Dual Eligible Beneficiaries are Losing OHP! Here’s why.

Medicare and Medicaid are two government programs that provide healthcare coverage to millions of Americans. Medicare is primarily designed for seniors over 65 and those with certain disabilities, while Medicaid is intended for low-income individuals and families. However, there are many people who are eligible for both programs, known as dual eligibles. For these individuals, Medicaid provides additional coverage for services not covered by Medicare, such as long-term care and home health care.

If you are a dual eligible beneficiary, you will need to undergo a OHP redetermination process periodically to ensure that you continue to meet the eligibility requirements for the program. In this article, we will explore the OHP redetermination process for Medicare Medicaid dual eligible beneficiaries, its importance, and what you need to do to prepare.

When will Oregon resume redetermination for OHP coverage?

Redetermination was halted due to the ongoing Federal Public Health Emergency declaration, but since the COVID 19 Crisis is officially over,  OHP was required to restart the redetermination process by April 1, 2023

Who will be subject to redetermination once the process resumes?

All Medicaid-covered individuals must undergo redetermination at some point between April 2023 and January 2024.

When will each individual be required to undergo redetermination?

OHA will carry out the redetermination process in stages, with redetermination notices being sent to a portion of members each month starting April 1, 2023. The final notices will be issued in January 2024.

What is the timeframe for Medicaid individuals to respond to OHA’s request for redetermination documentation?

Typically, individuals have 30 days to provide requested documentation, but OHA has extended this period to 90 days.

How to Prepare for OHP Redetermination?

To prepare for OHP redetermination, make sure you have copies of your income, citizenship or immigration status, residency, and medical information ready to submit. If you were deemed ineligible for OHP or your level of OHP changes, give us a call so we can go over Oregon Medicare Plan Options that may best suits your needs.

Here are some of the documents and information you may need for OHP redetermination:

• Proof of income: You will need to provide documentation of your income, such as pay stubs, tax returns, or bank statements. Make sure you have copies of these documents ready to submit.
• Proof of citizenship or immigration status: You will need to provide documentation of your citizenship or immigration status, such as a birth certificate or passport. Make sure you have a valid and current copy of these documents.
• Proof of residency: You will need to provide documentation of your current address, such as a utility bill or lease agreement. Make sure you have a recent copy of these documents.

How Medicaid redetermination affects Dual Eligible Beneficiaries

Medicaid redetermination is a process where beneficiaries’ eligibility for Medicaid is reviewed periodically to ensure they still meet the program’s requirements. These reviews normally happen yearly in Oregon.  Dual eligible Medicare and Medicaid beneficiaries may experience disruptions in their healthcare coverage during this process, which can have serious consequences.

Here are some of the ways OHP redetermination can affect dual eligible Medicare and Medicaid recipients:

1.Temporary loss of coverage

During the redetermination process, dual eligible beneficiaries may experience a temporary loss of Medicaid coverage. This can occur if the review process takes longer than expected, or if there are issues with the beneficiary’s eligibility documentation.

If a beneficiary experiences a temporary loss of coverage, it will be hard to access  medical services until their coverage is reinstated. This can be dangerous for individuals with chronic conditions that require ongoing care.

2.Changes to benefits

Medicaid redetermination can also result in changes to benefits, such as fewer covered services or changes to copayments. This can be challenging for dual eligible beneficiaries, who rely on both programs to access the medical services they need.

If a beneficiary experiences changes to their Medicaid benefits, they may need to explore alternative options for Medicare coverage. Some Medicare plans are only available to people who have full Medicaid.

3.Confusion and stress

Dealing with the redetermination process can be confusing and stressful, particularly for dual eligible folks who may already be dealing with multiple medical conditions. The process often requires submitting many documents and meeting strict eligibility requirements that may have changed.

In some cases, people who have been denied Medicaid can appeal that decision in order to avoid losing benefits. This can be a time-consuming and stressful process, and may require legal assistance.

What does it mean to be partially dual eligible?

Individuals who are eligible for both Medicare and Medicaid are commonly referred to as dual eligibles because they qualify for both programs. However, the difference between full and partial dual eligibility makes things even more confusing. Full dual eligibility means that individuals qualify for all state Medicaid benefits, including covered medical care. On the other hand, partial dual eligibility means that while individuals may not be eligible for medical benefits through their state Medicaid program, they may still qualify for some assistance from Meicaid.

There are different levels of partial dual eligibility, with four different categories in what is known as the Medicare Savings Program (MSP). The primary differences between MSP levels are based on income and assets, and whether the program covers copays, deductibles, and coinsurance for both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), or just Medicare Part B premiums for Medicare Part A premiums.

On the other hand, partial dual eligibility means that while individuals may not be eligible for medical benefits through their state Medicaid program, they may still qualify for some assistance from Medicaid.

What are Medicare Savings Programs?

These programs are actually Medicaid programs which are managed by the Oregon Department of Human Services. They are designed to provide financial assistance to individuals who need help with costs associated with Medicare.

There are three different types of Medicare Savings Programs available: QMB, SMB, and SMF.

• QMB can help cover expenses such as premiums, deductibles, co-pays, and co-insurance.
• Meanwhile, SMB and SMF are aimed at helping with Medicare Part B premiums. It’s important to note that SMF may not always be available, as it is dependent on federal funding.

How Do I Qualify for Medicare and Oregon Health Plan?

To be eligible for the Medicare Savings Programs, you must already be receiving Part A benefits and meet certain income requirements, which are outlined on the right-hand side of this brochure. It’s important to note that there may be other requirements that are not listed in this document. 

When determining eligibility, the Department of Human Services (DHS) begins by assessing your gross income, and then deducts $20 from that amount. If you have any earned income, DHS will subtract even more. It’s possible that you may still be eligible for these programs even if your income appears to exceed the income limits. Additionally, there are no resource limitations for these programs in Oregon.