HEALTH INSURANCE

Health Insurance Information, Counseling & Assistance Program (HIICAP)

The Health Insurance Information, Counseling & Assistance Program (HIICAP) provides counseling and assistance to older individuals and their families regarding EPIC, Medicare, Medicaid, “Medi-Gap, Medicare Savings Programs, Medicare Advantage Plans and long term care insurance.

Services offered include:

· information and education;

· policy review and comparison;

· client advocacy in problem and complaint resolution;

· assistance with claim tracking and submission;

· consumer protection assistance;

· appeals and hearings;

· assistance with eligibility and entitlement requirements.

Appointments are necessary – Call the health insurance counselor at (607) 753-5060.

EPIC

EPIC is the acronym for Elderly Pharmaceutical Insurance Coverage. EPIC is available to help eligible New Yorkers cope with the high cost of prescription drugs. EPIC is intended for seniors who don’t already have adequate insurance coverage for prescription drug expenses. EPIC also works with Medicare part D to lower drug costs.

EPIC is a cost-sharing plan. Coverage is not automatic. Persons must apply in order to be covered by EPIC. To be eligible, individuals must be age 65 or older, be a legal resident of New York State and meet the maximum income limits.

EPIC offers two plans. One plan has a fee schedule and the other a deductible schedule.

The Fee Plan applies to single seniors with annual incomes up to $20,000 and married seniors with combined annual incomes up to $26,000. The yearly fees range from $8 to $300, depending on the senior’s income and marital status.

The Deductible Plan is designed to help seniors with higher incomes. Single seniors with incomes between $20,000 and $35,000 and married seniors with incomes between $26,000 and $50,000 are eligible. The deductibles range from $530 to $1,715 a year, depending on income and marital status.

There are four co-pay amounts that range from $3 to $20 depending on the actual cost of the medicine.

For additional information about EPIC including brochures, applications, and assistance, call the HIICAP program of the Area Agency on Aging at (607) 753-5060.

Social Security Administration - Health Care Financing Administration

Medicare is a federally administered health insurance program for persons age 65 and older and some disabled individuals under age 65. Medicare includes: Hospital Insurance (Part A); Medical Insurance (Part B); Medicare Advantage Plans (Part C); and Prescription Coverage (Part D).

There is no premium for most individuals covered under Part A. Part A helps pay for in-patient hospital care, some (limited) nursing home care, home health care, and some hospice care. Part B helps pay for doctors’ services, outpatient hospital services, durable medical equipment, and a variety of other services and supplies.

Starting in 2007, the premium for Part B is based on yearly income. This amount is subtracted from Social Security checks.

Medicare Part B (Medical) Monthly Premium

If Your Yearly Income is		You Pay
File Individual tax Return	File Joint Tax Return
$80,000 or less	$160,000 or less	$93.50*
$80,001-$100,000	$160,001-$200,000	$105.80*
$100,001-$150,000	$200,001-$300,000	$124.40*
$150,001-$200,000	$300,001-$400,000	$142.90
Above $200,000	Above $400,000	$161.40*

* A late enrollment penalty may apply to certain individuals.

Medicare claims and payments are handled by private insurance companies under contract with the government. These contract companies are called intermediaries and carriers. (The carrier for Part B in our area is Upstate Medicare Services in Binghamton. The intermediary for Part A in our area is Empire Medicare Services in Syracuse.)

Hospitals bill Medicare Part A and receive payment directly. For an in-patient hospital stay, there is a deductible for days 1-60 of $992 (2007). This amount can be billed to the patient or to a Medicare Supplemental insurance plan.

Under Part B, there is variation in how claims are processed depending on whether a doctor or other provider accepts assignment (participating provider) or not. All doctors and providers have to submit a claim for medical services to Medicare Part B. If the doctor accepts Medicare assignment, he is agreeing to accept Medicare’s approved rate for the services as payment in full. In this case, if the annual Part B deductible of $131 (2007) has been met, Medicare will send 80% of the approved rate directly to the doctor. If the doctor does not accept assignment, the patient is responsible for the provider’s bill. Medicare will send 80% of their approved rate (if the $131 annual deductible has been met) directly to the patient. Bills from doctors who do not accept assignment may not exceed Medicare’s approved rate by more than 5%-15% depending on the procedure. (Balance Billing Law).

Among items that Medicare does not pay for are: eyeglasses (except following cataract surgery), dentures, hearing aids, and care outside the U.S.

More detailed information regarding Medicare is contained in the Medicare Handbook, available from the Social Security Administration (1-800-772-1213).

Information on specific claims can be obtained by contacting Medicare: (1-800-633-4227)

"Medi-Gap" Policies/Medicare Supplement Plans

Medicare supplemental plans, or “Medi-Gap” policies, are designed to pay most, if not all, of Medicare’s co-insurance amounts and may provide coverage for Medicare’s deductibles. Medi-Gap plans are regulated by the NYS Insurance Department. There are 12 standard benefit plans (labeled “A” through “L”) available for sale in the U.S. These standard plans were introduced in 1992 in an attempt to make policy comparison easier. For further information contact the Area Agency on Aging at (607) 753-5060.

Individuals should carefully consider the decision to purchase a Medi-gap plan. Not everyone needs such a policy. Persons enrolled in employer group plans, Medicaid eligible individuals and individuals eligible for the Medicaid Spend Down Program may not need a Medi-gap plan.

The following chart lists the 12 policies and the benefits offered by each.

Basic benefits pay the patient’s share of Medicare’s approved amount for physician services (generally 20% after $131 annual deductible); the patient’s cost of a long hospital stay ($248/day for days 61-90, $496/day for days 91-150, approved costs not paid by Medicare after day 150 to a total of 365 days of additional in-patient hospital care during the policy holder’s lifetime); and charges for the first 3 pints of blood not covered by Medicare.

Each of the 12 plans has a letter designation ranging from “A” through “L”. Insurance companies are not permitted to change these designations or to substitute other names or titles. While companies are not required to offer all of the plans, they all must make Plan A available if they sell any of the other 11 in a state.

12 STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS

BASIC BENEFITS

Part A Hospital Coinsurance Coinsurance for days 61-90 ($248)

Part A Lifetime Reserve Days 91-150 ($496)

Part A 365 Additional Lifetime Days 100%

Part B coinsurance 20%

50%*

75%*

First 3 Pints of Blood

50%*

75%*

ADDITIONAL BENEFITS

Hospital Deductible

50%*

75%*

Skilled Nursing Facility

Covers the first $992 of hospital charges for each benefit period

50%*

75%*

Part B Annual Deductible $131

Part B Excess Benefit Charges

100%

80%

100%

Emergency Care Outside the US

At-Home Recovery Benefit

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