- 98% of Americans over 65 are covered by Medicare.
- You do not have to be 65 or older to be on Medicare. If you are blind or disabled and qualify for Social Security Disability Income (SSDI), you qualify for Medicare 24 months after SSDI benefits begin.
- Of the 41.8 million individuals that qualify for Medicare, 17% are also on Medicaid (approximately 7.1 million individuals).
- Dual eligible (Medicare and Medicaid) recipients spend $20,840 annually in health care expenses compared to $10,050 for Medicare beneficiaries with higher resources.
- 61% of dual eligible individuals have no high school diploma compared to 28% of in non-dual segment.
- 27% of individuals with lower income responded to applications sent to them by Social Security to apply for Lower Income Subsidy (extra help) to help pay for Part D prescription drug premium and co-pays.
- 30% of individuals who are eligible for a Medicare Savings Program (helps pay Medicare premium and/or co-insurances and deductibles) have applied.
- Individuals who qualify for Low Income Subsidy (extra help paying for prescription drugs) must re-certify every year in order to retain their subsidy.
- 20% of lower income individuals responded to a letter about re-certifying for a lower income subsidy.
- Under the new Medicare Part D prescription drug program, any individual that qualifies for a subsidy to help with his/her prescription drug cost does not have a coverage gap (donut hole).
- All dual eligible individuals, or those who qualify for Low Income Subsidy, do not have enrollment seasons like everyone else. They are in a Special Election period (SEP) and can change plans any time of the year and as often as they choose.
- Medicare Part D will not cover barbituates, benzodiazepines , and some other prescription medications.
- Medicaid will pay for many Part D excluded drugs.
- Some Medicare Part D enhanced plans will pay for some Part D excluded drugs.
- Of the 8.2 million Low Income Status individuals, less than 300,000 picked a part D plan. The rest were automatically enrolled by the state.
- When automatically enrolled for Medicare Part D from Medicaid, no matching of individual’s prescriptions and formulary of the Part D they were enrolled in was taken into consideration. It was done from a lottery system.
- When lower income individuals reach the catastrophic level of $3850 in 2007 True Out Of Pocket Cost (TROOP) for Medicare Part D prescription coverage, they no longer have a co-pay.
- Many doctors and clinics will not accept out-of-state Medicaid. Consequently, when traveling Dual Eligible recipient may be relying on Medicare only benefits.
- If individuals has a Medicaid spend down, they are not required to pay their spend down every month, only on the months that health care is needed (dental, optical, hospital, tests, therapy, etc…).
- There are Medicare Part C plans specially designed for dual eligible individuals (called Special Needs Plans) that have 0 or low co-pays and save the spend-down recipients from having to pay their spend-down.
- Over 5 million Medicare beneficiaries are enrolled in a Medicare Advantage Plan (Approximately 12% of Medicare beneficiaries).
- Out-Of-Pocket cost for Medicare Advantage enrollees are 34% lower than beneficiaries that have traditional Medicare coverage.
- Medicare Advantage Plans (aka Medicare Part C) are commonly referred to as Medicare HMO. Why? Because all Medicare Advantage Plans were Managed Care in one form or the other HMO or PPO) until 2003. Now, many Medicare Advantage Plans are Private Fee For Service (PFFS) that have no network restrictions.
- Nearly 60% of Veterans are eligible for Medicare.
- Many veterans that receive care at VA facilities are eligible for a Medicare Advantage Plan that includes Part D prescription coverage. Most plans have no additional out-of-pocket cost besides Part B premium they, Medicaid or a third party is already paying.
- 70% of veterans that have a heart attack receive treatment at a Medicare Covered hospital.
- The VA’s formulary of medications includes about 1400 drugs, most part D formularies include about 4300 medications.
