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Legislature Restores Most EPIC Benefits for 2013 -- Seniors must Cope with Cuts for Rest of 2012

05 Apr, 2012
The 2012 NYS Budget restored significant parts of the EPIC program that were cut in the 2011 Budget.   Last year's EPIC cuts went into effect January 1, 2012 and have been devastating to many lower income seniors.  See this article.   The State Legislature heard these stories and restored many of the cuts  -- but these benefits will not be restored until January 1, 2013.  This means seniors will have to cope with the very pared down EPIC benefit for the remainder of 2012.  The chart below explains how EPIC "wraps around" Part D in the different periods of the Part D plan year -- and the differences between 2012 and 2013.  To understand more about the Part D coverage that EPIC "wraps around" see Selfhelp's outline on Part D, updated for 2012.  
To read more about the 2012 NYS Budget impact on health access, see this article.  

EPIC Benefits Comparison -- 2012 and 2013

2012 2013
Part D Deductible Period  EPIC pays nothing - member pays FULL drug cost EPIC pays nothing -  member pays FULL drug cost   
Part D "initial coverage period"  EPIC pays nothing - Part D plan pays part of drug cost charging member co-insurance.  Member must pay FULL cost for drugs "excluded by Part D. EPIC pays part of Part D co-insurance for drugs covered by Part D (which in 2013 will include classes of drugs presently "excluded" by Part D - see outline. ) Member pays between $3 and $20 EPIC copayment.   
Part D coverage gap or "doughnut hole" EPIC pays for most of drug cost for drugs covered by Part D plans as well as drugs "excluded" by Part D. Member pays between $3 - $20 copayment EPIC pays part of Part D co-insurance a - member pays between $3 and $20 EPIC copayment  
Part D "Catastrophic Coverage"

EPIC pays nothing - Part D plan pays most of drug cost, charging member lower co-insurance.

Member must pay FULL cost for drugs "excluded" by Part D  

EPIC pays part of Part D co-insurance  - member pays between $3 and $20 EPIC copayment  
Does EPIC charge fees or deductibles? EPIC eliminates all Fees and Deductibles that were charged in earlier years (but EPIC benefits significantly reduced) EPIC restores Fees - Annual Income up to $20,000 (singles) and $26,000 (couples)  and Deductibles for higher incomes.
Part D premium EPIC pays premium for singles with annual incomes under $23,000, couples under $29,000 EPIC pays premium for singles with annual incomes under $23,000, couples under $29,000  
Must member enroll in Part D plan? Yes - no exceptions Yes - no exceptions  

TIPS for 2012:  

1.   STAY IN EPIC.   Many EPIC members have dropped or will drop EPIC coverage in 2012 because there is very little benefit from being enrolled. However, EPIC members should stay enrolled.  If enrolled, they still have a "Special Enrollment Period" [SEP] that allows them to change Part D plans once during the year -- if, for example they need a new drug not covered by their Part D plan's formulary.    This is a special "SEP" beyond those normally allowed for other reasons.  See Medicare Rights Center's SEP Chart.  Also, they will hit the ground running  to take advantage of restoration of EPIC in 2013 if they stay enrolled now. 

2.   For 2012, look for ways to get the Part D Low Income Subsidy known as "EXTRA HELP" through the "back door" - even if income is normally too high.  See suggestions below.  

3.  For 2013, look for plans with NO PART D Deductible.  EPIC will not pay for drugs during the Part D deductible period.  (Many plans have no deductible). 

Who will be most affected by the EPIC cuts?

1.      The poorest one-third of EPIC members will not be significantly harmed by EPIC cuts -- they already have the Part D “Low Income Subsidy” also known as Extra Help.   See more about Extra Help

.  To qualify for this subsidy, income must be under:

    • 150% of the Federal Poverty Line (for "Partial Extra Help")(Singles = $16,335, Couples = $22,065). 
    • 135% of the Federal Poverty Line (for "Full Extra Help")   (Singles =  $14,701, Couples = $19,858)

2.   More than one-half of EPIC members have income above these limits, but still can't afford to pay the costs that EPIC used to help with:

  1. the FULL cost of drugs during the Part D deductible period, if their plan has one, since EPIC will no longer help with the deductible;
  2. the steep co-insurance for Part D during most of the year when EPIC will no longer subsidize it,
  3. the monthly Part D premium,  if their income is over the limit for EPIC to pay it  (SINGLES under  $23,000 income/year, COUPLES under $29,000 income/year). 

For background on Part D and these different coverage periods, and also about "Extra Help, see Selfhelp's Part D outline, updated recently for 2012 Part D year. 

Perhaps the highest-income EPIC members can afford these costs, but only 15% of EPIC members have income over $30,000 year  -- this leaves more than half of EPIC members in the middle - with too much income for Extra Help but not enough income to afford these costs.   See 08-09 data.  

ADVOCACY STRATEGY -- Qualify for Extra Help in 2012 Through the Back Door - through the Medicare Savings Program or by Obtaining Medicaid NOW Even for just ONE MONTH!   

People who enroll in MEDICAID or a MEDICARE SAVINGS PROGRAM so that it is active even for ONE month in the remainder of 2011 get a fantastic benefit -- they are AUTOMATICALLY ENROLLED in "FULL EXTRA HELP" for Part D for the rest of 2011 AND for ALL of 2012.  If they wait to enroll in Medicaid in the first half of 2012, they will be automatically enrolled in Extra Help for the rest of 2012, but not for 2013.  Enrollment must be in the last half of one year to carryover to the next year. 

Here are tips to qualify people whose income is higher than the regular MEDICAID or MSP limits -- since they only need to qualify for Medicaid or for an MSP for one month, these strategies may be possible

 1.    Take Advantage of Deductions from Income - Health Insurance Premiums

The cost of the client's Medicare supplemental insurance coverage (Medigap policy), COBRA or employe or retiree health premium, or any health insurance premium, is deducted from client's gross income for both Medicaid and the Medicare Savings Programs.  It may be worth buying a Medigap policy even temporarily, to bring income down to qualify for Medicaid or an MSP.

 2.    Use Spousal Refusal if one spouse can qualify without counting other spouse’s income or assets

The Spousal Refusal form used in New York City can be downloaded here.  This enables one spouse to apply for Medicaid or an MSP alone, only counting her own income (or assets for Medicaid),  The form can be adapted for any county since this is a statewide rule.  If "refusing" spouse wants to limit risk of being sued for support by the local Medicaid program, which is more likely in some counties than others in NYS, s/he can always withdraw the Spousal Refusal a month after Medicaid or MSP is approved.  Don't forget -- to qualify for Extra Help for as long as 1.5 years, one needs to have active Medicaid or MSP only for ONE MONTH.  Since the Medicare Savings Program has no asset limit, only the spouse's income would impact eligibility for the applicant for that program.  

3.   Enroll in a pooled supplemental needs trust - to qualify for either Medicaid or an MSP.

See fact sheets on how these trusts work to reduce countable income.    See list of pooled trusts in NYS here  Even if client does not want Medicaid, she can deposit just enough income into the trust to reduce countable income to MSP income level, not Medicaid level. 

4.   Use Bills Paid by EPIC - and other Past Medical Bills - to Meet the Medicaid "Spend-Down" for One Month

PROBLEM:    Mr. & Mrs. L have combined Social Security income of $23,096 year (gross) - over the 150% Federal Poverty Line limit for partial Extra Help.  Their net income, after the Part B premiums are deducted is $20,772/year -- or $1731/month.   They do not have any Medigap policy, so they do not qualify for an MSP.

 Mrs. L has very high prescription drug costs. They are so high that by the end of January 2012 she will already be in the "doughnut hole" for 2012.  By February, she will be out of the "doughnut hole" and into the "catastrophic coverage" period for the rest of the year.  Though Part D coinsurance during her "catastrophic coverage" period is only 5% of the cost of the drugs, for her that will be nearly $400/month..  an expense she and her husband cannot afford.  EPIC will no longer help her with any costs during that period.  See EPIC 2012 Chart.   

You see whether they can be eligible for Medicaid.   Their Medicaid spend-down would be:

    $1731  per month net income after Part B premium deducted (neither is in Medicare Savings Program)
   -   20  disregard (same amount for single or couple)
   - 1117  Medicaid couple limit
   =  594  per month SPEND-DOWN.  

You ask Mr. and Mrs. L. if they have had recent out-of-pocket medical expenses in the past 3 months, or if they have any old unpaid medical bills, which you know can be used to meet their spend-down when they apply.  See PowerPoint and other materials on Spend-down posted in this article.   They say no.  DON'T GIVE UP.  Here's what other bills count.

The State's own website confirms--   http://nyhealth.gov/health_care/medicaid/excess_income.htm#past_bills  that:

"Bills paid by EPIC or ADAP in the three months before the month in which you applied for Medicaid may be used to meet your excess income."

Since both Mr. and Mrs. L have EPIC, it is worth finding out how much EPIC paid during the past 3 months.  If the amount EPIC paid plus their own EPIC copayments paid during the 3 months before they file the Medicaid application, plus any other out-of-pocket medical expenses  equal their spend-down of  $594, they can both receive Medicaid for one month.  Since that month is in the 2nd half of 2011, they will automatically be enrolled into Full Extra Help for the rest of 2011 and all of 2012.  This will bring their drug costs down to even less than they were with EPIC as it used to be.

Here's how.   

1.       WRITE, FAX, or TELEPHONE EPIC to request a Claims History of what costs EPIC paid for the client and spouse.  The Claims History also includes the copayments paid by the EPIC member.   

PHONE:      800-332-3742 - they will probably ask you to fax a HIPAA release -  see below.

Fax is:        518-220-3920  
Address:    EPIC program, P.O. Box 15018, Albany, NY 12212-5018

In the letter, specify that you want the Claims History beginning on  the date should be the 1st of the month that is 3 months before the current month.  EXAMPLE:  It is now August 15th and you plan to file for Medicaid this month   Ask for Claims History since May 1, 2011 (the 3 months before August are May, June, and July)

  • INCLUDE A HIPAA RELEASE -- Use your own office HIPAA release, or use this  NYS Office of Court Administration HIPAA formSample here completed with Selfhelp as representative.  Here's how to fill out this form:
    • Just add CLIENT's name, date of birth and Social Security Number at the top

    • Box 7 - write EPIC program, P.O. Box 15018, Albany, NY 12212-5018

    • BOX 8 - write your name and organization, address, and relationship (such as "representative" or "case manager"

    • Box 9(a) - check OTHER and write in CLAIMS HISTORY SINCE [DATE] - The date is the 1st of the month that is 3 months before the current month.  EXAMPLE:  It is now August 15th and you plan to file for Medicaid this month   Ask for Claims History since May 1, 2011 (the 3 months before August are May, June, and July)

    • Box 10 - check "At request of individual"

    • Box 11 - Date Authorization Expires - MUST fill in some date.. Can pick a year from now or any other date.. allow enough time for the Medicaid application to be processed.  

    • CLIENT SIGNS AND DATES AT THE BOTTOM  (or their agent under a power of attorney)

2.      REVIEW CLAIMS HISTORY YOU RECEIVE FROM EPICSee Sample received for Mr. and Mrs. L.

The computer printouts have two important figures.  Look at the Columns labeled COPAY and the Column labeled EPIC PAID.   The totals of those two columns is the amount that can be used to meet the Medicaid spend-down.  In this case, the 1st 2 pages of the sample is for Mr. L.  During this 3-month period, he had only $15 copay + $27 in EPIC PAID = $42 that can meet the spenddown.  BUT the printout for Mrs. L shows she had COPAYMENTS of $93 plus EPIC PAID = $562.36.  Total that meets the spend-down is $655.36. 

Since MR. and MRS. L are applying together, you can use both of their EPIC claims to meet the spend-down.  

MRS. L  $655.36  = MR.  L   $  42  = $697.36 can be used to meet the spend-down!  Since their spend-down is $594, they qualify for one month!

3.    APPLY FOR MEDICAID.  In addition to all other usual documents, include the EPIC Claims History.  A sample cover letter that explains to the Medicaid worker how the EPIC bills meet the spend-down can be downloaded here and adapted to your case.   The letter includes excerpts from the State Dept. of Health's own website page on Medicaid spend-down (or "excess income" explaining how this works. 

  • Clients can attest to the value of their assets on the Medicaid application.  Documentation requirements vary depending on the Medicaid coverage sought by the Medicaid applicant.  Clients in the Disabled, Aged, Blind category of Medicaid also known as SSI-related, are subject to a resource limit.  When DAB clients apply for Medicaid, they are required to indicate the value of their resources, and in cases where these clients need long term care services, they are required to submit documentation verifying those resources.

However, for clients who are seeking Community Medicaid Coverage without Long Term Care services (like the clients in the example--Mr. & Mrs. L), these clients may attest to the amount of their resources, but don't have to submit the documentation with the Medicaid application.  Of course, these clients' resources still have to be under the Medicaid resource limit, but it might make it easier for clients to apply if they don't have to obtain current financial statements. 

For more information on Community Medicaid Coverage and Resource Documentation Requirements see the Medicaid Reference Guide Resource Section

For NYC Medicaid applicants, HRA has created a chart summarizing the three types of Medicaid coverage and the various resource documentation requirements.

  • TIMING your Medicaid application -- Keep in mind that you can only use bills paid by EPIC, and copayments paid by the client, if you file the Medicaid application within the 4th month after the month in which the bills were paid.  So if you are relying on bills paid by EPIC in April 2011, it is too late to use those bills in August 2011.  So.. you need to look carefully at your EPIC claims history printout.  For Mr. and Mrs. L, there are enough EPIC payments in May and June alone, without using April, so that they did not have to apply for Medicaid in JUly -- August was still OK. 

Download this Information in a PDF 

The information in this Article and the various sample Forms posted here can be downloaded in this PowerPoint presentation by Selfhelp, with attached forms. 

This article written by Selfhelp Community Services, Inc. 

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