apprise medicare presentation

Medicare  Presenta-on    

What  is    Medicare?  

 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.  

 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).  

How does Medicare

work?  

   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)    

   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  

     What  is  Medicare?  

Medicare  has  mulBple  parts,  each  of  which  offers  coverage  for  different  health  care  areas.    

 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  

 Medicare  Coverage  Basics

Part A

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

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  

Enrollment in “Basic”

Medicare  

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  

Enrollment  into  Medicare    

Enrollment  in  is  handled  2  ways:  §   AutomaBc  §   By  applicaBon  

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.    

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

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

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    

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

MEDICARE    PART  D  

Prescrip-on  Drug  Coverage  

 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  

MEDICARE  PART  D        Two  versions  of  coverage:  

§  Stand-­‐alone  PrescripBon  Drug  Plans      (PDP)  

§ Medicare  Advantage  plans  with  Rx  benefit  (MA-­‐PD)    

Medicare Prescription Drug Plan

Plan Pays 95%

Beneficiary Pays 5%

Plan Pays 75%

Beneficiary pays 25%

Coverage Gap

No Coverage “DOUGHNUT

HOLE”

Catastrophic Coverage

out  of  pocket  limit  $4750    

 Ini-al  coverage  limit    $2970  

Partial Coverage

Plan  Deduc-ble  (if  any)  

(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  

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      

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.    

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  

Medicaid  

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          

   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  

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”  

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  

Guidelines for Medicaid Eligibility (Aged or Disabled)

Single Married

(100% FPL)

INCOME: <$931 month

ASSETS: <$2,000

INCOME: <$1,261 month

ASSETS: <$3,000

 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”  

• 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      

• Can go to any 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      

•  “Special” Medicare Advantage 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)

• SNP Medicare Advantage Plan (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  

SSI

Supplemental Security Income

SSI makes monthly payments to individuals who have low income, few resources and are:

• Age 65 or older • Blind • Disabled (determined by SSA)

SSI Income Eligibility Limits:

• Individual $698 • Married Couple $1,048    

SSI Resource Eligibility Limits

• Individual $2,000 • Married Couple $3,000    

SSI Recipients

• Anyone eligible for 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

MAWD    

Medical  Assistance    for  Workers  with  

DisabiliBes    

MAWD  •  Can  be  individual’s  only  insurance  

or  •  Can  be  secondary  insurance  if:  

• Individual  is  enrolled  in  Medicare    • Individual  has  some  coverage  through  employment  

Individuals  Enrolled  in  MAWD  

• Receive  full  Medicaid  Assistance      

• Pay  a  monthly  premium  of  5%  of  countable  income    

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  

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  

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  

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  

The  PDA    Aging  Waiver    Program  

Home & Community Based Services

(HCBS) provides assistance

to the aged & disabled to permit them to live independently

in homes & communities

HCBS  Eligible  Individuals  Receive:    

• Medicaid  Benefits      

• AddiBonal  in-­‐home  Medical  Services    • In-­‐home  Non-­‐medical  Services    

Aging Waiver – Eligibility Requirements

•  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

Aging Waiver/ Health Care Benefits

•  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.

Aging Waiver/ Health Care Benefits

• 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.

Aging Waiver / Medicaid ACCESS 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.

Aging Waiver / Medicaid Access 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….

Aging Waiver / Medicaid ACCESS 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…..

Things to consider when 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.

 Medicare  Savings  Programs  

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

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

Guidelines for Medicare Savings Program

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

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.

• Those approved for QMB 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  

• Once person is approved 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  

MSP recipients who are 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  

• Automatically entitled to a 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  

 LOW-­‐INCOME  SUBSIDY  PROGRAM  

(LIS  or  ‘EXTRA  HELP’)  

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  

§ Income § 150% Federal poverty level

§ $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

§ 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      

Income Guidelines for Low Income 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

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

§ Some individuals automatically qualify 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

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  

§ Duel Eligibles – Have both 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

§ Enrolled in the Medicare 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

§ 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  

PACE/ PACENET  

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    

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  

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    

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”  

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  

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  

APPLYING for

PACE/PACENET    

1-­‐800-­‐225-­‐7223  or  

www.aging.state.pa.us  or  

PACECares.lsc.com