medicare 2016

PowerPoint Presentation

2016 MedicareCenter for Health Care Rights :: January 20161

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Center for Health Care Rights (CHCR)Center for Health Care Rights :: January 20162A non-profit advocacy organization that provides FREE information and help with Medicare, Medi-Cal and other health insurance in Los Angeles County.

We are NOT part of Medicare or any insurance company or health plan.

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

MedicareA 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.

Center for Health Care Rights :: January 20163

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;Under the age of 65 and has been receiving Social Security Disability for 24 consecutive months.Center for Health Care Rights :: January 20164

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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.Center for Health Care Rights :: January 20165

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2016 Medicare Part B PremiumIn 2016, the Medicare Part B premium is $104.90/month for 70% of the Medicare population because there is no Social Security Cost of Living Adjustment (COLA) in 2016.30% of the Medicare population pay the higher Part B premium of $121.80/month. Beneficiaries who pay the higher amount are:New Medicare beneficiaries


Beneficiaries not receiving Social Security benefitsHigh income beneficiaries who also pay an income related surcharge based only on their incomesIncome Single Person: > $85,000/yearIncome Married Couple: > $170,000/yearCenter for Health Care Rights :: January 20167

Medicare Enrollment PeriodsInitial Enrollment PeriodBegins 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.Center for Health Care Rights :: January 20168

Do 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.Center for Health Care Rights :: January 20169

Do I Have to Apply for Medicare if I am Working and Have Employer Insurance?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.Center for Health Care Rights :: January 201610

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.Center for Health Care Rights :: January 201611How Does Medicare Work with My Employer Insurance?

Medicare Coverage

Part AHospital InsurancePart BMedical InsuranceCenter for Health Care Rights :: January 201612

Medicare Part A Benefits Hospital

Skilled Nursing Facility

Home Health Care

HospiceCenter for Health Care Rights :: January 201613

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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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.

Center for Health Care Rights :: January 201615To apply for Medicare, contact the Social Security Administration.1-800-772-1213www.socialsecurity.gov

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2016 Medicare Part A Co-paymentsCenter for Health Care Rights :: January 201616Coverage Per Benefit Period*HospitalDays 1 - 60$1,288 first day deductible Days 61 - 90$322/dayDays 91 150(Lifetime reserve days)$644/day Skilled Nursing FacilityDays 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; andYou must need skilled care on a daily basis (minimum 5 times a week).Center for Health Care Rights :: January 201617

What Medicare Will Cover in a Skilled Nursing Facility

Medicare pays for skilled nursing and therapy services.

Medicare will not pay for custodial care unless daily skilled care is also provided.Center for Health Care Rights :: January 201618

Center for Health Care Rights :: January 201619You must meet all of the following requirements:

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

Medicare Home Health Benefits If you meet the Medicare requirements, Medicare will pay for the same type of services received in a Skilled Nursing Facility at home:Nursing carePhysical therapySpeech therapyOccupational therapyMedical social servicesHome health aide servicesMedical supplies and durable medical equipment Center for Health Care Rights :: January 201620

Medicare Part BBenefitsPhysician servicesAmbulanceOutpatient speech, physical and occupational therapyMedical equipmentMental health servicesLaboratory, x-rays, diagnostic testsPreventive services (e.g., flu shots)Center for Health Care Rights :: January 201621

2016 Medicare Part B Co-payments Center for Health Care Rights :: January 201622ServiceBeneficiary CostOutpatient Medical Care$166 annual deductible20% of Medicare-approved charges15% excess charges for most unassigned claims

Medicare 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 shots each year;Diabetic screening, supplies and self management services;


Medicare 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.


Medicare Part A and Part B Appeals Process

Center for Health Care Rights :: January 201625Initial Determination

Redeterminations

Reconsiderations

Administrative Law Judge Hearing

Medicare Appeals Council (MAC)

Federal District Court

Fast Track Appeals for Service DenialsAll 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.Center for Health Care Rights :: January 201626

Medicare Part D Drug Plan Choices

Prescription Drug Plan (PDP)

Medicare Advantage Plan (MA-PD)Center for Health Care Rights :: January 201627

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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 servicesCenter for Health Care Rights :: January 201628

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


Enrollment is voluntary.

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 uncovered month.30

The 2016 national base premium is $34.10Center for Health Care Rights 2015Do I Have to Enroll in a Part D Plan?

2016 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 $3,310 for the year.

Coverage GapWhen your total drug costs reach $3,310, you pay 45% of brand name prescription costs and 65% generic drug costs until the total cost reaches $7,062.50.

This gap in coverage is called the doughnut hole


In 2016, the Part D annual deductible* is no more than $360.

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

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

Center for Health Care Rights :: January 201632By 2020, you will pay only a 25% copayment for prescriptions you fill when you are in the doughnut hole.

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For questions about Medicare or other health insurance call: Center for Health Care Rights at1-800-824-0780Center for Health Care Rights :: January 201633

medicare 2016

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