Basics of Medicare Center for Health Care Rights April
20141
Slide 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. 2Center for Health Care Rights April 2014
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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. 3Center for Health
Care Rights April 2014
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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.
4Center for Health Care Rights April 2014
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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. 5Center for Health Care Rights April 2014
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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 2014
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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 65 th 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. 7Center for Health Care Rights April 2014
Slide 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. 8 To apply for Medicare, contact the Social
Security Administration. 1-800-772-1213 www.socialsecurity.gov
Center for Health Care Rights April 2014
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Medicare Premiums for 2014 Automatic Enrollee Voluntary
Enrollee Part A (Hospital) No premium $426/month if less than 30
work quarters $234/month if 30-39 work quarters Part B (Medical)
$104.90/month 9Center for Health Care Rights April 2014
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Premium Penalties Part 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 2014
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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. 11Center for Health Care Rights April 2014
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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. 12Center for Health Care Rights April
2014
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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. 13Center for Health Care Rights April 2014
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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. 14 Do I Have to Apply for Medicare if I am Working and
Have Employer Insurance? Center for Health Care Rights April
2014
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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. 15 How Does Medicare Work with My
Employer Insurance? Center for Health Care Rights April 2014
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Medicare Coverage Part A Hospital Insurance Part B Medical
Insurance 16Center for Health Care Rights April 2014
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Medicare Part A Benefits Hospital Skilled Nursing Facility Home
Health Care Hospice 17Center for Health Care Rights April 2014
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18 Coverage Per Benefit Period* Hospital Days 1 - 60$1,216
first day deductible Days 61 - 90$304/day Days 91 150 (Lifetime
reserve days) $608/day Skilled Nursing Facility Days 1 - 20Covered
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 2014
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Part A Skilled 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). 19Center
for Health Care Rights April 2014
Slide 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 20Center for Health Care Rights April 2014
Slide 21
21 Medicare will pay only if all of the following conditions
are met: 1.Patient needs intermittent skilled nursing care,
physical therapy or speech therapy; 2.Patient is homebound;
3.Physician determines patient needs home health and sets up a plan
of care; and 4.Home health agency providing the services is a
Medicare provider. Medicare Home Health Benefits Center for Health
Care Rights April 2014
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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) 22Center for Health
Care Rights April 2014
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2014 Medicare Part B Costs 23 ServiceBeneficiary Cost Most Part
B Services $147 annual deductible 20% of Medicare-approved charges
15% excess charges Center for Health Care Rights April 2014
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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; 24Center for
Health Care Rights April 2014
Slide 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. 25Center for Health Care Rights
April 2014
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Medicare Part D Drug Plan Choices Prescription Drug Plan (PDP)
Medicare Advantage Plan (MA-PD) Center for Health Care Rights April
201426
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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 201427
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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 201428
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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 201429
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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.) 30Center for Health Care Rights April 2014
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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 31Center for Health Care Rights April
2014
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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 32 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
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Medicare Part A and Part B Appeals Process 33 Initial
Determination Claim determinations made by intermediaries (Part A
claims) and carriers (Part B claims). Center for Health Care Rights
April 2014
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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. 34Center for Health
Care Rights April 2014
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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. 35Center for Health Care Rights April
2014
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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 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. 36Center for Health Care Rights April 2014
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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. 37Center for
Health Care Rights April 2014
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For questions about Medicare or other health insurance call the
Center for Health Care Rights at 1-800-824-0780. 38 Center for
Health Care Rights April 2014