Medicare or Medicaid….
Which do I qualify for, and what is all this I hear about Open Enrollment???
.This product was supported, in part, by funding from the U.S. Administration for Community Living (ACL), Dept. of Health and Human Services. Points of view or opinions expressed here do not necessarily represent official ACL policy
MEDICARE
Costs for Inpatient Hospital Stay
Medicare Pt. A
For Each Benefit Period in 2021 You Pay
Days 1-60 $1,484 deductible
Days 61-90 $371 per day
Days 91-150 $742 per day
All days after 150 All Costs
Skilled Nursing Facility (SNF) Costs
First 20 days $0 (with qualifying hospital stay)
Days 21-100 $185.50 per day
Beyond 100 days All Costs
Part B 2021 costs
MONTHLY BASE PREMIUM $148.50(DEPENDENT UPON YOUR TAXABLE INCOME 2 YEARS PRIOR)
ANNUAL DEDUCTIBLE $203.00
(ONCE DEDUCTIBLE IS SATISFIED, MEDICARE WILL PAY 80% OF
ALL APPROVED CHARGES)
Services not covered by original Medicare
❑ Long Term Care
❑ Routine dental care and dentures
❑ Routine vision care (unless medically necessary, ie. diabetics, glaucoma patients)
❑Glasses or contacts (unless after cataract surgery)
❑Cosmetic surgery
❑ Acupuncture
❑ Hearing aides and exams for fittings
❑ If you are 65 and receiving SSA benefits, or if you are under 65 and have received SSDI for 24 consecutive months, you will be automatically enrolled and mailed a Medicare card.
❑ Initial enrollment package should be mailed 3 months prior to 65th birthday OR 3 months prior to 24th month of SSDI payment
❑ If you are not receiving SSA benefits at age 65 you will have a 7 month Initial Enrollment Period (IEP)
❑ If you are working and plan to continue working after age 65 and have group health coverage through your (or your spouses) current employment you can delay Part B and will have a Special Enrollment Period (SEP) to enroll
❑ If you miss your IEP and SEP there is also an annual GeneralEnrollment Period (GEP) January 1-March 31, benefits wouldstart July 1, late enrollment penalty may apply
Medicare enrollment
Medicare enrollment periods chart
You must be enrolled in Part A and Part B to participate; Plans should include all benefits, services & provisions covered under Part A and Part B; may include additional benefits
Managed by Medicare-approved private insurance companies that follow rules set by Medicare
The plan you chose will REPLACE your Medicare benefits, make sure all providers accept that Advantage plan and NOT Original Medicare
Plans may require only in-network providers OR cost more money to go out of network
Co-pays and deductibles may apply for doctor visits, hospital stays, other provider services
Plans change every year, consumers should check on coverage every year during Open Enrollment (Oct. 15-Dec. 7 or Jan 1- March 31)
Part D- Drug Plan❑ Medicare requires you to have a drug plan
❑ Helps cover the cost of prescription drugs
❑ Managed by Medicare-approved private
insurance companies
❑ Monthly premium, deductible, cost sharing
will vary by plan
❑ Possible late enrollment penalty if not
enrolled when first eligible
❑ Not all plans cover the same medications
❑ Coverage is person specific based on
his/her medications
❑ Plans change annually
❑ Have your plan reviewed each year during
open enrollment Oct 15 – Dec 7
Medicare options:
Medicare Annual Open Enrollment…
October 15- December 7
Applies to Part C (Advantage) and Part D
(Drug) plans ONLY
Plans change every year and is always
good to ensure you aren’t paying too
much and your medical needs will still be
met
You can apply to change your
Supplement/Medigap plans at anytime
during the year, medical underwriting will
apply
Medigap/
Supplemental
Plans available
and benefits
offered
What is Extra Help and
how do I get it?There are programs in Virginia that can save you money:
The Extra Help Program and the Medicare Savings Programs
You may qualify to get help paying your Part D premium and lower
prescription costs.
If you can answer “Yes” to these questions, you should apply for help
paying your Medicare Part D Costs:
1. Is your monthly income (for 2021) at or below $1630 for a single person
or $2198 for a married couple?
2. Are your resources (for 2021) at or below $14,790 for a single person or
$29,520 for a married couple? Resources don’t include your home,
car, household items, burial plot or life insurance policies.
Medicare Savings Program (MSP)
financial eligibility guidelines
2021 MSP eligibility standards*
Qualified Medicare Beneficiary (QMB) pays Medicare coinsurance, copays, deductibles and Pt. B premiumGross monthly income limits: 100% Federal Poverty Level, or FPL, + $20**
Most states: $1,094 – Individual $1472 – Couple
Asset limits: $7,970 – Individual $11,960 – Couple
Specified Low-income Medicare Beneficiary (SLMB) pays Pt. B premium onlyGross monthly income limits: 120% FPL + $20
Most states: $1,308 – Individual $1,762 – Couple
Asset limits: $7,970 – Individual $11,960 – Couple
Qualifying Individual (QI) Grant funded each yearpays Pt. B premium only
Gross monthly income limits: 135% FPL + $20
Most states: $1,469 – Individual $1,980 – Couple
Asset limits: $7,970 – Individual $11,960 – Couple
Medicaid
MedicaidMedicaid is a wide-ranging, jointly funded state and federal health
care program for low-income persons of all ages.
Each state is provided funds through the Federal Government, with
additional funding from the state, and able to provide Medicaid
services within the specified federal and state guidelines.
Eligibility is based on income and resources, depending upon the
covered group you fall under and are applying for
Long Term Care
MedicaidYou must meet the functional, income and resource guidelines to qualify for Long Term Care Medicaid and there are 2 Different ways to use your LTSS (Long Term Services and Supports)
Community Based Care
Assistance in the home (need based)
Agency Support
Consumer Directed
Care coordinator may be assigned if eligible for Commonwealth Coordinated Care Plus (CCCPlus)
Will not cover 24 hour care
Nursing Home Care
Licensed care facility with 24/7 care
Care coordinator may be assigned if eligible for Commonwealth Coordinated Care Plus (CCCPlus)
HOW TO APPLY FOR MEDICAID
Apply online at commonhelp.virginia.gov.
Call the Cover Virginia Call Center Monday through Friday, 8 a.m. to 7 p.m. and Saturday 9 a.m. to 12 p.m. at 833-5CALLVA (TDD: 1-888-221-1590).
Apply online at the Health Insurance Marketplace at healthcare.gov.
Mail or drop off a paper application to your local Department of Social Services (DSS). Mailing may take longer than other ways of applying.
If you also want to apply for other benefits, you can apply online at commonhelp.virginia.gov. Or call the Virginia Department of Social Services Enterprise Call Center at 1-855-635-4370.
All Medicaid applications are process through your local Department of Social Services.
CCC Plus/ Medicaid Managed Care
PROTECT Your Medicare number….GUARD YOUR CARD!!
DETECT Fraud, errors and abuse…by reading your Medicare
Summary Notices as soon as you get them!
REPORT Questions or mistakes to your medical provider or health
plan…if not satisfied with their response…CALL SMP
1-800-938-8885
Aging Division of RRCS --- Area Agency on Aging
Long-Term Care Ombudsman Program: The Long-term Care Ombudsman investigates and assists in resolving complaints made by or on behalf of
individuals in nursing homes and assisted living facilities, or at home with community-based care—including adult day care. The Ombudsman can
provide information on licensed long-term care facilities in the state or local area. Call 540-825-3100 ex: 3416.
Senior Centers: Available in each of the five counties, the Senior Centers provide a nutritious lunch and the opportunity to socialize with peers.
Senior Centers are open to people 60 years of age and over and offer programs both informational and entertaining. An enrollment process needs to
be completed after the participant has visited three times. Donations are requested to help cover the cost of the meals. Contact the Senior Center in
your county or the RRCS main office for further information.
Home-Delivered Meals: Five nutritious frozen meals per week are available to persons at least 60 years of age who are homebound and have no one
to shop or prepare meals for them. Liquid nutritional supplements may also be available on a limited basis with a prescription. A Support Coordinator
must contact the individual and assess the situation before delivery starts. Donations are requested. Call 825-3100.
Virginia Counseling and Assistance Program: VICAP counselors educate and assist older consumers with medical benefit programs, long-term
care insurance and Medicaid. VICAP also helps by explaining and enrolling people in Medicare Part D or Medicare Advantage plans. Call the main
office and ask for a VICAP counselor for your county Senior Medicare Patrol informs people about Medicare Fraud and Abuse and who to call
Senior Cool Care: This program, sponsored by Dominion Energy, distributes window air conditioners or fans to eligible seniors at no cost. Applicants
must be 60 years of age or older and meet certain income guidelines. Clients must arrange to pick up the unit at our administrative office in Culpeper.
The program is open from June through September, or until funding has been depleted. Call main office and ask for a coordinator for your county.
Foothills Area Mobility Systems (FAMS) Call Center: FAMS is a transportation resource center for the five county area to identify, promote, and
assist with access to any form of transportation. Call center staff help to arrange volunteer transportation, assists with scheduling Medicaid transport
and more. Please call 540-829-5300
RRCS/AAA VICAP Counselors by County
MAIN OFFICE NUMBER 540-825-3100
Hanna Price……….Culpeper County
ext. 3467
Poppy Foddrell……Fauquier County
ext. 3427
Toni Browning……..Madison County
ext. 3471
Jenny Zamora…….Orange County ext. 3450
Kathi Walker…Rappahannock County
ext. 3416***counselors available year round***
Credits and Disclosure
Information on the above slides was provided in part
by Rappahannock Rapidan Community Services,
Department of Medical Assistance (DMAS), Medicare
Interactive, Medicare.gov, Centers for Medicare and
Medicaid Services (CMS), Social Security and Bureau
of Insurance State Corporation Commission of Virginia
Please consult with your family, financial and tax
advisor, attorney and insurance counselor to
determine the best coverage for your needs
Need Assistance?
Other Helpful
Contacts
Medicare
medicare.gov
1-800-MEDICARE
VICAPvdars.org
Virginia Department of Aging and (804) 662-7000
Rehabilitative Services1-800-552-5019
Social Security Administrationssa.gov
1-800-772-1213
NAICnaic.org
1-816-783-8300
Virginia Bureau of Insurance 1-877-310-6560
Life and Health Consumer Services
(804) 371-9691 (Richmond)
• General insurance-related questions :•
• Investigate insurance –related complaints:
scc.virginia.gov/pages/consumers
Questions