A Bridge to Health Medicare Transitions in a New Landscape National Home & Community Based Services Conference September 10, 2013 Stacy Sanders Federal Policy Director
Transitioning to Medicare Affordable Care Act a new landscape An already complicated transition Newly eligible must make many choices Original Medicare + Medigap (?) Medicare Advantage (?) Prescription drug plan (Part D) (?) Access to low-income benefits (?) www.medicarerights.org
Transitioning to Medicare Automatic for many Part A and Part B Already receiving Social Security or SSDI Others newly eligible must actively enroll Initial Enrollment Period: 7 months around 65 th Special Enrollment Period Annual Enrollment Period: October 15 December 7 Medicare Advantage Disenrollment Period www.medicarerights.org
Transitioning to Medicare Enrolling in Part A Premium free for most = smooth transition Too few work quarters complicates enrollment Enrolling in Part B 2013 Part B premium: $104.90 per month Decision to enroll hinges on coordination of benefits Coordination dependent on: type of insurance; why person is eligible for Medicare; and employer size www.medicarerights.org
Transitioning to Medicare Seamless transitions are critical A poorly managed transition can result in: Gaps in coverage due to limited enrollment periods Part B premium penalty Part D premium penalty www.medicarerights.org
Transitioning to Medicare Medicare transitions in a post-aca world QHP Medicare SHOP plan Medicare Medicaid Medicare Medicaid Medicare/Medicaid Medicaid Medicare + MSP + Extra Help www.medicarerights.org
QHP Medicare Beneficiary Considerations No premium tax credits or cost sharing subsidies Automatic termination upon becoming Part A eligible Must consider benefit coordination Must actively disenroll from QHP Plans must receive 14 days for reasonable notice Dire consequences of delaying Medicare www.medicarerights.org
QHP Medicare Policy Considerations Newly eligible must receive adequate education Benefit coordination rules must be clear QHPs may be leveraged to educate Abuses by QHPs must be avoided www.medicarerights.org
SHOP Medicare Beneficiary Considerations Determine need to enroll in Medicare Based on employer size and basis for Medicare Age 65+ and coverage from company with 20+ employees may consider delay Determine eligibility for Part B SEP Determine if prescription coverage is creditable www.medicarerights.org
SHOP Medicare Policy Considerations Newly eligible must receive adequate education Employers may be leveraged to educate Access to Part B SEP Access to creditable Part D coverage www.medicarerights.org
Medicaid Medicare Andrea Callow, Center for Medicare Advocacy Anna Rich, National Senior Citizens Law Center www.medicarerights.org
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Making the Transition from Expanded Medicaid to Medicare: Managing Transitions National Home & Community Based Services Conference September 10, 2013 Andrea Callow Policy Attorney
ACA changes to Medicaid ACA Medicaid (MAGI) No categorical eligibility requirements** Uses Modified Adjusted Gross Income (MAGI) for eligibility For people who have income below 133% (138%) of FPL No Asset Test Benchmark benefits package Will only exist in Expansion states Medicaid (MAGI-exempt) 65+, disabled, blind, medically needy, LTSS, SSI Uses old disregard income calculation system (SSI based) Most categories require income below 75%- 100% FPL Asset Test More comprehensive benefits package Exists in all states 2
Quick Review Medicare Low-Income Programs The Medicare Savings Programs (MSPs) QMB, SLMB and QI Pays Medicare Part B premiums (and sometimes Part A premiums as well as A and B coinsurance and deductible) Eligibility Under 135% of FPL and $6,940 assets (in most states) for a single person The Part D Low Income Subsidy (LIS) Sliding scale help with Part D plan premium and coinsurance Eligibility Under 150% FPL and $13,300 assets People who qualify for MSP automatically receive LIS 3
Moving into Medicare Medicare + Medicaid (MAGIexempt) ACA Medicaid (MAGI) Medicare + MSP and LIS Medicare only 4
Moving into Medicare Misaligned financial eligibility requirements Misaligned application and enrollment and requirements Lack of sufficient electronic data sharing to verify eligibility and facilitate enrollment Lack of education and outreach to prepare soon-to-be Medicare beneficiaries Source: Medicare Rights Center 5
Moving into Medicare From ACA Medicaid (MAGI) to Medicare with Full Medicaid (MAGI-exempt) The cliff effect upon redetermination ACA Medicaid (MAGI) has higher income threshold than Medicaid (MAGI-exempt) ACA Medicaid (MAGI) has no asset test while Medicaid (MAGIexempt) does ACA Medicaid uses simplified MAGI income standard while Medicaid (MAGI-exempt) uses complex current SSI-based rules (income disregard) There should be automatic screening for and enrollment in Medicare Savings Program 6
From ACA Medicaid (MAGI) to Medicare with Full Medicaid (MAGI-exempt) Case Study Ms. Smith is enrolled in ACA Medicaid. Her income is 90% of poverty ($744 per month) and no assets. In 2015 Ms. Smith turns 65 and qualifies for Medicare. Although she no longer qualifies for ACA Medicaid, she is still eligible for her state s Aged, Blind and Disabled Medicaid program (MAGI-exempt), which has an income limit of 100% of poverty and an asset limit of $4,000. 7
Case study (cont d) Even though Ms. Smith is still qualified for Medicaid, she will need to go through the re-determination process. This will involve submitting additional income and asset information to the Medicaid office. Ms. Smith should be screened for the Medicare Savings Program during the redetermination, but often this does not happen. Therefore, she should fill out an application for the MSP and the Part D Low Income Subsidy. 8
Moving into Medicare From ACA Medicaid (MAGI) to Medicare with a Medicare Savings Program and Part D Low Income Subsidy Medicaid re-determination is supposed to screen for and enroll eligible individuals into MSPs More detailed application with income and asset information Should be automatic eligibility for, and enrollment in, the Low Income Subsidy upon enrollment in the MSP 9
From ACA Medicaid (MAGI) to Medicare with a Medicare Savings Program and Part D Low Income Subsidy Case Study Mr. Jones is enrolled in ACA Medicaid. His income is 120% of poverty ( $1,149 per month) and he has $3,000 in assets. In 2015, Mr. Jones turns 65 and becomes eligible for Medicare. He is no longer eligible for Medicaid because his income and assets are too high. However, he is eligible for the Medicare Savings Program and for the Part D Low Income Subsidy.. 10
Case Study cont d Mr. Jones should go through Medicaid re-determination where he will need to supply additional income and asset information. Although he should not have to specifically indicate that he is applying for the MSP, he should. Upon approval for the MSP, Mr. Smith should be deemed eligible for the Part D LIS and enrolled in the program. However, he may want to follow up with the Social Security Administration to be sure. 11
TAKEAWAY Most people enrolled in ACA Medicaid (MAGI) will be eligible for some low-income program after their enrollment in Medicare Screening and application processes for Medicaid (MAGIexempt) and MSP should happen automatically upon becoming eligible for Medicare, but there is a high probability they will not. Follow up!! People receiving SSI should experience the smoothest transitions 12
August 27, 2013 California Perspective: Preserving Access to HCBS During the Transition from Expansion Medicaid Anna Rich, Senior Staff Attorney National Senior Citizens Law Center www.nsclc.org 1
The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation, and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our Web site at www.nsclc.org.
Medi-Cal Programs for Seniors and Persons with Disabilities in Community No share of cost Automatic through SSI eligibility Aged & Disabled Federal Poverty Level Program (noshare-of-cost), 100% FPL + $230 Pickle programs (would have been eligible but for Social Security cost of living increases) Working Disabled Program (with incomes no more than 250% of poverty level) Share of cost Medically needy -- $600 Maintenance need level!
Medi-Cal Resource Rules Resource limits Single: $2,000 Couple: $3,000 Exception for 250% Working Disabled Program
How to Determine Countable Income Counting Income Any Income Deduction - $20 Earned Income Deductions $65 Impairment-Related Work Expenses 50% of the remaining amount Deduction for health insurance premiums which beneficiary pays herself (other than for Medicare Part A and B premiums)
Medi-Cal v. Medicare for HCBS Medi-Cal Home Health Personal Care Adult Day Health Care Home Health Waiver Services Medicare Home Health 6
Medi-Cal Expansion Starts January 1, 2014 Expands Eligibility for Medi-Cal Individuals with Incomes Up to 133% FPL 5% Income Disregard = 138% $15, 856/individual Income - calculated using MAGI No Asset/Resource Limit Individuals up to age 64 No disability requirement Ineligible Medicare Enrollees Traditional Medicaid enrollees 5-year ban for immigrants 7
Medi-Cal Expansion: Effects on Benefits Traditional Medi- Cal Substance use disorder services Mental health services Long-term supports and services Alternative Benefit Package Substance use disorder services Mental health services?? 8
Medi-Cal Expansion: Options for Vulnerable Beneficiaries Expansion Medi-Cal Alternative Benefit Plan Vulnerable Consumers Traditional Medi-Cal Traditional Medi-Cal Benefit 9
Who will qualify for exemption? Individuals with disabilities Individuals who are dually eligible Terminally ill hospice patients Individuals qualifying for long-term care services Medically frail including disabling mental disorders, SUD, serious and complex mental disabilities, impairment of one ADL. 10
Health Insurance Marketplace Enrollment: No Wrong Door Enrollment October 1, 2013 March 31, 2014 Submit App to Marketplace Online By Phone By Mail In Person Eligibility determined and verified Deemed eligible for Qualified Health Plan, Medi-Cal, or CHIP Premium Tax Credit Cost-Sharing Reduction Enroll in Marketplace QHP Enroll in Medi- Cal 11
Income Eligibility Gap Incomes between ~124% of FPL and 138% FPL, or significant income not counted in MAGI. Needed: Help identifying alternative Medi-Cal programs, like 250% Working Disabled. Identify appropriate reductions to reduce countable income. Review eligibility for MSP and LIS. 12
Resource Eligibility Gap Assets above $2,000 for an individual. Needed: Education and notice about traditional Medi-Cal asset limits, rules regarding transfer of assets. Alignment of Medi-Cal asset tests. 13
Benefits Gap Affects those expansion Medi-Cal beneficiaries not already exempted from ABP. Needed: Good screening and redeterminations. Informed choice about treatment of Medi-cal application. 14
Affordability Gap For instance, on expansion Medi-Cal but cannot qualify for traditional Medi-Cal, or gets marketplace subsidies but not traditional Medi-Cal. Needed: Counseling about options for Medi-Cal (250% WD, HCBS/spousal impoverishment). Expansion/alignment of MSP, LIS, traditional Medi-Cal. 15
Enrollment Gap Breaks in enrollment are especially hard on people who need HCBS. Needed: Simplify enrollment in traditional Medi-Cal, MSP/LIS. Clarify counties obligations for ex parte review, and don t cut people off until after this is complete. Well trained and accessible consumer assistance programs, esp. for limited English proficient. 16
Call with questions or problems: Anna Rich Senior Staff Attorney arich@nsclc.org (510) 663-1055, ext. 305 www.nsclc.org www.nsclc.org