PA Behavioral Health & Aging Coalition

Transcription

1 PA Behavioral Health & Aging Coalition The Pennsylvania Behavioral Health and Aging Coalition (PBHAC) is a statewide coalition of individuals and organizations concerned about the unmet mental health and substance abuse needs of older adults across the Commonwealth. Formed in 1999 as a statewide coalition of individuals and organizations concerned about the mental health and substance use needs of older adults across the Commonwealth Primary Role: Advocate for changes that will improve services for older adults with mental health or substance use disorders 1

2 PA Behavioral Health & Aging Coalition What we do: Outreach/education Medicare counseling specific to behavioral health prescription medications Serve on statewide advisory committees Upcoming Training Topics: Aging, Mental Health and Chronic Illness Senior Bullying Seminar A Simulation of Hearing Distressing Voices Mental Health First Aid PA Behavioral Health (BHC) Began as a joint initiative in 2008 between the Pennsylvania Department of Aging APPRISE Program and the Behavioral Health Community (Mental Illness and Substance Use Disorders) Ensures individuals living with mental health issues have appropriate access to the APPRISE network and other CMS (Centers for Medicare and Medicaid Services) programs. Incorporates both the over and under 65 year old population Provides 1:1 counseling to beneficiaries, their families, and health professionals on CMS services Provides trainings, webinars and outreach events to the entire state 2

3 What is the APPRISE Program? Each state has a SHIP program (State Health Insurance Program). In Pennsylvania, this program is called APPRISE. APPRISE is a free health insurance counseling program designed to help older Pennsylvanians with Medicare. Counselors are specially trained staff and volunteers who can answer your questions about Medicare and provide you with objective, easy-to-understand information about Medicare, Medicare Supplemental Insurance, Medicaid, and Long-Term Care Insurance. APPRISE counseling sites are located in the offices of Pennsylvania s 52 Area Agencies on Aging. The PA Behavioral Health (BHC) is an APPRISE program that is statewide, specifically addressing the needs of the Behavioral Health Community BHC Outreach 2015 BHC is currently planning for Summer/Fall 2015 and would like to increase in-house trainings to consumer groups across the state. BHC is always available to provide Medicare trainings to professionals across the state. By working with all groups, we CAN provide help to the most at risk populations. BHC is willing to travel to provide education and outreach trainings please contact Corey Peterson, Program Director corey@olderpa.org 3

4 Our Staff Rebecca May-Cole, MPA - Executive Director ext Rebecca@olderpa.org Linda Shumaker, RN, MA - Outreach Coordinator Linda@olderpa.org Corey Peterson, MPA - Program Director-Behavioral Health ext Corey@olderpa.org Sarah Bowser, MA - Training Coordinator ext Sarah@olderpa.org What to Expect Today A General Background on Social Security Programs, specifically Social Security Disability Benefits (SSDI) Definitions and Concepts associated with Social Security Disability Preparing, Applying and Qualifying for Social Security Disability SSDI & Medicare: Overview and Timetable Medicare Benefits and Explanations for SSDI Beneficiaries 4

5 FIRST! SOCIAL SECURITY Many people, especially those under 65, do not realize that to receive Medicare you have to be eligible for Social Security. Your Social Security Benefits can be a result of retirement, disability, or other circumstances; However each Social Security program has its own set of guidelines and rules that dictate when Medicare benefits begin. Social Security Programs Include: Retirement Benefits, Disability Benefits, Dependent Benefits, Survivor benefits. For many people qualifying for SSDI the process to receive Medicare takes up to 29 months. General Rule: To receive Medicare you have to start with Social Security. Visit My Social Security Account Valuable source of information Get your benefit verification letter (if eligible) Check your benefit and payment information Review your earnings record Estimate your retirement and disability benefits Many People Do Not Even Realize this Exists Visit the Website and learn how to direct people to it 5

6 Social Security Defined A series of connected programs, each with its own set of rules and payment schedules. Based on lifetime Earning Work Credits (see following slide) Benefits are paid to a retired or disabled worker, or to the worker s dependent or surviving family based on the workers average wages, salary, or self-employment income from work covered by Social Security Four Basic categories of Social Security benefits are paid based upon this record of your earnings: retirement, disability, dependents, and survivors benefits. Four Social Security Programs Retirement Benefits-Can receive as early as 62, typically at 65, income based. Dependents Benefits-married to a retired or disabled worker who qualifies for Social Security retirement or disability benefits Survivors Benefits-Surviving spouses of a worker who qualified for Social security retirement or disability, along with minor or disabled children DISABILITY-Our Discussion Today 6

7 Social Security Programs for People With Disabilities Federal programs provide cash benefits for people with disabilities Social Security Disability Insurance Supplemental Security Income Administered by Social Security Programs don t provide cash benefits for people with partial or short-term disability Social Security Disability: Background People with disabilities The fastest-growing Medicare population group About 17 percent of Medicare beneficiaries Approximately 9 million have Part A and/or Part B Are often uninsured before qualifying for Medicare May qualify for both Medicare and Medicaid Studies show that a 20-year-old worker has a 3-in-10 chance of becoming disabled before reaching retirement age. 7

8 What s Social Security Disability Insurance (SSDI)? SSDI pays cash benefits if you meet the Social Security (SSA) definition of disability To you and certain members of your family Cash benefit amount is based on average lifetime earnings and work credits Who Can Get Social Security Disability Insurance? Social Security pays benefits to people who cannot work because they have a medical condition that is expected to last at least one year or result in death. Federal law requires this very strict definition of disability. While some programs give money to people with partial disability or short-term disability, Social Security does not. Certain members of your family may qualify for benefits based on your work. They include: Your spouse, if he or she is age 62 or older; Your spouse, at any age if he or she is caring for a child of yours who is younger than age 16 or disabled; Your unmarried child, including an adopted child, or, in some cases, a stepchild or grandchild. The child must be younger than age 18 or younger than 19 if in elementary or secondary school full time; and Your unmarried child, age 18 or older, if he or she has a disability that started before age 22. (The child s disability also must meet the definition of disability for adults.) 8

9 Who Can Get Social Security Disability Insurance? Worker Spouse* Child You must ve paid enough into Social Security to qualify At 62 or older At any age if you re caring for child who s under 16 or disabled At 50 if you re a disabled widow(er) Not married and under 18 (under 19 if still in high school) Not married and disabled before 22 *Divorced spouses may qualify How Social Security Defines Disability Medical (physical or mental) condition or combination of impairments Prevents substantial work for at least 12 months or Expected to result in death Considers age, education, and work experience To qualify for Medicare based on a disability Must meet Social Security definition of disability 9

10 Applying for Disability Benefits To apply for disability benefits, you ll need Social Security number Proof of age Health care provider information Medical records Work history Most recent W-2 or self-employment tax return Don t wait to apply Even if you re still gathering information How to Apply for Disability Benefits Visit socialsecurity.gov By phone Call (TTY ) to make an appointment to file your claim by phone In person Call (TTY ) to make an appointment to file your claim at your local Social Security office Average processing time is 4 months 10

11 Process for Determining Disability Social Security uses a 5-step process to decide if you re disabled Are you working? Is your medical condition severe? Is your medical condition on the List of Impairments? Can you do the work you did before? Can you do any other type of work? How the Decision is Made Social Secuirity uses a five-step process to decide if you are disabled: 1. Are you working? If you are working and your earnings average more than a certain amount each month, we generally will not consider you disabled. The amount changes each year. For the current figure. If you are not working, or your monthly earnings average the current amount or less, the state agency then looks at your medical condition. 2. Is your medical condition severe? For the state agency to decide that you are disabled, your medical condition must significantly limit your ability to do basic work activities such as walking, sitting and remembering for at least one year. If your medical condition is not that severe, the state agency will not consider you disabled. If your condition is that severe, the state agency goes on to step three. 3. Is your medical condition on the List of Impairments? The state agency has a List of Impairments that describes medical conditions that are considered so severe that they automatically mean that you are disabled as defined by law. If your condition (or combination of medical conditions) is not on this list, the state agency looks to see if your condition is as severe as a condition that is on the list. If the severity of your medical condition meets or equals that of a listed impairment, the state agency will decide that you are disabled. If it does not, the state agency goes on to step four. 11

12 How the Decision is Made 4. Can you do the work you did before? At this step, the state agency decides if your medical condition prevents you from being able to do the work you did before. If it does not, the state agency will decide that you are not disabled. If it does, the state agency goes on to step five. 5. Can you do any other type of work? If you cannot do the work you did in the past, the state agency looks to see if you would be able to do other work. It evaluates your medical condition, your age, education, past work experience and any skills you may have that could be used to do other work. If you cannot do other work, the state agency will decide that you are disabled. If you can do other work, the state agency will decide that Qualifying for Social Security Disability Insurance You must meet two different earnings tests Recent work test based on your age at the time you became disabled Duration of work test to show you worked long enough under Social Security Tests are based on how many credits you ve earned Also called working credits or quarters of coverage In 2015, you get one credit for each $1,220 of earnings Up to a maximum of four credits per year 12

13 Social Security Work Credits To receive any kind of Social Security benefit retirement, disability, dependents or survivors the person on who s work record the benefit is claimed must have earned enough lifetime work credits. A work credit for 2015 is equal to $1,220 per credit of earned income. You can earn four work credits per year. Work Credits to Receive SSDI 13

14 Disability Decision You ll get a letter when Social Security makes a decision on your claim If your application is approved, the letter will show Your benefit amount Your payment start date If your application isn t approved, the letter will show The reason(s) for denial How to appeal if you disagree with the decision Estimated Disability Benefits for 2015 Average Annual Lifetime Income in Current Dollars Monthly Benefits $10,000 to $20,000 $550-$825 (Individual) $935-$1,150 (Couple/Parent/Child) $20,000 to $30,000 $770-$1,100 (Individual) $1,210-$1,650 (Couple/Parent/Child) $30,000 to $40,000 $1,100-$1,980(Individual) $1,350-$2,530(Couple/Parent/Child) $40,000 and up $1,500-$2,200(Individual) $1,800-$2,700(Couple/Parent/Child) 14

15 Average Monthly Income for Disabled Individuals Average for Disabled Individual: $1,148 Average for Disabled Individual plus spouse and children: $1,943 Maximum monthly payment for Disabled Individual: $2,642 Compassionate Allowances (CAL) A way to expedite processing of SSDI and SSI disability claims for applicants with severe medical conditions It s not a separate program from SSDI/SSI If your medical condition is on the CAL list, your SSDI/SSI application is expedited You may get decision within weeks instead of months Examples: inflammatory breast cancer, pancreatic cancer, Huntington disease 15

16 Waiting Period for Social Security Disability Insurance (SSDI) There s a 5-month waiting period from the time disability began until SSDI benefits begin Except people eligible for childhood disability benefits Some people who were previously entitled to disability benefits (in the past 5 years) There s a 24 month wait for Medicare Benefits after qualifying for Social Security Disability (Totals 29 Months) Understanding the Different Parts of Medicare 16

17 What is Medicare? Who qualifies? A health insurance program administered by Centers for Medicare & Medicaid Services (CMS) To Qualify a person must be: 65 years of age and older Under age 65 who have been on Social Security Disability (SSDI) for two years (29 Months) People with End-Stage Renal Disease (ESRD) or ALS (Amyotrophic Lateral Sclerosis or Lou Gehrig s Disease ) 17

18 2015 Estimated Medicare Beneficiaries (By % or 3.3 million Pennsylvanians will be aged 60 and over) The Four Parts of Medicare Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans (like HMOs and PPOs) This includes Part A, Part B, & sometimes Part D Part D Medicare Prescriptio n Drug Coverage 18

19 Medicare Parts Part A Part B Inpatient hospital care Skilled nursing care Home health care (some) Hospice care Doctors services and outpatient care Preventive services Diagnostic tests Ambulance Services (Limited, medically necessary) Durable medical equipment Part C 2 options: MA or Medigap Medicare Advantage Plan (HMO, PPO) Bundled benefits (administers Parts A, B, and usually D) Medigap: covers remaining 20% (after Medicare covers 80%) Part D Outpatient prescription drugs How do the Parts Fit? Part B +Part C (Outpatient + Medicare Advantage Plan or Medigap + Part D) Part A (Hospital) Medicare Part B + Part D (Outpatient + Prescription coverage) *Part B (Outpatient) Part D (prescription coverage) 19

20 Medicare Part A: Inpatient Coverage Most people receive Part A premium free as a result of their payment of the Medicare tax while employed (Must have earned 40 working credits in a lifetime, each credit is equal to $1,220. Basically, ten years of employment earning at minimum $4,800 per year) People with less than 10 years of Medicarecovered employment Can still get Part A (Special Programs can cover premiums) Will pay a premium based on the number of quarters that they paid FICA Medicare Part B: Outpatient Coverage Monthly Part B Premiums for 2014 File individual tax return Less than or equal to $85,000 Greater than $85,000 and less than or equal to $107,000 Greater than $107,000 and less than or equal to $160,000 Greater than $160,000 and less than or equal to $214,000 File joint tax return Less than or equal to $170,000 Greater than $170,000 and less than or equal to $214,000 Greater than $214,000 and less than or equal to $320,000 Greater than $320,000 and less than or equal to $428,000 Income-related monthly adjustment amount Total monthly Part B premium amount $0.00 $ $42.00 $ $ $ $ $ Greater than $214,000 Greater than $428,000 $ $

21 Enrolling in Medicare Part B Initial Enrollment Period (IEP) 7 months starting 3 months before month of qualifying event (Example: 65 th birthday) General Enrollment Period (GEP) January 1 through March 31 each year Coverage effective July 1 Premium penalty (Part B specific) 10% for each 12-month period eligible but not enrolled (Example: 3 years of non-enrollment = 30% penalty on Part B premium) Paid for as long as the person has Part B Enrolling in Medicare Part B-Employer or Union Group Coverage Some people can delay enrolling in Part B with no penalty If covered under employer or union group health plan through active employment (self) or through a spouse Will get a Special Enrollment Period (SEP) Sign up within 8 months after coverage ends 21

22 Part C: Option 1 of 2-Medigap Health insurance policy Sold by private insurance companies Covers gaps in the Original Medicare Plan Deductibles, coinsurance, copayments Does not work with Medicare Advantage Plans Does not cover outpatient prescription medications People can buy a Medigap policy: Within 6 months of enrolling in Part B If they lose certain kinds of health coverage Through no fault of their own Losing Medicaid coverage is not a qualifying event Part C: Option 2 of 2-Medicare Advantage Plan Beneficiaries can obtain their Medicare covered benefits through a Medicare Advantage Plan These plans may offer coverage for additional services beyond Part A and B coverage These plans may help with Medicare costsharing These plans may or may not include a Part D prescription benefit 22

23 Medicare Advantage Plans (Part C) Health Maintenance Organization (HMO) Plans Network Requires referrals Preferred Provider Organization (PPO) Plans Regional PPOs Eligibility for Medicare Part C Live in plan s service area Enrolled in Medicare Part A and Part B Pay monthly premium to plan (if any) Don t have End Stage Renal Disease (ESRD) at time of enrollment 23

24 Medicare Prescription Drug Coverage (a.k.a. Medicare Part D) Available to all people with Medicare Part A or Part B or both Provided through Medicare Prescription Drug Plans (PDPs) Medicare Advantage Plans (MA-PDs) Some employers and unions Access to Part D Covered Drugs Plans can manage access to covered drugs Tiers Prior authorization Step therapy Quantity limits Plans must have processes in place Members must be provided all prescription medications determined to be medically necessary Request coverage determinations and appeals 24

25 Part D Coverage Part D Plan formularies must include drugs included in these categories: Cancer medications HIV/AIDS treatments Antidepressants Antipsychotic medications (may have high copays) Anticonvulsive treatments For epilepsy and other conditions Immunosuppressants Benzodiazepines Barbiturates The Doughnut Hole Most Medicare drug plans have a Coverage Gap, know as the Doughnut Hole. Coverage Gap begins when the total yearly cost (what plan pays and what beneficiary pays) reaches $2,960. When coverage gap is reached beneficiary will pay 45% of the plan s cost for brand named and 65% for the generic drugs. The coverage gap ends at $4,700, then beneficiary will be in Catastrophic Coverage. They will pay 5% of drug cost or $2.65 for generic and $6.60 for brand name (which ever is lowest. 25

26 Improved Coverage Gap Year What Beneficiary Pays for Brand Name Rx in Coverage Gap What Beneficiary Pays for Generics in Coverage Gap % 86% % 79% % 72% % 65% % 58% % 51% % 44% % 37% % 25% Late Enrollment for Part D (Rx Coverage) People who delay enrollment may pay a penalty Additional 1% of plan premium for every month eligible but not enrolled Must pay the penalty as long as enrolled in a Medicare drug plan 26

27 Medicare: Two Tracks Medicare Part A Medicare Part B Medicare Part D Medigap Supplements Medicare Part A Medicare Part B Medicare Part D All 3 Parts Can be Rolled into One this is know as Medicare Part C or Medicare Advantage Enrollment Periods Initial Enrollment Period (IEP) 7 months Starts 3 months before month, month of and 3 months after eligibility begins Annual Enrollment Period (AEP) October 15-December 7 Can join, drop, or switch coverage Effective January 1 of following year Special Enrollment Period (SEP) Those who experience triggering event (i.e. entering/leaving nursing home) 27

28 Medicare: Original Medicare Medicare Part A (Usually Free based on Work History) Medicare Part B (monthly premium) plus Annual Deductible & 20% Cost Sharing Medicare Part D (avg monthly premium 33.00) Medigap Gap-Monthly Premium (Helps cover extra Costs) PLEASE Note: Medicare Part A (charges $ 1,260 for days 1-60; $304 for days 61-90; $608 for days 90 and above for inpatient hospitalization) Medicare: Medicare Advantage Medicare Part A-Free depending on work history Medicare Part B-Will stay pay $ per month Medicare Part D-Most Medicare Advantage plans will include prescription Drug Coverage Most Medicare Advantage plans (Part C) will also include a monthly premium Please Note that many Medicare Advantage plans will significantly reduce inpatient hospital stays, as well include set co-pays for doctor visits and may or may not have annual deductibles for Part B coverage 28

29 Medicare Options: The Differences Original Medicare Part A-Premium Free Part B-$ month Part D-Stand alone; premium average is $33.12 Medigap option at a cost to reduce costs for inpatient stays and Part B deductibles and copays Medicare Advantage Part A-Premium Free Part B with set co-pays for doctor visits Part D-included in plan, may cost an additional premium Fees for inpatient stays reduced, as well as Part B co-pays and include some vision, dental, & Hearing Coverage Plan Choices for People With Disabilities All Medicare plans are available Original Medicare Medicare Advantage Plans Other Medicare plans Medicare Prescription Drug Plans May be restrictions on your eligibility for Medigap May not be available if under 65 (check with state) People with End-Stage Renal Disease have more limited choices 29

30 Medicaid: An Overview (2,417,000 Enrollees in PA) Medicaid Basics (Medical Assistance) State & federally funded health insurance for low-income, elderly and people with disabilities (also known as Medicaid or MA) Must be categorically, income & asset/resource eligible to qualify Medical Assistance is always payer of last resort People with Medicare & Medical Assistance are Dual eligibles 30

31 How Are Medicare and Medicaid Different? MEDICARE MEDICAID National program that is consistent across the country Administered by the federal government Health insurance for people 65 or over, with certain disabilities, or with End- Stage Renal Disease (ESRD) Nation s primary payer of inpatient hospital services for the elderly and people with ESRD Statewide programs that vary among states Administered by state governments within federal rules (federal/state partnership) Health insurance for people based on need; financial and non-financial requirements Nation s primary public payer of mental health and long-term care services (nursing home Medicaid Administration Federal/state partnership Jointly financed entitlement program Federally established national guidelines States receive federal matching funds Known as the Federal Medical Assistance Percentage o Used to calculate amount of federal share of state expenditures o Varies from state to state o Based on state per capita income 31

32 State Medicaid Administration Within broad federal guidelines, each state Develops its own programs Develops and operates its own plan Establishes its own eligibility standards Determines the type, amount, duration and scope of services Sets the rate of payment for services Partners with CMS to administer its program States may change eligibility, services, and reimbursement during the year The Single State Medicaid Agency Administers the Medicaid State Plan May delegate some administrative functions Local office names may vary Social Services Public Assistance Human Services 32

33 Medicaid Eligibility Eligibility tied to one of the main eligibility groups under the federal Medicaid law Pregnant women Children People with disabilities Seniors Financial and non-financial requirements Mandatory Medicaid State Plan Benefits Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnostic, and Treatment Services Nursing facility services Home health services Physician services Rural Health Clinic services Federally Qualified Health Center services Laboratory and X ray services 33

34 Mandatory Medicaid State Plan Benefits - Continued Family planning services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Freestanding Birth Center services (when licensed or otherwise recognized by the state) Transportation to medical care Tobacco cessation counseling for pregnant women Tobacco cessation Medicaid in Pennsylvania Program Description Medicaid provides payment for health care services on behalf of eligible low-income persons and individuals with limited income and high medical expenses. Payments are made directly to the health care providers for services, medications, and medical supplies. In some cases, persons may qualify for payment of medical services that were provided up to three months before the month in which a Medicaid application was submitted. General Program Requirements In order to qualify for the Medicaid benefit program, you must be a resident of Pennsylvania, a permanent resident for at least five years or a U.S. national or citizen in need of health care/insurance assistance, whose financial situation would be characterized as low income or very low income. If your financial situation is characterized as very low income, you must also be pregnant, have a child(ren) with a disability, or be responsible for children age 18 or younger 34

35 Medicaid in Pennsylvania Your Next Steps The following information will lead you to the next steps to apply for this benefit. Application Process For more information, see the Program Contact Information below. Program Contact Information For questions concerning the Pennsylvania Medicaid program, contact the Welfare Helpline at: TDD number for individuals with hearing impairments To apply for Medicaid, contact the County Assistance Office in the county where you live. Phone numbers and addresses of local offices can be found at the DPW website and in the blue pages of the phone book. You should apply even if you are not sure that you are eligible. Phone numbers and addresses can be found on the Department of Public Welfare's County Assistance Office Contact Information page. Application forms can also be downloaded from the DPW website. You may also apply online at the Compass website. Medicaid in Pennsylvania What is Health Choices? Pennsylvania residents, depending primarily on area of residence in the state, access their Medical Assistance (MA) benefits through either fee-for-service or Medicaid managed care. Most MA recipients in managed care are in a mandatory managed care Health Choices zone. Regardless of their delivery of care system, all recipients receive an ACCESS card. Those in fee-for-service use this ACCESS card as their insurance card. Managed care recipients receive a member card from the HMO of their choice. Occasionally a beneficiary living in a Health Choices area will not have managed care, and some fee-for-service areas also have voluntary managed care options. Services available under Health Choices and feefor-service are not identical. Consumers or providers with questions about services under Health Choices must contact their individual health plan. Consumers or providers with questions about services under fee-for-service must call the MA provider line ( ) or MA consumer line ( ; TDD ). The Department of Public Welfare has a web page with links to its important provider information. 35

36 Medicaid in Pennsylvania Are physical and behavioral health services covered separately? Physical health services are covered by managed care in five Health Choices zones Southeast, Southwest, New West, Lehigh/Capital, and New East. In addition, Health Choices plans are responsible for all medication coverage for physical and behavioral health in Health Choices zones. All behavioral health services are covered under managed care. The managed care provider varies by county. For more information see the DPW website. PA Health Choices: Behavioral Health Managed Care Map 36

37 PA Health Choices: Behavioral Health Managed Care Organizations After locating the Behavioral Health Managed Care organization that serves your region, click below to find contact information for Member Services: Value Behavioral Health (VBH) Community Care Behavioral Health Organization (CCBH) Community Behavioral Healthcare Network of PA (CBHNP) Community Behavioral Health (CBH) Magellan Behavioral Health of PA, Inc. (MBH) *The PBHAC and the BHC does not endorse any organization. This is for informational purposes only Medicare - Medicaid Enrollees Referred to as dual eligibles 9 million nationally Medicaid may partially or fully cover Part A and/or Part B premiums Other Medicare cost sharing Long term care Medicaid benefits provided to dual eligibles are also known as Medicare Savings Programs 37

38 What is a Dual-Eligible People with Medicare and Medicaid Must be Eligible for SSDI cash benefits for 24 months (29 months) or have End Stage Renal Disease to Receive Medicare Can Choose to Receive Traditional Medicare Parts A, B and D, with Medicaid paying the premiums along with some additional coverage. Medicaid coverage will be through the fee for service system (ACCESS Card). Medicare will become primary insurance, with Medicaid becoming secondary insurance Medicaid will no longer cover most prescription drugs (Will need to enroll in Medicare Part D Plan or Medicare Advantage Plan (SNP)) If Beneficiary does not enroll they will automatically be enrolled in a Part D plan Dual Eligible automatically reverie the full amount of Extra Help with Part D Coverage ($1.15/$2.65 for generic; $3.50/$6.60 for brand name) Dual-Eligibles: A Glance (Over 400,000 in PA) 38

39 Special Needs Plans (SNPs) Special because they are allowed to limit their enrollment to certain Medicare beneficiaries: Full dual eligibles Nursing home residents Persons with certain chronic conditions (Example: ESRD) Similar to Medicare Advantage Plans: must use providers in network Always include Part D drug coverage Most Medicare Advantage Health Plans also have Medicare SNPs (can get confusing) MAWD: Medical Assistance for Workers with Disabilities State health insurance program for individuals who have chronic health problems and are working Good option for low to middle income individuals who need health insurance Compared to other MA programs, MAWD has high income and resource limits. MAWD has Flexible work and Disability Requirements 39

40 MAWD: Qualifying Between 16 & 65 years of Age Disabled Working (Defined as being paid for a service. Can be by a private party or through a paystub) Income under 250% FPL $10,000 or less in Resources Can be receiving SSDI; If under $720 will not effect SSDI benefits Costs %5 on monthly income (Individual Income -$20) Medicare Part B premium assistance Low Income Subsidy/Extra Help PA Patient Assistance Program Clearinghouse (PAP) Medical Assistance RX Outreach; Manufacturer Programs 40

41 Medicare Savings Program (MSP) Medicare Savings Programs Help from Medicaid paying Medicare Part B premium QMB (Qualified Medicare Beneficiary) SLMB (Specified Low Income Beneficiary) QI-1 (Qualified Individual) For people with limited income and resources Medicare Savings Program Guidelines (Guidelines May Change Yearly) Program 2014 Single Resource Limit $7, Couple Resource Limit $10,750 QMB $973/month $1311/month SLMB $1167/month $1573/month QI-1 $1313/month $1770/month **Figures include $20 unearned income disregard 41

42 Who Can Qualify for a Medicare Savings Program? Medicare Savings Program Qualified Medicare Beneficiary (QMB) Specified Low- Income Medicare Beneficiary (SLMB) Individual Monthly Income Limit (2014) Married Couple Monthly Income Limit (2014) Helps Pay Your $993 $1,331 Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments) $1,187 $1,593 Part B premiums only Qualifying Individual (QI) Qualified Disabled & Working Individuals (QDWI) $1,333 $1,790 Part B premiums only $3,975 $5,329 Part A premiums only Qualified Medicare Beneficiaries (QMB) Qualified Medicare Beneficiaries (QMB) Pays for your Medicare Part A premium. Part B premiums, Medicare deductibles and coinsurance (copayment) costs. Monthly income cannot exceed 100% of the Federal Poverty Income Guideline. Resource limits are higher than most other Medical Assistance programs Qualified Medicare Beneficiaries also may be eligible for full Medical Assistance benefits 42

43 Specified Low Income Medicare Beneficiaries (SLMB) Specified Low Income Medicare Beneficiaries (SLMB) Pays your Medicare Part B premium. Monthly income cannot exceed 120% of the Federal Poverty Income Guideline. Resource limits are higher than most other medical programs. Contact the local CAO or Customer Service Center (CSC) at for current limits. Qualified Individuals (QI) benefits Qualified Individuals (QI) benefits Pays your Medicare Part B premium. Monthly income cannot exceed 135% of the Federal Poverty Income Guideline. Resource limits are higher than most other Medical Assistance programs. Contact the local CAO or Customer Service Center (CSC) at for current limits. 43

44 Paying for Medicare Part B Monthly Part B Premiums for 2014 File individual tax return Less than or equal to $85,000 Greater than $85,000 and less than or equal to $107,000 Greater than $107,000 and less than or equal to $160,000 Greater than $160,000 and less than or equal to $214,000 File joint tax return Less than or equal to $170,000 Greater than $170,000 and less than or equal to $214,000 Greater than $214,000 and less than or equal to $320,000 Greater than $320,000 and less than or equal to $428,000 Income-related monthly adjustment amount Total monthly Part B premium amount $0.00 $ $42.00 $ $ $ $ $ Greater than $214,000 Greater than $428,000 $ $ MSP: How is it calculated? If a beneficiary is below the Resource Limits to meet MSP criteria, we must then look at monthly income. Income can be Unearned (SSI income) or Earned (through current employer. Unearned Income: disregard $20 of SSI income Earned Income: disregard $65 dollars, then divide gross monthly wages in half Example: Mary gets 720 dollars a month through SSDI benefits, she also works 10 hours a week and earns $565 a month in earned income. To Calculate (720-20=$700); (565-65=500/2=$250) Mary s Monthly Income Would Be $950 per month; She would Qualify as a QMB 44

45 Applying for Medicare Savings Programs If you might qualify for a Medicare Savings Program Review your local guidelines Contact local agencies for more information Collect your personal documents Complete an application with your state s Medicaid program It may be called the State Medical Assistance office, or may have another name What s Extra Help? Known as the LIS Program Help paying Part D prescription drug costs Social Security or your state makes a determination These groups automatically qualify People with Medicare and full Medicaid Supplemental Security Income only Medicare Savings Programs All other people with Medicare must apply to get Extra Help You can apply online, by phone, or by mail 45

46 Extra Help With Drug Costs People with lowest income and resources get full LIS (Low Income Subsidy): Pay no premiums or deductibles Have no donut hole Have small co-payments* Those with slightly higher income and resources get partial LIS: Have a reduced premium and deductible Have no donut hole Pay a little more out of pocket * Those with full subsidy living in SNFs have no copays Eligibility for Extra Help (LIS) Some people automatically qualify for full LIS including: People with Medicare who get full Medicaid benefits Get help from Medicaid paying Medicare Part B premium Others must apply to Social Security Administration ( and be found eligible for full or partial LIS 46

47 Applying for Extra Help Apply if you might qualify Collect your personal documents Contact these local agencies for more information Social Security State Medical Assistance office Local State Health Insurance Assistance Program (SHIP) office Complete your application What s Covered and programs available 47

48 Mental Health & Hospitalization 190 day lifetime limit (for psychiatric hospitals) Your costs in Original Medicare Days 1 60: $1,216 deductible for each benefit period in 2014 Days 61 90: $304 coinsurance per day Days 91 and beyond: $608 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) 20% of the Medicare-approved amount for mental health services you get from doctors and other providers while you're a hospital inpatient. Partial hospitalization: covered if doctor states individual would otherwise need inpatient hospitalization Medicare covered BH Services Under Medicare Part B, covered services include, but are not limited to: Psychotherapy Patient education regarding diagnosis and treatment Post-hospitalization follow-up Prescription drugs administered during a hospital stay or injected at a doctor s office Methadone may be covered if provided to hospital inpatients but not provided in outpatient clinics. Outpatient prescription drugs covered under Part D Part D plans must cover medically necessary drugs to treat drug abuse either through a formulary (list of covered drugs) or through the exception process Note: plans cannot cover methadone to treat substance abuse, but can cover methadone for other conditions, such as pain. 48

49 Outpatient Mental Health Care- Original Medicare only After Part B Deductible To diagnose a condition: 20% copay of Medicare approved amount For outpatient treatment such as: psychotherapy In this year Beneficiary will pay % *Medicare Advantage Plans-must contact plan for copay amounts and participating providers Annual Depression Screening Screening in primary care setting Various screening tools available at the discretion of the clinician (Geriatric Depression Scale, PHQ-2, PHQ-9, etc.) 49

50 Resources nce/aidswaiverprogram/specialpharmaceuticalbenefitsprogra m/s_