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A CONNECTICUT CONSUMER'S GUIDE TO MEDICARE
AND RELATED PROGRAMS |
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For other information, follow one of the links below or scroll down the page.
WHAT IS MEDICARE?
Eligibility for Medicare is not based on the individual's financial status. Income and assets are not a consideration in determining eligibility for Medicare, and benefit payments are the same for all who qualify, regardless of their income.
Coverage under Medicare is similar to that provided by private health insurance companies. Like health insurance, Medicare pays a portion of the cost of some, but not all, medical care. Often, deductibles and co-insurance (partial payment of initial and subsequent costs) are required of the beneficiary.
What Does Medicare Cover?
Medicare helps pay for certain health care that is medically necessary to treat or diagnose an illness or injury. It usually does not pay for preventive services, for eyeglasses or hearing aids, or for convenience items such as private rooms or private duty nurses. Traditional Medicare has two coverage components, Part A and Part B. Part A covers inpatient hospital care, hospice care, some short-term inpatient care in a skilled nursing facility, and home health care services. Part B covers medical care and services provided by doctors and other medical practitioners, durable medical equipment, and some outpatient care and home health care services. Contrary to what many people think, Medicare does not pay for long term nursing home care.
Does Medicare Cost Anything?
Most beneficiaries do not pay a premium for Part A coverage. It is financed largely through federal payroll taxes paid into the Medicare Trust Fund by employers and employees. People who qualify for Social Security retirement benefits or for disability benefits for 24 months also qualify for Part A, and do not have to pay a premium for it. Individuals who have not accumulated enough Social Security credit may choose to purchase a Part A by paying a monthly premium after they turn 65.
Part B is financed by monthly premiums which are paid by all beneficiaries who choose this coverage, and by general revenues from the federal government. The monthly premium for Part B in 2007 is $93.50. Individuals who are automatically eligible for Part A will also be enrolled in Part B unless they inform Social Security not to do so.
In addition, beneficiaries share the cost of Medicare through co-payments and deductibles that are required for many of the services covered under both Part A and B.
What Hospital Costs Will Medicare Cover?
Medicare Part A pays the full cost of up to 60 days of necessary hospital care during each benefit period after the individual has met a deductible payment. The deductible is $1,024.00 in 2008. If the individual needs more than 60 days of hospital care Medicare pays part of the care and the individual must cover the rest.
Hospital Coverage and Cost Sharing - 2008:
Deductible: $1,024.00
for each benefit period
What Nursing Home Costs Will Medicare Cover?
Medicare covers a very limited amount of nursing home care. The coverage is available under Part A. Coverage is only available for up to 100 days of care, and only if the individual was first in a hospital for at least 3 days and receives daily skilled nursing or therapy in the nursing home. If coverage is available, coverage is for all services; there is no deductible, but there is a daily co-insurance payment due from the beneficiary. Nursing Home Coverage and Cost Sharing - 2008:
Deductible: $0
What Home Health Cost Will Medicare Cover?
Medicare covers home health care under both Part A and B. Coverage is available so long as the individual can not leave home without assistance and a taxing effort; this is called the homebound requirement. The individual must also need skilled nursing or physical therapy to get coverage. If coverage is available, Medicare pays for these services and also for occupational therapy, home health aides, medical social services, and supplies.
Note: There is no deductible or co-insurance for home health care.
What Physician Services Does Medicare Cover?
Physician services are covered under Medicare Part B. Most of the cost of going to your doctor when you are sick are covered by Medicare but Medicare generally does not cover routine physicals or check ups. When coverage is available, Medicare covers 80% of the Medicare approved charge for the doctor's services and the individual is responsible for the remaining 20%. In Connecticut most doctors accept this Medicare approved charge and, therefore, can not bill the individual any more than the 20% of this Medicare rate: This is known as the doctor accepting assignment.
What Prescription Drug Costs Does Medicare Cover?
As of January 1, 2006, Medicare offers some prescription drug coverage through Medicare Part D. For more details, visit our Medicare Part D FAQ pages.
What Preventive Medical Costs, Such As Flu Shots, Does Medicare Cover?
While Medicare usually only pays if health care is needed to treat or diagnose an illness or injury, there a number of specific preventive services covered by Medicare. They include the following:
What if the Individual is Told That Medicare Coverage is Not Available?
The Medicare program is complex. It is not uncommon for individuals to be told that coverage is not available when it should be granted. Sometimes these denials are a result of errors; sometimes they are result of efforts to save money. Regardless of the reason for the denial, the Medicare program has an appeal system that is meant to correct mistakes and help beneficiaries receive the Medicare coverage to which they are entitled.
When Should a Denial of Medicare Coverage Be Appealed?
Individuals should appeal if the health services in question are ordered by their attending physician and if the services are not clearly excluded from coverage (like most eyeglasses and hearing aids).
Appeal as soon as possible. There are deadlines which must be met for an appeal to be accepted. The first step in a Part A or Part B appeal must be filed within 120 days of a receipt of a Medicare Summary Notice that denies Medicare coverage of healthcare services. Note: The individual's attending physician is a key component to a successful appeal. Get a statement from the doctor explaining why the services are medically necessary and file this statement to with the request for an appeal. Always keep copies of everything you submit. Where Can I Get Help With Medicare Questions and Appeals?
The Medicare program and appeal system may seem too complex to handle alone. Help is readily available at no cost for residents of Connecticut at the Center for Medicare Advocacy, Inc. at (800)262-4414.
WHAT IS
MEDICARE MANAGED CARE, or "Medicare Advantage"?
Medicare Advantage is a means of receiving health care and Medicare coverage. The beneficiary must specifically opt to receive Medicare coverage and care through an HMO, or other private plan insurance. Once the choice is made, the beneficiary must generally receive all of his or her care through the plans providers in order to receive Medicare coverage. The main premise is that through preventive care and the use of a primary physician who acts as a "gatekeeper" to specialized care, health care costs can be reduced while beneficiary health can be maintained.
Private insurance plans are generally paid a fixed rate per beneficiary by Medicare, regardless of how many or how few services the beneficiary actually requires. While many Medicare beneficiaries in Connecticut can choose a Medicare Advantage plan, the number of plans available has diminished as some companies, maintaining that their reimbursement rates were too low, have withdrawn from the market in many areas of the state. Because Congress decided in 2003 to pay Medicare Advantage plans more on average than is paid under traditional Medicare, it is anticipated that the number of Medicare Advantage plans will increase.
HMOs and the private insurance plans are required to provide the full range of Medicare benefits to each enrolled beneficiary for a fixed payment per enrollee. Medicare HMOs are also required to provide additional services, over and above those available through the traditional Medicare program, without additional charge to Medicare enrollees. The HMO not only provides or arranges for direct medical services, but also, at initial decision stages, decides what care is reasonable and necessary. Enrollees are generally "locked in" which means they can receive Medicare coverage only for services provided through the HMO's providers.
For more information on Managed Care please click here.
WHAT IS MEDIGAP?
There are 12 standard Medigap policies which are labeled A through L. Policy A contains the basic or "core" benefit plan. The other nine policies contain the core benefits plus one or more additional benefits. Only Policies H, I and J include prescription drug coverage, as of January 1, 2006, when Medicare Part D began, these plans are no longer purchasable. The following is a list of the benefits that are contained in the core policy and that must be contained in all Medigap policies:
Additional benefits are offered through policies B through J. Each plan offers a different combination of these benefits in addition to the core benefits. Additional benefits are:
Policies B through L vary considerably. Each beneficiary must review the policies carefully and decide which coverages are appropriate. There are many considerations when purchasing Medigap insurance. The most important consideration is a person's medical needs. The individual should look at his or her current needs and also look to potential future medical needs. Another major consideration is cost. A person must be able to afford the particular policy he or she desires. Other considerations include medical underwriting practices, pre-existing condition limitations, and the ability to switch from one policy to another.
Connecticut residents can get free assistance to review the various Medigap plans in light of their personal needs by calling the Connecticut Department of Social Services CHOICES Program at (800)994-9422.
THE QMB and SLMB PROGRAMS The QMB program provides the following benefits:
Note: Medigap premiums are not covered by QMB, SLMB, or QI.
Eligibility criteria for this program require that:
Note: Individuals who are eligible for Medicare Part A but not enrolled, may conditionally enroll in Medicare Part A at any time during the year and then apply for QMB to cover the cost of the Medicare Part A premium which must otherwise be paid by voluntary enrollees (those not automatically eligible for Medicare Part A through Social Security or Railroad Retirement entitlement).
If an individual is eligible for this program, purchasing additional Medigap coverage for Medicare premiums, deductibles, and/or co-payments may be unnecessary. To determine whether or not to retain a Medigap policy, a review of the benefits covered by the Medigap policy must be made to see if the Medigap plan covers services other than the Medicare cost-sharing that may be useful to the person.
QMB Provider Certification for Title 19
The QMB program will pay the 20% Medicare Part B co-insurance only if the provider of services is certified as a Medicaid provider.
Note, however, a provider may choose to treat only QMB patients and not all Medicaid recipients and only the QMB patients he chooses to see. Providers have no obligation to treat Medicaid patients or anyone in particular.
Physicians and other Part B providers may become Medicaid certified by calling the State Medicaid contractor, EDS, at (860) 832-9259. EDS will send a provider enrollment package. The provider only has to fill out a form in order to become Medicaid certified. DSS also has a Medicaid provider relations department.
The SLMB program provides the following benefits:
Eligibility criteria for this program require that:
QI (Qualified Individual Program) - Limited Expansion of SLMB
The Balanced Budget Act of 1997 expanded the SLMB program for certain "qualified individuals" by increasing the income guidelines, but Congress only appropriated a limited amount of funds to each state to pay for this expansion. Once a state’s appropriated money is gone, even eligible individuals will not be able to get into the program.
The Balanced Budget Act of 1997 expanded the SLMB program for certain "qualified individuals" by increasing the income guidelines, but Congress only appropriated a limited amount of funds to each state to pay for this expansion. Once a state’s appropriated money is gone, even eligible individuals will not be able to get into the program.
Obtaining QMB, SLMB, and QI Benefits
Requests for applications for QMB, SLMB, or QI benefits are made to the state Department of Social Services (DSS) office serving the town of residence and may be conducted over the telephone. Eligibility for QMB is effective on the first day of the month following the month in which DSS has all the information and verification necessary to determine eligibility. This should not take more than 45 days. SLMB entitlement may be retroactive up to three months prior to the date of application if the person is otherwise eligible.
Remember income levels change April 1st each year.
Note: Applications and information about the QMB and SLMB programs are available at the individual's local Connecticut Department of Social Services office. Questions regarding eligibility can also be addressed to the Center for Medicare Advocacy, Inc. at (800)262-4414 or the Connecticut Department of Social Services CHOICES program at (800)994-9422.
THE CONNPACE
PROGRAM
To qualify, the individual must have resided in Connecticut for at least 183 days, and must be at least 65 years old, or at least 18 years old and disabled. The annual income of an individual cannot exceed $23,700; for a married couple it cannot exceed $31,900 (effective January 1, 2008).
In addition, the applicant cannot have another insurance plan that pays for all or a portion of each prescription on a continuous basis, including Medicaid (Title XIX) or a deductible insurance plan that includes prescriptions. Individuals can have an insurance plan with a maximum benefit, such as a Medicare managed care plan; they will become eligible for assistance when these benefits have been exhausted.
Annual Fee: There is an annual ConnPACE fee of $30.00. Co-Payments: All enrollees must pay a maximum of $16.25 toward the cost of approved drugs each time a prescription is filled.
Within 30 days after an application is processed, eligibility is determined and cards are mailed.
Individuals who are eligible for ConnPACE are also automatically eligible for the Connecticut ConnMAP program. ConnMAP requires Connecticut Medicare providers to accept assignment.
COORDINATION OF CONNPACE AND MEDICARE PART D
Click here for more information on how Connecticut has worked to "wrap around" the gaps in coverage created by Medicare Part D. Note: For ConnPACE information and application, telephone (800) 423-5026; in Hartford telephone (860) 832-9265.
THE CONNMAP PROGRAM
A ConnMAP card is issued to those who are eligible. It is best if individuals show the card to providers prior to receiving services to insure that the provider abides by the ConnMAP program terms and charge limitations. Individuals who are eligible and enrolled in ConnPACE are automatically eligible for ConnMAP and do not need to apply separately. Note: ConnMAP information and application, telephone (800)443-9946; in Hartford telephone (860)424-4925.
WHAT IS MEDICAID?
Also known as "Title 19", Medicaid is jointly financed by the federal and state governments. While each state is required to adhere to the basic eligibility and benefit requirements contained in the federal statute and regulations, significant details vary from state to state. Like Medicare, Medicaid provides payment for health care services, but it is very different from Medicare in a number of ways. Unlike Medicare, Medicaid eligibility is predicated upon the income and assets of the beneficiary. In general, Medicaid in only available for individuals who do not have sufficient income and assets to pay for their own medical treatment - according to Medicaid's strict income criteria. However, Medicaid is not available to all such individuals. Only certain people - those who are 65 years of age or older, those who are disabled, as defined by the Social Security Administration, young children, and their caretaker relatives, may qualify for Medicaid.
Medicaid covers far more nursing home care than Medicare, since it pays for necessary custodial, as well as skilled care, and it has no limit on how long nursing home care may be covered for eligible individuals. Significantly, both Medicare and Medicaid can be a source of funding for home care which extends over a long period of time. Medicare, however, only covers home health care if the individual is homebound and needs some skilled nursing or therapy services. Medicaid, on the other hand, does not always require that a person be homebound in order to receive home health benefits, and it may or may not require that the person need a skilled service to qualify for the home care benefit.
Medicaid financial eligibility rules differ depending upon the state of residence and living arrangement of the applicant. In particular, the rules for establishing eligibility for Medicaid for a person living in the community are very different from the rules governing eligibility for those residing permanently in nursing homes.
Click HERE for more information on Medicaid and related topics.
INTRODUCTION
Medicare and Medicaid home-based services can often make a critical difference for frail elders desiring to remain in their own homes and avoid institutional placement. Advocates with a thorough understanding of the home care resources available to Connecticut seniors under Medicare and Medicaid can assist clients in maximizing these home care options to further clients’ goals to live their lives in their own homes.
THE MEDICARE HOME HEALTH BENEFIT
In order to receive services under the Medicare home health benefit, a Medicare beneficiary must be homebound, as defined by the Medicare statute, and must be in need of intermittent skilled nursing or skilled therapy.
A beneficiary meets the homebound requirement if leaving home requires a considerable and taxing effort, and if the absences are infrequent or of relatively short duration. A considerable and taxing effort is established if the individual requires the assistance of another person or an assistive device, like a wheelchair, in order to leave home. Additionally, if leaving home unattended is contraindicated, the beneficiary meets the homebound criterion. The Medicare statute specifically provides that a person need not be bedbound to be considered homebound. Occasional and infrequent walks around the block or similar absences from the home are allowable. Absences from home for medical reasons, to attend certified or licensed adult day care programs, or to attend religious services are expressly permitted by the Medicare statute.
"Part time or intermittent services" are defined as skilled nursing and home health aide services, which, in combination, do not exceed eight hours a day and which are provided for no more than twenty-eight hours a week. An exception in the law calls for review on a case-by-case basis of those patients who need more care, up to a maximum of thirty-five hours per week.
In order to trigger coverage, skilled nursing care must be needed and received at least once every 60 days, but generally not daily - unless it can be shown that the need for daily nursing services will not continue indefinitely. In most cases, daily skilled nursing care will not be covered for more than 21 consecutive days. There are some exceptions to this general rule.
Skilled care is defined for purposes of Medicare coverage as care that is inherently complex and thus can only be safely and effectively performed by, or under the supervision of, professional or technical personnel. Examples of skilled nursing care include: wound care; catheter irrigation; and injections. Medicare also recognizes observation and assessment of a potentially changing condition, management of an overall care plan, and nursing education services as skilled nursing care.
The Medicare regulations and administrative guidelines are very clear that the stability and/or chronicity of an individual’s medical condition is not the determinative factor regarding entitlement to Medicare home health coverage. Likewise, coverage of rehabilitation therapy (physical, speech or occupational therapy) is not conditioned on restorative potential, or upon continued progress. Medicare coverage is available, so long as the skills of a trained therapist are required to safely and effectively deliver or direct the needed therapy services. Medicare home health services must be ordered by a treating physician and must be provided in accordance with a written plan of care, by or under arrangement with a Medicare certified home health agency. Medicare beneficiaries who meet the coverage criteria may receive skilled nursing, physical, speech and occupational therapy, medical social services, and home health aides.
The Medicare home health benefit is not currently subject to any deductible amount or copayment. Home health care may be covered by Medicare indefinitely; there is no durational limit on this Medicare benefit.
MEDICAID HOME CARE
The federal Medicaid (Title 19) mandatory benefit package includes a home health benefit. In addition, Connecticut has a Medicaid "waiver" home care program, called Category 3 of the Connecticut Home Care Program for Elders, (CHCPE). It offers more extensive services, including many services that are "non-medical" in nature, in order to prevent the premature institutional placement of frail elders who can be safely and cost-effectively maintained at home. Finally, Connecticut offers a fully state-funded component to the CHCPE, called Category 1 and Category 2.
THE MANDATORY MEDICAID HOME HEALTH BENEFIT
The mandatory Medicaid home health benefit is available to any Medicaid recipient in Connecticut, regardless of age, who qualifies for nursing facility placement. It must be determined that it is safe and cost-effective as compared to institutional placement to maintain the recipient at home. Cost effectiveness is measured by comparing the weighted average cost of the home care plan of care to the average comparable institutional Medicaid rate, (i.e., convalescent home, ICF/MR, hospital rate).
The home health benefit offers skilled nursing, physical, speech, and occupational therapy and home health aide services. Generally, services must be provided by a Medicare-certified home health agency. Prior approval must be obtained from the Department of Social Services for more than 20 hours of care each week.
The Medicaid home health benefit is similar to the Medicare home health benefit. Note, however, that a Medicaid recipient need not satisfy a homebound requirement. Furthermore, unlike Medicare, Medicaid will pay for home health aide services even when the individual does not require skilled care. In addition, services may be available in settings outside the recipient’s home, see Skubel v. Aaronson, 925 F Supp 930 (D. Conn 1996); Detsel v. Sullivan, 895 F. 2d 58 (2d Circuit, 1990).
Financial eligibility for Title 19 home care is based upon the Medicaid community eligibility standards. Generally, in 2006 single individuals in most parts of Connecticut may have no more than $683.00 in income (includes $207.00 unearned income disregard) and must have less than $1,600 in countable assets. Those who are otherwise eligible, but whose income is higher than permitted may "spend down" the "surplus income" to achieve Medicaid eligibility. Medicaid recipients are not required to contribute to the cost of the mandatory home health services unless they qualify as "medically needy" and are applying their "surplus income" to the cost of their home care services.
Medicaid home health recipients have a right to prior written notification regarding decisions about their services and they have a right to a Medicaid Fair Hearing to contest any denial, reduction or discontinuance of services. Importantly, if a Fair Hearing is requested within 10 days of a reduction or discontinuance in services, the service must be maintained until a Fair Hearing decision is rendered.
MEDICAID WAIVER HOME CARE: THE CONNECTICUT HOME CARE PROGRAM FOR ELDERS (CHCPE), CATEGORY 3
Connecticut has obtained a special Medicaid home care waiver in order to offer an expansive array of medical and social services to frail seniors who, in the absence of such services would be forced to accept nursing facility placement. The types of care which can be provided through the CHCPE include services which are not traditionally defined as medical services, such as shopping, laundering or companion services.
The goal of the CHCPE is to divert elders who would otherwise require nursing home care away from more costly institutional placement, when safe and cost-effective community-based care is appropriate and available. Only elders aged 65 and older are eligible for this program.
There are several tests of cost-effectiveness applied to recipients of Category 3 home care services. The total cost of the care may not exceed the cost to the state of institutional placement. Generally, the average Medicaid payment for nursing facility care is used in making this determination. In addition, the cost of any non-medical social support waiver services provided may not exceed 60% of the average Medicaid nursing facility payment. Under the cost cap calculations, 24 hour care could never be determined to be cost effective, unless other resources, such as family voluntary contributions of money or services were made.
Both financial and functional eligibility must be established by an applicant for Category 3 home care services. An applicant may have no more than $1,809.00 in monthly income in 2006. A single applicant must have less than $1,600 per month in countable non-excluded assets. Medicaid eligibility rules governing long term care, including transfer of assets prohibitions as well as spousal impoverishment prevention provisions apply to Category 3 of the CHCPE. The financial protections for the spouses of married applicants are similar to the spousal impoverishment prevention provisions governing Medicaid eligibility for nursing facility care. In 2006, at least $19,908.00 must be set aside for the "healthy spouse", in addition to the $1,600 the recipient may retain in assets. Thus, a couple may have at least $21,508.00 in assets while one spouse is a CHCPE Category 3 recipient. (For more information about spousal impoverishment prevention, see Paying for Nursing Home Care With Medicaid, published by the Legal Assistance Resource Center, Hartford, CT and available through any legal services office.)
Higher income Category 3 recipients must contribute to the cost of their care. They are permitted to retain an amount of monthly income equal to 200% of the federal poverty level as well as sufficient income to cover the Medicare Part B premium and any income which must be diverted to a "healthy spouse."
Functional eligibility is measured by whether or not the applicant requires the type of care provided by a nursing facility. The test used determines whether, in the absence of the package of home-based services available through the CHCPE, Category 3, the applicant would have to be placed in a nursing facility. It must also be safe to keep the applicant in a home setting.
Applications are made through the Department of Social Services Alternate Care Unit. Applicants complete a financial screening form. If it appears that eligibility can be established, a Medicaid application must be completed and submitted. The Alternate Care Unit screens for functional eligibility and refers cases to the regional access agency, a DSS contractor, which verifies eligibility and then proceeds to develop a cost effective care plan for each eligible individual. Medicaid appeals rights are applicable to Category 3 of the CHCPE.
STATE -FUNDED HOME CARE CATEGORIES 1 AND 2 OF THE CHCPE
Connecticut funds home care services with monies appropriated by the legislature. Like the Medicaid Waiver portion of Category 3 of the CHCPE, the services available under the state-funded levels of Categories 1 and 2 include social supports as well as medically-related home care. Financial eligibility is similar to Category 3.
There is no income limit imposed on applicants for categories 1 and 2. Asset eligibility is premised upon the minimum spousal impoverishment figure. If both spouses are eligible for services, they may have greater assets.
Functional eligibility for Category 1 is established by a risk of hospitalization or short-term nursing facility placement. For Category 2, an individual must need either short or long-term nursing facility placement. Category 1 services must cost no more than 25% of the average weighted nursing facility cost to the state. Category 2 services may cost up to 50% of the state’s cost of nursing facility care.
Category 1 and 2 recipients who are also Medicaid eligible may receive mandatory Medicaid home health benefits and additional services through the CHCPE. Similarly, Medicare home health services may also be combined with CHCPE services.
Applications are processed in the same manner as for Category 3. Effective October 1, 2000, several new services are included in the Connecticut Home Care Program for Elders. These include minor home renovations, such as grab bars, or widening doorways to accommodate wheelchairs and assisted living facility services in consenting state-funded congregate care residential facilities. In addition, a personal care attendant pilot project is available to serve 50 to 100 persons.
Click HERE for more information on home health care. CONNECTICUT AREA AGENCIES ON AGING
South Western Area Agency on Aging 10 Middle Street Bridgeport, CT 06604 203-333-9288
Agency on Aging of South Central Ct 1 Long Wharf Drive New Haven, Ct 06511 203-785-8533
Eastern Connecticut Area Agency on Aging 4 Broadway 3rd Floor Norwich, CT 06360 860-887-3561 http://www.seniorresources.org/
North Central Area Agency on Aging Two Hartford Square West, Suite 101 Hartford, CT 06106-1903 860-724-6443
Western Connecticut Area Agency on Aging 84 Progress Lane Waterbury, CT 06705 203-757-5449
CHOICES Health Insurance Hot Line 1-800-994-9422
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