PowerPoint Presentation

Basics of MedicareCenter for Health Care Rights April 20141

1Center 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.2Center for Health Care Rights April 2014We 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.

3Center for Health Care Rights April 2014MedicareA 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.

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Center for Health Care Rights April 2014Who 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.5Center for Health Care Rights April 20145 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 Gehrigs 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.6Center for Health Care Rights April 20146 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 forpersons 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.

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Center for Health Care Rights April 20147 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.

8To apply for Medicare, contact the Social Security Administration.1-800-772-1213www.socialsecurity.gov Center for Health Care Rights April 20148Medicare Premiums for 2014Automatic EnrolleeVoluntary EnrolleePart A(Hospital)No premium$426/month if less than 30 work quarters$234/month if 30-39 work quartersPart B(Medical)

$104.90/month$104.90/month9Center for Health Care Rights April 2014Premium PenaltiesPart A(Hospital)10% of premium for twice the number of years late.Part B(Medical)

10% for every year late, in effect for life.

10Center for Health Care Rights April 2014Medicare Part B and D premiums based on IncomeHigher 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.11Center for Health Care Rights April 2014Medicare Enrollment PeriodsInitial Enrollment PeriodBegins 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.12

Center for Health Care Rights April 2014Do I Have to Apply for Medicare if I am Working and Have Employer Insurance?Medicare Eligible Persons Age 65Persons 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.13

Center for Health Care Rights April 2014Medicare 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.14Do I Have to Apply for Medicare if I am Working and Have Employer Insurance?

Center for Health Care Rights April 2014 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.15How Does Medicare Work with My Employer Insurance?

Center for Health Care Rights April 2014Medicare CoveragePart AHospital InsurancePart BMedical Insurance16

Center for Health Care Rights April 2014Medicare Part A Benefits Hospital

Skilled Nursing Facility

Home Health Care

Hospice17

Center for Health Care Rights April 201418Coverage Per Benefit Period*HospitalDays 1 - 60$1,216 first day deductible Days 61 - 90$304/dayDays 91 150(Lifetime reserve days)$608/day Skilled Nursing FacilityDays 1 - 20 Covered in full.Days 21 - 100 $152/day*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 2014Part ASkilled Nursing Facility Coverage Requirements for coverage:Three day prior hospital stay;SNF stay must be ordered by physician;SNF must be Medicare certified; andYou must need skilled care on a daily basis (minimum five times a week).19Center for Health Care Rights April 2014Medicare Home Health Benefits If you meet the Medicare requirements, Medicare will pay for the same type of servicereceived in a Skilled Nursing Facility at home:Nursing carePhysical therapySpeech therapyOccupational therapyMedical social servicesHome health aide servicesMedical supplies and durable medical equipment 20Center for Health Care Rights April 201421Medicare 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; andHome health agency providing the services is a Medicare provider.Medicare Home Health Benefits Center for Health Care Rights April 2014Medicare Part BBenefitsPhysician servicesAmbulanceOutpatient speech, physical and occupational therapyMedical equipmentMental health servicesLaboratory, x-rays, diagnostic testsPreventive services (e.g., flu shots)22

Center for Health Care Rights April 20142014 Medicare Part B Costs

23ServiceBeneficiary CostMost Part B Services$147 annual deductible

20% of Medicare-approved charges15% excess chargesCenter for Health Care Rights April 2014Medicare Preventive BenefitsFree 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 yearDiabetic screening, supplies and self management services;

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Center for Health Care Rights April 2014Medicare Preventive BenefitsFree 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.

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Center for Health Care Rights April 2014Medicare Part D Drug Plan ChoicesPrescription Drug Plan (PDP)

Medicare Advantage Plan (MA-PD)Center for Health Care Rights April 201426

26Prescription Drug Plan (PDP)Obtain Medicare Part D coverage by enrolling in a PDP

Continue to use original Medicare to obtain Part A and B servicesCenter for Health Care Rights April 201427

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

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Types of Medicare Advantage PlansMA 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 plansCenter for Health Care Rights April 201429

2014 Medicare Part D Drug CoverageMonthly premiums for 2014 Prescription Drug and Medicare Advantage plans range from $0 to $147 per monthThe 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.)

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Center for Health Care Rights April 20142014 Medicare Part D Drug CoverageInitial Coverage PeriodAfter 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 GapWhen 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 $ 6,455This gap in coverage is called the doughnut hole

31Center for Health Care Rights April 2014 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

32By 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 201432Medicare Part A and Part B Appeals Process33

Initial DeterminationClaim determinations made by intermediaries (Part A claims) and carriers (Part B claims).Center for Health Care Rights April 2014 Redeterminations made by the carriers and intermediaries.

Reconsiderations by Medicare Qualified Independent Contractors (QICs).

Administrative Law Judge HearingA beneficiary must have at least $130 at issue to appeal to this level.

Medicare Appeals Council (MAC)

Federal District CourtA beneficiary must have at least $1,300 at issue to appeal to this level.34Center for Health Care Rights April 2014Fast Track Appeals for Service DenialsMedicare 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.35Center for Health Care Rights April 2014Fast Track Appeals for Hospital DischargesExample: 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 hospitals 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.36

Center for Health Care Rights April 2014The 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.37Center for Health Care Rights April 2014For questions about Medicare or other health insurance call the Center for Health Care Rights at1-800-824-0780.38Center for Health Care Rights April 2014