Transcript Medicare Madness: Navigating through open enrollment

Joani Shaver, Director
Blount County Office on Aging
November, 2014
Health insurance for the following
people:
◦ Those 65 and older
◦ Those younger than 65 with certain
disabilities
◦ Those with End-Stage Renal Disease
(permanent kidney failure)
•Most outpatient prescription drugs
•Routine vision care
•Long-term care
•Routine dental care
•Dentures
•Hearing aids (exams and fittings)
•Routine foot care
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Medicare Part A (Hospital Insurance)
◦ Inpatient care in hospitals
◦ Skilled nursing facility, hospice, and home health
care
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Medicare Part B (Medical Insurance)
◦ Doctors’ services, hospital outpatient care and
home health care
◦ Some preventive services

Medicare Part D
◦ Prescription drug option run by Medicareapproved private insurance companies
◦ Prescription drugs
◦ May help lower your prescription drug
costs and help protect against higher
costs in the future

Medicare Part C (Advantage Plan)
◦ Health plan managed by Medicareapproved private insurance companies
◦ Includes all benefits and services covered
under Part A and Part B
◦ May include extra benefits and services for
an extra cost
◦ Usually includes Medicare prescription
drug coverage (Part D)
ORIGINAL
MEDICARE
TOTAL
HEALTHCARE
COVERAGE
Premium remains $104.90
 Part B deductible remains $147
 Part A hospital inpatient

◦ deductible raised to $1260 for each
benefit period (was $1216)
◦ Days 61-90: $315 per day coinsurance
for each benefit period (was $304)
Annual deductible rises from $310 to
$320
 Number of plan choices will drop –
some are being eliminated
 Average monthly premium will be
$38.83
 Doughnut hole is shrinking

First method
Original Medicare (Parts A & B)
 Prescription Drug Plan (Part D)
 Medicare Supplement or Medigap
policy (identified by a letter)

◦ Supplements provide identical coverage,
but vary widely in price
Second Method

Medicare Advantage Plan (Part C)
◦ Includes Part A & B coverage

Prescription Drug Coverage (Part D)
◦ Some advantage plans include
prescription coverage

If you get retirement benefits from Social
Security or the RRB, then you automatically
get Parts A & B on 1st day of month you turn
65

If you get disability benefits from Social
Security or certain disability from the RRB,
then you automatically get Parts A & B on the
1st day of the 25th month after your benefits
begin

If your disability is ALS (Lou Gehrig’s
disease), then you automatically get
Parts A & B on 1st day of month your
disability benefits begin

If you’re still working and not getting
Social Security, then you’ll need to talk
with your HR department about your
choices related to Medicare. You may
want to delay enrollment, which you’ll
do online through www.ssa.gov.
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When you first turn 65, you have 3 months
before and after your birthday month
Coverage begins based on your enrollment
date
If you don’t sign up for Medicare when you’re
first eligible, then you may pay penalty for
Part B as long as you receive benefits
Go from Original Medicare to
Advantage Plan
 Go from Advantage Plan to Original
Medicare
 Switch Medicare Advantage Plans
 Join Part D plan
 Switch Part D plans


Medicare Supplement might make sense if you
◦
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Want flexibility in choosing your doctors
Visit doctors frequently
Travel extensively
Have a chronic medical condition
Don’t mind higher premiums to get lower out-ofpocket costs (predictability)
11 different plans

Medicare Advantage Plan might make sense if
you
◦ Are willing to change doctors, if necessary
◦ Prefer all benefits from single plan & premium
◦ Visit doctors infrequently & don’t mind paying per-visit
copayments and coinsurance
◦ Don’t mind researching your options annually
◦ Want lower premiums than supplements offer
◦ Are informed about your choices and don’t mind
comparison shopping for plans
◦ Want options beyond what Medicare provides
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19 different plans
Remember all that?
Simple: buy the
best insurance that
you can afford –
after doing your
homework!
Two ways to get Part D
◦ Purchase Medicare prescription drug policy
◦ Choose a Medicare Advantage Plan that offers
prescription drug coverage
Even if you feel it’s not needed in your case,
remember that you may pay a late enrollment penalty
if you join a Part D plan later.
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Monthly fee, varies by plan
In addition to Part B cost of $104.90
Some Advantage Plans include Part D
coverage in the cost
Avoiding Part D Enrollment penalty
◦ Join drug plan when first eligible
◦ Don’t go 63 days or more without drug coverage

Penalty = 1% of full uncovered months
(pg 105)

Always be sure that your prescription
drugs are in formulary of any plan
you’re considering
 Check what “tier” drugs are in – each
tier has different cost

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Do this every year during Open
Enrollment!
Call the plan for info or check plan’s
website
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Begins when total drug costs reaches $2,960
Includes what you & plan have paid
Plan no longer covers drugs for rest of year
You pay discounted amounts
◦ 45% on brand name drugs
◦ 65% on generic drugs

Once you’ve paid $4,700 out of pocket you
pay 5% of cost for covered drugs or copay of
$2.65/generic, $6.60 for brand name drugs

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Drug plans may include preferred and
non-preferred pharmacies in their
network
You may pay less for drugs at
preferred pharmacies

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Program to help people pay Medicare
prescription drug costs
For single person, income less than
$1,459 month and resources less than
$13,440 per year
For married person living with spouse,
income less than $1,966 month and
resources less than $26,860 per year
Apply through Social Security
www.ssa.gov
 Helps with monthly drug plan premium,
annual deductible, coinsurance and
copayments
 Eliminates doughnut hole
 Switch plans at any time during year
 Same application used to get help from
TN to pay your Medicare costs

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Benefit period: begins day you’re admitted
to hospital or skilled nursing facility (SNF) and
ends when you haven’t received any inpatient
hospital care or SNF skilled care for 60 days
in a row

Coinsurance: your share of cost for medical
service or supply, expressed in percentage

Copayment: set amount you pay as your
share of cost for medical service or supply

Deductible: amount you pay for health care
or prescriptions before Medicare or Advantage
Plan or Drug Plan begins to pay

Extra Help: helps those with limited income
pay health care costs

Formulary: list of drugs covered by

Medically necessary: services or supplies
prescription drug plan or other insurance plan
needed to prevent, diagnose or treat illness,
injury, condition, disease or its symptoms
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Medicare-approved amount: payment
accepted by doctor or supplier from Medicare
Preferred Provider: doctor or supplier who
is member of network for specific insurer’s
HMO or PPO plan
Preventive services: health care to prevent
illness or detect at early stage
Primary care doctor: person you see first
for most health problems
Referral: written order from primary care
doctor for you to see specialist or get some
medical services. Required in most HMOs.
 Signing
up too early or too late
 Not understanding difference
between Medicare Supplement and
Medicare Advantage
 Guessing when picking plan
 Not applying for extra help
 Not re-evaluating coverage yearly
 www.medicare.gov
 Medicare
& You 2015
 www.mymedicarematters.org
 SHIP (1-877-801-0044)
 www.aonhewittnavigators.com
 www.benefitscheckup.org
Joani Shaver, Director
Blount County Office on Aging
Blount County Community Action Agency
3509 Tuckaleechee Pike, Maryville 37803
(865) 983-8411 x25
[email protected]