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Medicare or Medicaid…. Which do I qualify for, and what is all this I hear about Open Enrollment???
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Page 1: Medicare or Medicaid….

Medicare or Medicaid….

Which do I qualify for, and what is all this I hear about Open Enrollment???

Page 2: Medicare or Medicaid….

.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

Page 3: Medicare or Medicaid….
Page 4: Medicare or Medicaid….
Page 5: Medicare or Medicaid….

MEDICARE

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Page 7: Medicare or Medicaid….

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

Page 8: Medicare or Medicaid….

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)

Page 9: Medicare or Medicaid….

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

Page 10: Medicare or Medicaid….

❑ 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

Page 11: Medicare or Medicaid….

Medicare enrollment periods chart

Page 12: Medicare or Medicaid….

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)

Page 13: Medicare or Medicaid….

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

Page 14: Medicare or Medicaid….

Medicare options:

Page 15: Medicare or Medicaid….

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

Page 16: Medicare or Medicaid….
Page 17: Medicare or Medicaid….

Medigap/

Supplemental

Plans available

and benefits

offered

Page 18: Medicare or Medicaid….

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.

Page 19: Medicare or Medicaid….

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

Page 20: Medicare or Medicaid….

Medicaid

Page 21: Medicare or 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

Page 22: Medicare or Medicaid….

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)

Page 23: Medicare or Medicaid….

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.

Page 24: Medicare or Medicaid….

CCC Plus/ Medicaid Managed Care

Page 25: Medicare or Medicaid….

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

Page 26: Medicare or Medicaid….
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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

Page 28: Medicare or Medicaid….

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***

Page 29: Medicare or Medicaid….

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

Page 30: Medicare or Medicaid….

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 :•

[email protected]

• Investigate insurance –related complaints:

scc.virginia.gov/pages/consumers

Page 31: Medicare or Medicaid….

Questions


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