Health
Insurance,
Help With Medicare
Health
Costs Care Reform
and
Resources
Artists Health Insurance Resource Center
inwww.ahirc.org
Chicago
A program of The Actors Fund
www.actorsfund.org
Dancers’ Health Insurance Resource Center
A program of The Actors Fund with
support from The Doris Duke Foundation
Presenter:
Presenter:
Jim
Elizabeth
Brown, Director
Tripp, Medicare
of HealthCounselor
Services,etripp@actorsfund.org
jbrown@actorsfund.org.
Introduction
This presentation was designed to help you understand:
• Programs that help cover costs associated with
Medicare
• Whether you are eligible for any of these programs
• How to apply for them
What does this tutorial cover?
The programs we will cover today are:
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Medicaid
Medicaid with spend-down
Medicare Savings Programs
Extra Help
State Pharmacy Assistance Programs (SPAPs)
Pharmaceutical Assistance Programs (also called
Patient Assistance Programs)
What is Medicaid?
Medicaid helps some people with limited income and resources with
medical costs. People who qualify for both Medicare and Medicaid
are called “dual eligibles.”
Medicare is their primary insurance, and Medicaid pays many of the
costs that Medicare does not. These costs include premiums, coinsurance, co-payments and deductibles.
Medicaid also offers benefits not normally covered by Medicare, like
nursing home care and personal care services.
If you qualify for Medicaid in your state, you automatically qualify for
Extra Help, a program that helps pay your Medicare Prescription
Drug coverage (Part D).
Am I eligible for Medicaid?
Every state uses financial eligibility guidelines to determine whether
you qualify for Medicaid. Generally, your income and assets must be
below a certain amount to qualify, but this amount varies from state
to state. Use your state’s Medical Assistance website to find the
income guidelines for where you live.
How do I apply for Medicaid?
You may be able to apply for Medicaid in-person at a Medicaid office
or community organization, online, by mail, or even over the phone
in some circumstances. Again, check with your state’s Medicaid site
to see your options.
What is Medicaid "spend down"?
If your income is over the Medicaid eligibility limit, you may still be
eligible under Medicaid “spend-down” rules. The spend-down is
intended to help people whose income is too high to qualify for
Medicaid, but who have significant medial expenses that reduce
their income.
How is it calculated?
The spend-down (also called the medically needy process, or excess
income program) allows you to “spend down”, or subtract, your medical
expenses from your income to become eligible for Medicaid. Your spenddown amount will be the difference between your income and the Medicaid
eligibility limit over a certain period of time.
To be eligible as “medically needy”, your measurable resources have to be
under the resource amount allowed in your state.
Example:
If the income limit for Medicaid is $800 per month, and your income is $920,
your monthly spend-down amount would be $120.
$920 income
-$800Medicaid income limit
= $120 spend-down, or the amount of your income that exceeds the
Medicaid limit
How does the "spend-down" process work?
In some states, the spend down amount is treated like a deductible
– after you pay the spend-down amount for medical co-pays out of
your own pocket, Medicaid will cover the rest of your expenses. In
other states, you pay a monthly premium directly to Medicaid for the
amount that your income is over your state’s Medicaid spend-down
level.
Your state will determine how long a period of time you will qualify
for a spend-down.
You may be required you to submit your medical bills to Medicaid to
prove the sum of medical expenses.
You can apply for a spend-down when you apply for Medicaid.
What are Medicare Savings Programs?
If you don’t qualify for Medicaid or the spend-down program, you
may still be able to get help paying some of your out-of-pocket
expenses. Medicare Savings Programs (MSPs) help pay your
Medicare costs if you have limited finances. There are three main
programs, as well as a special program for people who are disabled
and are working, and each has different income eligibility limits.
Medicare Savings Programs can pay premiums, deductibles, coinsurance, and co-payments.
Am I eligible for a Medicare Savings Program?
Eligibility for MSPs is based on a percentage of the Federal Poverty
level (FPL).
For a single person, 100% of the Federal Poverty Level is equal to
an annual income of $11,490. For a couple, it’s equal to $15,510.
See the following slide for the income limits for each program.
Medicare and Medicaid
Enrollee Category
Income Eligibility Level
Resource Standards
What the Program Pays
For
Qualified Medicare
Beneficiary (QMB)
100% FPL
($11,490 individual,
$15,510 married couple)
$6,680/ individual,
$10,020/ couple
Part A premiums, Part B
premiums,
deductibles/coinsurance/co-payments
Specified Low-Income
Medicare Beneficiary
(SLMB)
120% FPL
($13,788/ individual,
$18,612/couple)
$6,680/ individual,
$10,020/ couple
Part B premiums only
Qualified Individual (QI)
135% FPL
($15,511/ individual,
$20,938/couple)
$6,680/ individual,
$10,020/ couple
Part B premiums only
Qualified Disabled
Working Individual
(QDW)
200% FPL
($22,980/ individual,
$31,020/couple)
$4,000/ individual,
$6,000/ couple
Part A premiums only
How can I apply for an MSP?
Medicare Savings Programs are administered by a state’s Medicaid
Program.
Click here to find your state’s MSP, which has information about
eligibility, applications, and what documentation you will need to
apply.
What is Extra Help?
Extra Help is a program that helps people with limited income and
resources pay for some or most of their Medicare prescription drug
costs.
Extra Help works with Medicare Part D plans. If you qualify for Extra
Help and join a Medicare drug plan, you’ll:
• Get help paying your Medicare drug plan’s monthly premium, yearly
deductible, coinsurance, and co-payments
• Have no coverage gap
• Have no late enrollment penalty
Do I qualify for Extra Help?
• You may qualify for Extra Help if your yearly income and resources
are below these limits in 2013:
• For a single person— your annual income must be less than
$17,235 and resources less than $13,300
• For a married person living with a spouse and no other
dependants—your annual income must be less than $23,265 and
resources less than $26,580.
How do I apply for Extra Help?
You automatically qualify for Extra Help if you have Medicare and
also:
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Have full Medicaid coverage
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Are enrolled in a Medicare Savings Programs
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Get Supplemental Security Income (SSI) benefits
• If you don’t automatically qualify, you can fill out an application with
Social Security online.
• You can call Social Security for help with the application at 1-800772-1213.
What documents will I need
to apply for Extra Help?
To fill out the application, you will need access to:
• Your Social Security card;
• Bank account statements, including checking, savings, and
certificates of deposit;
• Individual Retirement Accounts (IRA), stocks, bonds, savings bonds
(including book entry securities*), mutual funds, other investment
statements;
• Tax returns;
• Payroll slips; and
• Your most recent Social Security benefits award letters or
statements for Railroad Retirement benefits, Veterans benefits,
pensions and annuities.
What counts as a resource or asset?
Countable resources include:
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Money in a checking or savings account
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Stocks
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Bonds
Countable resources don't include:
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Your home
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One car
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Burial plot
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Up to $1,500 for burial expenses if you have put that money aside
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Furniture
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Other household and personal items
What are State Pharmacy Assistance Programs
(SPAPs)?
State Pharmacy Assistance Programs help people pay for
prescription drugs based on financial need, age, or medical
condition. Each SPAP makes its own rules on how to provide drug
coverage to its members. Many states coordinate their SPAPs with
Medicare’s drug benefit (Part D).
Your SPAP may help pay for your Part D plan’s premium, deductible,
copayments, and coverage gap. Some SPAPs only give you
coverage during your Part D plan’s coverage gap or “donut hole.”
Find your SPAP here.
What are Pharmaceutical Assistance Programs?
Pharmaceutical Assistance Programs provide low-cost or free drugs
to people with low incomes. While many PAPs will not accept people
with Part D plans, some do.
Medicare.gov has a great tool for finding PAPs specifically for your
needs. Click here to enter the name of the prescription that you
need help paying for to see if there are any PAPs that will assist with
the cost.
For other tips on saving money on prescription drugs, see our
tutorial “10 Ways to Get Medications Discounted or Free”.
Additional Resources
This tutorial was designed to educate you on the programs that may
help you with your Medicare out-of-pocket costs.
For more detailed information on Medicare, visit:
www.medicare.gov
www.Medicareinteractive.org
Glossary
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Co-insurance – the amount you pay for your portion of medical services, usually expressed as a
percentage. For example, Part B has a 20% co-insurance rate. Medicare pays 80% of the cost of
a covered service, and you are responsible for 20%.
Co-pay – a flat dollar amount paid for a medical service, such as an office visit or prescriptions.
Deductible - The amount you must pay for health care or prescriptions before Original Medicare,
your prescription drug plan, or your other insurance begins to pay.
Extra Help - A Medicare program to help people with limited income and resources pay Medicare
prescription drug plan costs, such as premiums, deductibles, and coinsurance.
Medicaid - a public health insurance program for individuals and families with low incomes and
resources. It is jointly funded by states and the federal government, and is managed by the states.
Among the groups of people served by Medicaid are eligible low-income parents, children,
seniors, and people with disabilities.
Medicaid with spend-down – a program intended to help people whose income is too high to
qualify for Medicaid, but who have significant medial expenses that reduce their income.
Medicare Savings Programs – Four programs that help people with limited income and
resources cover their out-of-pocket Medicare expenses.
Glossary, cont'd
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Qualified Medicare Beneficiary (QMB) Program—Helps pay for Part A and/or Part B
premiums, deductibles, coinsurance, and copayments.
– Specified Low-Income Medicare Beneficiary (SLMB) Program - Helps pay Part B
premiums only.
– Qualifying Individual (QI) Program—Helps pay Part B premiums only. You must apply
every year for QI benefits and the applications are granted on a first-come first-served basis.
– Qualified Disabled and Working Individuals (QDWI) Program - Helps pay Part A
premiums only. You may qualify for this program if you have a disability and are working.
Out-of-pocket expense - medical expenses that are not covered by insurance and are paid for
directly by the individual.
Pharmaceutical Assistance Programs (also called Patient Assistance Programs) assistance programs for people with Medicare drug coverage who meet certain requirements
offered by major drug manufacturers
Premium - The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
State Pharmacy Assistance Programs (SPAPs) – state-run programs that help certain people
pay for prescription drugs based on financial need, age, or medical condition. Each SPAP makes
its own rules on how to provide drug coverage to its members.