Medicaid & Medicare Presented: May 7, 2013 Intersections Conference Radisson Paper Valley, Appleton, WI Presented by Employment Resources, Inc. Stephanie Drum (drum@eri-wi.org) Megan Koch (koch@eri-wi.org) www.eri-wi.org Medicaid Elderly, Blind & Disabled (EBD) Medicaid The federal government requires Medicaid (also called Medical Assistance, MA, and sometimes Title 19) programs for certain populations: low income children & their caretakers, pregnant women, the elderly, and people with disabilities. The focus of this handout is the programs in Wisconsin specific for individuals with disabilities and those ages 65+. These are called Elderly, Blind and Disabled (EBD) Medicaid programs. An individual or couple must meet both non-financial and financial criteria to be eligible for EBD Medicaid programs. There are certain non-financial eligibility criteria that apply to all EBD Medicaid programs. These criteria state that an individual/couple must: Have a disability determination or be age 65 or older, Be a resident of the State of Wisconsin, Be a US citizen or qualifying immigrant, and Pay any premiums or cost shares that apply. Contacts & Information Information about the general non-financial eligibility criteria for the all EBD Medicaid programs can be found in the Medicaid Eligibility Handbook (MEH) starting in chapter 4. http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm Wisconsin Consortia System: (Income maintenance agencies) http://www.dhs.wisconsin.gov/forwardhealth/imagency/index.htm Access: (Applications, check benefits and report changes) www.access.wisconsin.gov 1
Note: Each of the EBD Medicaid subprograms may have additional rules about non-financial eligibility criteria. This information can be found in the handbook under each specific program. Categorically Needy Medicaid Categorically Needy Medicaid, or Cat Needy Medicaid, is an EBD Medicaid program for people that don t qualify for SSI, but still have very limited income. An individual must meet all of the general Non-Financial Eligibility requirements for EBD Medicaid to be eligible for Cat Needy Medicaid. The asset limits for Categorically Needy Medicaid are $2,000 for an individual, and $3,000 for a couple. Financially eligibility for Categorically Needy Medicaid is based on an individual/couple s countable income and current living expenses. Individuals/couples on Categorically Needy Medicaid do not pay any premiums/cost shares for their Medicaid coverage. Medicaid Deductible The Medicaid Deductible program is an EBD Medicaid program for people who have income above the income limits for SSI and the Categorically Needy Medicaid program. An individual must meet all of the general Non-Financial Eligibility requirements for EBD Medicaid to be eligible for the Medicaid Deductible. The asset limits for the Medicaid Deductible program are $2,000 for an individual and $3,000 for a couple. To be eligible for Medicaid through the Medicaid Deductible program, an individual/couple must meet the income test or meet a 6-month deductible. Deductibles can get very high, and often times, it is a good idea to look into other Medicaid options, such as the Medicaid Purchase Plan (MAPP). An individual/couple must meet their 6-month deductible before they are eligible for Medicaid. The expenses that can and can t be used to meet the deductible are in the Medicaid Eligibility Handbook (MEH) 24.7. 2
Special Status Medicaid DAC Disabled Adult Child (DAC)* Special Status is a Medicaid program for people who have SSI terminated because of an initial DAC payment or an increase in a DAC payment. This type of Medicaid is premium and deductible free to individuals. Someone who is eligible for DAC Special Status Medicaid will automatically be eligible for Qualified Medicare Beneficiary (QMB). A person must receive a DAC payment from Social Security to be eligible for this type of Medicaid. Someone is not automatically eligible for DAC Medicaid because they receive a DAC benefit from Social Security. Someone must be financially tested to be eligible for DAC Special Status Medicaid. *DAC is also known as Childhood Disability Benefit (CDB). This benefit is a Social Security Title II benefit provided to individuals who have a disability which occurred prior to the age of 22. Individuals must be at least 18 years old to receive this benefit. Also, the individual must have a parent who is insured and receiving a Title II benefit or is deceased. Special Status Medicaid 503 503 Special Status is a Medicaid program for people who would be eligible for SSI and SSI related Medicaid if the Cost of Living Adjustments (COLA) provided by Social Security each year were disregarded from their income. This type of Medicaid is premium and deductible free to individuals. Someone who is eligible for 503 Special Status Medicaid will automatically be eligible for Qualified Medicare Beneficiary (QMB). A person must receive a Title II benefit from Social Security to be eligible for this type of Medicaid. A person must have received SSI in the past and had concurrent benefits (SSI and Title II benefit at the same time). Someone must be financially tested to be eligible for 503 Special Status Medicaid. 3
Medicaid Purchase Plan (MAPP) The Medicaid Purchase Plan (MAPP) program is for individuals who have disabilities. It is a program that offers people with disabilities who are working or interested in working the opportunity to buy health care coverage through the Wisconsin Medicaid Program. Depending on the individual s income, a premium payment may be required to receive coverage through the MAPP program. (MEH 26) The asset limit for MAPP for the individual is $15,000. People enrolled in MAPP can save more money in something called an Independence Account. Medicare Savings Programs The Medicare program has certain premiums, deductibles and co-insurance associated with coverage. This is sometimes called Medicare cost-sharing. Medicare Savings Programs (MSP) help cover some of the Medicare cost-sharing expenses. These programs are also sometimes called Medicare Buy-In Programs or Medicare Premium Assistance. There are three main eligibility groups for MSP in Wisconsin: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Specified Low-Income Medicare Beneficiary Plus (SLMB+). The asset limits for the MSP are: Individual (2013) Couple (2013) $7,080 $10,620 QMB has a countable income limit of 100% of the current Federal Poverty Level (FPL). Individuals receiving SSI-related Medicaid or a Special Status Medicaid program are automatically eligible for QMB (regardless of countable income). o QMB pays all Medicare Part A and B premiums, deductibles, co-insurance. SLMB has a countable income limit of 120% of the current FPL. o SLMB pays only Medicare Part B premiums. SLMB+ has a countable income limit of 135% of the current FPL. Individuals can t be eligible for SLMB+ while enrolled in any other type of Medicaid program. This includes all EBD Medicaid programs (unless someone has an unmet deductible) and BadgerCare Plus. o SLMB+ pays only Medicare Part B premiums. 4
Medicare Medicare is a Federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS). Medicare provides basic coverage for eligible individuals. There are different parts to Medicare discussed below. Citizens and permanent residents of the U.S. become eligible for Medicare under the following conditions: Age 65+ After 24 months of SSDI entitlement o Individuals with ALS will be eligible for Medicare immediately when SSDI entitlement starts o People with End Stage Renal Disease (ESRD) at any age are eligible Contacts: Social Security Offices can provide information about eligibility and current enrollment. Part A Hospital Insurance (HI) Hospital, skilled nursing facility, home health care, hospice No premium Yearly deductible and coinsurance Part B Supplemental Medical Insurance (SMI) $104.50 Premium in 2013 Yearly deductible and coinsurance Part D Prescription Drug Coverage (Prescription Drug Plans, or PDPs) Eligibility: entitled to Part A and/or enrolled in Part B and not incarcerated Many plans to choose from determined by state Premiums differ for each plan Plan have deductibles, co-payments and gaps in coverage (the donut hole ) Low Income Subsidy (LIS) extra help is for those below 150% FPL or enrolled in Medicaid o LIS allows individuals to pick low-cost Part D plans and have no: deductible, premium or gap in coverage. Individuals continue to be responsible for reduced medication co-payments. Medicare Part C Medicare Advantage Plans offers individuals an option to have Medicare differently than they do in Original Medicare. Coverage is included through private insurance companies. All Part A and Part B services are covered, and additional supplemental coverage is often included. Medicare Supplement Plans: These privately operated plans provide additional services that are not provided by original Medicare. Individuals must have Medicare Part A and Part B to enroll in a Supplement. There may be additional costs that are in addition to the original Medicare costs. 5