Everything You Need to Know About Medicare

San Antonio Association of Health UnderwritersAugust 28, 2014

Learn How Medicare Works

• What are the different parts of Medicare?• What are my Medicare coverage choices?• Where can I get my questions answered?• Important Enrollment Information

What are the different parts of Medicare?

• Part A – Hospital Insurance (pages 29-33)• Inpatient care in hospitals• Skilled nursing facility care• Hospice care• Home health care

What are the different parts of Medicare?

• Part B - Medical Insurance (pages 34-55)• Outpatient care• Home health care• Durable medical equipment• Some preventive services

What are the different parts of Medicare?

• Part C – Medicare Advantage (pages 72-83)• Includes all benefits and services covered under Part A and Part B• Run by Medicare approved private insurance companies• Usually includes Medicare prescription drug coverage (Part D) as a part of the

plan• May include extra benefits and services for an extra cost

What are the different parts of Medicare?

• Part D – Prescription Drug Coverage (pages 87-102• Helps cover the cost of prescription drugs• Run by Medicare approved private insurance companies• May help lower your prescription drug costs and help protect against higher

costs in the future

What are my Medicare coverage choices?

• Step One: decide how to get your coverage• Original Medicare

• Part A and Part B• Medicare Advantage Plan

• Part C – Combines Part A, Part B and usually Part D

• Step two: Decide if you need to add drug coverage• Stand alone PDP (Prescription Drug Plan)• MAPD (Medicare Advantage Plan with Drugs)

• Step three: Decide if you need to add supplemental coverage• Medicare Supplement Plan (sometimes called a Medigap plan)

Where can I get my questions answered?

• Independent agents• 1-800-MEDICARE (1-800-633-4227)• SHIP – State Health Insurance Assistance Program• Social Security• Medicare Coordination of Benefits Contractor (COBC)• Department of Defense

Where can I get my questions answered?

• Department of Health and Human Services (DHHS)• Department of Veterans Affairs (VA)• Office of Personnel Management (OPM)• Railroad Retirement Board (RRB)

Signing Up for Medicare Parts A & B

• Some people get Part A and Part B automatically• Some people have to sign up for Part A and Part B• If I am not automatically enrolled, when can I sign up?• Should I get Part B?• How does my other insurance work with Medicare?• How much does Part A coverage cost?• How much does Part B coverage cost?

Some people get Part A and Part B automatically• If you are already getting benefits from Social Security or the RRB• If you are under age 65 and disabled

• After you get disability benefits for 24 months

• If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease)

• You will get your red, white and blue Medicare card 3 months before your 65th birthday

Some people have to sign up for Part A and Part B

• If you are close to age 65, but not getting Social Security or RRB and want Part A and Part B, you need to sign up

• If you have ESRD, you need to sign up• If you live in Puerto Rico, you will get Part A when you turn age 65• If you live in PR, you need to sign up for Part B

• Note: if you are eligible for Part B, but do not sign up, and do not have other creditable coverage, you may have to pay a late penalty

If I am not automatically enrolled, when can I sign up?• Initial Enrollment Period (IEP)• General Enrollment Period• Special Enrollment Period (SEP)

Important Enrollment Information

• OEP – Open Enrollment Period (formerly called Annual Election Period or AEP)

• October 1 -15, 2014 (Start comparing coverage)• October 15 – December 7, 2014 (Enrollment period)• January 1, 2015 (Coverage begins)• January 1 – February 14, 2015 (MADP – Medicare Advantage

Disenrollment Period)

Initial Enrollment Period

• You may sign up for Medicare during the 7 month period that begins three months before the month you turn age 65, includes the month you turn age 65, and the three months after the month you turn age 65

• Example: November 12 birthday• August, September, October• November• December, January, February

General Enrollment Period

• January 1 – March 31 each year• Your coverage will begin July 1 of that year• You may have to pay a higher Part A and Part B premium for late

enrollment• (see pages 26 and 28)

Special Enrollment Period

• If you did not sign up when you were first eligible, you can sign up for Part A and Part B

• Anytime you were covered by a group health plan• During the 8 month period that begins the month after the employment ends

or the coverage ends, whichever happens first

• Do not confuse this period with a Special ELECTION Period!

Should I get Part B?

• Employer or Union Coverage• Tricare

How does my other insurance work with Medicare?

• See chart on page 24• Retiree• 20 or more employees• 19 or fewer employees• 100 or more employees and you are under age 65• 99 or fewer employees and you are under age 65• ESRD

How much does Part A coverage cost?

• $426 per month• Most people do not pay for Part A if you or your spouse paid

Medicare taxes while working

How much does Part B coverage cost?If your yearly income in 2012 (for what you pay in 2014) was

You pay (in 2014)File individual tax return File joint tax return File married & separate tax return

$85,000 or less $170,000 or less $85,000 or less $104.90

above $85,000 up to $107,000

above $170,000 up to $214,000 Not applicable $146.90

above $107,000 up to $160,000

above $214,000 up to $320,000 Not applicable $209.80

above $160,000 up to $214,000

above $320,000 up to $428,000 above $85,000 and up to $129,000 $272.70

above $214,000 above $428,000 above $129,000 $335.70

Part B Premium

• What is the Part B late enrollment penalty?• 10% for each full 12 month period in which you could have had Part B but did

not sign up for it

• How can I pay my Part B premium?• If you get Social Security, RRB, or OPM benefits, your Part B premium will be

automatically deducted• If you do not receive these benefits, you may pay by mail

Find Out if Medicare Covers Your Test, Service or Item

• What services does Medicare cover?• Part A covered services• Part B covered services• Want to keep track of your preventive services?• What’s NOT covered by Part A and Part B?

What services does Medicare cover?

• Certain medical services and supplies in hospitals, doctors’ offices, and other health care settings

• Services are covered by either Part A or Part B• You must be a US citizen or be lawfully present in the US

Part A covered services

• Inpatient care in hospitals• Inpatient care in a skilled nursing facility• Hospice care services• Home health care services• Inpatient care in a religious, non-medical health care institution• Blood

Part A covered services

• Home health care – must be unable to leave home• Hospice – doctor must certify that you are terminally ill and expected

to love 6 months or less• All items and services needed for pain relief and symptom management• Medical, nursing and social services• Drugs• Certain DME (Durable Medical Equipment)• Other services may include spiritual and grief counseling

Part B covered services

• See pages 34-54

Want to keep track of your preventive services?• Page 55

What’s NOT covered by Part A and Part B?

• Long term care (see pages 127-129)• Also called custodial care

• Routine dental or eye care• Dentures• Cosmetic surgery• Acupuncture• Hearing aids and exams for fitting them

Choose Your Health and Prescription Drug Coverage

• What if I need help deciding how to get my Medicare?• What are my Medicare coverage choices?• What should I consider when choosing or changing my coverage?

What if I need help deciding how to get my Medicare?• Visit www.Medicare.gov

What are my Medicare coverage choices?• Step 1: Decide if you want Original Medicare or a Medicare Advantage

Plan• You can choose Original Medicare.• You can choose a Medicare Advantage Plan (like an HMO or PPO).

• Step 2: Decide if you want prescription drug coverage (Part D)• You choose Original Medicare.• You choose a Medicare Advantage Plan.

• Step 3: Decide if you want supplemental coverage (Original Medicare only)

• You may want to get coverage that fills gaps in Original Medicare coverage. You can choose to buy a Medicare Supplement Insurance (Medigap) policy from a private company.

• Costs vary by policy and company.• Employers/unions may offer similar coverage.

What should I consider when choosing or changing my coverage?• Your other coverage• Cost• Doctor and hospital choice• Prescription drugs• Quality of care• Convenience• Travel

Get Information About Your Medicare Health Coverage Choices• How does Original Medicare work?• What are Medicare Supplement Insurance (Medigap) policies?• What are Medicare Advantage plans (Part C)?• Are there other types of Medicare health plans?

How does Original Medicare work?

• Can I get my health care from any doctor, other health care provider, or hospital?

• Are prescription drugs covered?• Do I need to choose a primary care doctor?• Do I have to get a referral to see a specialist?• Should I get a supplemental policy?• What else do I need to know about Original Medicare?

What do I pay?

What are Medicare Summary Notices (MSNs)?

www.MyMedicare.gov

What is Medicare assignment?

• Make sure your doctor, provider, or supplier accepts assignment• If your doctor, provider or supplier does not accept assignment

What are private contracts?

• Defined:• Rules for private contracts

• You do not have to sign a private contract

Creditable prescription drug coverage

• If you do not join a Medicare PDP when you are first eligible, you may have to pay a late enrollment penalty.

What are Medicare Supplement Insurance (Medigap) policies?• Medicare Supplement policies (a.k.a. Med Sup or Medigap policies),

sold by private health insurance companies, can help you pay for some of the health care costs that Medicare does not cover like deductibles, coinsurance and copays.

• Some offer coverage for services that Original Medicare does not cover

• Travel outside of the US• Discount vision, hearing or eye exams and related supplies• Gym memberships like www.SilverSneakers.com

Important facts about Medicare Supplement, Med Sup or Medigap policies• Medigap policies are standardized• How do you compare Medigap policies?• You must be enrolled in both Parts A and B• You must pay a monthly premium• Only one policy per person• Best time to buy is during your Medigap Open Enrollment Period

• 6 month period begins on the day in which you are either 65 or older ad enrolled in Part B

Medigap Benefits

Medigap Plans

A B C D F* G K L M N

Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Part B coinsurance or copayment Yes Yes Yes Yes Yes Yes 50% 75% Yes Yes*

**

Blood (first 3 pints) Yes Yes Yes Yes Yes Yes 50% 75% Yes Yes

Part A hospice care coinsurance or copayment

Yes Yes Yes Yes Yes Yes 50% 75% Yes Yes

Skilled nursing facility care coinsurance No No Yes Yes Yes Yes 50% 75% Yes Yes

Part A deductible No Yes Yes Yes Yes Yes 50% 75% 50% Yes

Part B deductible No No Yes No Yes No No No No No

Part B excess charges No No No No Yes Yes No No No No

Foreign travel exchange (up to plan limits) No No Yes Yes Yes Yes No No Yes Yes

Out-of-pocket limit** N/A N/A N/A N/A N/A N/A $4,940 $2,470 N/A N/A

How does Medigap work with Medicare Advantage Plans?

What are Medicare Advantage plans (Part C)?

• MA plans are another way to get your Medicare coverage• MA plans cover all Medicare services• MA plans must follow Medicare’s rules

Different types of Medicare Advantage Plans

• Health Maintenance Organization (HMO) plans• Preferred Provider Organization (PPO) plans• Private Fee-for-Service Plan (PFFS) plans• Special Needs Plans (SNPs) plans• HMO Point-of-Service (HMOPOS) plans• Medical Savings Account (MSA) plans

What else should I know about Medicare Advantage Plans?• Joining and leaving• Prescription drug coverage• Who can join?• What if I have other coverage?• What if I have a Medicare Supplement policy?• What if I have End Stage Renal Disease (ESRD)?• What do I pay?

How do Medicare Advantage plans work?

• Can I get my health care from any doctor, other health care provider or hospital?

• Are prescription drugs covered?• Do I need to choose a primary care doctor?• Do I have to get a referral to see a specialist?• What else do I need to know about this type of plan?

When can I join, switch, or drop a Medicare Advantage plan?• When you first become eligible for Medicare?• If you get Medicare due to a disability• Between October 15-December 7 each year for a January 1 eff date• Can I make changes after December 7th?

• MADP – Medicare Advantage Disenrollment Period (Jan 1 – Feb 14)• Special Enrollment Periods

• Move• Medicaid• Institutionalized• Chronic illness• 5-star Special Enrollment Period – year round

Are there other types of Medicare health plans?• Medicare Cost Plans• Programs of All-inclusive Care for the Elderly (PACE)• Medicare Innovation Projects

Get Information About Prescription Drug Coverage• How does Medicare prescription drug coverage (Part D) work?• When can I join, switch, or drop a Medicare drug plan?• What do I pay?• What drugs are covered?

How does Medicare prescription drug coverage (Part D) work?• There are two ways to get prescription drug coverage

1. Medicare Prescription Drug Plans2. Medicare Advantage Plans

Note: if you have employer or union coverage

When can I join, switch, or drop a Medicare drug plan?• When you are first eligible for Medicare• If you get Medicare due to a disability• Between October 15-December 7 each year• Anytime if you qualify for “Extra Help” (see page 103)

SEPs – Special Enrollment Periods

• Move out of your service area• Lose other creditable coverage• Live in an institution• Have Medicaid• Qualify for “Extra Help”• 5-Star Enrollment Period• Chronic Illness

What do I pay for a Medicare drug plan?

• Your prescriptions and whether they are on the formulary• The PDP you choose has a premium• Which pharmacy you use

• Preferred• Non-preferred• Out of Network• Mail order

• If you get “Extra Help”

What do I pay for a Medicare drug plan?

• If you have a higher income, you might pay more for your Part D coverage (See next slide)

• Yearly deductible• Copay or coinsurance• Coverage Gap• Catastrophic coverage

What drugs are covered?

• Formulary• Tier 1-5• Prior Authorization• Quantity Limits• Step Therapy

How do other insurance and drug plans work with Part D?• Employer or union health coverage• COBRA• Medicare Supplement Insurance policy with prescription drug

coverage

How does other government insurance work with Part D?• FEHB – Federal Employee Health Benefits Program• VA – Veterans’ benefits• TRICARE (military health benefits)• HIS – Indian Health Services

Get Help Paying Your Health and Prescription Drug Costs• What if I need help paying my Medicare prescription drug costs?• What if I need help paying my Medicare health care costs?

What if I need help paying my Medicare prescription drug costs?• “Extra Help” is a Medicare program to help people with limited

income and resources to pay Medicare prescription drug costs• Also called LIS or low income subsidy

• Note: “Extra Help” is not available in Puerto Rico, the US VirgonIslands, Guam, the Northern Mariana Islands, and American Samoa

What if I need help paying my Medicare health care costs?• Medicare Savings Program – four types

1. QMB2. SLMB3. QI4. QDWI

Other Assistance Paying for Rx

• Medicaid• Demonstration plans for people who have both Medicare and

Medicaid• State Pharmacy Assistance Programs (SPAPs)• Pharmaceutical Assistance Programs (also called Patient Assistance

Programs)• Programs of All-inclusive Care for the Elderly (PACE)• Supplemental Security Income (SSI) benefits• Children’s Health Insurance Program (CHIP)

Know Your Rights and Help Protect Yourself from Fraud• What are my Medicare rights?• What’s an appeal?• What’s an “Advanced Beneficiary Notice of Non-coverage” (ABN)?• How does Medicare use my personal information? (page 119)• How can I protect myself from identity theft? (page 122)• How can I protect myself and Medicare from fraud? (page 122)

Senior Medicare Patrol (page 124)

• Educates and empowers people with Medicare to take an active role in detecting and preventing health care fraud and abuse

Plan Ahead for Long Term Care

• How do I plan for long term care?• How do I pay for long term care?

• Personal resources• Medicaid• VA• PACE• LTCI

• What are advanced directives?

What are advanced directives?

• A legal document that allow you to put in writing the kind of health care you would want or name someone who can speak for you if you were too ill to speak for yourself

• Advance directives often include:• A health care proxy• A living will• After-death wishes

Get More Information

• Where can I get personalized help?• Where can I find Medicare information online?• How do I compare the quality of plans and providers?• What’s Medicare doing to better coordinate my care?• Can I manage my health information online?• Are there other ways to get Medicare information?• Are resources available for caregivers?

Using www.Medicare.gov

Medicare and Medicaid Coordination

• Health information technology (Health IT)• Electronic Health Records (EHRs)• Electronic prescribing• Accountable Care Organizations (ACOs)• Comprehensive Primary Care Initiative

Fraud, Waste and Abuse

Did you learn everything you ever wanted to know about

Medicare?

If not, now is the time to ask!