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This is an audio broadcast prepared by California Health Advocates entitled “Medicare & Low-Income Programs.” In this broadcast, we will briefly go over different programs that people with Medicare who also have a low-income may qualify for. We will discuss Medi-Cal, Medicare Savings Programs, and the Part D Low-Income Subsidy (or “Extra Help”). These programs can help cover some of your Medicare health care costs.
To qualify for each of these programs, people must have monthly income below certain amounts, as well certain amounts of assets or resources. The exact numbers for these amounts varies by the program, and many change yearly. This broadcast gives a quick overview of these programs and directs you where to go for help and more information. You can also visit our website at www.cahealthadvocates.org.
1) Medi-Cal
Medi-Cal, the Medicaid program in California, provides health coverage to people with low-income and asset levels who meet certain eligibility requirements. (These requirements are outlined in the Medi-Cal section under ‘Low-Income Help’ on our website.) While there are several ways to qualify for Medi-Cal, we focus here only on Medi-Cal beneficiaries who also qualify for Medicare — individuals who are 65 and over and/or disabled. People who qualify for both Medicare and full Medi-Cal are known as "dual eligibles" or "Medi-Medis."
In general, Medi-Cal covers “medically necessary” services, including some things that Original Medicare does not usually cover, such as some vision, hearing and dental services. Medi-Cal will only cover these costs and services if you use providers that accept Medi-Cal. If you have both Medicare and Medi-Cal, Medicare is the primary payer (meaning Medicare will pay first for Medicare-covered benefits) and Medi-Cal is the secondary payer. If you qualify for full Medi-Cal or have Medi-Cal with a share of cost under $500, Medi-Cal will pay your monthly Medicare Part B premium ($96.40 in 2009). Medi-Cal will also cover your Medicare Part A and B deductibles and copayments. Note: if you have Medi-Cal with a share of cost (which acts like a deductible each month), you must pay your share of cost amount in any given month before Medi-Cal will cover these expenses.
You can use Medi-Cal with either Original Medicare or a Medicare Advantage (MA) plan. (Note: Medicare Advantage plans are Medicare health plans offered by private insurance companies. These plans provide your basic Medicare benefits plus any additional benefits the plan chooses to offer, such as dental care or hearing aid coverage.) If you choose Original Medicare and fee-for-service Medi-Cal, make sure your doctor or hospital accepts Medi-Cal as well as Medicare. Present both your Medicare card and your Medi-Cal Benefits Identification Card (BIC) to your doctor and other providers before receiving services, so they can bill Medicare and Medi-Cal directly. Medicare and Medi-Cal will make payments directly to the providers.
If you choose a Medicare Advantage (MA) plan and fee-for-service Medi-Cal, present your BIC to the network providers of the MA plan so they can bill Medi-Cal for any cost-sharing (i.e., deductibles, copayments and coinsurance).
For services covered only by Medi-Cal, such as dental care or long-term care in a nursing home, Medi-Cal is the sole payer. Medi-Cal may also pay for certain at-home services through In-Home Supportive Services (IHSS) when you need long-term care.
There are several different ways to qualify for Medi-Cal. If you qualify for Supplemental Security Income (SSI) at your local Social Security Administration office, you are automatically enrolled in Medi-Cal and will be sent a Benefits Identification Card (BIC).
If you do not qualify for SSI, you may still qualify for Medi-Cal with or without a share of cost, depending on your income and resources. Again, a share of cost is an amount of money a person must pay in a given month before receiving Medi-Cal benefits. A share of cost is like an insurance deductible. People on Medi-Cal with a share of cost meet the resource limits for Medi-Cal but have incomes above the monthly income limits. Note that as of November 1, 2008, if your share of cost amount is over $500, Medi-Cal will no longer pay your Medicare Part B monthly premium in the months you do not meet your share of cost. This means your Part B premium will be deducted from your Social Security check each month.
If you are an individual with a disability, and you are working, you may still qualify for Medi-Cal through the 250% California Working Disabled (CWD) Program. See information on our website.
Rules relating to Medi-Cal eligibility and coverage may change, including due to the current state budget crisis in early 2009. Check our website to make sure information you have is up to date.
2) Medicare Savings Programs (MSP)
Medicare offers several Medicare Savings Programs (MSPs) that assist people with low income and assets. These programs include: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Individual (QI) and Qualified Disabled Working Individual (QDWI). You must meet certain income and asset limits to qualify for these programs, which are outlined on our website. These programs are administered by Medi-Cal.
QMB covers the Medicare Part A premium (if you don’t get it for free), Part B premium, and can cover Part A and B deductibles and coinsurance. SLMB and QI both cover the Medicare Part B premium for those who qualify; the QI program allows people to have higher income than the SLMB program.
The Qualified Disabled Working Individual (QDWI) program is available to people who had Social Security and Medicare benefits because of a disability, but lost them because they returned to work and their earnings exceeded the allowable limit. QDWI pays for the Medicare Part A premium, but it doesn't pay for Part B.
To apply for these Medicare Savings Programs, you must also be eligible to receive Medicare Part A and Part B. If you are already enrolled in both Medicare Parts A and B, contact your California Department of Health Care Services (DHCS) county office to apply for these programs.
3) Part D Low-Income Subsidy (LIS) or “Extra Help”
The Low-Income Subsidy (LIS, or “Extra Help”) helps pay for a portion of Medicare Part D’s prescription drug benefit costs. Offered through private drug plans, Part D costs include: Part D premiums, deductibles and copayments. Depending on your income and assets, you may qualify for the full subsidy or a partial subsidy. All beneficiaries who qualify for the Low-Income Subsidy program are permitted to change Part D plans once a month at anytime during the year.
Basic Medicare Part D plans with monthly premiums below the California average ($24.86 in 2009) are referred to as benchmark plans. The full Low-Income Subsidy program covers the premium and deductible of benchmark plans. This means you do not pay a premium or deductible if you receive the full LIS benefit and enroll in a benchmark plan. You are, however, still responsible for copayments of $1.10-$6 for each covered prescription.
If you enroll in a Medicare Part D plan with premiums higher than the benchmark, you may have to pay a portion of the plan’s premiums.
Some people automatically get the Low-Income Subsidy: those that have Medi-Cal without a share of cost, and those who are enrolled in the following Medicare Savings Programs: QMB, SLMB or QI. Others can apply for the benefit on their own. If you have Medi-Cal with a share of cost you may qualify for the LIS program. Unlike those who have full-benefit Medi-Cal, you do not automatically qualify for the Low-Income Subsidy, unless you meet your share of cost in a given month.
If you think you might qualify for the LIS, you can apply for the Low-Income Subsidy at your local Social Security Administration office or Medi-Cal office. If you apply at the Medi-Cal office, ask to be screened for qualification for other programs. You may also apply for LIS by phone (1-800-772-1213) or on the Social Security website.
Beneficiaries with low-income who have prescription drug coverage as a retiree benefit should check with the company that processes their retiree benefits before signing up for the Low-Income Subsidy program or a Medicare Part D plan. Some low-income retirees are permitted to keep their retiree coverage and receive the Part D Extra Help, while others are not.
4) Where to get more help and information
If you would like to talk to someone to learn more about your options under Medicare and related health coverage issues, you can get free individual counseling by calling the Health Insurance Counseling and Advocacy Program (HICAP), with offices in every county in California and a toll-free hotline. HICAP is a volunteer-supported program that provides unbiased information to help Medicare beneficiaries make the best choices for their individual health care needs. The California Department of Aging administers HICAP services.
Call 1-800-434-0222
Also, remember to visit our website at www.cahealthadvocates.org for more detailed information on these programs and other Medicare benefits.
This has been an audio broadcast produced by California Health Advocates. Thanks for listening.