Virginia Medicare Medicaid Dual Eligibles

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Unitedhealthcare Connected For Mycare Ohio

Dual-Eligible Medical Emergency Hits Houston

UnitedHealthcare Connected® for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected® for MyCare Ohio information, please contact our Member Services at from 7 a.m. to 8 p.m. Monday through Friday for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare Connected® de MyCare Ohio , comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al de lunes a viernes de 7 a.m. a 8 p.m. .

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

What Medicaid Helps Pay For

If you have Medicare and qualify for full Medicaid coverage:

  • You’ll automatically get Extra Help with your drug costs. Learn more about Extra Help.
  • Medicaid may pay for other drugs and services that Medicare doesn’t cover.
  • What Is Medicare Extra Help

    Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy

    The assistance that Medicare Extra Help may provide includes:

    • Help paying Part D premiums
    • Lowered out-of-pocket costs of prescription drugs
    • An annual Special Enrollment Period to enroll in a Part D plan or switch to a new one
    • Elimination of Part D late enrollment penalties

    You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income or a Medicare Savings Program.

    You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.

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    Qualified Disabled Working Individual Program

    The QDWI Program helps pay for the Medicare Part A premium for certain people who meet one of the following criteria:

    • Have a disability but are still working
    • Lost their premium-free Part A coverage when they returned to work
    • Are not receiving medical assistance from their state
    • Meet the income and resource limits below
    • Income of no more than $4,379 per month for an individual in 2021, or $5,892 for a married couple.
    • Resources of $4,000 for an individual in 2021, or $6,000 for a married couple.

    The income and resource limits listed above may increase in 2022. If your income and resources are slightly higher, you should still apply.

    Critical Analysis And Recommendations

    GALLERIES

    The analysis of the Medicaid Expansion Program and Dual Eligible Policy revealed that both could be considered as significant steps towards improving the existing healthcare delivery system in Virginia. Having had one of the leanest programs in the country, it currently provides high-quality services to approximately one million people and benefits the overall state budget. As regards FIDE-SNP, one may assume that the goal of this program was to develop person-centered care delivery system that would integrate the full range of healthcare services, as well as address challenges associated with the lack of care coordination. Though viewed as predominantly successful, it, however, requires some flexibility to better address dual-eligible beneficiariesâ needs and equip them to live independently in their communities.

    As one of the core values of Saint Leo Universityâs states, healthcare providers should âfoster a spirit of belonging, unity, and interdependence based on mutual trust and respectâ . Therefore, Virginia should aim to improve the entire state population care experience through the principles of wellness promotion, cultural competence, and independent living in order âto create socially responsible environments that challenge to listen, to learn, to change, and to serveâ . This means that healthcare providers must be more attentive to the unique demands of their patients given their diverse needs.

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    What Is A Snp

    A Special Needs Plan is a type of Medicare Advantage plan that combines all the benefits of Original Medicare with prescription drug coverage , but is only available to those beneficiaries who have an additional qualifying condition. For example, those who:

    • Have a specific chronic health condition
    • Are eligible for both Medicare and Medicaid
    • Are a resident of a long-term care facility

    Humana’s Special Needs Plans provide extra coverage to help you better manage your particular healthcare situation.

    Many of Humana’s SNPs have an affordable or even $0 monthly plan premium.

    What Is Medicare Dual Eligible And How Do I Qualify

    Most Americans understand that when they turn 65, Medicare will become their main health insurance plan. However, many Americans are less familiar with another health care program, Medicaid, and what it means if they are eligible for both Medicare and Medicaid. If you are dual eligible, Medicaid may pay for your Medicare out-of-pocket costs and certain medical services that arent covered by Medicare.

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    State Demonstration To Integrate Care For Dual Eligible Individuals

    Virginias duals demonstration proposes to cover full benefit Medicare-Medicaid enrollees , older persons and persons with physical disabilities, nursing facility residents, and persons who receive services through the Elderly or Disabled with Consumer Direction Waiver. Persons with intellectual/developmental disabilities who are not in the EDCD Waiver are excluded from the program. Assisted living services, intellectual/developmental disability services, and PACE programs will be carved out. The state targeted January 2014 for initial implementation in four regions, utilizing voluntary enrollment with opt out. The demonstration will use a capitated-managed care model. Programs: A 2012 Update, July 2012)State Website on Duals Demonstration

    On December 4, 2013, the state and CMS entered into a three-way contract with health plans for the delivery of coordinated services and supports to enrollees. Three-Way Contract

    In March 2014, Virginia began voluntary opt-in enrollment in Commonwealth Coordinated Care and passive enrollment began May 1, 2014. Residents must be dual eligibles and at least 21 years old to participate in the demonstration. Residents can opt out or withdraw from the plan at any time.

    Who Is Eligible For Medicare

    Medicare Basics and Dual Eligibles

    Medicare is a federally-run health insurance program for people age 65 and over and people under the age of 65 who have a qualifying disability. Original Medicare, which is proved by the federal government, consists of Medicare Part A hospital insurance and Medicare Part B medical insurance.

    To be eligible for Medicare, you must meet the following Medicare eligibility requirements:

  • You are at least 65 years old and are eligible for retirement benefits from Social Security or the Railroad Retirement Board, OR you are under 65 and are eligible for disability benefits from Social Security or the Railroad Retirement Board. You can also qualify if you have Lou Gehrigs disease or permanent kidney failure .
  • You are a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years.
  • You may also be eligible for Medicare if you or your spouse is a current or former government employee who has paid Medicare taxes while working.

    If you do not qualify for retirement or disability benefits, you may still be eligible for Medicare at age 65, but you may have to pay a monthly premium for Medicare Part A.

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    Subject Matter Expert Interviews

    We conducted semi-structured, key informant interviews with ten subject matter experts who are knowledgeable about the dual eligible population and state Medicaid eligibility, enrollment, and redetermination procedures. Seven of these interviews were with national experts and three were with state Medicaid officials. These interviews occurred from May-June 2017, and each lasted about 45 minutes. The goal of these interviews was to identify Medicaid policies regarding eligibility and enrollment procedures that are possibly related to the loss of full Medicaid benefits among dual eligible beneficiaries. Interviews were conducted according to standard qualitative data collection and evaluation practice, guaranteeing respondent anonymity and confidentiality.

    People Who Have Both Medicare & Medicaid

    People who have both Medicare and full Medicaid coverage are dually eligible. Medicare pays first when youre a dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.

    You can still pick how you want to get your Medicare coverage: Original Medicare or Medicare Advantage . Check your Medicare coverage options.

    If you choose to join a Medicare Advantage Plan, there are special plans for dual eligibles that make it easier for you to get the services you need, include Medicare coverage , and may also cost less, like:

    • Special Needs Plans
    • Medicare-Medicaid Plans
    • Program of All-Inclusive Care for the Elderly plans can help certain people get care outside of a nursing home

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    Medicaid Coverage Among Full

    Federal law requires states to provide Medicaid coverage to older people and individuals with disabilities who meet certain income, asset, and functional criteria. A categorization of key state Medicaid eligibility policies for older people and persons with disabilities is detailed in Appendix Table A-1). The most common pathways to Medicaid eligibility for older people and persons with disabilitiesare SSI and the Special Income Limit .

    In 39 states, individuals receiving SSI benefits are eligible to receive Medicaid benefits. Among these SSI states, where receipt of SSI benefits is the same as meeting Medicaid eligibility standards, a further subset, known as “1634 States,” automatically enroll individuals receiving SSI in Medicaid and do not require a separate application for Medicaid .

    Additionally, states may provide coverage to individuals if they are “medically needy.” Individuals are considered medically needy if their income minus out-of-pocket medical expenses places them below a state-established income and asset level during a specified period, known as the budget period. Both the amount of medical expenses and budget period are state specific.

    Who Is Eligible For Medicaid

    NDMS Definitive Care Overview Flow Chart

    Medicaid is a health insurance program that is jointly operated by federal and state governments and provides coverage for individuals and families who have low incomes or limited financial resources.

    Because each state administers its own Medicaid program, eligibility criteria can vary by state. Medicaid eligibility generally depends on your income, family size and state. You may use this tool from HealthCare.gov to help determine your Medicaid eligibility.

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    Es5 Discussion And Conclusion

    Contrary to expectations, a substantial number–nearly 30%–of new full-benefit dual eligible beneficiaries lose coverage for at least 1 month during the 12 months immediately following their initial transition to full-dual eligible status. This frequency of coverage loss among new, full-benefit dual eligibles is notably higher than reported in previous studies that typically included a cross-section of dual eligibles, most of whom were not new duals. In addition, nearly 30% of those who lost coverage had short coverage breaks for 1-3 months, likely for reasons that are administrative in nature. These findings suggest that new dual eligible beneficiaries may be more unstable, as compared to other, more “established” duals. According to subject matter experts, this coverage instability may be due in part to unfamiliarity with Medicaid policies and eligibility verification procedures.

    This analysis also sheds light on how Medicaid eligibility is associated with loss of Medicaid coverage at the individual level. Those who qualified for Medicaid coverage by receipt of SSI-cash benefits were the most stable group and those in the medically needy eligibility category were among the least stable. These findings are consistent with subject matter experts’ expectations.

    Qualified Medicare Beneficiary Program

    This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.

    Eligibility requires:

    • Income of no more than $1,094 per month for an individual in 2021, or $1,472 per month for a married couple
    • Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

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    Dual Eligibility: How Medicare And Medicaid Work Together

    If you are dual eligible and visit a health care provider who accepts both Medicare and Medicaid, Medicare will be the primary payer and Medicaid will be the secondary payer.

    This means Medicare will pay its share of your health care costs first. As the secondary payer, Medicaid can help pay for the out-of-pocket costs Medicare doesnt cover, such as your coinsurance, copayment and deductible costs. This combination of insurance payers means you pay little to nothing for your covered health care services.

    If you are enrolled in a Medicare Savings Program, you may also receive help paying for your Medicare premiums and deductibles.

    Dual eligible beneficiaries are also automatically eligible for the Medicare Extra Help program, which helps pay for prescription drug costs .

    Unitedhealthcare Senior Care Options Plan

    Dual Eligibility: Choice and Access for Individuals Eligible for Medicare and Medicaid, Judy Feder

    UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

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    Unitedhealthcare Connected General Benefit Disclaimer

    This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

    You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services, 8 a.m. – 8 p.m., local time, Monday – Friday . The call is free.

    You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future.

    Language Line is available for all in-network providers.

    Puede obtener este documento de forma gratuita en otros formatos, como letra de imprenta grande, braille o audio. Llame al Servicios para los miembros, de 08:00 a. m. a 08:00 p. m., hora local, de lunes a viernes correo de voz disponible las 24 horas del día,/los 7 días de la semana). La llamada es gratuita.

    Puede llamar a Servicios para Miembros y pedirnos que registremos en nuestro sistema que le gustaría recibir documentos en español, en letra de imprenta grande, braille o audio, ahora y en el futuro.

    Limited Understanding Of Medicaid Coverage Loss Among Full

    Past research has not specifically considered stability of enrollment among new, full-benefit dual eligible beneficiaries following their initial transition to full-dual eligibility. However, there are a few studies examining the loss of Medicaid coverage for full-benefit dual eligible beneficiaries. A 2014 study found that among a 5% sample of all full-benefit dual eligible beneficiaries nationally, 15.6% lost Medicaid benefits in the 36-month study period, January 2009-December 2011 . Among those losing benefits, almost one-third lost benefits for only 1-3 months and just over one-half eventually regained benefits. The authors also find that a higher probability of maintaining Medicaid coverage is associated with higher Medicaid fee-for-service expenses and with enrollment in a Dual Eligible Special Needs Plan . Those enrolled in Medicare Advantage plans were more likely to lose Medicaid coverage.

    A recent study considered the continuity of Medicaid coverage through the creation of Medicaid enrollment “continuity ratio,” which calculates the length of Medicaid enrollment in a year by dividing the average monthly number of Medicaid enrollees during a fiscal year by the number of unduplicated individuals enrolled in Medicaid at any time during the year . In the 2010-2011 period, the overall continuity ratio was 81% the ratio was 86% in the aged population, 90% in the blind/disabled population, 83% among children, and 72% among nondisabled adults.

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    Reasons For Loss Of Medicaid Coverage According To Subject Matter Experts

    To receive Medicaid benefits, generally an individual must apply to the program in the state in which they reside, and be certified as eligible at least annually, depending on state-specific criteria. Changes in income, assets, or medical need may result in an individual losing Medicaid benefits. Individuals may also lose Medicaid coverage if they fail to meet the administrative requirements, such as attending an in-person interview to renew their Medicaid benefits or providing documentation of income and assets to demonstrate their continued eligibility. Specific policies and renewal processes vary by state.

    In general, experts we interviewed expected that the full-dual population would have relatively stable income and assets over time and were likely to sustain Medicaid coverage. However, they noted several reasons that a full-benefit dual eligible beneficiary might lose coverage. They thought the most common reason would be failure to comply with certain administrative requirements less common reasons were changes in eligibility due to changes in income, functional status, or assets.

    Instability of full-dual status may vary by Medicaid eligibility category. Experts expected the greatest amount of instability to be among those eligible for Medicaid through the medically needy/spenddown pathway because of variation in medical and LTSS expenses.

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