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APPRISE Medicare Presentation
- 1.
- 2. What is Medicare?
- 3. What is Medicare? Medicare is the federal government program that provides health care coverage for individuals that are 65 or older, or have a disability.
- 4. What is Medicare? Medicare is run by U.S. Department of Health and Human Services through its regional Centers for Medicare and Medicaid Services (CMS).
- 5.
- 6. How Does Medicare Work? Originally, Medicare was intended to provide basic medical coverage for the treatment of illness and injury for eligible individuals— It was modeled a@er the Blue Cross/Blue Shield insurance system that was in existence at that Bme (1965)
- 7. How Does Medicare Work? • Fee for Service payment system • Use Red, White & Blue Medicare Card as actual insurance card • May go to any provider that accepts Medicare • Referrals are not necessary • DeducBbles & Coinsurances Apply • beneficiaries purchase supplemental insurance to cover these costs
- 8. What is Medicare? Medicare has mulBple parts, each of which offers coverage for different health care areas.
- 9. The Current Parts of The Medicare System Part A: Hospital Care • Covers in-‐paBent care/services Part B: Medical Care • Covers out-‐paBent care/services Parts A and B are usually referred to as “TradiBonal” or “Original” Medicare
- 10. Medicare Coverage Basics PartA n Inpatient Hospital Care n Skilled Nursing Care n Some Home Health Care n Hospice Care Part B n Doctors’ Services and Outpatient Care n Preventive Services n Diagnostic Tests n Outpatient Therapies n Durable Medical Equipment
- 11. Medicare Coverage Op-ons Basic Medicare (Parts A and B) as primary coverage Supplement (Medigap) Part D Drug Plan Medicare Part C (Managed Care Plan) as primary coverage Can include Part D coverage Op-on 1 Op-on 2 Access to Part C requires enrollment in Basic Medicare
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- 13. Medicare Eligibility WHO CAN ENROLL IN MEDICARE? § 65 years of age and older OR § Under 65 years and receiving disability benefits from SSA or RRB must receive these benefits for 24 months before eligibility for Medicare (ALS excepBon) OR § Under 65 years and diagnosed with End Stage Renal Disease
- 14. Enrollment into Medicare Enrollment in is handled 2 ways: § AutomaBc § By applicaBon
- 15. Enrollment into Medicare AUTOMATIC ENROLLMENT If already receiving: § Social Security Benefits § Social Security Disability § Railroad ReBrement Benefits beneficiary will receive Medicare card 3 months BEFORE benefits are to begin.
- 16. Enrollment into Medicare ENROLLMENT BY APPLICATION If not already receiving benefits – beneficiary applies through Social Security AdministraBon: § 3 months before turning 65 § The month beneficiary turns 65 § 3 months a@er turning 65 This is called the Initial Enrollment Period
- 17. Enrollment into Medicare May delay enrolling into Medicare if: Individual (or spouse) is acBvely employed AND Is covered under group health insurance policy based on acBve employment This is called Delayed Enrollment
- 18. Enrollment into Medicare May later enroll in Medicare when: Employer Group Health Insurance ends You have Eight Months to enroll. This Eight Month period is called the Special Enrollment Period
- 19. Enrollment into Medicare If you do not enroll during the Initial or Delayed Enrollment periods, Then you can enroll: § January 1st – March 31st of each year § Coverage begins July 1st § Penalty is assessed on Part B premiums This is called General Enrollment
- 20. MEDICARE PART D Prescrip-on Drug Coverage
- 21. Medicare Part D § Available since January 1, 2006 § Voluntary PrescripBon Drug Benefit § Provides assistance with prescripBon drug costs § Available for Medicare Beneficiaries enrolled in “Basic” Medicare (Part A or Part B) § Plans provided by private insurance companies § Plans must meet or exceed Medicare Guidelines and all plans are CMS approved
- 22. MEDICARE PART D Two versions of coverage: § Stand-‐alone PrescripBon Drug Plans (PDP) § Medicare Advantage plans with Rx benefit (MA-‐PD)
- 23. Medicare Prescription DrugPlan Plan Pays 95% Beneficiary Pays 5% Plan Pays 75% Beneficiary pays 25% Coverage GapNo Coverage “DOUGHNUT HOLE” Catastrophic Coverage out of pocket limit $4750 Ini-al coverage limit $2970 Partial Coverage Plan Deduc-ble (if any)
- 24. (2013) Coverage Through the “Donut Hole” • 52.5% discount on brand-‐name plan covered drugs (less small pharmacy dispensing fee). • Paid by manufacture (50%) and plan (2.5%) • Counts toward TrOOP • 21% discount on plan covered generic drugs • Paid by federal government. • Does NOT count toward TrOOP • Discounts will increase each year unBl 2020
- 25. Formulary • A list of prescripBon drugs covered by the plan • Plans have “Bers” that cost different amounts Example of Tiers (Plans can form -ers in different ways) Tier You Pay PrescripBon Drugs Covered 1 Lowest copayment Most generics 2 Medium copayment Preferred, brand-‐name 3 Highest copayment Non-‐preferred, brand-‐name Specialty Highest copayment or coinsurance Unique, very high-‐cost
- 26. When you can Join or Switch Medicare Prescrip-on Drug Plans Ini-al Enrollment Period (IEP) § 7 month period § Starts 3 months before month of eligibility Annual Enrollment Period October 15 – December 7 each year These are new dates Annual Medicare Advantage Disenrollment Period § Between January 1– February 14, you can leave an MA plan and switch to Original Medicare. If you make this change, you may also join a Part D plan to add drug coverage. Coverage begins the first of the month a@er the plan gets the enrollment form.
- 27. Joining or Switching Drug Plans Special Enrollment Periods (SEP) § Examples of when you get an SEP include § You permanently move out of your plan’s service area § You lose other creditable Rx coverage § You weren’t adequately informed your other coverage was not creditable or was reduced and is no longer creditable § You enter, live in or leave a long-‐term care facility § You have a conBnuous SEP if you qualify for Extra Help
- 28.
- 29. MEDICAID • Health Benefit program for individuals with low income/resources • Funded by Federal and State resources • Administered by the State In Pennsylvania by DPW – County Assistance Office • Also know as: Medical Assistance Medical Welfare
- 30. DIFFERENCE BETWEEN MEDICAID AND MEDICARE • Medicare is a Federal Insurance Program with eligibility criteria based on Age or Health Status • Medicaid is a joint State and Federal Benefit Program with eligibility criteria based on Income and Resources
- 31. Medicaid Eligibility • Not all people with low income/resources are eligible • Must be a member of a “group” • Rules for counBng income and resources vary from “group” to “group”
- 32. Examples of Medicaid Eligibility Groups • Eligibility based on cash assistance programs • Supplemental Security Income (SSI) • Aid to Families with Dependent Children (AFDC) • Eligibility based on non-‐financial categorical requirements • Pregnant Women • Children • Aged, blind, or disabled
- 33. Guidelines for Medicaid Eligibility (Agedor Disabled) Single Married (100% FPL) INCOME: < $931 month ASSETS: < $2,000 INCOME: < $1,261 month ASSETS: < $3,000
- 34. MEDICAID AND MEDICARE • People may be eligible for both programs For Medicare covered services: • Medicare pays first • Medicaid pays second People in this situaBon are called “Dual Eligibles”
- 35. • Basic Medicare (red,white & blue card) is Primary Coverage • ACCESS card is secondary coverage to Medicare & will also cover things Medicare does not – i.e. dental and eye care • Medicare Part D PDP is drug coverage, use Plan ID card at pharmacy • Can change Part D Plans at any time/multiple times • ACCESS card can cover drugs in classes that are excluded from Part D (benzos, barbs, some OTC medications) Accessing Care: Dual Eligible
- 36. • Can go toany doctor or other health care provider that takes Medicare • Must show both Medicare and ACCESS card when getting health care services • Provider who does not take ACCESS card can refuse to treat individual, or can treat the person & just accept what Medicare pays – they cannot bill the individual for Medicare cost-sharing – (Balance Billing) Accessing Care: Dual Eligible
- 37. • “Special” MedicareAdvantage Plans • “Special” because they limit their enrollment to certain Medicare beneficiaries. Examples: Medicare/Medicaid dual eligible, nursing home residents, or persons with certain chronic conditions • Must use in-network providers • Includes Part D drug coverage Special Needs Plans (SNPs)
- 38. • SNP Medicare AdvantagePlan (e.g. Gateway Medicare Assured, UPMC for Life Specialty Plan), is primary coverage – Must go to doctors & other providers in plan’s network • Can change Plans at any time of the year/multiple times • ACCESS card covers things Medicare/Advantage Plan does not cover (e.g. dental and eye) • Medicare Managed Care Plan can provide Part D coverage ACCESS card can cover drugs in classes that are excluded from Part D (benzos, barbs, some OTC medications) Accessing Care: Dual Eligible using SNP
- 39.
- 40. SSI makes monthlypayments to individuals who have low income, few resources and are: • Age 65 or older • Blind • Disabled (determined by SSA)
- 41. SSI Income Eligibility Limits: • Individual$698 • Married Couple $1,048
- 42. SSI Resource Eligibility Limits • Individual$2,000 • Married Couple $3,000
- 43. SSI Recipients • Anyone eligiblefor Supplemental Security Income (SSI) benefits automatically qualifies for MA • No application for MA required – automatic eligibility when SSI approved • Receive full MA benefits including Rx & dental • Persons on SSI receive help with their Medicare Part A and B premiums • State will pay Part B premium for these individuals • If Part A is not free, state will pay Part A premium
- 44. MAWD Medical Assistance for Workers with DisabiliBes
- 45. MAWD • Can be individual’s only insurance or • Can be secondary insurance if: • Individual is enrolled in Medicare • Individual has some coverage through employment
- 46. Individuals Enrolled in MAWD • Receive full Medicaid Assistance • Pay a monthly premium of 5% of countable income
- 47. MAWD – Eligibility Criteria • Age 16 -‐ 64 • Illness or condiBon that meets Social Security’s definiBon of disability • Be a recipient of SSDI or; • Provide documentaBon to DPW that demonstrates disability status • Working & earning compensaBon from work (no minimum work requirement) • Countable income <250% FPL • $2,325/month single individual – 2012 • $3,150/month married couple – 2012 • Countable assets less than $10,000
- 48. MAWD – Work Requirement No minimum requirements for: • Number of hours worked • Amount individual earns however • Individual must be reasonably compensated for work • Must provide wripen verificaBon of work and compensaBon to DPW
- 49. MAWD – Disability To demonstrate disability for MAWD individual must: • Receive SSDI benefits or; • Submit documentaBon which can include: • Employability assessment form • Health sustaining medicaBon form • Leper from physician • Medical records
- 50. MAWD – Disability Individuals who are: • On SSDI, employed & in Medicare • On SSDI, employed & waiBng to receive Medicare • Employed, not receiving SSDI but meets definiBon of disability
- 51. The PDA Aging Waiver Program
- 52. Home & CommunityBased Services (HCBS) provides assistance to the aged & disabled to permit them to live independently in homes & communities
- 53. HCBS Eligible Individuals Receive: • Medicaid Benefits • AddiBonal in-‐home Medical Services • In-‐home Non-‐medical Services
- 54. Aging Waiver – EligibilityRequirements • Resident of Pennsylvania • U.S. Citizen or qualified non-citizen • Age 60 years or older • Requires a level of care provided by SNF • Monthly income limit < 300% of the federal benefit limit for SSI • Asset limit - $8,000
- 55. Aging Waiver/ Health CareBenefits • Some Waiver enrollees are already receiving Medicaid benefits prior to entering the Aging Waiver Program. They already meet the income & asset guidelines for Medicaid eligibility.
- 56. Aging Waiver/ Health CareBenefits • Other enrollees would not otherwise qualify for Medicaid (do not meet the income & asset guidelines). However, enrollment in the Aging Waiver Program, makes them eligible for full benefits under Medicaid.
- 57. Aging Waiver / MedicaidACCESS Card • Aging Waiver enrollees will receive an ACCESS Card that covers Medicare Part A and Part B Cost Sharing (the deductibles, co-payments, and co-insurance that the beneficiary is normally responsible for in the Medicare system) • The ACCESS card also provides services that Medicare does not cover: dental, vision, and medical transportation.
- 58. Aging Waiver / MedicaidAccess Card • Some Aging Waiver enrollees will already have an ACCESS card, because they are already enrolled in the Medicaid program prior to entering the Waiver program. In either case….
- 59. Aging Waiver / MedicaidACCESS Card • For Aging Waiver enrollees the ACCESS Card can be an effective way to cover their cost sharing under Medicare Part A and Part B. As a result they can drop their existing Medicare Supplement (Medigap policy) or Medicare Advantage Plan (HMOs and PPOs) and rely on the ACCESS card instead. HOWEVER…..
- 60. Things to considerwhen deciding whether or not to drop Medigap or Medicare Advantage Plans after receiving the Access Card: 1. Will enrollee’s current medical care providers (physicians, clinics, medical facilities, etc.) accept the Access card as secondary insurance? 2. Dropping the Medicare Advantage Plan may also eliminate their current Part D drug coverage. Part D coverage is necessary to utilize the LIS-Extra Help benefit. As a result, the person will need to enroll in a new stand-alone Part D Plan. 3. The Access Card represents enrollment in Medicaid which will result in termination of enrollment in the PACE/PACE NET program.
- 61.
- 62. Medicare Savings Programs– Help from Medicaid paying Medicare Part B premium. For individuals with limited income and resources. § QMB (Qualified Medicare Beneficiary) § SLMB (Specified Low-Income Medicare Beneficiary) § QI-1 (Qualified Individual) MEDICARE SAVINGS PROGRAMS
- 63. MSP Eligibility To qualify for Medicare Savings Program: • An Individual must be enBtled to Medicare Part B and • Have Income and Assets within the program’s allowable limits MEDICARE SAVINGS PROGRAMS
- 64. Guidelines for Medicare SavingsProgram Single Married QMB (100% FPL) INCOME: <$931 month ASSETS: <$7,080 INCOME: <$1,261 month ASSETS: <$10,620 SLMB (120% FPL) INCOME: <$1,117 month ASSETS: <$7,080 INCOME: <$1,513 month ASSETS: <$10,620 QI-1 (135% FPL) INCOME: <$1,257 month ASSETS: <$7,080 INCOME: <$1,703month ASSETS: <$10,620
- 65. Medicare Savings Program QMB (100%FPL) Payment of Medicare Part B premiums; Payment of Medicare Part A and Part B Cost Sharing, Eligible for LIS (Prescription Drug benefits) SLMB (120% FPL) Payment of Medicare Part B premiums, Eligible for LIS (Prescription Drug benefits) QI-1 (135% FPL) Payment of Medicare Part B premiums, Eligible for LIS (Prescription Drug benefits.
- 66. • Those approved forQMB receive payment of Part B premium and receive an ACCESS card to cover their Medicare Part A & B deductibles & co-pays (also qualified for SNP Advantage Plan) • Those approved for SLMB & QI1 only receive payment of the Part B premium MSP Benefits
- 67. • Once person isapproved for MSP, the state transmits data to Social Security to arrange for Part B payments (usually takes 2 – 3 months) • The state then begins paying the Part B premium each month & the person’s Social Security or Railroad Retirement check increases • SSA will also reimburse the person for the Part B premiums already paid retroactive to the date MSP was approved MSP Benefits
- 68. MSP recipients whoare entitled to Medicare Part B but not yet enrolled will: • Be enrolled into Part B & receive coverage beginning the month MSP starts (regardless of Medicare Part B enrollment period) and • Not be subjected to a penalty (if any) for late enrollment into Part B MSP Benefits
- 69. • Automatically entitled toa full Low Income Subsidy (LIS/Extra Help) that will cover most of the costs of their Part D Prescription Plan • Will be enrolled in a Part D plan by CMS if they have not yet joined a plan on their own • Have an ongoing Special Enrollment Period to change their Medicare prescription plan or Medicare Advantage plan at any time during the year or enroll in Part D MSP Benefits
- 70. LOW-‐INCOME SUBSIDY PROGRAM (LIS or ‘EXTRA HELP’)
- 71. The Medicare Low Income Subsidy (LIS / Extra Help) • Provides extra help with the costs of PrescripBon MedicaBons for individuals enrolled in Medicare that have limited income and assets • Funded by the Federal Government • Administered by the Social Security AdministraBon
- 72. § Income § 150% Federal povertylevel § $1,396 per month for an individual or § $1,891 per month for a married couple § Based on family size § Resources § Up to $13,070 (individual) § Up to $26,120 (married couple) Low Income Subsidy
- 73. § Full LIS Benefit: § Pay no premiums or deducBbles § Have no “donut hole” § Have small co-‐payments – (Beneficiaries with Full LIS in LTC faciliBes or enrolled in the PDA Aging Waiver have zero drug co-‐payments) § Par-al LIS Benefit: § Have a reduced premium and deducBble § Have no “donut hole” § Pay slightly larger co-‐payments than full LIS beneficiaries Low Income Subsidy
- 74. Income Guidelines for LowIncome Subsidy (LIS) Single Married Full LIS INCOME: <$1,257 month ASSETS: <$8,440 INCOME: <$1,703 month ASSETS: <$13,410 Partial LIS INCOME: $1,257 to $1,396 month ASSETS: $8,440 to $13,070 INCOME: $1,703 to $1,891 month ASSETS: $13,410 to $26,120
- 75. Low Income Subsidy(LIS) Full LIS No monthly Premium (guaranteed only with LIS benchmark plans); No Deductible; Co-payments: $1.10 generic / $3.20 brand Partial LIS Monthly Premium (sliding scale based on income); $63 Deductible; 15% coinsurance till total drug costs exceed $4750 TrOOP total, then Co-payments of $2.50 generic / $6.30 brand
- 76. § Some individuals automaticallyqualify for full LIS § People with Medicare who § Receive full Medicaid benefits (includes SSI, MAWD, and Aging Waiver) § Receive help paying Medicare Part B premiums (QMB, SLMB, and QI-1) § Others must apply to Social Security Administration and be found eligible for full or partial LIS Eligibility for LIS
- 77. Applying for LIS • By mail (must be original LIS paper applicaBon SSA -‐1020) • On-‐line www.ssa.gov/prescrip-onhelp • By phone 1-‐800-‐772-‐1213
- 78. § Duel Eligibles – Haveboth Medicare and Medicaid benefits § CMS Notification § (Purple Notice) person is deemed eligible for full LIS § (Yellow Notice) auto-enrollment notice § Beneficiary Action § Beneficiary’s enrollment in a Part D plan will off-set auto-enrollment § If no action taken by beneficiary, CMS will auto-enroll into a Part D Plan LIS No-fica-ons
- 79. § Enrolled in theMedicare Savings Program (State pays the Medicare Part B Premium) § CMS Notification § (Purple Notice) person is deemed eligible for full LIS § (Green Notice) auto-enrollment notice § Beneficiary Action § Enrollment in a Part D plan will off-set auto-enrollment § If no action is taken by beneficiary, CMS will auto-enroll the beneficiary into a Part D plan LIS No-fica-ons
- 80. § Point-‐of-‐Sale Facilitated Process for pharmacists (LI NET Program) § Pharmacist can call the LI NET Pharmacy Line at 1-‐800-‐783-‐1307 § DPW “Extraordinary Coverage” § DPW will approve only as a last resort § Pharmacists calls 800-‐558-‐4477, opBon 1 during normal DPW business hours “Safety Nets” for LIS eligible
- 81.
- 82. The PACE/PACENET Program • PACE and PACENET offer comprehensive prescripBon coverage to older Pennsylvanians • Covers most prescripBon medicaBons including insulin, syringes, and insulin needles • Do not cover over-‐the-‐counter medicines, medical equipment or doctor, hospital, dental or vision services • Funded by the PA Lopery System
- 83. PACE § Cannot be eligible for full Medicaid benefits § Can choose to partner with Part D plan § PACE alone is creditable coverage § Income is based on previous year
- 84. PACE ELIGIBILITY § Must be 65 years or older § PA resident for at least 90 days § Income guidelines: Single – at or below $14,50 Married – at or below $17,700
- 85. PACE BENEFITS • No monthly premium – Partner plan – PACE only • Helps to lower cost of co-‐pays – $6 generic – $9 brand • No annual deducBble • No “donut hole”
- 86. PACENET ELIGIBILITY § Must be 65 years or older § PA resident for at least 90 days § Income guidelines: Single – between $14,500 -‐ $23,500 Married – between $17,700 -‐ $31,500
- 87. PACENET BENEFITS • Helps to lower cost of co-‐pays – $8 generic – $15 brand • No annual deducBble • No “donut hole” • Does not pay Part D premium
- 88. APPLYING for PACE/PACENET 1-‐800-‐225-‐7223 or www.aging.state.pa.us or PACECares.lsc.com