1. 2016 Medicare Center for Health Care Rights :: January 2016 1

2. Center for Health Care Rights (CHCR) Center for Health Care Rights :: January 2016 2 A 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.

3. 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. Center for Health Care Rights :: January 2016 3

4. 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 2016 4

5. 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 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. Center for Health Care Rights :: January 2016 5

6. Medicare Enrollment Periods Initial Enrollment Period Begins 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 2016 6

7. 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. Center for Health Care Rights :: January 2016 7

8. 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 2016 8

9. 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 M EDICARE SECONDARY. Center for Health Care Rights :: January 2016 9 How Does Medicare Work with My Employer Insurance?

10. Medicare Coverage Part A Hospital Insurance Part B Medical Insurance Center for Health Care Rights :: January 2016 10

11. Medicare Part A Benefits Hospital Skilled Nursing Facility Home Health Care Hospice Center for Health Care Rights :: January 2016 11

12. 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 65 th 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. Center for Health Care Rights :: January 2016 12

13. 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 2016 13 To apply for Medicare, contact the Social Security Administration. 1-800-772-1213 www.socialsecurity.gov

14. 2016 Medicare Part A Co-payments Center for Health Care Rights :: January 2016 14 Coverage Per Benefit Period* Hospital Days 1 - 60$1,288 first day deductible Days 61 - 90$322/day Days 91 – 150 (Lifetime reserve days) $644/day Skilled Nursing Facility Days 1 - 20Covered 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.

15. Part A Skilled Nursing Facility Coverage Requirements for coverage: 3 days 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 5 times a week). Center for Health Care Rights :: January 2016 15

16. 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 201616

17. Center for Health Care Rights :: January 2016 17 You must meet all of the following requirements: 1.Patient needs intermittent skilled nursing care, physical therapy or speech therapy; 2.Patient is homebound; 3.Physician determines patient needs home health and sets up a plan of care; and 4.Home health agency providing the services is a Medicare provider. Medicare Home Health Benefits

18. If you meet the Medicare requirements, Medicare will pay for the same type of services received in a Skilled Nursing Facility at home: Nursing care Physical therapy Speech therapy Occupational therapy Medical social services Home health aide services Medical supplies and durable medical equipment Center for Health Care Rights :: January 2016 18

19. Medicare Part B Benefits Physician services Ambulance Outpatient speech, physical and occupational therapy Medical equipment Mental health services Laboratory, x-rays, diagnostic tests Preventive services (e.g., flu shots) Center for Health Care Rights :: January 2016 19

20. 2016 Medicare Premium Automatic Enrollee Voluntary Enrollee Part A (Hospital) No premium $411/month if less than 30 work quarters $226/month if 30-39 work quarters Center for Health Care Rights :: January 2016 20

21. 2016 Medicare Part B Premium 70% of the Medicare population will pay $104.90/month for Medicare Part B because there is no Social Security Cost Of Living Adjustment (COLA) in 2016. Center for Health Care Rights :: January 201621

22. 30% of the Medicare population will pay $121.80/month for Part B. Persons who will pay the higher Part B premium include:  New Medicare beneficiaries  Beneficiaries not receiving Social Security benefits  High income beneficiaries who also pay an income related surcharge based only on their incomes  Income Single Person: > $85,000/year  Income Married Couple: > $170,000/year Center for Health Care Rights :: January 201622

23. Premium for Medicare Part B for High Income Beneficiaries Center for Health Care Rights :: January 2016 23 Income Bracket (Single ) Income Bracket (Jointly) Premium ≤$85,000≤$170,000 $121.80 (base premium) >$85,000 but ≤$107,000 >$170,000 but ≤$214,000 $170.50 >$107,000 but ≤$160,000 >$214,000 but ≤$320,000 $243.60 >$160,000 but ≤$214,000 >$320,000 but ≤$428,000 $316.70 >$214,000>$428,000$389.00

24. 2016 Medicare Part B Co-payments Center for Health Care Rights :: January 2016 24 ServiceBeneficiary Cost Outpatient Medical Care $166 annual deductible 20% of Medicare- approved charges 15% excess charges for most unassigned claims

25. Premium Penalties Part A (Hospital) 10% of premium for twice the number of years late. Part B (Medical) 10% for every year late, in effect for life. Center for Health Care Rights :: January 2016 25

26. Medicare Preventive Benefits Free 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; Center for Health Care Rights :: January 2016 26

27. Medicare Preventive Benefits Free 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. Center for Health Care Rights :: January 2016 27

28. Medicare Part D Drug Plan Choices Prescription Drug Plan (PDP) Medicare Advantage Plan (MA-PD) Center for Health Care Rights :: January 2016 28

29. 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 services Center for Health Care Rights :: January 2016 29

30. 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 Center for Health Care Rights :: January 2016 30

31.  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. 31  The 2016 national base premium is $34.10 Center for Health Care Rights © 2015 Do I Have to Enroll in a Part D Plan?

32. 2016 Medicare Part D Drug Coverage Initial Coverage Period After 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 Gap When your total drug costs reach $3,310, you pay 45% of brand name prescription costs and 58% generic drug costs until the total cost reaches $7,062.50.  This gap in coverage is called the “doughnut hole”. Center for Health Care Rights :: January 2016 32 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.)

33. 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 2016 33 By 2020, you will pay only a 25% copayment for prescriptions you fill when you are in the doughnut hole.

34. Medicare Part A and Part B Appeals Process Center for Health Care Rights :: January 2016 34 Initial Determination Redeterminations Reconsiderations Administrative Law Judge Hearing Medicare Appeals Council (MAC) Federal District Court

35. Fast Track Appeals for Service Denials All 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 2016 35

36. For questions about Medicare or other health insurance call: Center for Health Care Rights at 1-800-824-0780 Center for Health Care Rights :: January 2016 36