MEDICARE PARTS A, B, AND C

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1 MEDICARE PARTS A, B, AND C B A S I C B E N E F I T S T R A I N I N G E L D E R B E N E F I T S P R O G R A M S F E B R U A R Y 2 5, D O N N A M C C O R M I C K M E D I C A R E A D V O C A C Y P R O J E C T G R E A T E R B O S T O N L E G A L S E R V I C E S WHAT IS MEDICARE? A national health insurance program Like private health insurance the beneficiary pays premiums, deductibles, copayments, coinsurance Administered by Center for Medicare and Medicaid Services under Secretary of HHS Sylvia Mathews Burwell Coverage available if Reasonable and necessary for diagnosis or of illness or injury to improve functioning of a malformed member. 2 WHO QUALIFIES FOR MEDICARE? Majority of people in U.S. age 65 years or older Some people under 65 with disabilities Coverage begins after 24 months of receiving Social Security disability benefits (SSDI) Immediate coverage for people with ALS (amyotrophic lateral sclerosis) Can be extended up to 78 months after cash benefits end People, including children, with end-stage renal disease (ESRD) Eligibility not based on income and/or resources 3

2 HOW MANY PEOPLE DOES MEDICARE INSURE AND WHO ARE THEY? National figures: Total number of Medicare beneficiaries: 50,829 million Total number of Medicare beneficiaries 65 or over 42,204 Total number of Medicare beneficiaries under 65 8,624 Massachusetts: Total number of Medicare beneficiaries in Massachusetts : 1,104,483 Total number of Medicare beneficiaries 65 or older in Massachusetts: 892,859 Total number of younger disabled Medicare beneficiaries in Massachusetts: 211,624 50% of Medicare beneficiaries have income under 200% of the federal poverty line: $1,960 a month, $23,540 a year 4 WHAT IS THE A, B, AND C OF MEDICARE? Part A and B: Original Medicare, Fee for Service: Part A, Hospital Insurance Coverage Part B, Medical Insurance Coverage Part C, Medicare Advantage, Managed Care Plans Prescription drug plans, Part D. 5 ORIGINAL MEDICARE: ENROLLMENT No application required: If Medicare eligibility is based on disability, ESRD, or being at least age 65 and receiving Social Security Retirement cash benefits then: Individual is automatically enrolled in Part A and Deemed enrolled in Part B, with opportunity to decline Why? Part A is generally free; B costs at least $ in If you are age 65 and are not receiving cash benefits, must apply. 6

3 ORIGINAL MEDICARE: PART A (2015 COSTS AND COVERAGE) Hospital care: per benefit period Deductible ($1,216): 60 days; $304 day 61 through day 90 $608 day 91 through day 150 [once in lifetime] Skilled nursing facility care: if skilled care, 20 fully covered days + 80 w/$152 day co-pay Hospice care: two 90-day periods plus one indefinitely extendable 60-day period; small co-pay Some home health care: no co-pay 7 ORIGINAL MEDICARE: PART A No monthly Part A premium if: On Medicare for disability or ESRD, or 65 and eligible applicant or spouse worked at least 10 years (40 quarters) while paying Medicare taxes Premium required if insufficient work history Available to U.S. citizen or LPR living in U.S. for 5 consecutive years without a break or to persons with ESRD [$234 mo. if worked credits; $426 mo. if worked less than 30 credits] [2015] Necessary to enroll in both Parts A and B 8 ORIGINAL MEDICARE: PART B PAYS 80% Physician services Tests Ambulance Transportation Most home health care Durable Medical Equipment (DME) for use in the home, e.g.: Oxygen Wheelchairs, walkers Hospital beds Prosthetic, orthotic equipments Other outpatient services 9

4 ORIGINAL MEDICARE: PART B PREVENTIVE SERVICES Bone mass measurement Cardiovascular, colorectal cancer, diabetes, glaucoma mammography and prostate cancer screening Screening pap smears and pelvic examinations Flu, pneumonia and hepatitis b injections Initial preventive physical examination Medical nutrition therapy Smoking and tobacco use cessation Ultrasound screening for abdominal aortic aneurysms Elimination of Part B deductible for colorectal cancer screening 10 ORIGINAL MEDICARE: PART B (2014) Regular premium, $ or $ $ mo. as increased due to income >$85,000 Available without Medicare A Generally requires payment of 20% copayment amount plus yearly deductible amount, $147. Lifetime premium penalty of 10% for each full 12-month period that beneficiary could have enrolled but did not enroll in Part B UNLESS beneficiary had group health plan coverage from employer/union based on active work of self or spouse in past 8 months Equitable relief available to eliminate penalty if failure to enroll earlier due to misinformation or lack of information from a federal government employee or agency 11 ORIGINAL MEDICARE: MEDICARE SAVINGS PLAN (MSP) MassHealth Buy-In/Senior Buy-In Available to people who are over income/asset limits for full MassHealth benefits Assets up to $7,280 single, $10,930 married, exclusive of $1,500 per person burial account primary home/car not counted Income up to 135% Federal Poverty Level (FPL) Application through MassHealth 12

5 ORIGINAL MEDICARE: MEDICARE SAVINGS PLAN (MSP) ASSISTANCE MassHealth coverage of Medicare premium, copayment and deductible amounts Income no greater than 100% FPL MassHealth coverage of Medicare premiums, including any penalty Income no greater than 135% FPL Underutilized benefit which should be publicized; LIS/MSP applications No estate recovery 13 ORIGINAL MEDICARE: SUPPLEMENTS Medicare can be expensive: premiums, co-payments, deductibles, what is not covered. To cover out-of-pocket costs of Medicare Parts A and B can have: MassHealth (Medicaid) Health Safety Net Medigap insurance (e.g., MA Blue Cross/Blue Shield Medex), or Employer-based coverage Retiree coverage Coverage based on active work 14 ORIGINAL MEDICARE: MEDIGAP SUPPLEMENTS Private insurance coverage to help with Medicare Part A and B out of pocket costs, plus some additional benefits. No new medigap policies offering prescription drug coverage could be sold after December 31, Persons enrolled on January 1, 2006, in a medigap policy with prescription drug coverage can continue that enrollment. 15

6 MEDICARE ADVANTAGE (MANAGED CARE) PLANS: MEDICARE PART C Coordinated Care Plans Health Maintenance Organizations (HMOs), with or without a point of service (POS) option Special Needs Plans (SNPs) Preferred Provider Organizations (PPOs) Provider Sponsored Organizations (PSOs) Private Fee-for-Service (PFFS) Plans Medical Savings Account (MSA) Plans 16 MEDICARE PART C/MEDICARE ADVANTAGE PLANS Medical care received under terms and conditions of a private managed care plan Plans may charge an additional premium on top of Part B premium Out-of-pocket costs vary by plan, but must be actuarial equivalent of Medicare fee-for-service costs No need for Medigap policy Requires Medicare Parts A and B enrollment Unavailable if Medicare based on ESRD 17 MEDICARE PART C/MEDICARE ADVANTAGE PLANS May require staying in network, referrals for specialists, and prior authorizations Must provide all Medicare rights and protections Must cover at least all regular Part A and B services provided in fee for service Medicare, but may also provide extra benefits, e.g., vision, hearing, dental Can provide Part D prescription drug benefits 18

7 MEDICARE PART C/MEDICARE ADVANTAGE PLANS: ENROLLMENT Initial and special enrollment periods as with original Medicare Annual election periods October 15 through December 7 Coverage effective January 1 Annual disenrollment period January 1 through February 14 Disenrollment effective first of month following receipt of disenrollment request Coordinating SEP available to enroll in a prescription drug plan 19 RIGHTS AND PROTECTIONS Parts A, B, C and D have multistepped administrative appeals ultimately reaching federal court. Original A and B appeals follow a different procedure than Medicare Advantage and Part D appeals but share similarities: Expedited and standard timing available Specific time frames apply After taking administrative steps, all appeals end with Administrative Law Judge (ALJ) Hearing Medicare Appeals Council (MAC) Review Judicial Review ALJ, MAC and Judicial Review must be requested within 60 days of receipt of prior decisions Amount in controversy thresholds must be met (ALJ $140; Judicial Review $1,430) LIS appeals 20 RIGHTS AND PROTECTIONS: MEDICARE PARTS A, B, C AND D APPEALABLE EVENTS Medicare denies a request for a health care service, supply, or prescription Medicare denies payment for health care that the beneficiary has already received Medicare stops covering services that the beneficiary is already receiving Medicare pays a different amount than the beneficiary believes it should 21

8 PRE-ALJ APPEAL RIGHTS UNDER ORIGINAL PARTS A AND B Provider Initial Determination Medicare Contractor Determination Qualified Independent Contractor (QIC) Reconsideration Usually requires receipt of service [If necessary, then proceed to Administrative Law Judge, Medicare Appeals Council and Federal Court.] 22 PRE-ALJ APPEAL RIGHTS UNDER PART C Medicare managed care plan written notice explaining how to appeal Administrative Appeal Steps Organization (plan) Determination Organization Reconsideration Automatic forwarding for Independent Review Entity (IRE) Reconsideration unless decision totally favorable to beneficiary [If necessary, proceed to ALJ, Medicare Appeals Council, and Federal Court.] 23 PRE-ALJ RIGHTS UNDER MEDICARE D Exception or Coverage Determination Notification by plan sponsor Administrative appeal steps Redetermination by plan sponsor Reconsideration by Independent Review Entity (IRE) [Then on to ALJ, Medicare Appeals Council and Federal Court.] 24

9 RIGHTS AND PROTECTIONS: C AND D GRIEVANCES MEDICARE PARTS Procedure for resolving complaints Separate and distinct from appeals Generally address quality of service complaints Does not include a coverage determination May be filed orally or in writing within 60 days of incident Must be resolved within: 30 days or 24 hours if arising from plan decision not to expedite coverage determination, or redetermination under the appeals process. 25 MEDICARE ISSUES How observation status costs some Medicare beneficiaries thousands of dollars. How to implement Jimmo v. Sebelius. Medicare and the ACA Attacks on Medicare. 26 MEDICARE ADVOCACY PROJECT OF GREATER BOSTON LEGAL SERVICES Free legal assistance for Massachusetts Medicare beneficiaries on Medicare-related issues Coverage issues Part A: nursing homes, hospitals, hospice, home care Written notice of non-coverage Demand bill appeal Part B: doctor services, durable medical equipment, ambulance transportation Part C: Medicare Advantage Plans Written notice Appeal 27

10 MEDICARE ADVOCACY PROJECT Premium issues Eligibility issues Part B (sometimes Part A): penalties for late enrollment 28 MEDICARE STATUTES AND REGULATIONS Social Security Act XVIII s et. seq. 42 U.S.C. s et seq. 42 CFR c. 400 et seq. 29 MASSACHUSETTS RESOURCES Medicare Advocacy Project, SHINE (Mass.SHIP), , press 2 PrescriptionAdvantage, ,press 1 MassMedLine, (Mass. College of Pharmacy and Health Sciences Pharmacy Outreach Program) MassHealth,

11 NATIONAL INFORMATION AND ADVOCACY RESOURCES Center for Medicare Advocacy National Senior Citizens Law Center Kaiser Family Foundation Medicare Rights Center 31 FEDERAL RESOURCES Center for Medicare and Medicaid Services for providers and advocates for beneficiaries Medicare: MEDICARE Social Security Adminstration LIS and Medicare enrollment Medicare & You 2015, Massachusetts, CMS Product No (English); (Spanish) 32