HELPING MEDICARE BENEFICIARIES IN TIMES OF TRANSITION

Transcription

1 HELPING MEDICARE BENEFICIARIES IN TIMES OF TRANSITION APPRISE Regional Update Presented by the Pennsylvania Health Law Project September, 2014 HELPING LOW-INCOME INDIVIDUALS NEW TO MEDICARE Help with Part B Costs: The Medicare Savings Program Help with Part D Costs: Extra Help 2 1

2 HOW DOES THE MEDICARE SAVINGS PROGRAM HELP? This program, also called Medicare Buy-In, pays the Part B premium for those who qualify giving them an extra $ in their Social Security check each month Those who qualify for the Medicare Savings Program who have the lowest income also get help paying their Part A and B deductibles and other cost-sharing 3 / WHO QUALIFIES FOR THE MEDICARE SAVINGS PROGRAM? The Medicare Savings Program is available to anyone who: Is on Medicare, or is eligible for Medicare, and Has monthly income* below 135 % FPL, and In 2014 the limit is $1,333 if single ; $1,790 if married, Has resources* below the current limits. In 2014, the limits are $7,160 if single; $10,750 if married *Not all income and resources count so if it seems someone may qualify, it s best to help them apply and get a decision 4 2

3 APPLYING FOR THE MEDICARE SAVINGS PROGRAM Anyone interested should apply to Pennsylvania Medicaid by: Filling out an application called Payment of Medicare Premiums, Coinsurance and Deductibles (PA 600M that can be mailed or taken to their local County Assistance Office; or Applying online through Because this is a general Medicaid application, the applicant should note in the comment box at the end of the form that she wants to be reviewed for the Medicare Savings Program. Note: MIPPA Process is also available (see slides HOW DOES THE MEDICARE SAVINGS PROGRAM WORK? Once an application is received, the County Assistance Office has 30 days to decide whether the person qualifies and to mail out a notice If the person is approved, the decision will also tell him when the help will start Within a few months, the Part B premium will stop being taken out of the person s Social Security and their monthly check will increase by $ The person will also receive a refund from Social Security for the Part B premiums paid after the start date If the person is also approved for help with other Part A & B costs, he will be sent an ACCESS card to use with his Medicare card when getting any health care services 6 3

4 HOW DOES THE EXTRA HELP PROGRAM BENEFIT MEDICARE CONSUMERS? Extra Help significantly lowers a consumer s prescription drug costs by helping to pay Part D premiums, deductibles and co-pays In addition, anyone getting Extra Help never falls into the Part D donut hole or coverage gap There are two levels of Extra Help - Full and Partial The amount of Extra Help given is based on the applicant s income and assets 7 QUALIFYING FOR EXTRA HELP Medicare beneficiaries qualify for Extra Help in one of two ways: 1 Automatically, by being found eligible for any Medicaid benefit, or 2 Applying and meeting income and asset limits: Single person: income less than $1,479/month and resources < $13,440 Married couple: income less than $1,986/month and resources < $26,860 Not all income and resources count There are substantial disregards from earned income A primary residence, motor vehicles and life insurance are not counted as resources 8 4

5 HOW DOES EXTRA HELP WORK? If a beneficiary is awarded full Extra Help, no matter what Part D plan she has: She will pay a lower monthly premium for her Part D coverage (no premium if she joins one of the zero premium plans; She should have no annual deductible and no donut hole; and She should have prescription co-pays* no higher than $2.55/generic and $6.35/brand name drugs (and once she gets to a certain spending level, her co-pays are eliminated for the rest of the year * Note: anyone receiving Medicaid long term care in a nursing home or through an HCBS waiver has no Part D co-pays! 9 HOW DOES EXTRA HELP WORK? (CON T If a beneficiary is awarded partial Extra Help, no matter what Part D plan he has: He will get help paying his monthly Part D premium (sliding scale; His annual deductible should be no more than $63 and he should have no donut hole; and He should not pay more than 15% of the cost of his medications and, once he gets to a certain spending level, his co-pays will be limited to $2.55/generic and $6.35/brand name drugs for the rest of the year 10 5

6 APPLYING FOR EXTRA HELP A Medicare beneficiary who qualifies for any Medicaid benefits automatically is awarded full Extra Help and does not need to apply! A beneficiary who is not receiving any Medicaid benefit must apply for Extra Help: Online at ssa.gov/prescriptionhelp By phone at Call the PACE Application Center (Benefits Data Trust at MIPPA 6

7 WHAT IS THE MIPPA PROCESS? It is a way to apply for the Medicare Savings Program (MSP without having to do a separate application Someone applies for Extra Help and agrees to have the Social Security Administration (SSA share their application information with the Department of Public Welfare (DPW Steps in the MIPPA Process: 1 SSA reviews Extra Help application and determines eligibility 2 SSA sends Extra Help application info to DPW 3 DPW uses ONLY this information to review if someone qualifies for the Medicare Savings Program 13 MIPPA PROCESS LIMITATIONS Local programs cannot count MSP application if use MIPPA process (only count Extra Help application No retroactive MSP benefits Delays when someone starts actually receiving the MSP help since the Extra Help application needs to be processed first and then is sent to DPW for processing MIPPA does not work for everyone, especially if: Already approved for or receiving Extra Help Already getting benefits from CAO (i.e., SNAP, LIHEAP, Medicaid and have resources that would put them over the MSP limit 14 7

8 WHEN TO USE MIPPA The MIPPA process should only be used in limited cases where you have verified that someone: - is not already getting the Extra help (or has not yet been approved for this help; and - would not qualify for MSP if applied for directly because of life insurance or motor vehicles Before referring to Benefits Data Trust or helping individuals complete Extra Help application and using MIPPA process, check for Extra Help status - If person already has the Extra Help, help her complete MSP app to submit directly to the local County Assistance Office 15 HELPING DUAL ELIGIBLES THROUGH CHANGES 16 8

9 HELPING NEW DUAL ELIGIBLES Walter is 58. He s been on Medicaid and enrolled in United Healthcare Community Plan. He is on SSDI and will be going on Medicare as of 11/1. He s nervous about the changes to his coverage. He was told to call APPRISE for help. He s married. The only income is his SSDI of $1150/mo. They have minimal resources (< $2000. His wife is sick and had stop workingshe is applying for SSDI. 17 WHAT HAPPENS WHEN SOMEONE ON MEDICAID GETS MEDICARE? 1 Medicare becomes primary insurance and Medicaid becomes secondary (always payer of last resort 2 Individual is disenrolled from the Medicaid managed care plan and moves to Medicaid fee-for-service (ACCESS card unless under 21 years old Walter will need to start using his red, white and blue card when getting services as of 11/1 (or a Medicare Advantage/ D-SNP card He ll also need to start using his ACCESS card then If he gets SNAP benefits, that s the ACCESS card he uses (greenish blue If no SNAP, will need to start using yellow ACCESS card He may need to get new card 18 9

10 WHAT HAPPENS WHEN SOMEONE ON MEDICAID GETS MEDICARE? (CON T 3 Medicaid will no longer provide Rx coverage (except for some limited OTC Meds Individual must use Part D plan when getting meds at pharmacy Medicare will auto-enroll dual eligible into Part D plan if needed LI NET is available as short-term Part D coverage if needed You advise Walter that he ll need to start using Part D for his medication and should only use his ACCESS card at the pharmacy for OTC medications You check for him and learn that he s auto-enrolled into a Cigna Medicare Rx Secure Plan starting 11/1 and gets full Extra Help as of this date - Does this plan cover his drugs? - Did he get info/id card from Cigna yet? 19 WHAT HAPPENS WHEN SOMEONE ON MEDICAID GETS MEDICARE? (CON T 4 Individual will automatically get the full Extra Help with Part D costs Does not need to apply for this help (DPW sends info to Medicare and Medicare turns it on Small co-pays ( $2.55 if generic; $6.35 if brand name for Medicare covered drugs No co-pay if gets Medicaid long-term care in nursing home or HCBS Waiver program! For Walter Advise him about his expected Part D costs No monthly premium if stays in Cigna or switches to a different zero premium Part D plan No deductible and no donut hole! Only small co-pays when gets meds at the pharmacy--$1.20 if generic; $3.60 if brand name (since income < 100% FPL 20 10

11 WHAT HAPPENS WHEN SOMEONE ON MEDICAID GETS MEDICARE? (CON T 5 ACCESS card is only insurance for services that Medicare does not cover Dental Vision (limited OTC medications (limited Individual will still get Medical Assistance Transportation For Walter Advise him generally about Medicare Coverage Advise him to use his Medicare and ACCESS card when getting all services starting 11/1 If he needs a service that is only covered by Medicaid/ACCESS, he will need to find a provider that accepts the ACCESS card only 21 WHAT HAPPENS WHEN A MEDICARE BENEFICIARY QUALIFIES FOR MEDICAID? Medicaid will become their secondary coverage and will help pay for Medicare deductibles and co-pays (between two insurances, someone has complete coverage Medicaid will give them additional coverage for some services Medicare doesn t cover (i.e., dental, vision, some OTC meds, Medical Assistance Transportation Medicaid may pay the person s Medicare Part B premium if she qualifies for the Medicare Savings Program as part of her Medicaid benefits 22 11

12 WHAT HAPPENS WHEN A MEDICARE BENEFICIARY QUALIFIES FOR MEDICAID? (CON T Getting Medicaid (even if the person only gets the Medicare Savings Program qualifies the person for full Extra Help with Part D costs This happens automatically and the person does not need to apply for Extra Help Person will have small Part D co-pays for each prescription covered (unless they get help through a Waiver program or get Medicaid coverage in a Nursing Home-$0 co-pays then! 23 CONSIDERATIONS FOR COUNSELING A MEDICARE BENE NEW TO FULL MEDICAID Do they need to change their Medicare coverage? Should they suspend or cancel their Medigap? Do they need to enroll in a Part D Plan? If they have been in Medicare Advantage medical only plan-yes! If they have a MA-PD or PDP-MAYBE, depends on plan Is updated for Extra Help? Do they have an ACCESS card? Do they need to apply for MSP? 24 12

13 COMMON PROBLEMS FOR DUAL ELIGIBLES They often don t know what insurance they have They don t understand how their two insurances work together They don t tell providers about all their insurance 25 WHAT ABOUT HELPING A DUAL WHO LOSES MEDICAID? They continue to automatically get the full Extra Help for rest of the year (and sometimes the following year, too! They may still get some limited help from Medicaid (if not sure, check with CAO or PHLP They likely need to review their current Medicare plan and decide if they need to change (ongoing Special Enrollment Period so can change plans at any time Their out-of-pocket costs for Part A and Part B covered services will go up; Part D costs shouldn t change much (for some period of time 26 13

14 HELPING INDIVIDUALS TRANSITION FROM MARKETPLACE INSURANCE TO MEDICARE 27 MARKETPLACE BASICS In PA, people can buy a Marketplace Plan through Levels of plans-bronze, Silver, Gold, Platinum Marketplace plans must cover Essential Health Benefits Enrollment Periods Apply Open Enrollment for 2015: 11/15/14-2/15/15 Premium Tax Credits and Cost-Sharing Reduction Subsidies available (if someone qualifies Starting in 2014, individuals who do not have Minimum Essential Coverage may have to pay a penalty Medicare Part A only = Minimum Essential Coverage Medicare Part B only Minimum Essential Coverage SHOP (Small Business Health Options Program Marketplace is different this provides coverage to employers (and their employees 28 14

15 IF SOMEONE ALREADY HAS ANY MEDICARE COVERAGE Individual Marketplace: They cannot enroll in a plan sold through the individual Marketplace (it is illegal to knowingly sell or issue a Marketplace plan to a Medicare beneficiary This is true even if someone has Part A only or Part B only Individuals with Medicare don t need Marketplace coverage SHOP Marketplace: If a Medicare bene (or spouse is working and covered by SHOP Marketplace, Medicare Secondary Payer Rules apply in terms of coordination of benefits Medicare beneficiaries can enroll in SHOP plan 29 IF SOMEONE ALREADY HAS MEDICARE (CON T Only Exception to previous slide is for people who have to pay a premium for Part A These individuals may choose to drop their Premium Part A and Part B coverage and enroll in a Marketplace plan; if they do this, may get premium tax credits and cost-sharing subsidies if eligible Medicare Considerations: Late Enrollment Penalties Limited Enrollment Opportunities (GEP and delayed start date for Medicare coverage 30 15

16 IF SOMEONE HAS MARKETPLACE PLAN AND THEN BECOMES ELIGIBLE FOR MEDICARE For most Medicare beneficiaries, they should enroll in Medicare A and B when they become eligible and end their Marketplace plan Once Part A starts (which for most people happens automatically, person loses any premium tax credit and cost-sharing subsidy Must act to cancel Marketplace plan (if they don t, the Marketplace plan s costs go up and these plans do not coordinate with Medicare 31 IF SOMEONE HAS MARKETPLACE PLAN AND BECOMES ELIGIBLE FOR MEDICARE (CON T If someone would have to pay for Part A coverage, she could decide not to enroll in Medicare and keep Marketplace plan (and tax credits/subsidies Medicare Considerations: Late Enrollment Penalties Limited Enrollment Opportunities (GEP with delayed start date 32 16

17 IF SOMEONE HAS SHOP PLAN AND BECOMES ELIGIBLE FOR MEDICARE (CON T Person with SHOP coverage is treated as any other person with employer group health plan coverage Medicare Secondary Payer rules apply If person wants to enroll in Medicare after Initial Enrollment Period, can use the Part B Special Enrollment Period to avoid late enrollment penalties and limited enrollment opportunities SHOP plan is required issue annual written notice to plan members about whether or not it offers prescription coverage creditable to Part D 33 SPECIAL CONSIDERATIONS FOR INDIVIDUALS NOT COLLECTING SS BENEFITS AT AGE 65 These individuals are not automatically enrolled in Part A and must take action to enroll in Medicare If they decide NOT to enroll in Medicare at 65, then not entitled to Medicare: Would be able to enroll in Marketplace plan or other individual market coverage Would be able to get tax credits and cost-sharing subsidies if qualify Medicare Considerations-Late Enrollment Penalties and Limited Enrollment Opportunities 34 17

18 SPECIAL CONSIDERATIONS FOR INDIVIDUALS ENTITLED TO MEDICARE BASED ON ESRD If not yet enrolled in Medicare, Marketplace may be better option than Medicare Cannot join Medicare Advantage Plan Considerations for Medicare vs. Marketplace Medicare Late Enrollment Penalties Limited Medicare Enrollment Opportunities Medicare coverage of immunosuppressant meds (Part B vs. Part D depending on if someone has Medicare at time of transplant If someone has Medicare based on ESRD/Kidney Transplant and is already enrolled in Part A and/or Part B, then she cannot join Marketplace plan (and cannot drop Medicare in order to join one 35 IMMIGRANTS AND MARKETPLACE Individuals who are lawfully present in the US but not yet eligible for Medicare can enroll in a Marketplace plan and qualify for tax credits and cost-sharing reduction subsidies Lawfully present means here legally (i.e. green card, temporary visa holders, refugees/asylees If not eligible for Medicaid, can get tax credits and subsidies even if income < 100% FPL 36 18

19 FOR MORE INFORMATION Call PHLP s Helpline at Contact us directly Fran Chervenak ; fchervenak@phlp.org Erin Guay ; eguay@phlp.org Go to our website at Join the list to receive our monthly PA Health Law Newsletter for the latest information and updates about public health care programs in PA 37 19