The document provides information about Medicare coverage and how the Affordable Care Act affects different parts of Medicare. It discusses what is covered by Parts A, B, C, and D of Medicare as well as penalties for late enrollment. The Affordable Care Act eliminates co-pays for preventive services, links payments to quality outcomes, and begins closing the Medicare Part D coverage gap. It also means tests Part D premiums and Part B premiums are higher for those with higher incomes.

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2. Helping Seniors Age Well at
Home
Sourcewise provides expertise, education, and quality
support services to Santa Clara County seniors, their
families and caregivers.
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3. Medicare Beneficiaries and the
ACA
Marcelo Espiritu, Product Analyst
Health Insurance Counseling
& Advocacy Program
Connie Corrales, Director
Health Insurance Counseling
& Advocacy Program
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4. Background: Medicare
Coverage
“
“Medicare Advantage”
 Inpatient hospital care
 Skilled nursing care
managed care
capitation
Original Medicare fee-for-service”
Part A
 Home health care
 Hospice care
A
 Doctor’s services and outpatient care
 Annual Wellness Visit


Home health care
Diagnostic tests

Some therapies

Part D
Preventive services

Part B
Part C
Durable medical equipment
 Outpatient prescription drugs
B
Part D
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5. Not Covered by Medicare Part A or
B

Long-term care
 Routine dental care
 Dentures
 Vision
 Cosmetic Surgery
 Acupuncture
 Hearing aids and exams for fitting hearing aids
 Other- check on www.medicare.gov
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6. Enrollment: Delaying Part B
 Some people may delay enrolling in Part B with no
penalty
 Must be covered under employer or union group health
plan . . . AND
 coverage must be based on active employment
 Individual’s or spouse’s
Special Enrollment Period (SEP)
Anytime while working and
up to eight months after active employment or employer coverage ends,
whichever happens first.
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7. Late Enrollment in Part D
 People who wait to enroll may pay a penalty
 Additional 1% of national base premium ($32.42 in
2014)
 Must pay the penalty as long as enrolled in a
Medicare drug plan
 No penalty if one has “Creditable Coverage”
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8. ACA Effects on Part A and B
 Eliminates co-pay for preventive services
 Accountable Care Organizations
 Links payment to quality outcomes
 Hospital readmissions are being watched
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9. ACA Effects on Part C
 New Maximum Out of Pocket Limit
 Annual Election Period starts earlier
 Plans will have quality ratings
 Special enrollment periods
 Decreases capitation to Medicare Advantage
Organizations (overpaid by 14% per person)
 Pegs MA capitation to Quality metrics
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10. ACA Effects on Part D
 Means test for Part D premium
 The Coverage Gap or “Donut Hole” is closing
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11. 2013 Part D Premium Adjustment
If your Modified Adjusted Gross Income in 2011 was:
You pay Social
Security an extra
(Individual Tax Return)
(Joint Tax Return)
$85,000 or less
$170,000 or less
$0
$85,001-$107,000
$170,00-$214,000
$11.60
$107,001-$160,000
$214,001-$320,000
$29.90
$160,001-$214,000
$320,001-$428,000
$48.30
Above $214,000
Above $428,000
$66.60
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12. Part D Coverage Gap Shrinking
2014
“Donut Hole”
 What: Discount and subsidy apply to Part D- covered
drugs in plan’s formulary or granted an exception by
plan.
 Brand name drugs- 52.5% discount (same as 2013)
 Generic drugs- 28% discount (change of 7%)
 Where: Point-of-Sale (e.g. at the pharmacy)
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13. Comparing Part D Plans
Use the Medicare.gov Plan Finder Tool
 Based on your own
 Zip code
 Prescription drug list
 Pharmacy . . .
 Sorts plans by the lowest estimated annual drug cost
(calculates donut hole costs as well)
 Check the new quality star rating
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14. Prevent Fraud and Abuse
 Medicare Card
 SS#
 Just Say NO!!!
 Contact HICAP at (408) 350-3200 option 2
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15. Health Insurance Counseling &
Advocacy Program
 HICAP counselors are available at Sourcewise
and at senior centers throughout Santa Clara
County
 Call HICAP at (408) 350-3200 Option 2 to make
an appointment
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16. Thank You
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18. 2013 Part B Premium
If your Modified Adjusted Gross Income in 2011 was:
You pay Social
Security
Individual Tax Return
Joint Tax Return
$85,000 or less
$170,000 or less
$104.90
$85,001-$107,000
$170,00-$214,000
$146.90
$107,001-$160,000
$214,001-$320,000
$209.80
$160,001-$214,000
$320,001-$428,000
$272.70
Above $214,000
Above $428,000
$335.70
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