SHIBA | 800-562-6900 | April 2020 volunteer training | Page 1 of 20

Volunteer continuing education Statewide Health Insurance Benefits Advisors (SHIBA)

♥ Volunteer recognition andHelp paying for Medicare

April 2020 continuing education agenda • Learning objectives• Publications• Troubleshooting and sharing time• SHIBA issues and reference materials• Medicare & You, Section 7• 2020 continuing education topics• Continuing education evaluation

Note: Acronyms and Advanced study resources available on My SHIBA.

For training purposes only – do NOT share with consumers.

SHIBA | 800-562-6900 | April 2020 volunteer training | Page 2 of 20

Learning objectives After completing the training, you should be able to:

• Screen a client and help them apply for a Medicare Savings Program(MSP).

• Screen a client and help them apply for Extra Help (also referred to asLow-Income Subsidy or LIS).

• Explain the benefits of (and objections to) applying for MSP and ExtraHelp.

• Describe the purpose of the Get Help Paying for Medicare trifold inapplying for MSP and Extra Help.

• Describe how you know when you have reached your scope and needto refer clients to DSHS.

• List the sources that provide information for where to send clientswho have more detailed questions about getting help paying forMedicare.

• Describe which agencies determines eligibility for MSP and ExtraHelp.

• Describe how to refer people to the corresponding agencies.• Describe how eligibility for MSP impacts eligibility for Extra Help.

SHIBA | 800-562-6900 | April 2020 volunteer training | Page 3 of 20

Job aids and client publications

Medicare & You 2020Note: this is the national version. You should have a copy of theWashington state version.www.medicare.gov/sites/default/files/2020-02/10050-Medicare-and-You.pdf

Application for Medicare Savings Programs (MSP)Partner publicationwww.hca.wa.gov/assets/free-or-low-cost/13-691.pdf

Calling the Health Care Authority Medicaid phone systemSHIBA job aidwww.insurance.wa.gov/sites/default/files/documents/calling-hca-medicaid-phone-system_1.pdf

Get help paying for MedicareSHIBA client publicationwww.insurance.wa.gov/sites/default/files/documents/get-help-pay-for-medicare-brochure_2.pdf

Medicare help rainbow chartSHIBA job aidwww.insurance.wa.gov/sites/default/files/documents/medicare-help-rainbow-chart%20.pdf

SHIBA | 800-562-6900 | April 2020 volunteer training | Page 4 of 20

Notes ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HCA 13-691 (6/19)

Application for Medicare Savings Programs Please read the following before completing the application.

Depending on your income and resources, the Medicare Savings Program (MSP) can help pay your Medicare Part B premium. For some, the MSP can pay Medicare premiums and other Medicare costs not paid by Medicare. These include Medicare deductibles, coinsurance, and copayments.

You will need to answer all questions before we will know if we can help you. If you need help completing any part of this form, call your local Community Services Office.

Please print.

1. First name Middle initial Last name

2. Residence address City State ZIP code

3. Mailing address (if different) City State ZIP code

4. Telephone numberPrimary: Other:

5. Do you have trouble speaking, reading, or writing English? YES NO

Do you need an interpreter? YES NO

If yes, we will provide one. What language do you speak?

GENERAL INFORMATION

List self and all others living with you. Use legal names.

Name (First, MI, Last)

Relationship to you

Date of birth

Applying for benefits?

Yes No

Social Security Number

Sex

M or F

SELF

SPOUSE

MEDICAL COVERAGE INFORMATION

Check which applies Medicare number

Eligible for or receiving: Medicare Part A Self YES NO

Spouse YES NO

Other YES NO

Check which applies Medicare number

Eligible for or receiving: Medicare Part B Self YES NO

Spouse YES NO

Other YES NO

I /we have other medical coverage. YES NO

If yes, what insurance and whom does it cover?

Did you pay Medicare premiums for Medicare Part A or Part B in the last 3 months? YES NO

If so, please tell us which months

INCOME

For each person that you included on this application who has income, list the income below. List the income amount before deductions (such as taxes or insurance) are taken out. Income includes but is not limited to:

Wages

Self-employment

Commissions

Room and Board/Rent

Railroad Benefits

Social SecurityBenefits

Veterans Benefits

Alimony Benefits

Unemployment orWorker Compensation

SSU/Public Assistance

Pensions/Retirement

Dividends and Interest

Other

Name Employer or source of income Amount before

deductions How often received?

ASSETS

A. List all assets. Assets include bank accounts, certificates of deposit, savings bonds, IRAs, stocks and bonds, mutualfunds, cash, and property other than your home or automobile.

If yes, please list below:

Name of owner Type/account number of the asset Current value

B. Do you or your spouse own or are you buying a car or other vehicle(truck, boat, motor home, motorcycle, camper and/or trailer?)

YES NO

If yes, please list below:

Name of owner Item Year Make/model Is vehicle used to get to medical appointments?

Value Amount owed

YES NO

YES NO

YES NO

YES NO

C. Do you or your spouse have a whole life insurance policy with cash value over $1,500? Also listany burial insurance or burial plans.

Yes No

If yes, please list below:

Policy owner Name of insurance

company/policy number Face value Cash value Who is covered?

AUTHORIZED REPRESENTATIVE INFORMATION

An authorized representative is any adult who is aware of the household circumstances and is authorized by the

household to act on behalf of the household for eligibility purposes.

By designating an authorized representative, you are giving permission for your authorized representative to:

Sign the application on your behalf;

Receive notices related to your application and account; and

Act on your behalf for all matters related to the application and account.

1. Are you designating an authorized representative? Yes No

2. Do you want your authorized representative to receive notices related to your application and account? Yes No

3. Does this authorized representative have legal guardianship? Yes No If yes, who:

4. Does this authorized representative have power of attorney? Yes No If yes, who:

Authorized Representative Name / Organization

Phone Number

Mailing Address of Authorized Representative

E-mail Address

VOTER REGISTRATION

The Department offers voter registration services as required by the National Voter Registration Act of 1993.

Applying to register or declining to register to vote will not affect the services or amount of benefits that you may be provided by this agency. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Washington State Elections Office PO Box 40229, Olympia, WA 98504-0229 (1-800-448-4881)

Do you want to register to vote or update your voter registration? Yes No

If you do not check either box, you will be considered to have decided not to register to vote at this time.

AUTHORIZATION

I understand the information I provide to apply for assistance will be subject to verification by federal and state officials to determine if it is correct. I authorize the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS) to conduct asset verification to establish my eligibility and to verify the accuracy of my financial information. I understand the HCA and DSHS may investigate and contact any financial institution, state or federal agency, or private database, as part of the asset verification process. I understand this authorization ends when a final adverse decision is made on my application, my eligibility for benefits ends, or if I revoke this authorization at any time by providing HCA or DSHS with written notice. Should I revoke or refuse to provide authorization, I understand that I will not be eligible for any Washington Apple Health Aged, Blind or Disabled Medicaid program.

READ CAREFULLY BEFORE SIGNING

I understand that:

I must report immediately to the agency or the agency’s designee, in writing, or by telephone, any changes in mysituation. Late reporting may cause incorrect benefits.

My situation is subject to verification by the agency or other state or federal agencies.

To receive help, I must provide proof when asked. The agency or the agency’s designee may help me obtain theproof or contact other persons or agencies for it.

By asking for and receiving medical care benefits, I assign to the state of Washington all rights to any medicalsupport, and to any third party payments for medical care.

DECLARATION AND SIGNATURE(S)

I have read and understood the information in this application. I declare, under penalty of perjury, the information I have

given in this application is true, correct, and complete to the best of my knowledge.

Signature of applicant Date

Signature of spouse Date

Signature of person assisting applicant Organization Date

VOLUNTARY INFORMATION

We ask you to voluntarily tell us your race or ethnic background. This information will not be used in considering your

eligibility for benefits.

Caucasian Hispanic Black Native American/Alaskan Native

Vietnamese/Laotian/Cambodian Tribe:

Other Asian or Pacific Islander Other:

Sign and date your application and return it to your local Community Services Office or by mail to:

DSHS

CSD Customer Service Center

PO Box 11699

Tacoma, WA 98411-6699

HCA and DSHS comply with all applicable federal and Washington state civil rights laws and are committed to providing equal access to our services. If you need an accommodation, or require documents in another format or language, please call 1-877-501-2233.

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov

SHIBA JOB AID – UPDATED 2.11.20

Calling the Health Care Authority Medicaid Phone System

Available 24/7

Instructions for calling the HCA/Medicaid

phone system to check Medicaid and MSP

enrollment.

This phone system was updated in October

2017 and it no longer uses speech

recognition, you must enter prompts on the

telephone touch pad.

Tips for calling:

You need client’s Zip Code, and one of the

following:

o Social Security Number or

o Provider One Number (on the front

of a client’s Provider One card)

Have a pen ready to write what you hear

For best results, listen carefully to the

prompts before pressing the next button.

Dial 1-800-562-3022

“This call will be monitored or recorded for

documentation purposes…” (WAIT)

“Thank you for calling the Health Care Authority’s

Washington Apple Health/Medicaid…” (WAIT)

Press 1: English or stay on the line Press 2:

Spanish

Press 3: Other Languages

“If you have an extension number, press 1 now,

otherwise stay on the line” (WAIT)

“You may use one of our self-service options…”

(WAIT)

Press 1: Client Self-Service (WAIT)

Press 3: Check eligibility for coverage

Press 2 to enter 9 digit SSN with # at the end

Enter XXX-XX-XXXX#

“Enter Zip Code now” XXXXX

Press 1: To hear benefits for today’s date

To hear benefits for another date, enter the date

using dd/mm/yyyy format.

For training purposes only – do NOT share with consumers..

SHIBA job aid

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov

SHIBA JOB AID – UPDATED 2-20-2020

Medicare Help Rainbow Chart Screen clients for programs based on household size, monthly income and resources.

Program Income Limit Program Resource Limit

Household Size See Notes about who is counted

1 2 3 4 SSI-Related Medicaid Income Limit (AKA Categorically Needy/CN Medicaid S01, S02) $803 $1,195 Check with

DSHS/HCA Check with DSHS/HCA

SSI Resource Limit $2,000 $3,000 Check with DSHS/HCA

Check with DSHS/HCA

MN – Medically Needy / Spenddown Income basis (S95, S99) > $803 > $803 > $803 > $803

MN Resource Limit $2,000 $3,000 $3,050 $3,100 MSP- QMB Income Limit 100% FPL (Federal Poverty Level) (S03) $1,083 $1,457 $1,830 $2,203 MSP- QMB Resource Limit $,7860 $11,800 $7,860* $11,800* $7,860* $11,800*

MSP- SLMB Income Limit 120% FPL (S05) $1,296 $1,744 $2,192 $2,640 MSP- QI-1 Income Limit 135% FPL (S06) $1,456 $1,960 $2,464 $2,968 MSP- SLMB and QI-1 Resource Limit $7,860 $11,800 $7,860* $11,800* $7,860* $11,800*

Full Extra Help Income Limit 135% FPL $1,456 $1,960 $2,464 $2,968 Full Extra Help Resource Limit $9,360 $14,800 $9,360* $14,800* $9,360* $14,800*

Partial Extra Help Income Limit 150% FPL $1,615 $2,175 $2,735 $3,295 Partial Extra Help Resource Limit $14,610 $29, 160 $14,610* $29,160* $14,610* $29,160*

See Notes next page

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 2 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Notes: These are programs for people eligible for Medicare In all cases, if unsure about eligibility, encourage clients to apply!

Income comments • Income amounts are listed as GROSS, before any deductions.• These programs disregard $20 of monthly income per household, so the listed income levels are $20 higher than the Federal

Poverty Level.• People with “earned” income (from employment, including self-employment) can have a higher income than what’s shown on

this chart. Programs generally count half of someone’s earned income.Household size comments • This chart stops at a family size of four. Contact DSHS/HCA or SSA for information on larger families.• MSP family counts: Person applying for benefits + spouse (legally married) + any biological, adopted or step-children under age

19.• Extra Help family counts: Person applying for benefits, + spouse (legally married AND living together), + any relative living with

them who depend on them for at least half of their financial support. (Relative can be any age and related by blood, marriage oradoption.)

Resource comments • Resources are also sometimes called “assets.”• Resources include: Bank accounts, certificates of deposit, savings bonds, IRAs, stocks and bonds, mutual funds, cash, and

property other than client’s home or auto, furniture and household items.• *The two-person resource limit applies only if the married couple lives together. For households without a married couple, the

one-person resource limit applies.General comments • Numbers may vary slightly due to differences in rounding.• Income and Resource calculations for people applying for long-term care services and supports, such as nursing home care or

COPES, are not on this chart. For more information, see page 3 of the DSHS publication Medicaid and Long-Term Services andSupport for Adults at: www.dshs.wa.gov/sites/default/files/publications/documents/22-619.pdf

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 3 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

SSI – related Medicaid (DSHS)

(AKA Categorically

Needy/CN Medicaid S01,

S02)

Applicant must be: • 65 or over (aged) OR• Meet SSA definition of

blind OR• Meet SSA definition of

disabled ANDIncome and resources are the same or lower than the standards for SSI-Related Medicaid

See Eligibility Overview at: www.hca.wa.gov/Resources/free-or-low-cost/22-315.pdf

Full “Categorically Needy” (CN) Medicaid

• Medicare pays first• Medicare A or B co-payments or

deductibles covered, as long asproviders accept both Medicareand Medicaid.

• If joins a MA PD plan, will nothave co-pays or deductibles foranything Original Medicare A/Bwould cover.

• Automatically (“deemed”)eligible for Extra Help

• Part D will cover Rx• May have small Part D co-pays

Medicaid would cover some things thatMedicare does not cover (i.e.):

• Dental benefits• Transportation to medical

appointments.• Limited OTC drugs

• Explain what it covers.• Apply for SSI through Social

Security• Apply for Medicaid online at

www.washingtonconnection.org,or by paper application HCA 18-005

• If found eligible, will beautomatically eligible for ExtraHelp.

• Clients should show theirMedicare/MA plan card and theirProvider One (Medicaid card) toall providers.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs.

• Remind them they must respondto Eligibility Reviews from DSHS(usually once per year).

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 4 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

MN – Medically Needy/

Spenddown (S095, S99)

For people with income above the limits for the SSI-Related Medicaid. Spenddown is the amount of the person’s income minus the income limit for his/her particular program. A person is given a base period (typically 3 or 6 months) to spend down “excess income”. In other words, to incur medical expenses equal to his/her spenddown amount. The person receives MN healthcare coverage for the rest of the base period once the spenddown amount is reached.

See Eligibility Overview at: www.hca.wa.gov/Resources/free-or-low-cost/22-315.pdf

The Medically Needy (MN) program covers slightly less than the Categorically Needy program. If on Medicare, (ONCE they meet their spenddown-and then ONLY for the remainder of the base period):

• Medicare pays first• Coverage is nearly the same as

for CN (Full-Dual Eligible)-see above.

• Will be automatically(“deemed”) eligible for Extra Help.

• May have small Part D co-pays

Works best for people who have large expenses, such as hospital care. A person may be able to apply for “Charity Care” to help cover the spenddown amount.

• Explain what it covers.• Apply on line at

www.washingtonconnection.org,or by paper application HCA 18-005

• Explain to clients that ONCE theymeet their spenddown, and ONLYfor the rest of their base period,they should not be billed for anyremainder after Medicare pays forPart A and B-covered services.

• If they meet the spenddown, willbe automatically eligible for ExtraHelp which will last at least therest of the calendar year.

• Tell clients to show theirMedicare/MA plan card and theirProvider One (Medicaid card) toall providers.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs.

• Remind them they’ll need toreapply if they still need coverageafter their base period ends.

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 5 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

Medicare Savings

Program- QMB (DSHS) (S03)

Must be entitled to Medicare (any age) For QMB:

• Income less than 100%FPL

• Limited Resources perincome chart

See Eligibility Overview at: www.hca.wa.gov/Resources/free-or-low-cost/22-315.pdf

Sometimes people who apply for a MSP are also put on a spenddown (see Medically Needy section).

A person who has QMB does not have to meet their spenddown amount before they get help with their Medicare Part A or B copayments or deductibles.

This program acts as a cost-sharing program. It is not the same as full CN Medicaid. It covers

• Medicare Part A premium• Medicare Part B premium• Medicare A or B co-payments or

deductibles covered, as long as providers accept both Medicare and Medicaid.

• If they join a MA PD plan, will not have co-pays or deductibles for anything Original Medicare A/B would cover

• Automatically (“deemed”)eligible for Extra Help

• Part D will cover Rx• May have small Part D co-pays.

• Apply on line atwww.washingtonconnection.org,or by paper application HCA 18-005

• Explain to clients DSHS will paytheir monthly Medicare Part Aand B premiums, and they shouldnot be billed for any remainderafter Medicare pays for Part A andB-covered services.

• Tell clients to show theirMedicare/MA plan card and their Provider One (Medicaid card) to all providers.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs. They maystill have small drug co-pays.

• Remind them they must respondto Eligibility Reviews from DSHS(usually once per year).

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 6 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

Medicare Savings

Program- SLMB or QI-1

Level (DSHS)

(S05, S06)

Must be entitled to Medicare (any age) For SLMB:

• Income less than 120% FPL

• Limited Resources perincome chart

For QI-1: • Income less than 135%

FPL• Limited Resources per

income chart

See Eligibility Overview at: www.hca.wa.gov/Resources/free-or-low-cost/22-315.pdf

SLMB and QI-1: • Medicare Part B Premium only• Automatically (“deemed”)

eligible for Extra Help • Part D will cover Rx• May have small Part D co-pays.

• Apply on line atwww.washingtonconnection.org, or by paper application HCA 18-005

• Explain to clients DSHS will paytheir monthly Part B premiums.

• They will still have to payMedicare Part A and Part B orMedicare Advantage deductibles,co-pays or coinsurance.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs.

• Remind them they must respondto Eligibility Reviews from DSHS (usually once per year).

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 7 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

Full Extra Help (Social Security)

Must be entitled to Medicare (any age)

• Income less than 135%FPL

• Limited Resources perincome chart

This program assists qualified Medicare applicants with help paying their prescription drug plan costs. It covers part or all of premiums, deductibles, copays and the donut hole.

For details on costs breakdown, see “2020 Extra Help/LIS Co pay Levels & Costs”: www.insurance.wa.gov/sites/default/files/documents/extra-help-lis-levels-costs_3.pdf

• Clients must apply to SSA for thisbenefit, unless they get itautomatically by being onMedicaid/MSP.

• Can apply online:https://secure.ssa.gov/i1020/start

• Explain to clients they’ll pay either$0 or low-cost Part D premium,have no deductible or donut hole,pay out-of-pocket up to $3.60 forgenerics and $8.95 for brands,and can change their drugcoverage generally once perquarter.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs.

• Let clients know they may haveEligibility Reviews and to watchfor letters from Social Security.

Medicare Help Rainbow Chart

For training purposes only – do NOT share with consumers.

Contact: SHIBA | 800-562-6900 | shiba@oic.wa.gov Page 8 of 8

SHIBA JOB AID – UPDATED 2-20-2020

Program name General eligibility information What it covers (in general) Action to take

Partial Extra Help

(Social Security)

Must be entitled to Medicare (any age)

• Income less than 150%FPL

• Limited Resources perincome chart

This program assists qualified Medicare applicants with help paying their prescription drug plan costs. It covers part or all of premiums, deductibles, copays and the donut hole.

For details on costs breakdown, see “2020 Extra Help/LIS Co pay Levels & Costs www.insurance.wa.gov/sites/default/files/documents/extra-help-lis-levels-costs_3.pdf

• Clients must apply to SSA for thisbenefit.

• Can apply online:https://secure.ssa.gov/i1020/start

• Explain to clients they’ll pay eithera $0 or low-cost Part D premium,a $0 to $89 deductible, have nodonut hole, will pay up to 15percent of the full cost formedications, and can change theirdrug coverage generally once perquarter.

• Check to make sure clients are inthe most affordable Part D or MAplan for their needs.

• Let clients know they may haveEligibility Reviews and to watchfor letters from Social Security.

SHIBA | 800-562-6900 | April 2020 volunteer training | Page 19 of 20

Continuing education evaluation Date of Training: _______________ Training Location: ______________________

How can SHIBA improve the monthly trainings? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What additional trainings within our SHIBA scope would you like to see? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What SHIBA training materials — including SHIBA Job Aids — would you like to see added to My SHIBA? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other: _________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Optional: If you would like to be contacted, please provide your name and contact information. Someone in our office will contact you. Thank you! Name: ________________________________________________________________________ Day Phone: ________________________Email: ____________________________________

If you prefer to give electronic feedback about curriculum or training, please contact: Diana Schlesselman: dianas@oic.wa.gov or Liz Mercer: lizm@oic.wa.gov.

Thank you!