Case Study- Ty Juan On

Ty Juan On calls you at the SHINE office. He has just become eligible for Medicare and received his card. He wants to know if he would need a referral from a primary care physician to access medical services when using Part A or B. Also, he heard that he needs to buy additional insurance - something called a Medicare Advantage Medigap plan.

How would you help him?

Case Study —Travis Tee

Mr. Tee calls you at the SHINE office. He is 66 and retiring soon but does not plan to take Part B as his company will keep him on full insurance coverage for one year. A friend suggested he call the SHINE office to get information about Medicare.

What questions would you ask Mr. Tee?

What information would you give him?

  • No referral needed with Original Medicare
  • No such thing as Medicare Advantage Medigap plan
  • Medicare 101
  • Gaps in Medicare
  • Pros and cons of MA plans and Medigap plans
  • Will company consider him an active employee?

If not – Travis should take Part B or may have a delay and a penalty

  • Get 8 month SEP with no penaltyonly if he is leaving aactive employer group health plan (EGHP)
  • He can wait until the 8th month to enroll since has full insurance coverage- this will save 8 months of Part B premiums

Case Study— Mr. Tyme Leeness

Mr. Leeness comes to the SHINE office to get information on Medicare and Medicare HMO plans. He will be retiring in 3 months and wants to know when he can join a plan. He tells you that he spends 5 months of the year in Florida and the other 7 months in Massachusetts.

How would you assist him?

Case Study - Jan Itor

Ms. Jan Itor calls you at the SHINE office. Her parents are moving to Massachusetts from Florida. They are enrolled in a Medicare Advantage plan in Florida. She wants to start the process of getting them insurance coverage in Massachusetts, but she knows nothing about Medicare or where to begin.

How would you help her?

  • Assume over 65
  • Since leaving active employment EGHP, gets 8 month SEP to enroll in Medicare with no penalty
  • With Parts A & B can get Medigap or MA plan
  • 5 months in Florida - Medigap
  • MA plan only covers urgent or emergency care when out of network
  • SEP – moving to Mass, so can get another MA plan or Medigap and drug plan
  • Offer a Medicare 101 explanation
  • Gaps in Medicare
  • Pros and cons of MA plans and Medigap plans
  • Explain MA plan options in Mass
  • Explain Medigap plan options in Mass

Case Study - Ms. Heart

Ms. Heart meets with you at the SHINE office. She has just retired from her job. She has Medicare A+B and wants to know what her options are for additional insurance over and above Medicare. She asks you to explain the differences between Medicare and a Medicare Advantage plan, and wants to know which is better.

What would you tell her?

Case Study - Ms. Fran Chise

Ms. Fran Chise is 66 and has been retired for the past year. She did not sign up for Medicare Part B as her husband continued to work and she has been covered under his employer insurance plan. Her husband is retiring next month but the company will continue to provide full insurance coverage to both of them for 6 months after he stops working. Ms. Chise called Social Security to see when she must pick up Part B. Social Security told her she must pick up Part B immediately in order to avoid a penalty. Since she is covered in full for 6 months, she wanted to delay the Part B.

What information would you give her?

  • Offer a Medicare 101 explanation
  • Explain the gaps in Medicare
  • Discuss the pros and cons of MA plans and Medigap plans
  • No such thing as “better” – depends on medical needs, financial situation, philosophy of insurance
  • Does not have to take Part B immediately, can delay
  • Has 8 mo SEP with no penalty , when leaving husband’s active EGHP
  • Can wait until 6th month to enroll, since has full insurance coverage will save 6 months of Part B premiums

Case Study - Mr. Will B. Gone

Mr. Gone meets with you at the SHINE office to clarify questions about Medicare and other insurance. He will be turning 65 in a few months. He has a friend who belongs to a Medicare Advantage plan and is very pleased with the services he receives. Mr. Gone takes no medication and wants to enroll in the cheaper, non prescription plan. He doesn’t see why he should sign up for the prescription plan if he doesn’t take medication. Mr. Gone has already checked that his doctor participates, so he’s pretty well set on the plan. In discussing his upcoming retirement, Mr. Gone tells you of his plans to spend more timewith family in Florida.

What information would you give to Mr. Gone?

Case Study — Mr. Chad R. Boxx

Mr. Boxx comes to see you at the SHINE office. He recently movedfrom another part of the state to live closer to his daughter. The Medicare Advantage plan he had is not available in his new location. He wants toknow what hisoptions are.

How would you help him?

  • Assume retiring when turns 65
  • If don’t take MA with drug plan then, will only be allowed to get drug coverage during OEP with 1% lifetime penalty for every month did not have a drug plan since eligible
  • MA plans only cover urgent or emergency care when out of network (in FL)
  • Medigap may be better choice
  • Moved out of the service area so SEP to change plan
  • Explain MA plans in new area
  • Another option is a Medigap with a separate PDP plan

Medicare Advantage-2017

Medicare Advantage Quiz

  1. When can a Medicare beneficiary join a Medicare Advantage plan?
  • During IEP, OEP or if qualify for SEP
  • Cannot join MA plan if get on Medicare because of ESRD, except if

employer plan offers MA plan which has senior plan

  1. Gordon has ESRD (End Stage Renal Disease) and belongs to an HMO through his employer. Gordon will be 65 next month and will retire from his employment. Gordon has been on Medicare for the past 7 months and wants to purchase a Medicare Advantage plan once he retires. Gordon has Part A now and will enroll in Part B when he retires. Check all that apply.

_X__Gordon can purchase a Medicare Advantage plan if the employer HMO offers a Medicare Advantage plan.

____Gordon cannot purchase a Medicare Advantage plan under any

circumstances because he has ESRD.

____Gordon can purchase any Medicare Advantage plan and all plans have to accept him

  1. Ms. King joined a Medicare Advantage plan 6 months ago when she first became eligible for Medicare. She wants to change to a new PCP (primary care physician) but learned he is not affiliated with her MA plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Open Enrollment Period to make a change. How would you assist her?She was given incorrect information. She can change under the MA 12month SEP to Medigap with drug plan.
  1. List the eligibility criteria to enroll in a Medicare Advantage plan.
  • Must have Medicare Parts A & B
  • Cannot have End Stage Renal Disease*
  • Must live in the plan’s service area
  • Cannot be out of the service area for more than 6 consecutive months
  1. Rosa calls you having just enrolled into Medicare Parts A & B and wants to know if she should get additional coverage from a Medicare Advantage Plan. List some questions you would ask her to assist her in her decision.
  • Does she understand the “gaps” in Medicare coverage?
  • Does shehave other coverage to help pay for out-of-pocket costs associated with Medicare? (Retiree Coverage, Medigap plan, MassHealth)
  • Can she afford to purchase additional coverage? (screen for Public Benefit programs)

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