Transcript Minnesota’s ADRC Grant:

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
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• 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 Medicarecovered 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
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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 Services
Listing 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 Services
Listing 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
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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:
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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
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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:
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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:
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Extended Basic
Plan K
Plan L
Plan M
– Plan N
– High Deductible Plan F
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
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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
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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
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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
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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)
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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)
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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
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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/coinsurance. 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
2011
Part D Standard Benefit
No Extra Help (LIS)
Donut Hole
5%
50% discount on
Brand Name drugs
7% discount on coinsurance for
generic drugs
95% Catastrophic
Benefit
100%
25%
75%
$310 Deductible
Beneficiary Costs
Part D Plan
2012
Part D Standard Benefit
No Extra Help (LIS)
Beneficiary Costs
Part D Plan
95% Catastrophic
Benefit
5%
Donut Hole
50% discount on
Brand Name drugs
14% discount on
co-insurance for
generic drugs
100% with discounts
25%
75%
$320 Deductible
Monthly Premium
Drug Costs
Over $6,657.50
(copays of $2.60/$6.50 or 5%)
$2,930.01 - $6,657.50
$320.01 - $2,930
$.01 - $320
Extra Help Paying for Part D Costs
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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
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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?