Luther gets a job making $500 per month, plus he will continue to receive $1,270 of SSDI. His MAGI-based income is $1,770 per month, which is over the income limit for this group. As a result, the state would need to find him eligible under a different Medicaid eligibility group to maintain Medicaid. shouldn’t only identify those who could be eligible for this group, but should also be familiar with other Medicaid eligibility groups in their state that could benefit workers with disabilities, such as the Medicaid Buy-in group (if available). Home and Community-Based Services (HCBS) Waivers Historically, Medicaid only funded long-term care services in an institutional setting. Long-term care (LTC) services include support with activities of daily living (ADLs), such as bathing, dressing, and eating. LTC services have also included support with instrumental activities of daily living (IADLs), such as taking medications as prescribed, managing money, shopping for groceries, and transportation within the community. If an individual needed this type of support, in the past Medicaid would only provide those services in nursing facilities, intermediate care facilitates (ICF), intermediate care facilities for those with intellectual disabilities (formerly called ICF or MR), or hospitals. Example of LTC services: Denise was in a car accident that caused total paralysis below her waist. She was in the hospital for several weeks, which her parents’ insurance covered. Afterwards, she entered a nursing facility, where she had access to nursing care, physical therapy, and occupational therapy. Her parents’ insurance had covered much of her care, but there were limitations on the amount of rehabilitation care. She signed up for Medicaid, which covered the services her parents’ insurance didn’t cover. After three months of services in the nursing facility, Denise began asking when she could move back to her apartment. She met with the facility’s social worker, and they created a plan. Denise applied for a program through the state Medicaid agency that provided LTC services to people in their own homes (they also provided support to people in foster homes
Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled Working Individual (QDWI). As a reminder, a state may use different names for some or all of these programs, so CWICs need to research the appropriate term to use. Below is a chart summarizing the basic details of these programs for 2016. Program Income Limit Resource Limit How It Qualified Medicare Beneficiary (QMB) 100% Federal Poverty Level $7,280 single, $10,930 couple Pays Part A and B premiums, deductibles, co-insurance, and Specified Medicare Beneficiary (SLMB) 120% Federal Poverty Level $7,280 single, $10,930 couple Pays Part B premium only Qualifying Individual (QI) 135% Federal Poverty Level $7,280 single, $10,930 couple Pays Part B premium only Qualified Disabled Working Individual (QDWI) 200% Federal Poverty $4,000 single, $6,000 couple Pays Part A premium only It's important to point out these programs don't help with the Medicare Part D out-of-pocket expenses; a separate program called Low Income Subsidy, which will be covered later in this unit, covers those. trial
Scenario once the work goal is achieved Part A and B deductibles and co-insurance will be paid? Part B Premium will be paid? Has QMB, will have QMB Yes Yes Has QMB, will have SLMB/QI No Yes Has QMB, won’t have MSPs No No Has SLMB/QI, will have QMB Yes Yes Has SLMB or QI, will have SLMB/QI No Yes Has SLMB/QI, won’t have MSPs No No Scenarios for beneficiaries who will continue to be eligible for Medicaid or will become eligible when they working: Scenario once the work goal is achieved: Part A and B deductibles and co-insurance will be paid? Part B Premium will be paid? Has QMB, will have QMB Yes Yes Has QMB, will have SLMB Yes (Medicaid) Yes Has QMB, won’t have QMB/SLMB Yes (Medicaid) Maybe (Medicaid) Has SLMB, will have QMB Yes Yes Has SLMB, will have SLMB Yes (Medicaid) Yes Has SLMB, won’t have QMB/SLMB Yes (Medicaid) Maybe (Medicaid)
eligible for QDWI, assuming he meets all the nonfinancial requirements of the state’s Medicaid program. As this example demonstrates, an individual can have a substantial amount of earned income and use QDWI. Low Income Subsidy (Extra Help)- Financial Assistance Program #2 As explained in the first part of this unit, there are a number of Part D out-of-pocket expenses, which vary based on the private prescription drug plan the beneficiary chooses. For many beneficiaries, these costs are unaffordable. When Congress created Part D, it also created a financial assistance program to help low-income beneficiaries pay for the Part D out- of-pocket expenses. The formal name for this financial assistance program is Low Income Subsidy, but it’s also called “Extra Help.” LIS isn’t a state program, which is often a point of confusion. LIS is a program administered by CMS. The LIS program provides two levels of help: Full Low Income Subsidy and Partial Low Income Subsidy. To be eligible for LIS, some groups must have income below certain FPLs, which are published in the Federal Register each year by the Department of Health and Human Services (DHHS). The poverty levels are the same regardless of the age of the family members. One set of poverty levels applies to the 48 contiguous states and the District of Columbia, with Alaska and Hawaii having separate and slightly higher poverty levels. When an individual applies for LIS, Social Security will apply the FPL that corresponds to the individual’s state of residence in the month that the individual applied. Remember: Example FPLs provided in this unit are based on the 48 contiguous states and on the 2016 (not the 2017) FPLs. This manual is printed prior to the release of the new FPLs, which generally occurs in late January or, February. As a result, the 2016 FPLs are used throughout this unit. In addition to some groups having income limits, some groups must have resources below the current year’s resource limit. If a beneficiary indicates he or she would use some or all of his or her resources for
Enrollment and Enrollment Priority Groups The VA operates an annual enrollment system that helps to manage the provision of health care. Once the VA enrolls a veteran, that veteran remains enrolled in the VA health care system and maintains access to certain VA health benefits. During the enrollment process, the VA will use the veteran’s VA disability rating and other factors to place the veteran in one of eight Enrollment Priority Groups. Priority Group 1 is considered the highest priority group to receive care, and Group 8 is the lowest. The VA uses the Enrollment Priority Groups to ensure that veterans who need healthcare the most will be covered if the VA have enough funding to provide healthcare to all veterans. The number of veterans who can be enrolled in the health care program is determined by the amount of money Congress gives the VA each year. Because funds are limited, the VA set up Priority Groups to make sure that certain groups of Veterans can be enrolled before others. Some veterans may be eligible for more than one Enrollment Priority In that case, the VA will always place the veteran in the highest Priority Group the individual is eligible for. Under the Medical Benefits Package, the same services are generally available to all enrolled veterans. The Enrollment Priority Groups determine how much a veteran has to pay (in co- pays) when he or she receives medical treatment and medications. There are many other qualification rules for assignment into the Priority Groups, and this aspect of the VA healthcare system is very complex. The main qualifications are the following: Priority 1: Veterans with service-connected disabilities rated 50 percent or more; and veterans determined by VA to be unemployable due to service-connected conditions. Priority 2: Veterans with service-connected disabilities rated 30 percent or 40 percent. Priority 3: Veterans with service-connected disabilities 10 percent and 20 percent; veterans who are former Prisoners of War (POW) or were awarded a Purple Heart medal; and veterans whose
The essential health benefits package may vary slightly from state to state. Each state creates a benchmark plan, which provides more specific details about coverage including specific benefit limits, state required benefits, and a list of covered prescription drug categories and classes. State benchmark plans can be found on the following webpage: To make it easier for consumers to compare plans on the Marketplace, the plans are categorized using a metal grouping: platinum plans, gold plans, silver plans, and bronze plans. The difference between these categories of plans is the actuarial value, which is the overall healthcare cost that each plan covers. Plans with higher actuarial value (the health plan covers more healthcare costs) have a higher monthly premium. The lower the actuarial value, the lower the premium will be. Levels of Coverage Plan Pays On Average Enrollees Pay On Average* (in addition to monthly premium) Bronze 60 percent 40 percent Silver 70 percent 30 percent Gold 80 percent 20 percent Platinum 90 percent 10 percent *Based on average cost of an individual under the plan and may not be the same for every enrolled person. In looking at the plans, for example, an individual may have more out of pocket costs associated with the provision of health care services with a silver plan than he or she would with a gold plan. But, the individual would have less in premium costs with a silver plan than he or she would with a gold plan. Choosing a health plan is a financial decision based in large part on the individual’s expected health care needs. The monthly premiums will vary not only by metal category, but also by geographic area, age, family size, and tobacco use. Two financial assistance programs help those with low income afford coverage through the Marketplace: