Frequently Asked Questions

Is there someplace I can get help with drug bills for someone in my care?

Who is eligible for PACE?

• You must be 65 years of age or older.

• You must be a Pennsylvania resident for at least 90 days prior to the date of application. • You cannot be enrolled in the

Department of Human Services’

Medicaid prescription benefit.

For a single person, total income must be $14,500 or less. For a married couple, combined income must be $17,700 or less.

Prescriptions: Copay for generic drugs is $6; copay for single-source brand is $9.

Who is eligible for PACENET?

• You must be 65 years of age or older.

• You must be a Pennsylvania resident for at least 90 days prior to the date of application. • You cannot be enrolled in the

Department of Human Services’

Medicaid prescription benefit.

PACENET income limits are slightly higher than those for PACE. For a single person, total income can be between $14,500 and $33,500. For a married couple, combined total income can be between $17,700 and $41,500.

Prescriptions: Copay for generic drugs is $8; copay for single-source brand is $15.

Call your local Area Agency on Aging office for forms or for more information or go to https://pacecares.magellanhealth. com.

Effective Jan. 1, 2022, PACENET cardholders not enrolled in a Part D plan will pay a $40.74 premium at the pharmacy each month they use their PACENET benefit.

Income qualification is based on prior year’s income and includes taxable and nontaxable sources. Assets and resources are not counted as income. What is the Medicare Savings Program (MSP)?

The Medicare Savings Program helps pay for Medicare premiums. In some cases, the Medicare Savings Program may pay Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) deductibles, coinsurance, and copayments if a beneficiary meets certain conditions. QMB, SLMB, and QI are part of the program.

Qualified Medicare Beneficiary (QMB): The income limit is $1,153 a month if single and $1,546 a month if married. QMB pays for Part A and B cost sharing, Part B premiums, and – if a beneficiary owes them – it also pays their Part A premiums.

Specified Low-Income Medicare Beneficiary (SLMB): The income limit is from QMB levels up to $1,379 a month if single and $1,851 a month if married. SLMB pays for Part B premiums.

Qualified Individuals (QI): The income limit is from SLMB levels up to $1,549 a month if single and $2,080 a month if married. QI pays for Part B premiums. Provides financial assistance with Medicare Part D prescription drug coverage (monthly premiums, deductibles, and drug costs).

MSP asset limits: The asset limits for QMB, SLMB, and QI are $8,400 if single and $12,600.

For information, call (800) 633-4227.

– Medicare.gov

What is the Medicaid spend-down program for regular Medicaid for the aged, blind, and disabled benefits and LTSS?

Individuals with incomes too high to qualify for Medicaid for the aged, blind, and disabled can enroll in Pennsylvania’s Medicaid spend-down. This program allows applicants to qualify for Medicaid by subtracting medical and long-term care expenses.

When an applicant enrolls in the Medicaid spend-down, the state determines the amount of their income that is above the income limit; this is known as “excess income.” Enrollees activate their coverage by submitting medical bills equal to this amount.

Pennsylvania usually approves spenddown benefits in six-month increments, with additional coverage requiring new medical expenses be submitted.

In Pennsylvania, the Medicaid spenddown program covers long-term services and supports.

Income eligibility: The income limit is $425 a month if single and $442 a month if married.

Asset limits: The asset limit is $2,400 if single and $3,200 if married.

For information, call (866) 550-4355.

– American Council On Aging

What are Medicare Preventive Services?

Early detection and treatment of health conditions can help reduce medical costs and maintain health. Many preventive care services are covered at a low or no cost. Talk to your doctor about preventive services available to you through Medicare.

What is the Extra Help Program?

Extra Help is a federal program that helps pay for prescription costs, premiums, deductibles, and coinsurance of Medicare prescription drug coverage for qualified beneficiaries. It is also known as the Part D Low-Income Subsidy (LIS). Persons may become eligible if certain requirements are met:

• You have Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). • You live in one of the 50 states or the

District of Columbia.

• Your resources (excluding your primary residence) are not worth more than $29,520 if you are married and living with your spouse or $14,790 if you are not currently married or not living with your spouse. (Do not count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial

contracts, or back payments from Social Security or SSI.) If you have more than those amounts, you may not qualify for Extra Help. However, you can still enroll in an approved Medicare prescription drug plan for coverage.

If you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid, you do not have to apply for this extra assistance because you will automatically get Extra Help.

If your loved one becomes eligible, you can call (800) 772-1213, TTY (800) 325-0778, or visit Medicare.gov for more information.

What is the APPRISE Program and where can I get more information?

The APPRISE Program is a free program operated by the Area Agencies on Aging to provide healthinsurance counseling and assistance to Pennsylvanians age 60 and over. They can help you understand Medicare benefits by explaining Medicare, Medicare supplemental insurance, Medicaid, and long-term care insurance.

Program counselors can explain the Medicare appeals process, help you select a Medigap insurance policy, explain the Medicare prescription Part D benefit, and explain financial assistance programs. Call (800) 633-4227 or your local Area Agency on Aging for more information.

What is the difference between home care and home healthcare?

Home care agencies (HCAs) and home care registries (HCRs) provide nonskilled services to individuals in their homes or other independent living environments.

Home care services include:

• Assistance with self-administered medications

• Personal care (assistance with personal hygiene, dressing, and feeding) • Homemaking (housekeeping, shopping, meal planning and preparation, and transportation) • Respite care (assistance and support provided to the family) • Other nonskilled services • Wound care for pressure sores or a surgical wound • Patient and caregiver education

• Intravenous or nutrition therapy

• Injections

• Monitoring serious illness and unstable health status

– Medicare.gov

What is the difference between a nursing home and a personal care home?

Nursing homes are licensed medical facilities that are inspected and licensed by the Pennsylvania Department of Health. They must meet both state and federal regulations. There is third-party reimbursement (Medicare and Medicaid) for those who qualify based on income.

Personal care homes are residential facilities that offer personal care services, assistance, and supervision to four or more persons. They are inspected and licensed by the Pennsylvania Department of Human Services.

A personal care home must have a license to operate in Pennsylvania. There are state licensing regulations that apply to personal care homes. These regulations are aimed at protecting the health, safety, and well-being of the residents.

There are no federal regulations for personal care homes. There is no thirdparty reimbursement for personal care homes, but many accept residents of low income who receive Supplemental Security Income (SSI).

What is the difference between a personal care home and an assisted living community in Pennsylvania?

Many people frequently confuse the two to mean the same thing, which was pretty true until 2011. Personal care homes are for individuals who want to remain independent yet have supervision and help with daily living activities. An assisted living community allows its residents to age in place longer, often making it unnecessary for them to move to a nursing facility. Bathing & Dressing Assistance Grooming • Assistance with Walking • Medication Reminders • Errands • Shopping Light Housekeeping • Meal Preparation • Friendly Companionship • Flexible Hourly Care • Respite Care for Families

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