LEGAL CONCERNS FOR POLIO SURVIVORS:

Transcription

1 LEGAL CONCERNS FOR POLIO SURVIVORS: A Benefits Primer with an emphasis on Medicare and the Affordable Care Act Martha C. Brown Martha C. Brown & Associates, LLC 220 W. Lockwood, Suite 203 ST. Louis, MO (314)

2 Government Benefits to Review Social Security Disability Benefits Includes Supplemental Security Income Medicare Affordable Care Act Benefits and Trends Medicaid 2

3 Government Benefits Disability Medical Care Needs Based Social Security Disability Medicare Means Tested Supplemental Security Income Medicaid 3

4 Medicaid Means Tested Regulated Known by other names: Medical MO HealthNet Tenn Care 4

5 Medicare: Benefits and Trends 5 Eligible for benefits At age 65 or 24 months after 1 st receiving Social Security Disability or Diagnosis of end stage renal disease or ALS No wait period No income limits

6 Medicare: The Traditional Medicare Program Part A Inpatient care Skilled nursing care Part B Outpatient care Doctors Visits Lab Tests Durable Medical Equipment 6

7 Medicare: Private HMO Medicare Coverage 7 Part C Began in 1997 Must offer same benefits as traditional Medicare, but can have different restrictions and costs Must use hospitals, doctors, nursing homes in the network May offer additional benefits not covered by traditional Medicare i.e. dental benefits, vision benefits

8 Medicare: Medicare Prescription Drug Coverage Part D Initial enrollment must be within 7 months of eligibility Open Enrollment October 15-December 7 each year 8

9 Medicare: Enrollment 9 Automatic enrollment in Part A & B 24 months after first SSDI check; or at age 65 Open enrollment Period January March, each year All others must enroll when eligible Initial enrollment period or Special enrollment period, if qualified

10 Special Medicare Rules If contributing to a health savings account, must decline Medicare Part A Note: If receiving SSDI or Retirement Social Security, must enroll in Part A 10

11 Special Medicare Rules: Continued Penalty incurred when person fails to enroll in Part B Penalty is 10% multiplied by the number of years that the person did not get Part B Exceptions: 1. If have health insurance through current employment 2. Person is under 65 and covered by insurance through current employment 11

12 Deciding whether to enroll in Part B: Coordination of benefits 12 Coordination of benefits is the sharing of costs by two or more health plans In Medicare, who pays first depends on three things 1. The type of other insurance 2. Why the person is eligible for Medicare 3. If an employer group health plan, the size of the employer

13 Medicare and Employer Insurance: Coordination of benefits If a person s other insurance is a group health plan (GHP) provided by an employer then: 13 If the person is eligible for Medicare due to age: The GHP is primary if there are more than 20 employees at the company where the beneficiary or their spouse works Medicare is primary if there are fewer than 20 employees If the person is eligible for Medicare due to disability: The GHP is primary if there are more than 100 employees at the company where beneficiary, spouse or other family member works Medicare is primary if there are fewer than 100 employees

14 Medicare and Retiree/COBRA Insurance: Coordination of benefits COBRA continuation coverage is always secondary to Medicare It is also not coverage from current employment, meaning that there is no Part B SEP It may be creditable, meaning a person would not incur a Part D late enrollment penalty Retiree insurance is almost always secondary to Medicare One exception is Federal Health Insurance Benefit Program (FEHB) retiree plans 14 They will continue to pay primary if a person does not enroll in Part B, but the person will not have a Part B SEP and may face a penalty if they later enroll during the GEP

15 Medicare and the Marketplace What is the Marketplace (also called the Exchange )? The Marketplace is forum where people can shop for health insurance There is a common application to apply for all insurance on the Marketplace Marketplaces will operate in every State and the District of Columbia How Marketplaces are run varies based on the State 15 Some States have set up their own Marketplace and some will partner with the Federal Government States that do not have the resources to set up their own or even to set one up in partnership will rely on the Federal Government to establish their Marketplaces

16 What type of Insurance is available on the Marketplace? The insurance purchased through the Marketplace is called Qualified Health Plans (QHPs) From October 1, 2013 to March 31, 2014 individuals could purchase QHPs through the Marketplaces Coverage purchased between October 1, 2013 and January 1, 2014 began January 1,

17 Medigap Policies Supplemental policies that work with Medicare Medicare Advantage plans and Part D plans WILL NOT be sold in the Marketplaces People who are eligible for Medicare WILL NOT receive tax credits to purchase insurance in the Marketplace Note: A limited exception exists for people with ESRD and premium Part A The only type of insurance people with Medicare will likely want to purchase through the Marketplace is coverage for services Medicare doesn t cover 17 Stand-alone dental plans Stand-alone vision plans

18 Medicare and Medicaid Medicaid always pays secondary to Medicare, and can provide additional benefits that Medicare does not Pursuant to the 2012 Supreme Court decision, States have the option to expand Medicaid coverage to all individuals under the age of 65 with income up to 133% of the Federal Poverty Limit (FPL) 18

19 Medicare and Medicaid: Continued The ACA creates a Medicaid eligibility category for all people who are NOT eligible for Medicare using Modified, Adjusted Gross Income (MAGI) to determine eligibility People with Medicare will be able to apply for Medicaid and Medicare Savings Programs through the Marketplace, but the Marketplace will only do an initial screening and the person will probably still need to provide more information to the Medicaid office 19

20 Moving from the Marketplace to Medicare From Qualified Health Plan (QHP) with or without and Advance Premium Tax Credit (APTC) > Medicare An individual enrolled in a QHP through the individual Marketplace should enroll in Medicare when they become eligible From SHOP plan > Medicare An individual enrolled in a SHOP plan may be able to delay Medicare enrollment 20 They should take Medicare if they qualify for Medicare due to a disability They should take Medicare if >65 and insurance is from an employer with <20 employees They may be able to delay Medicare if they are >65 and their insurance is from an employer that has >20 employees

21 Moving from the Marketplace to Medicare Continued From ACA Medicaid (MAGI) > Medicare and Medicaid (MAGI-exempt) From ACA Medicaid (MAGI) > Medicare with subsidies like Medicare Savings Program and the Part D Low Income Subsidy 21

22 Moving from the Marketplace to Medicare Continued Medicaid and Exchange Subsidies Pre-Medicare Eligibility Medicaid and Exchange Subsidies Post-Medicare Eligibility 400%-138% Federal Poverty Level (FPL) Individuals who fall below 400% of the federal poverty level (FPL) are eligible for tax credits to purchase private qualified health insurance plans through the state health insurance exchanges. Medicare-eligible individuals are not eligible for tax credits. 0%-138% Federal Poverty Level (FPL) In participating states, individuals who fall below 138% of the FPL are eligible for a newly created category of Medicaid eligibility, with a benefit package that is at least as comprehensive as the health plans offered by the exchanges Medicare-eligible individuals are not eligible for tax credits. 0%-135% Federal Poverty Level (FPL) - $4,000/Assets Eligible for a Medicare Savings Program (MSP). MSPs pay for Medicare Part B premiums. Below 100% FPL, the MSP will pay for Part B other costs, including Part B deductibles. 0%-75% Federal Poverty Level (FPL) - $2,000/Assets Eligible for full Medicaid health benefits. 22

23 Moving from the Marketplace to Medicare Continued Moving OUT of a Qualified Health Plan (QHP) with an Advance Premium Tax Credit (APTC) into Medicare The APTC will terminate automatically upon becoming eligible for Medicare Part A Unless the person has ESRD Medicare or would have to pay for Part A The QHP will not terminate automatically and the enrollee must give the plan reasonable notice of at least 14 days 23

24 Moving from the Marketplace to Medicare Continued REMEMBER: Individuals should enroll in Medicare during the first three months of the Initial Enrollment Period If Part B enrollment is delayed, the beneficiary will face a late enrollment penalty and will have to wait for the General Enrollment Period 24

25 Moving from the Marketplace to Medicare Continued ACA Medicaid (MAGI) Medicaid (MAGI-exempt) No categorical eligibility requirements 65+, disabled, blind, medically needy, LTSS, SSI Uses Modified Adjusted Gross Income for eligibility (MAGI) For people who have income below 133% (138% of FPL) No Asset Test Benchmark benefits package Will only exist in Expansion States Uses old disregard income calculation system (SSI Based) Most categories require income below 75%- 100% FPL Asset Test More comprehensive benefits package Exists in all States 25

26 Medicare Low-Income Programs The Medicare Savings Programs (MSPs) The Part D Low Income Subsidy (LIS) 26

27 The Part D Low Income Subsidy LIS Sliding scale help with Part D plan premium and coinsurance Eligibility Under 150% FPL and $13,300 assets People who qualify for MSP automatically receive LIS 27

28 What to do when someone didn t enroll in Part B (and Medicare should be primary) 1. Enroll in Part B as soon as possible o Find out if they re eligible for an SEP o If not, enroll in Medicare during the next General Enrollment Period (GEP) o January 1-March 31 of every year with coverage beginning July 1 of that same year 28

29 What to do when someone didn t enroll in Part B (and Medicare should be primary) 2. Equitable Relief o Federal law lets people request relief from the Social Security Administration in the form of immediate or retroactive Medicare enrollment and/or elimination of Part B premium penalty o Must show failure to enroll was unintentional, inadvertent, or erroneous and the result of error, misrepresentation, or inaction of a Federal employee or any person authorized by the Federal government to act in its behalf 29

30 Equitable Relief - Example An employee at the SSA told someone that they could delay enrollment in Part B because they had COBRA coverage. They then faced the consequences of delayed Part B enrollment because of the misinformation from the SSA employee. 30

31 What to do when someone didn t enroll in Part B (and Medicare should be primary) 3. Medicare Savings Programs (MSPs) o Let people to enroll in Part B outside of the GEP and erase premium penalties 31

32 Other effects of the ACA on Medicare No cuts in guaranteed benefits Some benefit improvements Greater fiscal stability Extends solvency of Part A Trust Fund by 8 years until 2024 Potential for greater care coordination, increased quality and lower costs 32

33 Other effects of the ACA on Medicare Changes to: Medicare Part B Medicare Part D Medicare Advantage 33

34 Medicare Part B Benefits Eliminates cost-sharing for most preventive services Rated A or B by USPSTF Gives Secretary greater ease in adding preventive services Smoking Cessation Adds new annual wellness visit and Personalized Prevention Plan

35 Medicare Part D Gradually closes Part D Donut Hole gap in coverage (Closed by 2020) $250 Rebate % reduction on Brand Rx 2011 Begins phasing in discounts on Generics Reduce cost-sharing for dually eligibles who would be institutionalized but for community services to those in institutions

36 Regulates Medicare Advantage (Part C) Prohibits charging more for certain services than traditional Medicare SNF, Chemotherapy, Renal Disease care Similar to Part D, eliminates plans that do not offer benefits distinguishable from other plans by same sponsor Restructure payments to MA plans based on local spending in Traditional Medicare Adds bonus payments for certain quality plans Requires minimum 85% medical loss ratio starting

37 Jimmo Settlement Big changes to Medicare therapy and rehabilitation benefits Medicare denials based on improvement standard are inappropriate 37

38 What Jimmo Settlement Means: Medicare coverage for skilled services in SNF, HH, Outpatient should NOT be denied because: Individual is stable or chronic Not expected to improve In a reasonable period of time Services CAN be skilled and covered even if: Individual has plateaued Services are maintenance only 38

39 CMS must revise its Medicare Benefit Policy Manuals by 1/24/2014 After revising the manuals, CMS must begin an education campaign for providers, Medicare contractors, Medicare adjudicators, patients and caregivers 39

40 What does this mean for a patient? Can t deny Medicare coverage due to: Lack of restorative potential Can t deny coverage because condition is chronic, stable, terminal or expected to last a long period of time 40

41 Individual Assessments are Required Base decision on individual s unique condition and needs Coverage based on need for skilled care: Defined as care that is inherently complex that it can be performed safely and effectively by or under the supervision of professional or technical personnel 41

42 ACA Basic Facts Pre-existing conditions are no longer a reason to deny or change higher premiums for health insurance 42

43 ACA Basic Facts Effective January 1, 2014 Health Insurance Companies are capped as to how much profit they can have. If the profit is greater than a defined ratio, insurer must rebate any remainder 43

44 ACA Basic Facts Effective January 1, 2014 Marketplace Exchanges How individuals and small businesses purchase private health insurance There are tax credits for some health insurance premiums and caps on costs of health insurance 44

45 ACA Basic Facts Effective January 1, 2014 No lifetime or annual limits on number of claims or total amount of the claims Many have an exception for annual limits if insurer shows it can t work 45

46 ACA Basic Facts Effective January 1, 2014 Young adults may remain insured on parents policies until age 26 regardless of: Child has married Is or not enrolled in school Lives at home or has moved away 46

47 The Eleven Essential Benefits 1. Emergency Services 2. Hospitalizations 3. Laboratory Services 4. Maternity Care 5. Mental Health and Substance Abuse Treatment 6. Outpatient, Ambulatory Care 47

48 The Eleven Essential Benefits Continued 7. Pediatric Care 8. Prescription Drugs 9. Preventive Care 10. Rehabilitative and Habilitative (helping maintain daily functioning) Services 11. Dental and Vision Care for Children 48

49 Donut Hole is Eliminated The coverage gap existing under Medicare Part D is gradually eliminated by Year Co-Pay % % % % % % % % Patient pays first $325 Patient then pays 25% Coverage Gap at $2970 (2013) $4700 (2013) Catastrophic Coverage 49

50 Questions????? 50 Martha C. Brown Martha C. Brown & Associates, LLC 220 W. Lockwood, Suite 203 ST. Louis, MO (314)