Medicare Parts A, B, & Medicare Advantage - Mass Legal Services

5/5/2021

                           Elder Benefit Programs
                           Basic Benefits Training
                       Medicare Parts A, B, &
                        Medicare Advantage
                                     May 12, 2021
                    Donna McCormick, Medicare Advocacy Project
                           Greater Boston Legal Services

                      What is Medicare?
 A federal health insurance program established in 1965, currently insuring
  over 61,000,000 people (1,300,000 in Massachusetts)
 Resembles private insurance, including premiums, deductibles,
  copayments, and coinsurance
 Unlike MassHealth, it is not needs-based
 Administered by the Center for Medicare and Medicaid Services (CMS)
  under the Secretary of Health and Human Services

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                          What is Medicare?
    Covers a share of the cost of a medical service or equipment, only if it is
    “reasonable and necessary for the diagnosis of an illness or injury or to
    improve the functioning of a malformed member.” It does cover a limited
    number of preventive services such as screening for diabetes, cardiovascular,
    and colorectal cancer.

                     Who is eligible for Medicare?
 Age 65 and above: U.S. citizens and legal permanent residents (if they have resided
  in U.S. for 5 continuous years)
 Under age 65 with disabilities, same status as above
    Coverage begins with the 25th month of receiving Social Security Disability
      (SSDI) benefits (following 5 month waiting period). Except: immediate
      coverage for people with ALS (amyotrophic lateral sclerosis)
 End Stage Renal Disease (ESRD), advanced kidney disease requiring kidney
  replacement or dialysis, no waiting period, but start date depends on treatment.
 Certain public employees

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                            Medicare Parts
      “Part A” designates coverage of inpatient services (hospitalizations, skilled
        nursing facility stays, hospice care) and some home health services.
      “Part B” designates coverage for outpatient treatment (physician visits,
         ambulance transport, screenings, preventive treatment, durable medical
        equipment, limited drugs, and more). See Medicare & You, pp. 30-49.
      Together Parts A and B comprise “Original Medicare” or “Traditional
        Medicare”. Services are paid on a “fee for service” basis in which
        providers are paid per service. (vs. “bundled payments” Beneficiaries may
        choose providers, effective throughout U.S.

                    More Medicare Parts
 “Part C” or “Medicare Advantage” designates private health plans, approved by
  Medicare, which largely offer services through managed care models, including
  HMOs, Special Needs Plans, Preferred Provider Organizations. Often include
  prescription drug coverage. Limited to specific service area except for
  emergency/urgent services.
 “Part D” is Medicare’s outpatient prescription drug program . Like Part C or
  Medicare Advantage Plans, they have private sponsors approved by Medicare. May
  be incorporated in a Medicare Advantage Plan or be free-standing
 Knowing the Parts helps identify the amount of patient liability for a medical bill,
  appeal procedures, prescription drug questions, coverage effective dates , and how
  best to access additional information.

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                         Medicare Enrollment
  Rigid time frames for enrollment; if not met, beneficiary incurs Late
  Enrollment Penalties (LEP) and delayed effective date.
   Initial Enrollment Period (IEP) when first turning 65;
   General Enrollment Period (GEP) (annually from January – March)
   Special Enrollment Period (SEP), for people allowed to delay enrollment
    because they or spouses are actively employed and covered by employer
    group health insurance
   Open Enrollment for Medicare Advantage and Part D (Oct.15-Dec.7)

                  Original Medicare Enrollment:

Automatic enrollment in Original Part A and deemed enrollment in Part B. May
decline Part B, but at risk of LEP/delayed coverage, if not eligible for special
enrollment:

 65 if receiving SSA or Railroad Retirement benefits
 Under 65 if Medicare eligible based on disability
 Under 65 if Medicare eligible based on ALS

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Original Medicare: when/how to enroll if not automatic?
 Initial Enrollment Period (IEP) – 7 months
      Month of your 65th birthday
      Three months before
      Three months after
 General Enrollment Period (GEP)
      January through March 31st each year
      Effective July 1 of same year
      How: online, by telephone, in person, at local SSA office

                             Special Enrollment

  If an individual or spouse is actively working and is insured
   through an Employer’s Group Health Plan, beneficiary is eligible
   for a SEP:

     May enroll outside of the IEP and GEP, during employment or
     for 8 months after stops working.

  Must be actively employed. Neither COBRA, nor retirement
   insurance creates a SEP.

    No penalties, no delayed coverage.

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                             Late Enrollment

     If not eligible for a SEP, failure to enroll in Part B during the
     IEP subjects enrollee to a monthly premium penalty of 10%
     of standard premium for each 12 months individual foregoes
     available enrollment.

     If 65 or older, (LEP) lasts “for life”; if under 65, penalty is
     cleared at age 65.

     If not eligible for a SEP and fails to enroll during IEP, must
     wait until the General Enrollment Period (January – March
     31), and benefits do not become effective until July 1 which
     may create sizeable gaps in coverage.

                           Equitable Relief

Part B late enrollment penalties (LEP) may be waived and a special
enrollment date allowed based on a very specific premise: the
beneficiary is able to prove that the late enrollment was inadvertent
and due to misinformation provide by a federal employee.

Marketplace (Connector) Equitable Relied : If individual has delayed
enrolling in Part B or enrolled late in order to retain coverage under
Connector plan, may be eligible to have late enrollment penalties
waived if certain criteria are met, e.g., must be on premium free Part A,
timing of eligibility. May be temporary.

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            Original Medicare Part A Costs (2021)

Premium-Free Part A
   At 65:
    Beneficiary or current or former spouse worked for at least 10 years during
      which paid Medicare taxes.
    If eligible for Social Security Retirement Benefits or Railroad Retirement
      Benefits)
    If beneficiary/spouse had Medicare-covered government employment
   Under 65:
    Persons eligible for based on disability, ALS or ESRD

    Original Medicare Part A Costs (2021) (cont’d)

 If not eligible for premium-free Part A, may voluntarily enroll in Part A by
 paying premiums:
      $ 471 monthly in 2021 if worked less than 30 quarters
      $259 monthly in 2021 if worked 30-39 quarters

 Part A cost sharing: Part A will pay a portion of the Medicare approved cost for
 limited stays in a hospital or a skilled nursing facility. (See also hospice and home health
 services.) When the covered limit is reached and patient has gone 60 days without
 hospital or skilled care, a new benefits period is established.

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                  Original Part A Costs (2021) (cont’d)

Hospital care:
 deductible of $1,484;
 days 1-60 no co-payment;
 days 61-90-$371 daily copayment of $371
 days 90-150 daily copayment of $742 lifetime reserve
Skilled Nursing Facility:
 days 1-20 no co-payment
 days 81-100 copayment of $185.50 daily
 (2021 Original Medicare Costs in materials)

            Original Part A Costs (2021) (cont’d)

   Hospice: $0 for hospice care; small miscellaneous costs
   Home Health Care:
    $0 for home health services;
    20% of Medicare approved amount for durable medical
     equipment

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                       Original Part B Costs (2021)
Annual Part B deductible in 2021: $203

Standard Part B premium is $148.50 monthly.

 If Modified Adjusted Gross Income (MAGI) reported to IRS two years prior is above
  $88,000 (individual) or $176,000 (married couple), an Income-Related Monthly
  Adjusted Income Amount (IRMAA) increase is added to the monthly premium.
  Premiums may increase to $504.monthly depending on income.

 Life changing event: If beneficiary experiences a life changing event (e.g., marriage,
  divorce/annulment, spouse’s death; work stoppage or reduction, etc.), which reduces
  income on which IRMAA was based, beneficiary may apply for and secure premiums
  based on lower income.

                       Original Medicare Part B

  Medicare Part B pays 80% of the Medicare approved rate for:

       Physician services, tests, ambulance transportation, most
        home health aid
       Durable Medical Equipment for use in the home: oxygen,
        wheel chairs, scooters, walkers, hospital beds, prosthetic and
        orthotic equipment
        (See pages 30-49 of Medicare & You 2021)

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          Original Medicare Part B: Preventive Services
 Bone mass measurement
 Screenings: cardiovascular, colorectal cancer, diabetes,
  mammography and prostate cancer, pap smears and pelvic exams
 Injections: flu, pneumonia and hepatitis b
 Initial preventive physical exam
 Medical nutrition therapy
 Smoking and tobacco use sensation
(See pages 30-51 of Medicare & You 2021)

         Help with Original Medicare Costs
 Medicare is expensive: premiums, co-pays, co-insurance, deductibles
 and services that are not covered. Some out of pocket costs under
 Original A and B can be covered by:
     Medicare Saving Plans
     MassHealth
     Health Safety Net
     Medigap insurance
     Employment based coverage: retiree coverage or coverage
      through active work

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              Medicare Savings Plans (Buy-in)

 Three-part program which depending on income will pay Medicare
  premiums, deductibles, copays and coinsurance
 Known in Massachusetts as MassHealth Buy-In or Senior Buy-In. 130
  CMR 450.105(C) and (D);130 CMR 519.010, 519.011. Also, known as QMB,
  SLMB, and QI.
 Income and asset limits higher than for full MassHealth
 Countable asset limit up to $15,720 for an individual and $23,600 for a
  married couple who live together.
 Highest income limit is 165% of FPL. .
 No estate recovery.

                Medicare Savings Plans (cont’d)
  Automatic waiver of LEPs even after MSP ends.
  Automatic eligibility for LIS.
  Note: Effective January 2020, Massachusetts legislation expanded the
    income and asset limits to those reported here. Implementation of the
    expansion has been in phases according to respective categories. While
    most eligible groups may now access the benefits, MassHealth is
    seeking an 1115 Waiver amendment to secure coverage for all eligible
    CommonHealth members. Contact an advocate.
  (See 2020 Medicare Savings (Buy-In) Programs in materials.)

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                             Medigap Plans
    Medigap plans are private insurance plans that supplement Original Part A and B
     coverage out of pocket costs

    After December 31, 2005, no new Medigap policies could cover prescription drugs;
     grandfathered January 6, 2006.

    In Massachusetts, many Medigap plans are offered, but two basic kinds: Core Plan
     and Supplement 1 Plans. (See “Medigap in Massachusetts” in materials.)

                Medicare Advantage (Part C) Plans
 Private plans primarily managed care
    May require staying in network
    May require referrals for specialists
    May require prior authorization
 Must be enrolled in Parts A and B (charge A and B premiums additional)
 Out of pocket costs vary by plan, but must be actuarial equivalent of Medicare
  fee for service
 No need for Medigap; illegal to sell duplicative policies.

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             Medicare Advantage Plans: More

 Must provide all Medicare rights and protections
 Must cover at least all Original Part A and Part B services, but may also
  offer additional benefits (e.g., dental benefits, hearing aids, eyeglasses) at
  additional costs
 Annual spending cap
 Plans determine costs within approved limits

        Medicare Advantage Plans: Enrollment
   Initial and special enrollment periods: same as Original Medicare
   Annual election periods
      October 15 – December 7
      Coverage effective January 1
   Annual disenrollment period
      January 1- February 14
      Disenrollment effective 1st of month following receipt of
        disenrollment request
       Coordinate SEP available to enroll in prescription drug plan

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          Rights and Protections under Parts A, B, C, and D
Appeals and Grievances.
 Appealable events
    Medicare denies a request for a health care service, supply or prescription
    Medicare denies payment for health care received
    Medicare stops covering service that beneficiary is receiving
    Medicare pays a different amount than beneficiary believes it should
    Multi-step administrative appeals which may be pursued to federal court if necessary

 Specific time frames apply for filing and response, offer expedited or standard time frames.
 Initial procedural differences, but from Reconsideration on, steps are the same: to
  Administrative Law Judge, Medicare Appeal Board, Federal court

                      Appeal Steps Original Parts A and B

    Initial determination by provider
    Medicare Summary Notice
    Appeal within 120 days for Medicare Contractor Redetermination
    Appeal within 180 days for Reconsideration by a Qualified Independent Contractor
     (QIC)
  Proceed to Administrative Law Judge at the Medicare Office of Hearings and
     Appeals within 60 days but must meet amount in controversy (AIC) of $180 in
     2021; then to Medicare Appeals Council; then to Federal Court (AIC: $1,760 ).

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                      Appeal Steps under Part C

   Plan must provide written notice about how to appeal
   Must appeal within 60 days of Notice of Determination
   Redetermination by the plan
   Reconsideration by the plan
   Subsequent appeals identical to Original Parts A and B appeals

                     Appeal Steps under Part D

•   Exception or Coverage Determination by plan sponsor
•   Redetermination by plan sponsor
•   Reconsideration by Independent Review Entity (IRE)
•   Subsequent appeals identical to A, B, and C appeals

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                         Grievances
 Filing a grievance is a mean of expressing dissatisfaction with any
  aspect of the operations, activities or behavior of any Medicare
  health Plan (except Organization Determinations.
 Examples: Individual could not get an appointment or had to
  wait too long to get an appointment. Doctors, nurses, assistants
  were rude.
 Must file grievance within 60 days of incident; Plan must respond
  within 30 days.

                        Medicare issues

 Response to Pandemic
 Benes Act
 Jimmo v. Sebelius
 Observation

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               Medicare Advocacy Project
 Free legal assistance from advice to full representation for Massachusetts
  Medicare beneficiaries on Medicare and Medicare related issues
 Offices at Greater Boston Legal Services, Community Legal Aid and South
  Coastal County Legal Services (please see brochure)
 Coverage issues:
 Part A:
    How long with Medicare help pay for hospital or skilled care?
    Written notice of non-coverage
    Demand bill appeal-

                  Medicare Advocacy Project (cont’d)

Part B: physician services, durable medical equipment, ambulance transportation
.
Part B: enrollment penalties, terminations for non-payment, IRMAA issues

Part C: Medicare Advantage plans

Part D: coverage denials, exception, enrollment penalties

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                                Medicare Law

 Social Security Act XVIII §801 et seq.
 42 USC §1395 et. seq.
 42 CFR §400 et. seq.
 Local Coverage Determinations
 National Coverage Determination
 Internet –Only Manuals

                                   Resources
   Center for Medicare Advocacy www.medicareadvocacy.org
   Center for Medicare and Medicaid Services www.medicare.gov
   Justice in Law Center (formerly NSCL) www.justiceinaging.org
   Kaiser Family foundation www.kff.org
   Mass. College of Pharmacy and Health Services (Mass. Medline) 866-633-1617
   MassHealth 800-841-2900
   MEDICARE ADVOCACY PROJECT
   Medicare and You 2021, Massachusetts
   Medicare Rights Center www.medicarerights.org
   Prescription Advantage 800-243-4636 press 1 / SHINE 800-243-4636, press 2

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