Medicare Overview and Changes to 2014 Copyright (c) January 2014 by Center for Health Care Rights 1.

Medicare Overview and Changes to 2014

Copyright (c) January 2014 by Center for Health Care Rights 1

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.


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.


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.


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.


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 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.


MEDICARE ELIGIBILITY

Voluntary Enrollees (individuals with insufficient

or no Social Security work history).

Persons not otherwise eligible for Medicare may

enroll voluntarily if they meet the followingconditions:

Age 65 or over; Resident of the United States for at least five

years; U.S. Citizen or permanent legal resident; Purchase both Parts A and B of Medicare, or

purchase Part B only (They may not purchase part A only).


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 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.


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.


To apply for Medicare, contact the Social Security

Administration.


MEDICARE PREMIUMS FOR 2014


Automatic Voluntary

Part A: No premium $426/month

if less than 30 work quarters

$234/month if 30-39 work

quarters

Part B: $104.90/month $104.90/month

PREMIUM PENALTIES

Part A: 10% of premium for twice the number of years late.

Part B: 10% for every year late, in effect for life.


MEDICARE PART B PREMIUM

The Medicare Part B premium is $104.90 per month.

Higher income Medicare beneficiaries with annual incomes over $85,000 (single person) and over $170,000 (married couple) will pay a base premium of $104.90 per month and an additional income related monthly amount that is based on their income.


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.


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.


MEDICARE ELIGIBLE PERSONS - UNDER THE AGE OF 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.


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.


MEDICARE COVERAGE

Part A

Hospital Insurance

Part B

Medical Insurance


MEDICARE PART A BENEFITS

Hospital Benefit

Skilled Nursing Facility Benefit

Home Health Care

Hospice Benefit


2014 MEDICARE COVERAGE OF INPATIENT HOSPITAL SERVICES

Beneficiary Co-payDays 1-60 $1,216 first day

deductible

Days 61-90 $304/day

Day 91-150 $608/day (Lifetime reserve days) 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. Copyright (c) January 2014 by Center for Health Care Rights 21

PART ASKILLED 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).


MEDICARE SKILLED NURSING FACILITY BENEFITS

Days 1-20Covered in full.

Days 21-100 requires a co-pay of $152/day.


WHAT MEDICARE WILL COVER IN A SKILLED NURSING FACILITY

Skilled nursing care and therapy services; and

Room and board charges.

Medicare will not pay for custodial careunless daily skilled care is also provided.


MEDICARE HOME HEALTH BENEFITS If you meet the Medicare requirements, Medicare will pay for the same type of servicereceived in a Skilled Nursing Facility at home:

Nursing carePhysical therapySpeech therapyOccupational therapyMedical social servicesHome health aide servicesMedical supplies and durable medical equipment


MEDICARE HOME HEALTH BENEFITS

Medicare will pay only if all of the four following conditions are met:

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; and, Home health agency providing the services

is a Medicare provider.



Remember:

You can only qualify for home health aide services, such as assistance with bathing and eating, if you are receiving some form of skilled care. Medicare will not pay for custodial care only.

ELIGIBILITY FOR THE MEDICARE HOSPICE BENEFIT The patient is eligible for Part A; The patient’s doctor and the hospice

medical director certify that the patient is terminally ill;

The patient chooses hospice care instead of standard Medicare benefits for the terminal illness; and,

The patient receives care from a Medicare certified hospice program.


MEDICARE HOSPICE BENEFIT

If you qualify for the hospice benefit, Medicare will cover:

Physician services;Nursing care;Medical supplies and appliances; and,Outpatient drugs for symptom management and pain relief.


MEDICARE PART B MEDICAL INSURANCE INCLUDES -

Physician Services

Outpatient Therapy Services

Outpatient Hospital Services

Ambulance Services

Other Medical Supplies and Services


2014 MEDICARE PART B CO-PAYMENTS

Annual Deductible: $147

Part B co-payments: 20% based on the Medicare allowable charge and 15% above the allowable charge if your provider does not take Medicare assignment.


MEDICARE PREVENTIVE BENEFITS Annual mammograms for women age 40

and over; Screening pap smears and pelvic exams

every two years; Colorectal cancer screening for persons

age 50 or older; Flu and pneumococcal vaccines each

year; Diabetic screening, supplies and self

management services;


MEDICARE PREVENTIVE BENEFITS Annual prostate cancer screening for men

over age 50; Annual glucose screening for persons at-

risk for glaucoma; Cardiovascular disease blood tests; and, 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.


HEALTH CARE REFORM LAW AND CHANGES IN MEDICARE PREVENTIVE

SERVICES In 2011, copayments for many Medicare

preventive services were eliminated. The following preventive services are

free: mammograms, colorectal cancer screening, annual flu shots, prostate cancer screening and bone density measurements.


MEDICARE OUTPATIENT PSYCHIATRIC SERVICES

In 2013, the Medicare copayment for outpatient psychiatric services is 35% of the Medicare approved charge.

By 2014, the copayment will be 20%.


MEDICARE ASSIGNMENT Assignment is an agreement between the

health care provider and Medicare. The provider agrees to collect only the

amount Medicare approves for Medicare-covered services.

With assignment, the beneficiary’s out of pocket cost is limited to payment of the Medicare Part B deductible of $147 and the 20% copayment.


WITH ASSIGNMENT, HOW MUCH DO YOU PAY?

Part B Annual Deductible: $147

20% co-payment


MEDICARE ASSIGNMENT EXAMPLE


With Without

Provider’s actual charge $200 $200

Medicare-approved charge $100 $100

Medicare pays 80% of approved charge $ 80 $ 80

You pay 20% of approved charge (coinsurance)

$ 20 $ 20

The amount above Medicare’s approved charges for which you are responsible

$ -0- $ 15*

Total Cost to You $ 20 $ 35

*The limiting charge is 15% above the Medicare approved amount.

MEDICARE PART A AND PART B APPEALS PROCESS

Stages of the appeals process:

Initial DeterminationClaim determinations made by intermediaries (Part A claims) and carriers (Part B claims).

Redeterminations made by the carriers and intermediaries.


Reconsiderations by Medicare Qualified Independent Contractors (QICs).

Administrative Law Judge HearingA beneficiary must have at least $130 at issue to appeal to this level.

Medicare Appeals Council (MAC)

Federal District CourtA beneficiary must have at least $1,300 at issue to appeal to this level.


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.


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 hospital’s 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.


• 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.


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Medicare Overview and Changes to 2014 Copyright (c) January 2014 by Center for Health Care Rights 1.

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