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6 Types of Medicare Part A Hospital insurance (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services); Part B Medical insurance (physician services, outpatient care, durable medical equipment, home health services, and many preventive services); Part C Medicare Advantage (MA) (Medicare-approved private insurance companies provide all Part A and Part B services and may provide prescription drug coverage and other supplemental benefits); and Part D The Prescription Drug Benefit (Medicare-approved private companies provide outpatient prescription drug coverage). Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for monthly premiums, annual deductibles, and copayments. 6

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9 If you enroll before your birthday month, Medicare will start on the month you turn 65. If you enroll during your birthday month or later, your Medicare will start later. The later you enroll, the later Medicare will start For example, if you enroll during the 3 rd month after you turn 65, Medicare will start 3 months later. 9

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16 The Healthplanfinder will refer to WaConn for non-magi/classic Medicaid determinations and for other social services (food; cash; childcare eligibility). Step 1: Early Screen Out option before Eligibility Service is called if: 1. After the About You screen when a single individual indicates they are 65+ and they choose the Applying for myself option; or 2. After the household members screen, if all household members are 65+ or 3. After Additional Questionnaire screen, if all members on the application have been indicated as eligible for Medicare and are not pregnant or under 19 The early screen out message will give the individual two options: 1. Complete non-magi application in Washington Connection. 2. Complete application for low cost or free care in the HBE System. Step 2: If an individual applies for affordability programs after the Additional Questionnaire screen, HBE System will present a set of other screening questions to the user. The answer to these screening questions will be passed to the Eligibility Service along with the rest of the application data. 16

17 Step 3: The Eligibility Service will use the responses to the screening questions to create a pending classic Medicaid AU if 1) Individual indicates they are applying for coverage for one or more persons who are age 65+ or have Medicare, and who were not found MAGI eligible; or 2) individual answers Yes to needing a special program/service. As part of the Healthplanfinder eligibility screening process, application data is also screened for potential food, cash, and/or childcare eligibility. Step 4: HBE System will present the user a screen which notifies the user that they may be eligible for food assistance and/or cash assistance, and/or childcare assistance and/or more information is needed to determine eligibility for non-magi Medicaid. A member could first be determined MAGI-eligible or APTC-eligible (and receive coverage immediately), be referred to WA Conn to provide more information, and later be determined eligible for classic Medicaid (would be switched to that program as part of a coordinated process with HPF and ACES). Step 5: The Washington Connection application for classic Medicaid will be prefilled with relevant data passed by the HBE system for the user to proceed with the WA Conn. application process o HBE cannot transfer federal tax information o HBE does not transfer income data that would not be relevant to a non-magi (as opposed to a MAGI) income determination. Note: If an individual first goes to WA Conn, he/she will be referred to HPF, if not eligible for classic- Medicaid. No data will be transferred from WA Conn to HPF. 16

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26 Guaranteed available basis 25

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31 The customer will receive a request for proof of other coverage, but that correspondence generates the following day. When the customer initially submits their application, they will receive the standard Eligibility Results page, showing them as conditional. If the click the Why This Result? link, they ll receive the below screenshot. 30

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39 Medicare has four parts: 1. Part A is Hospital Insurance 2. Part B is Medical Insurance 3. Part C is Medicare Advantage which are plans like HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations). Part C includes Part A and Part B coverage and sometimes includes Part D. 4. Part D is Medicare Prescription Drug Coverage 38

40 Medicare Part A, hospital insurance helps pay for medically necessary services. Hospital inpatient care - Semi-private room, meals, general nursing, and other hospital services and supplies. Includes care in critical access hospitals and inpatient rehabilitation facilities. Inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). Skilled nursing facility (SNF) care - (not custodial or long-term care) under certain conditions. Home health care - A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you face-to-face before the doctor can certify that you need home health services. A Medicare-certified home health agency must provide your home health services. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services. Hospice Care - For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom 39

41 management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn t cover, such as grief counseling. Medicare Part B, medical insurance pays for medically necessary outpatient and doctor care Blood, Lab tests, X-rays, etc.- Outpatient Medical and Surgical Services and Supplies Durable Medical Equipment like walkers and wheelchairs. Preventive Services like exams, lab tests, screening and shots to help prevent, find, or manage a medical problem. 39

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43 Medicare Part D is Medicare Prescription Drug Coverage. Part D coverage is provided through Medicare Prescription Drug Plans, Medicare Advantage Plans, or other Medicare health plans. 41

44 Medicare Advantage is also called Part C. Medicare Advantage Plans are health plan options approved by Medicare and run by private companies. They are part of the Medicare program; they are just another way to get Medicare coverage. Medicare pays a certain amount for each member s care. If you join a Medicare Advantage Plan, you may have to use a network of doctors and/or hospitals. 42