Case Study — George Bell



Case Study — George Bell

George Bell is a 64 year old man who will soon be reaching his 65th birthday. George is so busy with a full-time career that his plans for retirement are far in the future. George will continue employment with a major corporation beyond his 65th birthday. What should he do about Medicare enrollment and his current group health insurance?

Case Study — Frank

Frank is 70 years old. He retired at 65 from the GMYM Savings and Loan. Since he was receiving retiree insurance, he did not sign up for Medicare Part B. He has recently received notification from the bank that the retiree insurance will be changing and some of the benefits will be eliminated. Frank has decided that he now wants to sign up for Medicare Part B. When Frank went to the local Social Security office on April 12, he was told that he would be penalized for not signing up for Part B when he was initially eligible.

Is this true?

What would Frank’s penalty be?

• He can enroll in Part A online at

• He can delay Part B enrollment to save the Part B premiums

• He should check with his employer to see if he needs to take Part B (less than 20{100 if disabled} employees, Medicare primary payer

• Has an active employment employer group health plan (EGHP) so therefore will have an 8 month SEP to enroll Part B with no penalty once he retires

• This is true

• A retiree plan offers no SEP as it is not “active employment”

• Can enroll Part B during the general enrollment period (Jan 1-March 31- July 1 start date)

• Lifetime penalty about 50% (10% per each 12 months not enrolled in Part B and w/out active employment EGHP)

Case Study — Ruth Rose

Ruth Rose comes to see you at the SHINE office. She says that she will be 65 in 5 months. She will continue to work and is covered by her employer group plan. She does not want to sign up for Medicare. However, her friend Rhoda told her that if he does not sign up now, she will not be able to get Medicare later. What information would you give her?

Case Study— Agnus

Agnus is 64 years old and has been divorced for 15 years. Agnus married soon after high school and was a full-time homemaker. Until 5 years ago, Agnus had never worked outside the home. For the past 5 years she has worked for the Red Dye Company. She will be retiring in 4 months when she turns 65. The benefits administrator of the Red Dye Company told Agnus that she will not be eligible for Social Security or Medicare since she has not worked for a full 10 years.

Is this true?

What would you tell Agnus?

• Rhoda is wrong

• If there are less than 20 employees, Medicare is primary payer, EGHP is secondary- should discuss with employer

• Enroll Part A online at

• Can delay Part B due to active Employment EGHP

• Will have an 8 month SEP to enroll in Part B with no penalty once she retires

• This is not true

• Agnus is eligible for SS and Medicare through her ex-husband (assuming she was married more than 10 years)

• Can enroll in Parts A & B at SSA

Case Study — Justin Time

Justin Time will turn 65 and be retiring in 4 months. After talking with the benefits manager at his employer, he is very confused about Medicare and what it does and does not pay for. Since he will be getting retiree insurance from his employer, he is not sure if he really needs Medicare at all.

What information would you give him?

*Complete a Client Contact form on Justin

Case Study - Mrs. Carroll

Mrs. Carroll called the SHINE office for help on June 1st for help with a problem. Mr. Carroll, much to his wife’s dismay, refused to sign up for Medicare Part B when he was initially eligible. He is very proud of the fact that he has only spent $1,000 for medical care in the last 3 years. As he repeatedly told his wife, that is cheaper than paying the Part B premium for the last 3 years.

Mr. Carroll now needs to have surgery. His wife is beginning to realize some of the problems involved as a result of an uninformed decision he made three years ago.

List the problems he will now face.

• Justin can enroll Parts A & B online at

• Retiree plan will supplement

• Part B penalty if he doesn’t enroll during SEP (8 months)- retiree coverage not “active employment”

• Must wait for the General Enrollment Period (Jan 1st -March 31st ; effective July 1st ) to enroll in Part B

• Lifetime penalty about 30% (10% per 12 months without Part B and EGHP)

• Part A will cover hospital costs for 60 days after deductible

• No coverage for doctors without Part B

• Cannot enroll in a Supplement – must have Parts A & B to enroll in a supplement

Case Study - Ms. Washington

Ms. Washington lives in Massachusetts. She goes to see Dr. Franklin in her town who does not accept assignment. Ms. Washington is required to pay the entire bill of $150. When she receives the Medicare Summary Notice (MSN), she notices that the Medicare approved amount is $100. She wants to know what the exact amount is that Medicare will pay and the amount that is her responsibility? She explains that she has already met her Part B annual deductible.

What would Ms. Washington owe if she lived in Florida?

Case Study — Hal

Hal will celebrate his 65th birthday in a couple of months. He just received his Medicare Initial Enrollment Package from the Social Security Administration. While he has a general understanding of Medicare Part A, Hal doesn’t feel well informed about Medicare Part B. What information would you provide Hal?

• Medicare - $80

• In MA she owes - $20 (20% coinsurance)

• In FL she owes - $35

• In MA – Ban on Bal Billing

• In FL – up to 115% Medicare amount

• Part B – doctors and outpatient services

• Medicare pays 80% after annual deductible

• Most people pay a Part B premium of $104.90

• Higher income=Higher Part B premium

Case Study - Bill Fold

Bill Fold comes to meet with you at the SHINE office. He will be turning 65 and retiring in 3 months and wants to know about Medicare. He tells you that he will be receiving retiree health insurance

• The retiree plan will supplement Parts A & B

• Ask whether the retiree plan include drugs? (probably will)

• Bill can enroll Parts A & B online at

• Explain Part B penalty without active employment

from his employer and would like to

know if he really needs Medicare. He

says that he is healthy and takes

no medication.

What questions would you ask and what

information would you give?

Medicare True/False/Multiple Choice Quiz

1. Raymond’s doctor just visited him in the hospital and told him he needs to stay for a few more days. He is concerned about the costs of his hospital stay. He understands that after he pays his deductible, Medicare Part A will cover the expenses associated with his hospital stay, but that he is responsible for the costs of his television and telephone service.

True __X_ False ___

2. Kirby is scheduled to have surgery in two months and will be hospitalized for a few days. He has Medicare A & B only. Kirby will have the Part A deductible to pay but all other costs will be covered.

True _X__ False ___

3. Mario is 65 years old and receives Social Security benefits. He is covered by the group health insurance policy provided by his wife’s employer. He wants to wait to enroll in Medicare Part B after his wife retires in 2 years. Delaying enrollment will result in an additional 10% penalty added to the monthly premium for each year he could have been enrolled in Part B but was not.

True ___ False _X__

4. Gretchen’s doctor has recommended that she receive care under hospice services. How much will Gretchen pay for her prescription medications?

a. Nothing

b. Up to a $5 co-payment for each prescriptions

c. 20% of the Medicare approved amount

5. Marta enrolled in Medicare A and B in 2003. She just had her annual checkup with her doctor. Medicare Part B will not cover which item listed below?

a. Flu shot

b. Routine Physical

c. Diabetes test

d. All of the above will be covered

Medicare Part A Quiz

1. What are the requirements for Medicare eligibility for age 65 and over? Entitled to SS & contributed to Medicare 40 qtrs/credits, entitled RR retiree, spouse or ex-spouse (>10 years) of entitled individual

2. What is the definition of a benefit period? – Begins 1st day inpatient in hospital and ends when out of hospital or SNF for 60 days

3. Name four services covered under Medicare Part A.

1.Inpatient Hospital

2.SNF

3.Home Health

4. Hospice

4. What is the current Part A deductible? $1260 (Part A& B Benefits and Gaps handout)

5. Which of the following services is not covered by Medicare Part A during a hospital stay?

a. Intensive Care

b. Operating Room

c. Physician services

d. Drugs provided during a covered stay in a hospital or SNF

6. How many days will Medicare provide full coverage in a skilled nursing facility? 20 days

7. What are the four requirements for coverage under Medicare’s Home Health Benefit?

1. Homebound

2. Under care of doctor

3. Need skilled care on part-time or intermittent basis

4. Medicare approved agency

8. Doctor and nursing services, homemaker services and short-term respite services are covered by:

a. Home Health

b. Hospice

c. Skilled Nursing Facility

Medicare Part B Quiz

1. What are the major areas of coverage under Part B?

a. Doctors

b. Outpatient Services and Supplies

c. Physical and Speech Therapy

d. Diagnostic Tests and Lab Tests

e. Ambulance

f. Home Health

g. DME

2. What is the current monthly premium for Medicare Part B?

a. Most people - $104.90

b. Over income – higher (IRMAA)

3. Explain the “Mass Ban on Balance Billing” law.

Limits what doctors may charge. But doctors who are “non-participating”

working in other states may charge up to 15% above the Medicare approved amount.

4. A non-participating physician may accept assignment on a case-by-case basis. True_X___ False ____

5. When physicians accept assignment, they accept Medicare’s payment of 80% of the Medicare approved charges as payment in full for the service. True____ False _X___

6. If you are unhappy with your looks, Medicare will pay for a face lift.

a. True____ False __X__

7. Medicare does cover an annual physical.

a. True____ False _X___

Medicare A/B Quiz

1. What is the definition of “homebound” for Medicare beneficiaries?

To qualify as “homebound” they MUST require either a supportive device, use of special transportation, or the assistance of another person to leave the home.

2. Describe Medicare’s Enrollment Periods.

• Initial (IEP): 7 months surrounding 65th bday. Date of enrollment determines effective date of Medicare

• Special (SEP): 8 months following loss of coverage from active employment

• General (GEP): Jan 1st -March 31st ; July 1st effective date

3. Mr. Hoover comes to ask about his mother’s hospitalization. His mother has been hospitalized for 62 days. His mother has no insurance other than Medicare.

a. After Medicare pays, what part of the bill is her responsibility?

Hospital Deductible ($1260), 2 days of hospital coinsurance (2 x $315=$630), Medical deductible ($147), 20% coinsurance for doctors

b. If she is discharged, but is readmitted 10 days later and stays for 10

days, what additional amount of money will she owe?

10 days insurance (same benefit period) = 10 x $315=$3150

c. If she stays an additional 40 days instead of 10 days, what additional

amount of money will she owe?

30 x $315 + 12 x $630 = $9,450 + $7,560 = $17,010

4. List gaps in Medicare Part B coverage.

Annual deductible, 20% coinsurance

5. Mr. Smith comes to see you at the Council on Aging (COA) office. He will be retiring soon and living on a limited income. His understanding is that he can get by with just Medicare A+B coverage. What would you tell him about having Medicare A+B coverage only.

Gaps in Medicare (amounts he would owe) – Hospital & Medical Deductible, extra days beyond 60 in hospital, extra days beyond 20 in SNF, 20% Part B cost. No prescription coverage.

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