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Medicare Supplements in Phoenix AZ – Do You Qualify for Medicaid?

Medicare is the principal state-administered health insurance program in Arizona and the rest of the US. It aims to address the needs of seniors (65 and older), as well as younger adults with qualifying disabilities and diseases. Since it’s not all encompassing in terms of coverage, many people purchase additional coverage, such as one of the Medicare supplements in Phoenix AZ, commonly referred to as Medigap plans.

Meanwhile, financially vulnerable populations can use the benefits of the joint federal and state program called Medicaid, designed to help with their medical costs. Here are some Medicaid basics explained to help you get more acquainted with this health insurance program.

What is Medicaid?

Medicaid is a health insurance program providing assistance to families with low income and limited resources that cannot afford healthcare coverage. The program provides full coverage for its low-income beneficiaries, whereas moderate-income beneficiaries receive substantial coverage.

Medicare supplements in Phoenix AZ Medicaid eligibility

Medicaid is jointly funded by the federal and state governments and managed by the states. Each state has the freedom to set its own eligibility criteria. Common criteria for all states include US citizenship and permanent residency status. Low-income families, people with certain disabilities and pregnant women can also qualify for Medicaid.

Poverty is a criterion, but it does not make a person automatically eligible for Medicaid. Financial eligibility is defined in terms of income and resources. Thanks to the Patient Protection and Affordable Care Act, the eligibility and funding for Medicaid have increased significantly.

What does Medicaid cover?

Medicaid coverage varies between states and people are advised to contact their state’s Medicaid office in order to fully understand the coverage options. Under federal law, each state must provide a minimum benefit package, including:

  • hospital inpatient and outpatient services
  • doctor services
  • skilled nursing  
  • home care
  • lab and x-ray tests
  • health screening follow-up services for children under 21
  • nurse-midwife services
  • family planning services
  • rural health clinic services
  • transportation services

Although Medicaid doesn’t cover prescription drugs, the program can pay the premium for Medicare prescription drug coverage (Medicare Part D). In addition to Medicaid, each state also runs a Children’s Health Insurance Program (CHIP), designed to cover children from families whose income is modest, but still too high to qualify for Medicaid. In some states, CHIP also assists parents and pregnant women.

Medicare supplements in Phoenix AZ, Medicaid CHIP

The Children’s Health Insurance Program covers dental care, eye exams and eyeglasses, regular checkups, prescription drugs and vaccines, specialty services and mental healthcare, hospital care, medical supplies, x-rays, lab tests and treatment of pre-existing conditions. In each state, Medicaid and CHIP work closely together to address the needs of their target populations. They are evolving and improving from the aspect of eligibility, enrollment and renewal, thanks mainly to the flexibility enabled by the Affordable Care Act.

Medicare supplements in Phoenix AZ and Medicaid – are they related?

Many people confuse Medicare and Medicaid, despite their apparent differences. In a nutshell, these are the main differences between the two programs:

  • Medicare is a federal program addressing the needs of people aged 65 and older, as well as people with certain diseases and disabilities. Medicare is available to people of all income levels and the coverage is the same in all states.
  • Medicaid is a joint federal & state program providing healthcare benefits to people of all ages, available to those of low income and resources. Medicare programs are different in each state.

Sometimes, Medicaid can work together with Medicare to cover healthcare costs. In other words, Medicaid can help Medicare policyholders with the payment of excessive medical bills that Medicare doesn’t cover. In this case, for services covered by both Medicare and Medicaid (doctor visits, hospital care, home care and skilled nursing facility care), Medicare is the primary payer, whereas Medicaid covers the remaining costs, such as coinsurances and copays.

Who is eligible for Medicaid?

Each state has its own eligibility and application rules within the federal standards, and the state Medicaid offices are best suited to answer all your questions. Medicaid and CHIP provide assistance to around 60 million Americans, including children, pregnant women, parents, elderly and disabled people. Federal law requires all states to include certain population groups in their Medicaid coverage (mandatory eligibility groups).

Each state has the freedom to cover additional groups (optional eligibility groups) and many states have decided to expand the scope of coverage, especially for children, beyond the required federal minimum. Since each state individually decides how to design its Medicaid program, a person’s ability to qualify can depend on whether their state of residence has decided to expand its Medicaid coverage to include more people.

Medicare supplements in Phoenix AZ,  Medicaid coverage

Generally, the eligibility assessment for Medicaid and CHIP coverage is based on income, household size, disability, family status and some additional factors. Certain states have expanded Medicaid coverage to all low-income adults. In this case, people can qualify for Medicaid based solely on income and family size.

Some people are eligible for both Medicare and Medicaid. This is called dual eligibility. If a person has Medicare and full Medicaid, most of their healthcare costs are likely to be covered. In all states, people can apply for Medicaid in one of two ways – either directly through the state’s Medicaid agency or by filling out a Marketplace application. The applications for Medicaid and CHIP can be submitted any day of the year (not only during Marketplace Open Enrollment).

What is Medicaid spend-down?

Spend-down is an option within Medicaid designed to help people pay huge medical bills, which are beyond their payment abilities. People whose income exceeds the Medicaid eligibility levels are referred to as having excess income.

Medicare supplements in Phoenix AZ, Medicaid spend-down

They can nonetheless become eligible under the spend-down program (as persons that are medically needy), if this excess income is spent on medical bills. With the spend -down option, the person pays the bills up to the excess amount and Medicaid pays the rest.

To become eligible as medically needy, a person’s resources must be under the resource amount allowed in the particular state. The spend-down option is available to children under 21 years of age, adults over 65 years of age, the disabled and the blind, as well as families where one or both parents are absent, diseased, disabled or out of work.

Medicare Part D Premiums Will Jump In 2011

For Medicare enrollees who are hoping to catch a break on their prescription drug costs, 2011 doesn’t hold out much promise. Industry analysts say that most major Part D prescription drug plans will increase their premiums for coverage in the 2011 year. Right now, Medicare Part D enrollees pay about $32 on average per month for prescription drug benefits, but a study conducted by Avalere Health says Part D subscribers should plan to pay about 10% more for prescription coverage in 2011.

Part D premiums aren’t limited, so some prescription drug plan costs could rise much more than average. The study cites one plan whose premiums will increase by nearly half for 2010. Avalere Health reviewed the top 10 Part D prescription drug plans, which serve about 70% of beneficiaries who are enrolled in the optional coverage plans.

The study also estimates that about 3 million Part D subscribers will need to switch their current Part D plan for 2011. Most of those beneficiaries should be able to find comparable coverage with their current provider, but about 300,000 beneficiaries may need to find a new provider altogether. Federal regulations require that Part De providers consolidate coverage into “non-duplicative plans” but some industry analysts say that consolidation may mean some beneficiaries will see higher premiums if they stay with their current insurer.

The AARP will eliminate its MedicareRx Saver plan, requiring about 1.5 million subscribers to enroll is the organization’s MedicareRx Preferred plan, which has a premium cost that is 15% higher than the Saver plan. Those already enrolled in the Preferred plan will see a drop of about 11% in the cost of their annual premiums.

The Centers for Medicare and Medicaid Services say the concern could be nothing more than a tempest in a teapot. According to the agency’s figures, most Medicare Part D subscribers will see an average increase of no more than 3% (about $1) per month in their premium costs, even if they need to switch plans.

One reason for the increase in premiums is the improved “gap” coverage beneficiaries will receive beginning in 2011. In the past, seniors who exceeded pre-established spending limits on prescription drug benefits had to pay the entire cost of their prescriptions until they became eligible for catastrophic drug coverage. Beginning this year, those who exceed the plan limits on spending will be eligible to buy prescription drugs at a reduced rate while in the coverage gap. By 2020, the gap should be entirely eliminated.

One-Third Of Medicare Hospital Stays Involve Dual-Enrollment Patients

A new report authored by the Agency for Healthcare Research and Quality (AHRQ) says that one-third of Medicare hospital stays in 2008 involved patients who were dually eligible for Medicare and Medicaid. According to the report, Medicaid pays the Medicare insurance premiums for about 8 million beneficiaries each year, about 18% of all Medicare beneficiaries. Dual-eligible patients account for about half of all Medicaid spending and about one-quarter of all Medicare spending in any given year.

Healthcare expenditures for dual enrollees are likely to be higher because dual enrollees typically have a number of chronic health conditions (some of which make them eligible for Medicare), and are more likely to need catastrophic medical coverage and long-term continuing care services.

The AHRQ report says that the three top causes of “potentially preventable” hospitalizations in 2008 among dual enrollees were bacterial pneumonia, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Other potential preventable hospitalizations included pressure ulcers, asthma, diabetes and urinary tract infections.

Among “potentially preventable” hospitalizations, Medicare and Medicaid spent more to treat pressure ulcers than any other diagnosis. The report also noted that dual enrollees were more than twice as likely to be admitted for pressure ulcers, asthma, diabetes and urinary tract infections than traditional Medicare beneficiaries were, and nearly one-third more likely to be admitted for bacterial pneumonia and COPD than Medicare beneficiaries.

More than half of all hospitalizations among dual-enrollees between 18 and 64 were for asthma- and diabetes-related illnesses, while more than one-third of hospitalizations for dually enrolled beneficiaries over the age of 85 were for falls. One quarter of hospitalizations among elderly dual beneficiaries 85 and above were for bacterial infections, UTIs and bacterial infections, UTIs.

The most likely group of dual beneficiaries to require hospitalization for potentially preventable conditions, however, were those between the ages of 65 and 74. The report, which was presented as a statistical brief, did not include recommendations on reducing the number of potentially preventable admissions among dual beneficiaries, however it does provide a basis for continued research into improved treatments and preventive care that could reduce the number of potentially preventable admissions among dually enrolled Medicare/Medicaid beneficiaries.

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