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Social Work Review Of Insurance in Florida

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).

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Social Work Review Of Insurance in Florida

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  1. Social Work Review Of Insurance in Florida Sarah Knott, MSW, LCSW

  2. Available Insurance Plans • Employee Group Health Plans • Medicare • Medicaid • HMOs • Medicare/Medicaid Replacement policies • Individual policies and Medigap

  3. 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

  4. 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

  5. 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.

  6. 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

  7. 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

  8. 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

  9. 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.

  10. 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. Changes in 2007

  11. 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)

  12. 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.

  13. 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

  14. 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

  15. 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.

  16. 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.

  17. 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.”

  18. 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.

  19. 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.

  20. 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

  21. 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

  22. 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.

  23. 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)

  24. 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

  25. Questions?????

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