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MEDICARE IN PICTURES Provider Number: 33714 Course Number: 25461 Eric Johnson – Agent Allies, LLC.

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Presentation on theme: "MEDICARE IN PICTURES Provider Number: 33714 Course Number: 25461 Eric Johnson – Agent Allies, LLC."— Presentation transcript:

1 MEDICARE IN PICTURES Provider Number: Course Number: Eric Johnson – Agent Allies, LLC




5 Governed by CMS



8 BCBS Has Evolved

9 But Not Medicare







16 Coverage for: Doctors (in/out) Diagnostic Tests Outpatient Svcs. DME


18 $1,100 deduct. $550 per day $275 per day $ per day HOSPITAL $1,100 per admission deductible $275 per day days $550 per day days No coverage after 150 days SNF $0 days 1-20 $ per day days

19 $155 deduct. 20% coins. 15% excess PART B $155 calendar year deductible 20% Coinsurance NO OUT OF POCKET MAXIMUM up to 15% excess charges if provider does not accept assignment

20 Medicare Supplements – fill in the holes in Original Medicare Medicare Advantage Plans – take over the administration of Medicare Part A and B for the government Medicare Part D Prescription Plans – only offered through private insurance companies Private Insurance to the Rescue!

21 $1,100 deduct. $550 per day $275 per day $ per day $155 deduct. 20% coins. 15% excess

22 $0

23 A b c d e f g h I j k l

24 A b c d e f g h I j k l I fill in most of the gaps in Original Medicare, including all hospital costs, all SNF copays, the Part B deductible, Part B coinsurance, and Part B excess charges.

25 Two new Medicare Supplement plans will be introduced on June 1, 2010, and will be added to the other current standardized plans. The new additions will be Plans N and M. Plan N will offer similar benefits to Plan F along with a $20 copayment for doctor visits and a $50 copayment for visits to the emergency room. Plan N will cost approximately 70 percent of the current Plan F depending on where you live. Medicare Supplement Plans being eliminated: Plans E, H, I and J will no longer be offered as of June 1, the preventive care and at-home recovery benefits will also be eliminated from the standardized Medicare Supplement options. Medicare Supplement (Medigap) plans have been the same since 1992, when they became federally standardized. However, the June 1, 2010 addition of plans M and N will be the first major changes to the Medicare Supplement marketplace since Additional changes will be to the current plans A through G, which will be phased out, and a new set of A through G plans will be phased in. This is a little confusing because the beneficiaries who are currently enrolled in plans A through G can either stay in their current option or migrate to one of the new A through G plans. Hospice care will be added to all standardized plans, and the preventive and at-home recovery benefits eliminated.

26 YES! NO! YES! OR Guarantee-issue for first 6 months After 6 months, applicants will have to answer medical questions and the carrier can decline coverage.

27 Supplement $150 + per month Part B: $ per month Part D: $28 per month

28 Source: PacifiCare Product Resource Manual / CMS Office of Research & Development Over 40% of Medicare Beneficiaries have annual incomes below $15,000

29 Clinton: BBA of 1997

30 Medicare Advantage Private Insurance paid for by Medicare Eligibility

31 Less expensive than a supplement – some plans have $0 premium. Guaranteed issue for people who live in service area, have A&B, and no ESRD YES! Covers everything Medicare does and may also cover:

32 From companies you know

33 HMO Network- based Copays PPO Out-of- network feature Copays, deductible, coinsurance PFFS No Network – deemed providers Copays, deductible, coinsurance

34 Distribution of Medicare Beneficiaries and Total Drug Expenditures, 2003 (40 million total beneficiaries) Source: Kaiser Family Foundation 11.2% $5, % $3,000-$4, % $2,000-$2, % $1,000-$1, % $1-$ % $0 Over 40% of Medicare Beneficiaries have annual incomes below $15,000 Donut hole starts here Average Total Rx Spending: $2,322 per Medicare Beneficiary 26.9% of Medicare Beneficiaries spend >$3k on Rx per year Prescription Usage


36 Eligibility OR Provided Through: Stand-Alone Medicare Prescription Drug Plans Medicare Advantage Plans Some Employers or Unions

37 Member pays first $310 Member pays 25% Plan pays 75% Member pays 5% Plan pays 95% Member pays 100% Deductible Coinsurance Coverage Gap Catastrophic Coverage $2830 Drug Cost $4550 TROOP

38 Deductible may or may not be waived Member pays copays Plan pays difference between copay and drug cost (4 tier formulary) Member pays 5% Plan pays 95% Member pays 100% Generics may be covered Deductible Coinsurance Coverage Gap Catastrophic Coverage $2830 Drug Cost $4550 TROOP


40 To find the best Part D plan for your clients, go to




44 Free for all Americans – no premiums, paid by taxes Everything would be covered, no cost sharing Private insurance companies would be illegal Those displaced by the move to a national program would be re-trained and hired into the public sector (wed all become government employees) 88 co-sponsors in the House

45 Health Reform

46 Sets Medicare Advantage payments based on the average of the bids from Medicare Advantage plans in each market.

47 Creates performance bonus payments based on a plans level of care coordination and care management and achievement on quality rankings.

48 Provides a four-year transition to new benchmarks beginning in Four-Year

49 New bidding process is expected to cut $120 billion in funding to the MA program. $120 billion

50 Prohibits Medicare Advantage plans from charging beneficiaries cost sharing for covered services that is greater than what is charged under the traditional fee-for-service program. ADVANTAGE

51 Requires plans that provide extra benefits to give priority to cost sharing reductions, wellness and preventive care, and then benefits not covered under Medicare. 1.Cost Sharing Reductions 2.Wellness & Preventive Care 3.Benefits Not Covered Under Medicare

52 Slightly extends the Medicare annual election period for Medicare Advantage and Part D enrollees by seven days and also moves it up to slightly earlier in the year, so that it will be Oct. 15 – Dec. 7, rather than Nov. 15 – Dec. 31.

53 Eliminates the traditional MA OEP, but allows Medicare beneficiaries enrolled in MA or MA-PD plans to return to original Medicare in the first 45 days of the Calendar Year.

54 Enhances penalties for those who do not comply with the Medicare Advantage rules, including the marketing requirements.

55 Provides protections against Medicare Advantage benefit cuts to residents of New York, Pennsylvania and Florida.

56 For Medicare beneficiaries, allows for coverage of an annual health risk assessment and expanded preventive care coverage.


58 Businesses that receive subsidies for providing prescription drug plans valued at as much as Medicare Part D for their retirees no longer would be allowed to exclude the subsidy payments from their gross income under the bill.

59 Increases the Medicare payroll tax from 2.9 percent to 3.8 percent for wages and self-employment income above $200,000 ($250,000 married). Current 2.9 percent rate retained for wages and self-employment income below this amount. In addition there will be a new 3.8% Medicare contribution on certain unearned income from individuals with AGI over $200k ($250k for joint filers).


61 The AP (4/14, Kennedy) reports, "Medicare fraud suspects would face longer prison sentences under a US House bill proposed Tuesday that also advocates biotechnology such as fingerprint scanning to ensure patients are getting the goods the government is billed for."AP Law enforcement officials "have warned Medicare fraud, an estimated $60 billion annual crime, is now more lucrative than dealing drugs. Until now the penalties have been far less severe." But, the "Medicare Fraud Enforcement and Prevention Act will double prison sentences from 5 to 10 years and fines from $25,000 to $50,000 for Medicare fraud- related crimes," and "create a new crime for illegally distributing patients' Medicare or Medicaid IDs or billing information, which would carry a maximum 3- year sentence."


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