The Centers for Medicare and Medicaid Services have created a FAQ Information
Sheet regarding Medicare and the Health Insurance Marketplace. The purpose of
this resource is to assure beneficiaries that their Medicare benefits are not changing. It also reinforces that the new marketplace health insurance is
designed for individuals who have NO health insurance. Please feel free to
distribute this resource within your counseling sites.
GIC Open Enrollment
April 10th 2013 to May 8th 2013 with changes effective
July 1st 2013
With GIC open enrollment upon us, we realize you may be meeting with a number of
Medicare beneficiaries who are retired state employees. These folks may be
eligible for GIC retiree health insurance. We wanted to share with all of you a
Fact Sheet that was adapted from the Metrowest SHINE Program. It provides some
basic information about the coordination of Medicare and GIC Retiree Supplement
Plans and coverage options for those state retirees who do not qualify for
Medicare. Feel free to use this guide as
a reference when working with state retirees. You can also view specific
information about GIC plan benefits and rates at www.mass.gov/gic.
In January 2013, an agreement was approved in the case of
Jimmo v. Sebelius. The plaintiffs alleged that Medicare
contractors were inappropriately applying an “Improvement Standard” in making
claims determinations for Medicare coverage of skilled nursing facility, home
health, and outpatient therapy benefits.
In your work as SHINE counselors, you may have assisted
beneficiaries who have been denied coverage for skilled nursing care, home
health care, or outpatient therapy because they are not improving or have
“plateaued”. Or providers may have told
them Medicare is likely to deny their future claims for the same reason and so
the beneficiary has stopped services.
CMS is affirming that claims for skilled nursing care,
home health, and outpatient therapy (physical, occupational, and speech) should
not be denied on the basis of this “Improvement Standard”. Instead, coverage
should be provided when “skilled services are required in order to provide care
that is reasonable and necessary to prevent or slow further deterioration”. In other words, Medicare will cover skilled
services that maintain a person’s condition or prevent it from worsening.