15.04 MEDICARE

 

Table of Contents

Title

MPG Cite

Medicare

15.04.01

Medicare Part B Benefits

15.04.02

Medicare Part B Buy-In

15.04.03

Medicare Part D Benefits

15.04.04

 


15.04.01 Medicare

 

A. 
General

This section provides staff with information about Medicare.  It describes Medicare Buy-In, the process in which DHCS pays premiums for Medicare Part B for some qualified Medi-Cal beneficiaries.

 

Medicare is a federally administered health insurance program for qualified persons.  Medicare benefits are divided into three parts:

 

1.  Part A - Hospital Insurance

2.  Part B - Supplementary Medical Insurance

3.  Part D - Prescription Drug Coverage

 

 

MEM Proc. 15F

 

 

 

ACWDL 91-46

 

B.
Medicare Eligibility
 

Eligible for Part A, Part B and Part D

The following persons are eligible for both Part A, Part B and Part D benefits:

  1. Persons or their spouses eligible to RR/SSA based Medicare with the required quarters of employment; and,
  2. Individuals who are any one of the following:

·         65 years of age or over;

·         Disabled or blind for at least 24 consecutive months under SSA Title II; or

·         Chronic renal disease meeting requirements for the receipt of Medicare.  This category may include SSA/RR recipient's dependent children who do not have to meet the conditions in 1 above.

 

Eligible for Part B Only

 

Persons who are eligible for Medicare Part B benefits only include:

  1. Persons who are not eligible for Medicare Part A;
  2. 65 years of age or over; and
  3. U.S. citizens or aliens legally present in the U.S. for at least five years.

 

 

 

 


15.04.02 Medicare Part B Benefits

 

A.
Medicare Part B Benefits

Coverage

 

After the beneficiary pays the required deductible amount, Medicare Part B medical insurance pays 80 percent of the reasonable charges for most non-institutional medical services such as physician services, home health agency services and drugs which cannot be self administered.  A zero SOC Medi-Cal card may pay both the deductible and charges over 80 percent for Medicare beneficiaries.

 

Payment of Premiums

 

·   This is a voluntary health insurance program, financed by premiums from qualified enrollees and supplementary federal funds.

·   DHCS pays these premiums for eligible Medi-Cal and SSI/SSP beneficiaries with zero SOC or those who have met their monthly SOC, or a certified SOC beneficiary, including individuals in long-term care who qualify to have their SOC verified on the first of the month.

·   Individuals eligible for MSP, QMB, SLMB, and QI-1 are eligible for payment of Part B premiums regardless of whether they are eligible for Medi-Cal under another program, with or without a SOC.

 

MPG LTR 726 (5/11)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACWDL 11-15

 


15.04.03 Medicare Part B Buy-In

 

A.
Persons Eligible for Buy-In

Buy-In refers to the arrangement through which DHCS pays the monthly premiums of Medicare Part B (supplementary medical insur­ance) for qualifying Medi-Cal beneficiaries.

 

A PA or MN applicant who is 65 or over, blind, disabled, or who has chronic renal disease is qualified for Buy-In, if the indi­vidual is entitled to Medicare.

 

B.
Worker Responsibilities for the Buy-In Process at Application

The worker has the responsibility of identifying applicants poten­tially eligible for Buy-In and providing the information required for Buy-In processing by DHCS.

 

At the intake interview, the worker will identify applicants potentially eligible for Buy-In.

 

If the applicant ...

Then the worker must...

 is not a current Medicare recipient

·   Verbally inform the applicant of his/her responsibility to apply for Medicare;

·   Send AL 978 to inform the client of the requirement to apply for Medicare;

·   Set up a case alert for 60 days for all applicants who are required to apply for Medicare.

 

Note: Individuals with a SOC are not required to apply for Medicare Part B, unless the individual is MSP eligible.

 is currently a Medicare recipient

·   Verify Medicare HIC number.

·   Enter HIC on automated system as appropriate even if previously entered and case has been closed.  This entry will send a notice to DHCS to begin the Buy-In.

·   Advise the applicant of the Buy-In system, including the anticipated raise in the net amount of the SSA check, and the time involved for the change to occur.

·   Check the MEDS Buy-In screen in 60 days to insure that Buy-In is set up. 

refuses to file for Medicare coverage and is not entitled to monthly Social Security benefits or Railroad benefits

Apply for medical insurance (Part B) on behalf of the applicant.  To apply for Medicare for a beneficiary, the worker will:

Step

Action

1

Complete an application, Form SSA-4040, and mail it to the local SSA office; or

2

If the applicant, upon request, refuses to provide the County with the necessary information for full completion of the SSA-4040, such as age, citizen­ship, or lawful alien status and residency, refer the case to DHCS Buy-In Unit using Form DHS 6166.

3

Advise the applicant of the following:

·   The applicant must apply for Medicare Part A even though DHCS enrolls the beneficiary in Medi-Cal Insurance (Part B).  He/She will not have hospital protection through either Medicare or Medi-Cal if he is eligible for Part A but refuses to apply.

·   By filing an application, the individual may establish entitlement to hospital insurance (Part A);

·   The filing of an application will permit SSA to determine the individual's eligibility for monthly retirement benefits.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACWDL 11-15

 

 

MPG LTR 726 (5/11)

 

 

C.
Worker Responsibilities for the Buy-In Process on Granted Cases

Collection of Buy-In information should be initiated by the worker for a Medi-Cal recipient when they reach the age of 64 years and 9 months.

 

MEDS generates a message for every Medi-Cal beneficiary when they reach age 64 and 9 months. This message alerts the worker to contact the beneficiary regarding the requirement to apply for Medicare.  The worker must take the following actions:

 

Step

Action

1

The worker will send client correspondence 978 advising the beneficiary of the requirement to apply for Medicare.

2

Set up a case alert for 60 days from the date the worker notified the beneficiary to apply for Medicare.  The three months prior to age 65 allows lead time for processing Buy-In information through channels.

 

D.
Buy-In Effective Date for MN Persons
 

Buy-In Effective Date for MN Persons

 

1.    Buy-In for an MN person begins the second month after the month he is approved for Medi-Cal.  The approval date means the date on which the worker makes the determination that the beneficiary is eligible for Medi-Cal.

 

2.    The two-month lag time is automatically calculated by DHCS from the date of approval reported by the Counties through MEDS.

 

3.    When a Medi-Cal eligible beneficiary receiving Medicare changes from PA to MN status, there should be continuous Buy-In and the two-month lag time does not apply.

 

 

 

ACWDL

90-48

 

 

 

4.    Any overstated SOC can be adjusted in later months on a month-by-month basis.  Refer to MPG Article 12, Section 1, for adjustment procedures.

 

5.    Buy-In is effective immediately for an MN person who becomes Medicare eligible.

 

6.    Buy-In coverage ends on the last day of the month in which a person loses eligibility for either Medicare or Medi-Cal.  So long as a beneficiary is continually Medi-Cal and Medi­care eligible, there should be no breaks in Buy-In coverage unless the Medicare eligible person has a SOC.

 

MPG LTR 726 (5/11)

 

 

 

 

 

 

 

 

 

 

 

ACWDL

11-15

 

 

 

E.
Predicting Buy-In for applications

Buy-In is to be predicted for those individuals with zero SOC in the second month following the month the granting action is taken, regardless of the beginning date of eligibility.

 

Example:       The applicant signs the application in May, and the granting action is taken in June, effective May 1.  Buy-In will be predicted for the month of August, the second month following the month the granting action is taken (June).

 

In the example above, Buy-In will be predicted for July when the granting action is taken in the same month the application is signed (May).

 

MPG LTR 726 (5/11)

 

F.
Buy-in Problems

The DHCS Buy-In Unit is available to assist in resolving problems.  The Buy-In Unit's responsibilities are limited to resolving problem cases which cannot be accomplished by routine Buy-In data processing.

 

Workers will use Form DHCS 6166 to communicate problems to the Buy-In unit.  In order to successfully resolve a problem case, it is imperative that enough information is provided to enable state staff to work the case.  Include the following data in the DHCS 6166, Complaint Form:

 

  1. Date of request.

 

  1. Beneficiary's full name.

 

  1. Social Security and Health Insurance Claim numbers.

 

  1. Date of Birth and Sex.

 

  1. 14-digit case identification number.

 

  1. Medi-Cal effective dates for each period relevant to the problem.

 

  1. County Representative information, name, return address and phone number.

 

  1. A description of the problem and the change being request­ed.  This should be detailed enough so that the technician in the Buy-In Unit will know exactly what the problem is and the action the County wants DHCS to take.  In those situations where the County is notified that an individual was inadvertently dropped from Buy-In, the County will:

 

·      Notify SDHS to resume Buy-In, using Form DHS 6166, State Buy-In Problem Report;

 

·      Adjust any overstated Share of Cost in those months where timely reporting occurred or occurs; and,

 

·      Assume Buy-In is effective in the second full month following the approval date for Medi-Cal.

ACWDL

08-48

 

 

 

 

 

 

G. 
Part B Premiums for Beneficiaries with a SOC

DHCS will not request Buy-in for an individual with a SOC until that SOC has been met or certified. 

 

SSA will deduct the Part B premium amount from the beneficiaries’ SSA the month following the SOC increase.  This should be counted in the Medi-Cal budget as a Medical insurance deduction.

 

When beneficiaries receive a deduction because they paid their own Medicare premium and the payment of that premium either:

 

·   Reduces their SOC to zero , or

·   Makes them eligible for the Aged and Disabled Federal Poverty Level Program; then

 

DHCS will pay their premium for that month retroactively.  The beneficiary will be reimbursed for that month through their SSA benefit retroactively.  When the reimbursement is received, it must be counted as property in the month of receipt.

 

When workers receive alert…

Then workers must…

8010 indicating that DHCS is no longer paying the Medicare premium.

add the premium payment as a health insurance deduction for the following month.  No 10 day notice is required to reduce the SOC.

8004 indicating that DHCS is paying the Buy-In

remove the premium payment as a health insurance deduction.  This change is an increase in the SOC, so 10 day notice is necessary.

 

MPG LTR 726 (5/11)

ACWDL 11-15

 

 

 

ACWDL 08-48

 

H. 
Part B Premiums for Beneficiaries with a SOC Met

DHCS does not pay Part B premiums for applicants and beneficiaries with a SOC unless the SOC is met on a monthly basis.  Below are some common examples of meeting the SOC:

 

·   Nursing home residents who regularly meet their SOC will have their Part B premiums paid for those individuals who are certified on the first of each month. 

 

·   IHSS recipients who regularly meet their SOC will have their Part B premiums paid for those months when the SOC is met.

 

·   A beneficiary with a Medi-Cal SOC and an IHSS SOC must meet the Medi-Cal SOC before Medi-Cal will pay the Part B premium.

 

MPG LTR 726 (5/11)

ACWDL 11-15

 

I. 
Ping Pong Effect for Beneficiaries with a SOC

There are some cases where allowing the Part B premium deduction will eliminate the SOC where DHCS will begin to pay the Part B premiums. However, once the Part B premium is paid by DHCS, the beneficiary will no longer be entitled to the deduction, which creates an SOC or ineligibility to MSP. This ineligibility forces DHCS to discontinue premium payments, starting the cycle all over again.

                       

Example:

 

November

 

A SOC is reported to MEDS November 7th.  The premium deduction is $100.

December

 

We know that SSA will deduct the Part B premium amount from beneficiaries’ SSA check December 1, so we budget the $100 medical insurance deduction and we get zero SOC.  That zero SOC is reported to MEDS prior to MEDS cutoff for December.  DHCS requests the Buy-In for January.

January

 

DHCS Medicare Buy-In is in effect.  Since DHCS is paying the Part B premium, the medical insurance deduction for Part B premium will be removed from the January budget and that will create a SOC for January. Based on January SOC, DHCS does not request Buy-In for February. 

 

February

 

Since DHCS did not request Buy-In for February, SSA will deduct the premium amount from beneficiaries’ SSA February check February 1, so we budget the $100 medical insurance deduction and arrive at zero SOC reported to MEDS for February.  DHCS requests Buy-In for March.

 

                       

Staff must make the changes to the budget as they receive the MEDS alerts, bearing in mind that any increase in the Medi-Cal SOC requires a 10 day notice.

 

MPG LTR 726 (5/11)

ACWDL 11-15

 

ACWDL 08-48

 

 

 

 

 

 

 

 

 

 

ACWDL 11-15

 

J. 
Required Assistance for beneficiaries with a SOC

Workers must take the following actions to assist affected beneficiaries:

 

Step

Action

1

Ensure that the beneficiary was evaluated for the following programs:

·    MSP;

·   250% WD; or

·   A&D FPL.

2

Review the MSP and SOC budgets and ensure that all appropriate deductions have been entered.   For example, if a beneficiary pays Part D premiums monthly, make sure those premiums are entered in the budget as a health insurance deduction.

3

Inform eligible beneficiaries of the 250% Working Disabled program.  This program can pay for Medicare Part B Buy-In and will usually have a much lower monthly premium.

4

Beneficiaries with a SOC are not required to apply for Part B, and may drop the coverage if they cannot afford it.  This would not be in their best interest, however. 

 

When beneficiaries choose not to pay their Part B Medicare

premium, beneficiaries will no longer have Part B Medicare. Consequently, the beneficiaries will be expected to pay for their Medi-Cal SOC in a given month before Medi-Cal can begin to pay for any of their health care services. 

 

When a beneficiary chooses to pay for the Part B Medicare premium (see Article 11, appendix B for the current premium amount), Medicare will continue to pay for services such as doctor visits, lab work X-rays and durable medical equipment.   For beneficiaries with a SOC, paying the premium is a better option.

 

Applicants/beneficiaries must be advised of the 10 % premium increase for each 12-month period they were eligible, but did not enroll in Medicare Part B.

 

MPG LTR 726 (5/11)

ACWDL 08-48

 

 

 

 

 

 

 

ACWDL 11-15

 


15.04.04 Medicare Part D Benefits

 

A.
Medicare Part D

Coverage

 

Medicare Part D provides prescription drug coverage to eligible Medicare beneficiaries through private Prescription Drug Plans (PDPs).  The PDP may be one of the following:

 

·   Fee-for-service PDP operated by a private prescription drug provider, or

·   Medicare Advantage-Prescription Drug Plan (MA-PDP) operated by a Managed Care Medicare provider.

 

Dual eligible individuals, who are eligible to both Medi-Cal and Medicare, must use a Medicare Part D PDP to obtain most of their prescription drugs. Medi-Cal will continue to cover certain drugs not covered by Medicare Part D.

 

Enrollment

 

Enrollment in Medicare Part D is voluntary for most Medicare beneficiaries.  Dual eligibles and Medicare Savings Program (MSP) eligibles will be automatically enrolled into a PDP if they do not voluntarily choose one.  These include Medicare beneficiaries that are:

 

Dual Eligible

Medicare Savings Program Eligible

Zero SOC Medi-Cal

Qualified Medicare Beneficiary (QMB)

SOC Medi-Cal and the SOC has been paid

Specified Low Income Beneficiary (SLMB)

Supplemental Security Income (SSI)

Qualified Individual (QI-1)

 

Dual eligibles that belong to a Medicare Advantage (MA) plan will be automatically enrolled into the MA-PDP if a different plan is not selected.  Individuals with questions regarding the PDP plan they have been enrolled into should be referred to Medicare at 1-800-633-4227.  Individuals that need help determining which plan best meets their prescription needs should be referred to the Health Insurance Counseling and Advocacy program (HICAP) at 1-800-434-0222.

 

Costs

 

Medicare Part D includes the following costs which Medicare beneficiaries may have to pay depending on their income and resources:

·   A monthly premium

·   An annual deductible

·   Prescription drug co-payments

·   Other prescription drug costs not covered by Medicare Part D

 

Deductions

 

The monthly premium payment, if paid out-of-pocket by a Medi-Cal beneficiary, would be treated as an “other health care deduction.” The monthly premium may vary depending on the PDP. All other Medicare Part D costs, paid out of pocket, can be applied to the SOC for Medi-Cal beneficiaries with a SOC.  

ACWDL 05-23

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACWDL 05-23

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.
Low Income Subsidy (LIS)

Medicare beneficiaries that are eligible to a low-income subsidy do not have to pay most of the costs associated with Medicare Part D.

Zero SOC dual eligibles /MSP eligibles/250% Working Disabled (WD)

Dual eligibles with zero SOC, MSP eligibles and 250% WD individuals are automatically eligible to a LIS, which eliminates all Medicare Part D costs except for a small prescription drug co-payment. These beneficiaries do not have to fill out a LIS application. LIS eligibility lasts for the remainder of the calendar year even if their Medi-Cal or MSP eligibility discontinues.

SOC dual eligibles (not in LTC)

Non-LTC dual eligibles with a SOC must meet the SOC in at least one month to be eligible to a LIS, which eliminates all Medicare Part D costs except a small prescription drug co-payment. SOC dual eligibles that meet the SOC do not have to fill out a LIS application. LIS eligibility lasts for the remainder of the calendar year even if their Medi-Cal eligibility discontinues or if they do not continue to meet the SOC.

SOC dual eligibles in Long Term Care (LTC)

LTC dual eligibles that have a SOC must meet the SOC in at least one month in order to be eligible to a LIS, which eliminates all Medicare Part D costs. Medicare Part D prescription drug co-payments are waived for beneficiaries in LTC. LTC dual eligibles that meet the SOC do not have to fill out a LIS application. LIS eligibility lasts for the remainder of the calendar year even if their LTC Medi-Cal eligibility discontinues.

Medi-Cal or MSP applicants

Medi-Cal or MSP applicants that are aged, blind or disabled must be provided a LIS application with their Medi-Cal/MSP application. In the event that their Medi-Cal/MSP application is delayed or denied, the applicant may proceed with a LIS evaluation through Social Security Administration (SSA).

Medicare beneficiaries requesting LIS, but not requesting Medi-Cal/MSP

Medicare beneficiaries requesting a LIS application that do not want to apply for Medi-Cal/MSP will be given a LIS application packet, available in English or Spanish, which includes the following:

 

·   LIS Application Packet Coversheet (14-80 HHSA)

·   MC 210

·   MC 14A

·   LIS application (SSA-1020B-OCR-SM)

 

Medicare beneficiaries requesting assistance with the LIS application

If the Medicare beneficiary requests assistance with completion of LIS, refer the individual to designated FRC staff who will assist the individual with the following activities as needed:

 

·   Read and explain the LIS application

·   Provide the SSA telephone number where applications can be completed by phone (800) 722-1213

·   Enter the English-only LIS application on-line at the SSA website www.ssa.gov with help from the individual

·   Print foreign language LIS instructions from SSA website

·   Refer to Medicare at (800) 633-4227 for answers to questions about the Medicare Part D drug benefit.

 

If the LIS application is returned to the FRC, forward it to SSA in the return envelope provided with the LIS application. If the individual objects to having the application forwarded to SSA for processing or insists upon DHS completing the evaluation, the application shall be mailed to:

DHS/MEB

Attn: MMA Analyst

1501 Capitol Avenue, MS 4607

Post Office Box 997417

Sacramento, CA 95899-7417

 

Note: County workers do not evaluate eligibility to the LIS. SSA or DHS determine LIS eligibility.