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Introduction to Medicare and Medi -Cal for Seniors

Introduction to Medicare and Medi -Cal for Seniors. Agenda. The different parts of Medicare: what is covered under each part costs and eligibility requirements. Medi -Cal: what is covered, costs and eligibility requirements.

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Introduction to Medicare and Medi -Cal for Seniors

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  1. Introduction to Medicare and Medi-Cal for Seniors

  2. Agenda The different parts of Medicare: • what is covered under each part • costs • and eligibility requirements. Medi-Cal: • what is covered, • costs • and eligibility requirements. Long Term Care (it is not covered under Medicare and may be covered under Medi-Cal).

  3. Medicare • Federal/National Program for Seniors 65 years and older • Created in 1965 by US Congress • US citizens or legal residents for at least 5 years • For Spouses, each person must reach age 65 to be eligible • Four Parts: A, B, C and D

  4. Medicare Part A • Covers Inpatient Hospital Stay: semiprivate room, food and tests • Free if you have worked in this country for 40 quarters. If not, $441 a month if you are otherwise eligible (citizen or legal resident for 5 years) • One copay at the beginning of $1,184 for up to 60 days of hospital stay, more if staying longer

  5. Medicare Part B • Covers physicians fees and outpatients services, lab and diagnostic tests such as x-rays and MRIs, ambulance transportation etc. • Optional, costs $104.90 a month even for those with 40 quarters of employment • First meet deductible of $147.00 and then generally Medicare pays 80%, you pay 20% • Doctor seeing you in a hospital is paid under Part B

  6. Medicare Part C • Medicare Advantage Plans – Private insurance companies funded partly by Medicare and partly by you. Regulated by CMS (Centers for Medicare & Medicaid Services) • You pay your Part B premium of $104.90 plus added amount of around $250 a month. You get some additional benefits such as dental, vision care and sometimes even gym memberships. • Some plans also cover Prescription Drugs, which is not covered by either A or B.

  7. Medicare Part D • Prescription Drug Plan - Went into effect on Jan 1 2006 – youngest member of the family • Administered by private companies. Must be enrolled either in Part A or B to be eligible. • Drugs covered is not standard. Each insurer has their own formulary: drug and dosage combination. • What is “donut hole?” Once you and your drug plan have spent a given amount ($2970 for 2013), you will have to pay more for your drugs(2013 - 47.5% for brand name, 79% for generic) till you reach catastrophic coverage (2013- $4,750) when the insurance plan starts paying a much larger amount.

  8. 2013 Costs at a Glance

  9. Affordable Care Act of 2010 • AKA Obamacare, mostly about private insurance for ages <65, some effects on Medicare • Gradually closing the donut hole for Part D till 2020 • Limits for costs for in-network care for Part C enrollees • Part B and D costs restructured to be less for most and more for the wealthy

  10. Medi-Cal • Medicaid is the health program for families with limited income and assets – funded by states and federal government, different in each state. • Medi-Cal is the Medicaid Program for the state of California – usually no coinsurance, that is you do not have to pay 20% etc. like Medicare • Dual-eligibles: Qualify for Medicare and Medi-Cal. Medi-Cal pays for all the Medicare costs listed previously. It also covers services that Medicare does not cover. • Dental services discontinued in July 2009 – partially restored from May 2014

  11. Santa Clara County Medi-Cal • Contracts with Santa Clara Valley Health Plan or Anthem Blue Cross • Good Resource: Guide to Medi-Cal in Santa Clara County • For most of us office is:North County District Office,100 Moffett BoulevardMountain View, CA 94043

  12. Medi-Cal Eligibility • If you get SSI, you are automatically eligible for Medi-Cal. You have to live here for 5 years to qualify for SSI. • If you are over 65, meet income and asset criteria and are a green card holder, you are eligible for Medi-Cal. • OK to have one home, one car as assets. Otherwise very minimal limits, (world-wide income? Not sure) • Must prove state residency - easy

  13. Qualified Medicare Beneficiary - QMB • Medi-Cal pays your Medicare Part A and B premiums as well as other Medicare out-of-pocket expenses • Must qualify for Medicare – US citizen or legal resident for 5 years. If 40 quarters of employment then no Part A premium. • Income and asset limits more than for straight Mede-Cal – for form, use link below (http://www.dhcs.ca.gov/formsandpubs/forms/Forms/mc14a.pdf)

  14. Medi-Cal Rates • http://www.cmanet.org/news/detail/?article=medi-cal-primary-care-rates-will-increase-to • Currently, California's rates rank 47th in the nation and are on average 50 percent below Medicare rates. Because of these low rates, two-thirds of California’s physicians cannot afford to participate in the program and more than 50 percent of Medi-Cal patients report they can’t find a doctor.

  15. Medicare with Medi-Cal • If you are over 65, once you become a citizen or you have been a green card holder for 5 years, you can apply for Medicare during the Open Enrollment Period (October 15–December 7) • If you qualify Medi-Cal will pick up your Medicare premiums and other costs • More choices of doctors with this option.

  16. Over 65, what are my choices? • Get insurance from India – I don’t know much about this • Get private insurance – some choices in the web- http://www.visitorscoverage.com/immigrants/health-insurance-for-green-card-holders/ • Get Medi-Cal if you satisfy the income and asset limitations • If you are a US citizen or have held your green card for 5 years, you can apply for Medicare or Medicare Advantage • Have Medi-Cal pay for Medicare if you satisfy asset and income limitations

  17. Long Term Care • Medicare has very limited support for long term care in skilled nursing facility. Also, limited home health care. No coverage for assisted living or retirement community • Medi-Cal covers nursing facilities as well as services to help you stay in your home or assisted living facility. • Depends on income, assets, “level-of-care” needed.

  18. Useful Links • http://www.medicare.gov/ • http://www.medicareinteractive.org/ • http://www.cahealthadvocates.org/low-income/medi-cal.html • http://www.californiahealthline.org/ • Immigration & Citizenship Table • Guide to Medi-Cal in Santa Clara County • QMB Application

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