Medicare and Medi-Cal Eligibility and Benefits
Center for Health Care Rights
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Center for Health Care Rights (CHCR)
• A non-profit organization that provides free education and help with Medicare, Medi-Cal and health insurance
• CHCR is not part of the Medicare program and does not endorse or recommend any insurance company or Medicare Advantage plan
• CHCR services are funded by the Los Angeles City Department of Aging and the Los Angeles County Area Agency on Aging HICAP grants
Medicare• A federal health insurance program providing a health care
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.
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Disabled Adult Children Eligible for SSDI and Medicare
• Disabled adult children can qualify for Social Security Disability Insurance (SSDI) under a parent’s eligibility for Social Security benefits
• The adult child must be age 18 or older• The parent must be retired (age 62 or older),
disabled or deceased• After receiving SSDI for 24 months, the adult
child is eligible for Medicare
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2016 Medicare Part B Premium• In 2016, the Medicare Part B premium is
$104.90 per month for most Medicare beneficiaries.
• Persons who are newly eligible for Medicare in 2016 pay $121.80 per month for Part B.
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.
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How Medicare Coordinates with Employer Based
InsuranceFor Medicare beneficiaries who are under the age of
65, the employer plan is primary and Medicare is secondary when-
• The younger disabled Medicare beneficiary is covered by a employer health plan that has 100 or more employees and
• The employer plan coverage is based on the beneficiary’s current employment status or the current employment status of a family member (e.g., spouse, parent)
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Medicare Beneficiaries With EGHP Coverage Can Delay
Medicare Enrollment • When younger, disabled Medicare beneficiaries are
covered by an employer health plan that meets Medicare requirements (see previous slide), they have the right to delay their enrollment in Medicare Part B.
• They can delay their Medicare enrollment until they or the family member who is providing the employer based health coverage stops working and the employer health plan coverage terminates.
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• Once the employer health plan coverage ends, Medicare provides an 8 month enrollment period to enroll into Medicare Part B.
• Under this special enrollment period, there is no penalty for late Medicare enrollment.
Medicare Part A Benefits • Hospital
• Skilled Nursing Facility
• Home Health Care
• Hospice
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2016 Medicare Part A Co-payments
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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 - 20 Covered 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.
Part ASkilled 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).
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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; and4. Home health agency providing the services is a
Medicare provider.
Medicare Home Health Benefits
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Medicare Part B Benefits• Physician services• Ambulance• Outpatient physical, occupational and speech
therapy• Medical equipment• Mental health services• Laboratory, x-ray, diagnostic tests• Preventive services (e.g., flu shots)Part B copayments – annual Part B deductible of
$166 and 20% copayments
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.
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Medicare Part D Drug Coverage
• Prescription drug plan (PDP)Obtain Medicare Part D drug coverage by enrolling
into a PDP planContinue to use original Medicare for Part A and B
services• Medicare Advantage drug plan (MAPD)
When you enroll into a MAPD plan you assign your Medicare A, B and D benefits to the plan
You obtain all your medical care from plan providers
2016 Medicare Part D Drug Coverage
• Initial Coverage Period Part D annual deductible is no more than $360
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 GapWhen 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”
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• 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
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Gaps in Medicare Coverage
• Medicare copayments and deductibles• No dental care• No custodial nursing home or personal care
services at home• No routine podiatry (only for diabetics)• No acupuncture
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Medi-Cal Eligibility -- SSI• Elderly and younger disabled persons who receive
Supplemental Security Income (SSI) are automatically entitled to Medi-Cal
SSI Income Limits SSI Resource LimitsSingle $889 $2000
Married $1499$3000– Resources not counted include: your home, one car,
personal belongings– Apply at Social Security Administration
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Medi-Cal Eligibility Aged and Disabled Federal
Poverty Level Program• California’s Medi-Cal program for elderly and younger disabled
persons whose incomes are too high for SSI
• Apply at L.A. County Dept. of Public Social ServicesIncome Resources
Single $1240 $2000
Married $1645 $3000
Resource rules same as SSI
Medi-Cal with a Share-of-Cost
• A program for persons whose income is too high to qualify for the Aged and Disabled Federal Poverty Level Program
• This program uses SSI asset limits
– Assets must be $2,000 or less if you are single and $3,000 or less if you are married
– Assets like the home and one car are not counted
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The share of cost works like an insurance deductible
You must meet the share of cost each month before Medi-Cal pays your medical expenses
Example: If your Medi-Cal Share of Cost is $800, you are responsible for $800 of medical expenses before Medi-Cal pays
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How Does the Share-of-Cost Work (SOC)?
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Medi-Cal Benefits• Hospital care• Doctor services• Prescription drugs• Ambulance• Lab, x-rays• Emergency services• Mental health
• Hearing aids• Dental care• Vision services• Non-emergency medical
transportation• Long Term Services and
Supports– Nursing home care– Adult day health care (CBAS)– IHSS– Home and community based
services
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Medi-Cal Managed Care• Most persons who have Medi-Cal are required to enroll into a Medi-Cal
managed care plan
• Populations excluded from mandatory Medi-Cal managed care Under age 21 Live in a VA nursing home Live in a ICF/DD facility Persons with other insurance (EGHP, retiree coverage, VA) Medi-Cal share of cost and not using MLTSS services
• Persons who have only Medi-Cal can request a medical exemption to stay in fee for service Medi-Cal; persons who have Medicare and Medi-Cal do not qualify for a medical exemption
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Los Angeles County Medi-Cal Managed Care Plans
• LA Care -- partner plans: Care 1st, Blue Cross, Kaiser
• Health Net-- partner plan: Molina
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Coordination of Medi-Cal with Other Health Coverage
Medi-Cal guidelines that apply when a Medi-Cal beneficiary has other health coverage –
• The other health coverage (OHC) pays as the primary insurance primary for any benefits provided by the OHC and Medi-Cal
• When the beneficiary has other health coverage, s/he is excluded from enrollment in a Medi-Cal health plan
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Coordination of Medicare with Medi-Cal
• Medicare is primary and Medi-Cal is the secondary insurance
• Medi-Cal pays the Medicare Part B premium for persons with full Medi-Cal
• Persons who are dually eligible for Medicare and full Medi-Cal cannot be balanced billed for Medicare copays and deductibles
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Coordination of Medicare with a Medi-Cal health plan
• Medicare is the primary payer and the beneficiary can see any Medicare provider
• The Medicare provider does not have to contract with the Medi-Cal plan or request authorization from the Medi-Cal plan
• The Medi-Cal plan is the secondary insurance and is billed for the Medicare copays
• Medicare providers cannot balance bill dual eligibles for the Medicare copayments
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Access to Medi-Cal Benefits Requires Authorization from a
Medi-Cal health plan• Medi-Cal plans will require prior
authorization to access Medi-Cal benefits e.g., adult day health care (CBAS), Medi-Cal nursing home care or incontinence supplies
• Authorization process generally delegated by the plan to the contracting medical group
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Medicare Part D and Medi-Cal• Persons with Medicare and full Medi-Cal (dual
eligibles) must enroll into a Medicare drug plan• If they do not select a drug plan, Medicare will
assign them to a plan• Temporary drug coverage for duals not in a Part
D plan – LiNet Humana• Part D copayments -- $1.20 generic and $3.60
brand name; dual eligible nursing home residents pay zero copays
• Subsidized Part D plans are zero premium
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For Help with Medicare
Call Center for Health Care Rights
1-800-824-0780