1. Medicare and Medicaid Coordination of Benefits
Rebecca Phillips
Training Specialist

2. MMAP Inc.
We are Michigan’s State Health Insurance Assistance Program (SHIP)
MMAP (Michigan Medicare/Medicaid Assistance Program)
Federal funding for the program began in 1991
Each state has their own SHIP
Most SHIPs are operated by the State, however, MMAP Inc. is a non-profit
All rely heavily on volunteers

3. MMAP’s Mission
To educate, counsel and empower Michigan’s older adults and individuals with disabilities, and those who serve them, so that they can make informed health benefit decisions

4. MMAP’s Vision
MMAP is the recognized leader in providing high quality and accessible health benefit information and counseling supported by a statewide network of unpaid and paid skilled professionals.

5. What is Medicare?

6. What is Medicare? Federal Health Insurance for:
People 65 years of age or older
Some persons with disabilities, after a 24 month waiting period – Must be deemed by Social Security
People with End-Stage Renal Disease
People with Amyotrophic Lateral Sclerosis (ALS)

7. Medicare Plan Choices Original Medicare Medicare Advantage
Part A- Hospital Insurance
Part B- Medical Insurance
Part D- optional Prescription Insurance
Medicare Advantage
Health Plan (HMO, PPO, PFFS) offered by private health plans
Sometimes referred to as Part C

8. Original Medicare Part A- Hospital Insurance Covers Costs
Hospital stays
Skilled nursing facility care
Hospice care
Costs
$1068 deductible a hospital stay of 1-60
$267 per day for days hospitalization
Paid for through FICA taxes; therefore anyone who has 40 work credits (about 10 years) does not pay a premium for Part A

9. Original Medicare- Part A cont.
Also covers skilled nursing facility after a 3 day hospital stay for care relating to hospital treatment
Covered in full for first 20 days.

10. Original Medicare Part B- Medical Insurance Covers Costs
Outpatient services, such as doctor’s visits, ambulance, lab, x-rays, medical equipment
Costs
Monthly premium of $96.40 for most people
Annual deductible of $135
20% co-pay for most services

11. Medigap Sold by private insurance companies
Fills the gaps of Original Medicare
Currently 12 standard plans “A-L”
Set core benefits for each standard plan
Costs vary
MIPPA – number of changes to Medigaps coming in June of 2010

12. Medigap Helps pay the costs with Original Medicare
Don’t need Medigap if you are
In a Medicare Advantage plan
Have retiree coverage
Have Medicaid

13. What Medigap Pays Co-insurance amounts for Part B (20%)
Some policies cover deductibles for Part A and/or Part B
Some policies offer additional benefits, like Foreign Travel Emergency or Routine Checkups

14. Part D- Prescription Coverage
Medicare Prescription Drug Coverage is part of the Medicare Prescription Drug Improvement and Modernization Act of (MMA)
First time Medicare provided prescription coverage for outpatient prescription drugs

15. Who is Eligible for Part D?
Anyone who has Medicare Part A and/or Part B
Enrollment is voluntary
In most cases, beneficiary must choose and join a Medicare drug plan to get coverage

16. Medicare Part D Costs
For coverage in 2009, beneficiaries will generally pay…
A monthly premium
$295 deductible
25% of yearly drug costs from $295 to $2700
100% of drug costs from $2700 to $
5% of drug costs (or smaller co-payment) after $4350 true out-of-pocket expenses

17. Standard Benefit Structure Chart
Out-of-Pocket Drug Spending in 2009 for Medicare Part D Basic Benefit
Beneficiary
Spending
Medicare
Part D Benefit
Catastrophic
Coverage 5%
$6,153.75*
$3, Gap
No Coverage
Plans may offer more than standard coverage, including
“Tiered” co-payments or co-insurance
Lower deductible
Keep the gap in coverage (doughnut hold) where the beneficiary pays 100% of their prescription costs, but change where it begins
Change the coverage limit (i.e. different dollar amount where the person begins to pay 100%)
No gap in coverage
A larger version of this chart can be found in the additional resources located at the end of this module (See Attachment #2).
$2,700*
Partial
Coverage
25%
Deductible
$295*
+ Monthly Premium
* Numbers represent actual prescription drug cost.

18. Types of Part D Plans Offered by private companies
Approved by Medicare
Two Types
Prescription Drug Plans (PDPs)
Medicare Advantage (MA-PDs)

19. Medicare Advantage Changes the structure of Medicare benefits
Offered by Private Insurance companies who have contracted with Medicare
Medicare Advantage Plan is primary
Subject to co-pays
Plans can be HMO, PPO, Private Fee for Service – basically these are Managed Care plans
Medicare Advantage wraps Medicare, supplement and prescription drugs into one policy
Must be enrolled in both A & B

20. Medicare Advantage Costs
Still Pay Part B premium
May have a Medicare Advantage Premium
Pay associated co-pays and deductibles for medical care

21. What is Medicaid?

22. What is Medicaid?
Medicaid provides medical insurance to groups of low-income individuals and families that may have inadequate or no medical insurance.
In Michigan, Medicaid has over 30 health care programs for children, families and adults who meet eligibility criteria.
This presentation will focus on those that are 65 or older, blind, or disabled.

23. Medicaid - Administration
The Federal government sets general guidelines for the Medicaid program, but each state determines the policy rules and regulations of their program.
The Michigan the Department of Community Health (MDCH) oversees this program and local Department of Human Services (DHS) offices administer the program.
DHS offices are usually located at the County level.

24. What does Medicaid Cover?
Federal law and regulations require that states provide to qualifying older adults and person with disabilities a set of mandatory benefits:
Inpatient hospital services
Outpatient hospital services and rural health clinic services
Other lab and x-ray services
Skilled nursing facility services
Physicians’ services
Home heath care services

25. What does Medicaid Cover?
Many states offer a some optional benefits as well, which may include:
Dental
Chiropractic
Hearing aid services
Podiatry
Vision
Occupational and speech therapy

26. Medicare Savings Programs
These are programs developed to help pay the premiums, deductibles, and copays for Medicare.
QMB (Qualified Medicare Beneficiary) – pays Part B premium, Part A & B deductibles, and all Medicare copays.
SLMB (Specified Limited Medicare Beneficiary) – pays Medicare Part B premium.
ALMB-QI-1 (Additional Low-Income Medicare Beneficiary) – pays Medicare Part B premium (not an entitlement)
These programs are administered by Medicaid and they have asset and income limits
A beneficiary may have both Medicaid and a Medicare Savings Program

27. Medicare Secondary Payer Rule and Coordination of Benefits

28. Medicare Secondary Payer Rule and Coordination of Benefits
Medicare Secondary Payer (MSP) Rule requires other insurers to pay before Medicare
Federal law passed in 1980 created this rule, prior to this Medicare was always primary
Determination is made based on other available insurance
MSP applies if the other insurance available is:
Employer Group Health Plans for current employees and their dependents (the “working aged”)
Worker’s Compensation Insurance
Automobile and Liability Insurance

29. Medicare Secondary Payer Rule and Coordination of Benefits
Medicare Secondary Payer Rule and Employer Group Health Plans (EGHP)
If the person covered by Medicare or his/her spouse is still working and covered by EGHP, the EGHP is primary for:
Employers with 20 or more employees
For persons with disabilities, rule applies to employers with 100 or more employees
These beneficiaries do not need to take Part B while they are covered by the EGHP. Once they retire or lose the EGHP they will need to enroll in Part B.

30. Medicare Secondary Payer Rule and Coordination of Benefits
Medicare is primary with the following:
Medicare Supplement (Medigap) insurance
Retiree group insurance – acts as a supplement
TRICARE for Life for military retirees
Medicaid
Generally, where the terms of the contract say that the insurance pays second to Medicare

31. Medicare
General rule with Medicare: If Medicare is Primary, the beneficiary must have both A and B before a secondary insurance will pick up any part of a claim.
Side note: if the beneficiary does not enroll in Part B when he/she first became eligible he/she may have to pay a late enrollment penalty.

32. Crossover Agreement
Medicare has agreement with other insurance companies that allows Medicare to send claims directly to the other insurance carrier automatically for processing.
This eases the claims process for the beneficiary.

33. Medicaid General rule with Medicaid: Medicaid always pays last.
If there is a possibility that another insurer or payer is available to pick up a claim Medicaid will not pay for that claim until it is proven otherwise.

34. Common Areas of Confusion
COBRA
Medicare is primary with COBRA (except for when End-Stage Renal Disease is involved)
Delay in disability claims at Social Security complicates this issue
Since SSA is sometimes years behind in processing disability claims it is not uncommon for someone to be eligible for Medicare retroactively.
When this happens the COBRA coverage will take back their payments to providers stating that Medicare should have paid.
This is where I see the most problems with beneficiaries being sent to claims.

35. Common Areas of Confusion
Medicare Advantage Plans
Will not coordinate with Medigap Plans
Most are not set up to coordinate with Medicaid or other insurance benefits (retiree)
May be able to get secondary insurance (Medicaid) to pick up deductibles or copayments but if a contract is not in place the chances are very slim.
Exception - Special Needs Plans (SNPs): Medicare Advantage plans that have a contract with Medicaid

36. Common Areas of Confusion
What if someone has Medicare, a retiree plan and Medicaid?
Medicare would be primary
The Retiree plan would pick up the pieces it will cover after Medicare pays their part.
Medicaid will then come in and possibly pick up anything that is left. In reality, there usually would be very little for Medicaid to pick up in this situtation.

37. Contact Information:
Rebecca Phillips
ext 12
MMAP