Case Study — Mike L Angelo

A while back Mike received the form from Social Security about help paying for the Medicare Prescription Drug Program. He filled it out at the time and returned it. He later received a notice that he was income eligible but was denied because his assets were too high. His old car finally gave out and he was forced to dip into his savings to purchase another one. He tells you his savings are now under $10,000. He wants to know if he can file for the extra help now or does he need to wait until next year.

How would you help him?

Case Study — Polly Graff

Polly calls you at the SHINE office. She lives in senior housing and has a limited income. She has been on MassHealth for the past 4 years. She was auto enrolled into a Medicare Part D plan when she first became eligible for Medicare. Her doctor just put her on 2 new medications. When she took her new prescriptions to the pharmacy, she discovered they are not covered on her plan’s formulary. They are expensive and she can’t afford to fill them because of the cost. She would like to find another plan.

How would you help her?

  • Can apply now
  • Check exact assets
  • Eligible for LIS (maybe only Partial)
  • Plan Finder search
  • Has MH, so SEP to change drug plan
  • Plan Finder search

Case Study — Arty Choke

Arty meets with you for assistance on May 1. He is 67 and never signed up for Part D because he didn’t take any medications. He now has three meds. He has Medicare A & B and BC/BS Medex Bronze. He is single and lives in senior housing. His gross income is $1,550/month. He is not a vet.

You review options for other health insurance — Core, Medicare Advantage — that would save him money in the cost of the monthly premium. He knows he could get a Medicare Advantage plan for a lower monthly premium, but he chooses to stay with Bronze. His daughter lives in Florida and he visits her a few times a year. He has never had a problem getting care in Florida and is comfortable staying with Bronze.

He called the Medicare Drug plan his friend is on but was told that he will have to wait until open enrollment in the fall to join and coverage would not begin until January 1st. He tells you he scrimps and saves in order to cover his bills and visit his daughter and grandchildren. He knows he won’t be able to continue his visits due to the cost of his meds.

How would you help him?

  • Prescription Advantge (category S2) application
  • SEP to get PDP now, but will be subject to penalty
  • Plan Finder search

Case Study — May B. Poor

May calls you at the SHINE office. She will be 65 and retiring in two months and will not have retiree coverage available through her former employer. She just heard about the Medicare Part D prescription program. She only takes one medication now and doesn’t really want the coverage. However, she heard that she will pay a penalty if she decides to enroll at a later date should her medications increase, as she believes they might. She is concerned about the monthly premium along with the premium for health insurance. She states that her only income will be Social Security and said the amount she’ll receive will be $1,120/month. In further discussion she tells you that her savings are minimal. She has no other assets other than her home and a car.

May wants to know if there is any way she can cut down on her health care costs or avoid taking Part D as she feels the additional premium will put her over the edge.

How would you help her?

  • LIS application - help with premiums and co-pays
  • PA application (especially with Partial LIS)
  • QI1 application – pays Part B premium
  • Plan Finder search

Case Study – Ella Vation

Ella contacts you in March for information about enrolling in Part D. She is 69 years old and has Medicare A & B only. She never enrolled in Part D because she did not take any medication and didn’t feel that she could afford the premium. Her doctor recently prescribed medication that is expensive. She tells you her gross income is $1500/month. You explain that the annual open enrollment period has ended, but that she should be eligible to join Prescription Advantage at no cost which would provide a Special Enrollment Period during which she could then join a Part D plan. You explain that PA will allow her to enroll in a Part D plan but she will be subject to a late enrollment penalty. In response to her question about how much the penalty will be, you begin to give her a rough calculation based on her getting on Medicare at age 65. She then tells you that she got Medicare at age 62 due to a disability. She had back surgery at age 59 and was not able to return to her job which required her to spend a great deal of time on her feet. She was on disability and became eligible for Medicare. Ella lives in her own home and is just making ends meet. She is hoping that she can get some help with her prescription costs or at least get an inexpensive Part D plan.

What plan(s) or program(s) would you discuss with her that might help with her health care costs?

  • If she can work (40 hrs/mo at $1.00/hr) can pay small premium and get CommonHealth
  • With her income CommonHealth will not pay Part B premium, but will give Full LIS
  • Explain Medicare 101 with MH as Supplement
  • Needs a PDP - do Plan Finder search
  • If she cannot work then no CommonHealth, but HSN
  • Discuss CORE and MA plans
  • Prescription Advantage (category S2) application for SEP to get drug plan
  • Plan Finder search

Case Study — Hal Loosinate

Hal is turning 65 and retiring in a few months. He has already met with a worker at his local Social Security office and signed up for Medicare Part A & B. He has done some research and received information from the regional SHINE office about his options and decided to do original Medicare with a Medigap Sup. 1 plan. He is in very good health and takes no medication. He is thinking that he won’t sign up for Part D. He’s heard his friends complaining about all the problems they’ve had with their plans. He understands that he’ll face a penalty when he does sign up but doesn’t feel like it’s significant enough to be concerned about. He is open to looking at this, however, and wants to talk with you about the pros/cons of not taking Part D to see if there is anything he has overlooked.

  • Check income and assets for MH programs, LIS and PA
  • Cheapest PDP would give insurance if he needed to take drugs and also protect from penalty in the future
  • Discuss Medigap CORE and Medicare Advantage plans

Case Study — Dan & Dee Lyon

Dan Lyon calls you at the SHINE office for assistance. His wife has Alzheimer’s disease and takes some expensive medications. He enrolled her into a Medicare Prescription Drug Program when it was first available, but the plan no longer covers all of her drugs. After calling the plan, he was told that 2 of her medications are not covered. Along with the drugs not covered, he is worried about the out-of-pocket costs he will face during the gap in Part D coverage. He wonders if there is any help available. He asks if you could meet with him in his home as he cares for his wife and doesn’t have anyone available to sit with her.

During the home visit you get the following information:

  • Dan’s SS is: $1990/month (net)
  • Dan’s Pension is: 600/month (gross)
  • Dee’s SS is: 1750/month (net)
  • They have a joint checking account with a current balance of $2,300.
  • They have a joint savings account of $68,000.
  • They live in their own home and own one car.
  • Dee has a life insurance policy with a face value of $1200.
  • Dan has a life insurance policy with a face value of $4000.
  • They are both on Bankers Life Supplement 1.
  • They are both enrolled in the Humana Enhanced Ptart D plan

Dan is determined to keep Dee at home, but it is difficult for him. He has paid for private help from time to time, but says this is quite costly and has drained their savings significantly. Their home is old and he’s concerned about having the resources to do upkeep and repairs as needed. Dan would like to know if he can get any help with some of their health care costs. He also wonders if you know of any personal care service agency that would be less costly than the one he has used in the past.

How would you help Dan & Dee?

  • Frail Elder Waiver for wife
  • Contact ASAP for Nursing evaluation
  • Transfer all but $2,000 of assets into his name
  • MH application – personal care services
  • MH will pay her Part B premium
  • Drugs will be $0 co-pays for her
  • Plan Finder search
  • Switch both to BCBS Medex Bronze
  • She may not need Supplement 1, if her doctors accept MH

Case Study — Lenda Hand

Lenda Hand’s daughter, Carin Foru, calls for assistance. Her mother, Lenda, lives alone in her own home. She has a disability and needs hands on assistance with some tasks. Carin goes to her mother’s home in the morning before work to help Lenda get out of bed and dressed. She returns in the evening to fix her supper and help her get into bed for the night. Carin’s husband is quite ill, and it has become increasingly difficult for her to provide assistance to both her mother and her husband. Carin tells you her mother’s income is a SS check for $1100/month and that she has $1300 in a checking account, a prepaid funeral plan for $8000 and a life insurance policy with a face value of$1200. Lenda has managed to stay on top of her bills including medical bills. She currently has BCBS Bronze to supplement her Medicare, is on a Part D plan and Prescription Advantage.

Carin wonders if Medicare would provide any in-home coverage that would supplement what she is able to provide so that she could give more time to her husband.

How would you help her?

  • Medicare doesn’t cover personal care
  • MH PCA program will provide personal care assistance
  • MH application
  • MH will pay Part B premium
  • Deemed for Full LIS
  • Can drop Bronze, if doctors take MH
  • Plan Finder search

Case Study — Martin Eyes

Mr. Eyes meets with you at the SHINE office. He retired at age 65 and is collecting Social Security. He has Medicare and Medex Bronze with Blue Cross/Blue Shield. He takes no medications and never signed up for Part D. Mr. Eyes recently took a part-time job at the local Whypaymore to supplement his income. He lives in senior housing, so his rent is affordable. Mr. Eyes tells you that he is having a difficult time paying for his health insurance and was told by a friend that he should apply for MassHealth which would cover his medical expenses. Mr. Eyes tells you that he gets $750/month from Social Security and $300/month from his job at Whypaymore. He has $600 in a checking account and $1,400 in a CD.

Is he eligible for MassHealth?

  • Eligible for MH (earned income $300 - $65 = $235/2 = $118 ($750 + $105 + $118 = $973)
  • MH will pay Part B premium
  • Deemed Full LIS
  • Can drop Bronze, if doctors take MH
  • If not, discuss Medigap CORE and Medicare Advantage plans
  • Plan Finder search

Case Study – Otto Pilot

Mr. Pilot was hospitalized for five days. (He was admitted as an inpatient for the full five days.) He went from the hospital into a SNF for rehab for 30 days during which time he received skilled care daily. Please list what his costs would be for the hospital/SNF stay if he has full MassHealth Health Safety Net and then what the costs would be without the Health Safety Net.

Tufts Medicare Preferred Basic Rx plan

  • With: 20(40) + 10(100) = $1800
  • Without:5(225) + 20(40) + 10(100) = $2925

Tufts Medicare Preferred Prime Rx plan

  • With: 20(20) + 10(0) = $400
  • Without: 200+ 20(20) + 10(0) = $600

AARP Medicare Complete Choice PPO plan

  • With In Network: 20(0) + 10(155) = $1550
  • Out of Network: 40% (30 days in SNF)
  • Without In Network: (3)(495) + 20(0) +10(155) = $3035
  • Out of Network: 40% (hospital) + 40% (30 days in SNF)

Blue Cross/Blue Shield Medex Bronze

  • With:$0
  • Without:$0

Blue Cross/Blue Shield Medex Core

  • With: 10(157.50) = $1575
  • Without: $1260 + 10($157.50) = $2835

Case Study — Benny Drill

Benny calls you on 4/1. He was on MassHealth until he turned 65 in January. He signed up for a Tufts plan for which he pays about $160/month because he needs the prescription coverage and his doctor takes it. He is finding the premium rather costly and wonders if there might be another plan his doctor will take that won’t be quite so expensive. Benny is single and living on $1580/month. He has a friend who gets his meds through the VA. Benny looked into the benefit for himself but he was in the Reserves and never did active duty so doesn’t qualify.

How would you help him?

Case Study — Bob Sled

Bob Sled meets with you for assistance. He turned 65 six months ago and is now collecting Social Security. He was on SSI and has been on Medicare for a little over a year. He was covered under his former wife’s employer plan until she retired four months ago. He now has Medex Bronze and First Health Value Plus. He is single and owns his home and is finding it difficult to manage on his SS check of $1390. He takes two inexpensive generic medications. He is not a veteran.

  • Must be disabled since MH (CommonHealth) <65
  • CommonHealth – discuss working option (Full LIS)
  • MH application
  • MH SEP to change plan
  • If cannot work, Prescription Advantage (category S2) application
  • PA SEP to change plan
  • Plan Finder search
  • Eligible HSN – discuss CORE and cheaper MA-PD plan
  • Must be disabled since Medicare before 65
  • CommonHealth – discuss working option (Full LIS)
  • MH application
  • MH SEP to change plan
  • Drop Bronze, if doctors take MH
  • If cannot work, eligible HSN
  • Discuss CORE
  • Prescription Advantage(category S2) application
  • PA SEP to change drug plan
  • Plan Finder search

Case Study — Benny Diction

Benny calls you to inquire about coverage for a health aid for his wife. She is 62 and disabled with MS which she has had for 20 years. She has been on Medicare for the past 10 years. Her disease has grown progressively worse over the years, and she is now homebound. She needs assistance daily with mobility, dressing, bathing and personal care. He is her primary caregiver and is no longer able to leave the home to visit with his children or grandchildren.

Benny is 66 and retired. He owned a successful business and was able to retire with a nest egg that has allowed him to make alternations to their home including a life to assist him in getting his wife in and out of bed. His wife’s income is modest ($1200/month) but his income and their assets make him ineligible for any benefit programs.

He wondered if SHINE would have information about agencies that provide home health aides. He would like to get some assistance, so he could visit his children and watch an occasional sports event in which his grandson participates.

How would you help him?

  • Frail Elder Waiver for wife
  • Contact ASAP for Nursing evaluation
  • Transfer all but $2,000 of assets into his name
  • MH application – personal care services
  • Drugs will be $0 co-pays for her
  • MH SEP to change plan
  • Plan Finder search

Case Study — Jill Tedd

Jill Tedd contacts you on May 10th . She is 54 and on CommonHealth. She will be on Medicare on June 1 have being on SSDI for 24 months. She tells you she is on several expensive medications and was told by someone at MassHealth that she will no longer be covered for her meds by MassHealth on June 1 and will be covered by Medicare Part D. Jill called Medicare to see what Part D plan she will be on and was told that they have no record of her. She is very worried that she will not be able to fill her prescriptions after June 1 and wants to know how she can make sure she has coverage if Medicare doesn’t even have a record of her.

How would you help?

Case Study — Charlie Horse

Charlie meets with you for help with his prescription coverage. He is in a Blue Cross PPO Medicare Advantage plan with prescription coverage. He takes several medications, one of which, Procrit, is quite expensive. His plan has been covering it, but he will be in the donut hole soon and is concerned because he can’t afford to pay the full price for his drug. He tells you he used to be in Prescription Advantage but that ended in January. He says his monthly income of $1,585 makes him ineligible for any benefit programs. He is not a veteran.