Medicare and Medi-Cal Eligibility and Benefits

Medicare and Medi-Cal Eligibility and Benefits

Center for Health Care Rights

Center for Health Care Rights 2016 2

Center for Health Care Rights (CHCR)

• A non-profit organization that provides free education and help with Medicare, Medi-Cal and health insurance

• CHCR is not part of the Medicare program and does not endorse or recommend any insurance company or Medicare Advantage plan

• CHCR services are funded by the Los Angeles City Department of Aging and the Los Angeles County Area Agency on Aging HICAP grants

Medicare• A federal health insurance program providing a health care

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.



Disabled Adult Children Eligible for SSDI and Medicare

• Disabled adult children can qualify for Social Security Disability Insurance (SSDI) under a parent’s eligibility for Social Security benefits

• The adult child must be age 18 or older• The parent must be retired (age 62 or older),

disabled or deceased• After receiving SSDI for 24 months, the adult

child is eligible for Medicare


2016 Medicare Part B Premium• In 2016, the Medicare Part B premium is

$104.90 per month for most Medicare beneficiaries.

• Persons who are newly eligible for Medicare in 2016 pay $121.80 per month for Part B.

Medicare Enrollment

Periods• Initial Enrollment Period

Begins 3 months before the month of Medicare eligibility and ends 3 months after (7 months total).

• General Enrollment Period January through March each year, benefits are effective July 1st.

• Special Enrollment Period Eight month enrollment period that begins on the first day of the month the beneficiary is no longer covered by an employer group health.



How Medicare Coordinates with Employer Based

InsuranceFor Medicare beneficiaries who are under the age of

65, the employer plan is primary and Medicare is secondary when-

• The younger disabled Medicare beneficiary is covered by a employer health plan that has 100 or more employees and

• The employer plan coverage is based on the beneficiary’s current employment status or the current employment status of a family member (e.g., spouse, parent)


Medicare Beneficiaries With EGHP Coverage Can Delay

Medicare Enrollment • When younger, disabled Medicare beneficiaries are

covered by an employer health plan that meets Medicare requirements (see previous slide), they have the right to delay their enrollment in Medicare Part B.

• They can delay their Medicare enrollment until they or the family member who is providing the employer based health coverage stops working and the employer health plan coverage terminates.


• Once the employer health plan coverage ends, Medicare provides an 8 month enrollment period to enroll into Medicare Part B.

• Under this special enrollment period, there is no penalty for late Medicare enrollment.

Medicare Part A Benefits • Hospital

• Skilled Nursing Facility

• Home Health Care

• Hospice


2016 Medicare Part A Co-payments


Coverage Per Benefit Period*

Hospital

Days 1 - 60 $1,288 first day deductible

Days 61 - 90 $322/day

Days 91 – 150(Lifetime reserve days)

$644/day

Skilled Nursing Facility

Days 1 - 20 Covered in full.

Days 21 - 100 $161/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.

Part ASkilled Nursing Facility

Coverage Requirements for coverage:• 3 days 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 5 times a week).



You must meet all of the following requirements:

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; and4. Home health agency providing the services is a

Medicare provider.

Medicare Home Health Benefits


Medicare Part B Benefits• Physician services• Ambulance• Outpatient physical, occupational and speech

therapy• Medical equipment• Mental health services• Laboratory, x-ray, diagnostic tests• Preventive services (e.g., flu shots)Part B copayments – annual Part B deductible of

$166 and 20% copayments

Fast Track Appeals for Service Denials

All Medicare beneficiaries have the right to request a fast track appeal in the following situations:

– Hospital discharges; and – Termination of skilled nursing facility and home health

services.

To request a fast track appeal contact Livanta LLC, the Quality Improvement Organization (QIO) at 877-588-1123.



Medicare Part D Drug Coverage

• Prescription drug plan (PDP)Obtain Medicare Part D drug coverage by enrolling

into a PDP planContinue to use original Medicare for Part A and B

services• Medicare Advantage drug plan (MAPD)

When you enroll into a MAPD plan you assign your Medicare A, B and D benefits to the plan

You obtain all your medical care from plan providers

2016 Medicare Part D Drug Coverage

• Initial Coverage Period Part D annual deductible is no more than $360

After you pay your deductible, you pay 25% of the total retail cost of your prescription drugs until the total cost reaches $3,310 for the year

• Coverage GapWhen your total drug costs reach $3,310, you pay 45% of brand name prescription costs and 58% generic drug costs until the total cost reaches $7,062.50 This gap in coverage is called the “doughnut hole”


• Catastrophic Coverage

Once your total drug costs are greater than $7,062.50, you pay $2.95 to $7.40, or 5% of the cost for each prescription drug



Gaps in Medicare Coverage

• Medicare copayments and deductibles• No dental care• No custodial nursing home or personal care

services at home• No routine podiatry (only for diabetics)• No acupuncture


Medi-Cal Eligibility -- SSI• Elderly and younger disabled persons who receive

Supplemental Security Income (SSI) are automatically entitled to Medi-Cal

SSI Income Limits SSI Resource LimitsSingle $889 $2000

Married $1499$3000– Resources not counted include: your home, one car,

personal belongings– Apply at Social Security Administration


Medi-Cal Eligibility Aged and Disabled Federal

Poverty Level Program• California’s Medi-Cal program for elderly and younger disabled

persons whose incomes are too high for SSI

• Apply at L.A. County Dept. of Public Social ServicesIncome Resources

Single $1240 $2000

Married $1645 $3000

Resource rules same as SSI

Medi-Cal with a Share-of-Cost

• A program for persons whose income is too high to qualify for the Aged and Disabled Federal Poverty Level Program

• This program uses SSI asset limits

– Assets must be $2,000 or less if you are single and $3,000 or less if you are married

– Assets like the home and one car are not counted


The share of cost works like an insurance deductible

You must meet the share of cost each month before Medi-Cal pays your medical expenses

Example: If your Medi-Cal Share of Cost is $800, you are responsible for $800 of medical expenses before Medi-Cal pays


How Does the Share-of-Cost Work (SOC)?


Medi-Cal Benefits• Hospital care• Doctor services• Prescription drugs• Ambulance• Lab, x-rays• Emergency services• Mental health

• Hearing aids• Dental care• Vision services• Non-emergency medical

transportation• Long Term Services and

Supports– Nursing home care– Adult day health care (CBAS)– IHSS– Home and community based

services


Medi-Cal Managed Care• Most persons who have Medi-Cal are required to enroll into a Medi-Cal

managed care plan

• Populations excluded from mandatory Medi-Cal managed care Under age 21 Live in a VA nursing home Live in a ICF/DD facility Persons with other insurance (EGHP, retiree coverage, VA) Medi-Cal share of cost and not using MLTSS services

• Persons who have only Medi-Cal can request a medical exemption to stay in fee for service Medi-Cal; persons who have Medicare and Medi-Cal do not qualify for a medical exemption


Los Angeles County Medi-Cal Managed Care Plans

• LA Care -- partner plans: Care 1st, Blue Cross, Kaiser

• Health Net-- partner plan: Molina


Coordination of Medi-Cal with Other Health Coverage

Medi-Cal guidelines that apply when a Medi-Cal beneficiary has other health coverage –

• The other health coverage (OHC) pays as the primary insurance primary for any benefits provided by the OHC and Medi-Cal

• When the beneficiary has other health coverage, s/he is excluded from enrollment in a Medi-Cal health plan


Coordination of Medicare with Medi-Cal

• Medicare is primary and Medi-Cal is the secondary insurance

• Medi-Cal pays the Medicare Part B premium for persons with full Medi-Cal

• Persons who are dually eligible for Medicare and full Medi-Cal cannot be balanced billed for Medicare copays and deductibles


Coordination of Medicare with a Medi-Cal health plan

• Medicare is the primary payer and the beneficiary can see any Medicare provider

• The Medicare provider does not have to contract with the Medi-Cal plan or request authorization from the Medi-Cal plan

• The Medi-Cal plan is the secondary insurance and is billed for the Medicare copays

• Medicare providers cannot balance bill dual eligibles for the Medicare copayments


Access to Medi-Cal Benefits Requires Authorization from a

Medi-Cal health plan• Medi-Cal plans will require prior

authorization to access Medi-Cal benefits e.g., adult day health care (CBAS), Medi-Cal nursing home care or incontinence supplies

• Authorization process generally delegated by the plan to the contracting medical group


Medicare Part D and Medi-Cal• Persons with Medicare and full Medi-Cal (dual

eligibles) must enroll into a Medicare drug plan• If they do not select a drug plan, Medicare will

assign them to a plan• Temporary drug coverage for duals not in a Part

D plan – LiNet Humana• Part D copayments -- $1.20 generic and $3.60

brand name; dual eligible nursing home residents pay zero copays

• Subsidized Part D plans are zero premium


For Help with Medicare

Call Center for Health Care Rights

1-800-824-0780

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Medicare and Medi-Cal Eligibility and Benefits