Transcript PowerPoint: Medicare and New and Existing Opportunities

Medicare and New and Existing
Opportunities for Financial Assistance
National Association of
Health Underwriters
June 2009
What we will cover today
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What is the Medicare drug benefit (Part D)?
Who can get extra help?
How do you get extra help?
How do you get drug coverage?
Are there other programs that can help?
Six things you should know about
the Medicare drug benefit
Medicare drug benefit began January 1, 2006
Anyone entitled to Medicare Part A and/or enrolled in
Part B can buy coverage
All coverage through private drug plans
You pay a premium as well as a deductible and
coinsurance up to a maximum of $4,350 in 2009
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Much lower costs for people with low incomes
Your premium does not count toward your maximum
$2.40/$6.00 co-pays or 5% of the price after yearly
$4,350 in out-of-pocket spending
You do not have to get the drug benefit, but you might
have to pay penalty if you enroll later
Medicare drug benefit might coordinate with drug
coverage you already have
Which drugs will the Medicare drug
benefit cover?
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Each Medicare drug plan has its own formulary (list of covered
drugs)
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Medicare drug plans must cover at least two drugs under each
type of drug class
A few drugs are excluded from Medicare coverage by law
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Can change formularies throughout the year
Some examples are benzodiazepines, and barbiturates
Drug plans usually provide incentives for you to use generic
drugs by offering lower out-of-pocket costs for those drugs (cost
tiers)
If a drug is not on the formulary or if you get it from a pharmacy
not in the plan's network, you will have to pay the full cost
yourself
You can ask your plan to cover the drugs you need
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You and/or your doctor can request an exception
People with Medicaid
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If you had Medicaid, your Medicaid drug coverage ended and
Medicare covered your drugs beginning January 1, 2006.
You do not have to pay a premium or deductible
(if your plan premium does not exceed the subsidy)
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You will have continuous coverage ( no gap)
You may have a small co-pay for each prescription:
 At or below 100% FPL (federal poverty level):
You pay $1.10 for generic and $3.20 for brand-name
 Above 100% FPL: You pay $2.40 for generic and $6.00 for
brand-name
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FPL $10,830 a year for singles and $14,570 a year for couples in 2009
No co-pay after reaching $4,350 in out-of-pocket spending
(your co-pays plus Medicare’s extra help)
Beneficiaries who have full Medicaid benefits and reside
in an institution will have no co-payments.
People without Medicaid and
incomes below 135% FPL
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If you do not have Medicaid, your assets are low and
your 2009 income is below $14,620 ($19,670 for
couples):
 You will not have to pay a premium or deductible
(if your plan premium does not exceed the subsidy)
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You will have continuous coverage ( no gap )
You will have a small co-pay for each prescription:
 $2.40 for generic and $6 for brand-name
No co-pays after reaching $4,350 in out-of-pocket
spending
People without Medicaid and
incomes below 150% FPL
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If you do not have Medicaid, your assets
are low and your 2009 income is below
$16,245 ($21,855 for couples) you will pay:
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Sliding scale monthly premium
Up to a $60 yearly deductible
Continuous coverage prior to reaching the $4,350
in out-of-pocket spending
Coinsurance of 15% up to the out-of-pocket limit
($4,350)
Co-payment of $2.40 and $6.00, respectively,
beyond the out-of-pocket limit.
How do you get extra help?
Some people will get extra help
automatically
 Some will have to apply for extra help
 Everyone will have to choose a Medicare
prescription drug plan to get Medicare
drug coverage
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Who gets extra help automatically?
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If you are enrolled in:
Medicaid
If you are enrolled in:
MedicaidSecurity Income (SSI)
 Supplemental
Supplemental Security Income (SSI)
Savings
Program (MSP)
 MedicareMedicare
Savings
Program
(MSP) such as
such as QI-1, SLMB or QMB
QI-1, SLMB
QMB
You do notor
have
to apply for extra help—
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you get it automatically
You do not have to apply for extra help—
you get it automatically
What happens if you have Medicaid
spend-down?
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You automatically get extra help the first month
you meet your spend-down amount
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Get extra help for the rest of the calendar year
Once eligible for extra help, treated like everyone with
Medicaid
What if you do not automatically get
extra help?
You have to fill out an application
 You can apply through:
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Social Security Administration
Print application
 Online application
http://www.ssa.gov/prescriptionhelp/
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Medicaid
Does it matter where you apply?
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Social Security—generally an easier process
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You can self-attest to your income and assets
You can apply online or mail-in application
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No in-person interview
But will not check to see if you are eligible for other assistance
programs
Medicaid
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Will check to see if you are eligible for other programs that
could help you with your health care costs
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If your assets are higher than limits, but state has no asset test for MSP,
you can get extra help that way
May have more liberal income calculations
You may need to show proof of income and assets
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May require in-person interview
How do you apply through Social
Security?
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Online application available on
http://www.ssa.gov/prescriptionhelp/
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Print applications mailed to people with low
Social Security income
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On a monthly basis
Must use original print application
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No photocopies
At local Social Security office
How should you count your income
and assets?
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Must include income and assets of spouse unless
separated
Earned income: wages, earnings from selfemployment
Unearned income: Social Security, Veterans Benefits,
pension, etc.
Assets: stocks, bonds, mutual funds, retirement
accounts, checking and savings accounts
Certain income and assets will not be counted, so
apply even if it looks like you are over the limits
Can you get help completing your
application?
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Call SSA at 800-772-1213
Talk to a counselor at your local Medicaid office
Call your State Health Insurance assistance program
(SHIP)
Ask a friend or relative for help
 A personal representative can fill out the application
for you
What if you are denied assistance?
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If you apply through Social Security,
request an administrative review from
Social Security.
Choose a telephone hearing or case review.
 You can appoint a personal representative.
 SSA decision can be appealed in federal
court.
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If you apply through Medicaid, you must
appeal through Medicaid.
How do you get drug coverage if
you have Medicaid?
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You must enroll in a Medicare private drug plan
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You will be randomly assigned and enrolled in a
plan if you do not sign up for one
Medicare will send you a letter telling you which
plan it is enrolling you in if you do not sign up for
one on your own
Medicare determines the prospective effective
date
You can change your drug plan once a month
How do you get drug coverage if
you have an MSP or SSI?
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Enroll in a Medicare private drug plan
 You will be randomly assigned and enrolled
in a plan if you do not enroll in one
 Medicare will send you a letter telling you
which plan it is enrolling you in if you do not
sign up for one on your own
 Medicare determines the prospective effective
date
 You can change your drug plan once a month
How do you get drug coverage if
you applied for extra help?
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Once you get notice saying you qualify
for extra help you should select and
enroll in a Medicare private drug plan.
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Medicare will determine when your
coverage begins
Medicare will automatically enroll you in
a plan if you do not enroll in one.
 You can change your drug plan once a
month
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There are other programs
that can help
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If your state has a prescription drug program,
sign up
 If your income is low and you do not have
Medicaid or help paying your Part B premium
through a Medicare Savings Program:
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Find out if you are eligible for a Medicare Savings
Program
If you enroll in an MSP you will not have to apply
for the extra help paying for your Medicare drug
costs
Extra help could affect other
assistance programs
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What you pay for prescription drugs now is
deducted from your income to qualify for:
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Food Stamps
Help paying your rent or public housing (such as
Section 8 Housing)
Help paying your heat (LIHEAP)
If Medicare pays for your prescription drugs,
your income will be higher
 If you are in several of these programs, call
your local social services department and ask
for a counselor who can help you
Timeline: important dates
Mid-May
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Social Security LIS and MSP Outreach
Letter: Informs people who may be
eligible for Medicare Savings Programs
about MSP and the extra help available
for prescription drug plan costs.
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Late August
Social Security - Letter to Review
Eligibility for Extra Help (SSA Form
No. 1026)
Informs people selected for
review that they should see if they
continue to qualify for extra help.
Includes an “Income and Resources
Summary” sheet.
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September
CMS Loss of Deemed Status Letter (GREY Letter)
Informs people that they no longer automatically
qualify for extra help as of January 1.
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Early October
CMS Change in Extra Help Co-payment Letter
(ORANGE Letter) Informs people that they will
continue to automatically qualify for extra help, but
their co-payment levels will change as of January 1.
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October
Plan LIS Rider By October 31, all people who
qualify for the LIS will get an LIS rider from their plan
telling them how much subsidy they will get in the new
year towards their Part D premium, deductible, and
copayments.
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Late October/ Early November
CMS LIS Choosers Letter (TAN Letter) Informs LIS
beneficiaries who chose a plan on their own that their
plan’s premium is rising above the regional LIS
premium subsidy amount, and they will be responsible
for paying a portion of their plan’s premium unless
they join a new plan.
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Late October/Early November
CMS Reassignment Letter (BLUE Letter) Informs
people that their current plan is leaving the Medicare
Program and they will be reassigned to a new plan
effective January 1, unless they join a new plan on
their own by December 31.
Late October/ Early November
CMS Reassignment Letter (BLUE Letter) Informs
auto-enrollees that because their plan’s premiums are
increasing above the regional LIS premium subsidy
amount, they will be reassigned to a new plan effective
January 1, unless they join a new plan on their own by
December 31.
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November
Social Security Part B Income-Related
Premium Adjustment Notice - Tells higherincome consumers about income-related Part
B premium adjustments.
 November
Social Security LIS Redetermination
Decision Letter Begins - Social Security
begins mailing decision letters about LIS
eligibility for the coming year.
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Late November
Social Security LIS and MSP Outreach Letter (Form
SSA-L441) Informs people who may be eligible for
QDWI about the Medicare Savings Programs and the
extra help available for Medicare prescription drug
plan costs.
Daily - ongoing CMS Deemed Status Letter (Pub
No. 11166) (PURPLE Letter beginning in Sept/Oct)
Informs people that they will automatically get extra
help, including people 1) with Medicare and Medicaid,
2) in Medicare Savings Program, and 3) who receive
Supplemental Security Income (SSI) benefits.
Timeline: important dates
November 15 to December 31st
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Annual enrollment period for Medicare
drug benefit.
January 1st
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Medicare drug benefits begin.
Things to remember
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Getting extra help is a two-step process:
1. Qualify for extra help (automatically or by applying)
2. Enroll in a Medicare private drug plan
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People with Medicare and Medicaid
(including spend-down) started getting their
drugs through Medicare January 1, 2006
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You can apply for extra help through Social
Security or your local Medicaid office
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Generally, applying through Social Security will be
easier
Any Questions?