Benefit Development Resource Toolkit: Medicare

Throughout the following section, links to various web pages are provided for reference.   Please note that web page addresses change frequently and while the addresses  provided were accurate as of the issuance of this Toolkit, if you are unable to access any of the web pages through the links, please refer to the main Medicare website at www.medicare.gov and navigate to the information you are seeking.

Definition

Medicare is health insurance for people age 65 or older, under 65 with certain disabilities, and any age with end-stage renal disease. Medicare was established to provide hospital and medical insurance protection to people who might not otherwise be able to afford health insurance. Medicare is designed to protect aged and disabled persons against the expenses of illnesses that could otherwise exhaust their savings. Eligibility for Medicare begins after a 24-month waiting period when a disabled individual becomes eligible to collect Social Security benefits. Medicare is administered by the Centers for Medicaid and Medicare Services (CMS).

The Centers for Medicaid and Medicare Services (CMS) publishes a handbook, Medicare & You, which provides information about the services covered under Medicare Parts A, B, C and D. A copy of this handbook is available by calling 1-800-MEDICARE (1-800-633-4227) and at www.medicare.gov.

The Social Security Administration also publishes a Medicare brochure that shares information on eligibility, the four components (Medicare A, B, C, and D), how to apply for benefits and information on various Medicare Savings Programs.  This publication can be found at  https://www.ssa.gov/pubs/EN-05-10043.pdf.  Application information for the Medicare Savings Programs can be found at:  https://www.ssa.gov/benefits/medicare/prescriptionhelp/cms.html

A person is eligible for Medicare if they have worked for at least 10 years in Medicare-covered employment, is at least 65 years old, and is a citizen or lawfully present in the U.S. Citizens and residents lawfully present in the United States who are younger than 65 years of age may qualify for coverage if they have certain disabilities or have end-stage renal disease (permanent kidney failure requiring dialysis or transplant).

For individuals served by OPWDD, eligibility for Medicare is usually based on a parent’s work record. (This is when the parent begins receiving Social Security Disability or Retirement benefits or when the parent dies - the individual is eligible for Adult Disabled Child (DAC) benefits.) Once the individual has received 24 months of DAC benefits, the person will then be eligible for Medicare.

Four Components of Medicare

An individual may be eligible for different Medicare components depending on their situations and preferences. OPWDD eligible individuals usually use the following four components.

Medicare Part A – Hospital insurance

Medicare Part B – Medical insurance

Medicare Part C – Medicare Advantage Plans

Medicare Part D – Prescription drug coverage

Medicare Part A, the hospital insurance component of Medicare, helps pay for care in hospitals and skilled nursing facilities, hospice services, and some home health care.

Most people do not pay a monthly premium for Part A because the coverage is based on a work record where Medicare taxes have already been paid.

A person who did not pay Medicare taxes while working but is age 65 or older may be able to buy Part A coverage. New York State may pay the Medicare Part A premium for New York State residents who receive Supplemental Security Income and are not entitled to premium-free Part A due to insufficient work history. More information about Part A coverage can be found at: Medicare Part A

Medicare Part A Enrollment Process

An individual who receives Social Security retirement or Railroad Retirement benefits (RRB) is automatically enrolled in Medicare Part A on the first day of the month of their 65th birthday. An individual receiving Social Security disability or RRB disability benefits is automatically enrolled in Medicare Part A after receiving disability benefits for 24 months; benefits start on the 25th month. About three months before the person becomes eligible for Medicare, they will receive information about Medicare.

If an individual is not receiving Social Security or RRB benefits before their 65th birthday, they will need to apply for Medicare Part A in order to obtain coverage.

Certain aged people who do not qualify for Medicare Part A (hospital insurance) under the requirements stated above may be eligible by paying a monthly premium. If a person chooses to purchase Part A coverage, they must also enroll in Part B (medical insurance).

To enroll in Medicare Part A, the individual or representative should call the Social Security Administration at 1-800-772-1213. If the individual was a railroad employee or receives benefits from the Railroad Retirement Board, they should call either the local RRB office or 1-800-772-5772, or visit Ready to sign up for Part A to get information for enrollment.

Medicare Part B (Medical Insurance) helps cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, mental health services, and other medical services. Part B also covers many preventive services. More information can be found at Medicare Part B.

Medicare Part B Eligibility

A person is eligible for Medicare Part B if they are entitled to premium-free Medicare Part A or are age 65 or older, a U.S. citizen or person lawfully present in the U.S.  Non- citizens lawfully admitted for permanent residence, who have resided in the U.S. for five continuous years immediately prior to the month of enrollment, are also eligible.

There is a monthly premium for Medicare Part B. The amount of the premium usually changes each January at the time of the Social Security Cost of Living Adjustment. In some cases, an individual’s premium amount may be higher if the individual did not choose to enroll in Part B when they first became eligible.

Medicare Part B Enrollment Process

A person who receives Social Security retirement or Railroad Retirement benefits is automatically enrolled in Medicare Part B on the first day of the month of their 65th birthday.

A disabled person under 65 who has received Social Security disability or Railroad Retirement disability benefits for 24 months will be automatically enrolled as of the 25th month of disability entitlement. About three months before the person becomes eligible for Medicare, they will receive information about how to turn down Medicare Part B coverage, if they wish to do so. For individuals residing in certified settings, the representative payee is responsible to ensure enrollment in Medicare Part B. Care Managers will assist individuals who do not have a representative payee and may provide assistance to the payee. The Financial Benefits & Entitlements Assistance & Management Office ensures that an individual in a state-operated living arrangement is enrolled in Medicare Part B.

Medicare Part B Enrollment Periods

There are three different enrollment periods for individuals who are not automatically enrolled, each with their own rules.  

Initial Enrollment Period

The initial enrollment period for Parts A and B is a seven-month period, which consists of the month the individual turns 65 plus three months before and three months after.

General Enrollment Period

The general enrollment period runs from January 1st to March 31st every year, with coverage beginning on July 1st. If an individual did not already sign up for Parts A and B during the initial enrollment period, there may be higher premiums.

Special Enrollment Period

The special enrollment period applies to individuals who wait to sign up for Part B because of a group health plan coverage based on employment or through their parent’s or spouse’s employment. During this special enrollment period, an individual can sign up for Part B anytime while covered by the group health plan or during an 8- month period that begins the month after employment or the group health plan coverage ends, whichever is first. Usually, there is no late enrollment penalty when signing up during a special enrollment period.

Part B Late Enrollment Penalties

Late enrollment penalties can increase an individual’s monthly premium by 10% for each 12-month period that the individual could have had Part B but did not sign up for it. There is no waiting period if an individual is eligible due to Amyotrophic Lateral sclerosis (ALS) or End-Stage Renal Disease (ESRD). Information regarding Late Enrollment Penalties can be found at:  https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty.

Medicare Part C – Medicare Advantage Plans

Medicare Advantage plans are private insurance companies approved by Medicare that can provide people with more choices and sometimes, extra benefits. There are four types of Medicare Advantage plans:

• Medicare Health Maintenance Organization (HMO) Plans
• Medicare Preferred Provider Organization Plans (PPO)
• Medicare Private Fee-for-Service Plans (MFFS)
• Special Needs Plans (SNP)

These plans provide care under contract to Medicare. All Medicare Advantage Plans must cover at least the same services covered by Medicare Part A and Part B. In addition, the plans must offer prescription drugs through the Medicare Part D Medicare Advantage prescription plans. Some plans may also offer additional coverage beyond the prescribed minimum set by the Medicare program.

The Medicare beneficiary’s costs for Part C coverage may be different from their costs for Medicare Parts A and B and may involve paying a monthly premium (in addition to the monthly Part B premium).

The Centers for Medicare and Medicaid Services’ (CMS) website, www.medicare.gov, provides information about Medicare Advantage Plans. A search for these plans can be done using the individual’s zip code. Information about selecting a plan can also be found on this website.

Most OPWDD eligible individuals elect not to enroll in Medicare Part C plans due to the monthly premium.

Medicare Part D – Medicare Prescription Drug Coverage

Medicare Part D is available to Medicare beneficiaries. This coverage helps Medicare eligible people pay prescription drug costs. Although it is primarily designed to provide the elderly with affordable prescription drug coverage through the Medicare program, all people who have Medicare coverage, regardless of age, are eligible for the benefit

Medicare Part D Eligibility

Participation in Medicare Part D is voluntary for most Medicare beneficiaries, but is mandatory for people who receive both Medicare and Medicaid benefits. People who receive both Medicare and Medicaid benefits are referred to as “Dual Eligible”.  The majority of the individuals served by OPWDD are Dual Eligible and are therefore required to participate in Medicare Part D.  Dual eligibles receive their prescription drug coverage through Medicare rather than through the Medicaid program. Medicare Part D replaces Medicaid as the pharmacy coverage for Dual Eligible enrollees. Information regarding Dual Eligibility can be found on the CMS website at: www.cms.gov. Within that website there is a helpful booklet “Dual Eligible Beneficiaries Under Medicare and Medicaid” that provides information and helpful resource links pertaining to Dual Eligible beneficiaries.

For people who live in residences certified or operated by OPWDD, there are additional guidelines on Medicare Part D.  Information can be found by reaching out to OPWDD’s Regional Offices who should have the latest information on any special OPWDD forms needed in order to enroll someone in Medicare Part D, as well as, how/when to change plans. General catchment area contact information can be found on OPWDD’s Public Website at:  https://opwdd.ny.gov/contact-us. 

Medicare Part D Benchmark Plans

Benchmark plans are plans that meet all the minimum Medicare Part D standards for coverage and cost. When Medicare Part D became available, Dual Eligible beneficiaries were automatically enrolled in a “benchmark” prescription drug plan and their Medicaid stopped covering their prescription drugs. Medicare, through the individual drug plans, notified Dual Eligible beneficiaries of the plan in which they were automatically enrolled. New Dual Eligible beneficiaries are now automatically enrolled in benchmark plans on an ongoing basis.  A list of benchmark plans for NYS can be found on the NYS Office for the Aging website at www.aging.ny.gov or

https://aging.ny.gov/programs/medicare-and-health-insurance.  

How to Determine and Identify Part D Enrollment

To find out about a person’s enrollment, the following information is required:

• The person’s Medicare Beneficiary Identifier
• The person’s last name
• The person’s date of birth
• The effective date of the person’s Medicare Part A or Part B coverage

The person’s zip code or the person’s representative payee’s zip code

Current enrollment information can be accessed at the Medicare website at: https://www.medicare.gov/ or refer to the letter sent to the enrollee by CMS containing enrollment information.

Medicare Part D - What to do if the Pharmacy will not Fill a Prescription

If the pharmacy will not fill a prescription, the person or their advocate should reach out to the Part D Plan first.  Information on how to contact the Plan and file an appeal can be found at: https://www.medicare.gov/medicare-prescription-drug-coverage-appeals

An individual or their authorized representative has the right to receive a written explanation from their Medicare Prescription Drug Plan, if a request for a prescription drug is denied.  More information can be found at: https://www.medicare.gov/claims-appeals

For Regulations and Guidance on Medicare Part D, there is a manual “Medicare Prescription Drug Benefit Manual” available at www.CMS.gov

NYS Department of Health also has helpful information on their website under a section called “Medicare Part D Frequently Asked Questions” that can be located at:  https://www.health.ny.gov/health_care/medicaid/program/medicaid_transition/faq.htm

Some Medicare beneficiaries with limited income may be eligible for help paying for their Medicare premiums. The Medicare Savings Program (MSP) is a Medicaid-administered program that can assist individuals with limited income in paying for their Medicare premiums. Depending on the individual’s income, the MSP may also pay for other cost-sharing expenses. The Social Security Administration publishes a brochure regarding the Medicare Savings Program at: https://www.medicare.gov/medicare-savings-programs

New York State pays the monthly premium for some Medicare Part B eligible people. These individuals include SSI recipients who are enrolled in Medicare, Qualified Medicare beneficiaries, and certain SSA beneficiaries who receive Social Security disability benefits including Disabled Adult Child benefits. 

The official U.S. Government Site for Medicare is at:  https://www.medicare.gov/index.php/.

Lifetime Reserve Days apply to individuals enrolled in Medicare Part A and/or Part B and are additional days that Medicare will pay for when a beneficiary is in a hospital for more than 90 days. Each beneficiary has 60 reserve days that can be used during their lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily co-insurance amount. If an individual chooses not to use their lifetime reserve days, they will be responsible for all the hospital’s charges not reimbursed by Medicare.  Information on Lifetime Reserve Days can be found at CMS.gov.

Information on Long-term care hospital services and Skilled nursing facility care can be found at www.medicare.gov

An individual’s Medicare coverage is available for medical treatment anywhere in the United States. Generally, Medicare does not cover medical services received outside the United States. “Outside the United States” is anywhere that is not one of the 50 states, District of Columbia, or U.S. commonwealth/territories.

CMS publishes a pamphlet, “Medicare Coverage Outside the U.S.”, (Publication 11037) which provides details about when Medicare will pay. This pamphlet can be found on the Medicare website: https://www.medicare.gov/Pubs/pdf/11037-Medicare-Coverage-Outside-United-States.pdf.

If a person living in an OPWDD operated or certified residence is out of New York and requires medical services, the individual’s Medicare card should be presented to the provider of the services. The individual’s residential agency is responsible for paying any cost not covered by Medicare unless the medical provider is a New York State Medicaid enrolled provider or is willing to enroll.