All Medicaid Programs |
Obsolete Policy |
Effective Date: July 1, 2018 - January 31, 2023
What are Medicare Benefits
1. Part A Medicare - Inpatient Benefits
Part A, Hospital Insurance benefits cover most of the costs of in-patient hospitalization, related post-hospital care, skilled nursing care, home health services, and hospice care.
a. The following people are eligible for free Part A Medicare:
o Individuals age 65 or over, who are eligible for Title II or Railroad Retirement benefits. Also individuals who have worked long enough in a federal, state or local government job to be insured. (Medicare is available at age 65 even if the person has not applied for retirement benefits.) Eligibility can be based on a spouse's or an ex-spouse's work history.
o Individuals under age 65 who have been entitled to disability benefits under Title II SSA or Railroad Retirement for at least 24 months, including Childhood Disability Beneficiaries (i.e., Disabled Adult Children) and Disabled Widows or Widowers.
o Government employees with enough work credits. This includes some of the older government employees who did not pay into the Medicare system. They must apply with Social Security. They must meet Social Security's disability criteria and would have been eligible for disability benefits for 24 months if their government employment were treated as Social Security employment. Usually these are federal employees, but in some cases they are state or local government employees. NOTE: some older government employees will not qualify for Medicare because their employment ended before 1983 when the law changed.
o Individuals who are not otherwise eligible but are medically determined to have end stage renal disease (kidney failure) and are receiving dialysis, have had a transplant or are scheduled for a transplant.
· The person must have at least 6 qualifying work quarters to be insured, or be the spouse or dependent child of an insured individual.
· They will receive free Part A Medicare and must enroll in Part B.
· Non-citizen status is not a factor of Medicare eligibility due to renal failure.
b. Premium Part A Medicare. The following individuals are not eligible for free Medicare Part A. They would have to pay a monthly premium to receive Part A. Medicaid does not require people to enroll in Part A Medicare if they must pay a monthly premium.
o Citizens and Lawful Permanent Residents age 65+ who are not eligible for Title II, Railroad Retirement or Civil Service benefits. This group includes SSI-only recipients, and older Civil Service and military retirees without sufficient Medicare-covered employment, and Lawful Permanent Residents with five years of U.S. residency.
o Enrollment in Part A Medicare must occur during an open enrollment time.
· Individuals who did not enroll in Part A at the first opportunity can only enroll from January 1 through March 31 each year. Benefits then begin July 1st.
· If the individual is not eligible for free Part A, Social Security bills the individual for premiums.
· The state can only pay the Part A premium for QMB-eligibles or for QDWIs. Contact the Program Specialists if you have questions about enrolling a person in Part A Medicare, because enrollment is not automatic.
c. Part A Enrollment
o SSA automatically enrolls people in Medicare Part A who are receiving SSA or Railroad benefits, once they meet the eligibility criteria (people described in 1.A. above.)
o Individuals not receiving SSA or Railroad benefits must apply with Social Security for Medicare when they first become eligible (3 months before through 3 months after the 65th birthday, or when a resident non-citizen meets the age and length of residency requirements.)
o Social Security enrolls individuals in Part B when Part A begins unless the person tells SSA he does not want Part B. Medicare allows people with an employer medical plan to defer enrollment in Part B without penalty.
o Individuals with kidney failure can apply for enrollment in Part A and Part B when they meet the eligibility criteria.
2. Part B Medicare - Outpatient Benefits
Part B-Supplemental Medical Insurance benefits cover medically necessary out-patient services performed by Medicare-certified facilities and providers. Everyone receiving Part B pays a premium. The State pays the Part B premium for anyone receiving Medicaid, QMB, SLMB, or QI assistance. Covered work quarters are not required to enroll in Part B Medicare.
The following individuals are eligible for Part B Medicare and are required to be on Part B to be eligible for Medicaid:
a. Individuals Entitled To Free Part A Benefits.
o Part B coverage begins the same month as Part A unless the person tells Social Security he or she does not want Part B.
o If someone is on Part A, but not currently enrolled in Part B, the state automatically enrolls the person in Part B when eligibility is approved for Medicaid, QMB, SLMB or QI.
b. Individuals Entitled to Premium Part A Coverage
o Citizens, and resident non-citizens with five years of residency, who are 65 or older can enroll in Part B Medicare even if they are not entitled to Title II SSA, Railroad Retirement or Civil Service benefits.
o Enrollment in Part A and payment of Part A premiums is not required to enroll in Part B Medicare.
o Check the SSA interface for verification of Medicare eligibility. The automated BUY-IN will enroll them in Part B (if not currently enrolled) and begin paying the monthly premium.
The SSA interface may show an end date for Medicare that is in the future. This occurs when a disabled person returns to work and has earnings over the SGA, but is still disabled. SSA continues the Medicare eligibility for a number of years. The person is eligible for Medicare until the future end date.
3. Part D Medicare
a. Part D Medicare is Medicare prescription drug coverage. Medicare prescription drug plans are voluntary. Individuals who want to enroll in Part D must be:
o Entitled to Medicare Part A for free; OR
o Enrolled in Part A and paying the monthly premium; OR
o Enrolled in Medicare Part B.
Medicaid recipients who receive Medicare will not receive most prescription drugs from Medicaid.
If someone is not on Part A, but could enroll in Part B, they must enroll in Part B before they will be allowed to enroll in Part D. This is why it is so important for Medicaid recipients to be enrolled in Part B Medicare as soon as the person is eligible for Medicare. When a Medicaid recipient could be eligible for Part B, but needs to enroll, see sec. 223-2.
Medicaid will still cover some prescribed over-the-counter medications that are on the OTC Drug list located at https://medicaid.utah.gov/pharmacy/resource-library.
b. Selecting a Drug Plan
Members who are newly eligible for Medicare Part A and/or Part B without a chosen Part D plan will have prescription drug coverage through the Limited Income Network plan until they choose a Part D plan or are randomly assigned a Part D plan.
Medicare will contract with private companies to offer this drug coverage. These companies must provide certain classifications of drugs and will most likely offer a variety of options with different prescriptions and different costs.
Any Medicare recipient who qualifies for Medicaid in any month from July through December will be auto-enrolled in a Prescription Drug Plan as Low Income Subsidy eligible (See section 320-8) They will also receive the subsidy for the entire following calendar year even if they later lose Medicaid coverage. They can change their Prescription Drug Plan to another plan at any time. Depending on the plan they choose, they will have no or a small monthly premium, no yearly deductible, no coverage gap and reduced co-payments.
Individuals eligible for Medicare Cost-Sharing programs (QMB, SLMB or QI), but not Medicaid will also be eligible for the Medicare Low Income Subsidy to help pay the cost of their prescription drugs. Depending on the plan they choose, they will have no or a small monthly premium, no yearly deductibles, no coverage gap and reduced co-payments.
4. Medicare Advantage Plans
a. Medicare beneficiaries with both Part A and Part B coverage may choose to enroll in one of the Medicare Advantage plans. These plans help manage coverage for enrolled beneficiaries. Providers may offer the following plans:
o Medicare Managed Care Plans
o Medicare Preferred Provider Organization Plans (PPOs)
o Medicare Private Fee-for Service Plans
o Medicare Specialty Plans
b. Most plans require members to use providers and facilities on the plan's network (participating providers and facilities.) Some plans provide services that are not covered under the Original Medicare Plan.
c. Medicare Advantage plans may or may not have drug coverage. Recipients need to ask their plan about drug coverage. If the plan does not offer drug coverage, and a member enrolls with that Medicare Advantage plan, the member will have to pay their own prescription drug costs.
d. Some Medicare Advantage plans may charge an additional premium over and above the Part B premium. If a Medicaid recipient is enrolled in a Medicare Advantage plan that charges an additional premium, deduct the amount in excess of the regular Part B premium as a health insurance expense.
5. Medicare Payments for Institutional Care
o Sometimes Part A Medicare pays skilled nursing home costs for residents of medical institutions. Medicare pays only for skilled nursing care that is rehabilitative. Medicare requires co-payments for days 21 through 100, which can be paid by Medicaid. The QMB program will cover the Medicare co-payments IF the person is already on QMB when the services are received. Retroactive QMB is not allowed. (SLMB and QI do not cover Medicare co-pays).