FEBRUARY 9, 2015 VOLUME 22 NUMBER 6
Health care programs for the elderly, the poor and the disabled can be complicated and confusing. We frequently find that clients are unclear about the differences — in eligibility and in coverage — between Medicare and Medicaid, for instance. Add in the fact that Arizona calls its Medicaid program AHCCCS (the Arizona Health Care Cost Containment System) but also ALTCS (the Arizona Long Term Care System) for some parts of the program, and the confusion begins to climb. Let us try to confuse things just a little bit more before (we hope) introducing some clarity.
First, the key distinctions between the two biggest government health care programs:
- Medicare is a federal program, with very little state involvement (other than what we’ll be detailing in a moment). Medicaid is a joint federal-state program, administered by the individual states but funded mostly by the federal government.
- Medicare beneficiaries are over age 65 OR they are receiving Social Security Disability Insurance payments. In other words, it is intended to cover the elderly and the disabled. Medicaid beneficiaries, on the other hand, may or may not be elderly or disabled — but they must be poor (with the state’s definition of “poor” quite variable).
- Medicare covers (to a greater or lesser extent) inpatient hospital care, outpatient doctors’ visits and medications. Medicaid covers all medical expenses, including long-term care costs (an item that Medicare covers to a very limited extent).
- Assets and income are irrelevant to Medicare coverage (except, of course, that if you are able to work you can’t be “disabled” in order to qualify before age 65). Medicaid pays close attention to income (whether earned from wages or received from investments, by gifts or otherwise) and assets (though there are differences state-to-state).
- Medicare beneficiaries frequently have to pay co-payments (a share of the cost of a doctor’s visit, for instance), deductibles (the first $XX of a year’s medical costs, with XX being highly variable) and premiums (a flat amount for Medicare Part B coverage, for instance). Other than fairly nominal copayments, Medicaid beneficiaries usually do not have to pay any significant share of their medical costs; once eligibility is established, Medicaid picks up the entire cost.
Obviously, a person over age 65 might also have limited resources and income. A person with a disability might, as well. And a Medicare beneficiary might need medical care not covered by the program — like nursing care, for instance. There are five little-known programs available to help people who qualify for Medicare but need help with their premiums, deductibles or co-payments (note that all the numbers listed here are 2015 figures, and scheduled to increase slightly each year):
- The Qualified Medicare Beneficiary (QMB) Program. The most generous of the four is the QMB program. It pays Medicare Part A and Part B premiums, and all co-payments and deductibles. QMB recipients also automatically qualify for “extra help” with their Medicare Part D premiums. In order to qualify, the applicant must have income of less than the federal poverty level (in 2015, that figure for a single person living in the continental U.S. is $11,770/year, or $981/month — for a married couple it is $15,930/year or $1,328/month) plus $20. In other words, a single person with income of less than $1,001/month will qualify. In addition, in many states (not including Arizona, which does not have an asset limitation for QMB benefits) the QMB applicant must have assets of less than $7,280 (for a single person) or $10,930 (for a married couple). Not counted among the assets in states which impose an asset limitation: the applicant’s home, car, household contents and a few other items (they use the same exclusions applied to the Supplemental Security Income (SSI) program).
- The Special Low-Income Medicare Beneficiary (SLMB) Program. SLMB applicants can have up to 120% of the federal poverty income figures (plus the $20 that is disregarded — in other words, up to $1,197/month for a single person or $1,613 for a married couple), but are held to the same asset levels as those in the QMB program. Upon qualifying, the SLMB applicant will have Medicare Part B premiums paid — that will amount to a $104.90 monthly benefit for most Medicare recipients. SLMB beneficiaries also get “extra help” with their Part D premiums.
- Qualifying Individuals (QI). A small group of people who do not qualify for any other Medicaid program might get help with their Medicare Part B premiums, if their income is between the $1,197 limit for a single person under SLMB and $1,345 (representing 135% of the federal poverty level, plus that ubiquitous $20). A married couple may have up to $1,813/month. As with QMB and SLMB, if you qualify for QI you also automatically get “extra help” with your Part D premiums.
- Qualified Disabled and Working Individuals (QDWI). This one requires a little more explanation. For someone who once received Social Security Disability payments but returned to work, QDWI can pay the Medicare Part A premium (that’s $426/month in 2015). Income limits are up to 200% of the federal poverty guidelines (plus that $20), or $1,982 for a single person or $2,675 for a married couple. The most important thing about QDWI, though, is how few people will qualify — Arizona’s AHCCCS program notes that almost every QDWI recipient would also be eligible for the much more generous “Freedom to Work” program.
- “Extra Help.” Programs that help pay co-payments and deductibles for Medicare’s Part D (drug) coverage go under the friendly name “extra help.” Any QMB, SLMB, QI, or SSI recipient will also get “extra help.” In some cases the program might reduce co-payment amounts but not eliminate them.
These programs can be bewilderingly complex, but they mean real benefits to recipients. Eligibility or the amount of benefit may also change year-to-year, as the beneficiary’s income goes up or down.