Presentation on theme: "Medicare and Medicaid Coordination of Benefits"— Presentation transcript:
1 Medicare and Medicaid Coordination of Benefits Rebecca PhillipsTraining 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 1991Each state has their own SHIPMost SHIPs are operated by the State, however, MMAP Inc. is a non-profitAll rely heavily on volunteers
3 MMAP’s MissionTo 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 VisionMMAP 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.
6 What is Medicare? Federal Health Insurance for: People 65 years of age or olderSome persons with disabilities, after a 24 month waiting period – Must be deemed by Social SecurityPeople with End-Stage Renal DiseasePeople with Amyotrophic Lateral Sclerosis (ALS)
7 Medicare Plan Choices Original Medicare Medicare Advantage Part A- Hospital InsurancePart B- Medical InsurancePart D- optional Prescription InsuranceMedicare AdvantageHealth Plan (HMO, PPO, PFFS) offered by private health plansSometimes referred to as Part C
8 Original Medicare Part A- Hospital Insurance Covers Costs Hospital staysSkilled nursing facility careHospice careCosts$1068 deductible a hospital stay of 1-60$267 per day for days hospitalizationPaid 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 treatmentCovered 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 equipmentCostsMonthly premium of $96.40 for most peopleAnnual deductible of $13520% co-pay for most services
11 Medigap Sold by private insurance companies Fills the gaps of Original MedicareCurrently 12 standard plans “A-L”Set core benefits for each standard planCosts varyMIPPA – 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 areIn a Medicare Advantage planHave retiree coverageHave Medicaid
13 What Medigap Pays Co-insurance amounts for Part B (20%) Some policies cover deductibles for Part A and/or Part BSome 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 BEnrollment is voluntaryIn most cases, beneficiary must choose and join a Medicare drug plan to get coverage
16 Medicare Part D CostsFor coverage in 2009, beneficiaries will generally pay…A monthly premium$295 deductible25% of yearly drug costs from $295 to $2700100% 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 BenefitBeneficiarySpendingMedicarePart D BenefitCatastrophicCoverage5%$6,153.75*$3, GapNo CoveragePlans may offer more than standard coverage, including“Tiered” co-payments or co-insuranceLower deductibleKeep the gap in coverage (doughnut hold) where the beneficiary pays 100% of their prescription costs, but change where it beginsChange the coverage limit (i.e. different dollar amount where the person begins to pay 100%)No gap in coverageA larger version of this chart can be found in the additional resources located at the end of this module (See Attachment #2).$2,700*PartialCoverage25%Deductible$295*+ Monthly Premium* Numbers represent actual prescription drug cost.
18 Types of Part D Plans Offered by private companies Approved by MedicareTwo TypesPrescription 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 MedicareMedicare Advantage Plan is primarySubject to co-paysPlans can be HMO, PPO, Private Fee for Service – basically these are Managed Care plansMedicare Advantage wraps Medicare, supplement and prescription drugs into one policyMust be enrolled in both A & B
20 Medicare Advantage Costs Still Pay Part B premiumMay have a Medicare Advantage PremiumPay associated co-pays and deductibles for medical care
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 servicesOutpatient hospital services and rural health clinic servicesOther lab and x-ray servicesSkilled nursing facility servicesPhysicians’ servicesHome heath care services
25 What does Medicaid Cover? Many states offer a some optional benefits as well, which may include:DentalChiropracticHearing aid servicesPodiatryVisionOccupational 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 limitsA 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 MedicareFederal law passed in 1980 created this rule, prior to this Medicare was always primaryDetermination is made based on other available insuranceMSP applies if the other insurance available is:Employer Group Health Plans for current employees and their dependents (the “working aged”)Worker’s Compensation InsuranceAutomobile 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 employeesFor persons with disabilities, rule applies to employers with 100 or more employeesThese 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) insuranceRetiree group insurance – acts as a supplementTRICARE for Life for military retireesMedicaidGenerally, where the terms of the contract say that the insurance pays second to Medicare
31 MedicareGeneral 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 AgreementMedicare 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 COBRAMedicare is primary with COBRA (except for when End-Stage Renal Disease is involved)Delay in disability claims at Social Security complicates this issueSince 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 PlansWill not coordinate with Medigap PlansMost 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 primaryThe 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.