The Virgin Islands State Health Insurance Assistance Program (VI SHIP) is the Virgin Islands local Medicare source, which is locally administered by the Office of the Lieutenant Governor and federally funded by the Centers for Medicare and Medicaid Services (CMS). Currently, there are SHIP Offices in all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. VI SHIP provides free information and personalized or group counseling to persons with Medicare, family members, and caregivers in the territory on:
Medigap (Medicare Supplement Insurance)
Long Term Care Insurance and Financing Options
Medicare Prescription Drug Coverage
Billing/Claims Resolution Assistance
Referrals to the Appropriate Government or Community-based Organizations.
Education and information are also provided to the general public by trained counselors via public forums, workshops, health fairs, etc. The goals of VI SHIP are to “assess, inform, advocate, protect, educate, and empower” Medicare beneficiaries.
OVERVIEW OF THE VIRGIN ISLANDS CONSUMER ASSISTANCE PROGRAM
On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act. This law was followed by the creation of the Health Care and Education Reconciliation Act of 2010 signed into law on March 30, 2010. The two laws are collectively referred to as the Affordable Care Act. The Affordable Care Act includes a wide variety of provisions designed to promote accountability, quality and accessibility in health care system. Included in the Affordable Care Act are significant grant funding for states to work with the Federal Government to implement health reform.
The Virgin Islands Consumer Assistance Program (“CAP”) was created in 2011 as part of the Division’s ongoing efforts to expand the consumer protection programs we offer to the Virgin Islands community. The Division of Banking and Insurance is the regulatory body charged with the supervision of different areas of the territory’s financial industries including the health insurance market. Our goal is to protect the financial interests of our residents.
The mission of the Virgin Islands Consumer Assistance Program is to assist health insurance consumers with health insurance enrolment, support the complaints and appeals process, and educate consumers about their rights and responsibilities with respect to individual and group health plans and the Affordable Care Act.
What is the Virgin Islands Consumer Assistance Program?
It is a program created to help our health insurance consumers navigate the changes to healthcare coverage that were brought about by the Patient Protection and Affordable Care Act. It is a federally funded program that has three major objectives…first, to investigate consumer complaints, second, to collect complaint data and third, to assist with claims and appeals.
Why is healthcare reform important?
There have been a growing number of healthcare consumers that do not have a voice when it comes to the type of health insurance coverage they receive or have access to. In some cases their coverage would be dropped if they have certain medical conditions. There has been a continual rise in the cost of health coverage which has outpaced the consumer’s average hourly wage. By the year 2019 without reforms in place, health spending per insured person is predicted to be about $16,800. On the other hand with reform, that amount will be reduced by approximately 10% to just over $15,000 (www.HealthReform.gov).
What new consumer protections will I get?
The Affordable Care Act requires all health plans, including grandfathered health plans to provide certain new protections for plan years beginning on or after September 23, 2010. The reforms that apply to all individual market health plans include:
• No lifetime plan limits;
• No rescissions of coverage when sick a have unintentional mistakes on application;
• Extension of coverage to young adults under 26 years old on parents’ plan.
What do the grandfather rules provide?
The grandfather regulation is intended to accomplish a sense of balance between permitting available health plans to make regular adjustments while inhibiting plans from creating such significant changes that people are unhappy with such modifications. Because of this, the transition will be made easy enough for the nation’s health care and health insurance industries to meet the terms of the Affordable Care Act.
What are some of the preventative care services for adult and how will they affect me?
• Blood pressure, diabetes and cholesterol tests
• Cancer screening
• Some vaccines
• Pap smears for cervical cancer prevention
• Well-baby and Well-child visits
• Mammograms for women over 40
• Shots for pneumonia and flue prevention
• Screening, vaccines and counseling for healthy pregnancies
• Colon cancer screening test for adults over age 50
If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without you having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.
What will the health reforms mean for employers?
The highest prices for insurance coverage are paid by small business owners and entrepreneurs. They suffer from the most limits on their benefits. Lack of leverage causes them to make significant changes in their coverage on a yearly basis. Now they can take advantage of the Affordable Care Act’s new protections and transition from their present grandfathered plans over the next couple of years. Some provisions they will enjoy with the new reforms by 2014 are tax credits for premiums paid and heavier restrictions against unacceptable insurance customs like refusing to insure employees with pre-existing health conditions.
Will it be complicated for employers take action in response to increasing health care expenses and new changes due to the grandfather rules?
No. Health plans that have grandfather status will still have the maneuverability to make adjustments as needed to stay effective but not modify benefits or cause health fees to rise significantly. Plans will be able to:
• Adjust premiums to reasonable rates yet keeping pace with health care expenses;
• Modify premiums within the limits of benefits being offered;
• Raise within reasonable limits Deductibles and out-of-pocket expenses; and
• Continue to enroll new employees and family members.
What is a health insurance exchange?
A group of state-regulated and standardized health care plans in the United States and Territories, from which persons can buy federally, subsidized health insurance. The territories of the United States are not mandated to implement an exchange program.
Medicaid is health care assistance that helps people with low incomes and limited resources to obtain medical care for some or all of their bills. Medicaid also helps to pay for nursing home care. Medicaid programs differ from state to state. In the U.S. Virgin Islands, Medicaid is called the Medical Assistance Program (MAP). The Department of Human Services Bureau of Health Insurance and Medical Assistance is the division responsible for administering Medicaid in the Virgin Islands.
Eligibility for MAP is determined by the Certification Units and is based on family income, resources, and other factors. Examples are documents needed for eligibility determination are:
Verification of U.S. Citizenship and age and
Verification of resources
Other documents may be required as well.
Individuals who receive cash assistance from the Department of Human Services and are classified as “Categorically Needy” are automatically eligible for Medicaid. Assistance (Spend-Down Program) is also available to persons whose incomes and resources are above or in excess of the allowable income level. The excess income is expected to be expended (spent down) before assistance is provided by MAP.
In addition, persons with Medicare who meet the eligibility requirements of MAP can receive assistance from MAP with paying their Medicare Part A deductible, Medicare Part B premium, and the share of allowable costs not covered by Medicare. Persons with both Medicare and Medicaid are called “Dual Eligibles” (DEs).
Starting January 1, 2006, Medicare will begin covering prescription drugs for DEs. MAP will still cover other care that Medicare doesn’t cover. MAP will be using Medicare and local funds to assist DEs with paying their premium, deductible, and co-pays for the Medicare prescription drug plan they are enrolled in. In order to get this help, DEs must enroll in a Medicare Prescription Drug Plan by December 31, 2005. For DEs who fail to enroll in a plan by this date, MAP will automatically assign them to a plan. (For more information on how DEs prescription coverage will be affected starting January 1, 2006, click on the link below the subject heading Medicare Prescription Drug Coverage).
For more information, contact the MAP Certification units at (340) 774-2399 or (340) 774-0930 extension 4378 in St. Thomas and (340) 718-1311, ext. 3095 in St. Croix.
Here’s information to help you understand Medicare coverage options, so you can make informed choices based upon your health, your budget or both. When you’re ready, our trained counselors can work with you one-on-one to help you make The Right Call.
What does Medicare cover?
Medicare has two parts.
Hospital Insurance (Part A)
Medicare Part A helps pay for four kinds of medically necessary care:
• inpatient hospital care
• inpatient care in a skilled nursing facility following a hospital stay
• home health care
• hospice care
Part A has deductibles and coinsurance, but most people do not have to pay premiums for Part A. If you have a specific question regarding Medicare Part A coverage or claims, call 1-800-MEDICARE (1-800-633-4227). The Medicare and You Handbook also has Part A benefit information.
Medical Insurance (Part B)
Medicare Part B helps pay for:
• doctor’s services
• outpatient hospital care
• durable medical equipment
• diagnostic tests
• many other health services and supplies that are not covered by Medicare Part A.
Part B has premiums, deductibles, and coinsurance amounts that you must pay yourself or through coverage by another insurance plan. If you have a specific question regarding Medicare Part B coverage or claims, call 1-800-MEDICARE (1-800-633-4227). The Medicare and You Handbook also has Part B benefit information.
Who can receive Medicare benefits?
Medicare is a health insurance program for:
• People 65 years of age and older.
• The disabled—those under age 65 who have received Social Security or Railroad Retiree disability benefits for 24 consecutive months. Call SHIIP at 800-351-4664 for the Medicare and Other Insurance for People with Disabilities factsheet.
• Those with a diagnosis of ALS or Lou Gehrig’s Disease.
• People with end-stage renal disease (permanent kidney failure treated with dialysis or a transplant).
To be eligible for Medicare, a person must be a US citizen and resident of the U.S. or an alien living in the U.S. for five years who has been lawfully admitted for permanent residence.
I am turning 65 but will continue to work. Should I sign up for Medicare Part B? You may be able to delay enrollment in Medicare Part B without penalty if you or your spouse continue to be actively employed and are covered by the employer’s group health plan. In this situation you can enroll in Medicare Part B during a special eight-month enrollment period when you retire (whether you keep employer-sponsored retiree insurance coverage or not). The Social Security Administration determines when you are eligible to enroll in Medicare. Call their toll-free number, 800-772-1213, with your specific questions. Ask Social Security to send information about your situation in writing. Keep this information on file.
If you’re 65 or older, you or your spouse are employed and the employer has 20 or more employees, you must be offered the same health insurance benefits under the same conditions offered to younger workers and spouses. [Note: If you’re eligible for Medicare because of a disability, there must be at least 100 employees.] The employer cannot provide a Medicare supplement insurance policy instead of regular group coverage.
Employers with fewer than 20 employees (100 if disabled) are not required to offer health insurance coverage to employees over age 65.
I am 62 years old. Can I sign up for Medicare since I am now receiving my Social Security benefits?
No, you will be eligible for Medicare when you are 65. Since you are currently receiving Social Security benefits the Social Security office will automatically enroll you in Medicare and send you a Medicare card shortly before you turn 65.
I lost my Medicare Card. How do I get a new one?
Contact the Social Security Administration at 1-800-772-1213 to ask for a new card. Medicare cards can also be replaced online. Go to www.ssa.gov/medicarecard.us.
I recently moved. How do I change my address with Social Security and Medicare?
Call the Social Security Administration at 1-800-772-1213 to make your address change. If you are a Railroad Retiree, call 1-800-808-0772. You can also go to www.ssa.gov .
Some people on Medicare have limited finances. Are there any programs to help them with health care costs?
Title XIX or Medicaid is a public assistance program that pays for certain health care costs for qualified people. It is funded by both federal and state governments. In Virgin Islands it is administered by the Department of Health. Eligibility is based on income and resource limits.
Prescription drug coverage is now available from Medicare through Part D plans offered by private insurance companies. SHIIP can help you sort through the choices to find a plan that best meets your needs, so you can make The Right Call.
Is there coverage for prescription drugs under Medicare?
In 2006 Medicare added a prescription drug benefit called Medicare Part D. Medicare contracts with private companies to offer prescription drug plans. You can enroll in a plan that offers only drug coverage or you can enroll in a Medicare Advantage plan which includes drug coverage, along with other health coverage.
There are many plans to choose from. Generally you must stay in the plan you choose for a calendar year (there are some exceptions). Every year from October 15-December 7 there is an annual election period when you can change plans, drop coverage or add coverage. The plans can change premiums, co-payments and formularies (list of drugs they cover) every year so reviewing plans during the election period is important. The best way to compare plans is to use the Medicare website. SHIIP counselors can also help you compare plans.
You may have “creditable drug coverage” through an employer, union or other plan. If it is creditable (as good as, or better than Medicare’s coverage) you do not need a Medicare Part D plan.
Medicare offers prescription drug coverage to everyone with Medicare. Even if you do not take a lot of prescriptions now, it’s important for you to consider joining a Medicare plan. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage (coverage that is as good as Medicare), or you don’t get Extra Help (from Medicaid or SPAP), you’ll likely pay a late enrollment penalty. To get Medicare prescription 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. 2 Ways to Get Medicare Drug Coverage There are two ways to get Medicare prescription drug coverage: 1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and. Currently this is the only way to get Prescription Drug Coverage in the U.S. Virgin Islands. There are two companies that offer Prescription Drug Plans; AARP and Community CCRx. 2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan. There are no Medicare Advantage Plans in the U.S. Virgin Islands. Both types of plans are called “Medicare drug plans.” In either case you must live in the service area of the Medicare drug plan you want to join. Those electing to join a Part D plan will have to pay a monthly premium and pay a share of the cost of prescriptions. Drug plans vary in what prescription drugs are covered, how much you have to pay, and which pharmacies you can use. All drug plans have to provide at least a standard level of coverage, which Medicare sets. However, some plans offer enhanced benefits and may charge a higher monthly premium. When a beneficiary joins a drug plan, it is important to choose one that meets the individual’s prescription drug needs. Although Part D plans’ benefit designs vary, they each include the following minimum level of coverage: • Deductible: This is the amount you pay each year for your prescriptions before your Medicare drug plan begins to pay its share of your covered drugs. No Medicare drug plan has a deductible more than $320 in 2012. Some drug plans do not have a deductible. • Copayments/Coinsurance: This is the amount you pay for each of your prescriptions after you have paid the deductible (if your plan has one). Some Medicare drug plans have different levels or “tiers” of coinsurance or copayments, with different costs for different types of drugs. • Coverage Gap: Also called the “donut hole”.
This means that there is a temporary limit on what the drug plan will cover for drugs. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs; in 2012 that amount is $2,930. Once you have enter the coverage gap, you get a 50% discount on covered brand name drugs and pay 86% of the plan’s cost for covered generic drugs until you reach the end of the coverage gap; when your out of pocket expenses reach $4,700. • Catastrophic Coverage: After your out-of-pocket expenses have reached $4,700 you automatically get catastrophic coverage. The beneficiary is responsible for the greater of 5% of drug cost or a $2.60 co-payment for generic medications and $6.50 for brand-name drugs. In addition to the 50% discount on covered brand-name prescription drugs, there will be increasing savings for you in the coverage gap each year until the gap is closed in 2020. When Can You Join a Medicare Drug Plan? • When you first get Medicare (Initial Enrollment Period): During the 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. • During Certain Times Each Year (Yearly Enrollment Periods): The yearly enrollment period is October 15 – December 7. You can join a Medicare Prescription Drug Plan, switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan or drop your Medicare prescription drug coverage completely. • In Special Circumstances (Special Enrollment Periods): You can make changes to your Medicare prescription drug coverage when certain events happen in your life, such as if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP. How to Join a Medicare Drug Plan You can join a Medicare Prescription Drug plan several ways: • Electronically on the internet, either through www.medicare.gov or the plan’s website. • Over the telephone by calling 1-800-MEDICARE or calling the plan directly. • Completing a paper application. • Visiting the VI SHIP Office How to Switch Your Medicare Drug Plan You can switch to a new Medicare drug plan simply by joining another drug plan during Initial Enrollment Period, Yearly Enrollment Periods or Special Enrollment Periods. You don’t need to cancel your old Medicare drug plan or send them anything. Your old Medicare drug plan coverage will end when your new drug plan begins. How to Drop Your Medicare Drug Plan If you want to drop your Medicare drug plan and you don’t want to join a new plan, you can do so during Initial Enrollment Period, Yearly Enrollment Periods or Special Enrollment Periods. • You can disenroll by calling 1-800-MEDICARE. • You can also send a letter to the plan telling them that you want to disenroll. • If you drop your plan and want to join another Medicare drug plan later, you have to wait for an enrollment period. You may have to pay a late enrollment penalty. How much is the Part D Penalty? The cost of the late enrollment penalty depends on how long you went without creditable prescription drug coverage. The late enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($31.08 in 2012) times the number of full, uncovered months you were eligible but didn’t join a Medicare drug plan and went without other creditable prescription drug coverage. The final amount is rounded to the nearest $.10 and added to your monthly premium. The national base beneficiary premium may increase each year, so the penalty amount may also increase every year. 3 Ways to Avoid the Late Enrollment Penalty
Join a Medicare drug plan when you’re first eligible. You won’t have to pay a penalty, even if you’ve never had prescription drug coverage before. 2. Don’t go 63 days or more in a row without a Medicare drug plan or other creditable coverage. Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or health insurance coverage. Your plan must tell you each year if your drug coverage is creditable coverage. You may get this information in a letter or in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later. 3. Tell your plan about any drug coverage you had if they ask about it. When you join a Medicare drug plan, the plan will send you a letter if it believes you went at least 63 days in a row without other creditable prescription drug coverage. The letter will include a form asking about any drug coverage you had. Complete the form and return it to your drug plan by the deadline in the letter. If you don’t tell the plan about your creditable drug coverage, you may have to pay a penalty.
Drug Plan Coverage Rules Medicare drug plans may have the following coverage rules:
Prior authorization—You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it. • Quantity limits—Limits on how much medication you can get at a time. • Step therapy—You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.
If you or your prescriber believe that one of these coverage rules should be waived, you can ask for an exception. Do I Need a Part D Plan if I Have Employer Health Coverage? If you have prescription drug coverage based on your current or previous employment, your employer or union will notify you each year to let you know if your prescription drug coverage is creditable. Keep the information you get. Call your benefits administrator for more information before making any changes to your coverage. Note: If you join a Medicare drug plan, you, your spouse, or your dependants may lose your employer or union health coverage. Extra Help If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage. There are two ways to get extra help in the U.S. Virgin Islands; through State Pharmaceutical Assistance Program (SPAP) or Medicaid. State Pharmaceutical Assistance Programs (SPAPs) Some states have State Pharmaceutical Assistance Programs (SPAPs) that help people pay for prescription drug based on financial need, age, or medical condition. How to Apply for SPAPs Each SPAP has different rules about eligibility, how to apply, and how it works with Medicare prescription drug coverage. For more information, call (340) 773-2323 on St. Croix and (340) 774-0930 on St. Thomas/St. John. Medicaid Medicaid is a joint federal and state program that helps pay medical costs for some people with limited income and resources and meet other eligibility requirements. Medicaid also offers benefits not normally covered by Medicare, like help with personal care and rides to doctor appointments. If you qualify for Medicaid in your state, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage. How to Apply for Medicaid Each state has different rules about eligibility and applying for Medicaid. Please call (340)773-1311 on St. Croix or (340) 774-0930 on St. Thomas/St. John to see if you qualify and learn how to apply.
A Medigap policy is available to persons who are seeking extra help (insurance coverage) with paying for services not covered by the Original Medicare Plan. A Medigap policy fills in the “gaps” in the Original Medicare Plan. Buying a Medigap policy is not mandatory. Medigap policies are offered by private insurance companies who must follow federal and state laws established to protect persons with Medicare.
The front of the Medigap policy must clearly identify it as “Medicare Supplemental Insurance”.
A Medigap policy must be one of ten standardized policies (Plans A – J) so comparisons can be made easily. Each policy has a different sent of benefits and different premiums that must be paid monthly.
Medigap policies have changed due to the Medicare Modernization Act (MMA) of 2003. Starting January 1, 2006, new Medigap policies with prescription drugs coverage (i.e., H, I, or J) can no longer be sold.
Plans K and L are new polices that were added in 2005 as a result of the MMA of 2003.
Two of the standardized policies (Plans F and J) may have a high deductible option.
Additionally, any of the standardized policy may be sold as a “Medicare SELECT” policy. Medicare SELECT policies are usually less expensive because certain hospitals and doctors must be used.The best time to buy a Medigap policy is during the Medigap open enrollment period which lasts for 6 months. The enrollment period begins on the first day of the month in which the individual is age 65 and enrolled in Part B.