MEDICAID created by Title 19 of the Social Security Act (SSA) in 1965 to provide medical assistance for certain individuals and families with low income and resources . MEDCAID is the largest program providing medical and health-related services to Alabama's poorest people MEDICARE created by Title 18 of the Social Security Act in 1965 to provide for seniors 65+ MEDICARE provides hospital insurance also known as Part A coverage, and supplementary medical insurance (SMI), also known as Part B coverage MEDICARE beneficiaries (65+) and who have low income and limited resources may receive help paying for their out-of-pocket medical expenses from Medicaid “ Dual eligibles ” are entitled to Medicare and are eligible for some type of Medicaid benefit
Thank you for the opportunity to provide basic information regarding Medicare’s new prescription drug plans called Medicare Part D. I hope this information will be helpful to you in understanding Medicare Part D. MMA (Medicare Modernization Act) will provide Medicare beneficiaries with prescription drug coverage regardless of income, resources, medical condition, or prescription drug costs. The effective start date is January 1, 2006. The goal is to lower prescription drug costs and help protect against higher costs in the future. Medicare is a federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). (There are appox.172,000 individuals in Alabama who have Medicare and Medicaid. However, there are approx. 88,000 who have Medicare and full Medicaid.) Prior to December 31,2005, full dual eligibles received prescription drug coverage through Medicaid.
Medicare Part A is coverage for hospital visits. Medicare Part B is coverage for doctor visits. Medicare Advantage plans (Part C) is a type of HMO, PPO, or FFS. Names of Medicare Advantage plans (Part C) include: Medicare Advantage, VIVA, Senior 1 st , HealthSprings, United Health Care, Medicare Health Plan. Part C was formerly known as Medicare Plus Choice. Humana and BCBS will begin offering drug plans beginning 1-1-06. Medicare Advantage plan is a plan in which you see physicians, hospitals, and providers that belong to a network. You can see physicians, hospitals, and providers outside of the network for an additional cost. Medicare Part D is an insurance provided by private companies that have been approved by Medicare. This drug coverage may help lower prescription drug costs and help protect against higher costs in the future. Drug plans will have a list of covered drugs called a formulary. This list must meet certain requirements but may change from time to time. If the list changes because of cost or , drug changes your plan must let you know 60 days in advance. Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. Like other insurance, if you join, you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium.
Everyone with Medicare is eligible for Medicare Part D drug coverage, regardless of income and resources, health status, or current prescription expenses. Some plans will operate nationwide, others in a certain region of the country. Medicare drug plans will vary in what prescription drugs they cover, and how much you have to pay, and which pharmacies you can use. Medicare Part D is not free. Like other insurances, there will be a monthly premium. Rules: Enrollment is voluntary for most. But individuals with Medicare and full Medicaid have been auto-enrolled if you didn’t sign up by the end of Dec. so you won’t miss a day of coverage. In order to join Part D, you must have Medicare (Part A and/or B). You must join a Medicare drug plan to get coverage. You must enroll in a plan that serves your area. If you don’t enroll in a drug plan by May 15, 2006, you may have to pay a penalty if you decide to join a drug plan later. Even if you don’t use a lost of prescription drugs now, you should consider joining. As we age, most people need drugs to stay healthy. For most people, joining now means protecting you from unexpected drug bills in the future. Costs will vary depending on which drug plan you choose. The enrollment period is from November 15, 2005 through May 15, 2006. If you joined by December 31, your coverage began January 1 st . If you join after that , your coverage is effective the first day of the month after the month you join. If you don’t sign up when you are first eligible or by May 15 th , you may pay a penalty. If you don’t sign up by May 15 th , your next opportunity to enroll is from November 15 through December 31 st . By the way, Medicare Prescription Discount cards will no longer be available beginning May 15, 2006. There is still time left to investigate which plan is best for you, so please don’t rush into signing up for a plan without doing your homework first.
Medicare contracted with 42 private insurance plans in Alabama. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. Extra Help is available through the Soc Security Administration. Income and asset restrictions apply. How can I receive extra help? Extra help is based on the amount of income and resources. What counts as Income? Social Security, wages, dividends, rental property, worker’s compensation and education grants. What counts as assets? Bank accounts and the value of investments, life insurance policies, and extra real estate. This does NOT include your home, vehicle, burial plots or personal possessions, or $1,500 in savings intended for burial expenses. Single people on Medicare with income below $14,700 and resources up to $11,500 may qualify for extra help. Married people on Medicare with income below $19,800 and resources up to $23,000 may qualify for extra help. There is no charge to apply. “If in doubt, fill it out”. Almost 1 in 3 people with Medicare will qualify for extra help and Medicare will pay for almost all of their prescription drug costs. If you qualify for extra help, you will get help paying for your drug plan’s monthly premium, and/or for some of the cost you would normally pay for your prescriptions. Again, the amount of extra help you get will be based on your income and resources. You may apply for extra help through the Social Security Administration.
The Initial Enrollment Period is November 15, 2005 through May 15, 2006. If you have Medicare and Medicaid – you are in a plan now whether you enrolled or not. If you did not enroll by Dec 31, 05, Medicare randomly assigned you to a plan and you should have received notification in the mail. You may switch to another plan anytime. If you fall in one of the other 4 groups (No drug coverage, Employer/union coverage, Medicare Advantage Plan, or Medigap), you have until May 15 th to enroll. There will be a 1% penalty for each month added to your monthly fee if: 1. If you have been notified that your current drug coverage is not at least as good as Medicare’s plan and you haven’t enrolled – or – If you enroll after May 15 th , Example: monthly fee costs $37 per month, your penalty will be 37 cents multiplied by the number of months delayed – plus your monthly fee. So if your one month late enrolling, you would pay $37.37 per month as long as you have Medicare Part D. If you have creditable coverage, you do not need to apply. However, please keep your letter of creditable coverage in case you need to apply later so that you won’t have to pay a late-enrollment penalty in addition to your monthly premium. Your current Medicare card will not change. When you join a plan, you will receive a Drug Plan Card that you will use to obtain your prescriptions. Until you receive your new drug card, you will receive a yellow letter telling you the drug plan you are in, that you will use until you receive your new Drug Plan Card. You can find out which plan you have been assigned to using any of the four resources listed below. The information you will need to find out your plan is located on your current Medicare card which is red, white and blue. A yellow letter you received from Medicare identifying the plan. Visit medicare.gov Call 1-800-Medicare (1-800-633-4227) Go to your pharmacy.
Your doctor may be able to switch you to a medicine that is covered by the plan Dual eligibles can change monthly. Others can change plans during open enrollment every year November 15 through December 31 of every year.
For Reference: (SHIP phone number for Alabama is the Age-line Number.)
We will also roll out a new interactive web portal. Within the portal, you can submit claims, verify eligibility, check remittance advises, request and view Prior Authorizations and check claim status. I have some screen shots of the web portal I will be showing you now.
Alabama Medicaid Update Tina G Pippin Dental Program Director Alabama Dental Association Annual Session June 16, 2006
20.7% of Alabama’s total population (includes all eligibility categories)
46% of all deliveries in Alabama
37.9% of Alabama’s children (under 19)
19.7% of Alabama’s elderly (65 and above)
74% of nursing home days in Alabama
Total Medicaid Eligibles As a Percentage of Alabama’s Population Note: Includes individuals eligible for Plan First FY
Medicaid Children Under age 19 as a Percent of Alabama’s Child Population FY
Children in Working Families As of September 2005 Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.
What are the sources of health insurance coverage in Alabama? 3.7% 31.4% 53.7% 11.2% AL Rate UNK Individual Coverage 25.3% Public Program 62.6% Employer Sponsored Coverage 14.6% Uninsured US Rate (CPS 2001) Coverage
AL Uninsurance Rates by Age All rates reflect point in time data.
Eligible and Payment Distribution By Age FY 2005
Eligibles Percent Distribution by Race FY 2005
Cost Per Eligible FY 2005 By Category By Gender By Age
Economic Impact Hospital Care Primary Care Maternity Care Pharmacy MEDICAID
High Medicaid Counties FY 2005 These 12 counties have the highest concentration of Medicaid eligibles across the general population (30% or greater). Bullock 35% Lowndes 33% Butler 33% Macon 31% Conecuh 31% Marengo 30% Dallas 41% Perry 43% Greene 40% Sumter 39% Hale 32% Wilcox 46%
These 11 counties have the highest concentration of Medicaid eligibles across the children’s population (50% or greater). Bullock 66% Lowndes 55% Butler 56% Macon 50% Conecuh 56% Perry 63 % Dallas 65% Sumter 65% Greene 66% Wilcox 71% Hale 50% High Medicaid Counties FY 2005
In FY 2004, Medicaid paid approximately $3.7 billion to providers for various health care services rendered; $2.7 billion represents federal funds brought into the State.
In FY 2005, Medicaid paid approximately $3.9 billion to providers for various health care services rendered; $2.8 billion represents federal funds brought into the State.
Medicaid expenditures supported more than 84,323 jobs in various industries within the state. 1 1 Economic Impact of the Alabama Medicaid Agency on the Economy of the State of Alabama and its Counties, Amy K. Yarbrough, MSHA, MBA, Administrative Fellow, University of Alabama at Birmingham Economic Impact (continued)
November 1, 2003 a Preferred Drug List (PDL) was implemented, requiring that drug classes be reviewed by our Pharmacy and Therapeutics (P&T) Committee for clinical recommendations for inclusion into the PDL.
Medicaid is currently re-reviewing implemented classes into our PDL to ensure up-to-date clinical information is taken into consideration for PDL clinical decisions.
To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child.
Three Primary Ways 1. Provider Electronic Solutions Free Software provided by EDS. Quick response time – one at time or in batches 2. Automated Voice Response Toll free Number 1-800-727-7848 Available 23 hrs/day, 7 days per week 3. Secure Website: