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SHINE: Serving the Health Insurance Needs of Everyone

Lorraine York-EdbergLorraine York-Edberg

To apply, fill out a simple one-page application.

Medicare buy-in programs, also called Medicare Savings Programs, can help low-income Medicare beneficiaries pay their share of the standard Medicare Part B premium, which is currently $135.50 monthly. Medicare beneficiaries may be eligible for different buy-in programs based on their income and assets.  The three programs are called QMB (Qualified Medicare Beneficiary); SLMB (Specified Low Income Medicare Beneficiary); and QI-1 (Qualified Individuals).

Eligibility Guidelines for these programs are as follows:

  • QMB is at 100% Federal Poverty Level as follows for an
    • Individual $1,041 monthly and less than $7,730 in assets
    • Couple $1,410 monthly and less than $11,600 in assets
  • SLMB is at 120% Federal Poverty Level as follows for an
    • Individual $1,249 monthly and less than $7,730 in assets
    • Couple $1,691 monthly and less than $11,600 in assets
  • QI-1 is at 135% Federal Poverty Level as follows for an
    • Individual $1,406 monthly and less than $7,730 in assets
    • Couple $1,872 monthly and less than $11,600 in assets

These programs are not subject to estate recovery since January of 2010, so the state will NOT place a lien on your property to recover benefits following your death.

And better still...

If you qualify for any of the three Medicare Savings programs, you will also automatically qualify for a full subsidy under the Medicare Part D Low Income Subsidy (LIS), which is also known as "Extra Help."  This program will pay the monthly premiums for your Part D plan, provided you are enrolled in a qualified plan.  The LIS will also assist with covering drugs during the Part D deductible and coverage gap.

If you are eligible as a Qualified Medicare Beneficiary (QMB), this program will pay for your Part A (hospital insurance) deductible and Part B annual deductible of $185 annually.  The 2019 Part B standard premium is currently $135.50 monthly, and the hospital deductible is $1,364 for each hospitalization.

If you are eligible as a Specified Low Income Medicare Beneficiary (SLMB) or the Qualified Individual Medicare Beneficiary (Q I-1), this program will pay for your Part B (medical insurance) premium.

To apply, it is a one-page application, and simple to fill out.  To get this application, you can contact MassHealth at 1-800-841-2900 and request the Medicare Buy-In application, and they can send it to you.  We also have applications available here at the regional SHINE office upon request. If you need assistance filling it out, we are happy to assist.

The SHINE program (Serving Health Information Needs of Everyone…on Medicare), provides free, confidential, and unbiased health insurance counseling for Medicare beneficiaries.  To reach a trained and certified counselor in your area, contact the Regional Office at LifePath at 1-800-498-4232 or 413-773-5555, or contact your local Council on Aging.

Volunteer Spring Training 2019 begins in April

Lorraine York Edberg headshotLorraine York-EdbergIf you’re interested in healthcare and looking for a volunteer opportunity, consider signing up to become a SHINE counselor with LifePath. The 2019 Spring Training is coming up in a few weeks, and there is no better time to get started.

SHINE, Serving Health Insurance Needs of Everyone, is a program that provides free, confidential and unbiased health insurance counseling for all Medicare beneficiaries. Volunteers in the LifePath SHINE program serve communities in all of Franklin County as well as the North Quabbin region of Worcester County and parts of Hampden and Hampshire counties.

SHINE counselors work one-on-one with individuals in their own communities providing information, counseling and assistance on Medicare, Medigap, Medicare Advantage Plans, Medicare Prescription Drug Coverage, Public Benefits, One Care Plans, and more. Those interested in becoming counselors should be comfortable working with a population consisting primarily of elders and persons with  behavioral health challenges and physical disabilities.

SHINE Counselor Larry Bezio enjoys the volunteer work the program offers, adding that he finds “personal satisfaction to be able to help someone” and “good socialization” with other counselors.

Feb 2019 SHINE Spring Training photo WEBSHINE Program Director Lorraine York-Edberg stands with the six participants of the 2017 SHINE Spring Training: Lauren Soules, Deb Prevost, Michael Naldrett, Judy Curley, Becky White, and Lisa Harris.Counselors benefit from ongoing monthly meetings, allowing them to stay up-to-date with new healthcare policies and programs, which are always changing. This year’s training is vast and comprehensive, and will address changes that have taken place in the past year.

The 2019 Spring Training is set to take place at LifePath in Greenfield from 10 a.m. to 3 p.m., with a break for lunch, beginning on April 2, 2019. Participants will meet weekdays for 11 sessions. A graduation celebration will take place in June.

If you are interested, want to learn more, or wish to sign up, contact me, Lorraine York-Edberg, Western Regional SHINE Program Director, at 413-773-5555 x2275 or 978-544-2259 x2275 or This email address is being protected from spambots. You need JavaScript enabled to view it..

SHINE logo

More about the SHINE Program

The SHINE Program, Serving the Health Information Needs of Everyone, provides free, confidential, and unbiased health insurance counseling for Medicare beneficiaries. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555.

Talking with your providers about your healthcare needs and coverage

Lorraine York Edberg headshotLorraine York Edberg

How can I communicate effectively with my providers?

Be prepared

Arrive at your doctor’s office prepared with any relevant insurance cards, a copy of your health history, and a list of questions you want to ask your doctor. Bring a pen and paper to take notes, and consider bringing another person, like a caregiver, to your appointment if you think they can help.

Share information

Tell your doctor about any current symptoms or concerns, or if you are having trouble with activities of daily living, like bathing or dressing. Tell them also about other providers you have seen and any treatments they recommended.

Ask questions

If you do not understand something your doctor says, ask them to explain it.

Get it in writing

Ask your doctor to write down what you should do between now and your next visit, including instructions for how to take medications, specialists you should see, and/or lifestyle modifications.

Follow up

If you experience any problems after your appointment, call your doctor’s office to schedule a follow-up. Ask your provider’s office if they use email or an online portal to communicate with patients.

What if my provider doesn’t think a service will be covered?

If you have Original Medicare

Jan 2019 SHINE Talking with your doctor photoWhen going to an appointment with your medical provider, there are steps you can take before, during, and after the appointment to make the most of your visit.If you have Original Medicare and your provider believes, based on Medicare’s coverage rules, that Medicare will not pay for an item or service, they may ask you to sign an Advance Beneficiary Notice (ABN) before you receive that service.

The ABN allows you to decide whether to get the care in question and to accept financial responsibility for the service if Medicare denies payment. The notice must explain why the provider believes Medicare will deny payment. Providers are not required to give you an ABN for services or items that are never covered by Medicare, such as hearing aids.

Note that your providers are not permitted to give you an ABN all the time or to have a blanket ABN policy.

If you have a Medicare Advantage plan

If you have a Medicare Advantage plan, you or your provider should contact your plan to request a formal determination about whether an item or service will be covered.

If the plan denies coverage before you receive the service, you should get a Notice of Denial of Medical Coverage within 14 days of requesting the determination (or within 72 hours if you request an expedited appeal and your plan approves your request).

Follow the instructions on this notice to appeal your plan’s determination. Ask your doctor to submit evidence to the plan that you meet the coverage criteria for the item or service and that it is medically necessary. If you need assistance filing an appeal, contact your State Health Insurance Assistance Program (SHIP) for information and counseling about the appeals process. See the last page for contact information.

Does Medicare cover second and third opinions?

A second opinion is when you ask a doctor other than your regular doctor for their view on symptoms, an injury, or an illness you are experiencing in order to better help you make an informed decision about treatment options.

Original Medicare covers second opinions if a doctor recommends that you have a surgery or major diagnostic or therapeutic procedure. Medicare does not cover second opinions for excluded services, like cosmetic surgery.

Medicare will also cover a third opinion if the first and second opinions are different from one another. The second and third opinions will be covered even if Medicare will not ultimately cover your procedure (unless it is an excluded service). If the first and second opinions were the same but you want a third opinion, you may be able to see a third doctor for a confirmatory consultation.

Medicare may cover a confirmatory consultation if your doctor submits the claim correctly and the service is reasonable and medically necessary.

If you are in a Medicare Advantage plan, your plan may have different cost and coverage rules for second and third opinions. Contact your plan for more information about costs and restrictions.

The SHINE Program, Serving the Health Insurance Needs of Everyone… with Medicare, provides free, confidential, and unbiased health insurance counseling for Medicare beneficiaries. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555 or contact your local council on aging.

new SHINE logoMedicare Part B premiums, deductibles and coinsurance for 2019

Lorraine York Edberg headshotLorraine York-EdbergThe Centers for Medicare and Medicaid announced the Medicare Part A and B premiums and deductibles for 2019.

These figures are based on the Social Security Cost of Living increase of 2.8% for 2019, which equates to an increase of $28 monthly for every $1,000 you receive in Social Security.

The standard monthly premium for Medicare Part B in 2019 will be $135.50, up from $134 in 2018. Some beneficiaries will pay less than the full standard monthly premium amount due to the statutory hold harmless provision, which limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits.

Medicare beneficiaries whose individual income is above $85,000 annually or a couple’s joint income above $170,000 annually will pay an increased amount for their Part B and Part D, called an income-related monthly adjustment amount, also known as “IRMAA.” The Federal government bases the 2019 adjustments on the beneficiaries’ 2017 Federal Income taxes. You may request a new initial determination through Social Security if you believe your IRMAA is incorrect by contacting your local Social Security office. Some other beneficiaries will be paying higher Part B premiums if they are on Medicare Part B, but not yet collecting their Social Security benefit.

The monthly Part B premium for those who are enrolled helps pay for doctors' services, x-rays and tests, outpatient hospital care, ambulance service, medical supplies, and other medical equipment. 

The 2019 Part B annual deductible will be $185 for all people with Medicare, an increase of $2 from 2018. The Part B deductible is annual; once you have incurred $185 of expenses for Medicare-covered services in any year, the Part B deductible does not apply to any further covered services you receive for the rest of the year.

Medicare Part A (Hospital Insurance) helps pay for hospital care, skilled nursing care, home health care, hospice care, and other services. The Part A deductible will increase from $1,340 to $1,364 for beneficiaries with Medicare only; the Part A deductible is the beneficiary’s only cost for up to 60 days of Medicare-covered inpatient hospital services. The 61st to the 90th day has increased from $335 to $341 a day, and beyond the 90th day has increased from $670 to $682 a day. For beneficiaries who have a Medigap plan to supplement Medicare, often most of these costs are covered by their supplemental insurance.

The skilled nursing facility coinsurance increased from $167.50 to $170.50 for the 21st to the 100th day. Medicare Part A covers the first 20 days in a skilled nursing facility, after a three-day qualifying stay in a hospital.

Many Medicare beneficiaries purchase additional insurance to cover the gaps of Medicare to help reduce out-of-pocket expenses.

This article is based on a news release from the Centers for Medicare and Medicaid Services.

The SHINE Program, Serving the Health Insurance Needs of Everyone… with Medicare, provides free, confidential, and unbiased health insurance counseling for Medicare beneficiaries. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555 or contact your local council on aging.

Medicare Open Enrollment is open and ends on December 7

Lorraine York Edberg headshotLorraine York-EdbergIf you have a Medicare, sometime during the month of September you should have received important information known as an Annual Notice of Change from your Prescription Drug Plan or your Medicare Advantage Plan HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization). The mailing explains any changes to your plan in the coming year regarding premiums, drug coverage changes (formulary), providers, and restrictions. It is very important to review the information to make sure the plan still works for you.

Starting October 15 through December 7, you can join, drop, or change your insurance, and the new coverage will begin on January 1, 2019. I like to call this time of year “Your Annual Insurance Checkup,” because it is a time when you can evaluate your current plan and decide if you want to make changes. If your current plan continues to meet your needs, then you may want to keep it. It is also a time when you may want to shop around for a new plan to help you save money, decrease or increase coverage.

Important things to consider when reviewing your plan changes are:

  • Does it still cover all your medications?
  • Are there any restrictions on your medication like quantity limits, prior authorization or step therapy that would make it difficult to access your needed medications?
  • Did you get a letter from your Medicare Prescription Drug Plan that your plan is changing or is no longer available in Massachusetts?
  • Have you been reassigned to a new plan? If so, contact the new plan to assure it will cover your current medications. If not, you should join a new plan before December 7, 2018, to access the medications you need without any problems.
  • Would you like to join a Medicare Prescription Drug Plan or Medicare Advantage Prescription Plan? Because [JR1] you’ve never joined previously, you can do it during this time.

Review and save all letters from your plan!

During the Medicare Open Enrollment (October 15 - December 7), you will have an opportunity to CHANGE your coverage for next year. You can decide to stay in Original Medicare or join a Medicare Advantage Plan. If you are already in a Medicare Advantage Plan, you can use the Open Enrollment to switch back to Original Medicare with a Medicare Prescription Drug Plan. State-certified SHINE (Medicare) counselors can help you understand your plan changes, as well as other options you may have. Call early to get a SHINE appointment (1-800-498-4232) during Open Enrollment!

Ways to get the help you need:

  • Visit www.medicare.gov/find-a-plan to use the Medicare Plan Finder.
  • Look at your most recent “Medicare and You” handbook to see plans in your area; 2019 books will be mailed late September.
  • Call 1-800-MEDICARE (1-800-633-4227) and say, “Agent.” Help is available 24 hours a day, including weekends.
  • Contact your local SHINE Program.
  • Attend a local presentation regarding the annual Open Enrollment period.

The SHINE program, Serving the Health Insurance Needs of Everyone, provides confidential, and unbiased health insurance counseling for Medicare beneficiaries. This is a free service, though contributions are welcome and will go a long way to help support this vital program. For further assistance with any Medicare issue, you can make a SHINE appointment. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555, or contact your local council on aging.