Social Work Review Of Insurance in Florida

Sarah Knott, MSW, LCSW

Available Insurance Plans

Employee Group Health Plans Medicare Medicaid HMOs Medicare/Medicaid Replacement policies Individual policies and Medigap

Employee Group Health Plan (EGHP)

Coverage through Employee’s or spouse’s employer

Usually provides better benefits than Medicare. Primary for 30 months from date of Medicare

Eligibility May be converted to COBRA for up to 29

months

Eligibility for Medicare

Over age 65 Permanently disabled for more than 2 years. ESRD – Based on Work Quarters 2007 definition – 1 quarter equals $1,000

earned in a 3 month period.• Fully Insured is determined by age and quarters

worked

• Currently insured is 6 quarters of the last 13

Eligibility for Medicare

May also qualify through spouse or parents.• If Divorced – marriage lasted at least 10 years

– Pt has never remarried.

• If under 21 – 1qualify through parents• If late filing, disability must have started prior to age

21 and continued to filing date.

Medicare B

In Center Hemo - Coverage begins 3 months from 1st date of dialysis

Calculated to include the whole 1st month – if starts on 10/29 – coverage will begin on January 1.

Home Hemo or PD – Begins 1st day of the month that Dialysis starts

Eligibility requires work quarters depending on age. May qualify under spouse’s Social Security if qualified. Also qualifications from parents or ex spouses. Pays 80% of Medicare Approved charges including

Injectables

Coverage for RXs from Part B Immunosuppressant Drugs following Transplant Oral Anti-Cancer Drugs for Cancer Treatment IDPN Prophylactic Vaccines

• Influenza, Pneumococcal, and Hepatitis B• D For all other

Oral Anti-Emetic Drugs• B if within 48 hours of Chemotherapy• D For all other Situations

EPO • B for Dialysis related• D For all other Situations

When is a Patient Eligible for Medicare Part D

When they become Medicare Eligible When their EGHP that had RX coverage

terminates If already enrolled for Part A & B, but did

not enroll in Part D they can enroll• During Open Enrollment

• When they become eligible for Medicaid benefits

Medicare Part D

Check Plan enrolment or apply for LIS at www.Medicare.com• Need Medicare #, Date of Birth, Effective date

of Medicare A or B, and Current Zip Code.

Changes in 2007

Increased Premium for most Part D Plans

Increased Deductible from $250 - $265

Increase from $3,600 to $3,850 for “donut hole”

Increase in Part B Premium

Increase in Part B Deductible to $131

Increase in Part A Deductible to $992 per hospital stay.

Medicare and FloridaLow Income Subsidy

Available to dual eligibles meeting certain income criteria Medicaid beneficiaries “deemed” eligible No premiums No deductibles Nominal cost sharing (Co-Pay) $1 generic/$ 3 brand if below FPL; $2 generic/$ 5 brand

$1 generic/$ 3 brand if below Federal Poverty Limit; $2 generic/$ 5 brand if above Federal Poverty Limit.

No gap in coverage (donut hole)

Medicaid One of the following criteria must be met in

order to qualify for any type of Medicaid Coverage.

Age 65 year of age or older. Child less than 18 years of age living in the

home Totally disabled. Disability can be established by Social Security

or by Department of Children and Families if not eligible for Social Security or SSI.

Medicaid (cont.)

Pays 100% of Allowed Charges Injectables – except EPO - must be

obtained from outside Pharmacy or Patient Assistance Program

Pays Secondary to Medicare for all billed charges

Provides coverage for Transportation

To Determine Medicaid Eligibility Medicaid Eligibility can be established by

calling: 1-800-925-1955 You will need:

• Clinic Medicaid Provider #• Patients Social Security #, Gold Card #, or Medicaid #

If using Social Security # you will need Patients Date of Birth

http://www.myflorida.com/accessflorida/• Need SS# or Application # and Date of Birth

Medicaid through SSI SSI is a Federal Program that provides income

for Disabled individuals up to a maximum of $____ per month.

May be less depending on Living situation. Eligibility for SSI is established through the

Social Security Office and the individual is immediately eligible for Medicaid.

These individuals are not subject to share of cost.

Eligibility is verified through Social Security office.

Individuals not eligible for SSI but income under the poverty limit

Disability established either through Social Security Disability Benefits or Department of Children and Families.

If not eligible for Medicare will have Share of Cost.

If eligible for Medicare individuals are eligible for QMB (Qualified Medicare Beneficiary.) QMB pays Medicare Premium, deductible, and 20% not paid by Medicare.

Individuals with incomes over the poverty limit

Disability established either through Social Security Disability Benefits or Department of Children and Families

Eligibility is based on income and requires Share of Cost.

Share of Cost must be met each month before Medicaid case is “opened.”

Share of Cost Medicaid Also called Medically Needy Medicaid Share of Cost is based on patient’s income. Can be met with dialysis bills before Medicare

becomes effective. Share of Cost cuts down on reimbursement for

Medicaid only patients because benefits begin AFTER Share of Cost has been met.

Individuals who are dual eligible (Medicare and Medicaid) must meet Share of Cost with 20% left after Medicare’s payment.

Emergency Medicaid for Aliens In US illegally. Disability Established through Department of Children

and Families May be Share of Cost. Recertification through Department of Children and

Families may be monthly with completion of new application each time.

Form 2039, verification of Medical Emergency, and dates of charges must be submitted to Department of Children and Families before claims can be billed. This must be done monthly.

Medipass, HMO’s, and PSN’s

Open to individuals with full Medicaid benefits only at this time.

Currently only SSI recipients are considered full Medicaid.

May not be available in All counties Restrictions on when plan can be

changed

HMO/Medicare and Medicaid Replacement plans

Different benefits dependent on Provider, plan, location.

Plans cover Hospital and Doctor’s charges

Some cover Prescription Drugs, Transportation, Home Health

Individual Policies

Provided by Insurance Company directly to insured.

Require proof of insurability Have no restrictions on what the can and

cannot cover May have restrictions on Dialysis May send check directly to patient.

Medigap – Over 65

Several Insurance Companies in Florida offer Medigap Plans to patients over 65.

Plans offered are all the same• AARP will not approve if on dialysis

• Different premium based on Age and location

Have a 3 month waiting period for pre-existing if not within 6 months of eligibility.

Choose plans that pay for Hosp and Medicare B deductibles. (Plan C)

Medigap under 65

No Florida Ins Companies offer Medigap to Patients under 65.

Medco offers Medigap with specific restrictions• Must be with in 6 months of Medicare

effective date.

• Or within 63 days of loss of EGHP or COBRA

• Premiums are around $500 - $600 per month

• Phone # 1-800-228-6080

A B C D FOffered as CompCoverage

Offered as CompCoverage

Offered as CompCoverage

Offered as CompCoverage Offered as CompCoverage

Part A Coinsurance

• Day 61-90 $238/day

• Day 91-150 $476/day

• 100% coverage for an additional 365 lifetime reserve days*

• First 3 pints of blood

Part B Coinsurance

• 20% after $124 deductible**

Part A Coinsurance

• Day 61-90 $238/day

• Day 91-150 $476/day

• 100% coverage for an additional 365 lifetime reserve days*

• First 3 pints of bloodPart B Coinsurance

• 20% after $124 deductible**

Part A Coinsurance

• Day 61-90 $238/day

• Day 91-150 $476/day

• 100% coverage for an additional 365 lifetime reserve days*

• First 3 pints of bloodPart B Coinsurance

• 20% after $124 deductible**

Part A Coinsurance

• Day 61-90 $238/day

• Day 91-150 $476/day

• 100% coverage for an additional 365 lifetime reserve days*

• First 3 pints of bloodPart B Coinsurance

• 20% after $124 deductible**

Part A Coinsurance

• Day 61-90 $238/day

• Day 91-150 $476/day

• 100% coverage for an additional 365 lifetime reserve days*

• First 3 pints of bloodPart B Coinsurance

• 20% after $124 deductible**

Part A Deductible: $992 Part A Deductible: $992 Part A Deductible: $992 Part A Deductible: $992

Skilled Nursing Facility: $119/day Coinsurance for days 21-100

Skilled Nursing Facility: $119/day Coinsurance for days 21-100

Skilled Nursing Facility: $119/day Coinsurance for days 21-100

Foreign Travel: $250 deductible then 80% to $50,000 max

Foreign Travel: $250 deductible then 80% to $50,000 max

Foreign Travel: $250 deductible then 80% to $50,000 max

Part B Deductible: $131 Part B Deductible: $131

At Home Recovery: $40 per day to a $1,600 calendar year max

Part B Excess Charges: 15% over allowance

Questions?????