Medicare: An Overview

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Medicare:

An Overview

This special regional educational effort is supported by funding provided by the California HealthCare Foundation

Presented by Elaine Wong Eakin Project Manager

California Health Advocates

Our Focus

California Health Advocates is dedicated to Medicare beneficiary advocacy and education for Californians. | Policy – Public policy research and recommendations for improved

rights and protections, partner with national Medicare organizations based in Washington D.C.

| Training – Professionals and informal helpers, vibrant web

resources, newsletter and regional forums

| Advocacy – Bring the experience of Medicare beneficiaries to the

public through media and educational campaigns with the legislative staff at federal and state levels.

www.cahealthadvocates.org

Overview

|What is Medicare?

|Who is eligible for Medicare?

|What are the different parts of Medicare: A,

B, C and D?

|Who can enroll and when can one enroll?

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What is Medicare?

|Federal health care insurance program. |For people 65 years and older, and people

younger than 65 years old with disabilities.

|No income requirements to be eligible. |Administered by the Centers for Medicare

and Medicaid Services.

|Part A and Part B enrollment handled by

the Social Security Administration.

Medicare card

What is Medi-CAL?

| State and federally funded health care program. | For people with lower or limited income and

resources/assets. To qualify, must meet resource requirements.

| Unlike Medicare, no age or disability requirements.

| Administered by the state Dept. of Health Care Services:

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Who is eligible for Medicare?

| Person 65 years or older or

| Person younger than 65 years old and ¾ has a disability and have been collecting Social

Security disability insurance (SSDI) for at least 24 months,

• Exception: ALS (amyotrophic lateral sclerosis), a.k.a. Lou Gehrig’s disease, no waiting period; OR

¾ has kidney failure (end stage renal disease)

In addition person is | a U.S. citizen or

| a permanent resident and has lived in the U.S. for 5 consecutive years.

The ABCD’s of Medicare

|Part A – Hospital Insurance

|Part B – Outpatient Medical Insurance

|Part C – Medicare Advantage plans

|Part D – Prescription Drug plans

Original Medicare Part A Hospital Insurance Deductible=$1024 Part B Outpatient Medical Services Premium=$96.40 Deductible=$135 Coinsurance=20% Part C Medicare Advantage Plans Must have Parts A+B Part D Rx drug Plans Must have Part A or B

Thumbnail sketch of Medicare

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Medicare Part A Covers

|Inpatient Hospital Care

|Psychiatric Hospital Care |Skilled Nursing Facility |Home Health Care

zintermittent skilled care prescribed by doctor |Hospice

zpain management program for terminally ill |Blood (after the first 3 pints, received during

hospital or SNF stay)

Medicare Part A Costs

|Monthly PREMIUM:

zIf you are 65 years or older

•$0 if you or your spouse worked 40 or more quarters.

Automatic enrollment.

•$233 if you worked 30-39 quarters. Voluntary enrollment.

•$423 if you worked fewer than 30 quarters. Voluntary

enrollment.

zIf you are younger than 65 years old with a

disability

•FREE if you have been receiving SSDI for 24 months.

|DEDUCTIBLE= $1024 for first day of hospital

stay

|COPAYMENTor COINSURANCE

Medicare Part B Covers

Outpatient Medical Services

Examples of Part B services:

|Mental health visits (limitation) |Outpatient physical, occupational,

speech therapy (limitation)

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What Medicare Part B Does Not

Cover

|Routine physical exams (except for a one-time “Welcome

to Medicare” physical exam)

|Routine dental care |Routine eye exams |Routine hearing care

|Routine foot care (some foot care for people with diabetes) |Acupuncture

|Cosmetic surgery

|Long term care, such as custodial care

Enrollment for Part B

| Medicare Part B is voluntary, but Social Security

Administration automatically enrolls you if you are entitled to Part A. If you do not want Part B, you must notify SSA.

| Three periods to enroll in Part B if you are not

automatically enroll :

1.Initial Enrollment Period (IEP)

2.General Enrollment Period (GEP) 3.Special Enrollment Period (SEP)

Part B Initial Enrollment Period

| Initial Enrollment Period (IEP) – 7-month period

zBegins 3 months before month of eligibilityand

ends 3 months after month of eligibility. | Month of eligibility= month of 65thbirthday or

25th_{month of receiving SSDI. Benefits effective} the first day of the month of eligibility.

| Example: 65thbirthday on October 13. Month of

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Part B General Enrollment Period

|January 1 through March 31 each year |Coverage effective the following July 1 |Late enrollment penalty added to premium

z10% of current Part B premium for each full

12-month period when person was eligible but delayed enrollment.

zPenalty imposed for as long as beneficiary has

Part B.

zException: People, including spouses, who are

currently working and covered by employer plan.

Part B Special Enrollment Period

| People who are currently working and covered

by employer plan may delay enrollment in Part B. Includes spouses who are covered by employer plan.

| Special Enrollment Period (SEP)

z8-month period beginning the 1st_{day of 1}st_month after employment or group health plan coverage ends, whichever comes first.

| No late enrollment penalty in this situation if you

enroll during SEP.

Medicare Part B Costs

| Medicare Part B is voluntary. If beneficiary wants

Part B, must pay for it.

| Standard monthly PREMIUM= $96.40 (2008) if

annual income is less than $82,000 for an individual, and less than $164,000 for a couple.

zRegardless of how many quarters you worked.

| Annual DEDUCTIBLE= $135 (2008) | COINSURANCE

zExample: For most Part B services, Medicare pays

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Medicare Summary Notice

(MSN)

| The MSN is an Explanation of Benefits. | The MSN lists Part A and Part B services

requested by beneficiary.

| The MSN lists which services were covered by

Medicare and which were not.

| Important to check for fraud detection. | Can access on www.medicare.govor

http://mymedicare.gov.

| Call 1-800-MEDICARE (633-4227) if you have

questions.

Dually eligible for

Medicare and Medi-CAL

|Medi-CAL is usually the payer of last

resort.

|For beneficiary who is dually eligible

and has no other insurance, Medi-CAL pays after Medicare pays.

|Dually eligible beneficiary must go to

providers who accept both Medicare and Medi-CAL.

Medicare Part D

| New as of January 1, 2006.

| Covers most drugs that may be dispensed only by prescription, both brand name and generic drugs.

| Drugs NOT covered under Part D include: zDrugs for anorexia, weight loss, or weight gain

zDrugs for cosmetic purposes or hair growth

zDrugs for symptomatic relief of cough and colds

zOver-the-counter drugs, e.g. aspirin, colace

zPrescription vitamin and mineral products

zBarbiturates

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Medicare Part D

(cont.)

| Drugs NOT covered under Part D maybe covered by Medi-CAL:

zDrugs for symptomatic relief of cough and colds

zOver-the-counter drugs, e.g. aspirin, colace zPrescription vitamin and mineral products

zBarbiturates

zBenzodiazepines

| Part D plans have different formularies, i.e., cover different drugs.

| Medi-CAL will NOT pay copayments of Part D plans.

Medicare Part D

Eligibility and Enrollment

| Eligibility – Beneficiary must have Part

A, or Part B, or both Parts A and B.

| Enrollment Periods

1. Initial Election Period – 7 months for newly eligible beneficiaries.

2. Annual Election Period – November 15 to December 31 of each year.

3. Special Enrollment Period

Part D

Initial Election Period

|7 months for newly eligible beneficiaries

zBegins 3 months before month of eligibility and

ends 3 months after month of eligibility.

zMonth of eligibility (month of 65thbirthday or

25th_{month of receiving SSDI.)}

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Late enrollment penalty (LEP)

| Penalty imposed when client was eligible, did not

have creditable coverage, and did not sign up for a Medicare Part D plan.

| Penalty = 1% of national base premium for every

month beneficiary delayed enrollment.

| Penalty not imposed if

zBeneficiary had creditable prescription drug

coverage OR

zBeneficiary is eligible for low-income subsidy (a.k.a. extra help.)

Medicare Part D

Special Enrollment Periods

(SEP)

| Certain situations give beneficiaries a Special

Enrollment Period to enroll, change or disenroll from Medicare Part D plans outside of IEP and AEP. Examples:

zBeneficiary has creditable prescription drug

coverage from employer health plan, which is terminating.

zBeneficiary relocates to an area not served by his/her Medicare Part D plan.

zBeneficiary qualifies for the LIS.

Medicare Part D Costs 2008

(standard plan)

| Monthly premium ranges from $14.30 to $102.70. | Deductible ≤ $275

| Cost-sharing (copayment or coinsurance)

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Low Income Subsidy (LIS)

a.k.a. Extra Help

|Helps pay for premium, deductible and

copayments for Medicare Part D.

|Administered by Social Security Administration. |Some people automatically qualify: those who

have full Medi-CAL benefits.

|People who do not automatically qualify may

apply on their own through Social Security (e.g. people who have Medi-CAL with SoC.)

|Eligibility is reviewed every year.

Low Income Subsidy (LIS)

a.k.a. Extra Help

(cont.)

|

Beneficiaries who qualify for the LIS

have an

ongoing

SEP, meaning

they can change plans once a

month,

anytime during the year

.

|

Beneficiaries who qualify for the LIS

are not subject to the coverage gap

(“doughnut hole.”)

Income and asset/resource

limits to qualify for the LIS

Assets/resources Annual income Monthly income $23,970* <$11,990* <$21,000 <$15,600 <$1,750 <$1,300 Couple Individual

* Includes $1,500 for burial expenses per person.

|Depending on income and asset levels,

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Full vs. Partial Subsidy

≤$2.25 generic ≤$5.60 brandname 15% ≤$1.05 generic ≤$3.10 brandname Cost-sharing $56 $0 Deductible $0 or discounted $0 Premium Partial Subsidy recipients pay Full subsidy recipients pay

Benchmark plans

| Benchmark plans are Medicare Part D plans with premiums

at or below the state’s weighted average premium.

| In 2008, there are 9 benchmark plans below the CA benchmark premium of $19.80.

http://cahealthadvocates.org/

| If a LIS recipient enrolls in a benchmark plan, he/she does

not pay the premium or deductible.

| A LIS recipient may choose other Part D plans. If he/she chooses a Medicare Part D plan that is not a benchmark plan, he/she pays the balance of costs after the subsidy has been deducted.

What are Medicare

Advantage Plans?

| Medicare Advantage plans are Medicare Part C. | Medicare contracts with private companies to offer

plans to Medicare beneficiaries.

| All MA plans include hospital (Part A) and medical (Part B) benefits.

| When you join a Medicare Advantage plan, it

becomes your Medicare or replaces Original Medicare.

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Types of Medicare Advantage

Plans

|

Five types of Medicare Advantage

plans:

zHMO (Health Maintenance Organization zPPO (Preferred Provider Organization) zPFFS (Private Fee For Service) zMSA (Medical Savings Account)

zSNP (Special Needs Population, e.g. for

those who have Medicare and Medi-CAL)

MA Special Needs Plans

|Designed for populations with specialized

needs

zCertain chronic disease and conditions zDually eligible

zIn certain institutions |Special Needs Plans cover

zHospital benefits (Part A)

zOutpatient medical benefits (Part B) and

zPrescription drug benefit (Part D)

Medicare Part C

SNP Eligibility

| Beneficiary must have both Part A and

Part B.

| Reside in the plan’s service area. | Meet the criteria of the target population.

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Medicare Part C

Enrollment Periods

1. Initial Election Period – 7 months for

newly eligible beneficiaries.

2. Annual Election Period – November 15

to December 31 of each year.

3. MA Open Enrollment Period – January

1 to March 31.

4. Special Enrollment Period – ongoing

SEP for dually eligible beneficiaries.

Medicare Advantage plan costs

|SNPs for dually eligible beneficiaries

zAll costs should be covered except for Medicare Part D plan copayments (same as for M+M beneficiary in fee-for-service.)

|MA plans that are not SNPs

zM+M beneficiary will have to pay premium, deductible and coinsurance if they choose to join. Medi-CAL will NOT pay for any of these costs.

MA Plan Marketing Alert!

|Options for beneficiaries with Medicare

and full benefit Medi-CAL:

zOriginal Medicare + fee-for-service Medi-CAL or

zMedicare Advantage SNP.

|Do NOT need to join Medicare Advantage

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Other LIS recipients and MA plans

|LIS recipients who do not have Medi-CAL

can join Medicare Advantage plans.

|The LIS will help pay for some or all of the

premium and deductible for the

prescriptiondrug benefit (depending on

the subsidy level and plan chosen.)

|Beneficiary will be responsible for the

premium, deductible and copayments for the medical and hospitalbenefits.

Medicare Appeals – Part A

and Part B

1. Redetermination by company that handles

Medicare claim (Medicare Administrative Contractor)

2. Reconsideration by Qualified Independent

Contractor

3. Hearing by an Administrative Law Judge

(amount in controversy ≥$120)

4. Review by Medicare Appeals Council 5. Federal court review (amount in controversy

≥$1,180)

| Details in CMS Pub. 11316, www.medicare.gov

Medicare Part D Appeals

| If plan will not cover a drug, beneficiary can

request a coverage determination. If plan still decides not to cover the drug, then appeal.

1. Redetermination by Part D plan. 2. Review by Independent Review Entity

(reconsideration)

3. Hearing by an Administrative Law Judge (amount in controversy ≥$120)

4. Review by Medicare Appeals Council 5. Federal court review (amount in controversy

≥$1,180)

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Medicare Part C Appeals

| If beneficiary asks the MA plan to provide or pay

for a service, and the plan denies the request, the beneficiary can appeal the decision.

1. Reconsideration by the Medicare Advantage plan 2. Review by Independent Review Entity

3. Hearing by an Administrative Law Judge (amount in

controversy ≥$120)

4. Review by Medicare Appeals Council

5. Federal court review (amount in controversy ≥$1,180) | Details in CMS Pub. 11312, www.medicare.gov

Where to find answers

|1-800-MEDICARE, www.medicare.gov |Social Security Administration, 1-800-772-1213

www.ssa.gov

|HICAP, 1-800-0222 (statewide)

www.cahealthadvocates.org

| California Dept. of Health Care Services (Medi-Cal) 1-916-636-1980

http://www.dhcs.ca.gov/services/medi-cal/Pages/default.aspx

Contact Information

|California Health Advocates

• Oakland satellite office– (510) 268-8030

464 7th_{Street, Oakland, CA 94607}

Elaine Wong Eakin, [email protected]

• Sacramento HQ– (916) 231-5110

5380 Elvas Avenue, Suite 104, Sacramento, CA 95819

|Websites:

www.cahealthadvocates.org(Professionals)