Medicaid Policy
Medicaid Policy
Effective Date: February 1, 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 aged 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 their initial enrollment (IEP), general enrollment (GEP) or a special enrollment period (SEP).
· Individuals who did not enroll in Part A at the first opportunity (IEP) can enroll from January 1 through March 31 each year which is the GEP or during a SEP. Start date of benefits will vary depending upon when the member enrolls.
· If the individual is not eligible for free Medicare 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, GEP, SEP 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 they do 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 (except the AEM, TAM, PE, Cancer and TB Positive programs), 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 B-ID Medicare – Immunosuppressive Drugs
Part B-ID benefits cover only immunosuppressive drugs for those who received Medicare because of End Stage Renal Disease (ESRD). Everyone who receives Part B-ID pays a premium. The State pays the Part B-ID premium for anyone receiving the Medicare Cost Sharing program for Part B-ID. There are no specific enrollment periods, no late penalties, and can be ended and started again.
4. Part D Medicare – Prescription Drug Coverage
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. Therefore 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.
5. 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 more than the regular Part B premium as a health insurance expense.
6. 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).
7. Medicare Enrollment Periods
A Medicare Enrollment Period is when an individual signs up for/enrolls in Medicare. There are three types of Medicare Enrollment Periods. They are Initial Enrollment Period (IEP), General Enrollment Period (GEP) and Special Enrollment Period (SEP).
a. Initial Enrollment Period (IEP) is the period when an individual is eligible for the first time to enroll in Medicare. This is around the 65th birthday (or 25th disability check), A 7-month window of time is given when you can sign up for Medicare. Depending on which month of the 7-month window you sign up in will determine when your coverage begins.
· If you sign up in the three months prior to the month you turn 65, your coverage will begin the month you turn 65. However, if the birthday is on the first of the month, your coverage will start the first of the prior month.
· If you sign up during your birthday month, your coverage will start the following month.
· If you sign up during the three months past your birthday month, your coverage will start the first of the month following the month of application.
b. General Enrollment Period (GEP) is January 1st through March 31st of each year. This is when you could enroll in Medicare Part B for the first time if you missed your IEP or if you disenrolled from Part B and which to re-enroll. You can also sign up for Premium Medicare Part A. Your coverage will start the first of the month following the month of application. Unless you have Medicaid, you may have to pay a late enrollment penalty.
c. Special Enrollment Period (SEP) are for those individuals who want to enroll in premium Part A, Part B or both but failed to enroll during their IEP and face a Late Enrollment Penalty (LEP) or a gap in coverage. SEPs were added to address extenuating circumstances which were not available before. SEPs are:
· For individuals who are enrolled in a qualified group health plan (GHP) or late GHP (LGHP) at the time they first become eligible for Medicare and elect not to enroll in Medicare during their IEP. Coverage begins the first of the month following application month. SEP begins the first month of after the end of employment and ends 8 months after.
· For individuals who, when first eligible for Medicare, were enrolled in a group health plan (GHP) or large group health plan (LGHP) by reason of their own (or a family member’s) current or former employment, and whose coverage ended at a time when enrollment in the plan was not based on current employment. Coverage begins the first of the month following application month. SEP begins the first month of after the end of employment and ends 8 months after.
· For individuals serving as volunteers outside of the United States at the time they first become eligible for Medicare, through a program covering at least a 12-month period, sponsored by a 501(c)(3) tax exempt organization, and who demonstrates health insurance coverage while serving in the program. Coverage begins first of month following month of application. SEP begins on the first day of the month which includes the date that the individual is no longer a volunteer and ends at 6 months.
· For certain individuals who are enrolled in TRICARE and become eligible to enroll in Part A on base of disability or ESRD status but who elect not to enroll during their IEP. Coverage begins the first day of the month in which the individual enrolls or the first month after the end of the initial enrollment period. SEP begins the day after the last day of the IEP and lasts for 12 months.
· For individuals who were not able to enroll in premium Part A or Part B or both if they reside (or resided) or their authorized representative, legal guardian or person who makes healthcare decision on behalf of the individual resided in an area for which a Federal, State, or local government entity declared a disaster or other emergency. Coverage would begin the first of the month following the month of enrollment. This SEP would begin the date the emergency or disaster was declared but no earlier than January 1, 2023 and ends 6 months after the end of the emergency or disaster declaration.
· Individuals who missed an enrollment period because of misrepresentation by or incorrect information from their employer, GHP, brokers or agents of health plans. Those individuals whose non-enrollment is unintentional, inadvertent, or erroneous and results from material misrepresentation or reliance on incorrect information provided by the individuals employer, GHP, brokers or agents of health plan or any person authorized to act on behalf of the employer or GHP. Coverage would begin the first of the month following the month of enrollment. The SEP would begin the day the individual notifies SSA of the misrepresentation or error occurred on or after January 1, 2023 and last for 6 months.
· Individuals who failed to enroll during their IEP or a GEP due to incarceration. Coverage begins the first day of the month following the month of enrollment or the option to choose retroactive to the first day of the month of their release from incarceration (not to exceed 6 months). The SEP would begin the date released for incarceration (no earlier than January 1, 2023) and ends last day of the 12th month after release from incarceration.
· Individuals who lose Medicaid eligibility entirely after the last day when COVID-19 PHE ends or on or after January 1, 2023 (whichever is earlier) and have missed a Medicare enrollment period. Coverage begins the month after the month of application or have the option to go back to first month after month of Medicaid termination. SEP starts when the beneficiary receives notice of an upcoming termination of Medicaid Eligibility and ends 12 months after the termination of eligibility.
· Individuals with exceptional conditions is based on a case-by-case basis for unanticipated situation that involve exceptional conditions and warrant an SEP which is not covered by other SEPs. Coverage would begin the first of the month following the month of application. SEP would be a minimum of a 6-month period.