Transitions from expansion Medicaid to Medicare - PowerPoint Presentation

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Transitions from expansion Medicaid to MedicareSlide2

The Medicare Rights Center is a national, nonprofit

consumer service organization that works to

ensure access to affordable health care for older adults and people with disabilities through

Counseling and advocacy

Educational programs

Public policy initiatives

Medicare Rights CenterSlide3

This toolkit for State Health Insurance Assistance

Programs (SHIPs), Area Agencies on Aging (AAAs),

and Aging and Disability Resource Centers (ADRCs)was made possible by grant funding from theNational Council on Aging.

The National Council on Aging is a respected national leader and trusted partner to help people aged 60+ meet the challenges of aging. They partner with nonprofit organizations, government, and business top provide innovative community programs and services, online help, and advocacy.

National Council on AgingSlide4

Learning objectivesUnderstand expansion Medicaid

Describe possible outcomes for transitioning to Medicare

Identify questions an individual should ask when transitioning to Medicare

Explain Medicare and Medicaid basicsSlide5

Medicare basicsSlide6

Medicare

Federal program that provides health insurance for those 65+, those under 65 receiving Social Security Disability Insurance (SSDI) for a certain amount of time, and those under 65 with kidney failure requiring dialysis or transplant

No income requirementsTwo ways to receive Medicare benefitsTraditional program offered directly through federal governmentPrivate plans that contract with federal government to provide Medicare benefitsOriginal MedicareMedicare AdvantageSlide7

Parts of MedicareMedicare benefits administered in three parts

Part A – Hospital/inpatient benefits

Part B – Doctor/outpatient benefitsPart D – Prescription drug benefit Original Medicare includes Part A and Part BPart D benefits offered through stand-alone prescription drug planWhat happened to Part C?  Medicare Advantage Plans (e.g., HMO, PPO)Way to get Parts A, B, and D through one private planAdministered by private insurance companies that contract with federal governmentNot a separate benefit: everyone with Medicare Advantage still has MedicareSlide8

Medicare eligibility: 65+After turning 65, individual qualifies for Medicare if they

Collect or qualify to collect Social Security or Railroad Retirement benefits

OR are a current U.S. resident and eitherA U.S. citizenOR a permanent resident having lived in the U.S. for five years in a row before applying for Medicare Slide9

Medicare eligibility: Under 65Individual not yet 65 qualifies for Medicare if

They have received Social Security Disability Insurance (SSDI) or Railroad Disability Annuity checks for total disability for at least 24 months  

If they have amyotrophic lateral sclerosis (ALS), there is no waiting period, and they are eligible for Medicare when they start receiving SSDIOR they have End-Stage Renal Disease (ESRD or kidney failure) and they or a family member have enough Medicare work historySlide10

Medicare costs

Cost

Part APart B Part DPremiumMonthly premium for those with fewer than 10 years of Social Security work historyMost people do not pay premium for Part AMonthly premium Monthly premium DeductibleDeductible for inpatient hospital staysAnnual deductibleAnnual deductible, depending on planCopayment and/or coinsuranceDaily coinsurance for inpatient hospital stays after day 60; daily coinsurance for skilled nursing facility (SNF) stay after day 20

20% coinsurance for covered outpatient services

Copayment or coinsurance for covered prescription drugs

Individual with Medicare can generally expect to pay premiums, deductibles, and copayments or coinsurance for covered careSlide11

Medicare Savings Programs (MSPs)Provide help with Medicare costsPay for Part B premium

Depending on program, may provide assistance with Part A premium (if applicable) and other out-of-pocket costs, like copays/coinsurances

Eligibility determined at state levelRules vary significantly among statesStates can count income differentlySome states have higher income limitsStates can have different asset limitsSome states do not count assetsSlide12

Types of MSPsQualifying Individual (QI)Has highest income limit

Pays Part B premium

Specified Low-Income Medicare Beneficiary (SLMB)Has lower income limit than QIPays Part B premiumQualified Medicare Beneficiary (QMB)Has lowest income limitPays Part B premiumPays Part A premium (if applicable)Protects beneficiary from being billed for Medicare cost-sharing amounts (deductibles, coinsurances, copayments)Slide13

Extra HelpFederal program that helps pay deductibles, premiums, copays, and coinsurances for Medicare Part D (prescription drug benefit)

Has federally set income and asset limits

Individuals pay no premium or very low premiumIndividuals pay low copayments for Part D-covered drugsIndividuals enrolled in MSPs will be automatically enrolled in Extra HelpSlide14

Medicaid basicsSlide15

Medicaid

Federal program administered by states

Provides health insurance for individuals who have limited income and assets and Are 65 years or olderHave certain disabilitiesAre blindNeed long-term careAre in a medically needy categoryAre former foster care youthMedicaid does not have a monthly premiumIndividual may pay small deductible or copayment for careSlide16

Medicare and MedicaidIndividual who has Medicaid and Medicaid is k

nown as a

dual- eligibleMedicare pays first for health care, and Medicaid pays after all other insurance has paidIndividual should see providers who accept both Medicare and Medicaid Will have low or no out-of-pocket costsMost people with Medicare have traditional MedicaidAlso known as Medicaid for the aged, blind, and disabled (ABD Medicaid)Slide17

Expansion MedicaidSlide18

Expansion Medicaid basicsUnder Affordable Care Act (ACA), some states expanded Medicaid income limits and categories of people who can receive Medicaid benefits

Expansion Medicaid covers individuals with incomes below 138% of federal poverty level (FPL) who are

Childless adults ages 19-64 (also called Adult Group)PregnantIncome limits are higher for pregnant individualsChildren up to age 19 (or 21, depending on state)Parent and caretaker relativesIndividuals approved for expansion Medicaid may receive benefits for up to a 12-month continuous coverage periodSlide19

Expansion Medicaid financial eligibilityEligibility for expansion Medicaid is based on individual’s

Modified Adjusted Gross Income (MAGI)

MAGI is individual’s taxable income If individual does not file taxes, eligibility rules match those for tax filers to maximum extent possibleSpouses, parents, stepparents, and children living together are included in same householdCertain income not countedVeterans’ benefitsWorkers’ compensationChild supportResources and assets not countedSlide20

Marketplaces and expansion Medicaid

Individual enrolls in expansion Medicaid through state or federal Health Insurance Marketplace

Affordable Care Act created MarketplacesUninsured and under-insured individuals can buy insurance through MarketplacesSome states created their own Marketplace, others use the federal MarketplaceMarketplace may be involved in individual’s transition from expansion Medicaid to MedicareSlide21

Transitions from expansion Medicaid to MedicareSlide22

BackgroundWhen individual becomes eligible for Medicare, they are usually no longer eligible for expansion Medicaid

These individuals should be evaluated to see if they are eligible for traditional Medicaid and a Medicare Savings Program (MSP)

Agencies involved in transition depend on stateMarketplace and local Medicaid office usually involved Screened forSlide23

Expansion Medicaid to Medicare transition process

Individual has expansion Medicaid and becomes eligible for Medicare

Evaluated for traditional MedicaidTiming and agency involved depend on state-specific rulesIndividual may be evaluated for traditional Medicaid as soon as they are Medicare-eligibleIndividual may be evaluated for traditional Medicaid at their expansion Medicaid renewal date 1. 2.Slide24

Evaluation for traditional Medicaid

Individual should receive notice about being evaluated for traditional Medicaid

Notice may come from Marketplace, local Medicaid office, or other agencyIndividual should ask if there is additional paperwork neededOnce individual fills out paperwork, case should be transferred to proper state agency for processingNote: Individual may be able to receive state reimbursement for their Medicare Part B premium while they transition. Rules vary by state, so contact Marketplace or local Medicaid agency to learn more. Slide25

Evaluation for traditional MedicaidRegardless of evaluation status, when individual has expansion Medicaid and becomes Medicare-eligible,

they should enroll in Medicare Parts A and B

Medicare pays primary, and Medicaid pays secondaryIf individual does not enroll in Medicare when first eligible, they may have a late enrollment penalty for delaying enrollmentIndividual may automatically receive Extra Help, which enrolls them in Medicare Part DIf individual is not enrolled in Extra Help, they can apply through Social Security Administration (SSA)Slide26

Possible transition outcomesSlide27

Expansion Medicaid to Medicare transitionsWhen individual becomes Medicare-eligible (thus losing expansion Medicaid) and is evaluated for traditional Medicaid, possible outcomes are

Transition from expansion Medicaid to Medicare with traditional Medicaid and Medicare Savings Program

Transition from expansion Medicaid to Medicare with MSP and without traditional MedicaidTransition from expansion Medicaid to Medicare without traditional Medicaid or an MSPIn limited circumstances, receive Medicare and remain in expansion MedicaidSlide28

Outcome #1

Individual found eligible for traditional Medicaid and MSP

Medicare pays first on claims, Medicaid pays second

Services not covered by Medicare may be covered by Medicaid

MSP pays individual’s Part B premium

Depending on type of MSP, individual may not have to pay Part A premium (if applicable) or Medicare cost-sharing

Transition to Medicare with traditional Medicaid and Medicare Savings ProgramSlide29

Outcome #2

Individual found eligible for MSP only

Income is above traditional Medicaid limit but below MSP limitMedicare may be individual’s only insurance Individual may lose coverage for services that only Medicaid covers (depending on the state), like certain vision and dental care MSP pays individual’s Part B premiumDepending on type of MSP, individual may not have to pay Part A premium (if applicable) or Medicare cost-sharingTransition to Medicare with MSP and without traditional MedicaidSlide30

Outcome #3

Individual found ineligible for MSP and for traditional Medicaid

Medicare may be individual’s only insuranceWill have to pay Part B premium and other Medicare cost-sharingIndividual may lose coverage for services that only Medicaid covers (depending on the state), like certain vision and dental careMay want to consider a Medicare Advantage Plan that includes some coverage for dental and/or vision servicesMay want to consider supplemental coverage to help with cost-sharingTransition to Medicare without MSP or traditional MedicaidSlide31

Outcome #4If individual is parent or caretaker relative, they may be able to stay in expansion Medicaid with Medicare as primary insurance

Individuals in this situation should contact Marketplace or local Medicaid office to learn more

In limited circumstances, transition to Medicare and keep expansion MedicaidSlide32

Questions to ask to help clients transition to MedicareSlide33

When will individual be evaluated for traditional Medicaid and an MSP?

Each state has a different process for transitioning individuals from expansion Medicaid to Medicare. Some states evaluate an individual when they become eligible for Medicare. Others evaluate an individual when their expansion Medicaid needs to be renewed. Knowing the timeline helps individuals keep track of when they can expect their benefits to change.

Questions to ask Marketplace representativeSlide34

Questions to ask Marketplace representative

Does an individual have to actively request or complete any materials in order to be evaluated for traditional Medicaid?

The Marketplace should transfer an individual’s case to their local Medicaid office, which should send the individual all the paperwork they need in order to be evaluated for traditional Medicaid, such as further proof of their income, address, and/or assets. An individual should contact their local Medicaid office with any questions. Slide35

Questions to ask Marketplace representative

Can an individual receive reimbursement for Medicare Part B premiums through their state? If yes, how do they request this?

An individual’s state may reimburse their Part B premium while the state is in the process of evaluating them for traditional Medicaid and an MSP. Reimbursement is different from state to state, but an individual may receive a check each month or receive a direct deposit in their bank account. Slide36

Other questions to considerHow might an individual’s benefits change once they enroll in Medicare?

Individuals found ineligible for traditional Medicaid will no longer have Medicaid benefits. In many cases, Medicare may be the individual’s only health insurance. The individual may lose coverage of services that only Medicaid covers (depending on the state), like certain vision and dental care.

Individuals in this situation may want to consider enrollment in a Medicare Advantage Plan that covers some of the services Medicare does not cover. They may also wish to consider supplemental coverage to assist with Medicare cost-sharing.

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Other questions to considerHas individual been, or will they be, enrolled in Extra Help and a Part D plan? If yes, does Part D plan cover all of their prescriptions?

Dual-eligibles are generally auto-enrolled in Extra Help and a prescription drug plan. If they are auto-enrolled in a plan that does not cover their prescriptions, they can change their coverage. Extra Help gives individuals the opportunity to change their prescription drug coverage once per month. Individuals can call 1-800-MEDICARE to change their plan. Slide38

ReviewSlide39

ReviewIndividuals with expansion Medicaid will transition to Medicare (possibly with traditional Medicaid and/or an MSP) when they become Medicare-eligible

State or federal Marketplace typically involved in transition

Individual should receive notice about being evaluated for traditional MedicaidPossible outcomes Medicare with traditional Medicaid and MSPMedicare with MSPMedicare without traditional Medicaid or MSPMedicare with expansion Medicaid (parent or caretaker relative only)Slide40

Resources for information and help

State Health Insurance Assistance Program (SHIP)

www.shiptacenter.org www.eldercare.gov Social Security Administration800-772-1213 www.ssa.gov Medicare1-800-MEDICARE (633-4227)www.medicare.govMedicare Rights Center800-333-4114www.medicareinteractive.org National Council on Agingwww.ncoa.org www.centerforbenefits.orgwww.mymedicarematters.org

www.benefitscheckup.org Slide41

Medicare Interactivewww.medicareinteractive.org

Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare

Easy to navigateClear, simple languageAnswers to Medicare questions and questions about related topics2+ million annual visits Slide42

Medicare Interactive Pro (MI Pro)Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare

Four levels with four to five courses each

Quizzes and downloadable course materialsBuilds on 25 years of Medicare Rights Center counseling experienceFor details, visit www.medicareinteractive.org/learning-center/courses or contact Jay Johnson at 212-204-6234 or jjohnson@medicarerights.org