Family and Children's Medicaid MA-3525 MEDICARE ENROLLMENT & BUY-IN

IV. OVERVIEW OF MEDICARE COVERAGE

A. Coverage Under the Two Parts of Medicare

1. Part A Hospital Insurance

a. Most people who have Medicare hospital insurance do not pay monthly premiums for this protection since they have credits for work under Social Security. Those who do not have work credits must pay a monthly premium.

(1) Individuals who begin receiving Social Security retirement benefits at age 62 will be automatically enrolled for free Medicare Part A at age 65.

(2) Individuals who begin receiving Social Security benefits at age 65 are also enrolled in free Medicare Part A at the same time.

REVISED 11/01/11 – CHANGE NO. 15-11

(IV.A.1.a.)

(3) Individuals who receive Social Security disability benefits are automatically enrolled in free Medicare Part A after 24 months.

c. Individuals receiving SSI benefits based on disability (ineligible for Social Security disability) are not eligible for Medicare Part A. Once they reach age 65, they may be eligible for Medicare Part A if they pay the premium.

Medicaid pays the Part A premium for Medicaid recipients who are not entitled to free Part A when they are authorized as MQB-Q or eligible for MAA, MAB, or MAD with Q class.

B. Automated Notices

1. EIS generates letters to Medicaid recipients age 65 or older or within three months of turning 65 without an RSDI claim number. These people are eligible for Medicare Part B buy in. Medicaid classifications F, H, O, and R do not receive the notices. The notice continues to be sent to Medicaid recipients until the RSDI claim number is entered into the EIS. The notice is in English and Spanish.

The notice advises the recipient of the following information:

a To contact the Social Security Administration for an appointment to apply for Medicare Part B.

b. Medicaid pays the monthly Medicare Part B premiums.

c. Medicaid pays Medicare Part A and Part B sharing amounts (up to the Medicaid allowable rate) for doctor and hospital care.

d. If the recipient fails to enroll in Medicare Part B, Medicaid does not pay for medical bills incurred that Medicare would have paid.

2. The return address on the automated recipient notice is the county dss address.

REISSUED 11/01/11 – CHANGE NO. 15-11

(IV.B)

3. NCXPTR displays two reports containing the name of each Medicaid recipient that receives the notice. The reports run monthly. Each report is sorted by county and then alphabetically by recipient name.

a. The report titles are DHRWDB AGE 65 NOTICE REGISTER and DHRWDB OVER 65 WITH NO RSDI #.

b. Caseworkers must review the reports to ensure those recipients received the notice. If the notice is returned, forward it to the correct address.

c. Caseworkers must review the DHRWDB OVER 65 report and verify monthly with SOLQ if the recipient is enrolled in Medicare. Once Medicare enrollment is verified, the IMC must enter Medicare A or B and the RSDI claim number into EIS.

C. Part B, Supplementary Medical Insurance

1. Covers medically necessary physician's services, outpatient hospital services, outpatient therapy and speech pathology services. It also covers other medical services such as laboratory, X-rays and medical supplies, and home health services when the individual does not have Part A.

2. There is a monthly premium for Part B. The premium is deducted from the Social Security check, or billed quarterly to those persons who do not receive monthly Social Security benefits, but who qualify and are enrolled in Medicare Part B.

3. Medicaid pays the Part B premium for Medicaid recipients eligible for Part B coverage or Part C coverage.

D. Medicare Deductible/Coinsurance

1. Medicare beneficiaries are responsible for paying a federally determined deductible expense before Medicare will pay 80 percent of the Medicare allowable charge.

a. This expense is incurred at the beginning of a calendar year for Part B services and at the beginning of each new benefit period for Part A services. (See MA-3315, Medicaid Deductible.)

b. The Part A deductible may be incurred more than once per calendar year.

c. After the Medicare deductible has been met, beneficiaries are responsible for paying the coinsurance amount, which is the remaining 20 percent of the Medicare allowable charge.

REVISED 01/01/07 – CHANGE NO. 02-07

(IV.D)

2. Medicaid pays the Medicare cost sharing up to the Medicaid maximum allowable rate for expenses incurred by Medicaid recipients who receive Part A and/or Part B or Part C Medicare.