Addendum to 2005 Guide to Health Insurance for People with Medicare

[LOGO] MITT ROMNEY GOVERNOR KERRY HEALEY LIEUTENANT GOVERNOR 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) 521-7475 TTY/TDD (617) 521-7490 http://www.mass.gov/doi BETH LINDSTROM DIRECTOR, CONSUMER AFFAIRS AND BUSINESS REGULATION JULIANNE M. BOWLER COMMISSIONER OF INSURANCE # Bulletin 2005-11 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations From: Commissioner Julianne M. Bowler Julianne M. Bowler Re: Addendum to "2005 Guide to Health Insurance for People with Medicare" Date: November 15, 2005 Attached please find a copy of the Massachusetts Addendum to the "2005 Guide to Health Insurance for People with Medicare." The Massachusetts Addendum must be provided along with the "2005 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. Questions regarding this bulletin may be directed to Nancy Schwartz, Director, Bureau of Managed Care at the Division of Insurance at (617) 521-7347. 5. [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: - The Original Medicare Plan (Parts A and B) - Medicare Supplement Insurance (Medigap) - Medicare Advantage Plans - Medicare Prescription Drug Coverage (program starting January 1, 2006) - Employee Group Health Plans (employer, union, retiree or other group plan) - MassHealth (Medicaid) (healthcare for people with limited income and resources - Senior Care Options (SCO) (an option for people on MassHealth) - PACE (Program of All-inclusive Care for the Elderly) - Free Care (Uncompensated Care Pool) for people with low income - Veterans' health benefits, Tricare and other programs This Bulletin provides basic information about Medicare Health Plans, Medicare Prescription Drug Coverage, Medigap (Medicare Supplement Insurance), MassHealth (Medicaid) and other health care programs for people with Medicare. If you have employer, union, retiree, or other group health coverage, contact the benefits administrator of your health plan for information about coverage and other questions. If you are a veteran, contact your local Veterans Agent for information about veterans health care services. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 Included in this Bulletin are: - Charts showing Medicare A and B benefits, copayments and deductibles - Charts detailing standard Massachusetts Medigap policies, 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, - people under age 65 with certain disabilities, and - people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) Medicare has three 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. Medicare Prescription Drug Coverage Beginning January 1st 2006, Medicare prescription drug coverage helps pay for prescription drug costs. ## Medicare Options People with Medicare can select health care coverage under the Original Medicare Plan or one of the Medicare Advantage Plans. Both options cover all Part A and Part B benefits. People with Medicare can get Medicare prescription drug coverage under Original Medicare or a Medicare Advantage Plan. Medicare prescription drug coverage starts January 1st 2006. ## Original Medicare The Original Medicare Plan is a fee-for-service plan managed by the Federal Government. You can go to any doctor, hospital or other provider that accepts Medicare. The Original Medicare Plan does not pay for all the costs for Medicare covered services. ## Medicare Advantage Plans (HMOs, PPOs etc) Medicare Advantage is insurance provided by private companies that contract with Medicare to provide Medicare Part A and Part B services. Medicare Advantage Plan SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 members generally get all of their Medicare covered health care through the plan's network. Most plans provide limited drug coverage through December 31, 2005. Many plans are offering Medicare prescription drug coverage to start January 1, 2006. Some plans provide additional services not covered by Medicare such as routine physical examinations, health screenings and vision services etc. Medicare Advantage Plans include Medicare Health Maintenance Organizations (HMOs), Medicare Preferred Provider Organization Plans (PPOs) and other Medicare plans. ### Medicare Prescription Drug Coverage (coverage starts January 1, 2006) Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. The drug coverage will help pay for prescription drugs costs. Most beneficiaries will pay a monthly premium, an annual deductible and copayments. People with limited income and resources may qualify for help paying for their monthly premium and other costs. ### Who is eligible to enroll in Medicare Prescription Drug Coverage? You are eligible for Medicare prescription drug coverage if you are eligible for Medicare Part A or enrolled in Medicare Part B. ### Do I have to join a Medicare prescription drug plan? No. Joining a Medicare prescription drug plan is your choice. However, if you don't join a Medicare prescription drug plan by May 15, 2006, and you do not currently have drug coverage that is at least as good as standard Medicare prescription drug coverage, you will have to wait until November 15, 2006 to join. When you do join, your premium cost will go up at least 1% per month for every month that you wait to join. You must pay this penalty as long as you have Medicare prescription drug coverage. ### When can I join? If you are already Medicare eligible, you can join a Medicare prescription drug plan between November 15, 2005 and May 15, 2006. If you join by December 31, 2005, Medicare prescription drug coverage will begin January 1st 2006. If you join after that, coverage will be effective the first day of the month after the month you join. The next open enrollment period is November 15th 2006 to December 31, 2006 for coverage to take effect January 1, 2007. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # How much will a Medicare prescription drug plan cost? You will pay: - a monthly premium (generally around $30 in 2006) - a yearly deductible (up to $250 in 2006) - a copayment for your prescriptions Costs will vary depending on which drug plan you choose. If you have limited income and resources and qualify for extra help, you may not have to pay a premium or deductibles. # Where can you get help or more information if you need it? For detailed information or help choosing a Medicare health plan and prescription drug coverage that works for you: - Read the "Medicare & You 2006" official government handbook which is mailed to all Medicare beneficiaries during October 2005. - Look at www.medicare.gov, Medicare's official consumer website. You can find the most up-to-date information, answers to your questions and order Medicare publications anytime. - Call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. This toll-free helpline is available 24 hours a day, seven days a week to answer your questions. - Call MassMedline at 1-866-633-1617 for information and questions about medications. (TTY users should ask the operator to call the MassMedline toll-free number) or visit their website at www.massmedline.com. MassMedline can assist you choosing the Medicare prescription drug plan that meets your needs. Pharmacists on staff can answer questions about medicines you take. - Call SHINE (Serving the Health Information Needs of Elders) at 1-800-AGE-INFO (1-800-243-4636) (TTY users call 1-800-872-1066) for health insurance information, counseling and help choosing a Medicare health plan, buying Medigap insurance and information regarding Medicare rights and protections. # Medicare Supplement Insurance ("Medigap") A Medigap policy is a health insurance policy sold by private insurance companies to individuals enrolled in the Original Medicare Plan to cover the "gaps" in the Original Medicare Plan such as, coinsurance, copayments and deductibles. Some Medigap policies also cover benefits that the Original Medicare Plan does not cover, like emergency health care while traveling outside the United States. The front of the Medigap policy must clearly define it as "Medicare Supplement Insurance." Individual Medigap insurance coverage and text is standard for all insurers. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 The three standard Medigap policies sold in Massachusetts are listed below. See attached Medicare Supplement charts for details. 1. Medicare Supplement Core 2. Medicare Supplement 1 (no outpatient prescription drug coverage) 3. Medicare Supplement 2 (unlimited outpatient prescription drug coverage). If you disenroll from Supplement 2, you cannot re-enroll in Supplement 2 in the future. In compliance with Federal regulations, Medicare Supplement 2 policies covering prescription drugs cannot be sold after December 31, 2005. However existing members may remain enrolled. By remaining enrolled, existing members will continue to have prescription drug coverage. Medigap policies are regulated by federal and state laws: - Medigap policies are guaranteed renewable and cannot be cancelled unless the beneficiary stops paying the premium or provides false information on the application when they buy the policy. - Medigap insurers cannot refuse to sell a policy, exclude or limit coverage, or require a waiting period before coverage starts due to existing health problems. - Medigap plans must offer the same premium (a "community rate") to all policyholders and cannot charge a different premium based on age or health problems. - Under the Massachusetts "Ban on Balance Billing" law licensed physicians cannot collect more than the Medicare approved charge for any Medicare service provided to a Medicare beneficiary. ### 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 You do not need to buy a Medigap policy if you are enrolled in a Medicare Advantage plan. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # When Can You Buy Medigap Insurance? You can purchase Medigap insurance during one of the following Medigap enrollment periods: 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. Special enrollment periods may be scheduled by Medigap insurers if approved by the Massachusetts Division of Insurance. c. A six month open enrollment period begins from the date a person becomes "initially eligible" for coverage in Massachusetts. A person becomes initially eligible on the date when they: - first enroll in Medicare Part B; or - lose employer sponsored health coverage for active employees due to: o termination of employment; or o employer bankruptcy; or o discontinuation of employer sponsored health coverage offered to similarly situated employees; or - covered by an HMO but then moved out of the HMO service area; or - became a resident of Massachusetts d. A 63 day 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, the person cannot get a Supplement 2 policy back, but could choose a Core policy or Supplement 1 policy instead. - 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. e. 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 the SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 person's 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. ## Help for People with Limited Income and Resources 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 (Medicaid) is the most complete coverage offered by MassHealth. It pays for a wide range of health-care benefits and is the only coverage that pays for long-term care services. You may enroll in Standard MassHealth if you are: - single and your income is not greater than 100%* of the Federal Poverty Level (FPL) and your assets do not exceed $2,000. - married and your combined marital income is not greater than 100%* of the FPL and your combined assets do not exceed $3,000. MassHealth Standard for people aged 65 or older who need personal care attendant (PCA) services You may enroll into Standard MassHealth if you are 65 or older and need PCA services if you are: - single and your income is not greater than 133%* of the FPL and your assets do not exceed $2,000*. - married and your combined marital income is not greater than 133%* of the FPL 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: - MassHealth Senior Buy-In (Qualified Medicare Beneficiary Program - QMB) SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 MassHealth Senior Buy-In pays Medicare Part A and Part B premiums, and Medicare deductibles and copayments. You may be eligible if you are: - single and your income does not exceed 100% FPL* and your assets do not exceed $4,000. - married and your combined income does not exceed 100% FPL* and your combined assets do not exceed $6,000. - MassHealth Buy-In (Specified Low-Income Medicare Beneficiary Program (SLMB) & Qualifying Individual (QI) Programs) Both SLMB and QI programs pay the monthly Medicare Part B premium. You may be eligible for SLMB if you are: - single and your income is less than 120% FPL* and your assets do not exceed $4,000. - married and your combined income is less than 120% FPL* and your combined assets do not exceed $6,000. You may be eligible for QI if your countable income including your spouse's income with whom you live is - less than 135% FPL* and your assets do not exceed $4,000 if single or combined assets of $6,000 if married. *Federal Poverty Level (FPL) guidelines are calculated each year. Contact MassHealth for details. Call the MassHealth Customer Service Center 1-800-841-2900 (TTY: 1-800-497-4686) or visit www.state.ma.us/masshealth for more information about MassHealth programs. ### SCO (Senior Care Options) 1-888-885-0484 www.state.ma.us/masshealth TTY: 888-821-5225 MassHealth Senior Care Options (SCO) is a coordinated health plan that combines Medicare and Medicaid health care services with social support services to help elders maintain their health and live in the community as long as possible. SCO is also available to most elders 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. 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 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 SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 • 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 more information call MassHealth Senior Care Options (SCO) at 1-888-885-0884 (TTY: 1-888-821-5225 for people with partial or total hearing loss) or visit www.state.ma.us/masshealth PACE (Program for All-Inclusive Care for the Elderly) (also called Elder Service Plan) www.state.ma.us/masshealth 1-800-408-1253 TTY: 1-800-231-5698 PACE helps certain frail people maintain their health and independence and live in the community while getting the health care and other services they need. PACE combines medical care, social services, and long-term care services for frail people. Services are provided by PACE-authorized health centers. To be eligible, an individual must meet the following criteria: • 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 SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 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 the MassHealth Enrollment Center at 800-408-1253 (TTY: 1-800-231-5698 for people with partial or total hearing loss). 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 created by the Commonwealth of Massachusetts and is administered by the Massachusetts Executive Office of Elder Affairs for certain Massachusetts residents age 65 and over. ### Free Care (Uncompensated Care Pool) The Uncompensated Care Pool pays hospitals and community health centers for certain services provided to low income patients. The Massachusetts Division of Health Care Finance and Policy administers the Free Care program. For information contact your hospital or community health center or contact the Division of Health Care Finance and Policy at 1-877-910-2100. ### Other Health Care Programs ### 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 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 SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 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 due 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 (TFL)/Military Retiree Benefits 1-888-363-5433 TRICARE is a health care program for active duty and retired uniformed services members and their families including National Guard members and reservists, Medicare-eligible uniformed services retirees age 65 or older, and certain family members have access to expanded medical coverage known as TRICARE for Life (TFL). To get TFL benefits you must have Medicare Part A and Part B. For more information on Medicare Prescription Drug Benefit contact Medicare at 1-800-Medicare (1-800-633-4277) or visit www.medicare.gov. For general TRICARE questions, call 1-888-DOD-LIFE (1-888-363-5433) or visit www.TRICARE.osd.mil. SHINE, State Health Insurance Assistance Program, is a statewide network of volunteers trained and certified by the Massachusetts Executive Office of Elder Affairs in partnership with elder service agencies and Councils on Aging. SHINE provides free health care information, assistance and counseling to Medicare beneficiaries of all ages. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # 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. 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.state.ma.us/doi Boston 617-521-7777 Springfield 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. 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. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # 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 (Health Quality Improvement Organization) Helpline 1-800-252-5533 www.masspro.org 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. # 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. # Medicare Helpline (24 hours a day, 7 days a week) 1-800-MEDICARE www.medicare.gov (1-800-633-4227) # MassMedLine 1-866-633-1617 www.massmedline.com 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 drug interactions and using medications correctly. MassMedLine is a service of the Massachusetts College of Pharmacy and Sciences and the Massachusetts Executive Office of Elder Affairs. # 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, 2005 # 2006 Medicare Part A Benefits and Gaps (Chart outlines gaps in Medicare coverage. Refer to Medicare Handbook for complete list of Medicare benefits.) | Coverage | Beneficiary Pays | Medicare Pays | | --- | --- | --- | | Medicare Part A | | | | Inpatient Hospital Care* | | | | Days 1-60* | $952 deductible | Balance | | Days 61-90* | $238 per day | Balance | | Days 91-150 (lifetime reserve days) | $476 per day | Balance | | Additional days | All costs | $0 | | Semi-private room and board, general nursing, and other hospital services and supplies. | | | | Skilled Nursing Facility Care** | | | | Days 1-20 | $0 | All costs | | Days 21-100 | $119 per day | Balance | | Additional days | All costs | Nothing | | After three-day inpatient hospital stay & admission to a Medicare approved SNF within 30 days of discharge | | | | Home Health Care | $0 | Up to 35 hours per week | | Part-time or intermittent skilled care, home health aide services, and | | | | Durable Medical Equipment and Supplies | 20% of approved amount | 80% of approved amount | | Hospice Care | Small co-payments for inpatient respite and drugs | Balance | | Pain relief, symptom management and support services for the terminally ill. | | | | Blood | For first 3 pints | All but first 3 pints per calendar year | *Each benefit period begins the day you go to the hospital and ends when you haven't received hospital or skilled care in a SNF for 60 days in a row. A new benefit period begins if you go to a hospital or SNF after a benefit period has ended. You must pay the inpatient hospital deductible for each benefit period Part A Premiums for Voluntary Enrollee (individuals who must purchase Part A): 30-39 work quarters $216/month in 2006 0-29 work quarters $393/month in 2006 For more information, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 or refer to the "Medicare & You" handbook SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # 2006 Medicare Part B Benefits and Gaps (Chart outlines gaps in Medicare coverage. Refer to Medicare & You Handbook for a complete list of Medicare benefits) | Coverage | Beneficiary Pays | Medicare Pays | | --- | --- | --- | | Medicare Part B | | | | Medical Expenses • Doctors' services • Inpatient and outpatient medical services and supplies • Physical and speech therapy • Diagnostic tests • Ambulance services Medicare also pays for other medically necessary services, see Medicare Handbook. | $124 deductible* then 20% ** of Medicare's approved amount after the deductible is met Limited charges above the approved amount may apply for some Part B providers. | 80% of Medicare's approved amount after $124 deductible is met. Reduced to 50% for most outpatient mental health services. | | Clinical Lab Tests Blood tests, urinalysis, and more. | $0 for tests if medically necessary. | Generally 100% of approved amount. | | Home Health Care Part-time or intermittent skilled care, home health aide services, and | $0 | Up to 35 hours per week | | Durable Medical Equipment and Supplies | 20% of approved amount | 80% of Medicare's approved amount | | Outpatient Hospital Treatment | After $124 deductible, you pay a copayment according to the service. | Medicare payment to hospital based fee schedule. | | Blood | For first 3 pints, plus 20% of approved amount (after $124 is met) | 80% of approved amount (after $124 deductible and starting with the 4th pint). | * Deductible is the amount you must pay before your Medicare plan begins to pay ** Coinsurance is the amount you may be required to pay after you pay any plan deductibles. A 20% coinsurance amount applies to most Part B services. A 50% coinsurance applies to most out-patient mental health services. Monthly Part B Premium is $88.50 per month for 2006. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # Standard Medigap Plans ## Massachusetts 2006 | Comparison of Plans | Core | Supplement 1 | | --- | --- | --- | | Basic Benefits Included In All Plans: | | | | Hospitalization Part A Co-payments | | | | Days 61 - 90: $238 per day | X | X | | Days 91-150: $476 per day | X | X | | 365 Additional Lifetime Hospital days - Paid in full | X | X | | Part B Coinsurance - | | | | Coverage of coinsurance, in most cases, 20% of approved amount | X | X | | Parts A and B Blood First 3 pints | X | X | | Additional Benefits | Core | Supplement 1 | | Part A Deductible for Hospital Days 1 - 60 | | X | | $952 per benefit period | | | | Skilled Nursing Facility Coinsurance | | X | | Days 21-100 - $119 per day | | | | Part B Annual Deductible - $124 | | X | | Foreign Travel - For Medicare-covered services needed while traveling abroad. | | 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 | SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # Medicare Supplement Plans ## Offered in Massachusetts for Coverage in 2006 | Medigap Carriers Please note that rates may change in 2006 | Medicare Supplement Core | Medicare Supplement 1 | | --- | --- | --- | | Blue Cross & Blue Shield of MA (Medex™) 1-800-678-2265 sales/apps 1-800-258-2226 member services 1-800-522-1254 (TDD) www.bluecrossma.com (open enrollment: Feb-Mar; initial eligibility^{1}; special open enrollment period: Sept-Dec 31, 2005 for Jan 2006) | $77.54 (Proposed rate of $81.11 to be effective 3/15/06 | 138.41 (Proposed rate of $149.19 to be effective 3/15/06) | | United HealthCare™ Insurance Company Only for members of AARP (American Association of Retired Persons) 1-800-523-5800 (continuous open enrollment as of January 1, 2006^{1}) | $110.25 | $150.50 | $^{1}$ Plan offers discounted rates to certain members joining when initially eligible. SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # Medicare HMO Plans ## Offered in Massachusetts for Coverage in 2006 | Medicare HMO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Blue Cross Blue Shield of Massachusetts, HMO Blue 1-800-678-2265 TTY: 1-800-522-1254 | Medicare HMO Blue $81 | Medicare HMO Blue $108 | Medicare HMO Blue $122 | Franklin, Hampden, Hampshire | | | Medicare HMO Blue $83 | Medicare HMO Blue $110 | Medicare HMO Blue $125 | Barnstable, Bristol, Plymouth | | | Medicare HMO Blue $92 | Medicare HMO Blue $120 | Medicare HMO Blue $134 | Essex, Middlesex, Norfolk, Suffolk | | | Medicare HMO Blue $98 | Medicare HMO Blue $126 | Medicare HMO Blue $140 | Worcester | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 | Medicare HMO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Fallon Community Health Plan, Inc. 1-800-868-5200 TTY: 1-877-608-7677 | Fallon Senior Plan Saver $0 | Fallon Senior Plan Saver $30 | Fallon Senior Plan Saver $47 | Worcester, portions of Franklin, Hampden, Hampshire, Middlesex and Norfolk | | | Fallon Senior Plan Standard $40 | Fallon Senior Plan Standard $71 | Fallon Senior Plan Standard $87 | Worcester, portions of Franklin, Hampden, Hampshire, Middlesex and Norfolk | | | Fallon Senior Plan Plus $70 | Fallon Senior Plan Plus $101 | Fallon Senior Plan Plus $117 | Worcester, portions of Franklin, Hampden, Hampshire, Middlesex and Norfolk | | Harvard Pilgrim Health Care, Inc. 1-800-779-7723 TTY: 1-888-259-8276 | First Seniority $96 | First Seniority $121 | | Essex, Middlesex (except Ashby), Norfolk, Suffolk | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 | Medicare HMO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Tufts Associated Health Maintenance Organization, Inc. 1-800-246-2400 TTY: 1-888-899-8977 | Medicare Preferred HMO Value $32 | Medicare Preferred HMO Value Rx $52 | Medicare Preferred HMO Value Rx Plus $67 | Barnstable, Norfolk, Plymouth | | | Medicare Preferred HMO Value $58 | Medicare Preferred HMO Value Rx $78 | Medicare Preferred HMO Value Rx Plus $93 | Bristol | | | Medicare Preferred HMO Value $78 | Medicare Preferred HMO Value Rx $98 | Medicare Preferred HMO Value Rx Plus $113 | Essex | | | Medicare Preferred HMO Value $37 | Medicare Preferred HMO Value Rx $57 | Medicare Preferred HMO Value Rx Plus $72 | Hampden | | | Medicare Preferred HMO Value $49 | Medicare Preferred HMO Value Rx $69 | Medicare Preferred HMO Value Rx Plus $84 | Middlesex, Suffolk | | | Medicare Preferred HMO Value $47 | Medicare Preferred HMO Value Rx $67 | Medicare Preferred HMO Value Rx Plus $82 | Worcester | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 | Medicare HMO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Tufts Associated Health Maintenance Organization, Inc. 1-800-246-2400 TTY: 1-888-899-8977 | Medicare Preferred HMO Prime $50 | Medicare Preferred HMO Prime Rx $70 | Medicare Preferred HMO Prime Rx Plus $85 | Barnstable, Norfolk, Plymouth | | | Medicare Preferred HMO Prime $96 | Medicare Preferred HMO Prime Rx $116 | Medicare Preferred HMO Prime Rx Plus $131 | Bristol, Essex | | | Medicare Preferred HMO Prime $75 | Medicare Preferred HMO Prime Rx $95 | Medicare Preferred HMO Prime Rx Plus $110 | Hampden | | | Medicare Preferred HMO Prime $87 | Medicare Preferred HMO Prime Rx $107 | Medicare Preferred HMO Prime Rx Plus $122 | Middlesex, Suffolk | | | Medicare Preferred HMO Prime $85 | Medicare Preferred HMO Prime Rx $105 | Medicare Preferred HMO Prime Rx Plus $120 | Worcester | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # Medicare PPO Plans ## Offered in Massachusetts for Coverage in 2006 | Medicare PPO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Blue Cross Blue Shield of Massachusetts HMO Blue 1-800-678-2265 TTY: 1-800-522-1254 | Medicare PPO Blue $96 | Medicare PPO Blue $123 | Medicare PPO Blue $137 | Franklin, Hampden, Hampshire | | | Medicare PPO Blue $101 | Medicare PPO Blue $128 | Medicare PPO Blue $143 | Barnstable, Bristol, Plymouth | | | Medicare PPO Blue $111 | Medicare PPO Blue $138 | Medicare PPO Blue $153 | Essex, Middlesex, Norfolk, Suffolk | | | Medicare PPO Blue $113 | Medicare PPO Blue $141 | Medicare PPO Blue $155 | Worcester | | Fallon Community Health Plan, Inc. 1-800-868-5200 TTY: 1-877-608-7677 | Fallon Senior Plan Preferred $135 | Fallon Senior Plan Preferred $166 | Fallon Senior Plan Preferred $182 | Worcester, portions of Franklin, Hampden, Hampshire, Middlesex and Norfolk | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 | Medicare PPO Plan | No Drug | Basic Drug* | Enhanced Drug* | Service Area by County | | --- | --- | --- | --- | --- | | Tufts Associated Health Maintenance Organization, Inc. 1-800-246-2400 TTY: 1-888-899-8977 | Medicare Preferred PPO $91 | Medicare Preferred PPO Rx $111 | Medicare Preferred PPO Rx Plus $126 | Barnstable, Bristol, Middlesex, Worcester | | | Medicare Preferred PPO $101 | Medicare Preferred PPO Rx $121 | Medicare Preferred PPO Rx Plus $136 | Essex, Norfolk, Plymouth, Suffolk | | | Medicare Preferred PPO $81 | Medicare Preferred PPO Rx $101 | Medicare Preferred PPO Rx Plus $116 | Hampden | *Contact health plan for details on "Basic Drug" and "Enhanced Drug" SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005 # Medicare Special Needs Plans ## Offered in Massachusetts ### for Coverage in 2006 | Company | Plans | Customer Service Phone Number | Service Area by County | | --- | --- | --- | --- | | Senior Whole Health 58 Charles Street, 2nd Floor Cambridge, MA 02141 | Senior Whole Health Dual Eligible | 1-888-566-3526 TTY: 1-888-749-6455 | Bristol, Essex, Middlesex, Norfolk, Suffolk | | Commonwealth Care Alliance 30 Winter Street, 7th Floor Boston, MA 02108 | Senior Care Options Program Dual Eligible | 1-866-610-2273 TTY: 1-866-322-7357 | Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk | | | Commonwealth Care Connection Dual Eligible | 1-866-610-2273 TTY: 1-866-322-7357 | Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk | | United Health Group 275 Grove Street, Suite 3-120 Auburndale, MA 02466 | Evercare Mass SCO Dual Eligible | 1-800-393-0939 TTY: 1-888-685-8480 | Bristol, Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester | | | Evercare Plan IP Institutional | 1-800-393-0939 TTY: 1-888-685-8480 | Bristol, Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester | | | Evercare Plan DP Dual Eligible | 1-800-393-0939 TTY: 1-888-685-8480 | Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester | | Fallon Community Health Plan One Chestnut Place, 10 Chestnut Street Worcester, MA 01608 | Fallon Senior Plan Value Dual Eligible | 1-888-846-5997 TTY: 1-877-608-7677 | Worcester, portions of Franklin, Hampden, Hampshire, Middlesex and Norfolk | Call MassHealth at 1-888-885-0484 for eligibility and enrollment in these "Special Needs" plans SHINE Counseling Program of the Executive Office of Elder Affairs November, 2005