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I HAVE MEDICARE…. and I need help paying for my medical expenses, including my Medicare premiums, coinsurance and drug costs. How can my state’s health care marketplace (a.k.a. exchange) help me?

►  What programs are available in the marketplace to help pay for Medicare?

Medicare Savings Programs (MSP) and Medicaid are insurance affordability programs that can help you pay for costs associated with your Medicare.  The marketplace should screen you with the single streamlined application for an MSP and Medicaid. You should not have to ask to apply for a particular insurance affordability program.  The marketplace should evaluate you for all programs available in the marketplace for which you potentially qualify.

  • Medicaid

Medicaid is health insurance that wraps around (supplements) Medicare and pays for Medicare’s deductibles and coinsurance as well as for services that Medicare does not cover, such as long term services and supports. Low-income people with Medicare must meet more stringent income and asset requirements than people without Medicare when applying for Medicaid. In most states, to qualify for Medicaid when you have Medicare, your income must be below 75% of the Federal Poverty Level (about $718/month in 2013). Furthermore, your income will not be determined based on your Modified Adjusted Gross Income (MAGI), but by a more complicated “income disregard” system. You will also be subject to an asset limit.

If, after completing the single streamlined application, you are found potentially eligible for Medicaid the marketplace will transfer your application to the single state Medicaid agency for processing.[1] The Medicaid agency will also use data matching with other government agencies like the Social Security Administration and the Internal Revenue Service (IRS) to collect as much information as possible, and will then request any missing data from you.[2] You will likely be required to fill out a supplemental application with more detailed questions and submit documentation of your income and assets.[3]

The Medicaid agency has 90 days to process your application and give you a decision if you are applying for Medicaid on the basis of disability.[4] For everyone else the Medicaid application must be processed in 45 days.[5] If denied, you have the right to an appeal.[6]

  • The Medicare Savings Program (MSP)

The Medicare Savings Program (MSP) will pay for your Medicare premiums and, in some cases, your deductible and coinsurance. The marketplace should screen you for a Medicare Savings Program with the single streamlined application, and if your income is below 135% (or 200% in limited circumstances) of poverty you should be enrolled in such a program. Most states may also have asset tests for the Medicare Savings Program. The Medicaid agency will need to use the same or a similar income-disregard eligibility calculation as they do for Medicaid, so they may request additional information about your income and assets from you.

Your application should be processed and you should get a decision within 45 days. If denied, you have the right to an appeal and your denial letter should give you instructions on how to pursue this.

  • Stand alone dental plans and long term care insurance

Medicare beneficiaries who would like to buy dental or long term care insurance to supplement their Medicare should be able to do so in the health care marketplaces. However, enrollees will not be eligible to receive advance premium tax credits for these policies.[7]

►  What programs ARE NOT available to me in the healthcare marketplace?

While the marketplace can screen you for Medicaid and MSP to help you afford your Medicare, there are still other subsidy programs you may qualify for that you will need to apply for outside the marketplace.

  • Part D and the Extra Help (the Low Income Subisdy)

You will not be able to shop for Part D drug plans in the health care marketplace. You must visit https://www.medicare.gov/find-a-plan or call 1-800-MEDICARE in order to enroll in a Part D plan. Remember, you must be in an enrollment period in order to enroll in a Part D plan.

Extra Help is a program that can help you pay for your drug plan premium and coinsurance. You cannot apply for the Extra Help through the marketplace.[8] In order to apply for Extra Help, you must visit www.ssa.gov/prescriptionhelp or call 1-800-MEDICARE.  If you qualify you will be able to enroll in a Part D plan outside an enrollment period.   

Remember, if you qualify for an MSP (which you can apply for through the marketplace) you will automatically qualify for and be enrolled in Extra Help.

  • Medicare Advantage

You will not be able to shop for Medicare Advantage plans in the marketplace. You should visit www.medicare.gov/find-a-plan or call 1-800-MEDICARE to learn what Medicare Advantage plans are offered in your area. Remember, you must be in an enrollment period in order to enroll in a Medicare Advantage plan.

  • Medigap

You will not be able to shop for Medicare Supplements, also known as Medigap plans, in the marketplace.

  • Qualified Health Plan (QHP) with Advance Premium Tax Credit

Remember, if you have Medicare, a qualified health plan is NOT NECESSARY and should not be purchased. Individuals with Medicare enrolled in QHPs are not eligible for an Advanced Premium Tax Credit (APTC) no matter how low their income.[9]

If somehow you accidently become enrolled in a QHP, you should have a special enrollment period to dis-enroll from the plan.[10] Be sure to report anyone fraudulently marketing a QHP to Medicare beneficiaries to your state’s department of insurance.

I AM ABOUT TO GET MEDICARE and I want to make sure I have the most affordable health insurance and there are no gaps in my coverage. What should I do if….

►  I am enrolled in a Qualified Health Plan with an Advance Premium Tax Credit (APTC)

  • Can I delay taking Medicare to stay in my current plan?

It would be very unwise to delay taking Medicare to remain in your QHP. You should enroll in Part B during the first three months of your Initial Enrollment Period. Delaying Part B enrollment will subject you to a premium penalty if you later decide to enroll.  If you later want to pick up Part B, you will only be able to do so during the General Enrollment Period from January through March each year, with coverage beginning up to six months after enrollment. Furthermore, a QHP will likely cost you more than either Medicare with a Medigap plan or a Medicare Advantage plan.

Your QHP will not terminate automatically upon Medicare eligibility.[11] In order to cancel your QHP, you must give the plan “reasonable notice.” Reasonable notice is 14 days or more, and you have the ability to require a specific termination date if reasonable notice is provided.[12]

  • Can I take Medicare and keep my QHP with an APTC?

If you have Medicare, you cannot be eligible for an APTC no matter how low your income.[13] If you choose to keep your QHP when you become eligible for Medicare, you will not be entitled to an APTC. Your APTC should cancel automatically upon becoming Medicare eligible.[14] 

►  I am enrolled in expansion Medicaid for people with incomes between 100% and 138% of poverty

  • Can I just keep Medicaid and not enroll in Medicare?

Assuming you have sufficient work history, you will automatically get Part A for free if you are receiving Social Security benefits when you turn 65.  You should also get Part B when you are eligible. You will want to enroll in a Medicare Savings Program (discussed on page 2) to pay for your Part B premium. Since you already have Medicaid, you should automatically go through a Medicaid redetermination upon becoming Medicare eligible, and you should be screened for the Medicare Savings Program (MSP) during this redetermination.[15] During the redetermination process the state Medicaid agency will ask you for information on your income and assets.[16] In most states, even if you no longer qualify for Medicaid after getting Medicare, you will likely qualify for an MSP.  Once you have an MSP, you will be “bought-in” to Part B, that is, you will be automatically enrolled without having to Pay a premium. Ideally, the process of redetermination and Part B enrollment should be automatically triggered and happen seamlessly. However, it is good idea to apply for an MSP with either the marketplace or the Medicaid office MSP one month before you are eligible for Medicare just be certain you are enrolled in an MSP and Part B as soon as you are eligible.

  • Can I enroll in Medicare and keep full Medicaid, too?

It depends on your income. Income limits for Medicaid for people with Medicare are lower than for people with only Medicaid—usually the income limit is between 75% and 100% of the Federal Poverty Level. You should be automatically reassessed for continued Medicaid eligibility upon becoming eligible for Medicare.[17] This renewal of eligibility will likely require you to submit additional documentation about your income and assets.[18] If you still meet more strict eligibility guidelines, you will be able to keep Medicaid in addition to Medicare. 

►  I am low-income and worried I won’t be able to afford my Medicare premiums and coinsurance.

The month before you become Medicare eligible, be sure to apply for an MSP either through the Marketplace or at your local Medicaid office.  This will ensure that when you become eligible for Part B, no premium payments will be deducted from you Social Security check.

You should also apply for Extra Help to see if you qualify for assistance with your Part D drug costs. You can apply for online at http://www.ssa.gov/prescriptionhelp/ or visit your local Social Security Office.

►  I have insurance through my job offered through a the Small Business Health Options Plan (SHOP)

Your employer insurance offered through a SHOP is still considered employer sponsored coverage for the purposes of Medicare Secondary Payer. Medicare will either pay primary to your employer plan or secondary to your employer plan depending on how large your employer is. See here for more details: http://www.medicare.gov/Pubs/pdf/02179.pdf

 


[1] If the Marketplace is a governmental entity, states will have the option to enable their state based Marketplace to make Medicaid eligibility determinations for non-MAGI eligibility groups (including people with Medicare). The Federally Facilitated Exchange/Marketplace will not be making Medicaid eligibility determinations for non-MAGI groups; the Federally Facilitated Exchange will either do final determinations or assessments for the MAGI eligibility groups. See Medicaid/CHIP Affordable Care Act Implementation: Coordination Across Insurance Affordability Programs (May 22, 2012)  http://www.medicaid.gov/State-Resource-Center/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation/Downloads/Coordination-FAQs.pdf
[2] Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17161, 171622 (to be codified at 42 C.F.R.. § 435.912(c))
[3] Id. at 17168
[4]In the case of individuals who may be eligible on a basis other than the applicable MAGI standard (for  example, based on disability), the obligation under 42 C.F.R. § 435.911(c)(1)  can be met either by promptly determining an individual eligible based  on the applicable MAGI standard and providing benefits on such basis  and then exploring eligibility for other eligibility categories excepted from MAGI methods, as appropriate, or, if possible to achieve  promptly and without undue delay, by first determining eligibility on the MAGI-excepted basis. Id. at 77 Fed. Reg. 17167 (to be codified at 42 C.F.R. § 435.912)
[5] Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17161, 17162 (to be codified at 42 C.F.R. § 435.912(c)(3))
[6] 42 C.F.R. §§ 431.206; 431.210; 435.912, 435.919
[7] While these policies will be available for purchase in the Marketplace, because they excepted benefits they are not eligible for an APTC. Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule 77 Fed. Reg. at 18411 ( to be codified at 42 C.F.R § 155.1065)
[8] 42 C.F.R. §435.4
[9] Medicare is considered minimum essential coverage. 26 U.S.C § 5000A(f)(1)(A)(i); Health Insurance Premium Tax Credit 77 Fed. Reg. 30388 (to be codified at 26 U.S.C. § 1.36B-2(c)).  See also Health Insurance Exchanges Under the Patient Protection and Affordable Care Act, The Congressional Research Service (January 31, 2013) http://www.healthreformgps.org/wp-content/uploads/crs0204.pdf
[10] Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule 77 Fed. Reg. 18390 (to be codified at 42 C.F.R. § 1455.420)
[11] Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule, 77 Fed. Reg. at 18371-18374, 18394, 18395, 18463 (to be codified at 45 C.F.R. §155.330 and 155.430);  Health Insurance Premium Tax Credit, 76 Fed. Reg. at 50933, 50934, 50941.
[12] Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule, 77 Fed. Reg. at 18394, 18395, 18463 (to be codified at 45  C.F.R. § 155.430)
[13]Supra note ix
[14] P.L. 111-148 Section 1401 as modified by P.L. 111-153 Sec. 1001; Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers; Final Rule and Interim Final Rule, 77 Fed. Reg at 18371-18374, 18395, 18463 (to be codified at 45 § C.F.R 155.430), Health Insurance Premium Tax Credit, 77 Fed. Reg. at 30379, 30380, 30388.
[15]42 C.F.R § 435.930; 42 C.F.R. § 435.916(c)(1) (requires state agency to redetermine eligibility when it receives information about changes in a recipient’s circumstances that may affect his/her eligibility); Individuals receiving SSI should be automatically “deemed” for an MSP without going through an ex parte redetermination requiring supplemental documentation. See SSA POMS HI 00815.006.  
[16] Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010, 77 Fed. Reg. at 17181-17183, 17210 (to be codified at 42  C.F.R. § 435.916)
[17] Medicaid Program; Eligibility Changes Under the Affordable Care Act of 2010 77 Fed Reg. at 17181 to be codified at 42 C.F.R. § 435.916(f)(1) in accordance with longstanding policy the agency must consider all bases of eligibility when conducting a renewal of eligibility. To meet this requirement, renewal forms will need to include basic screening questions, similar to those that will need to be on the single streamlined application, to indicate potential eligibility based on disability or other basis other than the applicable MAGI standard.
[18] Supra at Note xvii.

 

 

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