HealthCare ChoicesResource CenterBulletin
February 13, 2013
Medicare UpdatesMedicare Advantage Disenrollment Period
A Medicare beneficiary can disenroll from their Medicare Advantage plan with or without prescription drug coverage during the Medicare Advantage Disenrollment Period (MADP) from January 1-February 14every year. During this time, they can switch back to Original Medicare to receive Parts A and B services. Individuals who use the MADP will receive a Special Enrollment Period (SEP) to enroll in a stand-alone prescription drug plan (PDP). (Note: Beneficiaries with a Private Fee-for-Service Medicare Advantage Plan and stand-alone prescription coverage will not receive an SEP and must keep their current PDP.)
Individuals cannot switch to another Medicare Advantage plan during the MADP. They will also not receive any special guaranteed issue rights to buy a Medicare Supplement (Medigap) policy during this period. That is, they may apply for a Medigap policy, but could be denied due to their health history.However, in the state of Illinois, Blue Cross Blue Shield and Health Alliance offer guaranteed issue Medicare Supplement policies for individuals 65 and older throughout the year. People with disabilities under age 65 and on Medicare have guaranteed issue with these plans between October 15 and December 7 of each year. To view more information about Medicare Supplement Plans and the guaranteed issue policies, please visit the Illinois Department of Insurance website here:
To avoid a lapse in prescription coverage, a beneficiary should not contact the Medicare Advantage plan to notify them of disenrollment. It is best to first enroll into a PDP, which will automatically disenroll the beneficiary from their current Medicare Advantage plan. The PDP will be effective the first of the following month. If enrolling into a Medicare Supplement plan, request the effective date of the new Medicare Supplement Policy to be the first day that the Medicare Advantage plan ends to ensure continuous coverage.
Click here to view a fact sheet created by the National Council on Aging’s Center for Benefits Outreach and Enrollment that explains the MADP and coverage options a beneficiary has during this time.
General Enrollment Period
If an individual did not sign up for Medicare Part A and/or Part B when they were first eligible, they can enroll during the General Enrollment Period from January 1st through March 31st each year.
Their coverage will begin July 1st of the same year. They may have to pay higher premiums for late enrollment.
To view more information about Medicare enrollment periods and late enrollment penalties, please click on the link below:
Medicare Part D Transition Supply
Medicare Part D plans are required by the Centers for Medicare and Medicaid Services (CMS) to offer new enrollees a one-time 30 day fill of a prescription that is not on a Part Dplan’s formulary. This is called a transition supply and can be used any time within the first 90 days of coverage. The transition supply applies to people who are new to Part D or those who switched plans and discover a drug they are taking is not on the plan’s formulary. It also applies to drugs that are on the plan’s formulary but have utilization management requirements (like prior approval from a doctor or step therapy).
Individuals in long-term care facilities will be provided up to a 31 day transition supply during the first 90 days they are in a new to a plan. Note that Part D plans must provide multiple 31days transition as necessary during the 90 day transition period. Individuals in long-term care settings who use the transition supply policy should make sure the supply is from a participating pharmacy.
If an individual fills a transition supply of a current prescription with his/her new plan, the Part D plan is required to notify the member in writing within three business days, explaining that the one-time supply was a temporary fill. This is intended to allow the member enough time to work with his/her doctor to find another drug on the formulary that would work as well or to request a formulary exception.
To view more information about Part D transition policy, please click here and see section 30.4.5.
Extra HelpSpecial Enrollment PeriodsLoss of Extra Help Special Enrollment Period
People with Medicare who nolonger automatically receive Extra Help (called “deemed” status) in 2013 are eligible to receive a Special Enrollment Period (SEP) to switch Part D plans outside of the regular Open Enrollment Period. Individuals are “deemed” eligible for Extra Help if they have Medicaid, are enrolled in one of the Medicare Savings Programs (QMB, SLMB or QI) or receive Supplemental Security Income (SSI).
This SEP is valid for a one-time Part D plan switch January 1stthrough March 31st. Any plan changes will take effect the 1st of the following month. For example, a plan switch made anytime in March 2013 will take effect April 1, 2013.Individuals who lost their Extra Help should review their current plan before the end of this SEP to find out if it still works for them since Extra Help will no longer help pay for their Part D plan premium, deductible and co-pays.
Individuals who lost “deemed” status should have received a grey letter from CMS notifying them that they will no longer receive Extra Help beginning January 1, 2013. Click here to view the letter.Click here to read more about this SEP in the Medicare Part D Benefit Manual.
It is important to remember these individuals may still qualify for Extra Help and should submit an Extra Help application to determine eligibility.
Individuals Who Currently Have Extra Help Receive a Continuous SEP
Just a reminder that Medicare beneficiaries with Extra Help qualify for a continuousSEP to change Medicare Part D plans at anytime during the year(up to once per month). Any plan changes made will take effect the first of the following month the change is made.
Medicare Covered VaccinesMedicare Coverage of Vaccines
Flu Season is here and the state of Illinois has reported an increase in the number of reported flu cases. Older adults are especially at risk and should talk to their doctors about getting a flu shot. As a result, it is important to understand how Medicare covers this vaccine as well as other immunizations.
Influenza Vaccine
Medicare Part B will cover the flu vaccine and its administration once a year during flu season (in the fall or winter) at no cost to the beneficiary. People with Medicare Part B are not required to pay anything for the flu shot as long as the provider who administers it accepts Medicare assignment. Medicare coinsurance and the Medicare Part B deductible do not apply for the flu shot.
Medicare beneficiaries who pay out-of-pocket for a flu shot or receive the shot from a provider who does not accept Medicare assignment can submit their receipts to Medicare for reimbursement up to a certain dollar amount.
Pneumococcal Vaccine
Medicare Part B will pay for the pneumonia vaccine once per the beneficiary’s lifetime (most people only need this vaccine once). The shot is at no cost to the beneficiary if the doctor orders it and the provider that administers the vaccine accepts Medicare assignment. If the doctor does not accept assignment, the beneficiary may have to pay for the administration of the shot but not the vaccine.
Hepatitis B Vaccine
Medicare Part B will cover the Hepatitis B vaccine. People with Medicare who are at medium to high risk of contracting Hepatitis B are eligible to receive the Hepatitis B shot. If it is administered at the doctor’s office the beneficiary is responsible for 20% of the Medicare approved amount. If the shot is administered in a hospital outpatient department, the beneficiary pays a set co-pay amount. The Medicare Part B deductible does apply.
Shingles Vaccine
Medicare Part D will cover the shingles vaccine. It is not covered under Part A or Part B. The amount a beneficiary pays for this vaccine varies by plan. Individuals may call their Part D plan to find out how much it will cost. Click here to read an article by the Medicare Right Center’s on how Medicare Part D covers this vaccine.
To learn how Medicare covers other vaccines visit You can easily find out if vaccines and other services are covered by using the search tool displayed on their home page.
CountyCare – Medicaid Expansion in Cook CountyWhat is the Medicaid Expansion?
In 2014, the Affordable Care Act aims to expand Medicaid to a new eligibility group by providing states with funding to provide Medicaid coverage to uninsured adults ages 19-64 who meet income and eligibility criteria. Individuals will be required to have income below 138% of the FPLand meet citizenship requirements. Currently, Medicaid eligibility groups include people who are age 65+, blind, people with disabilities, pregnant women, children under 18 (AllKids) and parents with children at home under 18 (Family Care). It is estimated that about 350,000 uninsured adults in Illinois would be covered.
The Affordable Care Act would provide 100% federal matching funds for this expansion of Medicaid from 2014 through 2016. The federal match funds are phased down to 90% by 2020 but will never go lower than 90%. (Federal matching funds for individuals currently in Medicaid are at 50%.) States are not required to participate in the Medicaid expansion. However, there is current legislation in Illinois that supports this expansion called SB 26, “Medicaid Financing for the Uninsured under the Affordable Care Act”. Click here for more information about SB 26.
What is CountyCare?
CountyCare is a new Medicaid program operated by thestate of Illinois Cook County Health and Hospitals System (CCHHS) and the Illinois Department of Healthcare and Family Services (HFS). The CCHHS received a special waiver through the federal government to begin the Medicaid expansion early and provide Medicaid touninsured adults living in Cook County only.
Who Qualifies for CountyCare?
To qualify for CountyCare, an individual must:
- live in Cook County
- be 19-64 years of age
- have a household income less than 133% of the Federal Poverty Level (about $1,275 a month for a household of one). There is no spenddown option available for CountyCare.
- be a U.S. citizen or a legal immigrant for 5 years or more
- have a Social Security number or have applied for one
AND - not be eligible for Medicareor full Medicaid under existing categories (age 65+, blind, people with disabilities, pregnant women, children and parents)
If an individual qualifies receives Medicaid through certain programs such as Veterans Care, Illinois Healthy Women or through a Medicaid Spenddown, can they still qualify for CountyCare?
Yes. Individuals enrolled in Veterans Care, Illinois Healthy Women or Medicaid spenddown can choose to enroll in CountyCare if they are approved. Note: individuals who are 65+, have a disability or are blind (known as “Seniors or People with Disabilities” – formerly as AABD) and with a spenddown have to choose either CountyCare or Medicaid through spenddown as they can only have one active case. Click here for more information.
How Does CountyCare Work?
Individuals who are found eligible for CountyCare must receive their medical care through a CCHHS network provider in order to have the service(s) covered.There are some community health centers that are also part of the network. Individuals will be requiredto choose a primary care physician (PCP) and a “medical home” from a list of accepted providers. All of their care and services must be received through the medical home they select in order to make sure their care iscoordinated.
Once an individual is approved, he/she will receive a CountyCare medical card (a paper card similar to the medical card). Please note that not all providers who accept Medicaid will be covered by CountyCare. The card will only work at CountyCare providers.
Is there a list of CountyCare network providers available online?
CountyCare is still a new program and in the process of developing aprovider network. A provider list is not currently available online but individuals may call the CountyCare hotline at 1-855-444-1661 for a list of participating providers.
Which services are covered?
CountyCare services include a number of services. A complete list of covered services can be found here.
How Do You Apply?
Applications are taken by phone or in person. Applicants must submit required documentation. Click here to learn more about each process and to view a checklist of documents that are accepted.
For more information about the CountyCare program, please visit
Federal Poverty Levels2013 Federal Poverty Levels
The U.S. Department of Health and Human Services (HHS) recently announced the 2013 Federal Poverty Levels (FPLs). These levels are updated every year and used to determine the income limits for many federal benefit programs such as Medicaid, Medicare Savings Program and Extra Help. In 2013, the FPLs will slightly raise the income limits for a number of federal programs. Click here to view the 2013 FPLs. The MMW Coalition will email a new “Chart of Benefits” (created by AgeOptions) once the chart is updated to reflect the changes.
Social Security UpdatesChanges to Electronic Payments
Beginning March 1, 2013, everyone who receives Social Security benefits must receive their benefits electronically. People may have their Social Security benefits directly deposited into a bank account, or they may choose to receive them on a DirectExpress debit card. For more information and answers to frequently asked questions regarding the switch to electronic benefits, please visit the Social Security website here:
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The Make Medicare Work Coalition February 13, 2013