Welcome to the MEDICARE TRAINING

1
Welcome to the MEDICARE TRAINING
A Continuing Education Course presented
by UNICARE Life and Health Insurance Company
2
Course Objective

• To make Medicare coverage, guidelines and
  co-insurance issues easier to understand.
• To educate you so that you can better assist and
  educate your clients.

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Benefit to Attendees

• You will experience a "user-friendly,
  easy-to-understand" approach to an otherwise
  complex subject.
• You will better understand the senior citizen
  situation when seeking a quality Medicare
  Supplement.

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Seminar Agenda

• What is Medicare and Who is Entitled
• Centers for Medicare and Medicaid Services (CMS)
• Major Changes in Medicare
• Who Pays for Medicare
• Medicare Eligibility and Enrollment
• Part A -Benefits and Purchasing
• Part B - Benefits
• Medicare Assignment and Payment
• New Preventative Benefits

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Seminar Agenda (continued)

• Supplemental Insurance
• Supplement Open Enrollment
• Plans A-J
• Standardization and Medicare Select
• Remaining Gaps in Medicare
• Balance Budget Act of 1997
• Guarantee Issue Provision
• New Health Care Options

6

History of Medicare

• Through out history there have been many
  significant events that led to the enactment of
  Medicare.
• Medicare is the result of many attempts by union
  groups, congress and presidents to implement
  socialized medicine in the United States.
• Most efforts to block socialized medicine came
  from medical groups and hospital organizations

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What is Medicare and Who is Entitled?

• Medicare is federal health program for the aged
  and disabled
• It was established as part of the Social Security
  Act of 1965
• Medicare was introduced in 1966, when only 50of
  the nations elderly population had any health
  insurance.
• Today, only about 1 of the elderly are uninsured.

8

What is Medicare and Who is Entitled?

• When first implemented in 1966 Medicare covered
  19 million beneficiaries nation wide
• Medicare originally covered only most people age
  65 and older
• In 1999 Medicare covered about 39 million
  enrollees at an annual cost of about 213 billion
• The average calendar year cost was about 5500.
  per enrollee

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What is Medicare and Who is Entitled?

• Medicare expanded in 1973 to cover persons who
  were entitled to Social Security or Railroad
  Retirement disability for at least 24 months and
  persons with end-stage renal disease requiring
  continuing kidney dialysis or a kidney
  transplant. (End-stage renal disease now 6
  months)

10
Health Care Financing Administration

• In 1977, the Health Care Finance Administration
  was established under the Department of Health
  and Human Services to administer the Medicare
  program.
• In 2001 (HCFA) name was changed to Centers for
  Medicare Medicaid Services

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Centers for Medicare Medicaid Services

• (CMS) is the federal agency within the Department
  of Health and Human Services that administers
  Medicare and regulates the Senior Risk (HMO)
  Industry
• (CMS) responsibilities for Medicare include
  formulation of policy and guidelines, contract
  oversight and operations, maintenance and review
  of utilization records and the general financing
  of Medicare

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Major Changes in Medicare

• Part A
• Prospective Payment/DRGs for Hospital Care
• Medicare-Approved HMOs
• Part B
• Physicians Assignment
• Medicare Catastrophic Coverage Act
• Passed in 1988, Repealed 1989.
• Home Health Care adopts DRGs

13
Who Pays For Medicare?

• Medicare Part A is financed through mandatory
  payroll deduction (FICA tax).
• The FICA tax is 1.45 of earnings (paid by both
  the employee and employer), and 2.9 for
  self-employed persons. This tax is paid on all
  covered wages and self-employed income without a
  limit

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Who Pays For Medicare?

• Medicare beneficiaries also contribute in part by
  paying deductibles, coinsurance and premiums.
• For those people who are eligible due to age or
  medical conditions, but have not paid into Social
  Security, Medicare PART A is available at a
  premium.

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Who Pays For Medicare?

• For most people, the monthly premium for Hospital
  PART A is 319, if they have paid FICA tax for 30
  to 39 quarters the monthly premium is reduced to
  175.

16
Who Pays For Medicare?

• Medicare PART B is financed through
• monthly premiums paid by beneficiaries these
  premiums cover about 25 of expenditures
• monthly premium is 54.00
• contributions from the Federal Governments
  general fund.

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Medicare Eligibility

• To be eligible for Medicare, you
• or your spouse must have worked for at least ten
  years in Medicare covered employment.
• must be 65 years of age and a citizen or
  permanent resident of the United States.
• or a person younger than 65 with a disability or
  a chronic kidney disease.

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Medicare Enrollment

• Automatic Enrollment
• If already getting Social Security benefits when
  you turn 65, you will automatically be enrolled
  in Medicare Parts A and B.
• You will receive your card about three months
  before your 65th birthday.

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Medicare Enrollment

• Automatic Enrollment (continued)
• If disabled, you will automatically get a
  Medicare card in the mail after receiving Social
  Security Benefits for 24 months.

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Medicare Enrollment

• Applying for Medicare
• If not receiving Social Security benefits, you
  must apply by contacting any Social Security
  Administration office three months prior to your
  65th birthday.

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Medicare Enrollment

• Initial Enrollment Period
• Seven months, starting 3 months before the month
  in which you turn 65. If you do not enroll
  during this period, you must wait until the next
  general enrollment period.
• General Enrollment Period
• January 1st to March 31st each year
• Your Medicare coverage will be effective the
  following July 1st.

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Medicare Enrollment

• Late Enrollment Consequences
• If you wait 12 months or more to enroll and you
  do not have group health insurance as a result of
  your or your spouses current employment, Part B
  premiums increase 10 for each 12 months that you
  do not enroll.
• If you have to pay a premium for Part A,
• the cost increases is limited to10
• no matter how late you enroll.

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Medicare Enrollment

• Extenuating Circumstances
• You can delay Part B enrollment if
• you are over 65 and have group health insurance
  through you or your spouses current employment,
  or...
• you are disabled and have group health insurance
  through you or your spouses current employment.

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Medicare Enrollment

• Extenuating Circumstances (continued)
• You may enroll while you are covered by a group
  health plan or wait till your group coverage
  ends.
• A special 8-month enrollment period begins the
  month your coverage ends.
• If you do not enroll by the end of this period,
  you will have to wait until the Medicares next
  general enrollment period.

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What Is a Medicare Card?

• A Medicare Card is issued to every Medicare
  Beneficiary
• Card shows name of beneficiary
• Card shows Medicare claim number
• Card also shows if the beneficiary has Hospital
  (Part A) and Medical (Part B) insurance, as well
  as the effective dates of coverage.

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Health Insurance Claim Number

• Claim number usually is the beneficiaries Social
  Security number followed by an A
• If beneficiary is receiving benefits through
  their spouse, the claim number would be the
  spouses Social Security number followed by a B.
• If the beneficiary is receiving benefits through
  a deceased spouse the card would have the
  spouses Social Security number followed by a D

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MEDICARE BENEFITS
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Medicare consists of two parts

• Hospital Insurance protection - PART A
• Medical Insurance protection - PART B

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MEDICARE BENEFITSPART A
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Medicare PART A provides institutional care,
including

• PART A
• Medicare helps pay for
• care in a hospital
• skilled nursing facility
• home health care
• hospice care

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Part A Benefits

• Benefit Period
• Coverage is measured in a Benefit Period which
  begins the day you are admitted to a hospital and
  ends when you have been out of a hospital or
  skilled nursing facility for 60 consecutive days.
• If you go back to the hospital after 60 days a
  new benefit period starts
• There is no limit on the number of benefit
  periods you can have in a year.

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Part A Hospital Covered Services

• Semi-private room and board
• General nursing care
• Operating and recovery room
• Intensive care
• Inpatient prescription drugs
• Lab and X-Ray services
• All other medical necessary services and supplies
  provided in the hospital.

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Part A Hospital Benefits

• For each benefit period you pay
• Day 1 through 60 - Medicare pays all covered
  costs except a 812 in patient hospital
  deductible. Hospital deductible must be met each
  benefit period.
• Day 61 through 90 - Medicare pays all covered
  costs except 203 per day coinsurance.

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Part A Hospital Benefits

• Day 91 through 150 Lifetime Reserve Days.
  Medicare pays all covered costs except 406 per
  day.
• The 60 lifetime reserve days never renew.
• Beyond 151 days Medicare pays nothing

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Part A Skilled Nursing Facility

• A skilled nursing facility is different from a
  nursing home. It is a special kind of facility
  that primarily furnishes skilled and
  rehabilitation services.
• It may be a separate facility or a distinct part
  of another facility such as a hospital.

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Part A Skilled Nursing Facility

• Qualifications
• You require daily skilled care, which can only
  be provided on an inpatient
  basis
• You must be hospitalized for at least 3
  consecutive days
• Be admitted for the same condition for which you
  were hospitalized
• Be admitted within 30 days of your discharge from
  the hospital
• Certified as medically necessary

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Part A Skilled Nursing Facility

• Medicare will help pay for this care for up to
  100 days per benefit period...
• Day 1 through 20 - Medicare pays all covered
  costs.
• Day 21 through 100 - Medicare pays all covered
  costs except 99 per day.
• Day 101 - you pay full cost.

38
Part A Home Health Care

• Medicare will pay the full cost of medically
  necessary home health care visits provided by a
  Medicare approved home health care agency
• A home health agency is a public or private
  agency that provides skilled nursing care,
  physical therapy speech therapy and other
  therapeutic services

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Part A Home Health Care

• Qualifications
• You must be hospitalize for at least 3
  consecutive days.
• Home health services must be initiated within 14
  days of discharge from the hospital or skilled
  nursing home.
• Finding of Medical Necessity and prescribed by
  physician.

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Part A Home Health Care

• Qualifications
• Patient is receiving intermittent skilled nursing
  care, physical therapy or speech therapy.
• Patient is confined to their home.
• Care is not primarily custodial.

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Part A Home Health Services Cover

• Part-time or intermittent skilled nursing care
• Part-time or intermittent home health aide
  services
• Physical therapy, speech therapy, occupational
  therapy
• Medicare Social Services
• Durable medical equipment has a 20 coinsurance

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Part A Home Health Care Benefits

• The first 100 home health visits are financed
  under Part A as post institutional home health
  services.
• If home health not initiated within 14 days
  benefits are covered under Part B.

43
Part A Home Health Care Benefits

• If all 100 visits are exhausted under Part A then
  Part B finances home health care visits.
• If you do not have a qualifying hospital stay
  then all home health care is financed by Part B
  without a visit limit.

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Custodial Care

• Medicare will NOT cover care in a skilled nursing
  facility or pay home health benefits if the care
  is primarily custodial - as defined by Medicare

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Part A Hospice Care

• Medicare pays for hospice care if you are
  terminally ill with a life expectancy of 6 months
  or less and you choose to receive it, instead of
  the standard Medicare benefits for your illness.
• If you choose hospice care and require treatment
  for an illness other than a terminal condition,
  standard Medicare benefits apply.

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Part AHospice Care

• 100 Medicare payments for
• Physicians services
• Nursing care
• Medical appliances and supplies
• Physical, occupational and speech therapy
• Dietary and social counseling
• Home health aide and homemaker services
• Unlimited benefit period.

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Part A Hospice Care

• Nearly 100 Medicare payments for
• Prescription drugs for pain and symptom relief
  (5 but not to exceed 5 for each prescription)
• Respite care for care givers
  (cost of about 5 per day)

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MEDICARE BENEFITS PART B
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Part B Benefits

• Helps pay doctor bills and outpatient hospital
  care.
• The monthly premium is 54.00, deducted from your
  Social Security, or Civil Service Retirement
  check.
• If not receiving checks, they pay the premium
  directly to the Government usually on a quarterly
  basis.

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Part B Covered Services

• Doctors services
• Outpatient hospital services
• Ambulance services
• Durable medical equipment
• Lab, X-ray and radiation therapy
• Other health-related services

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Part B Physician Services

• Part B Deductible and Coinsurance
• you must pay the first 100 each year of the
  charges approved by Medicare.
• After the deductible has been met, Medicare will
  pay 80 of Medicare-approved charges.
• Outpatient mental health services are covered at
  50 of Medicare-approved charges.

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New Preventive Benefits

• New Medicare-covered benefits for 1998 edition
• Yearly mammogram and pap smear, including pelvic
  and breast exam, for which there is no Part B
  deductible (effective 1/1/98)
• Diabetes glucose monitoring and diabetes
  education for which there is no Part B deductible
  (effective 7/1/98)

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New Preventive Benefits

• New Medicare-covered benefits for 1998 edition
• Colon cancer screening (effective 1/1/98)
• Bone mass measurement (effective 7/1/98)
• Flu and pneumococcal pneumonia shots are covered
  100 if the physician accepts assignment.

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Part B Benefit Limits

• Therapeutic shoes - once a year.
• Durable medical equipment - must be prescribed by
  a doctor for use at home and be supplied by a
  Medicare-approved supplier.
• Ambulance services - must meet Medicare
  requirements.

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Part B Medicare Assignment

• Medicare has a fee schedule that lists the dollar
  amount that Medicare considers to be the
  reasonable charge for each of the services
  provided by a physician.
• Physicians that accept assignment are physicians
  that accept these fee schedules as full payment.

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Part B Medicare Assignment

• If a physician accepts Medicare assignment as
  payment in full, Medicare pays 80 of allowable
  charges to doctor.
• Your co-payment will never be more than
• 20 of charges.

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Part B Medicare Assignment

• If physician does not accept assignment
• they may charge up to an additional 15 above the
  Medicare approved amount
• You owe doctor the 20 of the approved charges
  PLUS excess charges of up to15 of the original
  Medicare approved amount

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Lets ReviewThe Gaps In Medicare
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Gaps In Hospital Part A

• 812 hospital deductible for the first 60 days
• 203 daily coinsurance for days 61 through 90
• 406 daily coinsurance for days 91 through 150
  (lifetime reserve days)
• All cost after 150 in the hospital
• First 3 pints of blood

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Gaps In Hospital Part A

• Private hospital room unless medically necessary
• Private duty nursing
• Personal convenience items such as telephone or
  television in your room.
• For care received outside the United States
  even if an emergency

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Gaps In Skilled Nursing

• 101.50 daily coinsurance for days 21 through 100
  
• All costs after 100 days
• All cost for care that is less than that of
  skilled care. (intermediate and custodial care)
• The first 3 pints of blood

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Gaps In Skilled Nursing

• All costs if you were not transferred to a
  skilled nursing facility in a timely manner after
  a qualifying hospital stay
• Personal convenience items that you request, such
  as a television or telephone in your room
• Private duty nursing

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Gaps In Home Health Care

• 24-hour nursing care at home
• Self-administered drugs and medications
• Meals delivered to home
• Homemaker services
• Blood transfusions
• 20 for durable medical equipment

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Gaps In Medical Part B

• 100 annual deductible
• The 20 coinsurance
• The permissible excess charges above Medicare
  approved amount (15)
• 50 of the Medicare approved amounts for most
  outpatient mental health treatment
• Charges for most self-administered prescription
  drugs

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Gaps In Medical Part B

• Homemaker services that are primarily to assist
  you in meeting personal care or house keeping
  needs
• Most dental care and dentures.
• Charges for acupuncture treatment
• All charges for routine eye examinations and
  eyeglasses except prosthetic lenses after
  cataract surgery

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Gaps In Medical Part B

• Hearing aids or routine hearing loss examinations
• All charges for care outside the United States
  (except limited in Mexico and Canada)
• Charges for routine foot care except when a
  medical condition affecting the lower limbs (such
  as diabetes) requires care by a medical
  professional
• The cost of the first 3 pints of blood

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Standardization andMedicare Supplement
Medigap Policies
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Standardization

• In 1992 the National Association of Insurance
  Commissioners in conjunction with Health Care
  Financing Administration formulated 10 standard
  Medicare Supplements Plans that could be sold to
  the public.
• These standardized plans must have a letter
  designation of A through J

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Standardization

• Benefits do not vary by company an A Plan is a A
  Plan, a C Plan is a C Plan, F is a F and so on.
  If they have the same letter designation the
  benefits are identical.
• Plans were designed to make the purchasing of a
  Medigap policy easier for senior citizens to
  understand
• Standardization is nationwide, Plans do not vary
  from state to state.

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Standardization
Medicare Select is a type of standardized plan

• The only difference between Medicare Select and
  Standard plans is the insurance company has
  specific hospitals and in some cases specific
  doctors in order to be eligible for full
  benefits.
• Full benefits are paid in case of emergency
• Generally has a lower premium in comparison to
  other Medigap policies

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Standardization

• Every company selling Medicare
  Supplements must offer Plan A.
• Companys may then offer any of the remaining
  plans (B through J)

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Standard Plan A The Basic Benefits included in
all plans

• Part A coinsurance 203 per day for the 61st
  through the 90th day of hospitalization
• Part A coinsurance 406 per day for the 91st
  through 150th day (lifetime deserve days)
• After Medicare hospital benefits are exhausted,
  covers 100 of hospital expenses for an extra 365
  days

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Standard Plan A The Basic Benefits included in
all plans

• Coverage under parts A and B for the cost of the
  first 3 pints of blood.
• Coverage for the coinsurance amount for Part B
  services (20 of approved amount for physicians
  services and 50 of approved amount for
  outpatient mental health services) after the 100
  annual deductible is met

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Standard Plan B

• Includes Basic Plan A Benefits
• Pays Medicare Part A Inpatient Hospital
  Deductible (812 per 60 day benefit period)

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Standard Plan C

• Includes Basic Plan A Benefits
• Part A Deductible (812)
• Coverage for Skilled Nursing Facility Coinsurance
  amount (101.50 per day for days 21 through 100
  per benefit period)
• Coverage for the Medicare Part B 100 Deductible
• Foreign Travel Emergency 80 coverage after a
  250 deductible with a lifetime maximum of
  50,000

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Standard Plan D

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Foreign Travel Emergency
• Coverage for At Home Recovery. The at home
  recovery benefit pays up to 1,600 per year for
  short-term, at home assistance with activities of
  daily living (like bathing, dressing, personal
  hygiene, etc.) for those recovering from an
  illness, injury or surgery

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Standard Plan E

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Foreign Travel Emergency
• Coverage for Preventive Medical Care. The
  preventive medical care benefit pays up to 120
  per year for things like a physical examination,
  serum cholesterol screening, hearing tests,
  diabetes screening and thyroid function tests

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Standard Plan F

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Part B Deductible (100)
• Foreign Travel Emergency
• Coverage for 100 of Medicare Part B Excess
  Charges (maximum of 15 above approved amount)

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Standard Plan G

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Foreign Travel Emergency
• Coverage for At Home Recovery. (1,600 per year)
• Coverage for 80 of Medicare Part B Excess
  Charges (maximum of 15 above approved amount)

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Standard Plan H

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Foreign Travel Emergency
• Basic Drug Benefit after a 250 annual deductible
  plan pays 50 of prescriptions with a maximum
  annual benefit of 1250

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Standard Plan I

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Foreign Travel Emergency
• Coverage for At Home Recovery. (1,600 per year)
• 100 of Medicare Part B Excess Charges
• Basic Drug Benefit (1250 Limit)

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Standard Plan J

• Includes Basic Plan A Benefits
• Part A Deductible(812)
• Skilled Nursing Coinsurance (101.50)
• Part B Deductible (100)
• 100 of Medicare Part B Excess Charges
• Foreign Travel Emergency

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Standard Plan J

• Includes Basic Plan A Benefits
• Coverage for At Home Recovery. (1,600 per year)
• Preventive Care (120)
• Extended Drug Benefit after a 250. annual
  deductible plan pays 50 of prescriptions with a
  maximum annual benefit of 3000.

84
Medicare Open Enrollment

• State and Federal laws guarantee that for a
  period of 6 months from the date you are enrolled
  in Medicare Part B and age 65 or older, you have
  a right to buy the Medigap policy of your choice
  regardless of any health problems you may have.

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Medicare Open Enrollment

• During this 6 month period you may purchase any
  Medigap sold by any insurer selling Medigap
  insurance in your state.
• The company cannot deny coverage, place wavers or
  charge you additional premiums because of your
  health history

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Medicare Open Enrollment

• The company can, however, impose as much as 6
  months waiting period for preexisting conditions
• Preexisting conditions are generally health
  problems that you have seen a physician within
  the last 6 months before the policy effective
  date.

87
Balance Budget Act of 1997

• Guaranteed issue Medicare supplement protection
  when other health insurance ends or is lost.
  Effective July 1, 1998
• To qualify you must apply for a new policy within
  63 days of loosing your other health coverage

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Balance Budget Act of 1997You qualify if

• You were enrolled in an employer group health
  plan with benefits that supplemented your
  Medicare benefits and the plan stopped providing
  those benefits.

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Balance Budget Act of 1997You qualify if

• You were enrolled in a Medicare Health
  Maintenance Organization or Medicare SELECT
  policy and your enrollment ended when you moved
  outside of the plans service area, or your plans
  contract with Medicare ended.

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Balance Budget Act of 1997You qualify if

• You were enrolled in a Medigap policy and
  coverage stopped because of the insolvency of the
  company, because of other involuntary termination
  of coverage or the company violated or
  misrepresented a provision of your policy.

91
Balance Budget Act of 1997

• The guarantee applies to you if
• You had a Medigap policy and dropped it to enroll
  in a Medicare HMO or care SELECT policy for the
  first time. You then decided to disenroll from
  the Medicare HMO or Medicare SELECT policy within
  12 months of first enrolling.

92
Balance Budget Act of 1997

• Under this guarantee, companies selling Medicare
  supplemental insurance must sell you one of 4
  guaranteed issue Medigap policies, Medicare
  Supplement Plans A, B, C or F.
• Medigap companies may not deny you coverage or
  charge you additional premium because of any
  health conditions.

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Balance Budget Act of 1997

• Creates new health care options called Medicare
  Choice
• Health Maintenance Organization (HMO)
• Health Maintenance Organizations with Point of
  Service options (HMOs With POS)
• Provider Sponsored Organizations (PSOs)
• Preferred Provider Organizations (PPOs)

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Balance Budget Act of 1997

• Creates new health care options called Medicare
  Choice
• Private Fee-for-Service Plan
• Medicare Medical Savings Account (MSA)
• Religious Fraternal Benefit Society Plans
• High Deductible Plans F and J
  (1500 deductible)

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Thank you for attending today's seminar on
Medicare!