2008 New Final Presentation V1.7


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Presentation given at the 2008 National Eligibility Workers Conference

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  • 2008 New Final Presentation V1.7

    1. 1. Dual Eligible Outreach & Advocacy We help people apply for assistance with Medicare premiums NEW: PATHS Training Conference Anaheim, California August 17 – 20, 2008
    2. 2. Did You Know? <ul><li>WITH MEDICARE, a senior citizen with diabetes or a heart condition can easily incur annual </li></ul><ul><li>out-of-pocket costs of : </li></ul><ul><ul><li>$1,156 for Medicare Premiums </li></ul></ul><ul><ul><li>$ 135 for Doctor and Clinic Services </li></ul></ul><ul><ul><li>$ 304 for Medicare D Premiums </li></ul></ul><ul><ul><li>$4,050 for Prescription Drugs </li></ul></ul><ul><ul><li>$1,024 for a Hospital Stay </li></ul></ul>$ 6,668 Total Out-of-Pocket Source: www.cms.gov
    3. 3. Did You Know? * Annual premium amount based on $27.93 national average monthly beneficiary premium (CMS, August 2007), amounts are rounded to the nearest dollar. ** Medicare Part D pays 95% of Rx costs after $4,050 out of pocket. $ 0 $1,159 $6,668 Total 0 0 3,216 Part D Coverage Gap (Donut Hole) ** 0 0 558 Part D Coinsurance 25% of first $2,235 0 0 275 Part D Deductible 0 0 *304 Part D Premium 0 1,024 1,024 Part A Hospital Deductible 0 135 135 Part B Deductible $ 0 $ 0 $1,156 Part B Premium Person with QMB Person with SLMB or QI-1 FFS Enrollee w/o MSP or Extra Help Out of Pocket Expense
    4. 4. Did You Know? <ul><li>A senior (without MSP) living at 100% of poverty ($867) spends a minimum of $96.40 for their Medicare benefits leaving them with $770 a month for shelter, utilities, food and other medical expenses </li></ul><ul><li>Eligibility Workers across the country have enrolled 7.9 million low income seniors and people with disabilities into programs to cover out-of-pocket Medicare costs </li></ul>
    5. 5. More on Medicare Advantage Plans <ul><li>Why Medicare Advantage? </li></ul><ul><ul><li>Broader benefits </li></ul></ul><ul><ul><ul><li>All Medicare covered services and more </li></ul></ul></ul><ul><ul><ul><li>Rx, preventive care services, routine eye and </li></ul></ul></ul><ul><ul><ul><li>hearing exams </li></ul></ul></ul><ul><ul><ul><li>Add’l monthly benefits valued at $96 </li></ul></ul></ul><ul><li>Reduced out-of-pocket </li></ul><ul><ul><ul><li>Some plans have no or low co-payments and deductibles </li></ul></ul></ul><ul><ul><ul><li>Several with no additional premium beyond Medicare Part B </li></ul></ul></ul>Source: CMS; The Heritage Foundation; The success of Medicare Advantage Plans: What Seniors Should Know; Robert E. Moffit, Ph.D
    6. 6. <ul><li>Medicare Advantage (MA) plans manage the Medicare coverage for members (including Part D) </li></ul><ul><li>Prescription Drug Plans (PDP) manage only the Part D prescription coverage </li></ul><ul><li>Medicare pays a set amount of money every month to these private health plans (capitation) based on: </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Sex </li></ul></ul><ul><ul><li>County of residence </li></ul></ul><ul><ul><li>Special Status Codes </li></ul></ul>What is a Medicare Advantage (MA) and a Prescription Drug Plan (PDP) ?
    7. 7. SSC Customers
    8. 8. <ul><ul><li>SSC serves Medicare beneficiaries who have chosen to join a Medicare Advantage (MA) plan </li></ul></ul><ul><ul><ul><li>Not involved in MA plan marketing or enrollment </li></ul></ul></ul><ul><ul><li>We help low income members access available benefits : </li></ul></ul><ul><ul><ul><li>Medicare Savings Programs </li></ul></ul></ul><ul><ul><ul><ul><li>QMB, SLMB, QI-1 </li></ul></ul></ul></ul><ul><ul><ul><li>Extra Help with R x Costs </li></ul></ul></ul><ul><ul><ul><ul><li>Low Income Subsidy (LIS) </li></ul></ul></ul></ul><ul><ul><ul><li>Golden Touch Programs </li></ul></ul></ul>What We Do
    9. 9. SSC-Submitted MSP Applications Total = 231,708
    10. 10. <ul><li>Spenddown and Medicare Advantage </li></ul><ul><ul><li>Concurrent Medicaid with or w/o spenddown is permitted for QMB and SLMB eligibles </li></ul></ul><ul><ul><li>Not permitted with QI-1 </li></ul></ul><ul><ul><li>Not likely to have enough expenses to meet a large spenddown </li></ul></ul><ul><ul><li>Compare potential spenddown benefit to $1,156 per year in reimbursed Medicare premiums </li></ul></ul><ul><li>Food Stamps </li></ul><ul><ul><li>Consider value of Food Stamp allotment to $96 monthly increase in income </li></ul></ul>Coordinating Programs
    11. 11. Did You Know? <ul><li>2.6 million more low-income Medicare beneficiaries are eligible for a Medicare Savings Program (MSP) but not receiving benefits </li></ul><ul><li>SSC has helped 208,000+ to enroll into Medicare Savings Programs. We identify an average of 13,000 more every month who appear to be eligible but are not receiving benefits </li></ul><ul><li>Many other agencies are helping </li></ul><ul><ul><li>State Health Insurance Program (SHIP) </li></ul></ul><ul><ul><li>Area Agencies on Aging (AAA) </li></ul></ul>Our Challenge ~ More in Need source: HHS January 2008
    12. 12. <ul><li>People with income under 150% of the FPG (and assets below certain limits) can get Extra Help with their out-of-pocket prescription expenses </li></ul><ul><li>Extra Help reduces monthly premiums, annual deductibles, Rx copays, and may eliminate the coverage gap (‘Donut Hole’) </li></ul><ul><li>People who are eligible for Medicaid (including MSP) or SSI-only are ‘deemed’ eligible for Extra Help </li></ul><ul><li>People who lose eligibility for Medicaid (including MSP) or SSI-only during the year must apply for Extra Help to remain eligible </li></ul>Extra Help for Part D Expenses
    13. 14. Why Don’t They Apply? Sources: Ebeler, Jack, Paul N. Van de Water, and Cyanne Demchak (eds.) 2006. Improving the Medicare Savings Programs. Washington: National Academy of Social Insurance Glaun, Kim, December 2002. Medicaid Programs to Assist Low Income Medicare Beneficiaries: Medicare Savings Programs Case Study Findings. Washington: The National Senior Citizens Law Center * MSP will be exempted from Estate Recovery starting 1/1/2010 <ul><li>Lack of Awareness </li></ul><ul><li>Hard-to-Reach Population </li></ul><ul><li>Burdensome Application Process </li></ul><ul><li>Connection to Welfare </li></ul><ul><li>Asset Reporting </li></ul><ul><li>Estate Recovery in some states * </li></ul>
    14. 15. <ul><li>Medicare Improvement for Patients and Providers Act of 2008 </li></ul><ul><ul><li>Extends QI-1 program to 12/31/2009 </li></ul></ul><ul><ul><li>Expands outreach and enrollment assistance for Extra Help and MSP </li></ul></ul><ul><ul><li>Increases MSP asset limits (Jan 2010) </li></ul></ul><ul><ul><li>Eliminates Estate Recovery for MSP (Jan 2010) </li></ul></ul><ul><ul><li>Eliminates consideration of in-kind income and life insurance for Extra Help (Jan 2010) </li></ul></ul>Our Challenge ~ More to Come
    15. 16. Retaining the Experts <ul><li>Eligibility Workers need to know more and do more than ever before </li></ul><ul><ul><li>Multiple programs </li></ul></ul><ul><ul><li>Increased complexity </li></ul></ul><ul><ul><li>Budget constraints </li></ul></ul>
    16. 17. We want to help <ul><li>SSC’s Govt Relations Mgmt Team has 100 years of combined state/county eligibility experience </li></ul><ul><li>SSC’s activities are regulated by federal laws </li></ul><ul><ul><li>HIPAA compliant </li></ul></ul><ul><ul><li>CMS approves materials and forms </li></ul></ul><ul><li>We listen to you </li></ul><ul><ul><li>Reorganize </li></ul></ul><ul><ul><ul><li>Specialized staff </li></ul></ul></ul><ul><ul><ul><li>Pending notices logged and tracked </li></ul></ul></ul><ul><ul><li>Keep the lines of communication open </li></ul></ul>
    17. 18. <ul><li>MA Plans give SSC the demographic information of all current members </li></ul>SSC Outreach <ul><li>Members return questionnaires or contact SSC directly </li></ul><ul><li>CMS-approved outreach materials are sent to members who are not already enrolled in Medicaid </li></ul>
    18. 19. SSC Outreach <ul><li>Potential MSP eligibles are interviewed by an In-progress Specialist and the official state application and required forms are completed </li></ul><ul><li>Intake Specialists screen members for eligibility for Extra Help and Medicare Savings Programs </li></ul><ul><li>Potential Extra Help eligibles are referred to a LIS Specialist to file an application on-line with SSA </li></ul>
    19. 20. SSC Outreach <ul><li>The application and an authorized representative form are mailed to the member for review and signature </li></ul><ul><li>A list of required verifications is included with the application packet </li></ul><ul><li>A Follow-up Specialist is assigned to answer questions and help the member gather documents </li></ul><ul><li>The documents are returned to SSC and reviewed for accuracy and completeness first by a case reviewer and then by QA staff </li></ul><ul><li>If complete, the application is submitted to the eligibility agency </li></ul>
    20. 21. Direct Mail Initial Phone Screening Single Interview Multiple Program Screening Home Visits (when needed) MSP Applications Completed Electronically Signature-Ready Applications Mailed to Member SSC Reviews Application and Sends to State Medicaid Administration MSP Award Letter Sent to SSC / Member SSC’s Application Process Summary Medicare Savings Advantage TM
    21. 22. Recertification Management <ul><li>Some members enroll in an MSP or Medicaid on their own </li></ul><ul><li>Member accepts SSC offer to assist with annual renewals and signs a Release of Medicaid Information </li></ul><ul><li>Request for redetermination date is sent to state or local agency </li></ul><ul><ul><li>Tape exchange may eliminate this step </li></ul></ul><ul><li>Members are notified of upcoming redeterminations: </li></ul><ul><ul><li>Automated reminder calls </li></ul></ul><ul><ul><li>Reminder letters in advance of state notice </li></ul></ul><ul><li>If the Medicaid indicator disappears, members are contacted immediately </li></ul>
    22. 23. A comprehensive ‘Social Advocacy’ benefit designed to help seniors and disabled individuals learn about and take advantage of a broad array of valuable programs. What is Golden Touch TM
    23. 24. Golden Touch TM Programs Property Tax Telephone Home Care Nutrition Transportation Energy Adult Care Home Repair Respite Emergency Assistance Rent State Pharmaceutical Assistance Programs (SPAP) Assistive Technology Water Total GT Programs– 4,052
    24. 25. <ul><li>83,376 members enrolled into 141,760 community assistance programs </li></ul><ul><li>$5.4M in monthly program value/savings to those members </li></ul><ul><li>$65M in annualized program value/ savings </li></ul><ul><li>Over 30% take up during first year </li></ul>Program Value Summary
    25. 26. Government Relations Service Areas
    26. 27. <ul><li>Feedback </li></ul><ul><ul><li>Suggestions are welcome </li></ul></ul><ul><li>Flexibility </li></ul><ul><ul><li>We can customize </li></ul></ul>Working Together <ul><li>Common Goal </li></ul><ul><ul><li>Helping seniors and people with disabilities </li></ul></ul><ul><li>Communication </li></ul><ul><ul><li>Let us help </li></ul></ul><ul><ul><li>Keeping each other informed </li></ul></ul>
    27. 28. Contact us: (888) 528 9488 Cindy – x 7123 Kathie – x 7652 Linda – x 5114