MEDICARE AND THE MARKETPLACE: THE BASICS

Assistance Network Program Development

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Overview

This training will help you understand• The different Parts of Medicare• Who is eligible for Medicare Part A• How people are enrolled in Part A and Part B• How Medicare eligibility and enrollment effects

APTC eligibility• How Medicare eligibility and enrollment effect QHP

coverage• Why we need to emphasize Medicare eligibility to

our customers• Resources/referrals

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Medicare Alphabet Soup

Part A: ‘Hospital Insurance’Covers: Hospital, limited Skilled Nursing Facility, Home Health, and Hospice Part B: ‘Supplementary Medical Insurance’Covers: Medically Necessary outpatient services, and Preventive ServicesPart D: ‘Prescription Drug Coverage’Administered by private Health Insurance CarriersCovers: Formulary medicationsPart C: ‘Medicare Advantage’Administered by private Health Insurance CarriersCovers: all benefits from Part A & B and usually D

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Who is Eligible for Medicare Part A?

Medicare part A & B is Federal Health Insurance for people lawfully present for 5 consecutive years and age 65=eligibleo Part A is ‘Premium Free’ for most people based on

– their own work history of 40 quarters – a spouse who worked 40 quarters and is at

least 62 years old or deceasedo Part A is ‘Premium Payment’ for people who did not

meet work history• Base payment = $426/month• Medicaid help for some people with lower income

and assets (Medicare Savings Program)

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Who Else is Eligible for Medicare Part A

o Some people with disabilities are eligible for Premium Free Part A, if they have a work history, or certain relationship to a person with a work history

• People with Social Security Disability Insurance (SSDI) benefits after 24 months of benefits

– Eligibility for Part A is automatic after SSDI for 24 months

• People with End Stage Renal Disease at any age– Eligibility is contingent on applying

• People with ALS (Lou Gehrig's Disease)– Eligibility is contingent on applying

• Some people with Asbestosis who lived in Libby, Mt– Eligibility is contingent on applying

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Enrollment in Part A & Part B

• Enrollment in Part A & B is automatic 3 months before coverage startso When drawing Social Security retirement

benefito When drawing Social Security Disability

Insurance benefit• Enrollment in Part A & B takes contacting Social

Securityo When turning 65 if not using retiremento When diagnosed with ESRD, ALS, or

Asbestosis from living in Libby, MT

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Why Do People Avoid Enrolling in Medicare Part B?

o Some people have Employer Sponsored Insurance through their own active work, or their spouse

• Part A is Premium free for most• Part B has a premium

– $104.90 usually– Higher incomes pay more– Penalty applied for those who delay– Medicaid pays the premium for some people

with lower incomes and assets (Medicare Savings Program)

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Medicare and the Marketplace: APTC

• Eligible for Premium Free Medicare Part A. o Not eligible for APTC, regardless of enrollment status

• Note, people who are eligible for Premium Free Part A can enroll through Social Security at any time and sometimes the coverage can be retroactive, on request

o If enrolled in Part A, MEC is met and the shared responsibility (penalty) does not apply

• Eligible for Premium Payment Medicare Part Ao If not enrolled in Premium Payment Part A they ARE eligible for APTC

(subject to Medicaid denial, income parameters, etc)o If enrolled in Premium Payment Part A they have MEC and are not eligible

for APTC

• Enrolled in Medicare Part B only (generally occurs when people have Premium Payment Part A and do not enroll in Part A but do start Part B)o Part B enrollment without Part A is not specified by the IRS to be MEC

• Note, people can only enroll in Part B during Enrollment Periods

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Medicare and the Marketplace-Coverage/Coordination of Benefits

o For people covered by Employer Sponsored Insurance including SHOP:

• If eligible for Part A and Employer has LESS than 20 Employees, Medicare could be the primary payor and QHP may only pay benefits as if Medicare already paid ***based on eligibility for Part A, not enrollment***

• If Employer has more than 20 Employees, Employer Sponsored Insurance is primary payor, and if enrolled in Medicare Part A, Medicare pays second

– Employee count goes to 100 if Medicare eligibility is because of disability

o For people on the Individual Marketplace, • If eligible for premium free Part A, marketplace QHP could

be secondary payor for Part A covered services ***whether or not the person is enrolled***

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Cautioning customers age 64 and with SSDI

NOTICES INCLUDE LANGUAGE ADVISING CUSTOMERS • Are you turning 65 or becoming eligible for Medicare due to

disability this calendar year? People who become eligible for Medicare will no longer be eligible for help paying costs through Connect for Health Colorado. Becoming eligible for Medicare may also affect your health coverage. For questions about Medicare eligibility, call the Social Security Administration at 1-800-772-1213. For questions about how Medicare eligibility might affect your health coverage, contact your health plan issuer. If you have questions about Medicare benefits or Medicare rights in your State, you should contact Medicare at 1-800-MEDICARE (1-800-633-4227) or the State Health Insurance Program, Colorado SHIP at 1-888-696-7213. You can also go online to www.ssa.gov, www.medicare.gov, or www.askdora.colorado.gov.

Emphasis on turning 65 and receiving Social Security Disability Insuranceo Early education on transition-SHIP officeso Applying for help with costso Planning for disenrollment in QHP

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Resources for Medicare Information

Entitlement and Enrollment in Part A and Part B:• Social Security Administration

o WWW.SSA.GOVo 1-800-772-1213

Questions about current Medicare benefits/claims/coverage• Medicare

o www.medicare.govo 1-800-MEDICARE; 1-800-633-4227

Local, In-person education and assistance with Medicare enrollment, applying for programs to help with costs, and appeals/fraud complaints• State Health Insurance Assistance Programs (SHIP)/DOI

o http://cdn.colorado.gov/cs/Satellite/DORA-HealthIns/CBON/DORA/1251623077142

o 1-888-696-7213o (866) 665-9668-Spanish

QUESTIONS?