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Medicare

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Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.  If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Medicare is funded through two trust accounts held by the U.S. Treasury:

  • Hospital Insurance Trust Fund which pays for:
    • Medicare Part A:
      • Hospital care
      • Skilled nursing facility care
      • Nursing home care (as long as custodial care isn’t the only care you need)
      • Hospice
      • Home health services
  • Supplementary Medical Insurance Trust Fund which pays for:
    • Medicare Part B:
      • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
      • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.  You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.  Part B covers things like:
        • Clinical research
        • Ambulance services
        • Durable medical equipment (DME)
        • Mental Health
          • Inpatient
          • Outpatient
        • Partial hospitalization
        • Getting a second opinion before surgery
        • Limited outpatient prescription drugs
    • Medicare Part D:
      • Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to join a Medicare Prescription Drug Plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty.  To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.

For more information on Medicare visit Medicare.gov The Official U.S. Government Site for Medicare or contact your Care Coordinator.

Qualified Medicare Beneficiary

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The Qualified Medicare Beneficiaries (QMB) program helps people who have Medicare pay for their medical care. To receive benefits from the QMB program you must be receiving Part A (Hospital insurance benefits) coverage of Medicare. Your income and resources must fall within certain limits. Income limits are changed annually based on the federal cost of living adjustment.  QMB has four benefit packages based on an individual’s income. The amounts listed are for 2014-2015.

Qualified Medicare Beneficiaries – Basic (QMB-BAS). In this benefit package the Department of Human Services pays for eligible clients’ Medicare premiums, deductibles and co-insurance. The income limit for this program is set at 100 percent of the poverty level or $973 for an individual and $1,311 for a couple.

Qualified Medicare Beneficiaries – Disabled Worker (QMB-DW). In this package the Department pays for the Medicare Part A premiums for some disabled workers who lost eligibility for Social Security because they are working. The income limit for this program is set at 200 percent of the poverty level or $1,945 for single person and $2,622 for a couple.

Qualified Medicare Beneficiaries – Specified Low-Income Medicare Beneficiary (QMB-SMB and SMF). In this benefit package, the Department only pays for the Medicare Part B premiums of eligible clients. The federal government pays for a portion of the cost of the SMB and SMF programs.

SMB – The income limit for SMB is set at 120 percent of the poverty level or $1,167 for individuals or $1,573 for a couple. The federal government pays 60 percent of this benefit.

SMF – The federal government also mandates that we serve people with incomes between 120 percent and 135 percent of the poverty level which equals $1,313 for an individual and $1,770 for a couple. This is called the SMF benefit. Unfortunately, we are only allowed to serve a specific number of people each year in this category. Once we reach our maximum number we must shut down enrollment. The federal government pays 100 percent of the SMF program.

Please note: Institutionalized clients (e.g. Nursing Facility residents) are not eligible for the SMF program.

For all QMB programs the allowed resource (asset) limit is set at $7,160 per individual or $10,750 per couple in 2014. This does not include your home, car, burial plan ($1,500) and merchandise.

For more information visit the Department of Human Services website.

Low Income Subsidy


Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is also known as the Low Income Subsidy (LIS).  The Extra Help is estimated to be worth about $4,000 per year.  Extra Help pays for the costs of monthly premiums,  annual deductibles, and prescription co-payments related to a Medicare prescription drug plan.

To qualify for the Extra Help:

  • You must reside in one of the 50 states or the District of Columbia;
  • Your resources must be limited to $13,440 for an individual or $26,860 for a married couple living together.  Resources include such things as bank accounts, stocks and bonds. We do not count your home, car or any life insurance policy as resources
  • Your annual income must be limited to $17,235 for an individual or $23,265 for a married couple living together. Even if your annual income is higher, you still may be able to get some help. Some examples where your income may be higher are if you or your spouse support other family members that live with you or have earnings from work.

Your eligibility for assistance can be determined by either the Social Security Administration (SSA) or you Senior Services office.  To apply online or get more information on Low Income Subsidy visit the Social Security website.

Insurance Information

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Through the Affordable Care Act there are several types of insurance to choose from.  Your Care Coordinator can help you navigate systems to enroll for the insurance you qualify for.  You can also apply by going to www.coveroregon.com/get-coverage/online.

There are many types of insurance available to people living with HIV, including persons who are also undocumented.  Below is a list of the most common types of insurance.  For more information click on the item listed.

  • Oregon Health Plan (Medicaid)
  • Medicare
  • Qualified Health Plans

There are also programs that can help you with the cost of insurance, medical care, and medications.  Below are a few, click on the name to learn more.

  • Low Income Subsidy
  • Qualified Medicare Beneficiary
  • CAREAssist

Qualified Health Plan

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Under the Affordable Care Act, starting in 2014, any insurance plan that is certified by the Health Insurance Marketplace and provides essential health benefits, follows established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meets other requirements is considered a Qualified Health Plan.

Essential Health Benefits:

  • Outpatient care
  • Trips to the Emergency Room
  • Inpatient hospital treatment
  • Care before and after your baby is born
  • Mental health and substance use disorder services such as behavioral health treatment, counseling, and psychotherapy
  • Prescription drugs
  • Services and devices to help you recover from injury, disability, or chronic condition including physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and more
  • Lab tests
  • Preventative services including counseling, screenings, and vaccines to keep you healthy and manage a chronic disease
  • Pediatric services such as dental and vision care

Under the Affordable Care Act, you can only apply for health insurance coverage during Open Enrollment, which is between November 15, 2014 and February 15, 2015.   However, if you had what is known as a “Qualifying Life Event” you are still eligible to enroll and even get financial help.  A Qualifying Life Event is simply a major life change – for example, you were recently married/divorced, had or adopted a child, lost a dependent/death in the family, graduated college, changed jobs, moved to a new state, etc. – then you can get coverage outside of the Open Enrollment period.  Remember this does not apply to Oregon Health Plan(OHP), you may apply for OHP at any time.

Individuals and families could qualify to receive help paying for a qualified health plan. Factors such as income and household size determine if a person or family are eligible for tax credits to help pay for monthly premiums. (An individual earning up to $45,900 a year or a family of four earning up to $94,200 a year could qualify for a tax credit.) Some people will also be eligible for cost-sharing reductions to help pay for copays, deductibles and other out-of-pocket costs.

If you have questions about how to apply for a qualified health plan and assistance with the costs, your care coordinator can help.

If you are uninsured and have not had a Qualifying Life Event and are unable to enroll for insurance, talk with your Care Coordinator about other options available to you until Open Enrollment begins.

Oregon Health Plan

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The Oregon Health Plan (OHP) provides health care coverage to low-income Oregonians through programs administered by the Division of Medical Assistance Programs (DMAP). Currently, more than 600,000 people each month receive health care coverage through the Oregon Health Plan.

Qualification for OHP is based on residency, income, and/or those who are elderly, sight impaired, disabled, pregnant or receiving Temporary Assistance for Needy Families (TANF) benefits. Individuals who want to apply for OHP should always submit a completed application to see if they qualify. OHP is opening to more low-income adults in 2014. You may qualify for OHP, even if you’ve been denied in the past.

You can apply for the Oregon Health Plan at any time. Enrollment is always open.  All people enrolled in the Oregon Health Plan will become a member of a Coordinated Care Organization (CCO) that serves your county of residence.  Some counties have more than one CCO and you may be asked to choose.  For more information visit the Oregon Health Authority website.

Your Care Coordinator can help you apply for OHP or you can go to the Cover Oregon website at Cover Oregon

CAREAssist

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CAREAssist is Oregon’s version of the AIDS Drug Assistance Program (ADAP). CAREAssist helps people living with HIV/AIDS pay for medication and other medical care expenses. CAREAssist is not health insurance, but they help individuals maintain and utilize health insurance by paying for insurance premiums, doctor visit co-pays and medication co-pays. To become a member of CAREAssist, you must:

  • Have a confirmed HIV status
  • Reside in Oregon
  • Currently have medical insurance or be in the process of applying for medical insurance. We can help you with this.
  • Have income below 400% of the Federal Poverty Level (FPL) (http://aspe.hhs.gov/poverty/15poverty.cfm).

Individuals who are uninsured and need coverage for prescription medications related to their HIV care may be eligible for up to a 30-day supply through the Bridge Program. This program can also assist with a limited number of medical services to confirm HIV diagnosis and determine appropriate HIV treatment regimens.  Payments for specialty care referrals are not available at this time, although exceptions will be considered with prior authorization. The Bridge Program application must be completed by a physician. All prescriptions covered by the Bridge Program must be obtained through a CAREAssist Network Pharmacy.

For persons who are unable to secure health insurance outside of an open enrollment period, CAREAssist can assist with payments for a limited number of medical services and medications necessary for HIV treatment, through the Uninsured Persons Program (UPP).

Your Care Coordinator at HIV Alliance can help you apply for CAREAssist and can answer any questions you might have.

For more information visit the Oregon Health Authority website.

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