B effective 6/1/03 and currently enrolled in a
Medicare Advantage HMO with the basic drug plan
Ms. Whites lives in senior housing
______
A neighbor told Ms. Whites she should apply for MassHealth which
would allow her to drop her insurance. She meets with you at the SHINE
office to learn how to apply for MassHealth.
How would you help her?
- Income too high for MH
- QI1 application – will pay Part B premium
- LIS application – assist with premium and co-pays
- HSN will help with MA hospital co-pays - MH application
MassHealth Quiz
- To qualify for a MassHealth Buy-in Program a beneficiary must have limited income and assets.
___X__True_____False
- If a beneficiary receives Medicare, he/she automatically qualifies for
MassHealth.
_____True__X___False
- Gail and Frank Smith are applying for MassHealth. Their combined gross
Income is $1500 per month. They have $5000 in assets. They qualify for
MassHealth Standard.
_____True___X__False
- Mr. & Mrs. Kelly’s income and assets are listed below. Would they qualify for a benefit program?
Gross Income: Mr. $850/month,Mrs. $350/month
Assets: $1200 — checking, $3000 — savings
Yes - QMB
- Calculate the spend-down for MassHealth Standard for Jerome.
$1025/mo (net) Social Security
$1,200 savings , $200 checking
No other assets
Assuming >65, Spend-down would be:
$1025 + $105 = $1130 - $20 - $522 = $588 x 6 = $3528
Public Benefits Part 1-20161