Minutes of the
Chair: Charmaine Graham, Marcelo Maia
Consumer-At-Large: David Martin
Tuesday, December 6, 2022, 2:00PM – 4:00PM
Agenda Item 1: Welcome & Roll Call, Ice Breaker, Moment of Silence, Reminder to Review Rules for Respectful Engagement, Approval of the Minutes
Minutes were approved with changes. The moment of silence was conducted. To accommodate the extensive content for the meeting, introductions were skipped.
Agenda Item 2: Benefits Navigation
Director, Benefits Plus Learning Center
Health Insurance (mostly about Medicare)
If you only remember 4 things:
1. Most people should enroll in Medicare when first eligible.
2. There are different ways to get Medicare benefits and they all require that you pay something for your health care.
3. There are programs that can assist with cost-sharing.
4. You have resources, including where to get free one-on-one help from counselors educated about Medicare.
Let’s focus on becoming Medicare eligible
● People become eligible for Medicare because:
○ They turn 65
○ Are collecting SSDI benefits for 24 months
○ Have End Stage Renal Disease
● What coverage do people have before becoming Medicare
○ Medicaid – can keep with Medicare
○ Essential Plan – ends with Medicare eligibility
○ Qualified Health Plan – someone with a QHP will typically want to
disenroll from their QHP when Medicare eligible
○ Employer-based coverage – not discussing today
Part A: hospital insurance (inpatient hospital, skilled nursing facility, hospice)
○ Premium-free for most people
○ Out-of-pocket costs (deductible and co-insurance) should you need services
● Part B: medical coverage (physician visits, lab tests, x-rays, etc.)
○ Monthly premium, deductible, co-insurance
○ Do NOT need a work history for Part B
● Part D: prescription drug coverage
○ Monthly premium, deductible, cost-sharing
○ Do NOT need a work history for Part D
What to do when you become Medicare eligible?
● Automatic Enrollment in Medicare Part A and Part B for some
○ Collecting Social Security Disability Insurance for 24 months
○ Collecting Social Security retirement before 65.
● Others have to apply for Medicare when first eligible for
benefits to start
○ Part A and Part B
§ Apply through Social Security
○ Part D
§ Apply through Medicare
What to do when you become Medicare eligible?
● Most people are well-advised to enroll in Medicare when first
eligible UNLESS you have employer-based health insurance
through your own or your spouse’s active, current employer.
○ ALWAYS confirm coverage with employer, since some require Medicare
enrollment if eligible.
○ Those with employer-based coverage will have a Special Enrollment
Period to enroll in Part B and D when they lose that coverage (Part A
enrollment is flexible).
○ Why apply when first eligible?
§ Avoid Late Enrollment Penalties (Part B: 10% for each 12 months; Part D: 1% per
□ Forever penalties, with few exceptions.
§ Delayed effective dates
§ Domestic partners are not spouses.
§ COBRA is not active employer-based coverage.
Open Enrollment/changing coverage
○ October 15 – December 7. New plan effective January 1.
○ Call for help if you need to make a change mid-year, since there are
some reasons why you can make a plan change.
Programs to Assist Medicare Beneficiaries with
● Medicare Savings Programs (MSP) – don’t count resources.
§ monthly income limits of $1,563 single/$2,106 married
§ Helps with all Part A and Part B cost-sharing (pays for the Part B premium of $170.10)
§ Monthly income limits of $2,107 single/$2,839 married
§ Pays Part B premium
● Extra Help (Low-Income Subsidy Program, LIS) – Helps with Part D costsharing
○ Most people get automatically because they have Medicaid or a Medicare Savings Program.
○ If not, people can apply with SSA, but they look at both income and resources (with lower limits than MSP).
● Medicaid through LDSS/HRA– fills in for gaps in Medicare A, B and D
○ Can pay for Service gaps: transportation OTC meds, home health aids, hearing aids, dental
○ Dollar gaps (all of the Part A and B cost sharing), Does not pay Part D copays for medications.
● Elderly Pharmaceutical Insurance Coverage (EPIC) – Helps with Part D costsharing
○ Annual income up to $75,000 single/$100,000 married couple.
○ Must be 65 or older and have Part D
Where to get free and objective help
● Start by joining a HIICAP Medicare Orientation
● Then seek out 1:1 Medicare counseling
○ Benefits Plus Learning Center:
§ MedicareHelpNYC@gmail.com or call 212-614-5310
○ Call HIICAP in NYC at 212-602-4180
You can get help with Medicare questions, as well as programs to assist with cost-sharing
Where to apply
● Medicare Part A and Part B and Extra Help
○ Social Security Administration: 800-772-1213
● Medicare Part D: 1-800-Medicare or Medicare.gov
● Medicaid for 65+, blind and disabled, and Medicare Savings Program
○ Facilitated Enrollers in your county: 1-888-614-5400
○ Call the Medicaid Helpline at 1-888-692-6116 to find the nearest Medicaid office,
office hours and directions.
● EPIC: Go to the EPIC website or call 1-800-332-3742
● NY State of Health: Medicaid for people under 65, who aren’t blind or disabled and with Medicare. (Once you have Medicare, you typically can’t apply for any coverage through NYSoH.)
○ Community Service Society’s Community Health Advocates: 1-888-614-5400
○ NY State of Health: 855-355-5777
Health Insurance Terminology
● Premium: An amount that you pay for the coverage. You pay this amount whether or not you use
● Deductible: An amount that you pay before the policy pays for your care. (Some services are
covered before you meet your deductible, such as preventive care.)
● Copayment: A fixed amount that you pay for a service (i.e. $20 copay for primary care visits; $40
copay for a specialist visit).
● Co-insurance: Rather than paying a set dollar amount (for example, $5 for each prescription), you
pay a percentage of the cost (i.e. 10% co-insurance for each prescription).
● Maximum Out-of-Pocket (MOOP): After you reach the maximum out-of-pocket costs, the plan
may cover all/most of the costs of care for the remainder of the calendar year. The MOOP includes
the deductible, copays/coinsurance, but NOT premiums.
of the process.
- Exciting to see consumers engaged from the beginning of the process
- It’s a lot of information – concerned about people understanding the process
- Want to know a concerted effort is being made to ensure consumer consent
- Should be easier for consumers to access their own data
- Would like to get a notification like those I get on my phone
- If PWH decide to consent to this sharing of information, they’re agreeing to have their um lack of viral suppression at a given time, or their loss to care at a given time be communicated to their behavioral health and or housing service provider under Ryan White party. This information is already routinely shared with medical providers, but it was not previously shared with support service providers. This consent will inform that process.
- A program may have a patient navigator help them to address the barriers that’s caused a person to be out of care or unsuppressed. So that patient navigator type person may recognize that a person could use help with getting a different primary care provider. They may recognize that they’re having problems receiving their medications if they’re getting mail order, or delivery, etc.
- Inside the research and evaluation unit, do not have contact info like email and phone for PWH – must reach people thru their provider – and we cannot give providers exact viral loads- can only give them categories of people, in care, lost to care, etc.
- We should really be empowering PWH to access and understand their own data
- Were the legal restrictions removed due to COVID?
- It’s independent of COVID – has to do with care coordination regulations in NYS and the following legal interpretation of the changes. Transition to share with behavioral health and housing providers happened in 2021
- Worry that data is being fudged if the meetings for this process are not in-person. And the lack of Consumer Advisory Boards to address these issues
- What about including when consumers don’t need certain services any longer? Is that represented here?
- When people cycle out of the program they are no longer included. Follow up would be with people who are identified to need additional services. Cannot share info with providers who no longer have a therapeutic relationship with the client. Sometimes out of care clients have realty just moved providers or out of the jurisdiction
- More wondering if people can remove their consent if they no longer want to be part of the project. Like maybe they transition to injectables.
- What are the fail safes for when others drop the ball (i.e., not documenting an appointment properly?)
- A missed appointment would not get someone on the list – would have to be missing evidence of a viral load for a 12-month period. No one is blaming clients who are not suppressed. It’s to identify the best approach and support to get people back into care.
- When gathering info from consumers, important to build trust and rapport first
- These reports are not just about the consumer – if a site is dropping the ball, it really shows on these reports. The reports help identify structural problems, and where to focus quality improvement strategies.
- This project is interested in feedback on how to recruit consumers to participate in focus groups and welcome participation from all CC members. Can share our recruitment plan once it is developed.
- Committee is interested in an overview of the various projects and initiatives taking place across HIV in the DOHMH
HOW ADAP/APIC CAN HELP WITH MEDICARE COSTS
Karin Timour, Director Downstate Outreach and Technical Assistance
New York State Department of Health
- Make sure your contact info is up to date with ADAP
- Starting in January, the monthly income eligibility limits for the Medicare Savings Program will increase to an estimated $2,107 for an individual and $2,839 for a couple, based on the 2022 federal poverty level. New Yorkers can apply for this program throughout the year and during open enrollment, which started earlier this month and continues through December 7.
- The expanded assistance goes into effect in 2023, but all beneficiaries should check to see if they are eligible under the new guidelines. Official income limits will be updated after the new federal poverty level goes into effect next year. Undocumented people can access Medicaid in 2023.
- Medicaid Spend-down is for people who are disabled, blind or over 65 who have assets below the Medicaid asset level ($16,800) but have income above Medicaid eligibility ($934/month in 2022).
- When Medicaid is active it will be the secondary payer for services not covered by Medicare.
- MUST GET OBJECTIVE ADVICE
Use ADAP to Help with Medicaid Spenddown
• Tell ADAP client has Medicare.
• Give ADAP “Medicaid Notice of Decision.”
• Each month check to see whether Medicaid is active
• Medicaid not active? Use ADAP to pay for medications.
• Pharmacy bills ADAP. ADAP mails receipt to participant.
• Participant faxes to Medicaid.
ADAP will pay for Medicaid spendown using an ADAP card. ADAP then mails the receipt to the client – which can be submitted to the Medicaid spenddown.
If someone has a spenddown, use ADAP to pay for service and count against the spenddown- which can count 6 months into the future – must have below level assets to qualify.
Many people do not know how to use an ADAP card to pay the spenddown.
THE FOUR HIV PROGRAM COMPONENTS:
- AIDS Drug Assistance Program (ADAP)
- Prescription Coverage
- ADAP Plus
- Outpatient Medical Care
- Dental care, including dentures
- HIV Home Care Program – up to $30K
- ADAP Plus Insurance Continuation (APIC)
- ADAP/ADAP Plus/APIC: Must be living with HIV
- PrEP-AP: Must be HIV-negative – will pay for PrEP, immigration status not required
- Must reside in New York State
- Income must be below 500% of the FPL
UCP INCOME ELIGIBILITY:
Income must be below 500% of the FPL 2022 FPL:
● Household of one: $67,950 annually
● Household of two: $91,550 annually
● Household of three: $115,150 annually
● Additional household members: Add $23,600 for each
APIC Can Pay for:
• Coverage through Employment i.e., monthly premiums
• COBRA Coverage
• Coverage purchased through NY State of Health
• Coverage purchased directly from health insurance company or agent – undocumented can get private insurance (currently cannot get state insurance)
• Medicare Part D coverage
• Medicare Advantage policies
• Medicare Supplemental policies
2022 Medicare and ADAP: Action Steps
1. Apply for APIC to pay for Premiums.
2. Apply for ADAP to pay out-of-pocket costs for Deductible, Co-payments and Donut Hole.
- Original part B requires clients to pay 20% of all bills – but APIC has a mechanism to pay this, so it does not fall on the client.
- Talk to navigation counselors to find out about these mechanisms
- There are so many benefits people are not aware of – the state and federal Medicaid do not communicate well -impacts the consumer.
- Social Security and Medicaid are out of the state’s control, but the state does a lot of training to help agencies navigate these issues on behalf of clients.
- Use ADAP staff to straighten out billing problems at pharmacies.
- Original Medicare does not have dental coverage – when signing up for dental coverage – need to ensure it will cover the providers you want.
- Assets: In Medicaid – income and assets, Medicare – neither, ADAP – income, not assets – not so straightforward
- ADAP is uniform and will work with the other benefits clients qualify for
- Can get an ADAP card online https://nyucp.providecm.net or at Minority AIDS Initiative contractors or call the ADAP hotline
- ADAP cards are usually awarded within 24 hours
- ADAP cannot pay Part B, but there are other mechanisms that do.
- NYS does not require person meet the asset requirement to qualify for Part B
- If you have Part A, B, D and Medicaid – do you need a Medigap program – because it would be duplicate coverage, not allowed in NY –
- If you have full Medicaid, cannot get ADAP. If you have Medicaid with a spend down – can access ADAP
- Concern that this information is not readily accessible to those who need it.
- Care in NYC clinics is not sufficient to meet the needs of aging PWH
- This is too much information for anyone to process
Benefits Plus Learning Center
- the more you know about what you’re receiving and how it behaves the better
An Explanation of Government Benefit Programs
1. Government benefit programs have rules or guidelines that applicants must meet to qualify.
2. These guidelines are the program’s eligibility criteria/qualifying factors.
3. Individuals must meet all established guidelines.
Social Security Administration (SSA)
- SSI – NYS Office of Temporary & Disability Assistance (OTDA), State Supplement Program (SSP)
There is a lot of confusion about all of these acronyms.
Supplemental Security Income (SSI)
- Needs Based Benefit
- There are income and resource requirements, if you are over these amounts, you are not eligible.
- The maximum benefit amount is a fixed rate based on other income and living arrangements.
- Recipients receive Medicaid automatically
- The maximum benefit amount for SSI is fixed.
- SSI looks not just at your income, but at your living arrangements. So, there’s a series of questions that they ask individuals about living arrangements
Social Security Disability Insurance (SSDI)
- Insurance Based Benefit
- Eligibility is not based on income/resources.
- You must have a work history to be eligible.
- Benefit amount is based on how much you paid into the “system.” Eligibility for an insurance based benefit is not based on your income and resources. It’s based on your work history.
- Beneficiaries receive Medicare after 24 month of SSDI.
Social Security Retirement and Survivors Insurance
- Insurance Based Benefit
- Eligibility is not based on income/resources.
- You must have a work history to be eligible.
- Benefit amount is based on how much you paid into the “system”
- Beneficiaries receive Medicare at age 65.
Social Security & Returning to Work
SSA Work Incentives
- The SSA has several provisions (rules) to assist SSI/SSDI recipients who return to work called work incentives.
- These provisions are designed to help disabled and blind individuals return to work and protect their cash and health benefits.
- What work incentives apply depends on what type of benefit individuals have: SSI, SSDI, or both.
- For help contact
What happens when I turn 62
On SSI only
- If you are insured, your benefit will change to early retirement age at 62. This is a reduced
- If you are not insured you will continue to get SSI (income is low enough), you KEEP your Medicaid.
On SSDI only
- You can continue to get your SSDI until you reach your full retirement age, there is no change in benefit amount.
Concurrent (SSI and SSDI)
- No Change in benefits
- If you are insured, you can choose to collect early retirement benefits at a reduced
What happens when am eligible at my full retirement age?
- If you are insured, you will continue to get retirement benefits at the reduced
- Not Insured, your SSI benefit will remain the same
- Your benefit amount will remain the same but now you will be getting social security retirement benefits
- If you opted to take early retire benefits you will continue to get the benefit at a reduced amount.
HIV/AIDS Services Administration (HASA)
- This benefit is administered by the NYC Human Resources Administration (HRA)
- HASA provides a rent enhancement, and an additional $376, cash assistance. If eligible, Medicaid and SNAP.
- HRA will calculate an enhanced standard of need using your full rent amount and your gross income.
- Your income must be below the enhanced standard amount of $376.
- Cost of living adjustment (COLA)
- In 2023, social security will be implementing a COLA increase of 8.7%
- This may impact some HASA recipients whose income is already close to going over the income guideline to continue to be financially eligible for HASA.
- Last year, a small number of HASA recipients lost access to HASA benefits because the COLA (5.9%) amount increased their income and were thus over the HASA financial guidelines.
- HASA is currently willing to accept higher rents than in previous years
Public Comment/Other Business