SSI Blog

While the Affordable Care Act (ACA) was signed into law in 2010, there is still confusion, particularly in the senior community about how the healthcare law impacts Medicare coverage.

Not Replacing Medicare

The new law established a Health Insurance Marketplace (online exchange) where consumers can go to purchase healthcare coverage. Many seniors are concerned that they are now obligated to purchase coverage through the Marketplace. Medicare isn’t part of the Marketplace. If you are enrolled in Medicare or have a Medicare Part C plan, your coverage will stay the same and you will never need to obtain your benefits through exchanges. It is against the law for anyone to knowingly sell you a health insurance plan through the Marketplace if you are currently enrolled in Medicare.

Essential Coverage

The individual mandate as described by the ACA can be confusing. While it is true that some people who are uninsured or underinsured will be required to pay a penalty, seniors on Medicare do not have to worry. Medicare is considered “essential coverage” and recipients will not be required to add healthcare coverage to an existing plan. Since most seniors are eligible for Medicare coverage at 65, as long as you are enrolled, you will not be responsible for paying a fee under the Affordable Care Act.

Preventive Care

The passage of the Affordable Care Act also means more services for seniors in Illinois, on Medicare, particularly preventive care. Medicare is now required to cover a host of services at no additional cost to you, including immunizations, mammograms, colonoscopies, annual wellness visits, and more – all without a co-pay.

Prescription Drugs

The coverage gap, also called the “donut hole” that many seniors experience with prescription drug coverage can make it challenging to afford medication. Provisions of the Affordable Care Act require Medicare to pay more, which reduces costs for seniors entering the gap. The ACA plans to eliminate the donut hole completely by 2020, but until then, seniors enjoy a 55 percent discount on covered brand name prescriptions and a 35 percent discount on generic drugs until out-of-pocket limits have been reached. While prescription drug costs have decreased for most recipients, costs have increased slightly for individuals who earn more than $85,000 and couples earning $170,000 or more.

References:

https://www.medicare.gov/Pubs/pdf/11493.pdf

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SSI Blog

A state and federally-funded health insurance program, Medicaid is designed to help low-income adults, children, pregnant women, and seniors get the medical care they need. To be eligible for benefits, recipients must meet the required income level and family size.

Eligibility

Income-based eligibility is determined using the federal poverty level, which is updated annually. Since 2014, when the Affordable Care Act passed, Medicaid eligibility has expanded. In addition to placing income requirements on recipients, states may charge enrollees a premium, along with copayments, deductibles, and coinsurance for benefits. Children and pregnant women are excluded from many of these fees, but all applicants must meet state and federal requirements concerning residency, immigration status, and documentation of U.S. citizenship.

Coverage

While Medicaid varies from state to state, each must meet certain mandatory federal minimum requirements. The program pays for basic inpatient and outpatient hospital services, nursing and home health care, laboratory and x-ray services, pediatric care, and necessary medical equipment. Many states have expanded the mandatory federal minimums to include benefits for physical, occupational, and speech therapy, optometry, podiatry, dental and vision care, chiropractic services, hospice care, and more. Benefits are provided through Medicaid that are not covered by Medicare, such as personal care and homemaker services. Medicaid covers out-of-pocket expenses associated with Medicare, like premiums, deductibles, and coinsurance.

Dual Enrollment

Dual eligibility in both Medicaid and Medicare is common, and millions of seniors receive benefits from both programs. As a Medicare recipient with low income, Medicaid may be able to help pay for out-of-pocket expenses associated with Medicare. Medicaid often covers treatment and services not typically covered by Medicare, such as prescription drugs, eyeglasses, and hearing aids. If you qualify for Medicaid benefits, you may be eligible to receive retroactive coverage that can help pay for medical debts you incurred up to three months before applying.

References:

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/seniors-and-medicare-and-medicaid-enrollees.html

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/cost-sharing/cost-sharing.html

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/eligibility.html

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SSI Blog

Illinois seniors suffering from a debilitating chronic health condition may qualify to enroll in a Medicare-approved Special Needs Plan. These different plans provide additional benefits above and beyond Medicare, offering seniors special healthcare and services.

Special Needs

Treatment of certain chronic health conditions such as cancer or dementia may require additional services above and beyond that which Medicare provides. For many seniors, the extra cost associated with treatment is a burden and Special Needs Plans address these concerns. Most benefits provided are paid in full for recipients who are enrolled in both Medicare and Medicaid. However, for seniors who do not qualify for Medicaid, participating in the plan costs about the same as enrollment in a typical Part C plan.

Eligibility

You must be enrolled in Medicare Part A and B, reside in the plan’s service area, and meet specific health requirements. Seniors with a disabling chronic condition or who live in a nursing home, require in-home care or currently receive both Medicare and Medicaid benefits may qualify. Plans may not be available in all states as insurance companies providing benefits decide which counties will offer plans.

Qualifying Conditions

You must have one or more of the following conditions:

Alcohol or drug dependence

Hematologic disorder

Autoimmune disorder

HIV/Aids

Cancer

Chronic lung disorder

Cardiovascular disorder

Disabling mental health conditions

Chronic heart failure

Neurologic disorder

Dementia

Stroke

Diabetes

End-stage liver disease

A Special Needs Plan may be the right choice, with an increased network of providers who specialize in treating your condition and providing additional benefits.

References:

https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/special-needs-plans.html

https://www.medicare.gov/Pubs/pdf/11302.pdf

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SSI Blog

Seniors over the age of 55 and in need of care may be eligible for the Medicare Pace Program ( Programs of All-inclusive Care for the Elderly) Designed to provide personalized, coordinated care for the disabled in a community setting. The goal is to help Illinois seniors preserve their independence and delay nursing home care as long as possible.

Eligibility

Enrollment in the program is involuntary, but to be eligible to receive benefits, seniors must meet a few conditions. Applicants must be at least 55 years old and certified by the state as requiring a nursing home level of care. Must reside in the service area of the PACE organization and be capable of living safely in the community. Seniors who are eligible for Medicare, Medicaid, or both can enroll. While PACE uses Medicare and Medicaid funds to pay for care and services, the cost of the program depends on each applicant’s financial situation. Medicaid recipients may pay nothing at all or a small fee for services. Medicare-only recipients who join pay a monthly premium for long-term care and prescription drugs. In either case, there are no deductibles or coinsurance. 

Coverage

Benefits in Illinois include all Medicare and Medicaid-covered services in addition to some services not covered by Medicare. This includes doctor and nursing services through a primary care physician, care while in the hospital (including laboratory and x-ray services), emergency services, physical and occupational therapy, nursing home and home care, prescription drugs, dental, meals, and nutritional counseling, social services, and transportation. Seniors who enroll will receive all of their Medicare benefits through the program. Each applicant is assessed daily on an individual basis by a team of skilled healthcare professionals.

Primary care physician

Activity Coordinator

Nurse

Dietitian

Social Worker

Center supervisor

Physical therapist

Home care liaison

Occupational therapist

Driver

For older adults suffering from a disability or chronic condition, having medical and supportive services available in a community setting offers peace of mind, promoting independence and delaying nursing home care. The mission of PACE is to help well-deserving seniors and their families accomplish this goal by offering comprehensive medical and social services provided by a team of health professionals.

References:

https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html

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SSI Blog

Medicare covers dual residence. With Part A and Part B, you can travel anywhere within the United States and still be covered, as long as you choose providers who accept Medicare. This is good news for anyone planning to spend part of the year in one state and part of the year in another. Whether you are in Florida or Michigan, any doctor or hospital that accepts Medicare will honor your benefits. Medicare does not cover the care you receive outside of the country.

Coverage Area

All 50 states

The District of Columbia

Puerto Rico

The Virgin Islands

Guam, American Samoa

The Northern Mariana Islands

Medicare Supplement

Like Medicare, Medicare Supplement does not rely on service networks, and as long as the doctor or hospital you choose accepts Medicare, you’re covered. As a senior with homes in two states, you can travel freely with the peace of mind and confidence that when you need medical care, you can get it and your plan will be applied. If you are a dual resident considering coverage, be sure to compare policies offered by each state to learn about any differences that may impact your benefits.

Part C and Part D

For Medicare Part C and D, the rules for out-of-state coverage are different and your plan may not cover your care while you travel within the United States. With many plans, you need to be a permanent resident of the state where you originally enrolled and you must live in the service area of your plan. In some cases, you can receive out-of-network care, but it will likely cost you more money. In addition, your plan may have specific rules you need to follow, such as needing prior authorization before receiving care that can impact your coverage. With all Medicare plans, Medicare, Medicare Part C, and Medicare Supplement, you are covered in any state if you need emergency medical care or urgent care out of network.

References:

https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/switching-plans/switch-medigap-.html#collapse-2514

https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/original-medicare/how-original-medicare-works.html#collapse-3111

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