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Apologies for two errors in the e-blast sent last week. We corrected a hyperlink to an online article on the 2016-17 budget which mistakenly linked to an article on the 2014 budget.
Second, we had incorrectly reported the final agreement as to how much Medicaid will subsidize the Medicare copayment or coinsurance for members of Medicare Advantage plans who also have Medicaid or Qualified Medicare Beneficiary (“QMB”) benefits. See revised information below.
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- FINAL BUDGET (CORRECTED) --Medicare beneficiaries who rely on Medicaid or "QMB" to pay the copayments charged by their Medicare Advantage Plans will now have 85% of the copayment paid for them, as long as the provider accepts Medicaid.
- This is much improved over the Governor's original proposal - which was that NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service.
Here is an example to illustrate the proposal and the final budget provision.
HYPOTHETICAL FACTS: The Medicare rate for Mary's specialist visit is $200, of which her Medicare Advantage plan pays $150 and Mary is charged a copayment of $50. The Medicaid rate for the same service is $150.
- FINAL NYS BUDGET: Medicaid will pay the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment. Since provider is getting $192.50 of the $200 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients.
- PROPOSED budget (not enacted): Medicaid would not pay specialist ANY part of the $50 copayment since the Medicaid rate for the service is less than the Medicare rate. Medicaid would view the doctor as already paid in full. This would have deterred doctors and other providers from being willing to treat dual eligibles and people with QMB.
Unfortunately, the budget does not change the cut enacted last year in 2015, which cuts the subsidy paid by for Medicaid and QMB recipients who have Original Medicare, rather than Medicare Advantage. They get no help at all with the 20% Part B coinsurance, if the Medicaid rate is lower than the Medicare rate for the service. While providers are banned from "balance billing," the reality is that the beneficiaries are still hurt when their provider is not paid. See CMS 2015 Report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)."
The rest of last week's e-lert is reprinted below as corrected.
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The final negotiations in the State Budget for 2016-17 are still going on, but some details for Medicaid were reached yesterday on March 30, 2016. So far we can report that the budget agreement –
- Keeps Spousal Refusal intact, along with “parental refusal” for children
- Keeps the "Spousal Impoverishment" Resource Allowance at $74,820 instead of reducing it to $23,820. This is the amount of resources a "well spouse" may keep when the other spouse is in a Managed Long Term Care plan, waiver program, or a nursing home. See analysis and examples here.
- Retains Managed Long Term Care eligibility for those currently eligible. The Governor had proposed excluding those who would not otherwise need nursing home care if they did not have home care. Advocates were concerned that these individuals would need to apply for personal care at their local county Medicaid offices, which have downsized their staff with the move to MLTC, and lack the staff to assess need and provide home care.
- TBI/ NHTDW Waivers - The Traumatic Brain Injury & Nursing Home Transition & Diversion Waivers were scheduled to essentially close on Jan. 1, 2017 with all members being transitioned to Managed Long Term Care or Managed Care plans, which would take over providing these services. The budget delays this transition one year until Jan. 1, 2018 to allow more time to ensure a safe and thoughtful transition and continuity of services for this fragile population.
- QMB and Dual Eligibles in Medicare Advantage - Reaches a compromise in which Medicaid will pay 85% of the coinsurance or copayment charged to Medicare Advantage members for Medicare Part B services, for members who are dual eligibles or are in the Qualified Medicare Beneficiary (QMB) program. See here for more info.
- Managed Care Assistance Program (MCCAP) funding preserved - Funding for this important program that funds community-based organizations throughout New York State, including NYLAG, to assist Medicare and Medicaid beneficiaries with Medicare Part D and access to subsidies for low-income Medicare beneficiaries was preserved. See this blog by NYLAG advocate Paula Arboleda describing this successful program.
Big thanks are due to NYS Assembly Health Committee Chair Richard Gottfried and Chair of the NYS Senate Health Committee Chair Kemp Hannon, for their leadership and commitment on these issues -- and a salute to Medicaid Matters NY and the NYS Bar Association Elder Law & Special Needs Section for their terrific advocacy for New Yorkers who rely on Medicaid!
Stay tuned for further news on the state budget. Read about the original proposals by Gov. Cuomo and testimony by NYLAG, the Empire Justice Center, and more here.
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The Evelyn Frank Legal Resources Program is pleased to announce a five-part Continuing Legal Education Webinar program that will provide professionals with tools to understand and navigate the complex world of Medicare and Medicaid in New York. The focus is on eligibility and application procedures for older persons and people with disabilities who need help paying the out-of-pocket costs for Medicare, and cannot afford services not covered by Medicare such as home care. This series will not include Medicaid eligibility for nursing home care or managed long term care in depth.
Click HERE for for more information, the complete schedule, and registration form.
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Beginning April 1, 2016, a parent may serve as the paid personal assistant for his or her adult child (21 years of age or older) in the Consumer-Directed Personal Assistance Program, if certain conditions are met.
- The parent may not also be the child/consumer's "designated representative," and
- If the parent lives with the consumer/child, the parent must "... [reside] with the consumer because the amount of care the consumer requires makes such relative's presence necessary...." 18 NYCRR 505.28(b)(3)
- This change applies regardless of whether the CDPAP services are authorized by a mainstream managed care plan (for people without Medicare), a managed long term care plan, or by the local county Medicaid program (HRA in NYC) for people excluded or exempt from managed care.
- This change is the result of an amendment to state law, which now prohibits only "legally responsible" relatives from being the CDPAP aide. Spouses may still not be the CDPAP assistant for their spouse, nor parents for a minor child under 21, but any other adult relative may be the CDPAP aide - again, provided that the individual is also not the "designated representative" and does not live with the consumer/ adult child, unless the relative lives with the consumer because the amount of care the consumer requires makes such relative's presence necessary.
- State directives include GIS 16 MA/006 - Changes to the Statute for the Consumer Directed Personal Assistance Program (CDPAP) PDF and NYS Dept. of Heath Medicaid Update (Vol. 32 No. 3, March 2016)
Click here for more information and see this article in Democrat & Chronicle, Nov. 25, 2015.
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