Tom Milonas » medicaid

Long Term Care Options In Florida

Tom Milonas — Wed, 18 Mar 2009 05:00:05 +0000

In the state of Florida, almost one quarter of the residents are over the age of 60. Quality long-term care is very important for many of these older Floridians. The Florida Agency of Health Care Administration (AHCA) regulates Health Care Facilities throughout the state and also administers Florida’s Medicaid program.

Below are a few of the long term care facilities regulated through AHCA:

Assisted Living Facilities: Provides housing, meals and some personal services for residents. Residents have to meet certain functional criteria and must be ambulatory and able to perform daily living activities like eating and able to care for basic bodily functions. Bed ridden residents are not accepted. Medicaid will pay for such a facility if both the resident and facility are eligible.

Adult Day Care: These are less than 24 hour care facilities. They offer therapeutic programs impaired adults. These centers offer many activities such as exercise, education, health screening and behavior modification. These centers also serve as a reprieve to the primary caregivers. These programs may be covered by Medicaid.

Adult Family – Care Homes: These family-type living arrangements provide a private home for up to 5 aged or disabled people (not related). The owner lives with the residents. The residents must not be bed ridden and are subject to other criteria as described in Florida law. Adult family care homes are for residents that do not require more care than can be provided by the owners. In some cases Medicaid will pay if both the resident and the AFCH are eligible.

Hospice: Hospice is a program that coordinates professional services including nutritional counseling, pastoral services, social work, and many other services for the terminally ill. These services can be provided at the hospital, hospice facility or the patient’s residence.

Medicare or Medicaid will pay for these services if the patient is eligible.

By Guest Writer: Jessica Farrell

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