Benefits Counseling
DESK REFERENCE
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[1]Table of Contents
1. Social Security 1
Railroad retirees: 1
2. MEDICARE 2
3. MEDICAID 5
4 .MEDICARE SAVINGS PROGRAMS 9
5. PUBLIC ASSISTANCE PROGRAMS 11
6. PRIVATE HEALTH INSURANCE 11
7. iNDIAN hEALTH 13
8. MILITARY RETIREES AND VETERANS 14
9. PROTECTIVE SERVICES 16
10. legal services 17
11.HOUSING & UTILITIES 19
12. oTHER pROGRAMS 22
13. oTHER CONTACTS 25
New Mexico Aging and Long-Term Services Department
Rev. 4/21/06
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2
Program / Eligibility / Benefit/ Service /1. Social Security
Railroad retirees:
/ 1-800-772-12131-877-772-5772 / http://www.ssa.gov/
see “Social Security Offices” list
a. Retirement Benefits / § Individual or spouse age 62 for reduced benefits
§ Individual or spouse age 66 for individuals born between 1943-1954 for full benefits
§ Spouse of any age if child is under 16 or disabled, receiving Social Security benefits and in your care / § Monthly cash benefits, amount determined by past earnings and any work record and earnings of spouse
b. Disability Benefits / § Varies, but in general, must have paid Social Security taxes for 5 of last 10 years
§ Disability medical condition is expected to last a year or result in death
§ Disabled worker, spouse and children / § Monthly cash benefit, amount determined by past earnings, 5 months after determined date of onset of disability
§ Medicare 24 months after disability pension starts
c. Survivors’ Benefits / § Widows or widowers age 60 or age 50 if disabled, if married 9 mos., or if divorced after 10 years of marriage
§ Widow or widowers any age if responsible for child under age 16 or disabled who is receiving benefits
§ Surviving children under age 18 (or age 19 if high school) or any age if disabled
§ Parents age 62 or older of a worker who dies and on whom they were dependent / § Monthly cash benefit, amount determined by past earnings
d. Family Benefits / § Spouse age 62 and over (unless collecting higher on own)
§ Spouse of any age if caring for a child under age 16 or disabled
§ Children unmarried and under age 18; under age 19 in elementary or secondary school full-time; or age 18 and over and severely disabled onset before age 22
DIVORCED: can get benefits based on spouse’s work record if married for 10 years or more and are over age 62; does not affect ex-spouse’s benefits / § Monthly cash benefit, amount determined by past earnings
e. Supplemental Security Income (SSI)
To apply call 1-800-772-1213 (or TTY 1-800-325-0778 if you are deaf or hard of hearing). / Supplemental Security Income (SSI) is a Federal income supplement program funded by general tax revenues (not Social Security taxes):
§ Eligibility is determined by the Social Security Admin
MAXIMUM MONTHLY MAXIMUM
“UNEARNED” INCOME RESOURCES
$698- Individual $ 2,000
$1,048* - Couple $ 3,000
BURIAL ACCOUNT -- $1,500 each / § It is designed to help aged, blind, and disabled people, who have little or no income; and
§ It provides cash to meet basic needs for food, clothing, and shelter
§
2. MEDICARE
/ 1-800-MEDICARE / www.medicare.gova. Medicare Applications/cards:
Social Security Administration
1-800-772-1213
RR retirees call 1-800-808-0772
RR retires who have questions about Medicare Part B services and bills call 1-800-833-4455 / § Individuals age 65 and older who are entitled to Social Security or Railroad Retirement benefits
§ Under age 65 on Social Security disability for 24 months OR
§ With End Stage Renal Disease or Lou Gehrig’s Disease / § See Part A and Part B below
b. Part A (Hospital Insurance)
Part A claims/billing:
Trail Blazer Health Enterprises
1-800-MEDICARE
(1-800-633-4227)
As of January 1 ,2012 / Hospitalization deductible:
§ Days 1-60 = $1156.00 (once per benefit period)
Hospitalization coinsurance:
§ Days 61-90 = $289.00 per day
§ Days 90+ = $578.00 per day up to 60 days in a lifetime (“ Lifetime reserve days”)
Skilled Nursing Facility coinsurance:
§ Days 1-20 = $0
§ Days 21-100 = $144.50 per day
§ Days >100 = 100% / · Coverage for inpatient hospitalization, skilled nursing facilities, and some home health and hospice;
· Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment;
· The Part A premium is$248.00 per month for people having 30-39 quarters of Medicare-covered employment;
· The Part A premium is $451.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
c. Part B (Medical Insurance)
Claims/billing for durable medical equipment, diabetic supplies, home health, and hospice:
Trail Blazer Health Enterprises
1-800-MEDICARE
(1-800-633-4227)
All other Part B claims/billing:
Trail Blazer Health Enterprises
1-800-MEDICARE
(1-800-633-4227)
As of January 1 ,2012 / PART B MONTHLY PREMIUM
Beneficiaries who file an Individual tax return with Income / Beneficiaries who file a joint tax return with income / Total Monthly Premium
Less than or equal to $85,000 / Less than or equal to $170,000 / $99.90
$85,001-107,000 / $170,001-214,000 / $139.90
$107,001-160,000 / $214,001-320,000 / $199.80
$160,001-213,000 / $320,001-426,000 / $259.70
Above $213,000 / Above $426,000 / $319.70
· $140.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $140.00 deductible.) / § Coverage for many outpatient services including doctor’s visits, tests, preventive care, and some home health and hospice
§ Eligible persons are automatically enrolled at age 65 unless they decline enrollment
§ Late enrollment is open from January through March of each year; takes effect July of that year
§ A permanent 10% penalty may be added for each 12-month period they were eligible for but did not enroll in Part B
d. Part D (Prescription Drug Coverage)
New Mexico Aging and Long Term Services Department
NM SHIP
Resource Center
1-800-432-2080 or
505-476-4846
As of January 1 ,2012 / § Medicare offers prescription drug coverage (Part D) for everyone with Medicare;
§ If a beneficiary is not new to Medicare, but wishes to enroll, he/she may enroll October15, 2011 – December 7, 2012. There may be a 1% per month late enrollment premium penalty fee (late enrollment penalty is eliminated through 2009 for beneficiaries who qualify for low-income subsidy). At this time, individuals may also “switch” plans;
§ Any individual new to Medicare can enroll within three months prior to their 65th birth date, the month of their birth date, and three months following. / In 2012, if an individual is in a Medicare Part D Prescription Drug Plan (PDP) with the standard benefit, he or she will pay a deductible of $320 and 25percent of allowable Part D prescription drug costs between $320 and $2,930 ($652.50). The individual then hits a coverage gap, where he or she is responsible for 100 percent of prescription drug costs until he or she reaches the out-of-pocket maximum of $4,700. After the individual incurs total drug costs of $6,657.50, he or she becomes eligible for catastrophic coverage, which generally covers 95 percent of prescription drug expenses. The chart below explains how the Medicare Part D standard benefit design will work in 2012.
§ An individual may also get their Part D drug coverage through their Medicare Advantage Plan;
§ Outside of NM companies vary;
§ Coverage costs vary per plan;
§ A dual eligible has a continuous open enrollment period;
§ In 2012, seniors who hit the "donut hole" will receive a 50 percent discount on their brand-name drugs.
e. LOW INCOME SUBSIDY/EXTRA HELP
1-800-432-2080 OR
505-476-4846
As of January 1, 2012 / Single: Annual Income: No greater than $16,775
Savings/Resources total less than $13,070
Married: Annual Income: No greater than $26,120
Savings/Resources total less than $26,120
Individuals and couples with higher income may still be able to get some help, for example;
· They support other family members who live with them
· They have earnings from work / · You could receive help paying for some or your entire monthly Part D premium; paying for some or all of your deductible for Part D; reduce your co-payments per prescription
· Up to 150 % Federal poverty Income
· You can mail in application or apply on line at
https://www.benefitscheckup.org/index.cfm?partner_id=70
f. Senior Medicare Patrol (SMP)
1-800-432-2080 / Senior MedicarePatrol (SMP) program help Medicare and Medicaid beneficiaries avoid, detect, and prevent health care fraud.In doing so, they not only protect older persons, they also help preserve the integrity of the Medicare and Medicaid programs / § Investigates possible Medicare/Medicaid billing errors, fraud, waste, and abuse.
§ Assists with appeals for denial of payment by Medicare, Medicaid, or private insurance/health plan.
3. MEDICAID
/ To apply for Medicaid:SEE HSD INCOME SUPPORT DIVISION LIST
Visit website: http://www.hsd.state.nm.us/mad/
Questions about Medicaid Benefits/Coverage/Getting a New Medicaid Card Call:
MEDICAL ASSISTANCE DIVISION CLIENT SERVICES BUREAU 1-888-997-2583
a. Medicaid Category 001 & 004 (SSI) / § Age 65 or older or with physical or mental disability expected to last 12 months OR disabled child under age 18 OR blind adult or child
§ SSI recipients automatically get full Medicaid benefits
The Substantial Gainful Activity (SGA) amount for individuals with disabilities, other than blindness, from is $1,010 for 2012. SGA amount for individuals who are blind is $1,690 for 2012.
The monthly earnings amount that is used to determine if a month counts for the Trial Work Period is $720 per month in 2012. The amount is unchanged from 2011.
The Supplemental Security Income (SSI) Federal Benefit Rates (FBR) is $698 per month for an eligible individual and $1,048 per month for an eligible couple for 2012.
For 2012, the amount of earnings that will have no effect on / § In-patient hospital services
§ Out-patient hospital services
§ Laboratory and x-ray services
§ SNF & ICF level of nursing home care
§ Home health care services
§ Physician services
§ Rural health clinic services
§ Durable medical equipment / § Eyeglasses
§ Hearing aids
§ Vision screening
§ Artificial limbs
§ Types of therapy
§ Dental care
b. Medicaid Extension (“Pickle Amendment” or “503 Lead” cases) / § Elderly, blind, or disabled
§ Must have lost SSI due to cost of living increase in Social Security (retirement, disability, or survivors) benefits
§ Income limit $ 698 month / § Continuation of full Medicaid benefits for one year after SSI ends
c. Medicaid (Institutional)
Note: Amounts will change in January / § Individual must medically and financially qualify
§ Must be a NM resident in a nursing home at least 30 days
MAXIMUM MONTHLY MAXIMUM
INCOME RESOURCES
$ 2,094.00* $ 2,000.00
(* Includes $20 disregard)
BURIAL ACCOUNT -- $ 1,500.00
§ The resident keeps $ 63 of income per month for personal needs; non covered medical expenses up to $99.90 for individuals who have Medicare and actual health insurance premiums and an allowance for maintenance of spouse and dependants tat home.
§ The resident’s home and car are not counted as assets / Coverage in nursing facilities and acute care hospitals
§ High or low-level nursing care, as well as all other medical care, equipment, medications, and supplies
§ If married, the spouse who remains at home may keep…
1. their home and car
2. one half of the couple’s assets (up to $113,640)
3. at least one half of the couple’s monthly income
d. CoLTS – Coordination of Long Term Services or -Home and Community
Based Waivers
To add a new client to the Central Registry or for status of those already on the Registry:
ALTSD Resource Center
1-800-432-2080 / CoLTS is a program that manages health care and long-term services for certain Medicaid recipients. CoLTS Managed Care Organizations manage and coordinate all physical health services, such as doctor visits, hospital services, prescriptions, etc., services that would be covered by Medicaid and long-term care services. There are two Managed Care Organizations (MCOs), who are contracted to manage and coordinate services for the CoLTS program: Evercare and AMERIGROUP. Individuals enrolled in CoLTS may choose which MCO they want to work with. All services are determined, approved, and coordinated by the CoLTS MCO.
The CoLTs program includes Individuals who are:
· receiving Personal Care Option (PCO) services;
· on the CoLTS Home and Community Based Waiver (formerly the D&E Waiver);
· receiving Medicaid and in a nursing home;
· receiving both Medicare and full Medicaid benefits (dual eligible); and,
· On the Mi Via Waiver through the CoLTS Home and Community Based Waiver or Brain Injury program. / Please refer to the following website for a summary of CoLTs covered services
http://www.hsd.state.nm.us/mad/CCoLTSDetail.html
e. Mi Via Self-Directed Waiver
ALTSD Resource Center
1-800-432-2080
/ MAXIMUM MONTHLY MAXIMUM
INCOME RESOURCES
$ 2,094.00* $ 2,000.00
(* Includes $20 disregard)
BURIAL ACCOUNT -- $ 1,500.00
· Client must be on the CoLTS Central Registry / § Consumer decides what services, supports or goods are needed
§ Consumer decides how to spend the funds available / § Consumer consultant agency assists with implementation of service plan
§ Medicaid recipients who receive long-term services through home-and-community based waiver programs, such as the Disabled and Elderly, Developmental Disabilities, Medically Fragile, AIDS, and individuals with brain injuries will be eligible for Mi Via.
f. Mi Via Self-Directed
Waiver Brain Injury
ALTSD Resource Center
1-800-432-2080 / MAXIMUM MONTHLY MAXIMUM
INCOME RESOURCES
$ 2,094.00* $ 2,000.00
(* Includes $20 disregard)
BURIAL ACCOUNT -- $1,500.00
§ Client must be on the CoLTS Central Registry /Brain Injury List
§ Must be under 64 years of age to get on Mi Via BI / § Consumer decides what services, supports or goods are needed
§ Consumer decides how to spend the funds available / § Consumer consultant agency assists with implementation of service plan
g. Personal Care Option (PCO)
If you are currently enrolled in AMERIGROUP Community Care please call 1-877-269-5660 to be assessed for PCO services.