Note: CT residents only can contact the Center for Medicare Advocacy toll-free at 1-800-262-4414
If you have Medicare, Social Security deducts money from your check each month to pay for your Medicare Part B premium.
If you qualify for one of Connecticut’s three Medicare Savings Programs (MSP), the State of Connecticut will pay this monthly Part B premium on your behalf. Your Social Security check will then increase each month.
In addition to paying the Part B premium, one of the Medicare Savings Programs, called QMB, also pays all Medicare Part A and Part B co-pays and deductibles. To benefit from this program you must use providers that accept Medicaid patients. With QMB, it may be unnecessary to purchase a Medigap policy to supplement Parts A and B of Medicare.
The chart on the next page describes each MSP program, what it covers, and the income limits to qualify. Please note: There are no asset limits for any of the three Connecticut Medicare Savings Programs. In addition, the state will not place a lien on your property to recoup benefits from your estate when you die.
The Medicare Savings Programs are administered by the Connecticut Department of Social Services (DSS). Program brochures and applications are available from the DSS or may be downloaded from the DSS website at: http://www.ct.gov/dss/cwp/view.asp?a=2352&q=390772#Appl
If you qualify for MSP, you will also automatically receive help with your prescription drug costs under Medicare Part D. This help comes in the form of a full subsidy under the Part D Low Income Subsidy (LIS), also known as “Extra Help.”
With the full Low Income Subsidy:
- the monthly Part D premium is paid in full, up to the benchmark plan threshold. You pay the excess premium out-of-pocket if you join a more expensive plan.
- You do not have a deductible or “donut hole” gap in coverage.
- You have minimal co-pays for both generic brand name drugs.
Current (3/2012) Income Limits for MSP in Connecticut
What it Covers
Qualified Medicare Beneficiary
Covers all Medicare Part A and B co-pays and deductibles (similar to a Medigap plan)
Covers the Medicare Part A premium if the person does not qualify for premium-free Part A. Also pays the Part B premium.
Must use Medicaid-enrolled providers
Specified Low Income Medicare Beneficiary
Pays the Part B premium only
* Additional Low Income Medicare Beneficiary
* Also called the “QI” program (Qualified Individual)
Note: ALMB is subject to annual Congressional funding
Pays the Part B premium only
NOTE: Due to state budget constraints, the ConnPACE program is ending for people with Medicare on June 30, 2011. The program will no longer wrap around Medicare Part D. Disabled individuals over 18 who do not have Medicare may still qualify. A brief history and current status of the program follows.
ConnPACE is Connecticut’s State Pharmacy Assistance Program (SPAP). It began in 1986 as a pilot program to help the uninsured elderly pay for their outpatient prescription drugs by limiting drug co-pays (ultimately to a maximum of $16.25 per script). In 1987 ConnPACE expanded to include people with disabilities and it became a permanent program. ConnPACE has been administered by the CT State Department of Social Services through private contractors and has always been 100% state funded.
When Medicare Part D began in 2006, ConnPACE “wrapped around” Part D to cover drugs not eligible for payment under Part D (excluded drugs), as well as non-formulary drugs (drugs coverable under Part D but not on a plan’s formulary). ConnPACE also paid toward the Part D premium and paid all Part D co-pays over $16.25. All ConnPACE members with Medicare were required to apply for the Part D Low Income Subsidy as a means of shifting costs from state to federal dollars.
Due to budget constraints, beginning in 2009 the CT legislature made significant changes to the ConnPACE program. ConnPACE ceased to pay for non-formulary drugs (but continued to cover excluded drugs); the program also ceased to contribute toward Part D premiums and enrollment was generally limited to a six week period each November 15 – December 31.
Also in 2009 the DSS significantly raised MSP income limits and eliminated all MSP asset limits. In 2010 estate recovery was eliminated. The goal of these changes was to shift all or most ConnPACE members to the federally funded LIS program. Extensive outreach was done to encourage ConnPACE members to apply for MSP, and thus automatically qualify for the Part D LIS. With LIS, ConnPACE recipients’ co-pays dropped from $16.25 to a maximum of $6.30. The only reason to remain on ConnPACE was the coverage of excluded drugs.
By 2011, 80% of ConnPACE members were on MSP and the LIS. In mid 2011 MSP income limits were further increased to ensure that all ConnPACE members would qualify if the ConnPACE program was terminated. At this writing another outreach campaign is underway to capture the remaining 20%.
Effective July 1, 2011, the ConnPACE program will no longer be open to people who have Medicare. Applications from people with Medicare will be denied and current ConnPACE members with Medicare will lose coverage on June 30, 2011.
Effective July 1, 2011, only disabled individuals over age 18 who are not yet eligible for Medicare may qualify for ConnPACE. Current members will be redetermined annually and will be discontinued once they obtain Medicare. New applicants can apply between November 15 – December 31, or at other times of the year within 31 days of being determined disabled. Basic requirements and program rules are:
- Applicants must be at least 18. Individuals 65 and over generally do not qualify because they have Medicare. Age must be verified.
- Applicants must meet SSDI disability criteria. Disability status must be verified by SSA.
- Income limits as of September 2012 are $26,100 for a single and $35,000 for a couple. Income must be verified.
- There is no asset limit.
- The annual application fee is $45. Eligibility is redetermined annually.
- There is a six-month residency requirement (subject to verification).
- Applicants may not have other available prescription drug coverage.
- Members may not have Medicare.
- Co-pays are $16.25 per 30 day script, or 120 units, whichever is greater.
- ConnPACE covers most prescription drugs, insulin and insulin syringes. Some drugs are subject to prior authorization, e.g., brand name drugs if a generic is available, or some drugs not on the ConnPACE Preferred Drug List (PDL). Some drugs are excluded, e.g., OTC and DESI drugs, antihistamines, contraceptives, ED and cosmetic drugs, vitamins, etc.
- ConnPACE does not work with mail order pharmacies.
The ConnMAP Program
ConnMAP is a Connecticut program which requires physicians and other Medicare Part B providers to accept Medicare's approved payment rate for individuals with moderate incomes. ConnMAP is available only to those who meet the following criteria:
A ConnMAP card is issued to those who are eligible. It is best if individuals show the card to providers prior to receiving services to insure that the provider abides by the ConnMAP program terms and charge limitations. Individuals who are eligible and enrolled in ConnPACE are automatically eligible for ConnMAP and do not need to apply separately.
Note: ConnMAP information and application, telephone (800)443-9946; in Hartford telephone (860)424-4925.
Medicaid is a needs-based program which was created by Congress to help pay for medical care for certain elderly, disabled, and other persons who meet the very strict income eligibility criteria. Medicaid policies are complex and have been debated and changed often during recent years.
Also known as "Title 19", Medicaid is jointly financed by the federal and state governments. While each state is required to adhere to the basic eligibility and benefit requirements contained in the federal statute and regulations, significant details vary from state to state.
Like Medicare, Medicaid provides payment for health care services, but it is very different from Medicare in a number of ways. Unlike Medicare, Medicaid eligibility is predicated upon the income and assets of the beneficiary. In general, Medicaid in only available for individuals who do not have sufficient income and assets to pay for their own medical treatment – according to Medicaid's strict income criteria. Until 2010, only certain people – those who are 65 years of age or older, those who are disabled, as defined by the Social Security Administration, young children, and their caretaker relatives, were eligiblefor Medicaid. IN 2010 The CT Department of Social Services (DSS) created the Medicaid for Low-Income Adults program (LIA) It extends Medicaid benefits to adults without minor children who have incomes up to 56% of the Federal Poverty Limit (FPL).
Medicaid covers far more nursing home care than Medicare, since it pays for necessary custodial, as well as skilled care, and it has no limit on how long nursing home care may be covered for eligible individuals. Significantly, both Medicare and Medicaid can be a source of funding for home care which extends over a long period of time. Medicare, however, only covers home health care if the individual is homebound and needs some skilled nursing or therapy services. Medicaid, on the other hand, does not always require that a person be homebound in order to receive home health benefits, and it may or may not require that the person need a skilled service to qualify for the home care benefit.
Medicaid financial eligibility rules differ depending upon the state of residence and living arrangement of the applicant. In particular, the rules for establishing eligibility for Medicaid for a person living in the community are very different from the rules governing eligibility for those residing permanently in nursing homes.
Click HERE for more information on Medicaid and related topics.
Medicare and Medicaid home-based services can often make a critical difference for frail elders desiring to remain in their own homes and avoid institutional placement. Advocates with a thorough understanding of the home care resources available to Connecticut seniors under Medicare and Medicaid can assist clients in maximizing these home care options to further clients’ goals to live their lives in their own homes.
The Medicare Home Health Benefit
In order to receive services under the Medicare home health benefit, a Medicare beneficiary must be homebound, as defined by the Medicare statute, and must be in need of intermittent skilled nursing or skilled therapy.
A beneficiary meets the homebound requirement if leaving home requires a considerable and taxing effort, and if the absences are infrequent or of relatively short duration. A considerable and taxing effort is established if the individual requires the assistance of another person or an assistive device, like a wheelchair, in order to leave home. Additionally, if leaving home unattended is contraindicated, the beneficiary meets the homebound criterion. The Medicare statute specifically provides that a person need not be bedbound to be considered homebound. Occasional and infrequent walks around the block or similar absences from the home are allowable. Absences from home for medical reasons, to attend certified or licensed adult day care programs, or to attend religious services are expressly permitted by the Medicare statute.
"Part time or intermittent services" are defined as skilled nursing and home health aide services, which, in combination, do not exceed eight hours a day and which are provided for no more than twenty-eight hours a week. An exception in the law calls for review on a case-by-case basis of those patients who need more care, up to a maximum of thirty-five hours per week.
In order to trigger coverage, skilled nursing care must be needed and received at least once every 60 days, but generally not daily – unless it can be shown that the need for daily nursing services will not continue indefinitely. In most cases, daily skilled nursing care will not be covered for more than 21 consecutive days. There are some exceptions to this general rule.
Skilled care is defined for purposes of Medicare coverage as care that is inherently complex and thus can only be safely and effectively performed by, or under the supervision of, professional or technical personnel. Examples of skilled nursing care include: wound care; catheter irrigation; and injections. Medicare also recognizes observation and assessment of a potentially changing condition, management of an overall care plan, and nursing education services as skilled nursing care.
The Medicare regulations and administrative guidelines are very clear that the stability and/or chronicity of an individual’s medical condition is not the determinative factor regarding entitlement to Medicare home health coverage. Likewise, coverage of rehabilitation therapy (physical, speech or occupational therapy) is not conditioned on restorative potential, or upon continued progress. Medicare coverage is available, so long as the skills of a trained therapist are required to safely and effectively deliver or direct the needed therapy services.
Medicare home health services must be ordered by a treating physician and must be provided in accordance with a written plan of care, by or under arrangement with a Medicare certified home health agency. Medicare beneficiaries who meet the coverage criteria may receive skilled nursing, physical, speech and occupational therapy, medical social services, and home health aides.
The Medicare home health benefit is not currently subject to any deductible amount or copayment. Home health care may be covered by Medicare indefinitely; there is no durational limit on this Medicare benefit.
Medicaid Home Care
The federal Medicaid (Title 19) mandatory benefit package includes a home health benefit. In addition, Connecticut has a Medicaid "waiver" home care program, called Category 3 of the Connecticut Home Care Program for Elders, (CHCPE). It offers more extensive services, including many services that are "non-medical" in nature, in order to prevent the premature institutional placement of frail elders who can be safely and cost-effectively maintained at home. Finally, Connecticut offers a fully state-funded component to the CHCPE, called Category 1 and Category 2.
The Mandatory Medicaid Home Health Benefit
The mandatory Medicaid home health benefit is available to any Medicaid recipient in Connecticut, regardless of age, who qualifies for nursing facility placement. It must be determined that it is safe and cost-effective as compared to institutional placement to maintain the recipient at home. Cost effectiveness is measured by comparing the weighted average cost of the home care plan of care to the average comparable institutional Medicaid rate, (i.e., convalescent home, ICF/MR, hospital rate).
The home health benefit offers skilled nursing, physical, speech, and occupational therapy and home health aide services. Generally, services must be provided by a Medicare-certified home health agency. Prior approval must be obtained from the Department of Social Services for more than 20 hours of care each week.
The Medicaid home health benefit is similar to the Medicare home health benefit. Note, however, that a Medicaid recipient need not satisfy a homebound requirement. Furthermore, unlike Medicare, Medicaid will pay for home health aide services even when the individual does not require skilled care. In addition, services may be available in settings outside the recipient’s home, see Skubel v. Aaronson, 925 F Supp 930 (D. Conn 1996); Detsel v. Sullivan, 895 F. 2d 58 (2d Circuit, 1990).
Financial eligibility for Title 19 home care is based upon the Medicaid community eligibility standards. Generally, in 2006 single individuals in most parts of Connecticut may have no more than $683.00 in income (includes $207.00 unearned income disregard) and must have less than $1,600 in countable assets. Those who are otherwise eligible, but whose income is higher than permitted may "spend down" the "surplus income" to achieve Medicaid eligibility. Medicaid recipients are not required to contribute to the cost of the mandatory home health services unless they qualify as "medically needy" and are applying their "surplus income" to the cost of their home care services.
Medicaid home health recipients have a right to prior written notification regarding decisions about their services and they have a right to a Medicaid Fair Hearing to contest any denial, reduction or discontinuance of services. Importantly, if a Fair Hearing is requested within 10 days of a reduction or discontinuance in services, the service must be maintained until a Fair Hearing decision is rendered.
MEDICAID WAIVER HOME CARE: THE CONNECTICUT HOME CARE PROGRAM FOR ELDERS (CHCPE), CATEGORY 3
Connecticut has obtained a special Medicaid home care waiver in order to offer an expansive array of medical and social services to frail seniors who, in the absence of such services would be forced to accept nursing facility placement. The types of care which can be provided through the CHCPE include services which are not traditionally defined as medical services, such as shopping, laundering or companion services.
The goal of the CHCPE is to divert elders who would otherwise require nursing home care away from more costly institutional placement, when safe and cost-effective community-based care is appropriate and available. Only elders aged 65 and older are eligible for this program.
There are several tests of cost-effectiveness applied to recipients of Category 3 home care services. The total cost of the care may not exceed the cost to the state of institutional placement. Generally, the average Medicaid payment for nursing facility care is used in making this determination. In addition, the cost of any non-medical social support waiver services provided may not exceed 60% of the average Medicaid nursing facility payment. Under the cost cap calculations, 24 hour care could never be determined to be cost effective, unless other resources, such as family voluntary contributions of money or services were made.
Both financial and functional eligibility must be established by an applicant for Category 3 home care services. An applicant may have no more than $1,809.00 in monthly income in 2006. A single applicant must have less than $1,600 per month in countable non-excluded assets. Medicaid eligibility rules governing long term care, including transfer of assets prohibitions as well as spousal impoverishment prevention provisions apply to Category 3 of the CHCPE. The financial protections for the spouses of married applicants are similar to the spousal impoverishment prevention provisions governing Medicaid eligibility for nursing facility care. In 2006, at least $19,908.00 must be set aside for the "healthy spouse", in addition to the $1,600 the recipient may retain in assets. Thus, a couple may have at least $21,508.00 in assets while one spouse is a CHCPE Category 3 recipient. (For more information about spousal impoverishment prevention, see Paying for Nursing Home Care With Medicaid, published by the Legal Assistance Resource Center, Hartford, CT and available through any legal services office.)
Higher income Category 3 recipients must contribute to the cost of their care. They are permitted to retain an amount of monthly income equal to 200% of the federal poverty level as well as sufficient income to cover the Medicare Part B premium and any income which must be diverted to a "healthy spouse."
Functional eligibility is measured by whether or not the applicant requires the type of care provided by a nursing facility. The test used determines whether, in the absence of the package of home-based services available through the CHCPE, Category 3, the applicant would have to be placed in a nursing facility. It must also be safe to keep the applicant in a home setting.
Applications are made through the Department of Social Services Alternate Care Unit. Applicants complete a financial screening form. If it appears that eligibility can be established, a Medicaid application must be completed and submitted. The Alternate Care Unit screens for functional eligibility and refers cases to the regional access agency, a DSS contractor, which verifies eligibility and then proceeds to develop a cost effective care plan for each eligible individual. Medicaid appeals rights are applicable to Category 3 of the CHCPE.
STATE -FUNDED HOME CARE CATEGORIES 1 AND 2 OF THE CHCPE
Connecticut funds home care services with monies appropriated by the legislature. Like the Medicaid Waiver portion of Category 3 of the CHCPE, the services available under the state-funded levels of Categories 1 and 2 include social supports as well as medically-related home care. Financial eligibility is similar to Category 3.
There is no income limit imposed on applicants for categories 1 and 2. Asset eligibility is premised upon the minimum spousal impoverishment figure. If both spouses are eligible for services, they may have greater assets.
Functional eligibility for Category 1 is established by a risk of hospitalization or short-term nursing facility placement. For Category 2, an individual must need either short or long-term nursing facility placement. Category 1 services must cost no more than 25% of the average weighted nursing facility cost to the state. Category 2 services may cost up to 50% of the state’s cost of nursing facility care.
Category 1 and 2 recipients who are also Medicaid eligible may receive mandatory Medicaid home health benefits and additional services through the CHCPE. Similarly, Medicare home health services may also be combined with CHCPE services.
Applications are processed in the same manner as for Category 3. Effective October 1, 2000, several new services are included in the Connecticut Home Care Program for Elders. These include minor home renovations, such as grab bars, or widening doorways to accommodate wheelchairs and assisted living facility services in consenting state-funded congregate care residential facilities. In addition, a personal care attendant pilot project is available to serve 50 to 100 persons.
Click HERE for more information on home health care.
South Western Area Agency on Aging
10 Middle Street
Bridgeport, CT 06604
Agency on Aging of South Central CT
1 Long Wharf Drive
New Haven, Ct 06511
Eastern Connecticut Area Agency on Aging
19 Ohio Ave.
Norwich, CT 06360
North Central Area Agency on Aging
151 New Park Ave., Box 75
Hartford, CT 06106
Western Connecticut Area Agency on Aging
84 Progress Lane
Waterbury, CT 06705
CHOICES Health Insurance Hot Line 1-800-994-9422
- Medigap Rates December 1, 2011
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