Basics of Medicare

1. Basics of Medicare Center for Health Care Rights April 2014

2. Center for Health Care Rights(CHCR) • A non-profit advocacy organization that provides free information and help with Medicare and health insurance issues. • Our services are FREE for Los Angeles County residents. Center for Health Care Rights April 2014

3. We are NOT part of Medicare or any insurance company or HMO. • We are primarily funded through the Health Insurance Counseling and Advocacy Program grants provided by the Los Angeles City Department of Aging and the County Area Agency on Aging. Center for Health Care Rights April 2014

4. Medicare • A federal health insurance program that was created to provide a safety net for persons who are elderly (65 years and older) or younger and disabled (under the age of 65) adults. • Eligibility for Medicare is not based upon income or resources. Center for Health Care Rights April 2014

5. Who is Eligible for Medicare? Automatic Enrollees (Eligible for Free Part A) • Age 65 and older entitled to Social Security Retirement Benefits; • Age 65 and older and the spouse or former spouse of someone entitled to Social Security or Railroad Retirement Benefits; • Age 65 or older and eligible for Federal Civil Service or Railroad Retirement benefits; • Under the age of 65 and has been receiving Social Security Disability for 24 consecutive months. Center for Health Care Rights April 2014

6. Automatic Enrollees (Eligible for Free Part A) • Have End-Stage Renal Disease (ESRD). Eligible for Medicare only if they are insured for Social Security or Railroad Retirement benefits. • Have Amyotrophic Lateral Sclerosis (ALS) also known as Lou Gehrig’s disease (individuals with ALS do not have to wait 24 months for Medicare to begin). Eligible for Medicare only if they are insured for Social Security or Railroad Retirement benefits. Center for Health Care Rights April 2014

7. Eligibility for Medicare based on age 65 • Persons who elect to receive retirement benefits before age 65 will receive their Medicare card three months before their 65th birthday. • Persons who apply for Social Security Retirement at age 65 will generally also apply for Medicare at the same time. • Starting in 2003, the retirement age for persons born in 1938 and after has been increased. Some of these individuals may become eligible for Medicare (at age 65) before they are eligible for full Social Security retirement. Center for Health Care Rights April 2014

8. Eligibility for Medicare based on disability • Persons receiving Social Security disability will receive Medicare after they have received Social Security benefits for 24 consecutive months. • They will receive their Medicare card three months before the month they become eligible. To apply for Medicare, contact the Social Security Administration. 1-800-772-1213 www.socialsecurity.gov Center for Health Care Rights April 2014

9. Medicare Premiums for 2014 Center for Health Care Rights April 2014

10. Premium Penalties Center for Health Care Rights April 2014

11. Medicare Part B and D premiums based on Income • Higher income Medicare beneficiaries with annual incomes over $85,000 (single person) and over $170,000 (married couple) pay an additional income related monthly premium for Medicare Parts A and B that is based on their income. Center for Health Care Rights April 2014

12. Medicare Enrollment Periods • Initial Enrollment Period Begins three months before the month of Medicare eligibility and ends three months after (seven months total). • General Enrollment Period January through March each year, benefits are effective July 1st. • Special Enrollment Period Begins on the first day of the month the beneficiary is no longer covered by an employer group health plan and ends eight months later. Center for Health Care Rights April 2014

13. Do I Have to Apply for Medicare if I am Working and Have Employer Insurance? Medicare Eligible Persons – Age 65 • Persons who are turning 65, working (or whose spouse is working) and are covered by an employer health plan do not have to enroll in Medicare Part B. • They can delay their Medicare enrollment until they or their spouse retires and will not be charged a penalty for late enrollment. • This rule applies only if the employer has 20 or more employees. Center for Health Care Rights April 2014

14. Do I Have to Apply for Medicare if I am Working and Have Employer Insurance? Medicare Eligible Persons – Under 65 • These individuals can delay their enrollment in Medicare Part B with no penalty for late enrollment. • This rule applies only if the employer has 100 or more employees. Center for Health Care Rights April 2014

15. How Does Medicare Work with My Employer Insurance? If a Medicare eligible person is covered by an employer health plan and he/she enrolls in Medicare, the employer plan will be primary and Medicare secondary. Center for Health Care Rights April 2014

16. Medicare Coverage Part A Hospital Insurance Part B Medical Insurance Center for Health Care Rights April 2014

17. Medicare Part A Benefits • Hospital • Skilled Nursing Facility • Home Health Care • Hospice Center for Health Care Rights April 2014

18. *A “benefit period” begins the day a beneficiary is admitted to the hospital and ends when the beneficiary has been out of the hospital or nursing facility for 60 consecutive days. The 60 “lifetime reserve days” can be used only once. Center for Health Care Rights April 2014

19. Part ASkilled Nursing Facility Coverage Requirements for coverage: • Three day prior hospital stay; • SNF stay must be ordered by physician; • SNF must be Medicare certified; and • You must need skilled care on a daily basis(minimum five times a week). Center for Health Care Rights April 2014

20. Medicare Home Health Benefits If you meet the Medicare requirements, Medicare will pay for the same type of service received in a Skilled Nursing Facility at home: • Nursing care • Physical therapy • Speech therapy • Occupational therapy • Medical social services • Home health aide services • Medical supplies and durable medical equipment Center for Health Care Rights April 2014

21. Medicare Home Health Benefits Medicare will pay only if all of the following conditions are met: Patient needs intermittent skilled nursing care, physical therapy or speech therapy; Patient is homebound; Physician determines patient needs home health and sets up a plan of care; and Home health agency providing the services is a Medicare provider. Center for Health Care Rights April 2014

22. Medicare Part B Benefits • Physician services • Ambulance • Outpatient speech, physical and occupational therapy • Medical equipment • Mental health services • Laboratory, x-rays, diagnostic tests • Preventive services (e.g., flu shots) Center for Health Care Rights April 2014

23. 2014 Medicare Part B Costs Center for Health Care Rights April 2014

24. Medicare Preventive Benefits • Free annual mammograms for women age 40 and over; • Screening pap smears and pelvic exams every two years; • Free colorectal cancer screening for persons age 50 or older; • Free flu and pneumococcal vaccines each year • Diabetic screening, supplies and self management services; Center for Health Care Rights April 2014

25. Medicare Preventive Benefits • Free annual prostate cancer screening for men over age 50; • Annual glucose screening for persons at-risk for glaucoma; • Cardiovascular disease blood tests; • A one time physical exam within the first 12 months of becoming eligible for Part B. • After the first year of Medicare eligibility, Medicare will also now pay for an annual wellness visit that will include a comprehensive risk assessment. Center for Health Care Rights April 2014

26. Medicare Part D Drug Plan Choices • Prescription Drug Plan (PDP) • Medicare Advantage Plan (MA-PD) Center for Health Care Rights April 2014

27. Prescription Drug Plan (PDP) • Obtain Medicare Part D coverage by enrolling in a PDP • Continue to use original Medicare to obtain Part A and B services Center for Health Care Rights April 2014

28. Medicare Advantage Plan (MA-PD) • Obtain Medicare Part D coverage by enrolling in a MA-PD • When you enroll into a MA-PD plan, you must receive all Medicare Parts A, B and D services from the plan Center for Health Care Rights April 2014

29. Types of Medicare Advantage Plans • MA Health Maintenance Organizations (HMOs) • MA Preferred Provider Organizations (PPOs) • MA Special Needs Plans (SNPs) • MA Private Fee For Service Plans (PFFSPs) • MA HMOs, PPOs and SNPs are all managed care plans Center for Health Care Rights April 2014

30. 2014 Medicare Part D Drug Coverage • Monthly premiums for 2014 Prescription Drug and Medicare Advantage plans range from $0 to $147 per month • The 2014 national base premium is $32.42 • Higher-income Medicare beneficiaries pay higher Part D premiums. Persons whose incomes are: • $85,000/individual • $170,000/couple • In 2014, the Part D annual deductible is no more than $310. (The deductible is the amount you pay before your drug plan starts to pay anything.) Center for Health Care Rights April 2014

31. 2014 Medicare Part D Drug Coverage • Initial Coverage Period After you pay your deductible, you pay 25% of the total retail cost of your prescription drugs until the total cost reaches $2,850 for the year • Coverage Gap When your total drug costs reach $2,851, you pay 47.5% of brand name prescription costs and 72% generic drug costs until the total cost reaches $ 6,455 • This gap in coverage is called the “doughnut hole” Center for Health Care Rights April 2014

32. Catastrophic Coverage Once your total drug costs are greater than $ 6,455, you pay $2.55 to $6.35, or 5% of the cost for each prescription drug By 2020, you will pay only a 25% copayment for prescriptions you fill when you are in the doughnut hole. Center for Health Care Rights April 2014

33. Medicare Part A and Part B Appeals Process Initial Determination Claim determinations made by intermediaries (Part A claims) and carriers (Part B claims). Center for Health Care Rights April 2014

34. Redeterminations made by the carriers and intermediaries. • Reconsiderations by Medicare Qualified Independent Contractors (QICs). • Administrative Law Judge Hearing A beneficiary must have at least $130 at issue to appeal to this level. • Medicare Appeals Council (MAC) • Federal District Court A beneficiary must have at least $1,300 at issue to appeal to this level. Center for Health Care Rights April 2014

35. Fast Track Appeals for Service Denials Medicare beneficiaries have the right to request a fast track appeal in certain situations when Medicare services are denied. Fast track appeals apply to: • Hospital discharges; and • Termination of skilled nursing facility and home health services. Center for Health Care Rights April 2014

36. Fast Track Appeals for Hospital Discharges Example: Client is being discharged from an acute care hospital because the hospital does not believe that a continued stay will be covered by Medicare. • If the client disagrees with the hospital’s decision, he/she has the right to receive a notice from the hospital that provides information on why the stay is no longer covered and his/her appeal rights. Center for Health Care Rights April 2014

37. The client has the right to fast track appeal and should contact the Quality Improvement Organization (QIO) as soon as possible. In California, the QIO is Health Services Advisory Group and the number to call is 1-800-841-1602. • Persons in a Medicare Advantage HMO have the right to a fast track review. Center for Health Care Rights April 2014

38. For questions about Medicare or other health insurance call the Center for Health Care Rights at 1-800-824-0780. Center for Health Care Rights April 2014