Medicare and Medicaid Coordination of Benefits

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Medicare and Medicaid Coordination of Benefits

• Rebecca Phillips
• Training Specialist

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MMAP Inc.

• We are Michigans 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

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MMAPs Mission

• To educate, counsel and empower
• Michigans older adults and individuals with
  disabilities, and those who serve them, so that
  they can make informed health
• benefit decisions

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MMAPs 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.

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What is Medicare?
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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)

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Medicare Plan Choices

• Original Medicare
• 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

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Original Medicare

• Part A- Hospital Insurance
• Covers
• Hospital stays
• Skilled nursing facility care
• Hospice care
• Costs
• 1068 deductible a hospital stay of 1-60
• 267 per day for days 61-90 hospitalization
• Paid for through FICA taxes therefore anyone who
  has 40 work credits (about 10 years) does not pay
  a premium for Part A

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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.

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Original Medicare

• Part B- Medical Insurance
• Covers
• Outpatient services, such as doctors 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

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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

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Medigap

• Helps pay the costs with Original Medicare
• Dont need Medigap if you are
• In a Medicare Advantage plan
• Have retiree coverage
• Have Medicaid

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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

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Part D- Prescription Coverage

• Medicare Prescription Drug Coverage is part of
  the Medicare Prescription Drug Improvement and
  Modernization Act of 2003 (MMA)
• First time Medicare provided prescription
  coverage for outpatient prescription drugs

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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

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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 6153.75
• 5 of drug costs (or smaller co-payment) after
  4350 true out-of-pocket expenses

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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
3,453.75 Gap
No Coverage
2,700
Partial Coverage
25
Deductible
295
Monthly Premium
Numbers represent actual prescription drug
cost.
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Types of Part D Plans

• Offered by private companies
• Approved by Medicare
• Two Types
• Prescription Drug Plans (PDPs)
• Medicare Advantage (MA-PDs)

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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

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Medicare Advantage Costs

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

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What is Medicaid?
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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.

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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.

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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

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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

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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

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Medicare Secondary Payer Rule and Coordination of
Benefits
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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)
• Workers Compensation Insurance
• Automobile and Liability Insurance

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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Contact Information

• Rebecca Phillips
• rebecca_at_mmapinc.org
• 517-886-1242 ext 12
• MMAP
• 1-800-803-7174