Medical benefits 10

Overview of Presentation: What’s it al  Goals- Differentiate between programs Eligibility Rules Coverage  Basic Rights and Responsibilities  Keeping Eligibility  Appealing Adverse Decisions  1965 Federal matching dollars for state dollars Entitlement Program- You’re eligible, you apply,  States have authority to administer, increase eligibility to additional groups, rates of payments,  September 2008: packets mailed regarding  October 1, 2008: chose plan February 1, 2009: services received through Q-ExA: What is it? (cont.)In Hawai’i Medicaid is only for the verifiably: QUEST: What is it? 1994 State Waiver Program from Medicaid Limit to number of Enrollees (125,000) Managed Care Plan  Pick a plan and a Primary Care Physician Currently: Kaiser, HMSA, Aloha Care,  Same Income and Asset Eligibility as  Covers those who are not aged, blind, QUEST: Basic Health Hawaii In August of 2009, the State announced  This includes the Republic of Palau, citizens had been eligible since August of QUEST: Basic Health Hawaii Lawyers for Equal Justice (www.lejhawaii.org) filed a temporary injunction to stop the implementation of BHH. The matter is currently  At the time of this writing, COFA citizens eligible for QUEST have been returned to their applicable QUEST program pending the outcome of the  A hearing on new BHH rules will be held on January 25 at 1:30 PM at 1390 Miller St.
QUEST: Basic Health Hawaii COFA citizens are to be eligible only for  COFA adults already in long term care services under QExA or part of the State QUEST: Basic Health Hawaii Non-financial  Income: Less than 100% Federal Poverty Line  $2000: Single adult $3000: Couple +$250: Additional household member  10 days of medically necessary inpatient  12 outpatient visits 6 mental health visits 3 medically necessary ambulatory  Bonafide emergency room procedures Coverage of 4 generic prescriptions per QUEST: Basic Health Hawaii Diabetic supplies Family planning services to include drugs and  Maternal care (1 routine visit to confirm pregnancy and additional visits for certain  Interpreter services Emergency dental  Relief of pain Eliminate infection Treatment of injuries  Federal program, tax taken out of income Not Financially Need Based  Different Parts (A, B, C, D, etc.) Eligibility:  Disability: After receiving Social Security Disability  Can you think of some of the differences  What are the eligibility differences?  Which programs might a 75yr old get? What about a disabled person? Someone with a lot of money?  Which one limits the number of people that can be on  First, Aged, Blind or Disabled?
 AGED: 65 years or older BLIND: <20/200 vision DISABLED: Impairment that would cause an inability to engage in significant gainful activity (SGA) for at least  Social Security definition of disabled  For example: Birth Certificate, Social Security Citizenship & ID must be verified for all applicants  Second, Financial Eligibility:
 Must be below 100% of Federal Poverty Level (FPL)  Includes any money received in a particular month  Add an extra $250 for additional household members  Anything which is legally available, with exceptions  The home the person lives in Household goods and belongings All Motor Vehicles (includes yachts, mopeds, etc.) One burial plot per person Certain burial plans There are new transfer of asset rules for long-
term care.
 Disposal of assets for less than fair market  Disposal of assets into irrevocable trust:  Disposal of asset less than fair market value:  Disposal of asset into irrevocable trust: 60  Disposal of asset: 60 month look back period Quest: Eligibility Requirements Hawai’i Resident US Citizen or qualified immigrant  Must provide a valid SSN  Proof of Citizenship & identity  Not Aged, Blind or Disabled as defined by  Not institutionalized or eligible for  Cap must not be in place, or be exempt Financially eligible  Pregnant women Lost coverage due to loss of job w/in 45 days Children under age 19  Up to age 21 if under care of Child Welfare Services  Generally, single individuals with incomes under $450 a month (GA & TANF recipients). (Income does not  Must be under 100% of FPL (same as Quest-  Children under age 19: under 300% of FPL  Pregnant Women: (incl. unborn child), under 185%  All sources of income except: Some earnings of minor children, federal Earned Income Tax Credit, subtract certain business expenses from self- employment income. Other deductions available. Quest: Financial Eligibility, Asset Limits  Equivalent to SSI program (same as Quest-  $2,000 for individual $3,000 for two people $250 for each additional SAME EXEMPT ASSETS as Quest-ExA  No asset limit for pregnant women or children
under age 19
MEDICARE: Eligibility INCOME AND ASSETS DON’T MATTER!!!  Disabled, for at least 24 months (Social Security  End Stage Renal Disease or ALS (Lou Gehrig’s  Automatically receive a card on your 65 birthday if you are qualified for Social Security  Worked at total of 40 quarters! (about ten years).
 Can enroll at age 65, if US Citizen or Legal Permanent Resident with at least five years  Will have to pay premiums (may qualify for  25th month of being eligible to receive SSDI/RSDI  All individuals with End Stage Renal disease (ESRD) or amyotrophic lateral sclerosis (ALS/Lou Gehrig’s  What is one major difference between  Who can get Quest when the cap is in  Who would be eligible for Medicare?  Can you get Medicare and Quest-ExA? Quest-ExA Benefits Switch fee-for-service Medicaid to HMO  Home and community-based services (long term care): adult day care, personal attendants, residential care  Disease management programs (i.e. diabetes)  Currently: Kaiser, HMSA, Aloha Care, Summerlin  Need to see Primary Care Physician (PCP) Use In-Network Doctors, etc.
 Provide “comprehensive health services”  Doctors, specialists, medications (unless Medicare),  EPSDT (Early Periodic Screening, Diagnosis, and Quest Benefits: Dental In August of 2009, adult dental benefits under QUEST were limited to emergency services.
 Emergency services cover incidents of dental pain, elimination of infection, and treatment of acute injuries. Preventative and restorative procedures like dentures are no longer covered.
 Individuals under 21 years of age still receive Medicare Benefits Medicare: What part do you have?  Also, Medigap plans, which cost money to restructure your benefits and add new benefits  Inpatient hospital visits, skilled nursing  No premium with sufficient work history (40  $461 per month if less than 30 quarters  Deductibles and co-payments for services  Physician services, outpatient hospital care, ambulance, durable medical equipment, lab,  Income related increase starting in 2007 Penalty for joining late  $155 annual deductible 20% co-payment after deductible  QMB (Qualified Medicare Beneficiaries)  Income less than 100% of federal poverty  Assets less than $4000 (single) or $6000  Premiums, deductibles, and copayments  Income less than 120% of the Federal Poverty  Assets less than $4000 (single) or $6000  Income less than 200% of the Federal Poverty  Assets less than $4000 (single) or $6000  Kaiser Senior Advantage HMSA 65C Plus Aloha Advantage  Must provide all A & B services Many have extra options or additional  Some are optional, most are mandatory  Can change the cost structure (co-pays, deductibles) Can charge a separate premium The Newest Member…Part D Prescription drug benefits started 1/1/06  First open enrollment from 11/15/05-5/15/06 Annual open enrollment will be from 11/15-12/31  Available with either Part A, B, or C Bizarre Cost structure for most:  $310 annual deductible,  25% cost share up to $2,830 worth of drugs,  100% cost share until $4,550 out-of-pocket (doughnut  After that, 5% cost share (non-formulary drugs not  PLUS, average premium is $30 per month Example of Medicare Part D Spending Sarah takes two expensive brand name medications to treat her chronic leukemia and  $310 for the deductible 25% for drugs until coverage limit of $2830 ($2405 in actual drug costs: not out of pocket expenses)  100% for drug costs after $2830 limit until paid $4550 Source: Understanding the Medicare Part D Donut Hole by Michael Bihari, M.D. (http://drugs.about.com/od/medicarepartd/a/Donut_Hole.htm)  How do Quest-ExA and Quest differ from  What are the various types of Medicare? Responsibilities for Quest-ExA & Quest  Must report all income & assets of all household  Must report SSN just for APPLICANTS and verify  Must provide sufficient proof of citizenship & a photo ID Cooperate with Child Support Enforcement Agency,  Cooperate with third party liability, unless good cause Must report all household changes within ten days Give permission to DHS to contact fed, state, local gov’t offices, as well as financial institutions to verify info.
 Otherwise, will get sent to collection agency  Need to keep part A or B or C to retain the  Must notify plans of change of address Must notify of any additional drug coverage  Interpreter and translation services, as well as  Large print, accessible parking, telephone interviews,  Confidentiality, except where consent is given  Non-discrimination based on race, color, age, sex, national origin, disability or religious or  Within 45 days (presumptive eligibility on 46th day)  90 days for Quest-ExA (presumptive eligibility on 91st day for Quest-ExA. This is expanded from 60 days in  Proper & Timely Notice of Denial (10 days prior to  Proper and timely notice to any adverse changes to benefits (10 days prior to action)  90 days to request a fair hearing from DHS  Can bring legal counsel or anyone as a representative  Can continue to receive benefits if a hearing is requested within ten days of the adverse action  Can challenge almost ANY change, including denial of  To receive accurate information Receive ER services Translation services & accommodations File complaints Non-discrimination Confidentiality, except when consented Participate in treatment decisions  Receive a “Medicare Summary Notice (MSN)”  A written, signed request within 120 days of the  Must be filed with the office indicated on the MSN,  180 days to file a reconsideration with a Qualified Independent Contractor (QIC), like Maximus  Same Asset Limits ($2,000/$3,000 plus $250)  Sometimes referred to as the “medically needy”  Must meet all other eligibility requirements  Must spend down to the “Standard of Need” Amount  So, an individual with $2469 a month gross income must spend $2000 a month on medical expenses to  100%-300% - about $70 per month premium  Asset limit: $5,000 individual, $7,000 couple  Cost share similar to spend-down, but not supposed to exceed amount of capitated cost  Scope- limited medical and behavioral health  Cannot qualify for QUEST because of cap (125,000) Limited coverage  10 days of inpatient hospital care related to medical care, surgery, psychiatric care, and substance abuse.  3 medically necessary ambulatory surgical care procedures  All employees over 20hrs a week need

Source: http://www.legalaidhawaii.org/PBOT/MedicalBenefits101.pdf