2911 Medicare and Medicare Buy-In

See Policy Memo, 1999-10-03 re: Application of Medicare Premiums to Spenddown .

The federal Medicare program provides health insurance coverage to persons who qualify (see 2911.2 ). Medicare is composed the following parts.

Part A (Hospital Insurance) - Provides coverage of inpatient hospital care, hospice and home health benefits. Very limited coverage of skilled nursing facility care is also provided. Part A coverage does not have a premium for most people.

Part B (Supplemental Medicare Insurance) - Provides coverage of doctors services, outpatient hospital care. Part B also provides coverage for other services such as clinical laboratory services, some therapies, and certain preventative services such as prostate cancer screens and mammography. All services must be medically necessary. Most people pay a monthly premium for Part B coverage through a withholding from their Social Security or Railroad Retirement benefit.

Part C (Medicare Advantage) - Provides coverage under a managed care model and is only open to people who live in an area of the state where a plan is offered. Persons receiving Medicare through an Advantage plan agree to receive services from a contracted network of providers but may have additional services covered (such as dental) they may also have an additional premium for coverage.

Part D (Prescription Drug Insurance) - Effective January 1, 2006. Provides coverage of outpatient prescription drugs. Medicare beneficiaries will receive Part D coverage through a private plan, known as Prescription Drug Plan (PDP). A Medicare health plan can also provide coverage under Part D, Medicare Advantage - Prescription Drug (MA PD). All plans must offer prescription drugs in specified therapeutic drug classifications, but the specific formularies may vary. Beneficiaries eligible to enroll in Part D must do so through the private plan. A monthly premium is charged to the beneficiary and is collected through a reduction in the Social Security benefit or paid directly to the PDP. Individuals who are incarcerated are not entitled to Medicare D.

Medicare beneficiaries who are eligible for Medicare only due to end stage renal disease (ESRD) lose Medicare coverage 36 months after a kidney transplant. Beneficiaries who meet certain criteria, including not having any other health insurance coverage that covers immunosuppressive drugs, are able to qualify for continuous Medicare-covered immunosuppressive drugs through the Medicare Part B Immunosuppressive Drug (Part B-ID) benefit. The Part B-ID benefit covers only immunosuppressive drugs and no other items or services.

From June 1, 2004 - December 31, 2005 Medicare beneficiaries have the option to participate in a Medicare Approved Drug Discount Card. These cards, offered through approved sponsors, provide discounts for specified prescription drugs to the holder of the card. An annual enrollment fee is required. Persons receiving prescription drug coverage through Medicaid are not eligible to enroll. In addition, a special $600 credit also called Transitional Assistance is available to persons under 135% of poverty, except for those participating in Medicaid and other specified forms of prescription drug coverage (e.g., TriCare for Life and employer-based coverage).

As part of the Medicaid plan, the state is required to provide Medicare Part B coverage to certain groups of individuals. The state pays the standard premium charge on behalf of each enrolled individual. This is accomplished through the buy-in process. Through this process the state ensures entitled individuals are enrolled in Medicare Part B and Medicaid claims are offset by Medicare payments. The state will also pay the Medicare Part A premium for individuals receiving QMB coverage.

Incorporated into the appropriate application form is a statement of client consent to buy-in and for Medicare benefit payments to be made directly to medical providers. Utilization of Medicare is required if eligible for any medical assistance program (see 2120 for cooperation).