Understanding Medicare

1
Understanding Medicare

• Module 1

2
Lessons

1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C) and other
   Medicare plans
4. Medicare prescription drug coverage (Part D)
5. Programs for people with limited income and
   resources

3
Medicare Basics

• Module 1 Lesson 1

4
Medicare BasicsLesson 1 Topics

• Medicare overview
• Enrollment
• Part A
• Part B
• Medicare plan choices

5
Medicare

• Health insurance for people
• Age 65 and older
• Under age 65 with certain disabilities
• Any age with End-Stage Renal Disease (ESRD)
• Administered by
• Centers for Medicare Medicaid Services (CMS)
• Enroll through
• Social Security Administration (SSA) or
• Railroad Retirement Board (RRB)

6
Applying for Medicare

• Apply 3 months before age 65
• Need not be retired
• Automatically enrolled if receive Social Security
  or Railroad Retirement benefits
• If dont already receive benefits, apply
  3 months before age 65
• Call SSA at 1-800-772-1213
• TTY users call 1-800-325-0778

7
Medicare

• Medicare has
• Part A Hospital coverage
• Part B Medical coverage
• Part C Medicare Advantage Plans (like HMOs and
  PPOs)
• Part D Prescription drug coverage

8
Paying for Medicare Part A

• Most people receive Part A premium free
• People with less than 10 years of
  Medicare-covered employment
• Can pay a premium to get Part A
• For information, call SSA
• 1-800-772-1213
• TTY users call 1-800-325-0778

9
Enrolling in Medicare Part B

• Initial Enrollment Period (IEP)
• 7 months beginning 3 months before age 65
• General Enrollment Period (GEP)
• January 1 through March 31 each year
• Coverage effective July 1
• Premium increases 10 for each 12-month period
  you were eligible but did not enroll
• Pay this penalty as long as you have Part B
• Limited exceptions

10
Enrolling in Medicare Part B

• Special Enrollment Period
• Sign up within 8 months of the end of employer or
  union health plan coverage
• No increased premium
• For questions or to enroll
• Call SSA or RRB

11
Paying for Medicare Part B

• Monthly Medicare Part B premium
• 2006
• Most people pay 88.50
• 2007
• Most people pay 93.50
• Some with higher incomes pay more
• Some programs may help

12
Paying the Part B Premium

• Taken out of your monthly payment
• Social Security
• Railroad Retirement
• Federal Government retirement
• For information about premiums
• Call SSA or RRB
• Office of Personnel Management if a retired
  Federal employee
• May be billed every 3 months
• Medicare Easy Pay

13
Part A Helps Pay for

• Hospital inpatient care
• Skilled nursing facility (SNF) care
• Home health care
• Hospice care
• Blood

14
Hospital Stays

• Covered services
• Semi-private room
• Meals
• General nursing
• Other hospital services and supplies
• Includes care in critical access hospitals
• 190 days in a lifetime for inpatient mental
  health care

15
Skilled Nursing Facility Care

• Must meet all of the following conditions
• Require daily skilled services
• Hospital inpatient at least 3 consecutive days
• Admitted to SNF within 30 days after leaving
  hospital
• Care is for a condition treated in the hospital
• MUST be Medicare participating SNF

16
Skilled Nursing Facility Coverage

• Semi-private room
• Meals
• Skilled nursing care
• Physical, occupational, and speech-language
  therapy
• Medical social services
• Medications, medical supplies/equipment
• Ambulance transportation
• Dietary counseling

17
Home Health Care

• Covered services
• Part-time skilled nursing care
• Therapy
• Occupational
• Physical
• Speech-language
• Some home health aide services
• Durable medical equipment

18
Home Health Care

• For as long as you are eligible
• Limited hours per day
• Limited days per week
• Four conditions
• Doctor must make a plan for your care at home
• Must need specific skilled services
• Must be homebound
• Home health agency must be Medicare-approved

19
Hospice

• Special care for terminally ill
• And family
• If you likely have less than 6 months to live
• Certification required for each period of care
• Two 90-day periods
• Unlimited 60-day periods
• Hospice provider must be Medicare-approved

20
Covered Hospice Services

• Medical equipment and supplies
• Drugs for symptom control and pain relief
• Respite care in a Medicare-certified facility
• Up to 5 days each time
• No limit to number of times
• Home health aide and homemaker services
• Social worker services
• Dietary counseling
• Grief counseling

21
Part B Helps Pay for

• Doctors services
• Outpatient medical and surgical services and
  supplies
• Diagnostic tests
• Outpatient therapy
• Outpatient mental health services
• Some preventive health care services
• Other medical services

22
Covered Preventive Services

• Welcome to Medicare physical exam
• Bone mass measurement
• Cardiovascular screenings
• Colorectal cancer screenings
• Diabetes screenings
• Glaucoma tests

• Mammograms (screening)
• Pap test/pelvic exam/ clinical breast exam
• Prostate cancer screening
• Flu shots
• Pneumococcal shots
• Hepatitis B shots
• Smoking cessation

23
Part B Also Helps Pay for

• Clinical laboratory tests
• Home health services
• Durable medical equipment
• Outpatient hospital services
• Blood
• Ambulance service
• If other transportation would endanger your health

24
Medicare Plan Choices

• Original Medicare Plan
• Medicare Advantage Plans
• Other Medicare plans
• Medicare drug plans
• Medicare Prescription Drug Plans
• Medicare Advantage Plans and other Medicare plans
  with prescription drug coverage

25
Original Medicare Plan

• Module 1 Lesson 2

26
Original Medicare PlanLesson 2 Topics

• What it is and how it works
• Your costs in Original Medicare Plan
• Assignment
• Medigap (Medicare Supplement Insurance)

27
Original Medicare Plan

• Red, white, and blue Medicare card
• Part A and/or Part B
• Go to any provider that accepts Medicare
• You pay
• Part B premium
• Part A free for most people
• Deductibles
• Coinsurance or copayments

28
Medicare Card (front)
Jane Doe
29
Medicare Card (back)
30
Medicare Claims Contractors

• Fiscal Intermediary (FI)
• Regional Home Health Intermediary (RHHI)
• Medicare Carrier
• Durable Medical Equipment Regional Carrier
  (DMERC)
• Medicare Administrative Contractors (MAC)

31
Original Medicare PlanPart A

• Charges based on benefit period
• Inpatient hospital care and SNF services
• Begins day admitted to hospital
• Ends when no care received in a hospital or SNF
  for 60 days in a row
• You pay deductible for each benefit period
• No limit to number of benefit periods

32
Paying for Hospital Stays

• Each benefit period in 2006 you pay
• Inpatient hospital stay of 1 60 days
• 952 total
• Days 61 90
• 238 per day
• Days 91 150
• 476 per day
• 60 Lifetime Reserve Days
• All costs for each day beyond 150 days

33
Paying for Hospital Stays

• Each benefit period in 2007 you pay
• Inpatient hospital stay of 1 60 days
• 992 total
• Days 61 90
• 248 per day
• Days 91 150
• 496 per day
• 60 Lifetime Reserve Days
• All costs for each day beyond 150 days

34
Skilled Nursing Facility Care

• Each benefit period in 2006 you pay
• Days 1 20
• 0
• Days 21 100
• 119 per day in 2006
• 124 in 2007
• All costs after 100 days
• Must meet requirements for Medicare-covered stay
• Does NOT include custodial care

35
Paying for Home Health Care

• In the Original Medicare Plan you pay
• Nothing for covered home health care services
• 20 of the Medicare-approved amount for covered
  durable medical equipment

36
Paying for Hospice Care

• In the Original Medicare Plan you pay
• Up to 5 for prescription drugs
• 5 for inpatient respite care
• Amount can change each year

37
Paying for Part B

• In the Original Medicare Plan you pay
• Monthly Part B premium
• 88.50 in 2006
• 93.50 in 2007
• Yearly deductible
• 124 in 2006
• 131 in 2007
• 20 coinsurance for most services
• Some copayments
• Some programs may help

38
Assignment

• Agreement between you, doctor, and Medicare
• Applies to Original Medicare Part B claims
• Providers who accept assignment
• Cant try to collect more than Medicare
  deductible and coinsurance amounts
• Providers who dont accept assignment
• May charge more than Medicare-approved amount
• Limit of 15 more for most services
• Doesnt apply to supplies
• May ask you to pay entire charge at time of
  service

39
Assignment

• In some cases, providers must accept assignment
• Some examples
• Medicare Part B-covered prescription drugs
• Ambulance providers
• Doctors/providers generally have to file claim
• May have to file own claim for Part B-covered
  drugs or supplies
• If supplier or pharmacy not enrolled in Medicare

40
Private Contracts

• Agreement between you and doctor
• Original Medicare Plan will not pay
• Medigap will not pay
• Other Medicare plans will not pay
• You will pay charges
• No claim should be submitted
• Cannot be asked to sign in an emergency

41
Therapy Limits

• 1,740 cap
• Effective January 1, 2006
• Combined physical therapy and speech-language
  pathology services
• Separate cap for occupational therapy
• Exceptions allowed
• If medically necessary
• Certain diagnoses get automatic exception
• Some situations justify automatic exception

42
What Is Medigap?

• Health insurance policies
• Sold by private insurance companies
• Follow Federal and state laws that protect you
• Must say Medicare Supplement Insurance
• Cover gaps in Original Medicare Plan
• 12 standardized policies, plans A L
• Except in Massachusetts, Minnesota, Wisconsin
• Costs may vary
• By plan
• By company
• Where you live

43
How Medigap Works

• Only works with Original Medicare
• Dont need Medigap policy in
• Medicare Advantage Plan
• Other Medicare plans
• Can go to any doctor, hospital, or provider that
  accepts Medicare
• Except with a Medigap SELECT policy
• You pay a monthly premium

44
Medicare Advantage Plans and Other Medicare Plans

• Module 1 Lesson 3

45
Medicare Advantage PlansLesson 3 Topics

• What are Medicare Advantage Plans and other
  Medicare plans
• Who can join
• How plans work
• Joining and switching plans

46
What Are Medicare Advantage Plans?

• Health plan options approved by Medicare
• Run by private companies
• Part of the Medicare program
• Sometimes called Part C

47
Medicare Advantage Plans

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

48
Other Medicare Plans

• Medicare Cost Plans
• Demonstrations/Pilot Programs
• Programs of All-inclusive Care for the Elderly
  (PACE)

49
Who Can Join?

• Eligibility requirements
• Live in plans service area
• Have Medicare Part A
• Have Medicare Part B
• Not have ESRD at time of enrollment
• Some exceptions

50
How Do Medicare Advantage Plans Work?

• Generally get all Medicare-covered services
  through the plan
• Can include prescription drug coverage
• May have to see certain doctors or go to certain
  hospitals to get care
• Benefits and cost-sharing may be different from
  those in Original Medicare Plan

51
Out-of-Pocket Costs

• Generally must still pay Part B premium
• Some plans may pay all or part
• May pay additional monthly premium
• Pay other out-of-pocket costs
• Different from Original Medicare Plan
• Vary from plan to plan

52
In a Medicare Advantage Plan

• Still in Medicare program
• Still have Medicare rights and protections
• Still get all regular Medicare-covered services
• May get extra benefits
• Such as vision, hearing, or dental care
• May be able to get prescription drug coverage

53
Medicare HMO Plans

• Copayment amounts set by plan
• Generally must get care and services from plans
  network
• Use doctors and hospitals that join the plan
• May have to pay in full for care outside plans
  network
• Covered if emergency or urgently needed care
• Point-of-Service option allows visits to
  out-of-network providers

54
Medicare HMO Plans (contd)

• May need to choose primary care doctor
• Usually need a referral to see a specialist
• Doctors can join or leave
• May get Medicare drug coverage

55
Medicare PPO Plans

• Can see any doctor or provider that accepts
  Medicare
• Dont need referral to see specialist
• Dont need referral to see out-of-network
  provider
• Copayment amounts set by plan
• Will usually pay more for out-of-network care
• May get Medicare drug coverage

56
Medicare PFFS Plans

• Can see any Medicare-approved doctor or hospital
  that accepts the plan
• Can get services outside service area
• Dont need referral to see a specialist
• Plan sets copayment amounts
• Can get emergency care anywhere
• Without prior approval
• If offered, can get Medicare prescription drug
  coverage
• If not offered, can join a Medicare Prescription
  Drug Plan

57
Medicare Special Needs Plans (SNPs)

• May limit membership to people
• In certain institutions (like a nursing home)
• Eligible for both Medicare and Medicaid
• With certain chronic or disabling conditions
• Designed to provide
• Special expertise of providers
• Focused care management
• Available in limited areas
• Must provide prescription drug coverage

58
Medicare MSA Plans

• Will be offered beginning in 2007
• Similar to Health Savings Account plans
• Have two parts
• Medicare Advantage Plan with high deductible
• Pays covered costs after you meet annual
  deductible
• Deductible varies by plan
• Medical Savings Account
• Medicare deposits money the person may use
• To pay health care costs
• MSA demonstration available in some areas

59
Medicare Cost Plans

• Available in limited areas
• Similar to Medicare HMO Plans
• Except out-of-network services covered under
  Original Medicare Plan
• Can join any time plan accepts new members
• Can leave at any time
• Prescription drug coverage may be offered
• If not offered, can join a Medicare Prescription
  Drug Plan
• Plans may differ for some rules

60
Medicare Demonstrations/Pilot Programs

• Special projects
• Test improvements in Medicare coverage, payment,
  and quality of care
• Eligibility usually limited
• Specific group of people
• Specific area of country
• Examples
• Medicare Advantage Plan for ESRD patients
• New Medicare preventive services

61
Medicare PACE Plans

• Programs of All-inclusive Care for the Elderly
• Combine medical, social, and long-term care
  services for frail elderly people
• Include prescription drug coverage
• Might be better choice than nursing home
• Only available in states that offer it under
  Medicaid
• Qualifications vary from state to state
• Contact state Medical Assistance office to see if
  you qualify

62
When Can You Join?

• You can join a Medicare Advantage Plan or other
  Medicare plan
• When first eligible for Medicare
• Initial Enrollment Period
• Specific enrollment periods
• Annual Coordinated Election Period
• Medicare Advantage Open Enrollment Period
• Special Enrollment Periods

63
When Can You Switch?

• Annual Coordinated Election Period
• Medicare Advantage Open Enrollment Period
• Special circumstances
• Move out of the plans service area and cant
  stay in the plan
• Plan leaves Medicare program
• Other special situations

64
Annual Coordinated Election Period

• November 15 December 31
• Can choose new plan
• New plan starts January 1 (in most cases)
• Plan must accept new members

65
Medicare AdvantageOpen Enrollment Period

• January 1 March 31, 2007
• Same period each year
• Change effective first day of following month
• Cannot be used to start or stop Medicare drug
  coverage

66
Medicare Advantage PlanOpen Enrollment Period
Limits
If coverage is Can use OEP to get Cannot use OEP to get
Medicare Advantage Plan with prescription drug coverage (MA-PD) MA-PD or Original Medicare and PDP MA-only or Original Medicare only (Exception PFFS and PDP)
Medicare Advantage Plan with no prescription drug coverage (MA-only) MA-only or Original Medicare only MAPD or Original Medicare and PDP
Original Medicare Plan and a prescription drug plan (PDP) MA-PD MA-only or A different PDP to use with Original Medicare
Original Medicare Plan only MA-only MA-PD or Original Medicare and PDP
67
Medicare Prescription Drug Coverage

• Module 1 Lesson 4

68
Lesson 4 Topics

• Overview
• Eligibility and enrollment
• Extra help

69
Prescription Drug Coverage

• Coverage began January 1, 2006
• Available for all people with Medicare
• Provided through
• Medicare Prescription Drug Plans
• Medicare Advantage Plans and other Medicare plans

70
Prescription Drug Costs

• Costs vary by plan
• Most people will pay
• Monthly premium
• Deductible
• Copayments or coinsurance
• Very little after 3,850 out-of-pocket in 2007
• Extra help available for people with limited
  income and resources

71
Eligibility and Enrollment

• You must
• Have Medicare Part A, Part B, or both
• Live in plans service area
• Enroll in a Medicare prescription drug plan to
  get coverage

72
Enrollment Periods

• Initial Enrollment Period (IEP)
• 7 months beginning 3 months before the first
  month of Medicare eligibility
• Can change plans
• Annual Coordinated Election Period
• November 15 December 31 each year
• Some special enrollment periods available
• Some people are enrolled automatically

73
Late Enrollment Penalty

• People who wait to enroll after their IEP
• Pay additional 1 of base beneficiary premium
• For every month eligible and not enrolled
• For as long as they have Medicare drug coverage
• Except those with other creditable drug coverage
• Coverage at least as good as Medicare
  prescription drug coverage

74
Special Enrollment Periods

• For people who
• Permanently move out of plans service area
• Lose creditable prescription drug coverage
• Enter, reside in, or leave a long-term care
  facility
• Like a nursing home
• Have Medicaid or are in a Medicare Savings
  Program
• Have a continuous special enrollment period
• Have other exceptional circumstances

75
Extra Help

• Help with drug plan costs for people with limited
  income and resources
• Eligibility determined by SSA or state
• Income and resources are counted
• Some groups are automatically eligible
• People with Medicare and
• Medicaid
• Supplemental Security Income only
• Medicare Savings Programs
• Everyone else must apply

76
Income and Resource Limits

• Income
• Below 150 Federal poverty level
• 1,225 per month for an individual or
• 1,650 per month for a married couple
• Based on family size
• Resources
• Up to 11,500 (individual)
• Up to 23,000 (married couple)
• Includes 1,500/person funeral or burial expenses
• Counts savings and stocks
• Does not count home you live in
• Higher amounts for Alaska and Hawaii

2006 amounts
2006 amounts
77
How to Apply for Extra Help

• Multiple ways to apply
• Paper application
• www.socialsecurity.gov
• State Medical Assistance office
• Local organization
• You or someone on your behalf can apply

78
Drug Plan Costs for People with Extra Help

• Those below Federal poverty level save over 95
  on average
• People with lowest income and resources
• Pay no premiums or deductibles
• Have small or no copayments
• Those with slightly higher income and resources
• Have a reduced deductible
• Pay a little more out of pocket

79
Programs for People with Limited Income and
Resources

• Module 1 Lesson 5

80
Lesson 5 Topics

• Medicaid
• Medicare Savings Programs (MSP)
• Help for people living in U.S. territories

81
Medicaid

• Federal-state health insurance program
• People with limited income and resources
• Certain people with disabilities
• If eligible, most health care costs covered
• Eligibility determined by state
• Application processes and benefits vary
• Office names vary
• Social Services
• Public Assistance
• Human Services

82
Medicare Savings Programs

• Help from Medicaid paying Medicare premiums
• For people with limited income and resources
• May also pay Medicare deductibles and coinsurance
• Programs include
• Qualified Medicare Beneficiary (QMB)
• Specified Low-income Medicare Beneficiary (SLMB)
• Qualifying Individual (QI)

83
Programs in U.S. Territories

• Help people pay their Medicare costs
• U.S. territories
• Puerto Rico
• Virgin Islands
• Guam
• Northern Mariana Islands
• American Samoa
• Programs vary
• Contact state Medical Assistance office

84
If you think you might qualify

• Review guidelines
• Collect your personal documents
• Get more information
• Call your state Medical Assistance office
• Call your SHIP
• Call your local Area Agency on Aging
• Complete application with state Medical
  Assistance office

85
Module 1 Lessons

1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C) and other
   Medicare plans
4. Medicare prescription drug coverage (Part D)
5. Programs for people with limited income and
   resources

86
For More Information

• 1-800-MEDICARE (1-800-633-4227)
• TTY users should call 1-877-486-2048
• Medicare You handbook
• Other Medicare publications
• www.medicare.gov
• www.cms.hhs.gov
• Your local State Health Insurance Assistance
  Program (SHIP)

87
Thanks for your attention!