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

2.  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. Copyright (c) January 2014 by Center for Health Care Rights 2

3.  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. Copyright (c) January 2014 by Center for Health Care Rights 3

4.  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. Copyright (c) January 2014 by Center for Health Care Rights 4

5. 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. Copyright (c) January 2014 by Center for Health Care Rights 5

6.  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. Copyright (c) January 2014 by Center for Health Care Rights 6

7. Voluntary Enrollees (individuals with insufficient or no Social Security work history). Persons not otherwise eligible for Medicare may enroll voluntarily if they meet the following conditions:  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). Copyright (c) January 2014 by Center for Health Care Rights 7

8.  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. Copyright (c) January 2014 by Center for Health Care Rights 8

9.  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. Copyright (c) January 2014 by Center for Health Care Rights 9

10.  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. Copyright (c) January 2014 by Center for Health Care Rights 10

11. To apply for Medicare, contact the Social Security Administration. Copyright (c) January 2014 by Center for Health Care Rights 11

12. Copyright (c) January 2014 by Center for Health Care Rights 12 AutomaticVoluntary Part A:No premium $426/month if less than 30 work quarters $234/month if 30-39 work quarters Part B:$104.90/month

13. Part A:10% of premium for twice the number of years late. Part B:10% for every year late, in effect for life. Copyright (c) January 2014 by Center for Health Care Rights 13

14.  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. Copyright (c) January 2014 by Center for Health Care Rights 14

15.  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. Copyright (c) January 2014 by Center for Health Care Rights 15

16. 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. Copyright (c) January 2014 by Center for Health Care Rights 16

17.  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. Copyright (c) January 2014 by Center for Health Care Rights 17

18.  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. Copyright (c) January 2014 by Center for Health Care Rights 18

19. Part A Hospital Insurance Part B Medical Insurance Copyright (c) January 2014 by Center for Health Care Rights 19

20. Hospital Benefit Skilled Nursing Facility Benefit Home Health Care Hospice Benefit Copyright (c) January 2014 by Center for Health Care Rights 20

21. Beneficiary Co-pay Days 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

22. 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). Copyright (c) January 2014 by Center for Health Care Rights 22

23.  Days 1-20 Covered in full.  Days 21-100 requires a co-pay of $152/day. Copyright (c) January 2014 by Center for Health Care Rights 23

24.  Skilled nursing care and therapy services; and  Room and board charges. Medicare will not pay for custodial care unless daily skilled care is also provided. Copyright (c) January 2014 by Center for Health Care Rights 24

25. If you meet the Medicare requirements, Medicare will pay for the same type of service 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 Copyright (c) January 2014 by Center for Health Care Rights 25

26.  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. Copyright (c) January 2014 by Center for Health Care Rights 26

27. Copyright (c) January 2014 by Center for Health Care Rights 27  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.

28.  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. Copyright (c) January 2014 by Center for Health Care Rights 28

29. 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. Copyright (c) January 2014 by Center for Health Care Rights 29

30. Physician Services Outpatient Therapy Services Outpatient Hospital Services Ambulance Services Other Medical Supplies and Services Copyright (c) January 2014 by Center for Health Care Rights 30

31.  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. Copyright (c) January 2014 by Center for Health Care Rights 31

32.  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; Copyright (c) January 2014 by Center for Health Care Rights 32

33.  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. Copyright (c) January 2014 by Center for Health Care Rights 33

34.  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. Copyright (c) January 2014 by Center for Health Care Rights 34

35.  In 2013, the Medicare copayment for outpatient psychiatric services is 35% of the Medicare approved charge.  By 2014, the copayment will be 20%. Copyright (c) January 2014 by Center for Health Care Rights 35

36.  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. Copyright (c) January 2014 by Center for Health Care Rights 36

37.  Part B Annual Deductible: $147  20% co-payment Copyright (c) January 2014 by Center for Health Care Rights 37

38. Copyright (c) January 2014 by Center for Health Care Rights 38 WithWithout Provider’s actual charge$200 Medicare-approved charge$100 Medicare pays 80% of approved charge$ 80 You pay 20% of approved charge (coinsurance) $ 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.

39. Stages of the appeals process:  Initial Determination Claim determinations made by intermediaries (Part A claims) and carriers (Part B claims).  Redeterminations made by the carriers and intermediaries. Copyright (c) January 2014 by Center for Health Care Rights 39

40.  Reconsiderations by Medicare Qualified Independent Contractors (QICs).  Administrative Law Judge Hearing A beneficiary must have at least $130 at issue to appeal to this level.  Medicare Appeals Council (MAC)  Federal District Court A beneficiary must have at least $1,300 at issue to appeal to this level. Copyright (c) January 2014 by Center for Health Care Rights 40

41. 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. Copyright (c) January 2014 by Center for Health Care Rights 41

42. 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. Copyright (c) January 2014 by Center for Health Care Rights 42

43. 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. Copyright (c) January 2014 by Center for Health Care Rights 43