Addendum to 2004 Guide to Health Insurance for People with Medicare

[LOGO] COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE One South Station • Boston, MA 02110 - 2208 (617) 521-7794 • FAX (617) 521-7750 TTY/TDD (617) 521-7490 http://www.state.ma.us/doi MITT ROMNEY GOVERNOR BETH LINDSTROM DIRECTOR, CONSUMER AFFAIRS AND BUSINESS REGULATION KERRY HEALEY LIEUTENANT GOVERNOR JULIANNE M. BOWLER COMMISSIONER OF INSURANCE ## Bulletin 2004-11 To: Commercial Health Insurance Companies, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations From: Commissioner Julianne M. Bowler Julianne M. Bowler Re: Addendum to "2004 Guide to Health Insurance for People with Medicare" Date: November 19, 2004 Enclosed please find a copy of the Massachusetts Addendum to the "2004 Guide to Health Insurance for People with Medicare." The Massachusetts Addendum must be provided along with the "2004 Guide to Health Insurance for People with Medicare" to those people eligible for Medicare pursuant to Massachusetts regulations 211 CMR 42.09(4) and 211 CMR 71.13(2)(d)4. Please note that the Massachusetts Addendum is in 14-point type. Please do not inadvertently include this bulletin cover memo with the Addendum when it is given to consumers. Questions regarding this bulletin by licensed carriers may be directed to Nancy Schwartz, Director, Bureau of Managed Care at the Division of Insurance at (617) 521-7347. [LOGO] The Commonwealth of Massachusetts Executive Office of Elder Affairs One Ashburton Place, Boston, MA 02108 Mitt Romney Governor Kerry Healey Lieutenant Governor Jennifer Davis Carey Secretary Phone (617) 727-7750 Fax (617) 727-9368 TTY/TTD 1-800-872-0166 ## Massachusetts Bulletin for People with Medicare Medicare beneficiaries and others have options for receiving their health care. Major health care options include: - Original Medicare Plan (Parts A and B) - Medicare Supplement Insurance (Medigap) - Medicare Advantage Plans (Medicare HMOs) - Medicare-Approved Drug Discount Cards - Employee Group Health Plans (employer, professional, union, trade group) - Retiree Group Health Plans (employer, professional, union, trade group) - MassHealth (Medicaid) helps pay medical costs for people with limited income and resources - Senior Care Options (SCO) combines health care and social support services to help seniors receive medical care and other services while living at home or in a long-term care facility - PACE (Program of All-inclusive Care for the Elderly) also known as Elder Service Plans combine health care and social services to help frail people receive medical care and other services while living at home - Prescription Advantage, a state sponsored prescription insurance plan for seniors and adults with disabilities - Additional programs include free care at community health centers or hospitals and individual (“non-group”) health insurance. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 2 This Bulletin provides basic information about Medicare, Medigap, Medicare HMOs, MassHealth and other health care programs for people who do not have any group insurance available to them. If you have group health coverage from an employer, call the benefits administrator of your health plan for information. If you are a veteran, contact your local Veterans Agent for information about veterans health care services. Included in this Bulletin are: - Charts showing Medicare A and B benefits, copayments and deductibles - Charts detailing the three standard Massachusetts Medigap policies and alternative benefit rider, Medigap insurance carriers, and premiums - Charts listing Medicare HMOs with premiums and co-payment amounts ## Medicare Medicare is a health insurance program for: ☐ People age 65 or older, ☐ Certain people with disabilities under age 65, and ☐ People with End-Stage Renal Disease (permanent kidney failure) Medicare has two parts: ☐ Part A (Hospital Insurance) helps pay for hospital care, skilled nursing care, home health care, hospice care and other services. ☐ Part B (Medical Insurance) helps pay for outpatient medical services such as doctors' services, x-rays and tests, physical, occupational and speech therapy, outpatient hospital care, ambulance service, medical supplies and equipment and other medical services. Most people do not have to pay a premium for Part A coverage. A monthly premium is charged for Part B coverage. Contact the Social Security Administration to find out if you are eligible for Medicare. You can select your health care coverage under the Original Medicare Plan or a Medicare Advantage Plan (Medicare HMO). Both options cover all Part A and Part B benefits. ## Original Medicare Under the Original Medicare Plan you may go to any doctor, specialist, hospital or other provider that participates in Medicare. The Original Medicare does not pay for all the costs for Medicare covered services. See the attached chart Medicare Part A and Part B Benefits and Gaps; also, read the Medicare & You Handbook for details. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 3 ## Medicare Advantage (Medicare HMOs) A Medicare HMO is a private company under yearly contract to provide Medicare Part A and Part B covered services as a Medicare Advantage Plan. Medicare HMOs may provide additional benefits including but not limited to periodic routine exams, health screenings, vision services, prescription drugs, dental visits, hearing exams, eyeglasses and/or wellness programs. Medicare HMO services are provided through a network of contracting medical providers. Medical providers, however, may terminate their contract with the Medicare HMO during the year. Most Medicare HMO plans require members to get all health care (except for emergency and out of service area urgently needed services) from the HMO's network of providers and facilities. Beneficiaries must follow all plan member rules including rules for getting referrals and prior authorization when necessary. You may join a Medicare HMO if: - ☐ You are enrolled in both Part A and Part B of Medicare, - ☐ Your permanent residence is in the HMO's service area, and - ☐ You do not have End Stage Renal Disease. You may join a Medicare HMO up to three months before your Medicare coverage begins or at any time thereafter. You may switch to another HMO plan or disenroll and return to Original Medicare throughout the year. See the attached Medicare HMO charts for comparisons of premiums and co-payments of Medicare HMOs in your area and who to contact for information and enrollment. For assistance contact a SHINE counselor at your local senior center. ## Medicare-Approved Drug Discount Cards Beginning May 3, 2004, private organizations began marketing Medicare-approved drug discount cards to people with Medicare. The discount cards will be honored by most retail and mail-order pharmacies beginning June 1st and are expected to offer Medicare beneficiaries discounts on their prescription drugs of between 10 and 25 percent. An annual enrollment fee should not be more than $30. Low income beneficiaries may also receive credit of up to $600 each year in 2004 and 2005 to help pay for their prescriptions. To qualify for a $600 credit, your 2004 annual income cannot exceed: - $12,569 for a single person, or - $16,862 for a married couple If you qualify for the $600 credit, you do not pay an enrollment fee. For detailed information contact 1-800-Medicare and www.medicare.gov. For free one-on-one assistance and counseling contact a SHINE counselor at your local senior center. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 4 # Medicare Supplement Insurance ("Medigap") Medigap is health insurance sold by private insurance companies to individuals enrolled in Original Medicare. Medigap insurance helps pay for some of the Medicare deductibles and co-payments not covered under Original Medicare. Medigap policies must be clearly marked "Medicare Supplement Insurance" Insurance coverage and text is standard for all carriers. The attached Medigap chart that shows the three standard Medigap policies that can be sold in Massachusetts. Medigap policies are regulated by federal and state laws. The three standard Medigap policies sold in Massachusetts are: - "Medicare Supplement Core" - "Medicare Supplement 1" (no outpatient prescription drug coverage) - "Medicare Supplement 2" (unlimited outpatient prescription drug coverage) Federal law requires that Medigap policies be "guaranteed renewable". A guaranteed renewable policy cannot be cancelled unless the beneficiary stops paying the premium or provides false information on the application when they buy the policy. The company must continue the policy, with no changes in benefits (except to keep up with changes in Medicare). Note: Group health insurance (employer, professional, union, or trade group, etc.) may supplement Original Medicare but is not technically Medigap insurance and does not have to meet federal and state Medigap requirements. Medigap beneficiaries pay premiums for Medigap coverage. Medigap companies selling policies in Massachusetts offer the same premium (a "community rate") to all policyholders; they cannot charge a different premium based on your age or health problems. Medigap companies may offer a premium discount for up to three years if a person enrolls in a Medigap plan within the first 6 months of initial eligibility (see "When Can You Buy Medigap Insurance" paragraph b). You do not need to buy a Medigap policy if you are enrolled in a Medicare HMO plan. Medigap policies in Massachusetts do not include coverage for "excess physician fees" above the Medicare approved charge because under Massachusetts law a licensed physician cannot collect more than the Medicare approved charge for any Medicare service provided to a Medicare beneficiary. This law is known as the "Massachusetts Ban on Balance Billing". SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 5 # Additional Benefits Available through Alternative Benefits Rider Medigap companies may also sell a separate “rider” that provides additional health benefits that are not otherwise covered by Medicare or a Medicare Supplement Core or Medicare Supplement #1 policy. An Alternate Innovative Benefit Rider may offer additional preventive health care services, medical care while traveling abroad, and outpatient prescription drugs. In Massachusetts, Blue Cross and Blue Shield of Massachusetts, Inc. sells an Alternate Innovative Benefit Rider for their Medicare Supplement Core Policy. See the charts at the end of this Bulletin for a description of the benefits that must be included in any alternative benefit rider offered for sale in Massachusetts. Please note: While all Medigap policies must be “guaranteed renewable”, the alternative benefit riders are not “guaranteed renewable”. Federal law requires that Medigap policies be “guaranteed renewable”. A guaranteed renewable policy cannot be cancelled unless the beneficiary stops paying the premium or provides false information on the application when they buy the policy. The company must continue the policy, with no changes in benefits (except to keep up with changes in Medicare). However, alternative benefit riders are not “guaranteed renewable” and may be changed or cancelled in the future. If a company decides to not renew or to change a rider, it must notify you 90 days before the date of the change or cancellation. At that time, you would have the option to change to another Medicare Supplement policy during a special 60-day open enrollment period without any break in coverage. ## Who Can Buy A Medigap Policy? Any Massachusetts resident enrolled in Medicare Part A and Part B may buy Medigap insurance in Massachusetts except for individuals under age 65 who are eligible for Medicare solely due to End-Stage Renal Disease. Medigap insurers in Massachusetts cannot refuse to sell a policy, exclude or limit coverage, or require a waiting period before coverage starts due to existing health problems. However, Medigap companies do limit sales to certain times in the year. ## When Can You Buy Medigap Insurance? In Massachusetts, you can buy Medigap insurance (policies or alternative benefit riders) during one of the following Medigap Open Enrollment Periods: SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 6 a. The annual open enrollment period starts February 1st and ends March 31st. Benefits for people who enroll during the annual open enrollment period begin June 1st. b. A six month open enrollment period begins when a person is “initially eligible” for Medigap. To be initially eligible, an individual must have just: - enrolled in Medicare Part B for the first time - become a resident of Massachusetts - moved out of the service area of their HMO plan - lost or is about to lose employer coverage - turned age 65, after becoming eligible for Medicare Part B benefits due to disability or end stage renal disease occurring before turning age 65. c. A 63 day Medigap open enrollment period begins when a person: - has employer health insurance coverage that pays second to Medicare but the coverage was stopped or is about to be stopped, or - loses retiree health insurance coverage, or - has a Medigap policy end due to an involuntary termination, or - is insured by a Medigap policy or Medicare HMO and the company or its agent misrepresents the policy’s terms and conditions during marketing or substantially violates a provision of its policy or contract; or - is enrolled in their first Medicare HMO plan and decides to disenroll (for any reason) from the plan within the first 12 months of enrollment. - If a person cancels a Medigap policy to join the HMO, that person can get the old policy back if it is still offered for sale; if not, they can choose a Core policy or Supplement 1 policy. - If a person selects a Medicare HMO as their first choice, that person may select any Medigap policy offered for sale in the state. To avoid a break in coverage, that person can apply for Medigap insurance up to 60 days before the actual HMO disenrollment date. d. A five-month open enrollment period occurs if a person is enrolled in a Medicare HMO or Elder Service Plan that announces it will stop doing business in their area as of December 31st. If this happens, the Medigap open enrollment period would begin upon the receipt of an October 2nd notification letter from the plan and end March 4 of the following year. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 7 # Other Programs That Help Pay for Your Health Care MassHealth (Medicaid) www.state.ma.us/masshealth Customer Service Center 1-800-841-2900 (TTY:1-800-497-4648) MassHealth provides a wide range of health care services that pay for all or part of health care costs for elders with limited income and resources and adults with disabilities through its Office of Long Term Care. MassHealth is administered by the Office of Medicaid in the Executive Office of Health and Human Services. MassHealth manages insurance programs for elders, children, low-income parents, disabled adults and pregnant women. MassHealth Standard Health Insurance pays for Medicare premiums, deductibles and co-payments for Medicare beneficiaries and provides additional benefits, too, including outpatient prescription drugs, medical transportation, adult day health programs, and other services. You may enroll in MassHealth Standard if you are: - single and your income is not greater than $776* per month and your assets do not exceed $2,000* - married and your combined marital income is not greater than $1,041* per month and your combined assets do not exceed $3,000*. ## MassHealth Standard for Elders Who Need Personal Care Attendant (PCA) Services You may enroll into MassHealth Standard if you are 65 or older and need PCA services if you are: - single and your income is not greater than $1,032* per month and your assets do not exceed $2,000*. - married and your combined marital income is not greater than $1,385* per month and your combined assets do not exceed $3,000.* Medicare Savings Programs are federal programs that help pay for Medicare premiums and other medical costs such as deductibles and copayments for qualified residents of Massachusetts with limited income and resources. Medicare Savings programs in Massachusetts are administered by MassHealth and include the following: ### Qualified Medicare Beneficiary Program (QMB) QMB pays the Medicare Part A and Part B premiums, Medicare deductibles and copayments. You can enroll in QMB if you are: - single and your income does not exceed $776* per month and your assets do not exceed $4,000.* SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 8 ▪ married and your combined income does not exceed $1,041* per month and your combined assets do not exceed $6,000*. # **Specified Low-Income Medicare Beneficiary Program (SLMB) & Qualifying Individual (QI-1) Programs** SLMB and QI-1 programs pay the monthly Medicare Part B premium. You can enroll if you are: - single and your income does not exceed $1,048* per month and your assets do not exceed $ 4,000*. - married and your combined income does not exceed $1,406* per month and your combined assets do not exceed $6,000*. To find out if you are eligible for any of the MassHealth Standard Programs or Medicare Savings Program, contact the MassHealth Customer Service Center 1-800-841-2900 (TTY:1-800-497- 4678 for the deaf and hard of hearing) or visit their website at www.state.ma.us/masshealth * valid until 03/31/05 and subject to change on April 1st of each year # **SCO (Senior Care Options)** www.state.ma.us/masshealth 1-888-885-0484 TTY: 888-821-5225 MassHealth Senior Care Options (SCO) is a new program that combines Medicare and Medicaid services with social support services to help seniors maintain their health and live in the community as long as possible while getting the health care and other services they need. SCO is also available to most seniors residing in long-term care facilities. SCO covers all of the services covered by MassHealth. If the person also has Medicare, all Medicare services are also covered. SCO services include: - primary care and specialty services - preventive health care services - prescription drugs (no co-pays) - limited dental services - lab and x-rays - emergency care - inpatient hospitalization - mental health and substance abuse treatment services - nursing facility care - community long-term care - transportation for medical care SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 9 - 24-hour access to professional staff - rehabilitative therapies - medical equipment - home care services - respite care for family or other caregivers - geriatric support services and other services specified in the individual's personal care plan To be eligible for enrollment in SCO, the person must meet the following requirements: - be aged 65 or older - be eligible for MassHealth Standard - live in a the service area of a senior care organization - not be diagnosed as having end-stage renal disease - if enrolled in Medicare, must have Parts A&B - not be subject to a six-month deductible period ("spend-down") - not be a resident or inpatient in a chronic hospital or intermediate care facility For information contact MassHealth Senior Care Options (SCO) at 1-888-885-0884 (TTY: 1-888-821-5225 for the deaf and hard of hearing) or visit www.state.ma.us/masshealth ### PACE (Program for All-Inclusive Care for the Elderly) 1-800-841-2900 (also called Elder Service Plan) TTY:1-800-497-4648 www.state.ma.us/masshealth PACE combines medical care, social services, and long-term care services for frail people. PACE helps frail people maintain their health and independence and live in the community while getting the health care and other services they need. PACE provides the following services: - primary health care - physical and occupational therapy - social services - personal care - home services - transportation - prescriptions - day health center participation - other services as needed To be eligible, an individual must meet the following criteria: SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 10 - be age 55 or older, - live in the service area of the PACE (Elder Service Plan) program - be certified as eligible for nursing home care by MassHealth - be able to live safely in the community Enrollment in PACE is voluntary and a member may disenroll at any time. Persons may have to pay a monthly premium depending on MassHealth or Medicare eligibility. The PACE program model is a health-care program sponsored by the Centers for Medicare and Medicaid Services and the Commonwealth of Massachusetts Division of Medical Assistance. The following six organizations operate PACE-Elder Service Plans in designated service areas in Massachusetts: Elder Service Plan of the East Boston Neighborhood Health Center 10 Grove Street East Boston, MA 02138 617-568-4602 Harbor Health Services Elder Service Plan 2216 Dorchester Ave. Dorchester, MA 02124 617-296-5100 Elder Service Plan of Uphams Corner 1140 Dorchester Avenue Dorchester, MA 02123 617-288-0970 Elder Service Plan at Fallon* 277 East Mountain Street Worcester, MA 01608 508-856-2026 * You do not need to be a Fallon Community Health Plan Member to join. Cambridge Hospital Elder Service Plan 270 Green Street Cambridge, MA 02139 617-575-5850 Elder Service Plan of North Shore 20 School Street Lynn, MA 01901 781-581-7565 For information about eligibility and to find out if you live in a designated service area call MassHealth at 800-841-2900 (TTY: 1-800-497-4648 for the deaf and hard of hearing). SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 11 Prescription Advantage P.O. Box 15153 Worcester, MA 01615-0153 www.800ageinfo.com 1-800-AGE-INFO (1-800-243-4636) TTY: 877-610-0241 Prescription Advantage is an insurance plan available to all Massachusetts residents age 65 and over, and younger, low-income individuals with disabilities. Prescription Advantage offers prescription drug coverage that is combined with an annual out of pocket spending limit. Prescription Advantage was created by the Commonwealth of Massachusetts and is administered by the Massachusetts Executive Office of Elder Affairs. Massachusetts residents can enroll in Prescription Advantage at any time if: - Over 65 (but not yet 66); or - Under Age 65 and meet disability guidelines; or - Age 66 or older and: - Moved to Massachusetts in the past 6 months; or - Involuntarily lost health care coverage within the past six months; or - Became ineligible for Medicaid within the past six months Members of the plan pay monthly premiums, a quarterly deductible and co-payments, all of which are graduated, based on your gross annual household income. However, you will never pay more than your annual out-of-pocket spending limit (excluding premiums) in any given plan year. SHINE counselors can assist with applications if needed. For enrollment information and applications contact Prescription Advantage at 1-800-AGE-INFO (1-800-243-4636). ### Other Health Care Programs #### Free Care (Uncompensated Care Pool) 617-988-3222 The Massachusetts Division of Health Care Finance and Policy administers the Free Care Pool program that helps pay for medical services at acute care hospitals and community health centers for uninsured and underinsured Massachusetts residents. For information contact your hospital or community health center or call 617-988-3222. #### Veterans' Administration (VA) Health Care System 1-800-827-1000 The VA Health Care System provides inpatient and outpatient medical service, prescription drugs and medical supplies. Veterans may enroll at any time at any VA SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 12 medical center or clinic and at any veteran's agent office in Massachusetts. For more information, call the VA Health Benefits Service Center or visit www.va.gov/health/elig # COBRA # Employee Benefits Security Administration (EBSA) 1-866-444-3272 COBRA (The Consolidated Omnibus Budget Reconciliation Act of 1985) is a federal law that gives certain employees and their dependents the right to continue health coverage at group rates when coverage is lost due to specific events. COBRA applies to employers with 20 or more employees. For information about COBRA contact your employee benefit administrator or call EBSA at 1-866-444-3272 or visit www.dol.gov/ebsa. # Mini-COBRA # Massachusetts Division of Insurance 617-521-7777 Mini-COBRA is a Massachusetts state law that gives certain employees and certain dependents the right to continue health coverage at group rates when coverage is lost to specific events. Mini-COBRA applies to Massachusetts employers with 1 to 19 employees. Coverage and eligibility of Mini-COBRA is similar to COBRA. For detailed information about Mini-COBRA, contact your employee health plan benefit administrator or call the Massachusetts Division of Insurance at 617-521-7777 or visit www.state.ma.us/doi # TRICARE for Life/Military Retiree Benefits 1-888-363-5433 TRICARE for Life provides expanded medical coverage for Medicare-eligible uniformed service retirees, including National Guard members and reservists, Medicare-eligible family members, widows/widowers and certain former spouses. A person must have Medicare Part A and Part B to be eligible for TRICARE. For detailed information about TRICARE, call 1-888-363-5433 or visit www.TRICARE.osd.mil. # What is the SHINE Health Insurance Counseling Program? The SHINE Health Insurance Counseling Program provides free health care information, counseling and assistance to Medicare beneficiaries of all ages. SHINE Counselors are trained and certified by the Massachusetts Executive Office of Elder Affairs in all areas of elder health insurance. SHINE Counselors meet face to face with Medicare beneficiaries and caregivers in confidential community settings and explain Medicare, Medicare HMOs, Medigap, Medicaid (MassHealth), Medicare Savings Programs, prescription drug programs and other insurance options for Medicare beneficiaries. SHINE Counselors help consumers evaluate, compare and choose a health plan that best meets the personal SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 13 needs of the client. SHINE Counselors also help dealing with payment denials or appeals, Medicare rights and protections and Medicare bills. The SHINE Program is administered by the Massachusetts Executive Office of Elder Affairs in partnership with councils on aging and many other community based social service agencies throughout the state. The SHINE program is partially funded by the Centers for Medicare & Medicaid Services To contact a SHINE Counselor, call 1-800-AGE-INFO (1-800-243-4636) (TTY: 1-800-872-0166) or call or visit your Council on Aging. For SHINE Fact Sheets and charts, contact your local SHINE counselor or visit the Office of Elder Affairs web site at www.800ageinfo.com. SHINE charts, fact sheets and other information are also available at www.medicareoutreach.org SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 14 # Health Care Directory SHINE Health Insurance Counseling Program www.800ageinfo.com or www.medicareoutreach.org 1-800-AGE-INFO (1-800-243-4636) TTY: 1-800-872-0166 The SHINE Program provides free health insurance information, assistance and counseling to Medicare beneficiaries of all ages. SHINE Counselors help beneficiaries compare costs and benefits of various health plans, explain the benefits of Medicare and additional insurance options, including Medigap, HMOs, MassHealth and prescription drug options, and sort out problems with claims, billing or denials in care. MassHealth www.mass.gov/masshealth Customer Service 1-800-841-2900 TTY: 1-800-497-4648 MassHealth provides a wide range of health care services that pay for all or part of the health care cost for elders with limited income and resources. Contact MassHealth for information about their health care programs including MassHealth Standard and Medicare Savings Programs. MassHealth Senior Care Options (SCO) www.mass.gov/masshealth 1-888-885-0484 TTY: 1-888-821-5225 A health plan that combines Medicare and Medicaid services with social support services that helps seniors maintain their health and continue to live in their own homes. Massachusetts Division of Insurance www.mass.gov/masshealth Boston Springfield 617-521-7777 413-785-5526 The Division of Insurance monitors insurance companies authorized to sell insurance in Massachusetts, reviews insurance contracts, forms and rates to ensure compliance with Massachusetts regulations, and investigates consumer complaints against insurance companies, brokers, agents and other licensees. The Division provides general insurance information, publications and advice on consumer rights and protections. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 15 Medicare 24-Hour Information Hotline www.medicare.gov 1-800-MEDICARE (1-800-633-4227) Protective Services Elder Abuse Hotline 1-800-922-2275 Protective Services provide services to eliminate or alleviate abuse of elders. Community agencies and case workers coordinate and provide a variety of health, mental health, legal and social services. To report elder abuse, call the Elder Abuse Hotline 24-hours a day, 7 days a week. Office of the Massachusetts Attorney General Hotline www.ago.state.ma.us 1-888-830-6277 The Attorney General's Hotline staff answers questions and assists with consumer complaints for all types of insurance. The Attorney General's Office mediates problems and provides educational materials. MassPRO (Massachusetts Peer Review Organization) www.masspro.org Helpline 1-800-252-5533 MassPRO contracts with Medicare as a Quality Improvement Organization (QIO) that oversees and improves the care given to Medicare patients. MassPro processes appeals for Medicare patients denied Medicare hospital coverage and reviews Medicare beneficiary medical quality of care complaints ncerning hospitals, skilled nursing facilities, home health agencies, health centers, HMOs and doctor's offices. Massachusetts Medicare Advocacy Project (MAP) 1-800-323-3205 MAP provides Medicare beneficiaries free legal advice and legal representation for appealing medical decisions made by Medicare providers in both fee-for-service Medicare and Medicare HMOs and for other insurance programs. National Medicare Hotline 1-800-MEDICARE Publications, benefits information and claims processing Medicare Part B 1-800-882-1228 Benefits information and claims processing Medicare Part A 1-888-896-4997 Benefits information and claims processing Durable Medical Equipment 1-800-842-2052 Benefits information and claims processing SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 16 MassMedLine www.massmedline.com 1-866-633-1617 MassMedLine provides prescription medication information and help to Massachusetts residents applying for prescription drug assistance programs. MassMedLine is staffed by pharmacy professionals who work with patient's doctors to obtain medications at the lowest price. MassMedLine provides information about processing. # Social Security Administration 1-800-772-1213 www.ssa.gov Contact Social Security to enroll in Social Security, SSI, SSDI and Medicare, or to report a change in address or income, or to replace a lost Medicare card. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 17 # Standard Medigap Plans Sold in Massachusetts | Comparison of Plans | Core | Supplement 1 | Supplement 2 | | --- | --- | --- | --- | | Basic Benefits Included In All Plans: | | | | | Hospitalization Part A Co-payments | | | | | Days 61 - 90: $228 per day | X | X | X | | Days 91-150: $456 per day | X | X | X | | 365 Additional Lifetime Hospital days - Paid in full | X | X | X | | Part B Coinsurance - | | | | | Coverage of coinsurance, in most cases, 20% of approved amount | X | X | X | | Parts A and B Blood First 3 pints | X | X | X | | Additional Benefits | Core | Supplement 1 | Supplement 2 | | Part A Deductible for Hospital Days 1 - 60 | | X | X | | $912 per benefit period | | | | | Skilled Nursing Facility Coinsurance | | X | X | | Days 21-100 - $114 per day | | | | | Part B Annual Deductible - $110.00 | | X | X | | Foreign Travel - For Medicare-covered services needed while traveling abroad. | | X | X | | Inpatient Days in Mental Health Hospitals In addition to Medicare's coverage of 190 lifetime days and less any days previously covered by plan in same benefit period | 60 days per calendar year | 120 days per benefit period | 120 days per benefit period | | Outpatient Prescription Drugs ** | | | | | From Retail Pharmacies after a you meet a $35 calendar quarter deductible: | | | X | | • 100% coverage for generic drugs | | | | | • 80% coverage for brand-name drugs | | | | ** These drugs include: insulin needles and syringes provided by home infusion therapy providers; drugs used on an off-label basis for the treatment of cancer or HIV/AIDS; medically necessary services associated with the administration of such drugs. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 18 # Medicare Supplement Core with Alternate Innovative Benefits Rider ## Medex Core Plus Rider This Alternate Innovative Benefits Rider is a Blue Cross and Blue Shield of Massachusetts, Inc. rider to the company's Medicare Supplement Core Policy. The Medex Core Plus Rider offers preventive and prescription drug benefits that are in addition to what is available through the Medex Core Policy. The Medex Core Plus Rider is not guaranteed renewable and the benefits can be changed as of the Medex rate anniversary. If the rider is to be non-renewed or changed you will be notified 90 days before the anniversary date of March 15. At that time, you will have the option to change to another Medicare Supplement plan during a special 60-day open enrollment period without any break in coverage. | Services | Plan Pays | | --- | --- | | Foreign Travel | Remainder of charges including portion normally paid by Medicare | | Preventive Services | | | Routine Vision | Every two calendar years: One exam; $100 towards corrective lenses | | Routine Dental | Every six months: One routine cleaning | | Routine Hearing | Every two calendar years: One exam; $200 towards hearing aids | | Fitness | Every calendar year: $150 reimbursement | | Weight Loss Programs^{†} | Every calendar year: $150 reimbursement | | Outpatient Prescription Drugs – *$150 limit on brand name drugs per calendar quarter | | | Generic Drugs | | | Retail | 50% Coinsurance | | Mail Service | 70% Coinsurance | | Brand Name Drugs | | | Retail | 50% Coinsurance* | | Mail Service | 70% Coinsurance* | † Covered programs include certain Weight Watchers and hospital based programs. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 19 # Medicare Supplement Plans Offered in Massachusetts | Medigap Carriers Please note that rates may change in 2005. | Medicare Supplement Core | Medicare Supplement 1 | Medicare Supplement 2 | Medicare Supplement Core with Medex Core Plus Rider | | --- | --- | --- | --- | --- | | Blue Cross & Blue Shield of MA (Medex™) 1-800-678-2265 sales/apps 1-800-258-2226 mbr svcs 1-800-522-1254 (TDD) www.bluecrossma.com (open enrollment: Feb-Mar²; initial eligibility¹; special open enrollment period: Nov-Dec 2004 for Jan 2005) | $84.34 (Rate of $77.54 to be effective 3/15/05) | $139.01 (Rate of $138.41 to be effective 3/15/05). | $476.01 (Rate of $523.13 to be effective 3/15/05) | $157.24 (Rate of $162.76 to be effective 3/15/05) | | United HealthCare™ Insurance Company Only for members of AARP (American Association of Retired Persons) 1-800-523-5800 (open enrollment: Feb-Mar²; initial eligibility¹) | $110.25 | $148.50 | $442.75 | Not available | 1. Plan offers discounted rates to certain members joining when initially eligible. 2. Plan adds surcharge for enrollment after initial eligibility period. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 20 # Medicare HMO Plans Offered in Massachusetts ## for Coverage in 2005 | Medicare HMO | Monthly Premium | Copays and Deductibles | Prescription Drug Benefit | Service Area by County | | --- | --- | --- | --- | --- | | Fallon Community Health Plan, Inc. 1-800-868-5200 TTY: 1-877-608-7677 | Fallon Senior Plan Saver $0 | $15 PCP copay $20 specialist copay $450 inpatient deductible | No drug coverage | Worcester, portions of Hampden, Hampshire, Franklin, Middlesex and Norfolk: $0 | | | Fallon Senior Plan Standard $30-$35 See Service Area by County | $15 office visit copay $250 inpatient deductible | No drug coverage | Worcester, portions of Hampden, Hampshire, and Norfolk: $30 Portions of Franklin and Middlesex: $35 | | | Fallon Senior Plan Plus $80-$85 See Service Area by County | $10 office visit copay $100 inpatient deductible | $175/calendar qtr at discounted price ($700 total/year) Retail copay (up to a 30-day supply): $ 10 Tier 1 $ 20 Tier 2 $ 40 Tier 3 Mail order copay (up to a 90-day supply) $ 20 Tier 1 $ 40 Tier 2 $ 120 Tier 3 | Worcester, portions of Hampden, Hampshire, and Norfolk: $80 Portions of Franklin and Middlesex: $85 | SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 21 | Medicare HMO | Monthly Premium | Copays and Deductibles | Prescription Drug Benefit | Service Area by County | | --- | --- | --- | --- | --- | | HMO Blue Blue Cross Blue Shield of Massachusetts, Inc. 1-800-678-2265 TTY: 1-800-522-1254 | Blue Care 65 $100 to $124 See Service Area by County | $10 PCP copay $20 specialist copay | $150/calendar qtr at discounted price ($600 total/year) Retail Copay (up to 34-day supply): $ 10 Generic $ 25 Brand Mail Order (up to 90-day supply): $ 20 Generic $ 50 Brand | Barnstable, Bristol: $119 Franklin, Hampden, Hampshire: $116 Essex, Plymouth: $100 Middlesex, Norfolk, Suffolk: $121 Worcester: $124 | | Harvard Pilgrim Health Care, Inc. 1-800-779-7723 TTY: 1-800-439-2370 | First Seniority (without drug coverage) $81 | $15 office visit copay $50 emergency room copay $300 inpatient deductible (max 600/year) | No drug coverage | Essex, Middlesex Norfolk, Suffolk: $81 | | | First Seniority (with drug coverage) $122 | $15 office visit copay $50 emergency room copay $300 inpatient deductible (max 600/year) | $150/calendar qtr at retail price ($600 total/year) Retail copay (30-day supply): $ 10 Tier 1/generic $ 20 Tier 2 $ 35 Tier 3 Mail Order copay (90-day supply): $ 20 Tier 1/generic $ 40 Tier 2 $ 105 Tier 3 | Essex, Middlesex Norfolk, Suffolk: $122 | SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 22 | Medicare HMO | Monthly Premium | Copays and Deductibles | Prescription Drug Benefit | Service Area by County | | --- | --- | --- | --- | --- | | Tufts Associated Health Plan 1-800-246-2400 TTY: 1-888-899-8977 | Secure Horizons (without drug coverage) $50 to $111 See Service Area by County | $10 PCP copay $15 specialist copay $200 inpatient deductible | No drug coverage | Barnstable: $50 Bristol: $96 Essex: $97 Hampden: $75 Middlesex: $87 Norfolk: $51 Plymouth: $51 Suffolk $111 Worcester: $85 | | | Secure Horizons (with drug coverage) $80 to $141 See Service Area by County | $10 PCP copay $15 specialist copay $200 inpatient deductible | $150/calendar qtr at negotiated price ($600 total/ year) Retail Copay (30-day supply): $ 10 Generic $ 20 Pref Brand $ 40 Non-preferred Mail Order (90-day supply): $ 20 Generic $ 40 Pref Brand $ 80 Non-preferred | Barnstable: $80 Bristol: $126 Essex: $127 Hampden: $105 Middlesex: $117 Norfolk: $81 Plymouth: $81 Suffolk $141 Worcester: $115 | The premium and co-payment levels printed in this chart have been submitted for approval to the Centers for Medicare and Medicaid Services, the agency that administers Medicare. Contact the company for more information about these products. SHINE Counseling Program of the Executive Office of Elder Affairs November 2004 23