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


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 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


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


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


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


ASSETS: <$10,620

SLMB (120% FPL)


ASSETS: <$7,080


ASSETS: <$10,620

QI-1 (135% FPL)


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

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