Tom Milonas » cost sharing

What Does Dual Eligible Mean?

Tom Milonas — Thu, 01 May 2008 17:10:37 +0000

Medicare / Medicaid Dual Eligibles

Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.

Medicare – Medicaid Relationship

The Medicare Program (Title XVIII of the Social Security Act) provides hospital insurance, also known as Part A coverage, and supplementary medical insurance, also known as Part B coverage. Coverage for Part A is automatic for people age 65 or older (and for certain disabled persons) who have insured status under Social Security or Railroad Retirement. Most people don’t pay a monthly premium for Par A. Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B also requires payment of monthly premiums.

People with Medicare who have limited income and resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program. There are various benefits available to “dual eligibles” who are entitled to Medicare and are eligible for some type of Medicaid benefit. These benefits are sometimes also called “Medicare Savings Programs” (MSP).

For people who are eligible for full Medicaid coverage, the Medicaid program supplements Medicare coverage by providing services and supplies that are available under their states Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the states payment limit. Medicaid also covers additional services (e.g., nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids).

Limited Medicaid benefits are also available to pay for out-of-pocket Medicare cost-sharing expenses for certain other Medicare beneficiaries. The Medicaid program will assume their Medicare payment liability if they qualify. Qualified Medicare Beneficiaries (QMBs), with resources at or below twice the standard allowed under the Supplemental Security Income (SSI) program and income at or below 100% of the Federal poverty level (FPL), do not have to pay their monthly Medicare premiums, deductibles, and coinsurance. Specified Low-Income Medicare Beneficiaries (SLMBs), with resources at or below twice the standard allowed under the SSI program and income exceeding the QMB level, but less than 120% of the FPL, do not have to pay the monthly Medicare Part B premiums. Qualifying Individuals (QIs), who are not otherwise eligible for full Medicaid benefits and with resources at or below twice the standard allowed under the SSI program, will get help with their monthly Medicare Part B premiums, if their income exceeds the SLMB level, but is less than 135% of the FPL.

Individuals who were receiving Medicare due to disability, but have lost entitlement to Medicare benefits because they returned to work, may buy Medicare Part A. If the individual has income below 200% of the FPL and resources at or below twice the standard allowed under the SSI program, and they are not otherwise eligible for Medicaid benefits, they may qualify to have Medicaid pay their monthly Medicare Part A premiums as Qualified Disabled and Working Individuals (QDWIs).

To learn more about Medicaid eligibility and/or the Medicare Program, see Related Links Inside CMS at the bottom of the page.

Screening Tools

Screening tools are available to help assess an individual’s eligibility for a variety of governmental programs, including Medicaid and/or Medicare, by accessing the GovBenefits and BenefitsCheckUp websites. (See Related Links Inside CMS and Related Links Outside CMS at the bottom of page.)

Integrated Medicare and Medicaid Models

CMS has created a specific website to provide information about our initiative for Integrated Care programs. This website provides valuable resources regarding integrated Medicare and Medicaid programs for States, health plans, and providers.

Source www.medicare.gov

Medicare / Medicaid Dual Eligibles

Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.

Medicare – Medicaid Relationship

To learn more about Medicaid eligibility and/or the Medicare Program, see Related Links Inside CMS at the bottom of the page.

Screening Tools

Integrated Medicare and Medicaid Models

Financial help for Certain Medicare Recipients

Tom Milonas — Sat, 05 Jan 2008 18:33:24 +0000

As of January 1, 2006, elderly and disabled people on Medicare have access to an outpatient prescription drug benefit (Medicare Part D) offered through private drug plans. The drug benefit includes substantial premium and cost-sharing subsidies for Medicare beneficiaries with low incomes and modest resources, including beneficiaries eligible for full Medicaid benefits (dual eligibles), who previously had
drug coverage through their state Medicaid program.

These low-income subsidies are intended to reduce or eliminate enrollees’ out-of-pocket expenses associated with the drug benefit, including premiums, deductibles, copayments, and costs in the coverage gap (sometimes called the doughnut hole). Part D plans are required to offer a statutorily defined standard benefit or one that is actuarially equivalent.

WHO QUALIFIES FOR LOW-INCOME SUBSIDIES AND WHAT HELP DO THEY GET?

Dual eligibles who qualify for Medicaid on the basis of their income and assets automatically qualify for Medicare prescription drug low-income subsidies.

Additionally, those who receive premium and/or costsharing assistance from Medicaid through the Medicare
Savings Programs (QMB, SLMB, QI), and those only eligible for SSI cash assistance are also automatically deemed eligible for low-income subsidies and need not apply for them.

Dual eligibles and others deemed eligible for low-income subsidies pay no Part D plan premiums or deductibles, and copayments for brand-name drugs, depending on their income. Though nominal, these copayments are a new expense for many dual eligibles who were not charged for drugs under their state Medicaid programs. Dual eligibles in nursing homes have no drug copayments.

Other low-income Medicare beneficiaries must meet an income and resource test and submit an application to determine if they qualify for low-income subsidies. These individuals must apply separately for the additional assistance through the Social Security Administration (SSA) or their state Medicaid program. The level of assistance for other low-income beneficiaries who qualify for drug benefit subsidies varies based on their income and resources. In general, greater assistance is targeted to those with lower incomes and resources (Figure 1).

HOW IS ELIGIBILITY DETERMINED?

Income and other resource levels are used to determine eligibility for the low-income subsidy. Social Security benefits, Veterans benefits, public and private pensions, annuities, and in-kind support are counted as income. Eligibility is based solely on the income of the applicant (and spouse, if applicable), regardless of whether there are other household members with income.

Resource levels used to determine eligibility for low income subsidies are higher (more generous) than those used for SSI and Medicaid. Resources are defined as assets that can typically be converted to cash within 20 days, such as stocks, bonds, and checking, savings, and
retirement accounts. An applicant’s principal home, car, and life insurance policies do not count toward the resource limit. Individuals with Medicare and Medicaid $0 $0 No copays benefits in nursing homes

HOW DO BENEFICIARIES APPLY FOR SUBSIDIES?

Beneficiaries who are not automatically eligible for low income subsidies must apply for this assistance through SSA or their state Medicaid programs. Signed applications (even those not entirely complete) may be submitted in person, by mail, by phone, or online through the SSA Web site. Documenting income or resources is not required. Applicants found eligible in 2006 retain eligibility for the remainder of the year. After 2006, SSA and states can set their own redetermination timeframes.

If beneficiaries apply for the Part D low-income subsidy through their state Medicaid program, Medicaid must also screen for eligibility for benefits under the Medicare Savings Programs. However, SSA is neither required to screen for Medicare Savings Program eligibility nor refer applicants to Medicaid for screening. Since SSA has processed the vast majority of low-income subsidy applications, many beneficiaries may have missed a key opportunity to learn about Medicare Savings Program or Medicaid benefits for which they might also qualify.

HOW DOES DRUG PLAN ENROLLMENT WORK?

Beneficiaries who apply and are found eligible for the low-income subsidy must also enroll in a Medicare drug plan for the subsidy to take effect. In 2006, the Administration facilitated enrollment in drug plans for one million beneficiaries who qualified for the subsidy but had not signed up for a plan prior to the May 15, 2006 enrollment deadline.

In 2006, beneficiaries who apply and qualify for the low income subsidy after the enrollment deadline have a special enrollment period that enables them to sign up for a Part D plan for the remainder of the year, or they will be automatically enrolled. Those who are
automatically enrolled can switch plans once before the next enrollment period which begins on November 15.

Individuals who qualify for the low-income subsidy after May 15th will not be subject to the late enrollment penalty in 2006. However, like all other Medicare beneficiaries, those with low incomes who do not have drug coverage in 2006 and who later decide to enroll in a Part D plan will face a penalty for late enrollment – although the penalty will be reduced for those eligible for low-income subsidies.

Dual eligibles, unlike other low-income beneficiaries, were automatically enrolled in plans with premiums at or below the state average at the beginning of 2006. They are permitted to switch plans throughout the year, unlike other Part D enrollees who will be able to switch plans only during the annual coordinated enrollment period at the end of each year.

Source: www.medicare.gov

what is the difference between an advantage plan and a Supplement?

Tom Milonas — Sat, 05 Jan 2008 15:20:29 +0000

Medicare Advantage Plans

Medicare Advantage Plans are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include prescription drug coverage. Medicare Advantage Plans include:

Medicare Health Maintenance Organization (HMOs)
Preferred Provider Organizations (PPO)
Private Fee-for-Service Plans
Medicare Special Needs Plans

When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, generally there are extra benefits and lower copayments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer.

If you join a Medicare Advantage Plan, your Medigap policy won’t work. This means it won’t pay any deductibles, copayments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.

To compare Medicare Advantage Plans, go to the Medicare Options Compare.

Medigap (Supplemental Insurance) Policies

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs.

Insurance companies can only sell you a “standardized” Medigap policy. These Medigap policies must all have specific benefits so you can compare them easily.

You may be able to choose up to 12 different standardized Medigap policies (Medigap Plans A through L). Medigap policies must follow Federal and State laws. These laws protect you. A Medigap policy must be clearly identified on the cover as “Medicare Supplement Insurance.” Each plan, A through L, has a different set of basic and extra benefits.

It’s important to compare Medigap policies because costs can vary. The benefits in any Medigap Plan A through L are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company.

You and your spouse must each buy separate Medigap policies. Your Medigap policy won’t cover any health care costs for your spouse.

For additional information on Medigap policies, including why you would want to buy a Medigap policy and information about what Medigap policies cover, please read our publication, Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.