Welcome to Medicare:A,B,C and D

Rhonda Whitenack, Public Affairs Specialist,

Social Security Administration

Robert Grams, Health Insurance Counselor

Metropolitan Area Agency on Aging and MN SHIP

What is Medicare?

• Health Insurance Program for: – People age 65 and older

– People under 65 with a certified disability

– People of any age with End-Stage Renal Disease (ESRD)

• Permanent kidney failure or kidney transplant

– People of any age with ALS (Lou Gehrig’s Disease)

Medicare Parts A thru D

• Part A: Hospital Insurance• Part B: Medical Insurance

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~• Part C: Medicare Advantage

– Option that replaces Original Medicare (Parts A and B)

• Part D: Prescription Drug Coverage– Through a Medicare Advantage plan or a Stand Alone

Prescription Drug Plan (PDP)

Medicare Card (Front)

Medicare Card (Back)

Medicare Eligibility Age 65 and Older

• May receive Part A premium-free if: – Worked 40+ quarters (at least 10 years)– Spouse of someone with 40 work quarters

• May purchase Medicare: – U.S. citizens who have not worked 40 quarters– Legal aliens admitted for permanent residence who

have lived in the U.S. for 5+ consecutive years– Also known as “voluntary enrollees”

Other types of Medicare Eligibility

• Person under 65 who has received 24+ months of Social Security Disability benefits

• Person of any age with End Stage Renal Disease who has had a kidney transplant or who receives regular dialysis

• Person of any age with ALS (Lou Gehrig’s Disease)

Types of Medicare Enrollment

• Initial Enrollment

• Special Enrollment

• General Enrollment

Initial Enrollment Period

• 7 Month Period– 3 months before you are eligible

– The month you are eligible• The month you turn 65 OR• The 25th month you are certified disabled

– 3 months after you are eligible

How do I enroll?

• If you already receive Social Security or RR Benefits:

– Entitled to Medicare the first of the month you turn 65

– Do not need to do anything to enroll• A card will be mailed three months before you turn 65

• If you are not receiving Social Security or RR Benefits: – Apply online or visit your local Social Security Office

When to Waive Part B• You can delay enrolling into Part B and avoid paying the

monthly premium until you need it if you are age 65 or older and have health coverage through your or your spouse’s employer or union – Must contact Social Security and inform of your

decision– Have a clear understanding of employer’s plan

coverage before making this decision– Must be actively employed

Special Enrollment Period for Part B

• Can enroll in Part B anytime while covered under the group plan

OR• During the 8 month period that begins the month

active employment ends or when the group health coverage ends, whichever comes first

General Enrollment Period

• January 1st through March 31st of every year• Coverage will begin the following July 1st

• Part A Penalty: 10% for voluntary enrollee who does not elect Part A during initial or Special Enrollment Period

• Part B Penalty: 10% of the Part B premium charged for every 12 months one was late enrolling

Medicare Part A

• In-patient hospital care

• Skilled nursing facility (SNF) care

• Home health care

• Hospice Care

Medicare Part A Premium

• Most receive Part A premium-free because they have at least 40 quarters or work credits of Medicare-covered employment

• Voluntary enrollees pay: – $248/month if have 30 – 39 quarters of employment

– $450/month if have less than 30 quarters of employment

– 2012 cost sharing to be announced

Medicare Part A Cost of Coverage• Hospital Coverage

– Deductible for days 1 – 60: $1,132– Days 61 – 90: $283 co-payment per day– Days 90 – 150: $566 co-payment per day

• Skilled Nursing Facility Coverage– No costs for days 1 – 20– Days 21 – 100: $141.50 per day

• Home Health Care Coverage and Hospice Coverage– No cost for covered services

(2012 cost sharing to be announced)

Medicare Part B

• Physician Services

• Outpatient Services

• Ambulance Services

• Durable Medical Equipment (DME)

Medicare Part B Cost Sharing

• Premium: $115.40– Those on Medicare before 2010 who had their premium deducted

from the Social Security check continue to pay $96.50, unless income is greater than $85,000. 2010 enrollees continue to pay $110.50 unless income is greater than $85,000.

• Deductible: $162• Co-insurance: 20% for most services

– 45% for mental health services

(2012 cost sharing to be announced)

Medicare Part B Premium

Income Threshold Part B Individual Monthly Premium

Less than or equal to $85,000 ($170,000 couples) and did have Social Security withhold Medicare Part B premiums in 2010

$96.50

Less than or equal to $85,000 ($170,000 couples) and did not have Social Security withhold Medicare Part B premiums in 20

$115.40

Greater than $85,000 and less than or equal to $107,000 ($170,000 to $214,000 couples)

$161.50

Greater than $107,000 and less than or equal to $160,000 ($214,000 to $320,000 couples)

$230.70

Greater than $160,000 and less than or equal to $214,000 ($320,000 to $428,000 couples)

$299.90

Greater than $214,000 ($428,000 couples) $369.10

Medicare Covered Preventative Services• NEW Annual Medicare Wellness Visit• Welcome to Medicare physical• Bone Mass Measurements• Cardiovascular Screening• Colorectal Cancer Screening• Diabetes Screening• Immunizations: Flu, Hepatitis B, Pneumococcal• Mammograms• Pap Test and Pelvic Exam• Prostate Cancer Screening

Medicare Covered Items and ServicesListing limited to frequently asked about items and services

• Ambulance Services – when medically necessary

• Diabetic Supplies– glucose testing monitors, test strips, etc.

• Durable Medical Equipment– walkers, wheelchairs, oxygen

• Emergency Room Services• Eyeglasses

– After special cataract surgery

Medicare Covered Items and ServicesListing limited to frequently asked about items and services cont.

• Foot Exams/Treatment– If diabetes related & meet certain conditions

• Kidney Dialysis Services• Prescription Drugs

– A limited number of drugs are covered under Part B

• Prosthetic/Orthotic Items• Second Surgical Opinions• Tests

– X-rays, MRIs, CT Scans, EKGs

Services Not Covered by Medicare

• Dental Care and Dentures

• Health care outside the U.S.

• Hearing Aids and Hearing Exams

• Orthopedic Shoes

• Routine foot care, eye care and physical exams

• Long-term Care

• Shots – except those for prevention

Medicare Summary Notice (MSN)

• In Original Medicare, an MSN is issued every 3 months if Part A or Part B services were provided

• It is not a bill

• Shows the amount that will be owed to the provider after Medicare has paid– “You may be billed” field

• Includes instructions on how to file an appeal

Medicare Summary Notice and Medicare Fraud

• Review MSN when received for: – Procedure/services provided

– Amount you may owe the provider

– Provider name

– Dates of Service

• You may appeal discrepancies within 120 days• If you feel you have been a victim of fraud and intentionally

billed incorrectly: – Call the provider to discuss issue

– Call the Senior LinkAge Line® to file a report

Original Medicare

• Medicare Part A and B– Fee-for-service plan managed by Federal Government

– Use your red, white and blue card when receiving services

– Can go to any doctor or hospital that accepts Medicare

– Must pay deductibles and co-insurance or co-payment amounts

Medigap Insurance

• Supplements Original Medicare

• Must have Parts A and B to buy a Medigap policy

• Sold by private insurance companies

• Minimum benefit levels are mandated by Minnesota law

• Covers costs or “gaps in coverage” that Medicare does not pay

• Must pay a monthly premium

Standardized Medigap Plans in Minnesota

• Basic Plan Coverage:

– Medicare Part A co-insurance– Part B co-insurance– Blood – 1st three pints/year– 80% of emergency foreign travel– 45% of most outpatient mental health services– 20% of physical therapy– State mandated benefits

Standardized Medigap Plans in Minnesota

• Optional Riders: – Medicare Part A deductible – Part B annual deductible– Excess Rider – Preventive Care Rider

• Additional Medigap Policies: – Extended Basic – Plan N– Plan K – High Deductible Plan F– Plan L– Plan M

When to Buy a Medigap Policy

• Open Enrollment Period– Starts the month you are 65 or the 25th month of certified

disability and enrolled in Part B– Lasts 6 months

• During the Open Enrollment Period the company cannot: – Deny you any Medigap policy it sells– Make you wait for coverage to start, with some exceptions– Charge you more for a policy because of existing health

problems

Cost Plans

• Available in limited areas

• May be able to join even if you only have Medicare Part B

• Can join anytime plan is accepting new members

• Can leave and return to Original Medicare at any time

• May see a non-network provider– Services are then covered under Original Medicare

• Can get Medicare prescription drug coverage

Medicare Part C: Medicare Advantage

• Provided by private insurance companies approved by Medicare– May only receive coverage through the Medicare Advantage

plan

• Most charge a monthly premium– Must still pay your Medicare Part B premium

• May include Part D

• May include extra benefits, such as hearing and vision

Medicare Advantage Plans cont.

• In some cases, you must take the drug coverage that is included with the plan– You may not choose a Stand Alone Part D plan

• Cannot have a Medigap policy

• Are responsible for the co-pays and co-insurance set by the plan

• May have a network of doctors you must use

Enrollment in a Medicare Advantage Plan• Must live in the service area of the plan you would like to join• Must have Medicare Part A and B• Cannot have End-Stage Renal Disease• NEW – Beginning Fall 2011, the Annual Open Enrollment Period

will change to October 15 – December 7 (plan effective date January 1, 2012)

Medicare Advantage Disenrollment Period

• January 1, 2012 – February 15, 2012• During this new Medicare Advantage Disenrollment period:

– Beneficiaries can disenroll from a Medicare Advantage plan and switch to Original Medicare

– Beneficiaries can enroll in a Stand Alone PDP plan when returning to Original Medicare

– Beneficiaries enrolled in a Medicare Advantage plan cannot switch to another Medicare Advantage plan

– Beneficiaries in Original Medicare cannot enroll in a Medicare Advantage plan

Medicare Advantage Plan Options in Minnesota

• Health Maintenance Organizations (HMO)

• Preferred Provider Organization Plans (PPO)

• Private Fee-for-Service Plans (PFFS)

• Special Needs Plans (SNPs)

Things to Consider When Choosing a Plan

• Cost

• Benefits

• Doctor & Hospital Choice

• Travel

• Prescription Drugs

• Pharmacy Choice

• Quality of Care

Medicare Part D – Prescription Drug Coverage• Began January 1, 2006• Coverage is through a Stand Alone prescription drug coverage

or as part of a Medicare Advantage Plan – Plans are offered by private insurance companies approved by

Medicare

• Separate monthly premium for most plans• Must have Medicare Part A, Part B or both• Is a voluntary benefit

– However, if you do not enroll when first eligible you may face a penalty later

Medicare Part D Enrollment Periods

• Initial Enrollment Period (IEP)– 7 month period starting 3 months before the month of 65th birthday

or 25th month of certified disability

• Annual Open Enrollment Period (OEP)– November 15 though December 31– Coverage is effective January 1 of following year– Beneficiaries may join, drop or switch coverage– NEW! Beginning Fall 2011, Annual Election Period will change to

October 15 – December 7

• Special Enrollment Period (SEP)– Moving, plan leaves the market, dual eligible, loss of creditable coverage

Late Enrollment Penalty• People who do not join a Part D plan when they are

eligible may pay a penalty– Add 1% of the national base premium for each month you

should have had a plan, but did not enroll– Must pay the penalty as long as you are enrolled in a Part D

plan

• Penalty does not apply to those who have creditable coverage or if you have dual eligibility– You are a dual eligible if you receive Medicare and are on

Medical Assistance or a Medicare Savings Program

2012 Standard Benefit for Medicare Part D: You Pay

• Monthly Premium• Deductible: $320• Initial Coverage Limit: 25% co-insurance per prescription drug• Donut Hole: 100% of prescription drugs once you and the plan

both pay $2,930.01. 50% discount on brand name and 14% discount on generic drugs purchased while the beneficiary is in the donut hole.

• Catastrophic Coverage: 5% co-insurance per drug after you pay $4,700 out of pocket

*Plans may have a lower deductible or set their own co-pays/co-insurance. It is important to compare plans when deciding.

Medicare Part D Premiums

• Higher income beneficiaries will pay higher Medicare Part D monthly premiums – $85,000 individuals

– $170,000 couples

– Not indexed for inflation• Waiting for additional information from CMS

2011Part D Standard BenefitNo Extra Help (LIS)

75%

5%95% Catastrophic Benefit

100%

25%

$310 Deductible

Beneficiary CostsPart D Plan

Donut Hole50% discount on Brand Name drugs

7% discount on co-insurance for generic drugs

5%95% Catastrophic Benefit

100% with discounts

75%25%

$320 Deductible

Monthly Premium

$2,930.01 - $6,657.50

$320.01 - $2,930

$.01 - $320

Over $6,657.50 (copays of $2.60/$6.50 or 5%)

Drug Costs

Beneficiary CostsPart D Plan

2012Part D Standard Benefit

No Extra Help (LIS)

Donut Hole50% discount on Brand Name drugs

14% discount on co-insurance for generic drugs

Extra Help Paying for Part D Costs

• Administered by Social Security Administration

• Helps pay for Medicare Part D cost sharing

• Full and Partial LIS are available

• Must complete application and send to SSA or complete online application at www.ssa.gov

• Income must be below 150% of FPG or $1,362/single or $1,839/couple

• Assets must be below $12,640 for single and $25,260 for a couple

Additional Extra Help is Available

• Medicare Savings Programs– QMB– SLMB– QI-1

• Medical Assistance

Send completed application to your county– Application assistance is available through Senior LinkAge

Line®

MinnesotaHelp Network™ is here to help you

• Senior LinkAge Line® 1-800-333-2433• Disability Linkage Line ® 1-866-333-2466• Veterans Linkage Line ™ 1-888-LinkVet• www.MinnesotaHelp.info ®• http://longtermcarechoices.minnesotahelp.info/• Local community based sites throughout Minnesota

Questions or Comments?