HEALTH INSURANCE

Health Insurance Information, Counseling & Assistance Program (HIICAP)

The Health Insurance Information, Counseling & Assistance Program (HIICAP) provides counseling and assistance to older individuals and their families regarding EPIC, Medicare, Medicaid, “Medi-Gap, Medicare Savings Programs, Medicare Advantage Plans and long term care insurance.

Services offered include:

· information and education;

· policy review and comparison;

· client advocacy in problem and complaint resolution;

· assistance with claim tracking and submission;

· consumer protection assistance;

· appeals and hearings;

· assistance with eligibility and entitlement requirements.

Appointments are necessary – Call the health insurance counselor at (607) 753-5060.

EPIC

EPIC is the acronym for Elderly Pharmaceutical Insurance Coverage. EPIC is available to help eligible New Yorkers cope with the high cost of prescription drugs. EPIC is intended for seniors who don’t already have adequate insurance coverage for prescription drug expenses. EPIC also works with Medicare part D to lower drug costs.

EPIC is a cost-sharing plan. Coverage is not automatic. Persons must apply in order to be covered by EPIC. To be eligible, individuals must be age 65 or older, be a legal resident of New York State and meet the maximum income limits.

EPIC offers two plans. One plan has a fee schedule and the other a deductible schedule.

The Fee Plan applies to single seniors with annual incomes up to $20,000 and married seniors with combined annual incomes up to $26,000. The yearly fees range from $8 to $300, depending on the senior’s income and marital status.

The Deductible Plan is designed to help seniors with higher incomes. Single seniors with incomes between $20,000 and $35,000 and married seniors with incomes between $26,000 and $50,000 are eligible. The deductibles range from $530 to $1,715 a year, depending on income and marital status.

There are four co-pay amounts that range from $3 to $20 depending on the actual cost of the medicine.

For additional information about EPIC including brochures, applications, and assistance, call the HIICAP program of the Area Agency on Aging at (607) 753-5060.

Social Security Administration - Health Care Financing Administration

Medicare is a federally administered health insurance program for persons age 65 and older and some disabled individuals under age 65. Medicare includes: Hospital Insurance (Part A); Medical Insurance (Part B); Medicare Advantage Plans (Part C); and Prescription Coverage (Part D).

There is no premium for most individuals covered under Part A. Part A helps pay for in-patient hospital care, some (limited) nursing home care, home health care, and some hospice care. Part B helps pay for doctors’ services, outpatient hospital services, durable medical equipment, and a variety of other services and supplies.

Starting in 2007, the premium for Part B is based on yearly income. This amount is subtracted from Social Security checks.

Medicare Part B (Medical) Monthly Premium

If Your Yearly Income is		You Pay
File Individual tax Return	File Joint Tax Return
$80,000 or less	$160,000 or less	$93.50*
$80,001-$100,000	$160,001-$200,000	$105.80*
$100,001-$150,000	$200,001-$300,000	$124.40*
$150,001-$200,000	$300,001-$400,000	$142.90
Above $200,000	Above $400,000	$161.40*

* A late enrollment penalty may apply to certain individuals.

Medicare claims and payments are handled by private insurance companies under contract with the government. These contract companies are called intermediaries and carriers. (The carrier for Part B in our area is Upstate Medicare Services in Binghamton. The intermediary for Part A in our area is Empire Medicare Services in Syracuse.)

Hospitals bill Medicare Part A and receive payment directly. For an in-patient hospital stay, there is a deductible for days 1-60 of $992 (2007). This amount can be billed to the patient or to a Medicare Supplemental insurance plan.

Under Part B, there is variation in how claims are processed depending on whether a doctor or other provider accepts assignment (participating provider) or not. All doctors and providers have to submit a claim for medical services to Medicare Part B. If the doctor accepts Medicare assignment, he is agreeing to accept Medicare’s approved rate for the services as payment in full. In this case, if the annual Part B deductible of $131 (2007) has been met, Medicare will send 80% of the approved rate directly to the doctor. If the doctor does not accept assignment, the patient is responsible for the provider’s bill. Medicare will send 80% of their approved rate (if the $131 annual deductible has been met) directly to the patient. Bills from doctors who do not accept assignment may not exceed Medicare’s approved rate by more than 5%-15% depending on the procedure. (Balance Billing Law).

Among items that Medicare does not pay for are: eyeglasses (except following cataract surgery), dentures, hearing aids, and care outside the U.S.

More detailed information regarding Medicare is contained in the Medicare Handbook, available from the Social Security Administration (1-800-772-1213).

Information on specific claims can be obtained by contacting Medicare: (1-800-633-4227)

"Medi-Gap" Policies/Medicare Supplement Plans

Medicare supplemental plans, or “Medi-Gap” policies, are designed to pay most, if not all, of Medicare’s co-insurance amounts and may provide coverage for Medicare’s deductibles. Medi-Gap plans are regulated by the NYS Insurance Department. There are 12 standard benefit plans (labeled “A” through “L”) available for sale in the U.S. These standard plans were introduced in 1992 in an attempt to make policy comparison easier. For further information contact the Area Agency on Aging at (607) 753-5060.

Individuals should carefully consider the decision to purchase a Medi-gap plan. Not everyone needs such a policy. Persons enrolled in employer group plans, Medicaid eligible individuals and individuals eligible for the Medicaid Spend Down Program may not need a Medi-gap plan.

The following chart lists the 12 policies and the benefits offered by each.

Basic benefits pay the patient’s share of Medicare’s approved amount for physician services (generally 20% after $131 annual deductible); the patient’s cost of a long hospital stay ($248/day for days 61-90, $496/day for days 91-150, approved costs not paid by Medicare after day 150 to a total of 365 days of additional in-patient hospital care during the policy holder’s lifetime); and charges for the first 3 pints of blood not covered by Medicare.

Each of the 12 plans has a letter designation ranging from “A” through “L”. Insurance companies are not permitted to change these designations or to substitute other names or titles. While companies are not required to offer all of the plans, they all must make Plan A available if they sell any of the other 11 in a state.

12 STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS

BASIC BENEFITS

Part A Hospital Coinsurance Coinsurance for days 61-90 ($248)

Part A Lifetime Reserve Days 91-150 ($496)

Part A 365 Additional Lifetime Days 100%

Part B coinsurance 20%

50%*

75%*

First 3 Pints of Blood

50%*

75%*

ADDITIONAL BENEFITS

Hospital Deductible

50%*

75%*

Skilled Nursing Facility

Covers the first $992 of hospital charges for each benefit period

50%*

75%*

Part B Annual Deductible $131

Part B Excess Benefit Charges

100%

80%

100%

Emergency Care Outside the US

At-Home Recovery Benefit

Preventive Medical Care

Hospice Care

50%*

75%*

Outpatient Prescription Drugs

*Out-of-Pocket Maximum Pays 100% of Part A and Part B coinsurance after annual maximum has been spent.

$4140

$2070

Points to consider:

· When considering the purchase of a Medi-gap plan, individuals should first understand Medicare and what it covers. Persons should not be misled about claims that they will be fully protected by buying a private plan. There are gaps in all coverage.

· Carefully consider the benefits offered under the 12 plans—whether they meet individual needs, and are worth the cost.

· Compare premiums charged by several companies. Benefit plans are standard, but premiums charged for the same policies vary.

· If a person has an existing Medicare Supplement, it is not necessary – nor always advisable – to switch to one of the new standard plans.

· It is illegal for anyone to sell insurance that duplicates existing coverage. In addition, one Medi-gap plan is all that is needed. If a person wishes to change coverage, they must sign a statement indicating that they intend to replace their current policy and will not keep both plans.

· Individuals should guard against being pressured into purchase of insurance. Take time to carefully consider the decision. If a sales agent indicates an unwillingness to allow time for study and evaluation, you may not want to do business with them.

· Remember that a 30-day “free look” provision is required. Individuals have 30 days from the date the policy is received to return it for a full refund of policy premiums paid.

· Do not confuse Medi-gap plans and other types of insurance such as nursing home plans, “dread disease” policies, and accident and indemnity policies. Information and counseling about these types of plans are available from the Area Agency on Aging.

· Individuals who continue to be employed after age 65, or who have a spouse who is employed, fall into a special category. If the employer has 20 or more employees, the same employer-sponsored health plan must be offered to the employee and their spouse. In those cases, the employer’s health plans are primary insurance and Medicare is secondary coverage. These persons do not need a Medi-gap plan.

· Seek impartial advice from knowledgeable individuals. The Health Insurance Information, Counseling & Assistance Program offered by the Area Agency on Aging has booklets and literature to offer, as well as individual counseling to help in making an informed decision.

Medicare Advantage Plans are offered in many areas of the country by private companies that sign a contract with Medicare. Medicare pays a set amount of money to these private health care plans for your health care.

You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Medicare Advantage Plans provide Medicare-covered benefits to Medicare members through the plan, and may offer extra benefits that Medicare doesn’t cover, such as vision or dental services. You may have to pay an additional monthly premium for the extra benefits. The plan may have special rules that you need to follow.

Medicare Advantage Plans include:

*Medicare Managed Care Plans (like HMOs) – You see doctors in the plan’s network. A primary doctor coordinates your health care. Referrals are usually required to see specialists. These plans have been part of Medicare longer than any other Medicare Advantage Plan.

*Medicare Preferred Provider Organization Plans (PPOs) – You can see any doctor, but it costs less to see doctors in the plan’s network. Some plans don’t require a referral to see a specialist. PPOs are among the most common and popular plans right now for Americans with private insurance.

*Private Fee-for-Service Plans – You can see any doctor that accepts the plan’s payment terms. The private company, not Medicare, negotiates with providers to decide how much it will pay and what you pay for the services you get. No referrals are necessary.

Medicare Special Needs Plans—Designed to meet the needs of people who live in certain facilities (such as nursing homes), and are eligible for both Medicare and Medicaid. Also available to people who have certain chronic diseases or disabling conditions.

Medicare Medical Savings Account Plans (MSA’s)—These plans have two features. The first establishes a high deductible, which must be met before benefits are paid. The second feature is a Medical Savings Account. Medicare deposits money into the account for your use to pay health care costs.

*This Medicare Advantage information was provided by the Center for Medicare/Medicaid Services (CMS).

Cortland County Department of Social Services, County Office Building, Cortland - (607) 753-5133

Medicaid is a health insurance program for persons with low income and limited financial resources. Medicaid is administered in each county by the Department of Social Services. Funds come from the federal government, the state and the county. An individual on Medicare may want to apply for Medicaid – if eligible – for help with services and supplies Medicare does not cover. The Medicaid program is very comprehensive in the benefits approved. These include: eye glasses; hearing aids (if prior approved); prescription drugs and medical supplies; “wheelchair/cab” transportation; and care provided in nursing homes and by home health agencies.

There are two types of Medicaid assistance programs: Community-Based Medicaid and Institutional-Based Medicaid.

Community-Based Medicaid allows those who qualify for Medicaid in a hospital or nursing home to receive care in their own homes and communities. Services can include case management, homemaker/home health aide services, personal care services, adult day health care, rehabilitation care and respite care.

Institutional-Based Medicaid provides reimbursement to nursing facilities for individuals who require skilled nursing beyond Medicare coverage as well as long-term care. Resident must meet Medicaid eligibility requirements.

Medicaid is an eligibility based assistance program, funded by Federal, State and County tax money. The program is administered in each county by the Department of Social Services (DSS). Medicaid can provide help in paying for medical expenses if you meet the income and resource requirements.

Applicants for Medicaid must meet income and resource guidelines. For individuals age 65 and over, the 2007 financial guidelines are as follows:

COMMUNITY-BASED MEDICAID

FAMILY SIZE MONTHLY INCOME RESOURCE LEVEL

1 $700 $4200

2 900 5400

INSTITUTIONAL-BASED MEDICAID

FAMILY SIZE MONTHLY INCOME RESOURCE LEVEL

Community-based spouse $2541 $74,820

Institutionalized spouse $ 50 $ 4,200

For all Medicaid applicants who are aged, blind or disabled, the first $20 of unearned income per household will not be counted toward eligibility. In addition, a $1500 burial fund is allowed per person, or any amount in an irrevocable pre-need funeral agreement.

INCOME INCLUDES: Social Security, Veteran benefits, rent received, pension, wages, and any other source of income.

RESOURCES INCLUDE: Bank accounts (checking and savings), credit union accounts, bonds, IRAs, CDs, stocks, trust accounts, cash value on life insurance policies, revocable burial agreements, any property or homes (the home you live in is exempt), and any vehicles in excess of one.

To apply, call the Cortland County Department of Social Services at (607) 753-5133 for an appointment and an application form. The completed application and required supporting documents and verification must be brought to the application interview. In some cases, a representative may make an application on behalf of a person unable to do so.

STEPS TO APPLYING FOR MEDICAID

1. A Pre-screening phone call must be placed to the County Medicaid Office: (607) 753-5133. You will speak with a Medicaid Caseworker, who will ask you financial questions to ensure that you are eligible for Medicaid assistance.

2. Based on your eligibility, the Medicaid Caseworker will set an appointment time to meet with you, usually within two to four weeks after your pre-screening call.

3. The Medicaid Caseworker will also mail you the application packet. This packet includes the application and the documentation list that is required to process the Medicaid application. During these 2-4 weeks, you will need to complete the application and gather the documentation that is required.

4. You or your designated representative will present your completed application and copies of the required documentation at your appointment with your Medicaid Caseworker.

LONG TERM HOME HEALTH CARE PROGRAM (LTHHCP) “WALLS”

1. After the Pre-Screening phone call, the family should contact LTHHCP to make them aware of the need for services. Medicaid will do a referral to both Adult Services (AS) and LTHHCP.

2. LTHHCP and AS will not assess the client until the Medicaid appointment is complete.

3. If the client is deemed appropriate for services, LTHHCP will start once the case is opened.

4. Communication with LTHHCP is important.

DOCUMENTATION THAT WILL BE REQUIRED:

Financial Records:

For Community-based Medicaid -- a current bank statement on all open bank accounts, investments, CDs, credit union accounts, bonds, IRAs, trust accounts.

For Institutional-based Medicaid --copies of the past 36 months of ALL open and closed bank accounts, investments, CDs, credit union accounts, bonds, IRAs, trust accounts.

For either type of Medicaid -- real property deeds, burial space deeds, pre-paid burial agreements, life insurance policies (including face and cash values), vehicle titles/registrations.

Income Records:

For either type of Medicaid -- copies of verification of current income for both spouses

Health Insurance:

For either type of Medicaid -- verification of any health insurance, including Medicare and any other policies. Verification of health insurance premium notices.

Identity, Citizenship and Marital Status:

For either type of Medicaid -- birth certificates, death certificate (if widowed), Social Security cards, marriage certificates, naturalization paperwork.

Miscellaneous:

For either type of Medicaid -- Military discharge papers, Power-of-Attorney paperwork.

IMPORTANT FACTS TO REMEMBER

Pre-Paid Burial Accounts

An “Irrevocable Pre-Need Burial Trust” may be executed with a funeral home. This amount will not be counted as a resource. Two basic rules apply: 1) The contract must be irrevocable (nonrefundable); 2) There is no limit on the dollar amount placed in the trust; however, any monies remaining after the funeral will revert to Medicaid.

Spend-down Program

If an applicant’s monthly income is higher than the Medicaid income limit, but the resources are within the Medicaid limit, Medicaid may still be able to help with high medical bills through the “Spend-down Program.” Individuals in this situation can apply to Medicaid. If you pay medical bills equal to the amount that you exceed the Medicaid monthly limit, Medicaid will pay the remainder on the monthly medical bills. This works on a month-by-month basis.

Estate Claim

When older individuals receive and use Medicaid, DSS has a right to file a claim against the estate (including any property) to try to recoup the amount of assistance provided. The right to exercise this claim is not available if a spouse or disabled child survives. In an estate claim, DSS is called a “preferred debtor” and this takes precedence over any will.

Transfer Rules & Penalties

Medicaid has transfer rules and penalties. The factors to be considered when reviewing transfers under the transfer rules are to know: 1) when the transfer was made; 2) what assets were transferred; 3) to whom they were transferred; 4) the type of Medicaid assistance for which the applicant is applying.

The Medicaid application is extensive and lengthy, in most cases.

Assistance is available to help you through this application process. The Area Agency on Aging has a Health Insurance Information Counseling and Assistance Program (HIICAP). HIICAP can help to explain the whole process. It can assist you through the process, from step one of placing the Pre-Screening phone call, to accompanying or representing the applicant at the appointment held with the Medicaid Caseworker. The Cortland County Area Agency on Aging phone number is (607) 753-5060. The Cortland County Medicaid Office phone number is (607) 753-5133.

The Medicare Savings Programs help low-income beneficiaries who are not eligible for Medicaid pay for their Medicare premiums, deductibles, and co-payments. Certain income and eligibility guidelines must be met and an application with the Department of Social Services Medicaid office must be filed.

The guidelines are as follows:

QMB-Qualified Medicare Beneficiary

The Medicaid Program will pay Medicare’s deductibles and co-payments, and the Medicare Part B Premium of $93.50.

To qualify one must:

- be entitled to Medicare Part A

- meet income and resource guidelines

Household Size Monthly Income Resources

1 $ 851 + $20 unearned income $ 4,000

2 $1,141 + $20 unearned income $6,000

SLIMB-Specified Low Income Medicare Beneficiary Program

For these individuals, the Medicaid Program will pay the Medicare Part B premium, $93.50, only.

To qualify one must:

- be entitled to Medicare Part A

- meet income and resource guidelines

Household Size Monthly Income Resources

1 $1021 + $20 unearned income $ 4,000

2 $1369 + $20 unearned income $6,000

QI-1 – Qualified Individual 1

The Medicaid Program will pay the Medicare Part B premium of $93.50

To qualify one must:

- be entitled to Medicare Part A

- meet income guidelines

Household Size Monthly Income Resources

1 $1149 + $20 unearned income no limit

2 $1540 + $20 unearned income no limit

A $1,500 burial allowance for each individual is permitted in addition to the resource level listed.

For further information and an application for QMB, SLMB or QI-1 programs, contact the Department of Social Services at (607) 753-5011 or the Area Agency on Aging at (607) 753-5060.

Beginning January 1, 2006, Medicare began to offer prescription drug coverage to all beneficiaries with Medicare. Insurance companies and other private companies have contracted with Medicare to offer Medicare approved drug plans that provide insurance coverage for prescription medications. Drug plans vary in terms of the drugs they cover, the cost of the drugs, the monthly premium and the participating pharmacies. All plans must provide at least a standard level of coverage comparable to the Medicare Standard Benefit as listed below. Costs will vary depending on the plan a beneficiary chooses.

The 2007 Medicare Standard Drug Benefit:

You Pay Medicare Pays

Monthly Premium $ 32

Annual Deductible $ 265

Yearly drug costs between $265 and $2,400 25% 75%

Drug costs between $2,400 and $5,450 100%

After $5450 in drug spending 5% 95%

When a beneficiary enrolls into a Medicare drug plan it is generally for the entire year. It is important that a person chooses a plan that will meet their individual drug needs. For further information or assistance, call the Cortland County Area Agency on Aging at (607) 753-5060.

Insurance covering long-term care services is sold by a number of private insurance companies in New York State. It is available both on an individual and a group basis. Before purchasing long-term care insurance it is important to determine exactly what services are covered and under which care situations the benefits can be used. Benefits may or may not include services in a home care situation, with hospice, at adult homes or in a skilled nursing facility.

The Area Agency on Aging provides assistance in understanding long-term care insurance through the Long Term Care Insurance Education and Outreach Program. Counselors can assist individuals in determining if long-term care insurance is a product they need and then provide direction in choosing a policy to meet that need. Contact the Area Agency on Aging at (607) 753-5060 to speak with a counselor.

Federal and state laws require that insurance agents provide a copy of a long-term care policy to consumers once the consumer has filed an application and their eligibility has been determined. The policy should be carefully read prior to signing. Counselors at the Area Agency on Aging can assist with that review.

The information provided by the Long Term Care Education and Outreach Program is intended for the sole purpose of educating consumers in regard to the choices available for financing their long-term care needs. Particular emphasis is placed on understanding long-term care insurance. Nothing is intended nor should it be construed as an endorsement by the State of New York or Cortland County Area Agency on Aging of any specific insurance product or of any insurer.

For additional information on long-term care insurance, contact:

· Area Agency on Aging

o Long Term Care Insurance Education and Outreach Program

(607) 753-5060

· Plan Ahead NY

o www.planaheadny.com

o 1-866-950-PLAN

· New York State Department of Insurance

o www.ins.state.ny.us

§ Select the “Consumer” icon, then scroll down to Long Term Care Insurance section

· New York State Department of Health: Partnership for Long Term Care

o www.nyspltc.org

· New York State Office for the Aging

o www.aging.state.ny.us

· National Clearinghouse for Long Term Care Information

o www.longtermcare.gov

New York State Partnership for Long Term Care

New York State has established a Partnership for Long Term Care designed to assist residents of New York in planning for the possibility of needing to pay for long term care in the future. The Partnership is between participating private insurance companies and New York State Medicaid Extended Coverage. Partnership policies contain unique features that will allow New Yorkers to protect some or all of their assets, depending on the insurance plan purchased. If the beneficiary’s long-term care needs extend beyond the period covered by the private long-term insurance policy, Medicaid Extended Coverage may assist in paying for on-going care without requiring a “spend down” of assets. However, Medicaid Extended Coverage does require that you contribute to the cost of your care with your income according to Medicaid rules.

More detailed information about the NYS Partnership, including a list of participating insurers offering individual policies, is available by visiting the Partnership website at www.nyspltc.org.

For further information contact: Area Agency on Aging

Long Term Care Insurance Program

(607) 753-5060

New York State Partnership for Long Term Care

1-888-697-7582 (1-888-NYSPLTC) in New York

1-518-473-8083 from anywhere