MEDICARE MEDICARE ADVANTAGEADVANTAGE

MEDICARE MEDICARE SUPPLEMENT SUPPLEMENT

PLANSPLANS

SCOPE OF SCOPE OF APPOINTMENTAPPOINTMENT

Independent AgentIndependent Agent

• I work for the best interest of my clients.

• Each year I spend 4-6 weeks familiarizing myself with all the changes in Medicare and private insurance companies.

Unique ServiceUnique Service

• I represent 20 of the major health insurance carriers in California

• Each of my clients are enrolled into an approved Medicare plan with the richest benefits that best suits their lifestyle and healthcare needs

• Uncompromised Integrity

• Unbiased information to help you select the right plan

• ALL OF THIS at NO COST to you!

MedicareMedicare

• Medicare is a health insurance program for:– People 65 years of age and older– People under age 65 with certain disabilities– People of all ages with End-Stage Renal Disease

• Medicare is an entitlement

• Part A premiums paid up with beneficiary or spouse working 40 quarters

• Part B premiums $110.50 (or $96.40 if enrolled prior to 2009) per month.

Parts of MedicareParts of Medicare

Medicare

PART A

PART B

PART C

PART D

Medicare Basics: Part AMedicare Basics: Part AOriginal Medicare – Part

A

• Hospital Stays– $1,100 Deductible for

hospital stays days 1-60– 61-90 days: $275/day

coinsurance – 91-150 days: $550/day

coinsurance

• Skilled Nursing Facility Care– 1-20 days $0 per day– 21-100 days $137.50 per

day– Days 100+ beneficiary pays

100% of costs

Medicare Basics: Part BMedicare Basics: Part B

Original Medicare – Part B

• Doctors’ Services

• Outpatient Hospital Care

• Durable Medical Equipment

• Some Medical Services (not covered by Part A)

• For details, see "Medicare & You" at www.medicare.gov

Medicare Basics: Part BMedicare Basics: Part B

• $110.50 monthly Part B premium (varies per income)

• $155 Annual Deductible*

• Other deductibles, copayments, coinsurance (20% coinsurance for most services)

• If you don't sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.

Medicare Basics: What Medicare Medicare Basics: What Medicare DOESN’TDOESN’T CoverCover

Original Medicare does NOT cover:

• Deductibles

• Coinsurance and co-pays

• Most outpatient prescription drugs

• Dental care

• Hearing aids, hearing exams and screenings

• Routine eye care and most glasses

• Most health care outside the U.S.

How To Cover what Medicare How To Cover what Medicare Does Not:Does Not:

• Medicare Supplement or Advantage plans

• One must:– Have Medicare parts A

& B– Live in the plans

service area– NOT have ESRD

• Unless aging in or in CareMore service area

12

Medicare Supplement Medicare Supplement PlansPlans

• Health Insurance Plan sold by private insurance companies (policies)

• Designed to fill in “gaps” of Original Medicare Part A and Part B

• Companies must offer certain plans (A, C, F) but not all

• Plans are standardized (6/2010) and regulated by states and Federal (CMS)

• Plan premiums are in addition to Part B premiums

• Do not include a Prescription Drug Plan (Part D)

13

Advantages of Med-Supp Advantages of Med-Supp PlansPlans

• Choice of any Medicare contracted physician or hospital

• Portable – Policy moves with the policyholder anywhere in the U.S. and its territories

• Guaranteed renewable

• May lower out-of-pocket costs– Covers co-pays and coinsurance

Where to go for Where to go for InformationInformation

• I represent 8 of the most competitive Medicare Supplements

• Medicare and You Guide (2011)

• 2011 Choosing a Medi-Gap Policy

• Websites for Medicare and Social Security– www.medicare.gov– www.socialsecurity.gov

• Medicare Beneficiaries also may want to check with their local State Health Insurance Assistance Program (SHIAP)

Prescription Drug Plans Prescription Drug Plans (Part D)(Part D)

• Medicare has minimum requirements

• Plans can choose to increase benefits, but not fall below minimum requirements

• Stand alone Prescription Drug Plans (PDP’s) have a monthly premium

• Plans have different formularies, tiers, and co-pay amounts

• One may have to pay a late enrollment penalty if not enrolled in a Part D plan when first eligible

Part D Terms DefinedPart D Terms Defined

• Formulary: A list of prescription drugs, both generic and brand name that are available through your health plan.

• Tier: Drugs on a formulary are usually grouped into tiers, and your co-payment is determined by the tier that your medication is on.

• Co-Pay: Your share of the cost of a prescription. The remaining cost is paid by your health plan.

• Mail-Order: Prescriptions ordered through mail-order may receive discounts, such as receiving a 3 month supply for the co-pay of 2 months

Medicare Minimum Part D Medicare Minimum Part D RequirementsRequirements

• $310 Annual Deductible

• Initial Coverage (IC) - 25% Co-insurance for next $2,530 of approved formulary prescription costs ($635.50)

• Beneficiary pays 100% of all formulary drugs costs for next $3,607.50 (GAP). New 50% brand name donut hole discount applies.

• When TROOP (TRue Out Of Pocket costs) reaches $4550, begin catastrophic coverage

• Catastrophic Coverage - $2.50-6.30 copay or 5% co-insurance (whichever is greater) for formulary drug cost for remainder of calendar year

TROOP

DED $310.00IC $635.50

GAP $3,607.50$4,550.00

How Will the Donut Hole Discount How Will the Donut Hole Discount Work?Work?**

• Part D plan members who reach the donut hole (after incurring $2,840 in drug costs in 2011) will immediately receive a 50% discount on Part D approved brand name drugs plus a $2-$5 dispensing fee.

• “Applicable drugs” refer to brand name drugs provided by manufacturers who have signed an agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the discount program. Drugs sold by manufacturers who do not sign an agreement will not be covered under Part D and cannot be requested by exception. CMS expects that most, if not all, manufacturers will sign agreements. Beneficiaries with non-applicable drugs will automatically receive the 7% generic drug discount.

What Costs Count Toward TrOOP — True Out-Of-Pocket Costs?

For brand name drugs, the total cost of the drug will be counted toward one’s TrOOP, not just the 50% the beneficiary pays. For generics, however, only the amount the beneficiary pays, which in this case includes the dispensing fee, will count toward their TrOOP. This is because the 7% discount is provided through an additional subsidy from Medicare, rather than through rebates from the drug manufacturers.

For example, Anne just entered the donut hole and her brand-name prescription drug costs $70, plus a $2 dispensing fee. She’ll pay $37 ($35 for 50% of the drug’s cost + $2 dispensing fee), but $70 will be counted toward her TrOOP.

Anne also takes a generic drug which costs $10 plus a $2 dispensing fee. The 7% subsidy applies to both her drug cost and the dispensing fee, so she’ll pay a total of $11.16, all of which will count toward her TrOOP.

*http://www.cahealthadvocates.org/news/drugs/2010/discount.html

Donut Hole Discount Donut Hole Discount ExceptionsExceptions**

• The brand name and generic drug donut hole discounts do not apply to people with the low-income subsidy (LIS) and/or people in a retiree drug subsidy program.

• As mentioned, the discount is only available if the drug's manufacturer has signed an agreement to participate in the discount program. Drugs sold by manufacturers who do not sign an agreement will not be covered under Part D and cannot be requested by exception.

• The discount is only available if Medicare Part D is the primary payer. If there is secondary insurance, it will pay after the Part D discount has been applied.

• In addition, if a beneficiary fills a prescription that crosses Part D stages of coverage, also referred to as a “straddle claim,” the discount will only apply to the portion of the prescription that falls under the donut hole.

*http://www.cahealthadvocates.org/news/drugs/2010/discount.html

Extra HelpExtra Help

You may qualify for Extra Help, also called the low-income subsidy (LIS), from Medicare to pay prescription drug costs if your yearly income and resources are below the following limits in 2010: – Single person—Income less

than $16,245 and resources less than $12,510

– Married person living with a spouse and no other dependants—Income less than $21,855 and resources less than $25,010

Resources DefinedResources Defined• Resources include money in a checking or savings

account, stocks, and bonds.

• Resources DO NOT include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person), or life insurance policies.

• If you qualify for Extra Help and join a Medicare drug plan, you will get the following: – Help paying your Medicare drug plan’s monthly

premium, any yearly deductible, coinsurance, and copayments

– No coverage gap– No late enrollment penalty

Medicare Advantage Plans Medicare Advantage Plans (Part C)(Part C)

• Are offered by private companies approved by Medicare

• Provide all Part A and Part B coverage and must cover, at least, all services of Original Medicare except hospice care

• Hospice care is covered by Medicare

• May offer extra coverage such as vision, hearing, dental, and/or health and wellness programs, and Part D.

• Plan benefits are subject to yearly changes as approved by Medicare

• Any Medicare Advantage premiums are in addition to Part B premiums

Medicare Advantage Plan Medicare Advantage Plan TypesTypes

• Health Maintenance Organization (HMO) Plans

• Preferred Provider Organization (PPO) Plans

• Private Fee-for-Service (PFFS) Plans

• Special Needs Plans (SNP)

Health Maintenance Organization (HMO) PlanCan I get my health care from any doctor or hospital?

No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out ‑of ‑area urgent care, or out dialysis). In some plans, you may be able to go out for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

Are prescription drugs covered?

In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?

In most cases, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services like yearly screening mammograms don’t require a referral.

What else do I need to know about this type of plan?

•If your doctor leaves the plan, your plan will notify you. You can choose another doctor in the plan. •If you get health care outside the plan’s network, you may have to pay the full cost.•It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

Preferred Provider Organization (PPO) Plan

Can I get my health care from any doctor or hospital?

In most cases, yes. PPOs have network doctors and hospitals, but you can also use out ‑network providers for covered services, usually for a higher cost.

Are prescription drugs covered?

In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers it.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

No.

What else do I need to know about this type of plan?

There are two types of PPOs: Regional PPOs and Local PPOs. Regional PPOs serve one of 26 regions set by Medicare. Local PPOs serve the counties the PPO Plan chooses to include in its service area.

Private Fee-for-Service (PFFS) PlanCan I get my health care from any doctor or hospital?

In some cases, yes. You can go to any Medicare ‑approved doctor or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members.

Are prescription drugs covered?

Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan (Part D) to get coverage.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

No.

What else do I need to know about this type of plan?

•PFFS Plans aren’t the same as Original Medicare or Medigap. •The plan decides how much you pay for services. •Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before. •If you join a PFFS Plan that has a network, you may pay more if you choose an out-of-network doctor, hospital, or other provider. •Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before. •For each service, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms. •In an emergency, doctors, hospitals, and other providers must treat you.

Special Needs Plan (SNP)Can I get my health care from any doctor or hospital?

You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out ‑of ‑area dialysis).

Are prescription drugs covered?

Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

Do I need to choose a primary care doctor?

Generally, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services like yearly screening mammograms don’t require a referral.

What else do I need to know about this type of plan?

•A plan must limit membership to the following groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, ESRD, or HIV/AIDS).•Plans may further limit membership. Plans should coordinate the services and providers you need to help you stay healthy and follow your doctor’s orders. •If you have Medicare and Medicaid, your plan should make sure that all plan doctors or other health care providers you use accept Medicaid. •If you live in an institution, make sure plan providers serve people where you live.

Medicare Advantage Election Medicare Advantage Election PeriodsPeriods

• Annual Enrollment Period (AEP): November 15th through December 31st. (in 2011 changes to October 15th through December 7th)

• Annual Dis-enrollment Period (ADP): January 1st through February 14th

• Initial Election Period (IEP):7 month Election Period Begins 3 months before month of entitlement Ends last day of 3rd month after month of the earlier effective date of Part A/B entitlement (usually 65th birthday).

• Lock-In: People with a Medicare Advantage plan are “locked-in,” meaning they can only switch Medicare plans during certain times of the year unless they qualify for a Special Election Period.

• Special Election Period (SEP): A time when beneficiaries can change their benefits because of specific life changes. Examples are moving out of a plan service area, or becoming eligible for Medicaid/Medi-Cal.

Medicare Advantage Medicare Advantage PlansPlans

For all plans:

• How to change your PCP (Primary Care Physician)

• Enrollment and Dis-enrollment process

• Appeals and Grievance process

• Membership Card and Welcome Kit

Selecting Suitable PlansSelecting Suitable Plans

www.medicare.gov• Medications• Preferred Doctors• Specialists• Important Added Value

Benefits