Navigators & SHIBA
The SHIBA Town Hall in October 2024 covers important topics like qualified health plans, Medicaid, Medicare eligibility, enrollment, and support resources for beneficiaries. Presenters share valuable insights and notes to aid navigators and professionals in their daily work. Attendees engage in discussions and Q&A sessions focused on serving individuals transitioning to Medicare and those already enrolled in healthcare programs.
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Presentation Transcript
Navigators & SHIBA Oct. 2024
PCHS Navigator Elmarie Anderson Compliance Coordinator Peninsula Community Health Services Phone: 360-377-3776 Ext: 4134 Email: eanderson@pchsweb.org SHIBA Town Hall October 2024 10/4/2024 2
SHIBA Program Manager Tim Smolen SHIBA Program Manager 360.725.7091 tim.smolen@oic.wa.gov SHIBA Town Hall October 2024 10/4/2024 3
Agenda Introductions Part 1: Qualified health plans and Medicaid Part 2: Medicare eligibility Part 3: Medicare enrollment Part 4: Medicare systems of care Part 5: SHIBA support and resources for beneficiaries Part 6: Navigators and SHIBA as partners Discussion / Q&A SHIBA Town Hall October 2024 10/4/2024 4
Part 1: Qualified health plans and Medicaid SHIBA Town Hall October 2024 10/4/2024 5
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- You all are doing important, complex work every day that makes a huge difference in people s lives. Thank you. So much of the work you re doing is like the work we do for people in the transition to getting started in Medicare and after they are enrolled. Qualified health plans Marketplace Subsidies, MAGI Medicaid Enrollment and SEP s Dis-enrollment Appeals Outreach & Education Person -centered, trauma-informed counseling Different rules for AI/AN SHIBA Town Hall October 2024 10/4/2024 6
Part 2: Medicare eligibility SHIBA Town Hall October 2024 10/4/2024 7
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- We re going to make a distinction between eligibility and enrollment. It s always important, but even more so for the clients that you are working with every day. About eligibility, there are two conditions Entitlement One of these - and One of these Citizen or LPR 65 or disabled or ESRD or ALS Citizen Legal Permanent Resident Age 65 + Disabled ESRD ALS SHIBA Town Hall October 2024 10/4/2024 8
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- Eligibility is determined by SSA Requirements They also determine whether Part A is premium-free for you It s not free for everyone. SSA determines eligibility Also, monthly premium for Medicare Part A or not If it s premium-free it s because you earned it when you were working or you qualify using the work history of a spouse or parent The distinction between premium-free and not is important to many HBE clients Not just for the fact of the monthly cost, but because it s a different kind of decision point and eligibility concern for 10/4/2024 qualified health plans and MAGI SHIBA Town Hall October 2024 9
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- When we say eligible for Medicare what we really mean is that a person is eligible for Medicare Part A or Medicare Part B or both of those. Medicare 1.0 Medicare Part A Hospital insurance (HI) Medicare Part B Supplemental medical insurance (SMI) We re going to talk about Medicare Part C and Medicare Part D in a few minutes. A person is eligible for Part C if and only if they are enrolled in Medicare Part A and Medicare Part B A person is eligible for Part D if they are enrolled in Medicare Part A or Medicare Part B UWRA Presentation September 24, 2024 10
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- For most people but not many of your clients - there is a monthly premium for Medicare Part B. Your Medicare entitlement Part A Hospital (inpatient) No monthly premium (for most people) payroll taxes to trust fund Part B Medical (outpatient) monthly premium = 25% of cost Standard premium = $174.90/mo. (2024) Indexed to income Some pay more or less SHIBA Program, DRS October 11, 2024 11
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- One key to understanding Medicare is that this was explicitly an anti-poverty program. The notion was keep people from being bankrupted due to being hospitalized. Private insurance for older Americans was uncommon way back in 1965. Medicare: majormedical insurance 1.Does not cover all medically needed services 2.Does not pay 100% for all covered services There is cost sharing for patients Deductibles Co-insurance Co-pays UWRA Presentation September 12, 2024 12
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- These are some examples of the kinds of benefits and services that are not covered -- or are covered with significant limits -- by original Medicare alone. Not covered by Original Medicare Prescription drugs Eye exams Hearing aids Therapies Acupuncture Chiropractic Massage Naturopathy Dental care UWRA Presentation September 24, 2024 13
Presenter Notes 2024-10-04 23:59:23 -------------------------------------------- I think you can see how this feels like a takeaway for people that you re helping. Some people will be reluctant to sign-up (to enroll) just because it does feel like a take-away. Other people are going to struggle just because it is very confusing. Before enrollment This does not feel good at all. SHIBA Town Hall October 2024 10/4/2024 14
Part 3: Medicare enrollment SHIBA Town Hall October 2024 10/4/2024 15
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- Let s talk about before and Medicare the space where eligibility and enrollment happen and then after Medicare. For today, we re focused on gettingstarted . There can be a whole other program about switching during the annual Medicare OEP and other kinds of special enrollment periods. Map of the world Before Medicare After Medicare Employer group health plan Employer group health plan Small group, Individual market Commercial insurance market Eligibility & Enrollment Qualified Health Plan, in Washington, that s the Health Benefits Exchange with subsidies (MSP, LIS) Medicaid, in Washington, that s AppleHealth Medicaid (CN, MN) Other No health insurance Other assistance programs (IHS, VA, etc.) Other assistance programs (IHS, VA, etc.) SHIBA Town Hall October 2024 10/4/2024 16
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- If a person with a QHP is about to turn 65, they may soon be eligible for Medicare. The HBE will mail a notice called the Special Medicare Notice for Consumers Turning 65 informing you that: You may soon be eligible for Medicare and can change your health coverage There are different ways to enroll in Medicare There may be late enrollment penalties if you don t sign up when you re first eligible You may cancel your Marketplace plan when you sign up for Medicare or if you keep it, you may lose your financial subsidies Sample notice: Special Medicare Notice for People Turning 65 Informs you: That you may be eligible for Medicare and can change your health coverage when you turn 65 There are different ways to sign up for Medicare There may be late enrollment penalties if you don t sign up when you re first eligible That you may cancel your Marketplace plan when you sign up for Medicare CMS.gov/marketplace/applications- and-forms/notice-for-consumers- turning-65.pdf Marketplace to Medicare: What You Can Expect November 2023 17
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- I want to acknowledge that there are SO many reasons this is hard for people. One thing is that HBE coverage can be for one or many people and Medicare eligibility and enrollment can be for one or many people ultimately, Medicare coverage is per-person and financial support for Medicare beneficiaries is similar but different even though we both ask about income and (sometimes) assets. Ugh. Sample notice https://www.cms.gov/marketplace/applications-and- forms/notice-for-consumers-turning-65.pdf SHIBA Town Hall October 2024 10/4/2024 18
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- Just a reminder that being 65, in and of itself, does not necessarily mean eligible for Medicare. And if eligible, it does not mean eligible for premium-free Medicare Part A. Turn age 65 Remember: there are two conditions So, you might not be eligible for Medicare or you might be eligible for Medicare, but not for premium- free Medicare Part A SHIBA Town Hall October 2024 10/4/2024 19
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- I m sure you get this question all the time, right? The letters people get can be super- confusing. What we re going to tell you is that starting is optional and it is certainly advisable. The consequences for waiting and especially for being late can be quite severe. Can I keep my Marketplace coverage? You can keep your Marketplace plan after your Medicare Part A coverage starts (generally through the end of the year). But, you'll no longer be eligible for the premium tax credit or other cost savings you may be getting for your Marketplace plan. You'll pay full price for your Marketplace plan if you keep it. You may have to pay back any tax credits you get after your Medicare coverage starts when you file your federal taxes. SHIBA Town Hall October 2024 10/4/2024 20
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- I m going to say that consequences are about delays for coverage and also about financial penalties. Just because our time is short today, we re not going to focus here, but please ask us later, in the room or on e-mail. Penalties You may have to pay a monthly late enrollment penalty for as long as you have Part B coverage. The penalty goes up the longer you wait. You may also have to pay a penalty if you have to pay a Part A premium, but don't enroll when first eligible. SHIBA Town Hall October 2024 10/4/2024 21
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- I wonder if you re using this handout and is it helpful? Handout https://www.cms.gov/marketplace/outreach-and- education/medicare-and-the-health-insurance- marketplace.pdf SHIBA Town Hall October 2024 10/4/2024 22
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- Lots of confusion about Medicare and Medicare enrollment. A common question: is enrollment automatic? It depends. Can I wait to sign up without penalty? It depends. Which scenario? NOT drawing SSA benefits Drawing SSA benefits Stop work at age 65 1 2 Work past age 65 3 4 23
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- For today, we re going to say: Not drawing SSA cash benefit Not covered as a subscriber or dependent in an employer group plan There are several scenarios We re going to presume a person is not drawing a cash benefit (retirement) from SSA Not covered as a subscriber or dependent in an employer group plan SHIBA Town Hall October 2024 10/4/2024 24
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- The ideal way is on-line. We re going to encourage people to create an account at SSS.gov now as a good tool for things like checking their work and earnings history and for fraud prevention. Of course, lots of people need help with on-line resources. You can call SSA or a SHIBA volunteer can help you, too. Take action to enroll in Medicare If you are NOT drawing a SSA retirement benefit when you reach age 65, you will be NOT automatically enrolled into Medicare Part A + Medicare Part B You need to take action to enroll on-time SSA.gov The start date of coverage is the 1st day of the month when you turn age 65 25
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- We re going to talk about Step #2 choosing your Medicare in the next section. Instructions 1. Sign up for Medicare through Social Security www.ssa.gov 2. Choose which way you want to get your Medicare coverage www.medicare.gov End your HBE coverage SHIBA Town Hall October 2024 10/4/2024 26
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- You can first sign up for Part A (Hospital Insurance) and Part B (Medical Insurance) during your Initial Enrollment Period. It lasts for 7 months, starting 3 months before you turn 65 and ending 3 months after the month you turn 65. When can I sign up for Medicare? Initial Enrollment Period Lasts for 7 months, starting 3 months before you turn 65 and ending 3 months after the month you turn 65. SHIBA Town Hall October 2024 10/4/2024 27
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- Throughout this program, I am going to tell you the IDEAL path as well the other ways that people elect. Start your Medicare benefits on the first day of the month that you turn age 65. In this example, our client be 65 on April 6th. So, start Medicare on April 1st. You can sign-up as early as January. She is not LATE as long as she signs up by the end of July. But she would have a break in her coverage and risk other problems, too. Initial enrollment period (IEP) April May June July January February March 6th This is your ideal plan. SHIBA Program, DRS October 4, 2024 28
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- In Medicare, we call the MAGI -- IRMAA: income-related monthly adjustment amount. Higher- income people pay more for Medicare Part B. For our clients, we re motivated to screen them for eligibility for the State to pay the monthly Part B premium. Part B premium (per month, 2024) Low- income Higher- income Standard MSP Subsidized IRMAA Depends on income Depends on income $174.70 UWRA Presentation September 24, 2024 29
Part 4: Medicare systems of care SHIBA Town Hall October 2024 10/4/2024 30
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- For today we are going to focus on our program on people who at the time and they turn age 65 are enrolled in the HBE or Medicaid (Apple Health) SHIBA volunteers do help with all kinds of people, of course. Starting coverage Employer group health plan Small group insurance, Individual market insurance Qualified Health Plan in Washington, that s the Medicaid in Washington, that s AppleHealth No health insurance Health Benefits Exchange 31
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- There are two systems of care for Medicare benefits. You choose to get your entitlement: Medicare Part A and Medicare Part B as well as other insurance in addition to Medicare in one system of the other these are exclusive: so one or the other not some of each. Medicare systems of care This includes Medicare Supplement Insurance (Medigap). Or, you can use coverage from a current or former employer or union, or Medicaid. SHIBA Town Hall October 2024 10/4/2024 32
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- Again depending upon where people start before Medicare and what options and preferences they have after Medicare matters a lot. What you need to know is that people in each of these three (3) markets Employer group health plan Commercial market plans Medicaid Can choose either system of care Original Medicare Coverage in addition to Medicare Employer group insurance programs Offered through (former) employer or union Commercial market insurance Medicare Advantage plans Medicare Supplement plans Medicaid Full-benefit programs Partial-benefit programs Medicare Advantage SHIBA Program, DRS October 4, 2024 33
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- That expression Medicaid is tricky. We mean MAGI Medicaid as well as non-MAGI Medicaid as well as Medicaid programs that are financial assistance for people with Medicare. It s a lot. Let s unpack that. MAGI v non-MAGI Aged, Blind, and Disabled (ABD) this is a CN program MN this is spenddown Institutional care and HCBS (and waivers) this is nursing home and in-home care Medicare Savings Programs (MSP) this is QMB SLMB QI-1 QWDI SHIBA Town Hall October 2024 10/4/2024 34
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- We say categoricallyneedy CN for people that non-MAGI Medicaid. This can include people who are enrolled in SSI. We also call me when these beneficiaries full-benefit, dual- eligible people. They can enroll through either system of care. Medicaid for them works a lot like insurance for people that retired and have an employer group plan in the sense that it provides comprehensive coverage in Original Medicare. To be sure, there can challenges with provider access so it is not equivalent. Your options for Medicare coverage Original Medicare Medicare Advantage Medicare Part C MA-PD plans Consolidate in one package Hospital (inpatient) Medical (outpatient) Prescription drugs Additional benefits Medicare Part A Hospital (inpatient) Medicare Part B Medical (outpatient) Medicare Part D Prescription drug plans More insurance UWRA Presentation September 24, 2024 35
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- The reality is that many of our MAGI Medicaid (Apple Health) and subsidized enrollment in HBE plans clients will experience the transition to Medicare as being pretty difficult and confusing. I think you re already doing this all the time, but the key is to help people qualify and apply if possible for the Medicare Savings Programs: SLMB, QMB and Extra Help (LIS) for Medicare Part D. Rainbow chart https://www.insurance.wa.gov/sites/default/files/docu ments/2024-rainbow-chart-extra-help_0.pdf This is a tool that our volunteer advisors use to help in screening people for eligibility. They can also help with the application at waconnection.org SHIBA Town Hall October 2024 10/4/2024 36
Presenter Notes 2024-10-04 23:59:24 -------------------------------------------- The left-hand side of the chart shows how original Medicare also called fee-for-service Medicare works. Beneficiaries access benefits for Part A hospital and Part B medical through providers that contract with Medicare (CMS). Medicare prescription drug benefits are provided through private companies: stand-alone Part D plans. The right-hand side of the chart shows how Medicare Advantage plans work. Beneficiaries access benefits for Part A and Part B and Part D through providers that contract with private companies that contract with Medicare (CMS). Medicare in context CMS Medicare Medicare Advantage - Prescription Drug Plan Part D Plan Hospital Medical Rx drug Rx drug Hospital Medical UWRA Presentation September 24, 2024 37
D-SNPs Dual-eligible, special needs plans These are a form of Medicare Advantage plans they align to that system of care All people with MSP can choose these. SHIBA Town Hall October 2024 10/4/2024 38
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- Enough said, right? Let s compare?! This Photo by Unknown Author is licensed under CC BOYc-tNoCber 4, 2024 SHIBA Program, DRS 39
Part 5: SHIBA support & resources SHIBA Town Hall October 2024 10/4/2024 40
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- Who we are SHIBA is free, confidential, unbiased service of the Washington State Office of the Insurance Commissioner Statewide Health Insurance Benefits Advisors UWRA Presentation September 24, 2024 41
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- This would be like our top10 kinds of things we often help people solve. Some ways we help Become eligible for Medicare Enroll in Medicare Transition into retirement Switch plans Complaints Compare or change your approach to Medicare Apply for Medicaid or Extra Help Medicare Part D Fraud SHIBA Program, DRS March 2024 42
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- We can help you make sense of Medicare and get what you deserve. What we do Train volunteer advisors to help Educate about rights and options Explain how to compare plans Introduce programs that might save people money UWRA Presentation September 24, 2024 43
Part 6: Navigators and SHIBA as partners SHIBA Town Hall October 2024 10/4/2024 44
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- Your work is over here on this side - people that don t have Medicare, yet One reality for us is that the people that are your clients today will be our clients tomorrow. Our purpose is ask: how we can help you to help your clients through this transition and even after they are on the other side? Connector organizations SHIBA Town Hall October 2024 10/4/2024 45
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- I m going to tell you one thing right now: we need to be more like you. There is an incredible diversity in your teams that we don t have, yet. And you are closer to the lived experiences of your clients than we are. I am sincerely asking for you all to help us get better faster. Thank you. Equity We need your help - today - to get our own selves ready to be better. SHIBA Town Hall October 2024 10/4/2024 46
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- Affordability is determined by how the provider's charges relate to the client's ability and willingness to pay for services. Availability measures the extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client. Accessibility refers to geographic accessibility, which is determined by how easily the client can physically reach the provider's location. Accommodation reflects the extent to which the provider's operation is organized in ways that meet the constraints and preferences of the client. Of greatest concern are hours of operation, how telephone communications are handled, and the client's ability to receive care without prior appointments. Acceptability captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice versa. These characteristics include the age, sex, social class, and ethnicity of the provider (and of the client), as well as the diagnosis and type of coverage of the client. Access (5 A s) Affordability Availability Accessibility Accommodation Acceptability SHIBA Town Hall October 2024 10/4/2024 47
Presenter Notes 2024-10-04 23:59:25 -------------------------------------------- Thank you for inviting us to be here with you today. It s really an honor. Opportunities I want you to be appreciated by us and so let s just have with a standing ovation. Please join me in applauding you all. SHIBA volunteers are (winged) unicorns, too! You re made for each other. Besties. Let me ask you to please do me a favor. Take a minute or two and make a note or draw a picture that helps you remember a person that you helped in your work and what made it memorable. Now let me ask you to share a word or two about that experience. Let s start from your point of view. How did you feel, in the moment or as you look back? Let me ask now about the experience and point of view of the person you helped - what was their experience like? How did they feel? It s sort of magic, right? People are finding you - or through outreach you are finding them - when they have important, urgent needs. They are facing difficult decisions. The complexity of the task can feel overwhelming to them. They are vulnerable, fearful, confused. SHIBA Town Hall October 2024 10/4/2024 48 This is the before and after experience of getting help from
Discussion / Q&A SHIBA Town Hall October 2024 10/4/2024 49
Rules of engagement Audience questions and commentary Opinions are not facts, but both matter. Civility and respect are invaluable. Humor and perspective and humility are gold UWRA Presentation September 24, 2024 50
