2017 All-Ohio Legal Forum. Medicare and Insurance Coverage: What to Know

Transcription

1 2017 All-Ohio Legal Forum Medicare and Insurance Coverage: What to Know Senior Lawyer Section 1.0 General CLE Hour August 23 August 25, 2017 Cleveland

2 Speaker Biographies Alexandra Bohne Jeanblanc Jeanblanc & Rosser, LLP Cleveland, Ohio Ms. Jeanblanc received her BA and MA from Case Western Reserve University and her JD from the Cleveland State University Cleveland-Marshall College of Law. Her professional membership includes the Ohio State Bar Association (Delegate, Council of Delegates). As an attorney with a background in sociology and statistical analysis, Ms. Jeanblanc has built a reputation for keen insights, relentless intellectual curiosity, and the ability to mediate solutions to complex problems. Prior to becoming a partner with Jeanblanc & Rosser, LLP, she externed with the Office of Medicare Hearings and Appeals, clerked with a small local law firm, and was a National Institute on Aging Pre-Doctoral Research Fellow at Case Western Reserve University. She has coauthored and presented multiple publications in the fields of gerontology and social science, and continues to be involved in quantitative statistical analysis in social and behavioral research. For additional information, please visit

3 Medicare, Medicaid, and Changes to the American Health Care System Alexandra Bohne Jeanblanc Jeanblanc & Rosser, LLP Cleveland, Ohio Table of Contents I. Medicare v. Medicaid...1 II. Eligibility Not Means Tested...1 III. The Application Process...1 IV. Picking a Plan...1 V. Supplemental Plans and the Impact of Dual/Overlapping Coverage (Closing the Donut, Etc.)...1 VI. Potential Pitfalls...1 VII. Medicaid...1 VIII. Impact of the Affordable Care Act...2 IX Health Law Changes...2 X. Resources...2 PowerPoint Presentation...3 Medicare, Medicaid, and Changes i

4 ii Medicare and Insurance Coverage: What to Know

5 Medicare, Medicaid, and Changes to the American Health Care System Alexandra Bohne Jeanblanc Jeanblanc & Rosser, LLP Cleveland, Ohio I. Medicare v. Medicaid A. Brief overview. B. Dual-eligible individuals. II. Eligibility Not Means Tested A. Parts A and B. B. Part D drug benefit. III. The Application Process A. Automatic enrollment. B. Manual application. C. How to apply. IV. Picking a Plan V. Supplemental Plans and the Impact of Dual/Overlapping Coverage (Closing the Donut, Etc.) VI. VII. Potential Pitfalls Medicaid A. Eligibility (Ohio). B. Enrollment (Ohio). Medicare, Medicaid, and Changes 1

6 VIII. Impact of the Affordable Care Act A. Elimination of pre-existing condition restrictions/benefit caps. B. Mandatory coverage guidelines. C. Medicaid expansion. IX Health Law Changes To be determined. X. Resources A. B. Ohio Senior Health Insurance Information Program (OSHIIP). 2 Medicare and Insurance Coverage: What to Know

7 Medicare from A to D ALEXANDRA BOHNE JEANBLANC, J.D., M.A. JEANBLANC & ROSSER, LLP Medicare vs. Medicaid Medicare Federal medical health insurance program for the elderly Eligibility based on age and work history, not means tested Medicaid Medical assistance program funded partly by state and partly by federal dollars Benefits vary by state Eligibility is meanstested (based on total assets and monthly income) Medicare, Medicaid, and Changes 3

8 Components of Medicare Part A: Covers medically necessary hospital, skilled nursing facility, home health and hospice care Part B: Covers medically necessary doctor s services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, some home health and ambulance services Part C: Privately run HMO-like plans, often called Medicare Advantage plans (substitute for Parts A & B. May also include Part D) Part D: Prescription drug coverage Dual Eligibles Some individuals qualify for both Medicare and Medicaid Income and Asset guidelines sort dual eligible beneficiaries into one of seven assistance categories Depending on which category they qualify for, beneficiaries may receive: Assistance with premiums Assistance with deductibles Assistance with coinsurance/copayments 4 Medicare and Insurance Coverage: What to Know

9 Medicare Eligibility Basics Eligible over the age of 65, or Under 65, eligible if: You have received SSDI for at least 24 months, or You have ALS, Huntington s Disease, or End-Stage Renal Failure (ESRD), or You are a resident of Puerto Rico and receiving benefits under Social Security or the Railroad Retirement Board Cost Part A: Free if you have worked 40 quarters (10 years), available for a premium if you have not. Part B: Available for a monthly premium Part C: Varies by plan, cost can be higher than Original Medicare (Parts A and B) Part D: Varies by plan Medicare, Medicaid, and Changes 5

10 The Enrollment Process Automatic Enrollment If already receiving SS or RRB benefits, card arrives automatically Under 65 and disabled (after 24 months of benefits) Resident of Puerto Rico (Part A) Manual Enrollment If you are still working Individuals with ESRD Resident of Puerto Rico (Part B) Individuals with Huntington s Disease (24 months postdiagnosis) Original Medicare vs. Medicare Advantage Original Medicare (A & B) Government run Can use any provider who accepts Medicare Medicare Advantage (C) Privatized HMO-type plans Typically more restrictive regarding coverage and benefits Less discretion in the appeals process if you need to dispute a denial of coverage Limited to practitioners taking your specific plan Some plans allow for out of network services, but at a higher cost 6 Medicare and Insurance Coverage: What to Know

11 Supplemental Plans Supplemental plans cover what Medicare does not Part D: Prescription Drug Benefit Provides prescription drug benefit Donut hole: Gap in Part D coverage Individual responsible for 25% of drug costs after the first $295 of spending (up to $2,700), 100% of costs between $2,700 and $6,154, 5% thereafter. Donut to be completely closed by 2020 Medigap Plans Covers a variable range of services that Medicare does not cover, including copays and extended hospital stays Optional coverage can include the cost of medical care incurred while traveling abroad Not available with Part C/Medicare Advantage Plans Medicare Savings Programs Means-based help for low income individuals Can cover premiums, deductibles, and coinsurances Supplemental Plans: Medigap Once you have enrolled in a Medigap plan, the insurance provider may NOT drop you from the plan Even if you develop new health problems, they must renew your coverage Medigap plans may NOT cover prescription drug coverage Until January 1, 2006, some Medigap plans did provided donut hole coverage, this is no longer permissible. BEWARE: If a plan offers donut hole coverage, it is NOT a Medigap plan, but is probably a Medicare Advantage plan that would replace your Parts A and B coverage. It is illegal to sell a Medigap plan to any individual enrolled in a Medicare Savings Program Medigap plans do not cover: long-term care, vision, dental, hearing aids, eyeglasses, or private-duty nursing. Some (less expensive) Medigap plans limit coverage to hospitals and physicians in their network Medicare, Medicaid, and Changes 7

12 Supplemental Plans: Medicare Savings Programs Means-tested program designed to help low-income individuals afford Medicare coverage Beneficiaries meet with specialists to determine eligibility Beneficiaries must provide copies of identity paperwork as well as documentation detailing assets and living expenses Supplemental Plans: Medicare Savings Programs Qualified Medicare Beneficiary (QMB) available to all eligible Acts like a free Medigap plan Covers all deductibles, coinsurances, and the Part B premium Eligibility: Single Married Monthly Income: $978 $1313 Total Resources: $7080 $10, 620 Specified Low Income Medicare Beneficiary (SLMB) available to all eligible Pays only the Part B premium including retroactively for the 3 months prior to enrollment Eligibility: Single Married Monthly Income: $1169 $1571 Total Resources: $7080 $10, 620 Qualified Individual (QI) limited availability Pays only the Part B premium Eligibility: Single Married Monthly Income: $1313 $1765 Total Resources: $7080 $10, Medicare and Insurance Coverage: What to Know

13 How to Enroll Online at the Social Security website At a local Social Security office Via phone call to Social Security or the RRB Enrollment Periods Initial Enrollment Periods Part A and B 3 months prior to your 65 th birthday Parts C and D 7 month window starting 3 months prior to your 65 th birthday Supplemental Plans Within 6 months after your 65 th birthday General Enrollment Period January 1 st March 31 st of each year (for individuals who sign up late) Coverage starts July 1 st of that year Special Enrollment Periods If your employer sponsored plan is terminated, you may enroll as if you were within the initial enrollment period for an 8 month window after your coverage ends. Open Enrollment A 3 month period each year when you change what plan you are covered under for the following year. Medicare, Medicaid, and Changes 9

14 Potential Pitfalls Picking the wrong plan Once enrolled in a plan, you must wait for the annual open enrollment to change it Signing up for a Part C plan removes you from Parts A & B If you have a Part C plan that does include prescription drug coverage, enrolling in a Part D plan will change you back to Parts A & B Waiting too long to enroll Part B Delays in coverage Higher Premiums Part D Higher Premiums Medigap May be denied entry into plan Appealing Enrollment Denials If you are denied coverage for Medicare, and you believe that you are eligible, you should file an appeal as soon as possible Although Medicare appeals overall have a high rate of success, enrollment appeals will only succeed if: If you were denied coverage on the basis of eligibility when you were, in fact, eligible If your delay in enrollment was due to the inaccurate advice of an SSA employee during the enrollment process 10 Medicare and Insurance Coverage: What to Know

15 Medicare and Other Insurance Many individuals have other health insurance in addition to Medicare Most commonly these are spouse-employer plans, or retiree benefits Some individuals choose to be insured under a private individual health plan in addition to Medicare Whenever you have multiple insurance products, you need to weigh the costs and benefits of keeping both products How much additional coverage will you receive keeping your non-medicare plan? Will your non-medicare plan cause difficulty in determining which insurer pays your claims? Medicare and Other Insurance Who Pays? If you are on a retiree health plan Medicare pays first. If you are on your working spouse s employer provided group health plan Employer plan pays first Only applies to employers with 20 or more employees Under 65, disabled, on your own or a family member s employer plan Employer plan pays first (if >100 employees) On Medicare due to ESRD First 30 months, group plan pays first, after that Medicare pays first If you are in an accident Medicare will pay second for accident related injuries. Medicare, Medicaid, and Changes 11

16 Finding and Comparing Medicare Plans The best resource for finding and comparing the costs of Medicare plans is online, through Medicare.gov The Medicare.gov website offers you the ability to enter geographic and personal details that show you what plans are available to you and at what cost. Finding a Plan Online 12 Medicare and Insurance Coverage: What to Know

17 Medicare, Medicaid, and Changes 13

18 Once you enter a drug name, the site will provide you with multiple selections to identify which specific drug you take. The site also prompts you for dosage, frequency, and what pharmacy you use to fill your prescription. 14 Medicare and Insurance Coverage: What to Know

19 You can view all available plans, or narrow them down by category. Using the drop down menu, you can select a number of limiting factors to narrow down your plan choices: Medicare, Medicaid, and Changes 15

20 The website will then provide you with a list of plans available to you, along with estimates of your cost. Note that Original Medicare is the first option listed. The plans that follow are Medicare Advantage Plans. You can also do a separate search for Part D Prescription Drug Coverage Where available, you can also enroll online. Enrolling in Medicare To enroll online for Original Medicare, the Medicare website will redirect you to the Social Security Administration website where you will enter your relevant information. The site verifies names and birth dates against Social Security Numbers and will only proceed if your information is accurate. 16 Medicare and Insurance Coverage: What to Know

21 Medicare Advertising Once you near Medicare eligibility, you will be inundated with a mountain of official looking advertising materials as well as phone calls. Many of these materials are designed to look as official as possible Always check to see if material is marked as advertising Look out for unsolicited phone calls and even home visits from insurance sales staff Agents may claim that they have been assigned to you for your Medicare enrollment Medicare, Medicaid, and Changes 17

22 Permissible Sales Practices Insurance Agents may: Distribute promotional materials at scheduled events or at their place of business Meet beneficiaries in their home IF invited to do so Assist beneficiaries in applying for public benefits Call potential enrollees IF they follow FTC telemarketing guidelines Impermissible Sales Practices Insurance Agents may NOT: Sell Medicare Advantage plans door to door Send unsolicited Collect enrollment applications or beneficiary information at health fairs Sell non-health related products during a Medicare product presentation Lie about benefit coverage, or the consequences of signing up for their product High pressure tactics such as telling beneficiaries that rates will go up if they do not sign up immediately 18 Medicare and Insurance Coverage: What to Know

23 Examples of Misleading Sales Practices Marketing Medicare Advantage plans as supplemental plans Beneficiaries have been induced to enroll in Medicare Advantage plans, only to find themselves withdrawn from their Part A and B plans Look out for the phrase includes Medicare A and B coverage Enrolling beneficiaries in plans that do not fit their budget Misleading beneficiaries to think that their current providers will be in-network under Medicare Advantage plans Things to Remember If you are still working, or are on a retiree health plan: Check with your HR department or plan administrator to find out how Medicare will work with your existing coverage If you retired early, ask if your monthly premiums change once you reach Medicare eligibility Compare your costs and benefits with and without your existing coverage Find out how long your retiree benefits will last Medicare, Medicaid, and Changes 19

24 Things to Remember When meeting with insurance sales staff: Bring a buddy it s always good to have a second set of ears Make sure to get quotes from multiple providers When comparing quotes, check to make sure that the plans include the same coverage Don t give in to high pressure sales tactics feel free to go home and think about your options before signing up for a plan If you decide to sign up for a Medicare Advantage plan, check with your doctors to make sure they accept the specific plan you are considering Medicare Subrogation In the event that a Medicare beneficiary receives a judgment or settlement for injuries, Medicare is entitled to be repaid for any medical expenses that had been advanced. Plaintiff s attorneys are responsible for arranging for Medicare to be compensated for medical expenses advanced. Although the insurance company paying the claim is responsible for notifying Medicare, it is a good idea for the Plaintiff s attorney to separately notify Medicare. 20 Medicare and Insurance Coverage: What to Know

25 Medicare Subrogation, cont. Medicare subrogation claims are handled by the Coordination of Benefits Contractor (COBC) Attorneys must provide proof of representation (see the Medicare Secondary Payer Portal for details) The MSPRC should provide attorneys automatically with a list of conditional benefits provided Attorneys should use the MSPRS site, as well as the conditional benefit summary to estimate Medicare s likely share of any settlement or judgment Attorneys should hold this estimated amount in trust Failure to hold back enough money from a settlement, or to obtain a large enough settlement may result in a clawback of attorney fees Medicaid Eligibility Ohio eligibility: Adults with an income of up to 133% of the Federal Poverty Line Children in a household up to 206% of the FPL Pregnant women with household income of up to 200% of the FPL Medicare, Medicaid, and Changes 21

26 Medicaid Enrollment Enrollment is on a rolling basis, no annual sign-up times How to enroll Online through Healthcare.gov or using their phone line: Through the Ohio benefits portal (includes an eligibility screening): Though your county Department of Job and Family Services Office: Affordable Care Act The Affordable Care Act ( Obamacare ) did not cut benefits to Medicare beneficiaries However: some Medicare Advantage plans were canceled for failure to provided minimum coverage requirements Added coverage for some preventative health screenings Medicaid expansion Ohio did participate in the ACA expansion of Medicaid eligibility 22 Medicare and Insurance Coverage: What to Know

27 2017 Legislative Changes (content to be added closer to date of presentation) Resources Medicare Includes information on coverage and plans Plan by plan comparisons customizable by information you provide Subrogation: Medicare Secondary Recovery Port CMMS handbook Medicare and You Ohio State Health Insurance Information Portal (OSHIIP) Medicare, Medicaid, and Changes 23

28 Resources OSHIIP Services: Telephone hotline to answer questions about coverage and available financial assistance Publications available online covering all aspects of Medicare enrollment, coverage, and how to sign up for/buy a plan Over 800 volunteers statewide who will meet with beneficiaries in person or by phone to help you with Medicare related issues Annual Medicare Check up Presentations Speakers are available upon request 24 Medicare and Insurance Coverage: What to Know