Medicare: Parts A and B and Donna McCormick Medicare Advocacy - PowerPoint PPT Presentation

Medicare: Parts A and B and • Donna McCormick Medicare Advocacy Project Medicare Greater Boston Legal Services Advantage • Elder Benefits Training June 2020

• A national health insurance program established in 1965. • Looks and acts like private insurance: premiums, deductibles, copayments, and coinsurance. • Administered by the Center for Medicare and Medicaid Services (CMS) under the Secretary of What is Health and Human Services • Pays a share of the cost of a medical service or Medicare? equipment, if it is “ reasonable and necessary for the diagnosis of an illness or injury or to improve the functioning of a malformed member.” In recent years, has begun to offer preventative services.

• Age 65 and above: U.S. citizens and Legal Permanent Residents who have resided in the U.S. for 5 continuous years, have worked and paid into Medicare for ten years or who buy into Medicare. Who is • Under age 65,with disabilities, same immigrant status above: • Coverage begins with the 25th month of receiving Social eligible for Security Disability (SSDI) benefits • Except: immediate coverage for people with ALS (amyotrophic Medicare? lateral sclerosis) • People who have End Stage Renal Disease (ESRD), advanced kidney disease requiring kidney replacement or dialysis

• As of 2018, Medicare insured almost 60 million people nationally, 42.8 How many million of whom were age 65 or older millions of • In Massachusetts, Medicare insures people does 1,042, 302 people. Medicare • Predicting national enrollment of 79,000,000 by 2030 insure?

• “Part A” designates inpatient coverage (hospitalizations, skilled nursing facility stays, hospice care, as well as some home health services). Limited service areas • “Part B” designates coverage for outpatient The treatment (physician visits, ambulance transport, screenings, preventive treatment, Language of certain drugs) Medicare • Together Parts A and B comprise “Original Medicare” a/k/a “Traditional Medicare” or “Fee for Service Medicare in which providers are paid per service, beneficiary may choose providers without referral, effective throughout U.S.

More Medicare Terms • “Part C” or “Medicare Advantage” designates private health plans , approved by Medicare, which largely offer services through managed care . Part C or Medicare Advantage plans often include prescription drug coverage. • “Part D” is Medicare’s outpatient prescription drug program and how beneficiaries secure most of their medication coverage outside the hospital. Like Part C plans, they have private sponsors approved by Medicare. • What kind of Medicare is a person on? When is it effective? Is the prescription drug plan free standing or part of a Medicare Advantage plan? Is there supplemental coverage? The answers effect coverage, appeals, where to go for information.

• Medicare has rigid time frames for enrolling and imposes penalties if they are not met. Enrollment time frames include an Initial Enrollment Period (IEP), a General Enrollment Period (GEP), a Special Enrollment Period; Medicare Advantage plans have a 5-star open enrollment and Medicare Advantage Open Enrollment and Part D plans have an Open Enrollment. • The following individuals are automatically enrolled in Original Enrollment Medicare Part A and deemed enrolled in Part B (may decline Part B, but without a SEP, they do so at risk of incurring late enrollment penalties.) • at age 65 and if receiving Social Security Retirement cash benefits (or Railroad Retirement Benefits) • if Medicare eligibility is based on disability or End Stage Renal Disease

• Initial Enrollment Period (IEP) – 7 months, Original beginning 3 months prior to 65 th birthday, including month of 65 th birthday and 3 Medicare: months after when to • General Enrollment Period (GEP) • January through March 31 st each year enroll? • Effective July 1 of same year

• Premium-Free Part A • At 65 : You will pay no premium for Part A: if you or your spouse (current or former) worked for at least 10 years and paid into Medicare; if you Original are eligible for Social Security Retirement Medicare Benefits (or Rail Road Retirement benefits); or if you or your spouse had Medicare-covered Part A Costs government employment (2020) • Under 65 : Those who received SSDI for 24 months, have ALS or End Stage Renal Disease

• If not eligible for premium-free Part A, may buy into Part A by paying the following premiums: • $ 458 monthly if you paid Medicare taxes for less than 30 quarters Original • $252 monthly if you paid Medicare taxes for 30-39 quarters Medicare • What is Part A cost sharing? Part A will pay a portion of Part A Costs the Medicare approved cost for stays of up to 150 days in a hospital or up to 100 days in a skilled nursing facility (2020) per benefit period . A benefit period begins the day, the individual is admitted to the facility and ends when the person has not received that level of care for 60 days. At that point, a new benefits period begins.

• Hospital care and Skilled Nursing Care: Medicare will pay a portion of the approved cost, leaving a portion for the beneficiary (or supplemental coverage) to pay. Please see Original Part “Medicare Costs” for specific amounts and time periods. Note: must receive skilled care A Coverage • Hospice : $0 for hospice care; small (2020) miscellaneous costs • Home Health Care: $0 for home health services; 20% of Medicare approved amount for durable medical equipment

Original Medicare Part B Costs (2 (2020) • Annual Part B deductible: $198.00 • Standard Part B monthly premium is $ 144.60 if modified adjusted gross income (MAGI) reported on your IRS from two years ago is below $86,000 for an individual or $172,000 for a married couple • IRMAA: if MAGI exceeds above limits, an Income Related Monthly Adjustment Amount is added. Please see IRMAA amounts • Plus penalties for late enrollment, if applicable.

• Persons who do not enroll in Medicare Part B during their Initial Enrollment Period (IEP) at 65, are subject to a premium penalty of 10% for each 12 months they could have enrolled but did not, unless they qualify for a “special enrollment” (SEP). Part B Late • For those 65 and older, the Late Enrollment Penalty (LEP) Enrollment lasts a “life - time”, as long as person is enrolled in Medicare; for those under 65, penalty is cleared at age 65. Penalties • If individual fails to enroll during IEP (and has no SEP), must wait until the General Enrollment Period (January through March 31 annually) to enroll, and benefits do not become effective until July 1.

• Equitable Relief : Part B Late Enrollment Penalties may be waived and a special enrollment date assigned if a Medicare beneficiary can prove to SSA that failure to enroll timely was due to misinformation or lack of information from a federal government employee. Equitable Relief from • Connector Market Place Equitable Relief: If a Medicare beneficiary delayed enrolling in Part B and retained coverage under a Connector Part B Penalties Market Place Plan (QHP) may be eligible to have late enrollment penalties waived or reduced if certain criteria are met. and Delayed See https://www.medicareinteractive.org/get-answers/medicare health-coverage-options/original-medicare-enrollment/time-limited Coverage equitable-relief-for-enrolling-in-part-b

• Special Enrollment Period (SEP): i f individual and/or spouse is insured through Special an employer’s large group health plan based on active work (COBRA does not Enrollment apply), individual may enroll without penalty Period (SEP) for up to 8 months after active employment ceases.

• Medicare Part B pays 80% of the Medicare approved rate for: • Physician services, tests, ambulance Original transportation, most home health aid • Durable Medical Equipment for use in the home: Medicare oxygen, wheel-chairs, scooters, walkers, hospital beds, prosthetic and orthotic equipment Part B See Medicare and You 2020 for more.

• Bone mass measurement • Screenings: cardiovascular, colorectal cancer, Original diabetes, mammography and prostate Medicare cancer, pap smears and pelvic exams • Injections: flu, pneumonia and hepatitis b Part B: • Initial preventive physical exam Preventive • Medical nutrition therapy Services • Smoking and tobacco use sensation • See Medicare and You 2020

Help wit ith Paying Ori riginal Medicare Costs • Medicare can be expensive, including payment of premiums, deductibles, co-pays, co- insurance and penalties if applicable. The following programs can reduce a Medicare beneficiary’s out of pocket expense: Medicare Savings Programs Medigap or Supplemental Medicare plans MassHealth Health Safety Net Employer-based insurance (Retirement/active)