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MEDICARE 101An overview of Medicare

What is Medicare?Medicare is health insurance for thefollowing people:People who are 65 years of age and olderPeople under 65 with certain disabilitiesPeople with End-Stage Renal disease

When do you sign up forMedicare?Open enrollment for Medicare is a 7 month period,the three months before your birthday, the monthof your birthday and three months after yourbirthday. If you delay signing up after yourbirthday, your effective dated will be delayed.

How do you sign up?You can call Social Security at 1-800-772-1213 anytimeduring your open enrollment period to sign up.Sometimes Medicare will automatically send you yourcard. If you delay signing up because you are coveredunder a group health plan, you will not incur a penalty.If you delay signing up and you are not covered by agroup health plan then you could be penalized. Late signup is from Jan 1-March 31 with an effective date of July 1of the same year.

There are four parts toMedicare:A- HospitalB- MedicalC- Medicare Advantage PlansD- Prescription Drug Plans(A and B are original Medicare)

Medicare A (Hospital)ƔƔCovers in-patienthospital, skillednursing, HospiceNo premium if you orspouse have worked40 quarters. If notyou can purchase itfor a monthlypremium of 461in2010.ƔƔCoverage for hospitalsemi-private roomrateHome care: medicallynecessary part-time,intermittent skillednursing care, PT, SP,OT, home health aideservices, medicalsupplies for use athome.

Medicare B (Medical)Covers medically necessary expenses:medical, doctors, labs, x-rays, therapies(speech, occupational, physical), out patientsurgery, some part B drugs

Medicare B (Medical)continuedYou must pay a premium for this coverage.There is a base premium and then additionalpremium is charged according to your 1040income. (Based on modified adjusted grossincome from 2 years ago). You can request areevaluation of this premium if you disagree.

Medicare B (Medical)continuedSome covered expenses include: ambulance, surgicalcenters, blood, bone density tests, cardiac rehab,cardiovascular screening, some chiropractic, lab, cancerscreening, diabetes screening and equipment, durablemedical equipment like walkers, oxygen supplies, diabeticsupplies, emergency room, flu shots, foot exams,glaucoma tests, hearing and balance exams, hepatitis Bshot, home health kidney dialysis, mammograms, mentalhealth care, occupational therapy, pap and pelvic exams,annual physicals, transplants

Not covered by Medicare A or BCustodial Long Term CareDenturesCosmetic SurgeryAcupunctureHearing AidsRoutine Dental Care

Medicare C(Medicare Advantage and Medicare AdvantagePrescription Drug Plans)ƔƔƔƔBenefits provided byprivate companiesTypically low or no monthlypremiumsƔƔMust keep Medicare A andB in forceProvide all the benefits ofMedicare A and B andsome value added benefitsƔƔSome plans have drugcoveragePlans include PPO, HMO,PFFS, SNP's, HMO, Pointof-Service, MSA (MedicalSavings Accounts)Guaranteed issueHave specific enrollmentperiods

Medicare C PlansƔƔHMO- Health Maintenance Organization. Must go toNetwork or contracted providers, small or no premium,must have referrals, value added benefitsPPO-Preferred Provider Organization. Benefits in andout of network, no referrals, out of net work moreexpensive. Small or no premium

Medicare C PlanscontinuedƔƔƔPFFS- Private-fee-for-service- Can go to any providerthat accepts the plans payment. No contracting, pervisit basisHMOPOS, An HMO that may allow you to get someservices out-of-network for a higher costMSA- Medical Savings Account Plans- a plan thatcombines a high deductible health plan with a bankaccount.

Who can join aMedicare C plan?ƔYou have Medicare part A and Part BƔYou live in the service area of the planƔƔƔ RX GRQ¶W KDYH (QG-Stage Renal Disease (ESRD)(permanent kidney failure requiring dialysis or a kidneytransplant)Can join only at certain times of the yearIf you join a Medicare plan and you had employer orunion coverage you may not be able to get it back

Medicare Part D(Prescription Drug Coverage)ƔƔƔBenefits designed to help withthe cost of prescription drugsBenefits provided by privatecompaniesPlans have a monthlypremium and same basicstructure, some have adeductible, all have initialcoverage, coverage gap andcatastrophic coverageƔƔƔƔƔStand alone plans and those inMAPD's are the sameEnrollment periodsCovers approximately half thecost of medsMust have Medicare A and/or BCaution, if you have employeror union coverage, by enrollingin these plans, you may loseyour other coverage

Medicare Part D specificsƔƔƔƔPlans have deductible of up to 310 in 2011Pay co-pays and plan pays its share for covereddrugs until their combined amount plus thedeductible reaches 2,840 (initial coverage limit)Coverage gap, in 2011, receive a 50% discount oncovered brand-name drugs that count as out-ofpocket spendingOnce spent 4,550 out-of-pocket for the year,coverage gap ends. Now pay small co-pays foreach drug until end of year

Medicare Part D specificscontinuedƔƔƔƔPlans use a formulary, specific Medicare prescriptiondrugsPlans have certain rules to control costs and quality:Quantity limits, Step therapy, Prior AuthorizationPlans change annually, sometimes formularieschange during the yearSpecific enrollment periods, 2011, October 15th toDecember 7th. For changing and enrolling in plansunless aging in and leaving group coverage

Clarifications of terms for Part DƔƔƔƔStandard Benefits for Part D include: Formulary, CatastrophicCoverage, Deductible, Coverage GapTotal Out-of-Pocket drug costs: Amount consumer pays forRX drugs, from 1/1, not including premiums, but includesdeductible, co-pays/coinsurance, coverage gap drug costsDefinition of Formulary: A list of the drugs that are covered bythe planFormulary Exception Request: Request for the plan to covera medication that is not included in the formulary

Clarifications of terms for Part DcontinuedƔƔƔQuantity Limits: Plan will only cover a certain amount of thesedrugs for one co-pay, limits may be placed to ensure safe andefficient use of a drug.Step therapy: Effective, clinically proven, lower-cost alternativeto some drugs that a plan wants a member to try first. If amember has already tried other drugs or a provider thinksRWKHUV DUH QRW ULJKW D PHPEHU RU D PHPEHU¶V GRFWRU FDQ DVN the Plan to cover these drugs.Prior Authorization: Some Drugs require approval by the Planprior to a member receiving the drug.

Part D Enrollment BasicsƔƔƔƔMember must keep Medicare A and or B in forceMember can only be enrolled in one Medicare health planand enrollment into a MA will automatically disenroll themfrom any other Medicare health plan and prescription drugplanMembers have certain rights, guaranteed, be treated withdignity and respect, be protected from discrimination, havequestions answered, receive information, receive emergencycare, rights to appeal decisions, can file complaints, havetheir personal and health information kept privateDo your homework!

Extra Help for paying forprescription drugsƔƔƔHelp is available for somepeople with limited incomeand resourcesSingle person-income lessthen 16,245 and resourcesless than 12,510Married person-income lessthan 21,855 and resourcesless than 25,010ƔMay receive help with drugplan's monthly premium,yearly deductible,coinsurance and copaymentsƔNo coverage gapƔNo late enrollment penaltyƔAutomatically qualify for helpif you have full Medicaidcoverage, get SSI orMedicaid is paying your PartB premiums in a MedicareSavings Program

If you don't automaticallyqualify for Extra Help, you canapply to the agencies below:www.socialsecurity.govSocial Security, 1-800-772-1213State Medical Assistance (Medicaid) office 1-800633- VD\ ³0HGLFDLG State health insurance Assistance Program(SHIP)- call 1-800-MEDICARE

Most Common MedicareEnrollment PeriodsƔƔƔAEP- Annual enrollment period for 2010, November 15Decembder 31st, in 2011, October 15, 2011 to December 7,2011. Change Drug and Medicare C plansNo OEP, now MAPD Medicare Advantage Disenrollment Periodfrom Jan 1-)HE HDFK \HDU FDQ¶W VZLWFK SODQV RQO\ FDQ return to original Medicare and pick up a stand-alone drug plan.SEP, Special Enrollment Period- Occurs anytime during year forpeople aging into Medicare, losing group coverage, moving outof service area, qualifying or disqualifying for Medicaid, movinginto or out of long term care facility, etc

Medicare SupplementsƔƔƔSold by private companiesbut government hasdesigned plans, A-NHave varied monthlypremiums but all have thesame coverage for the sameplansCovers the co-pays,deductibles and coinsuranceof MedicareƔƔƔƔCan use any MedicareproviderOnly covers MedicareexpensesCan be used in all statesOnly guaranteed issue atcertain times: aging in toMedicare, leaving group orunion coverage, plan leavingservice area

How Medicare Supplements work(plan F shown below)Hospital benefitNursing home benefit (first 100 daysonly with Medicare)Medical part B- 155 annualdeductible20% coinsurance under BPart B excessForeign Travel EmergencyOut of pocket costs for most part Aand part B expensesDeductible paid by Supplementfor each benefit periodBalance paid by supplementPaid by SupplementPaid by SupplementPaid by Supplement 250 deductible, 20% to 50,000 0- for Medicare expenses and aMedicare provider

Medicare Decision tree:Choose one side onlyƔOriginal Medicare AƔ ƔMedicare Advantage PrescriptionDrug PlanOriginal Medicare B ƔPrescription Drug plan, Medicare D ƔMedicare SupplementƔƔMonthly premium over 100ƔƔNo networks or referralsƔAny Medicare providerƔNo co-pays, deductibles, coinsurancePremiums 0- under 100/monthNetworks, co-pays, deductibles,co-insuranceƔMaximum out of pocketƔEnrollment periodsƔchange annually

Frequently Asked Questions about MedicareQ: If I am working, do I need to sign up for Medicare, and will Iincur a penalty if I don't?A: Depends on each individual situation, but as long as youhave credible coverage you do not incur a penalty.

Frequently Asked Questions about MedicareQ: Why am I having to pay the full cost of my drugs, I was onlypaying a small amount all year?A: You have probably reached the coverage gap and thecoverage changes. You will pay 50% of the cost ofcovered Brand drugs and 93% of the cost of mostgenerics until you have spend 4,500 out of pocket.

Frequently Asked Questions about MedicareQ: How do I switch and change plans or join a plan?A: Some insurance agents have gone through certificationwith CMS and they may assist you, or you can callMedicare or call the plans directly.

Frequently Asked Questions about MedicarecontinuedQ: How do I decide whether to leave the group and go onMedicare?A: You should have an analysis done by an insurance brokerwho has gone through CMS certifications with Medicarecontracted private insurance companies who can assistyou in comparing the cost and benefits of the decision.