MMW Meeting Recap Webinar June 21, 2013

Transcription

1 MMW Meeting Recap Webinar June 21, 2013

2 Speakers Georgia Gerdes, AgeOptions Medicare DMEPOS Competitive Bidding Program John Coburn, Health & Disability Advocates Countable Income for SSI, Medicare Extra Help and Medicaid Alicia Donegan, AgeOptions Medicaid Spenddown 2

3 Medicare DMEPOS Competitive Bidding Program

4 DMEPOS Competitive Bidding Program Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program Saves Medicare money by having suppliers submit competitive bids to Medicare for certain types of medical equipment at rates lower than what Medicare currently pays Requires beneficiaries in selected geographic areas to obtain certain durable medical equipment from Medicare contracted suppliers in order for Medicare to cover the equipment Round 2 of the program begins in select areas of Illinois on July 1, 2013 Beginning July 1, 2013, only Medicare contract suppliers can sell or rent competitive bidding items to Medicare beneficiaries 4

5 DMEPOS Competitive Bidding Program Affects beneficiaries in original Medicare who permanently reside in a competitive bidding area zip code or get certain competitive bid items while visiting a competitive bidding area Can call Medicare or visit to find out if a zip code is in a competitive bidding area People in Medicare Advantage plans can continue to use the suppliers designated by their plan 5

6 DMEPOS Products Included in Competitive Bid Categories CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories Enteral Nutrients, Equipment and Supplies Hospital beds and related accessories Mail-order diabetic supplies Negative Pressure Wound Therapy Pumps and Related Supplies and Accessories Oxygen, oxygen supplies and equipment Standard (Power & Manual) Wheelchairs, Scooters, and Related Accessories Support Surfaces (Group 2 mattresses and overlays) Walkers and Related Accessories 6

7 Grandfathered Suppliers If a beneficiary is already renting medical equipment from a noncontract supplier when the program starts, he or she may be able to continue renting from the supplier if the supplier chooses to become grandfathered If a supplier decides not be grandfathered, the beneficiary must switch to a Medicare contract supplier May continue using the grandfathered supplier until the rental period for the equipment ends Only applies to oxygen, oxygen equipment and certain rented equipment Non contract suppliers should let beneficiaries know in writing 30 days before programs begins if they will be grandfathered. 7

8 Medicare National Mail Order Program for Diabetic Testing Supplies Begins July 1, 2013 National mail order program includes all of the U.S and districts All beneficiaries in original Medicare who use diabetic testing supplies will be affected Will need to use a Medicare national mail order contract supplier for Medicare to pay for diabetic testing supplies mailed to them Mail order includes all home deliveries If beneficiary does not want mail order, s/he can purchase diabetic testing supplies at a pharmacy or store that participates in Medicare The beneficiary's coinsurance will not change and s/he will continue to pay 20% coinsurance and any Part B deductible that is unmet Visit or call Medicare for more information 8

9 Resources DMEPOS Supplier Locator Tool: CMS DMEPOS Toolkit: Education/Outreach/Partnerships/DMEPOS_Toolkit.html (for professionals) Details about the program Map of competitive bidding areas Product categories and more 9

10 Countable Income for SSI, Medicare Extra Help, and Medicaid

11 Three Different Calculations SSI determined by federal law. Extra Help based on SSI, but some differences. Medicaid and Medicare Savings Programs determined by Illinois law because of 209(b) status and flexibility under Medicaid law.

12 SSI and The Formula SSI uses a formula and as unearned and earned income increase, the SSI check is decrease. The first $20 of unearned income is disregarded and the rest counts against the SSI check dollar for dollar. With earnings, any part of the $20 not used on unearned income is subtracted. Then, another $65 is subtracted and the remainder is divided by 2. What s left counts dollar for dollar against the SSI check. With no other deductions, SSI will be $0 when earnings reach $1505. There are deductions in the formula: Student Earned Income Exclusion, Impairment Related Work Expense, Blind Work Expenses, and Plan for Achieving Self-Support SSI deems income and counts In-Kind Support and Maintenance.

13 Example of $8.25/ Hr. Total Gross Earnings From Work Part Time Full Time $8.25 Hourly Wage $ 8.25 x 20 Hours/Week x 40 $ $ x 4.33 Avg Hours/Month x 4.33 $ Gross Monthly Earnings/Employment $1,428.90

14 Calculating Total Monthly Countable Income From Employment Part Time Full Time $ Monthly Income $1, $20.00 General Income Exclusion - $20 $ $1, $65.00 Earned Income Exclusion - $65 $ Gross Monthly Earnings/Employment $1, /2 Divide by 2 /2 $ Total Monthly Countable Income $671.95

15 Calculating Federal SSI Payment in 2013 Part Time Full Time $ Federal Benefit Rate $ Total Countable Income $ Adjusted SSI Benefit Check $ 38.05

16 Total Monthly Income in 2013 Adjusted SSI Benefit + Monthly Income From Employment Part Time Full Time $ Earnings from Employment $1, Adjusted SSI Benefit Check $ Total Monthly Income $

17 Extra Help vs. SSI Extra Help uses same formula to count earnings and unearned income. Extra Help uses set percentages for work-related deductions (16.2% or 25%) Extra Help looks at household size and then the income limits for that household size. Extra Help does not count Deeming or In Kind Support and Maintenance.

18 Illinois Medicaid and Medicare Savings Program Unlike most states, Illinois does NOT use SSI income calculating rules for Medicaid or Medicare Savings Program. Illinois uses household size and income standards. Illinois does not consider in-kind support and maintenance. Illinois uses its own formula to determine countable income.

19 Medicaid Income Deductions SSI does not count. $25 General Income Deduction Net Income so deduct taxes Earned income deduction: first $20 of earnings and ½ of the next $60 Mileage to work 19 cents/mile Lunch: between $3 - $9 month depending Special Tools or Uniforms Day care cost up to $160/ mo per child or $128 if working part time Special Work Expenses like Impairment Related Work Expenses

20 Medicaid Spenddown

21 Seniors and People with Disabilities (SPD) Medicaid Eligibility Requirements Age 65 or older OR Blind OR Disabled AND U.S. Citizen or Eligible Non-Citizen AND Illinois resident AND Meet income and asset standards (without spenddown status)

22 SPD Medicaid Income and Asset Limits Income Limit $983 for one person or $1,318 for a couple The $25 income disregard is included in these amounts Asset Limit $2,000 for one person or $3,000 for a couple Excludes home, one car Up to $1500 pre-paid burial plan or life insurance policy may be exempt from asset limit If applicant is over the income and/or asset limit, may spend down for help

23 Medicaid Spenddown Helps people who are over asset and/or income eligibility limits qualify for Medicaid Medicaid will pay for medical care when a person can show that he or she has paid or unpaid medical bills equal to their spenddown amount The amount of the spenddown depends on a person s income and assets Local DHS office will determine how much your spenddown amount will be

24 Income Spenddown Income spenddown amount is the difference between your monthly countable income and the Medicaid income eligibility limit Can meet income spenddown in 3 ways: Using paid or unpaid medical bills Pay-In monthly amount in the form of a premium Combination of medical bills and Pay-In spenddown Must meet income spenddown monthly Must meet monthly income spenddown amount at least one time every three months after initial 6 months of enrollment to stay in the program

25 Asset Spenddown Asset spenddown amount is the difference between countable assets and the Medicaid asset eligibility limit Can meet asset spenddown in 2 ways: Using paid or unpaid medical bills Spend assets until under asset eligibility limit CAUTION: Medicaid has 60 month look back period for transfers Must meet asset spenddown once until Medicaid re-determination/re-application

26 Income and Asset Spenddown Ex. David is single, 67 years old, and is covered under Medicare. He has a monthly income of $1200. David has $1,000 in his checking account, and a life insurance policy with a $3,000 cash value. What are his income and asset spenddown amounts? o Income: $1200 -$983 (Medicaid income eligibility) $217 monthly spenddown o Asset: $ $1500 (Life Insurance disregard) $2,500-2,000 (Medicaid asset eligibility) $500 one time asset spenddown How can David meet his income and asset spenddown?

27 Medical Expenses to Meet Spenddown Can use unpaid bills and/or receipts for medical services and supplies including: -Doctor, hospital, nursing home, dental, and chiropractic services that are medically necessary -Eyeglasses -Medical supplies and equipment -Health insurance premiums including Part B and Medicare Supplement Premiums -Transportation to and from medical services -Any co-pays and deductibles on medical care and prescriptions -Cost of services received through the Community Care Program (CCP) or Division of Rehabilitation Services (DRS)

28 Medical Expenses to Meet Spenddown You can use your own medical bills, as well as for those whom you are financially responsible for (spouse and children under 18 living with you) You can only use bills or receipts for medical services or supplies one time to meet your spenddown If you do not have enough unpaid or paid bills to meet your spenddown for one month, you can use those bills to meet spenddown in a future month

29 Paid Medical Bills Used to Meet Spenddown You can use paid bills to meet spenddown for up to six months after the payment of the bill is made You can qualify for up to 6 months of Medicaid if your receipts equal more than one month of your spenddown amount You can be reimbursed by Medicaid for paid bills incurred 3 months before the application if you met your income and asset spenddown during those months

30 Unpaid Medical Bills Used to Meet Spenddown Can use unpaid bills, no matter how long ago the bill was incurred Must be a current bill with a billing date within 6 months of the month that the client wants coverage Ask provider for new bill if dated longer than 6 months ago Unpaid bills may be paid for by Medicaid within the past 3 months of the application if you can meet asset and income spenddown for those past three months Unpaid bills can be used to meet future months of spenddown indefinitely, past 6 months If you use an unpaid bill to meet your spenddown in one month, you cannot use a receipt for the payment of that bill to meet spenddown in a later month

31 Pay-In Spenddown You may pay-in the spenddown amount in the form of a premium to receive medical care for the month -May pay-in the entire spenddown amount if you do not have any medical bills, or if you do not have enough medical bills to meet spenddown, you may pay in the difference. -Send medical bills to DHS caseworker, not Pay-In Unit You must be enrolled in the Pay-In Spenddown program -Call the Health Benefits Hotline at (800) and ask for the Pay-In Spenddown Unit to apply You will receive a Pay-In Spenddown Statement each month with the amount that you need to pay-in If you do not need care for a specific month, do not send in the pay-in amount or medical bills to DHS to meet spenddown

32 How to Apply for Spenddown

33 Decide which month you want coverage to begin -Do you have enough medical bills to meet spenddown every month? (Can submit bills every month to receive coverage moving forward) -Do you want a past bill to be paid for by Medicaid or do you want to be reimbursed for a medical bill? (Can request 3 months back or not receive payment and apply toward coverage in a later month) -Do you have a scheduled procedure in the near future that you would like coverage for? (Can request future coverage up to 6 months from application) -Do you want to receive assistance from the Extra Help program? (Explained on next slide)

34 Medicaid and Extra Help If someone with Medicare also has Medicaid (even for 1 month through Spenddown program), s/he will be automatically be enrolled in full Extra Help/LIS No premiums, deductibles or gaps Pay $1.15 generic or $3.50 brand name in 2013 Pay $0 if in a nursing home, Community Integrated Living Arrangement Effective 1/1/12 pay $0 co-pay if receiving home or community-based services and on Extra Help Join a Part D plan or one will be assigned to you If you apply for Medicaid before July, you will receive Extra Help for the rest of that calendar year If you apply for Medicaid after July, you will receive Extra help the rest of the current calendar year, and the entire next calendar year

35 Fill Out Application Fill out the Medicaid ONLY form (HFS 2378H) here: Submit application and copies of medical bills being used to meet spenddown along with a cover letter explaining how you are using each medical bill/receipt to qualify Indicate which month you would like coverage on the application and cover letter (Otherwise coverage usually begins the first month in which medical expenses or payments add up to spenddown amount) Write Social Security number on every page of application and on every supporting document

36 Submit Verification Proof of age Proof of income and resources Proof of U.S. Citizenship or legal residence Medical proof of disability or blindness (if applicable) Proof of state residency

37 Where to Apply Go to the local DHS (Medicaid) office To locate a local office, go to Mail in an application to your local office Go to to apply online

38 Thank You!