Basics of Medicare20152015

Center for Health Care RightsCenter for Health Care Rights

f l h h ( )Center for Health Care Rights(CHCR)A non profit advocacy organization that provides freeA non‐profit advocacy organization that provides free information and help with Medicare, Medi‐Cal  and other health insurance in Los Angeles County.g y

• We are not part of Medicare or any insurance company or health planhealth plan.

• Our services are funded primarily by the Health Insurance Counseling and Advocacy Program grant a program of theCounseling and Advocacy Program grant, a program of the Los Angeles City Department of Aging and the Los Angeles County Area Agency on Aging. 

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y g y g g

MedicareMedicare A federal health insurance program that was created to

provide a safety net for persons who are elderly (65 years p y p y ( yand older) or younger and disabled (under the age of 65) adults.

Eligibility for Medicare is not based upon income or Eligibility for Medicare is not based upon income or resources.

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Wh  i  Eli ibl  f  M di ?Who is Eligible for Medicare?

Automatic Enrollees (Eligible for Free Part A)

Age 65 and older entitled to Social Security Age 65 and older entitled to Social Security Retirement Benefits;

Age 65 and older and the spouse or former spouseAge 65 and older and the spouse or former spouse of someone entitled to Social Security or Railroad Retirement Benefits;

Under the age of 65 and has been receiving Social Security Disability for 24 consecutive months.

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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 benefitsSocial Security or Railroad Retirement benefits.

Have Amyotrophic Lateral Sclerosis (ALS) also k L G h i ’ di (i di id l ithknown 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.

Eli ibilit f M di b d 65Eligibility 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 mayincreased. Some of these individuals may become eligible for Medicare (at age 65) before they are eligible for full Social Security retirementretirement.

Eligibility for Medicare based on disabilityPersons receiving Social Security disability will receivePersons 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.the month they become eligible.

To apply for Medicare,To apply for Medicare, contact the Social Security Administration.

1-800-772-1213www socialsecurity govwww.socialsecurity.gov

Medicare Premiums for 2015Medicare Premiums for 2015Automatic VoluntaryAutomaticEnrollee

Voluntary Enrollee

$407/month

Part AH it l)

No premium

$407/month if less than 30 work

quarters

$224/ thHospital) $224/month if 30-39 work quarters

Part BMedical)

$104.90/month $104.90/month)

Premium Penalties

P t APart A(Hospital)

10% of premium for twice the number of years late.

Part B 10% for every year late, in (Medical) effect for life.

M di P t B d DMedicare Part B and D Premiums Based on IncomePremiums Based on Income

Higher income Medicare beneficiaries with annual incomes over $85,000 (single person) and over $170 000 (married couple) pay anand over $170,000 (married couple) pay an additional income related monthly premium for Medicare Parts B and D that is based on theirMedicare Parts B and D that is based on their income.

Medicare Enrollment Periods

itial Enrollment Periodegins 3 months before the month of Medicare eligibility nd ends 3 months after (7 months total)nd ends 3 months after (7 months total).eneral Enrollment Period anuary through March each year benefits are effectiveanuary through March each year, benefits are effective

ly 1st.pecial Enrollment Period pght month enrollment period that begins on the first day the month the beneficiary is no longer covered by an

l h lthmployer group health.

o I Have to Apply for o I Have to Apply for edicare if I am Working and 

l ?ave 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 Parthealth 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 orThis rule applies only if the employer has 20 or more employees.

o I Have to Apply for Medicare o I Have to Apply for Medicare  I am Working and Have mplo er Ins rance?edicare Eligible Persons – Under 65

mployer Insurance?

These individuals can delay their enrollment in Medicare Part B with no penalty for late enrollment.p y

This rule applies only if the employer has 100 or lmore employees.

How Does Medicare Work How Does Medicare Work with My Employer Insurance?

If a Medicare eligible person is covered by an employer health plan and he/she enrollsan employer health plan and he/she enrolls in Medicare, THE EMPLOYER PLAN WILL BE

PRIMARY AND MEDICARE SECONDARYPRIMARY AND MEDICARE SECONDARY.

Medicare Coverage

Part AHospital Insurance

Part BMedical InsuranceMedical Insurance

Medicare Part A Benefits

Hospital

Skilled Nursing Facility

Home Health Care

Hospice

015 Medicare Part A Co payments015 Medicare Part A Co‐paymentsCoverage Per Benefit Period*

Days 1 - 60 $1,260 first day deductible

Hospital Days 61 - 90 $315/day

Days 91 – 150(Lifetime reserve days)

$630/day (Lifetime reserve days)

Skilled NursingDays 1 - 20 Covered in full.

Skilled Nursing Facility Days 21 - 100 $157.50/day

*A “benefit period” begins the day a beneficiary is admitted to the hospital and ends when the *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

Medicare Part B Benefits

Physician servicesAmbulanceAmbulanceOutpatient speech, physical and occupational therapyp pyMedical equipmentMental health servicesLaboratory, x-rays, diagnostic testsPreventive services (e.g., flu shots)

015 Medicare Part B Co‐payments 

Service Beneficiary Cost

Outpatient

$147 annual deductible

Outpatient Medical Care 20% of Medicare-

approved charges

15% excess charges formost unassigned claims

Medicare Supplement PoliciesMedicare Supplement Policies“Medigaps”

Medigap policies are private health insurance policies that cover some of the costs not covered by Medicare.

Medigaps supplement your original Medicare g p pp y gbenefits by paying for some or all of the Medicare co-payments and deductibles.

Some Medigaps also cover benefits not covered by Medicare such as emergency medical care received outside the United States.

Medicare Preventive BenefitsMedicare Preventive BenefitsFree annual mammograms for women age 40 and over;Screening pap smears and pelvic exams every two years;years;Free colorectal cancer screening for persons age 50 or older;Free flu shots each year;Diabetic screening, supplies and self management services;services;

Medicare Preventive BenefitsMedicare Preventive Benefitsee annual prostate cancer screening for men over

ge 50;

nnual glucose screening for persons at-risk for aucoma;

ardiovascular disease blood tests;

one time physical exam within the first 2 months of becoming eligible for Part B.g g

fter the first year of Medicare eligibility, Medicare ll also now pay for an annual wellness visit that will p yclude a comprehensive risk assessment.

Medicare Part D Drug Plan Choices

Prescription Drug PlanPrescription Drug Plan (PDP)

Medicare Advantage Plan (MA-PD)(MA PD)

Prescription Drug Plan (PDP)

Obtain Medicare Part D coverage by enrolling incoverage by enrolling in a PDP

Continue to use original Medicare to obtain Part A d B iA and B services

edicare Advantage Plan (MA‐PD)

Obtain Medicare Part D coverage by enrolling in a MA PDMA-PD

When you enroll into a MA-PD plan, you must receive all Medicare Partsreceive all Medicare Parts A, B and D services from the plan

 I H    E ll i    P  D Pl ?Enrollment is voluntary.

o I Have to Enroll in a Part D Plan?y

If you have drug coverage that is equal to or better than the standard Medicare drug benefit you do not have to enroll into a Medicare drug plan.

If you have no drug coverage, there is a penalty for late enrollment into a Part D plan.

The penalty is 1% of the base premium for each d thuncovered month.

The 2015 national base premium is p$33.13

015 Medicare Part D Drug Coverage015 Medicare Part D Drug CoverageIn 2015, the Part D annual deductible* is no more than $320.

Initial Co erage Period

*(The deductible is the amount you pay before your drug plan starts to pay anything.)

Initial Coverage PeriodAfter you pay your deductible, you pay 25% of the total retail cost of your prescription drugs until the total cost reachescost of your prescription drugs until the total cost reaches $2,960 for the year.

Coverage GapWhen your total drug costs reach $2,960, you pay 45% of brand name prescription costs and 65% generic drug costs until the total cost reaches $ 6 680until the total cost reaches $ 6,680. This gap in coverage is called the “doughnut hole”

Catastrophic Coverage

Once your total drug costs are greater than $ 6 680Once your total drug costs are greater than $ 6,680, you pay $2.65 to $6.60, or 5% of the cost for each prescription drug

By 2020 you will pay only a 25%By 2020, you will pay only a 25% copayment for prescriptions you fill when

you are in the doughnut hole.y g

Medicare Part A and Part B Medicare Part A and Part B Appeals Process

Initial Determination

Redeterminations

Reconsiderations

Administrative Law Judge Hearing

C ( C) Medicare Appeals Council (MAC)

Federal District Court

Fast Track Appeals Fast Track Appeals for Service Denials

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

Hospital discharges; and Termination of skilled nursing facility and home g y

health services.

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

Medicare andMedicare and Veterans Affairs (VA) Benefits

You can ha e both Medicare and Veterans Affairs (VA) You can have both Medicare and Veterans Affairs (VA) benefits.However  Medicare and VA benefits do not work However, Medicare and VA benefits do not work together. Medicare does not pay for any care that you receive at a p y y yVA facility. In order for Medicare to cover your care, you must use M di   d f iliti   d  idMedicare approved facilities and providers.

In order for your VA coverage to cover your care, you must generally receive health care services at a VA facility  generally receive health care services at a VA facility. 

di dMedicare Part B and VA CoverageYou may use your VA health benefits to get coverage for You may use your VA health benefits to get coverage for health care services and items not covered by Medicare.

However  you may want to consider enrolling into However, you may want to consider enrolling into Medicare Part B, even if you have VA coverage.

Part B may cover services you receive from Medicare Part B may cover services you receive from Medicare providers and provide you with medical coverage outside the VA health system.

n addition, if you do not enroll into Part B when you are first eligible to do so, you will most likely incur a 

lPart B premium penalty .

Medicare Part D and VA CoverageMedicare Part D and VA Coverageou may only use your VA drug coverage to get your 

medications, since VA drug coverage may offer more generous g g y grescription drug coverage than Medicare Part D. 

A drug coverage is considered creditable, meaning it is as good    b tt  th  th  M di   i ti  d  b fit    s or better than the Medicare prescription drug benefit, you an delay enrolling into Medicare Part D without penalty.

 you do lose VA drug coverage, make sure you enroll into a Part  you do lose VA drug coverage, make sure you enroll into a Part  plan within 63 days of losing your VA benefits.

ote that although you can have both Medicare Part D and VA rug coverage, the two do not work together. 

 you have questions about VA benefits and coverage, contact he VA Health Administration Center at 1 800 733 8387 or 1 877he VA Health Administration Center at 1‐800‐733‐8387 or 1‐877‐22‐VETS (877‐222‐8387).

For questions about Medicare orqother health insurance call:

Center for Health Care Rights at

8 8 81‐800‐824‐0780