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Medical
Benefits for People with HIV/AIDS |
PDF VERSION |
By: Barbara A. Isenhour and Sean R. Bleck
There are several government benefits available to people with HIV/AIDS to
help pay for
the cost of medical care and treatment. The following is a brief discussion of
those
programs.
Medicare
To qualify for Medicare you must meet the Social Security definition of
"disabled."
Your disability must be total and permanent. That means that your disability
is expected
to last for at least one year or result in death. Depending upon your age,
education and
prior employment the Social Security Administration will evaluate whether you
can be
re-trained to perform less strenuous work given your medical condition.
To qualify for Medicare you must not only meet the Social Security definition
of
"disabled" but you must also have worked sufficient quarters in the past and
paid into the
Social Security system. As a general rule, to qualify for Medicare you must
have paid
into the social security system for at least 40 quarters with 20 of those
quarters being in
the prior ten years. If you become disabled before the age of 31 fewer
quarters are
required.
Twenty-nine months from the date the Social Security Administration determines
your
disability started you will be eligible for Medicare health insurance. If you
are employed
at the time you become disabled and have employer-offered health insurance,
you can
extend your employers insurance under a federal law called COBRA until the 29
month
waiting period has expired and Medicare begins. If you do not have health
insurance
through a former employer at the time you become disabled you will need to
look into
one of the other programs discussed below to obtain health insurance coverage
during the
29 month waiting period for Medicare.
There is no asset or income test to qualify for Medicare. The premium is
deducted from
your SSDI income benefit and is very reasonable compared to other health
insurance.
The premium for Medicare Part A (hospital care, home health, hospice, limited
skilled
nursing home benefit) is free. The premium for Medicare Part B (doctor visits,
durable
medical equipment for 2005 is $78.50 per month. Medicare does not currently
cover
prescription drugs.
Beginning in 2006 Medicare will offer a prescription drug benefit under
Medicare Part D.
See our separate article on that program to get more detailed information.
Medicaid
If you meet the Social Security definition of "disability" discussed above you
may
qualify for Medicaid benefits to help with medical expenses. The Medicaid
program is
administered by the Department of Social and Health Services (DSHS). If you
are receiving SSI income benefits then you will automatically receive Medicaid
benefits without applying separately with DSHS.
Unlike Medicare, the Medicaid program has asset limits in order to qualify for
benefits.
For a single person your assets must be below $2,000 ($3,000 for a married
couple).
Your home, household furnishings, and certain burial arrangements are exempt
assets
that will not affect your eligibility. You can also own a vehicle that does
not exceed
$5,000 in value (or a vehicle of any value if you need the vehicle to get to
medical
appointments). If your assets exceed the $2,000 asset limit you should seek
legal advice
about your options to qualify for Medicaid.
Medicaid does not have an income cap but your income above a set amount called
the
Medically Needy Income Level (MNIL) must be contributed towards your medical
expenses as a co-payment. This is referred to as "spenddown". The MNIL for
2005 is
$579 ($798 if you are receiving COPES Medicaid benefits for an in-home
caregiver).
This is a simply illustration of how "spenddown" works. If you have $1,000 of
monthly
income, $421 must be "spent down" or applied towards medical expenses before
Medicaid will cover the remaining medical expenses for the month. As a
practical matter
that leaves you with $579 of monthly income to meet all of your non-medical
expenses
for the month including rent, food and utilities. You have to pay $421 towards
your
medical bills and then Medicaid will pay for the medical bills above the $421.
One of the
benefits of the EIP program discussed below is help in paying the "spenddown"
amount
to DSHS. Instead of having to pay the $421 towards medical bills, the EIP will
pay
DSHS the $421 and you can use all of your $1,000 of income to meet your
non-medical
living expenses.
Medicaid coverage includes:
Hospital care
Physician care if the doctor has a contract with EIP
Durable medical equipment
Medications (until January 2006)
Laboratory tests
Nursing home care (including hospice care facilities like Bailey Boushay)
In-home caregivers under the COPES program
Beginning in 2006 you will need to enroll in Medicare Part D to receive
prescription drug
coverage that is currently being paid by Medicaid.
Early Intervention Program (EIP)
The Department of Health (DOH) Early Intervention Program (EIP) provides the
following benefits:
- Prescription Drug Coverage: The EIP has a
formulary for early intervention
HIV drugs and drugs for related conditions. If you have private insurance that
covers medications, EIP will help with co-payments for drugs in the formulary.
- Medical Care: The EIP pays for limited HIV
related medical visits and tests. If
you have private insurance, EIP will pay up to $500 for co-payments and costs
incurred during a pre-existing condition period for certain covered services.
- Insurance Premiums: EIP will help you obtain
private health insurance and help
with the premiums. The program helps with health insurance is the Evergreen
Health Insurance Program (EHIP). The program can help with COBRA health
insurance premiums when you leave your current employment, premiums with a
current employer or premiums with private insurance including the Washington
State Health Insurance Pool (WSHIP).
- Spenddown Assistance: If you are eligible
for Medicaid benefits and have a
spenddown (see Medicaid discussion above), EIP will pay up to $900 to DSHS
each month to help meet your spenddown.
To qualify for EIP you must meet the following
criteria:
1. You have a medical diagnosis of HIV;
2. You reside in the State of Washington;
3. You are not eligible for Medicaid (unless you are applying for the Medicaid
spenddown payment);
4. Your income averaged over 12 months cannot exceed the income limit set by the
DOH (currently 300% of the federal poverty level or $2,393 for 2005). If you
were enrolled in EIP before September of 2002 you may be grandfathered into the
program under a higher income limit. There is also a higher income limit if you
have dependents. Income includes lump sum payments such as an inheritance or
law suit insurance payment;
5. Your assets cannot exceed $10,000. You may be grandfathered into the program
under a higher asset limit of up to $15,000 if you enrolled in a program for
assistance with insurance premiums through DSHS prior to July of 2003. Assets
include trust funds available to you. Exempt assets include:
Your residence in the State of Washington and surrounding land not to
exceed 5 acres;
One vehicle;
Commercial property or property used to produce income, not to exceed
$20,000 of value;
Household furnishings;
Pensions, IRA, 401K plan or other deferred income retirement plan.
The EIP program for payment of prescription drugs will change for people who are
eligible for Medicare and Medicaid when the Medicare Part D program starts in
January of 2006
Additional Information
For additional information on the Medicare program go to
www.ssa.gov
Regulations on the Early Intervention Program are at WAC 246-130.
See also
http://www.doh.wa.gov/cfh/HIV_AIDS/Client_Svcs/EarlyInterventionProgram.htm
http://www.ehip.org/
http://www.cms.hhs.gov/medicarereform/
http://www.hrsa.gov/medicare/HIV/about.htm
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