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Office For The Aging

 


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EPIC (Elderly Pharmaceutical Insurance Coverage) Program

EPIC is a New York State sponsored prescription program for senior citizens who need help paying for their prescriptions. Over 260,000 seniors already belong and are saving, on average, over 80% of the cost of their medicines.  You can apply to EPIC if:

  • New York State residents can join EPIC if they are 65 or older, and have an annual income of $75,000 or less if single, or $100,000 or less if married.
  • Seniors who receive full Medicaid benefits are not eligible for EPIC benefit
  • EPIC works with Medicare Part D as a secondary payer.  Seniors should make sure their Part D plan covers their prescription drugs, since EPIC will not pay primary for most medications.

EPIC is a cost sharing program. Seniors with lower incomes pay a low quarterly fee, and participate in the Fee Plan. Seniors with higher incomes meet an annual deductible, and participate in the Deductible Plan. Their EPIC is free. Those who pay a fee or meet their EPIC deductible make a co-payment at the pharmacy when purchasing prescriptions.  Please note: EPIC does NOT provide drug coverage during their Part D deductible, if they have one.

 

EPIC operates a toll-free Helpline which is available from 8:30AM to 5:00PM, Monday through Friday. Call 1-800-332-3742 (TTY 1-800-290-9138) for more information or to request an application. You can also write:  EPIC, PO Box 15018, Albany, NY 12212-5018.  email:  mailto:epic@health.state.ny.us.  Visit them on the web at: http://www.health.ny.gov/health_care/epic/

 

HEALTH INSURANCE

COBRA:  The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) allows continuation and/or conversion of an employer group health plan at the individual’s expense plus a 2% administrative fee for a period of 18 or 36 months.  Conversion policy benefits are often less comprehensive and more costly than the group plan with the employer.

Privately Purchased Health Insurance:  Individuals, not eligible for Medicare, may purchase individual HMO or Point of Services (POS) plans at premium rates approved by the NYS Insurance Department.  If affiliated with a trade, civic or religious association, an individual may find less costly premiums for such plans.  New York law requires all insurers writing small group or individual health insurance policies to accept all applicants and prohibits insurers from making any rate distinctions on the basis of age, gender, health status, or occupation.  Pre-existing condition clauses will apply if a 60-day lapse occurs between coverage.

Healthy NY:  Established January 1, 2001 by the Health Care Reform Act of 2000 helps New York State’s small business owners provide their employees with affordable health insurance coverage and helps income eligible sole proprietors or individuals obtain insurance coverage.  Eligibility is limited to those who were (1) uninsured for the 12 month period preceding application; (2) individuals whose gross household income is at or below 250% of the federal poverty level; (3) individuals who are ineligible for Medicare.  For information contact the NYS Insurance Department at 1-866-432-5849, visit the web site at http://www.dfs.ny.gov/healthyny/ or contact Dutchess County HIICAP at 845-486-2555 or 1-866-486-2555.

NY State of Health:  An organized marketplace designed to help people shop for and enroll in health insurance coverage.  Individuals, families and small businesses can use the Marketplace to help them compare insurance options, calculate costs and select coverage online, in-person, over the phone or by mail.  The Marketplace helps people to check their eligibility for health care programs like Medicaid and sign up for these programs if they are eligible.  The Marketplace also tells what type of financial assistance is available to applicants to help them afford health insurance purchased through the Marketplace.  Help is available by calling the Marketplace at 1-855-355-5777 or by visiting the website http://info.nystateofhealth.ny.gov/ or contact Dutchess County HIICAP at 845-486-2555 or 1-866-486-2555.

Supplementing Medicare:  Medicare Supplemental insurance, sometimes called Medigap insurance, may be purchased by people who are enrolled in Medicare Parts A and B and who are enrolled in the Original Medicare Plan.  The Medigap policy premium is regulated by the NYS Insurance Department.  Policies help by paying some of the costs that are not covered by Medicare.

Medigap policies are sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage.  In New York State there are thirteen (11) standardized Medigap plans A through N.  Benefit plans vary in the coverage provided.

Federal law prevents insurance companies from selling more than one Medigap policy to an individual.  New York State requires insurers to offer continuous open enrollment to all Medicare beneficiaries regardless of age.  A maximum six-month pre-existing condition clause is imposed if more than 63 days passes between credible insurance and purchase of a Medigap policy.

Medigap policies do not cover long term care, vision or dental care, hearing aids, private-duty nursing or prescription drugs.

Up-to-date Medigap insurance information is available on the web and Dutchess County HIICAP at 845-486-2566 or toll free at 1-800-701-0501.

Health Insurance Information, Counseling and Assistance Program (HIICAP):  HIICAP is part of a statewide network and national network of State Health Insurance Programs (SHIP). NYS Division of Aging Services coordinates HIICAP with a consortium of advocacy agencies and health care insurance providers.

HIICAP’s mission is to educate the public about Medicare and other health insurance issues and to provide accurate and objective information, counseling, assistance, and advocacy relating to Medicare, private health insurance and related health coverage plans for Medicare beneficiaries, their representatives, or persons soon to be eligible for Medicare.

In addition to individual counseling sessions, HIICAP offers New York residents a toll-free hotline at 1-800-701-0501.  Dutchess County residents in the 845 area code can call the hotline direct at 486-2566.

 

MEDICARE

Medicare is the nation’s largest health insurance program.  Medicare provides health insurance to people age 65 and over, and to people who have permanent kidney failure, certain people with disabilities and all persons who receive 24 months of Social Security Disability payments. Medicare usually is the first payer of health care costs, the foundation of health insurance for 97% of older Americans.

The Center for Medicare and Medicaid (CMS) is the federal agency that administers Medicare, Medicaid and the Child Health Insurance programs.   The majority of these individuals receive their benefits through the fee-for-service delivery system but there is an increasing number that are choosing managed care plans available through insurance companies.

Medicare Part A is known as the hospital coverage component of Medicare.  Part A helps pay for care in hospitals as an outpatient, skilled nursing facilities, hospice care and some home health care.

Medicare Part B is the medical insurance component of Medicare.  Part B helps pay for doctors’ services, outpatient hospital care, durable medical equipment, ambulance services, labs and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care.  Part B helps pay for these covered services and supplies when they are medically necessary.

Medicare Part C is known as Medicare Advantage plans.  These are an alternative to original Medicare administered by insurance companies.

Medicare Part D is the prescription drug portion of Medicare and is delivered by private insurance companies.

Unless an individual or his/her spouse is working and covered by Employee Group Health Insurance, enrollment in Medicare is required at age 65.  If an individual is receiving Social Security benefits, enrollment will occur automatically.  Those who are not receiving Social Security benefits should contact SSA three months before their 65 birthday and ask to be enrolled.  The toll free number is 1-800-772-1213. and calls are taken from 7:00 A.M. to 7:00 P.M. Those with benefits from the Railroad Retirement Board can call 1-800-808-0772.

Medicare Advantage Plans are private health plans that provide Medicare benefits under the management of an insurance company.  This coverage can include prescription drug coverage. Medicare Advantage Plans include Medicare Health Maintenance Organization (HMOs), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, or Medicare Special Needs Plans.

Part D or Medicare Prescription Drug Plans cover brand-name and generic prescription drugs at participating pharmacies in your area. Everyone with Medicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses.

Dutchess County HIICAP staff and volunteers are available to help Medicare participants in making choices among the various drug plans and/or health plans.  During the annual open enrollment period from October 15 through December 7, one-on-one counseling is available by appointment at local libraries and other convenient locations throughout the county.  Individualized counseling is also available throughout the year by appointment at the Office For The Aging at 27 High Street in Poughkeepsie.

If you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan you choose. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible.

Railroad Retirement beneficiaries with questions about RRB benefits, Medicare bills and coverage, lost Medicare cards, Medicare premium amounts and Medicare enrollment should call (877) 772-5772

Questions about Medigap policies, long term care insurance, Medicare health plan choices, Medicare rights and protection and help with filing an appeal should be made to the local Health Insurance Information Counseling and Assistance Program (HIICAP) in Dutchess County as 845-486-2566 or toll free at (800) 701-0501.

General Medicare information, ordering Medicare booklets and information about health plans is available at (800) 633-4227, TTD/TDD: (877) 486-2048; on line at http://www.medicare.gov/.

 

LONG TERM CARE INSURANCE

Long-term care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, and using the bathroom. Long-term care can be provided at home, in the community, in assisted living or in nursing homes.

Long term Care Insurance is a type of private insurance policy that can help pay for many types of long-term care, including both skilled and non-skilled care. Long-term care insurance coverage can vary widely. Long-term care insurance premiums vary, depending on your age and health status when you buy the long-term care insurance policy and how much coverage you want. You must be in generally good health to pass underwriting when purchasing a policy.

The cost of care, especially in nursing homes and assisted living facilities, varies from state to state. Make sure that the long-term care insurance policy you buy will cover the costs of care where you plan to use it.  Most long-term care insurance policies offer certain tax benefits..

The Partnership for Long-Term Care is a partnership between Medicaid and long-term care insurers and is currently available in New York State.  It provides an alternative to spending down or transferring assets. The Partnership for Long Term Care has focused on creating affordable products that encourage people to self-insure, enable purchasers to provide better protection against impoverishment, and reduce long-term care costs for the Medicaid program

Consumers would be wise to carefully research long-term care insurance choices and benefits before calling an insurance company.  The New York State Division of Aging Services’s HIICAP web site at http://www.aging.ny.gov/HealthBenefits/HIICAPIndex.cfm, the New York State Partnership for Long-term Care web site at www.nyspltc.org and www.planaheadny.com and Dutchess County Office For The Aging's HIICAP at 845-486-2566 or 1-800-701-0501 are excellent sources for information and objective counseling.

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Todd N. Tancredi,Director Todd N. Tancredi
Director
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