Medicare Realness
Explain Guaranteed Issue Period.
The first 6 months after you get Part B of Medicare for the 1st time either at or above age 65, you get a GIP. This means during that 6 month period, you can pick up a Supplemental Medigap plan for the lowest available premium costs and no healthcare related underwriting.
What is this company? Whose company is it? What can it be?
NEW
OURS
SPECIAL
ID: Pt. has no insurance, lost his EGHP when he stopped working, and could not afford COBRA. Unsure of what to do next for coverage.
FD: Pt. plans to apply for Medicaid at his local DHS office.
General Insurance
Explain what a patient would need to know about Medicaid.
100% covg, Medicare needed if eligible, income, state.
Points to hit: Peritoneal Dialysis, through catheter in abdomen, can often be done by own self, typically nighttime cycler but also daytime manual possible, explain time amounts for cycler and manual.
Explain Extra Help.
RX help through Mdcr - pays Part D premiums, income limit around $1500 per month for a single person. $2000 a month for a couple. Low Rx copays - around $1, $3, $5. Can have OE at any time of year for MA plans.
1). Name HT's Director.
2). Name HT's VP.
1). Brittany Music
2). Stu Bachelder
ID: Pt. has Mdcr and a Plan F Supplement. Not seeing any bills so far, no plans to change.
FD: Pt. very happy with his insurance plan, feels great about his level of coverage. Not wanting to change it.
No Impact.
Vernon has Tricare, and he's 62 years old. What does Vernon need to know?
Tricare covg 1st 3 months if there's a waiting period, some ded and oop costs, then Tricare for Life w/ Mdcr - pt. likely required to pick up Mdcr. 80/20.
Roleplay Time: "I don't want to go on dialysis. I'm choosing palliative care."
Explain, as if to a patient, a Medicare Advantage plan's deductible, coinsurance, and OOP max.
The deductible is the amount of money you may have to meet before your insurance begins to pay. Once it starts paying, your plan may start coinsurance - which is when your plan typically pays a certain % of healthcare costs, and you may be paying your remaining %, until an OOP max is reached. This is the cap on the plan, meaning once its met, you should see full coverage for the remainder of the plan year.
Scenario: Pt. likes his EGHP. He thinks its working well so far. After education, he is willing to look into plans during his EGHP OE, but he isn't sure there's going to be anything different or better for him to choose. He is thinking about picking up Medicare as a secondary due to ESRD to save at least some money, he thinks.
Should ICARL be read or not?
Yes.
ID: Pt. considering switching into a different Medicare Advantage plan during this year's OE, since she's been seeing high copays. Doesn't know where to start looking.
FD: Due to education, pt. plans to call SHIP services in her area to look into MA plans, and knows to look out for networks, OOP max, copays, premiums, and deductibles.
Quality of Life: Insurance Support.
Explain the 30 month COB flip. What does this mean for the patient?
When a patient has an EGHP primary, and picks up Medicare due to dialysis, their plan typically stays primary for 30 months, and then Medicare becomes primary at that time. This could mean that after the flip, the patient may start seeing a few more bills, and they also now have network considerations with Mdcr primary.
Roleplay Time: "I don't need your education because I'm never going to go on dialysis. I'll be fine. My GFR is getting better!"
-> PA should speak about how our education is useful for anyone, for any type of medical appts, and it's good to know how your plan works for other things like transplant, and we aren't education for just dialysis. This call is not for dialysis specifically.
B - 10% every uncovered year.
D - 1% every uncovered month.
Incur a penalty if don't have creditable covg and didn't enroll in time.
Could drop off if start a new Medicare eligibility reason.
You're about to call Bobbie May. You go to the ________ Meeting page to check the forms. You notice that she requested education (checked the box!) but didn't sign any of her forms.
What can you do? Also, fill in the above blank.
Kidney Smart Meeting page.
She filled out her main form, so therefore we can call her. Because she didn't sign consent forms, we can only do GE education, even if she is TC eligible.
ID: Pt. has an EGHP. Working okay so far, but she's feeling more and more concerned about costs as dialysis is getting closer.
FD: Pt. now wants to look into picking up Medicare as a secondary insurance for fuller covg.
Quality of Life: Insurance Support.
If someone is struggling financially, what kinds of things can you talk to them about other than CRDPs?
Spreadsheet. CRDPs can often times cover dialysis expenses for people who meet certain income requirements. Sometimes, they don't cover dialysis but may cover other things, like meds, dental care, transport, rent/utilities assistance, etc.
Other help: premium assistance in a clinic, 211 resources, food stamps, getting back to work, RX samples, needy meds online, asking provider for charity care program or payment plans.
How much time may a patient need to take off for work for each modality:
- Transplant
- ICHD
- HHD
- PD
- Transplant: 6-8 weeks on average
- ICHD: a few days for fistula, some days or a few weeks to feel okay for transition.
- HHD: a few days for fistula, and then a few weeks, anywhere btwn 2-6 for training
- PD: a few days for catheter, then avg about 2 weeks for training
Scenario: Jim has Medicare A, B, and D only. He is 69 and concerned about bills. Stage 4. What would you educate on? What else do you need to know?
Educate on: Mdcr 80%, MA plans and OE with ESRD restrictions, Supplements possible but with underwriting, Medicaid.
Assess for income. Could he be eligible for Medicaid, an MSP, or Extra Help?
Role-Play Time!
Introduce yourself as if you just connected with a patient!
Points to hit: Name, PA, our role, class date, how was class, how are you, TC info.
Remember: Let it breath. If you act comfortable during your intro, then the patient will be comfortable, too.
ID: Pt. has ACA plan. Concerned about coverage and bills. Has no plan to change. Also, very concerned about starting dialysis, very worried about treatment.
FD: Pt. now plans to call HOPEline to speak to a peer about treatment for support. He also now plans to enroll into Mdcr and a Supplement instead of his ACA plan once he starts dialysis.
Quality of Life: Insurance Support
Jay has a Marketplace plan. He's 56 and self-employed. What do you need to educate him on. Explain each part.
Marketplace coverage: ded, coins, OOP max.
ACA OE - Nov 1 - Dec 15.
Mdcr eligiblity, switch or not, but can only have 1 or the other. Can lose tax credits.
What is motivational interviewing? Explain. Also, list at least 3 different MI/Rapport building techniques and give an example.
Change talk: allowing someone to decide they are ready to make changes. Empowerment!
Ex: saying pt.'s name, asking OEQs, mirroring, reflecting, affirmations,