Medicare: An Overview

Transcription

1 Medicare: An Overview Presented by Elaine Wong Eakin Project Manager This special regional educational effort is supported by funding provided by the California HealthCare Foundation Our Focus 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. 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? Medicare appeals

2 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:

3 Who is eligible for Medicare? Person 65 years or older or Person younger than 65 years old and 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 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 Thumbnail sketch of Medicare 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 MA-PD MA-only HMO PPO PFFS MSA SNP Part D Rx drug Plans Must have Part A or B Premium Deductible $275 Cost-sharing Initial coverage Coverage gap Catastrophic coverage

4 Medicare Part A Covers Inpatient Hospital Care Psychiatric Hospital Care Skilled Nursing Facility Home Health Care intermittent skilled care prescribed by doctor Hospice pain management program for terminally ill Blood (after the first 3 pints, received during hospital or SNF stay) Medicare Part A Costs Monthly PREMIUM: If you are 65 years or older $0 if you or your spouse worked 40 or more quarters. Automatic enrollment. $233 if you worked quarters. Voluntary enrollment. $423 if you worked fewer than 30 quarters. Voluntary enrollment. If 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 COPAYMENT or COINSURANCE Medicare Part B Covers Outpatient Medical Services Examples of Part B services: Physician visits Diagnostic tests Rehabilitation services Durable Medical Equipment Ambulance Mental health visits (limitation) Outpatient physical, occupational, speech therapy (limitation) Care must be medically reasonable and necessary.

5 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 Begins 3 months before month of eligibility and ends 3 months after month of eligibility. Month of eligibility = month of 65 th birthday or 25 th month of receiving SSDI. Benefits effective the first day of the month of eligibility. Example: 65 th birthday on October 13. Month of eligibility is October. IEP begins July 1 and ends January 31. Benefits can be effective October 1.

6 Part B General Enrollment Period January 1 through March 31 each year Coverage effective the following July 1 Late enrollment penalty added to premium 10% of current Part B premium for each full 12- month period when person was eligible but delayed enrollment. Penalty imposed for as long as beneficiary has Part B. Exception: 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) 8-month period beginning the 1 st 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. Regardless of how many quarters you worked. Annual DEDUCTIBLE = $135 (2008) COINSURANCE Example: For most Part B services, Medicare pays 80% of the Medicare-approved amount, and beneficiary pays 20% if beneficiary sees providers who accept assignment.

7 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 or Call MEDICARE ( ) 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, Covers most drugs that may be dispensed only by prescription, both brand name and generic drugs. Drugs NOT covered under Part D include: Drugs for anorexia, weight loss, or weight gain Drugs for cosmetic purposes or hair growth Drugs for symptomatic relief of cough and colds Over-the-counter drugs, e.g. aspirin, colace Prescription vitamin and mineral products Barbiturates Benzodiazepines

8 Medicare Part D (cont.) Drugs NOT covered under Part D may be covered by Medi-CAL: Drugs for symptomatic relief of cough and colds Over-the-counter drugs, e.g. aspirin, colace Prescription vitamin and mineral products Barbiturates Benzodiazepines 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 Begins 3 months before month of eligibility and ends 3 months after month of eligibility. Month of eligibility (month of 65 th birthday or 25 th month of receiving SSDI.) Example: 65 th birthday on October. 13. Sevenmonth period begins July 1 and ends January 31.

9 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 Beneficiary had creditable prescription drug coverage OR Beneficiary 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: Beneficiary has creditable prescription drug coverage from employer health plan, which is terminating. Beneficiary relocates to an area not served by his/her Medicare Part D plan. Beneficiary qualifies for the LIS. Medicare Part D Costs 2008 (standard plan) Monthly premium ranges from $14.30 to $ Deductible $275 Cost-sharing (copayment or coinsurance) Before meeting deductible Initial coverage Coverage gap (doughnut hole) Catastrophic coverage Drug costs 0-$275 $275-$2,510 $2,511- $5, Over $5, Beneficiary pays 100% 25% 100% 5% Plan pays 0% 75% 0% 95%

10 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 Monthly income Annual income Assets/resources Individual <$1,300 <$15,600 <$11,990* Couple <$1,750 <$21,000 $23,970* * Includes $1,500 for burial expenses per person. Depending on income and asset levels, people may qualify for full or partial subsidy.

11 Full vs. Partial Subsidy Premium Deductible Costsharing Full subsidy recipients pay $0 $0 $1.05 generic $3.10 brandname $2.25 generic $5.60 brandname Partial Subsidy recipients pay $0 or discounted $56 15% 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 $ 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. Many MA offer additional benefits not covered in Original Medicare such as dental and vision. With Rx drug benefits = MA-PD plans. Without Rx drug benefits = MA-only plans.

12 Types of Medicare Advantage Plans Five types of Medicare Advantage plans: HMO (Health Maintenance Organization PPO (Preferred Provider Organization) PFFS (Private Fee For Service) MSA (Medical Savings Account) SNP (Special Needs Population, e.g. for those who have Medicare and Medi- CAL) MA Special Needs Plans Designed for populations with specialized needs Certain chronic disease and conditions Dually eligible In certain institutions Special Needs Plans cover Hospital benefits (Part A) Outpatient medical benefits (Part B) and Prescription 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. If SNP is designed for those who are dually eligible, only those who have both Medicare and full benefit Medi-CAL can join the plan.

13 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 Special Enrollment Period ongoing SEP for dually eligible beneficiaries. Medicare Advantage plan costs SNPs for dually eligible beneficiaries All 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 M+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: Original Medicare + fee-for-service Medi- CAL or Medicare Advantage SNP. Do NOT need to join Medicare Advantage plans that are not SNP s, especially PFFS plans.

14 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 prescription drug benefit (depending on the subsidy level and plan chosen.) Beneficiary will be responsible for the premium, deductible and copayments for the medical and hospital benefits. 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 , 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) Details in CMS Pub ,

15 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 , Where to find answers MEDICARE, Social Security Administration, HICAP, (statewide) California Dept. of Health Care Services (Medi-Cal) Contact Information Oakland satellite office (510) th Street, Oakland, CA Elaine Wong Eakin, eweakin@cahealthadvocates.org Sacramento HQ (916) Elvas Avenue, Suite 104, Sacramento, CA Websites: (Professionals) (Consumers/General Public)