Welcome to Aging Health Matters, a podcast from Kepro, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. The information in today’s show may help you or someone you know in their healthcare journey. Thanks for joining us; now let’s get started.
Scott Fortin
Hello everyone, and welcome to another edition of Kepro’s podcast, Aging Health Matters. This is Scott Fortin, Kepro QIO’s Director of Communications and Outreach, here to introduce today’s topic. As a reminder, being the QIO for 29 states, we have three key services for people who have Medicare: appeals, quality of care complaints, and Immediate Advocacy services. More information on these topics is available on our website at www.keproqio.com. As we reach out on these topics to Medicare recipients, we work with many outstanding partners to help spread information about the Medicare program and its benefits. Today’s podcast includes one of our partnering organizations, the State Health Insurance Assistance Program, also known as SHIP for short. We are happy to bring you a conversation between Kia Weaver, a member of Kepro’s Outreach team, and her guest from SHIP, Shirley Thomas. As a reminder, we sometimes invite our partners to participate in our podcasts based on the topic.
While we greatly appreciate their partnerships, we also want to be clear that the opinions and guidance expressed by them in this podcast are solely theirs or their agencies and are not necessarily those of Kepro, CMS, or the Medicare program. Please keep in mind that state-by-state guidance may differ as well. With that, I’ll send it over to Kia and today’s guest, Shirley.
Kia Weaver
Thanks Scott. Hi everyone. Thanks for tuning in to today's episode. Today we have a guest from the State Health Insurance Assistance Program in Georgia. We have Shirley Thomas here with us. She's a Medicare counselor working with the Georgia Cares program.
Shirley, can you please tell us a little bit about your background and your role with the Georgia SHIP?
Shirley Thomas
Sure. I used to be a medical social worker in the state of Ohio, so I'm very familiar with Kepro because we used your services there as well, and I retired and moved to Georgia in 2010 and began volunteering with the SHIP program. Then, in 2015, I became an employed counselor for the SHIP program, and SHIP stands for State Health Insurance Assistance Program. So I guess that means I've been working about 12 years with the program.
Kia Weaver
Can you please tell us what your organization does and how they help the Medicare community?
Shirley Thomas
SHIP is trained by Medicare to provide Medicare information. We help you understand your healthcare benefits, the difference between a wellness and a preventative service. We help you find and sometimes apply for financial assistance programs. We help you with the first and second level of appeals and grievances. We explain Parts A,B,C&D, the Advantage plans, and the difference between Advantage plans and supplemental insurance. We are impartial, and we provide personalized counseling through presentations, counseling, health and benefit fairs, and with our community partners.
We do not sell or solicit for any insurance company. We just tell you exactly what the plans are and what might be most cost effective for you.
Kia Weaver
And can you just tell our listeners how to find their local SHIP?
Shirley Thomas
There is a website, www.shiphelp, one word, shiphelp.org or contact 877-839-2675. There is a SHIP in all 50 states, Puerto Rico, Guam, and the Virgin Islands. So there is someone there to help.
Kia Weaver
Perfect. Thanks so much. Can you also briefly review the Medicare Summary Notice and the Explanation of Benefits?
Shirley Thomas
Sure. Once you have had an appointment with your doctor, they send the claim to Medicare. Medicare quarterly sends you the information that they have received, the claims that they have received.
The first column tells you who the doctor was that sent the information to them. The next is the charges that were presented to them. The next column will show what Medicare considers reasonable and what they will cover, and the final column shows you what you would be responsible for, and if there's a letter like A or C or X, that says turn it on the back and it explains why something was or was not covered, or why you owe the amount they state that you may owe.
Kia Weaver
Do you have any tips for our listeners who may be on Medicare or listeners who are community organizations who also provide services to seniors?
Shirley Thomas
Yes, I know that Medicare is very confusing. They have added additional plans, especially since the pandemic. So Medicare itself sets the guidelines on what will and will not be covered. The Medicare Advantage plans are private insurance companies that have a contract with Medicare, and they have to cover what they say they will cover. So they present a contract with Medicare saying that for the amount of the Part B premium, this is what they will cover for the beneficiaries. Currently, there are at least 43 different Medicare Advantage plans for each county, so an individual can be looking at between 43 and I have seen 71 different plans in their zip code area that might cover what they need.
What was the other part of your question?
Kia Weaver
Just any tips you had, but if you can also talk a little bit about how you work with other stakeholders as well.
Shirley Thomas
With senior centers, they have the SHIP come in and do presentations, and certain centers have SHIP counselors come in once a month or every other month, to assist with whatever arises. So currently it is Open Enrollment, and during Open Enrollment, people have different enrollment periods. They're either newly enrolled in Medicare, so that is trying to find out whether they should stick with original Medicare or enroll in an Advantage plan. And so they come in to find out what the difference would be for them and what might be most cost effective for them. And we try to have them remember that you must consider different things, like will your medications be covered if you enroll in an Advantage plan. How does that affect your family members? Some people are jumping from the health market to Medicare, and so how will that affect your family? If your family was on the health market plan with you, do you have another prescription drug coverage under another agency or your employer? And will that be considered credible, so that you won't incur a penalty?
Open Enrollment is also the time that you can change your plan. You've been in something and now you want to try something else, or you've been in something, and you don't like it, or you've been in something, and they are moving. They will no longer be available. An example of that is the United Healthcare. United Healthcare announced that their Medicare Advantage Plan Choice Plan One, a PPO, and their nursing home plans, Plan One and Two, the special needs plan. will no longer be available in the state of Georgia, so they're canceling those. Now people have to find a new plan or a new way of getting their medical coverage. And we try to assist them with that. But you must remember, you need to take note of what is it that you need. What do you need covered? What are the supplemental benefits that you need included?
With the wide range of Advantage plans that are available, make sure the Advantage plan covers what it is that you need, and the coverage that they provide is sometimes different. There are different levels of coverage, so will they cover exactly what you need? Will they cover your prescriptions? Is your doctor and hospital in that plan? What is the quality of care? And the cost is not just the premium cost but also
the copays and deductibles. Can you afford that? Is that available to you? Do you qualify for assistance in paying those copays and deductibles? There are a lot of things to take into consideration, and that is why we are there to assist you.
Kia Weaver
Perfect. Thank you so much for all that information, and I would also like to add as well that I know you work with many other stakeholders statewide to provide services to seniors and especially during Open Enrollment. We also partner with SHIPs as well. Kepro provides presentations during staff trainings. There is sometimes a lot of turnover during Medicare Enrollment. We do just provide refreshers to staff on our services and how we can also assist seniors in the community. So I just wanted to add that as well. There is a great partnership between Kepro and the SHIPs in every state as well.
Shirley Thomas
I also wanted to add that we work really closely with the Senior Medicare Patrol, and that agency assists with fraud to investigate. Is this something fraudulent? Was it a mistake that they can help correct or was it actually fraud that has to be handled in specific manners, so we work very closely with them because you know that during Open Enrollment period and with the changes in the plans that are available and the doctors that are available, scam artists are running rampant, and they are doing different things that people are not aware of. So the Senior Medicare Patrol makes people aware of the different scams that are there and helps them learn how to protect themselves.
Kia Weaver
I'm so glad you brought that up. Thank you for sharing a little bit about your partnership with the SMP, and some of the work that they do to help seniors as well. And before we conclude, do you have anything else that you'd like to share with our listeners?
Shirley Thomas
Finding a plan or a Medigap or sticking with original Medicare and having a prescription drug plan is sometimes very confusing, sometimes very difficult. I believe that you should check with a SHIP counselor first, make sure that you have the correct information, you have the correct plans that are available to you, and then reach out to the insurance companies or to Medicare itself; do not call Social Security first to ask about a Medicare plan because that is not their role in enrolling you in Medicare. What Social Security does is enroll you and work on the financial end. How are you going to pay for Medicare? But as far as the insurance plans themselves, it is Medicare directly or SHIP that will provide you with unbiased information.
Kia Weaver
Thank you so much, Shirley. Thank you for taking the time to share all of this information with us. I've learned so much new things about what you do and your role as well helping with seniors. So I'm sure it's been beneficial for our listeners. And again, Kepro is the Beneficiary and Family Centered Care Quality Improvement Organization, also known as the BFCC-QIO.
If you would like more information about our services, please feel free to sign up for our newsletter as well as subscribe to our YouTube channel. Our helpline phone number as well as a link to sign up for our newsletter will be available in the show notes, and we also have several resources on our website, which is keproqio.com.
Thank you again Shirley. Thanks so much for taking this time out and sharing all that information with us, and for our listeners, thank you for listening and please stay tuned for our next episode.
Shirley Thomas
Thank you very much for having me.