3 Medicare For people 65+ and under 65 with a disability 4 parts of MedicarePart A: Hospital InsurancePart B: Medical InsurancePart C: Medicare Advantage PlansPart D: Prescription Drug CoveragePart A & B called Original MedicareAge 65 + :Must be a citizen/lawfully permitted resident for 5 years ANDQualify under ONE of the following 3 conditions:Be entitled to receive Social Security benefits and contributed to the Medicare Tax (having earned 40 credits from about 10 years of work)Be entitled to receive Railroad Retirement Act retiree benefitsBe a spouse or ex-spouse (marriage lasted at least 10 years), widow or widower (age 65+) of a person who qualifies for Social Security or Medicare benefitsFYI: Increase in age for full Social Security benefits does NOT affect MedicareUnder 65: Individuals of any age entitled to Social Security (SSDI) or Railroad Retirement Disability Insurance benefits for 24 months including individuals with ESRD (End Stage Renal Disease) and individuals with ALS (Amyotrophic Lateral Sclerosis, aka “Lou Gehrig’s Disease”)Part A (Hospital Insurance) helps pay for inpatient hospital stays, skilled nursing facility care, home health care, hospice care and blood.Part B (Medical Insurance) helps cover medically-necessary services like doctor visits and outpatient care. Part B also covers many preventive services (including screening tests and shots), diagnostic tests, some therapies and durable medical equipment like wheelchairs and walkers. Together, Parts A and B are also referred to as “Original Medicare.”Part C (Medicare Advantage [MA]) is another way to get your Medicare benefits. It combines Parts A and B, and sometimes Part D (prescription drug coverage). MA Plans are managed by private insurance companies that are approved by Medicare. These plans must cover medically-necessary services. However, plans can charge different copayments, coinsurance, or deductibles for these services than Original Medicare.Part D (Medicare Prescription Drug Coverage) helps pay for outpatient prescription drugs and may help lower your prescription drug costs and protect against higher costs in the future.Original Medicare is one of the coverage choices in the Medicare program. A beneficiary will be in Original Medicare unless they choose to join a Medicare Advantage Plan or other Medicare health plan. Original Medicare is a fee-for- service program that is managed by the federal government. With Original Medicare, a beneficiary can go to any doctor, supplier, hospital, or facility that accepts Medicare and is accepting new Medicare patients.In Original Medicare, a beneficiary pays deductibles, coinsurance, or copayments.With Original Medicare, a beneficiary can join a Medicare Prescription Drug Plan (Part D plan) to add drug coverage.
4 Medicare Pays for reasonable and medically necessary services There are coverage gaps in Medicare including:Part A in-patient hospital deductiblePart A daily co-payment for in-patient hospital days 61-90Part A daily co-payment for in-patient hospital daysPart A daily co-payment for SNF daysPart B annual deductiblePart B co-insurance (usually 20%)First three pints of bloodCoverage outside the United StatesMedicare is NOT a comprehensive health insurance program. It forms the foundation for the beneficiary’s protection against heavy medical expenses. Medicare was never intended to pay 100% of health care costs.There are “gaps” in Medicare which require the beneficiary to pay a portion of her/his medical expenses.Refer to Medicare Part A and B Benefits and Gaps chart for amounts
5 Medicare 3 Enrollment Types 3 Enrollment Periods Automatic: Already receiving Social Security benefitsVoluntary: Don’t have enough SS work credits, must purchase A+BStandard Enrollment: Eligible for SS and didn’t take benefit before 653 Enrollment PeriodsInitial: 7 months surrounding 65th birthday monthSpecial: 8 months following loss of coverage from ACTIVE employment (individuals or spouses)General: Jan 1st–Mar 31st of each year . July 1st effective dateAutomatic: For individuals already receiving Social Security benefits. Beneficiary receives automatic enrollment notice 3 months before 65th birthday month (4 months before if birthday on 1st of month - Medicare begins 1st of month prior to birthday month). Individuals with a disability receive notice 24 months after Social Security Disability payments began.Voluntary: For individuals who don’t have sufficient Social Security work credits (40 quarters/10 yrs). Can purchase Part A. Must be an American citizen OR an alien lawfully admitted for permanent residence and resided in US for 5 consecutive yearsCan purchase Part A AND Part B OR Part B only. CANNOT have Part A alone as a voluntary enrollee.FYI: Having Part B only does NOT meet the minimum essential coverage requirement under the Affordable Care Act and beneficiary may have to pay a penaltyStandard: This is for individuals who have NOT been collecting a Social Security pension prior to age 65. These individuals must notify Social Security of their intent to enroll in Medicare. A common myth about Medicare is that Medicare will know when an individual turns 65. However, this is NOT the case. Medicare and Social Security are two entirely separate entitlement programs.FYI: People often file to receive Social Security benefits prior to age 65 so only these early retirees can expect Medicare to know that their 65th birthday is approaching.
6 MedicareCan delay Part B enrollment if receiving health coverage through ACTIVE employment of individual or spouse8 month SEP to join Part B once ACTIVE employment coverage has endedLate Enrollment PenaltiesPart A: Capped at 10% of premium and goes away after penalized for twice the length of time the person delayed enrollmentFor voluntary enrollees who don’t enroll when initially eligiblePart B: 10% of premium for each full 12 month period the individual delayed enrollmentDelaying or Rejecting Part B: An individual can reject Part B without facing a penalty in the future if she/he is covered by employer group health insurance through ACTIVE EMPLOYMENT, either through her/his own employment or the employment of a spouse.Penalty Notice For Delayed Part B Enrollment: A penalty will be assessed to an individual who rejects Part B when initially eligible and was NOT covered by an Employer Group Health Plan (EGHP) through active employment (either through her/his own employment or a spouse’s employment). Having a retiree plan or COBRA coverage does NOT protect an individual from the penalty.
7 Medicare Physician’s Services Medically-necessary physician’s services coveredWelcome to Medicare Exam & Annual Wellness VisitDoes not cover yearly routine physical examsBenefit periodPeriod of time that Medicare pays for a person’s care in a hospital or SNFBan on Balanced BillingMassachusetts has a law prohibiting excess charges by physiciansPhysician’s Services: Medicare covers medically-necessary doctor services (including outpatient and some doctor services you get when you’re a hospital inpatient) and covered preventive services. Medicare also covers services provided by other health care providers, like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists.Welcome to Medicare Exam: Includes a review of medical and social history related to the beneficiary’s health and education and counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed. Annual Wellness Visit: This yearly visit will include a discussion about developing or updating a personalized plan to prevent disease or disability based on the beneficiaries current health and risk factors. A wellness visit is NOT a physical exam.Medicare does NOT pay for a yearly routine physical exam.Benefit Period: For a hospital, it begins the first day a beneficiary receives inpatient care and ends when a beneficiary has been out of the hospital or skilled nursing facility for 60 days in a row (including the day of discharge). There is no limit to the number of benefit periods a beneficiary can have for hospital and skilled nursing facility care. The Part A deductible will apply to each benefit period.Massachusetts Ban on Balance Billing:Limits what doctors may charge. Doctors who are “non-participating providers” working in other states may charge a patient up to 15% above the Medicare approved amount. These are called legitimate excess charges. Durable Medical Equipment Suppliers Exception: Suppliers of DME and supplies can charge more than the Medicare approved amount.
8 Medicare Advantage (Part C) Many aspects of the Medicare program are complex and confusing. A newly eligible Medicare beneficiary may be uncertain about what Medicare covers and doesn’t cover and how much it pays toward medical expenses. She/he may not realize that Medicare was established to help pay for some, but not all, health care costs.For instance, as we have learned, Medicare beneficiaries are responsible for deductibles and co-insurance under Medicare Hospital (Part A) and Medical (Part B) Insurance. In addition, many benefits, such as preventive physical exams and outpatient prescription drugs were originally excluded entirely from the fee-for-service Medicare Program.This is where Medicare Advantage, Part C comes in.
9 OverviewAlso known as “Medicare Part C”, “MA Plan”, or a “Medicare Health Plan”One option available for beneficiaries to get additional coverage to cover the gaps in Original MedicareOffered by a private company that contracts with Medicare to provide a beneficiary with their Part A & Part B benefitsIs a “replacement” plan where beneficiary gets Part A & B coverage from MA Plan, not Original MedicareMust still pay Part B premiumMost MA plans include prescription drug coverage (Part D)Medicare Advantage, also often referred to as “Medicare Part C”, “MA Plan”, or “Medicare Health Plan” is one way for a beneficiary to get additional Medicare coverage to cover the gaps in Original Medicare.Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare to provide a beneficiary with their Part A and Part B benefits. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. If a beneficiary is enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare.Beneficiaries may get additional benefits offered through the plan, including Medicare prescription drug coverage (Part D). Other extra benefits could include coverage for vision, hearing, dental care, and/or health and wellness programs.Most Medicare Advantage Plans offer prescription drug coverage.
10 Medicare Advantage Plans Must cover at least services covered under Original Medicare (Part A & Part B)Provide all the rights and protections guaranteed under MedicareMust offer extensive network of health care providersPlan must offer a plan with Part D drug coverage – members who want drug coverage may only take drug plan offered by Medicare Advantage PlanIf enroll in stand alone PDP, will be dis-enrolled from Part C and returned to Original MedicareMedicare Advantage HMO’s and PPO’s have different coverage, standards, etc. than regular HMO’s and PPO’sMedicare Advantage Plans are health plan options approved by Medicare (in fact they are part of the Medicare program, they’re just another way to get Medicare coverage) so they must cover at least the services covered under Original Medicare (Part A and Part B) and provide the same rights and protections guaranteed under Medicare.Medicare pays the plan a certain amount for each member’s care. The plans offer networks of providers so that beneficiaries may have to use a particular network of doctors and/or hospitals.There are different types of Medicare Advantage plans including HMO’s and PPO’s which offer different coverage and standards than regular HMO’s and PPO’s. An HMO service referral area includes those communities in which an HMO is authorized by the federal government to offer its Medicare contracted plan. Therefore, Medicare HMO plans may have a different network of providers than non-Medicare HMO plans. (For example, the directory for the Tufts Medicare plans is not the same as the directory for the Tufts non-Medicare plans.)
11 Medicare Advantage Companies Companies are required to:Have package of benefits approved by MedicareGive beneficiaries written information about coverage, cost, and effective dateProvide a quality of service which meets Medicare standardsGive members information about appeal rightsWith a Medicare Advantage Plan, beneficiaries still have all of the Medicare rights and protections.
12 Eligibility Eligibility requirements: Have Medicare Part A & Part B (must pay Part B premium)Cannot have ESRD (except if have coverage with a non-Medicare plan from the same company prior to being diagnosed)Must live in the plan’s service areaCannot be out of plan’s service area for more than 6 consecutive monthsMedicare Advantage (MA) Plans are available to most people with Medicare. To be eligible to join an MA Plan, a person must:Have Medicare Part A and Part B.Not have End-Stage Renal Disease. People with ESRD usually can’t join an MA Plan or other Medicare plan. However, there are some exceptions.If a person with ESRD is a current member of a Health Maintenance Organization (HMO) plan when they first become eligible for Medicare and the plan has a Medicare contract, they will be able to change from their current plan to the Medicare HMO within the same company. The application to transfer enrollment must be made within 6 months of the effective date of their Medicare Part B.If a person with ESRD belongs to a Medicare Advantage plan and that plan moves out of the service area, the member will be allowed to join another Medicare Advantage plan.A beneficiary with ERSD can join a special ESRD MA plan if one is available.Live in the plan’s geographic service area or continuation area.Agree to provide the necessary information to the plan.Agree to follow the plan’s rules.Belong to only one plan at a time.Not be out of the plans’ service area for more than 6 consecutive months.
13 Four Enrollment Periods Initial Enrollment Period (IEP)Open Enrollment Period (OEP)Special Enrollment Period (SEP)Medicare Advantage Disenrollment Period (MADP)A person can join a Medicare Advantage (MA) Plan during one of these 4 enrollment periods.
14 Initial Enrollment Period Same as Part B seven month enrollment period3 months before 65th birthday (or year of entitlement to Medicare for those under 65 with a disability), month of birthday, 3 months after birthday monthMonth earlier if birthday is the 1st of the monthA person can join when they first become eligible for Medicare, during their Initial Enrollment Period, which begins 3 months immediately before their first entitlement to both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).
15 Open Enrollment Period October 15th -December 7th (effective Jan 1st)During this period a beneficiary may change from:Original Medicare to Medicare Advantage PlanMedicare Advantage Plan to Original MedicareMedicare Advantage Plan to another Medicare Advantage PlanUpgrade to include Medicare Prescription Plan coverageDowngrade to exclude Medicare Prescription Plan coverageA beneficiary can switch to another MA Plan or to Original Medicare during the Open Enrollment Period, which runs from October 15th through December 7th each year, with coverage starting January 1st.A beneficiary can only join one MA Plan at a time, and enrollment in a plan is generally for a calendar year.Plans must be allowing new members to join. Plans may be prohibited from accepting new members if there is a Centers for Medicare & Medicaid Services (CMS)–approved capacity limit or a CMS-issued enrollment sanction is in effect.
16 Special Enrollment Period Some qualifying events for SEP eligibility:Move out of plan’s service areaNonrenewal or termination of planHave or lose MassHealthHave Extra Help or Prescription AdvantageWithin “trial period“ (first 12 months) of MA plan if enrolled into MA plan when first eligible for Medicare at age 65In last 12 months, left a Medigap policy to join a MA plan for the first timeFYI: There is NO SEP if a doctor leaves the plan networkA special enrollment period (SEP) is a designated period of time when a beneficiary may make a change or election in coverage based on a special/qualifying event or circumstance. Medicare should tell beneficiaries how long they have to choose a new plan when the event occurs. If the beneficiary does not choose a new plan, they will automatically be assigned to Original Medicare.These are some of the qualifying events for a SEP, the complete list can be found on the Medicare PDP/MA-PD SEP chart located in your tool kit.FYI: There is no SEP if a doctor leaves the plan network on their own initiative or if the plan removes them.
17 Special Enrollment Period How long beneficiary has to make new selection depends on eventOnce selection is made, the SEP is overIf coverage is lost and no other selection is made, beneficiary returns to Original Medicare with no drug coverageIf beneficiary is eligible and selects a stand alone Medicare drug plan, beneficiary will automatically be dis-enrolled from Medicare Advantage PlanCannot have a stand alone Medicare Prescription Drug Plan along with a Medicare Advantage PlanThe time frames and effectives dates for SEP’s vary according to the qualifying event.
18 Medicare Advantage Disenrollment Period (MADP) January 1st – February 14thCan leave plan and return to Original MedicareCoverage begins the first of the month after dis-enrollingIf switch to Original Medicare during this period, will have until February 14th to also join a Medicare Prescription Drug PlanCoverage begins the first day of the month after the plan gets enrollment form.Cannot join another MA plan during this periodBeneficiaries who belong to a Medicare Advantage (MA) Plan can switch to Original Medicare from January 1st through February 14th .If they go back to Original Medicare during this time, coverage under Original Medicare will take effect on the first day of the calendar month following the date on which the election or change was made.Cannot switch MA plans during this period.
19 Changing MA plansAutomatic disenrollment when changing Medicare Advantage PlansBeneficiaries don’t need to call the plan they are leaving to dis-enrollEnrolling in the new MA plan will automatically alert the old plan
20 Plan Types Types of Medicare Advantage Plans HMO (Health Maintenance Organization)HMO-POS (HMO with Point-of-Service option)PPO (Preferred Provider Organization)SNP (Special Needs Plan)PFFS (Private Fee for Service)Not all plans are offered in all regions of the stateThere are 5 different types of Medicare Advantage Plan options available in Massachusetts. Not all plans are available in every region of the state. Refer to you Medicare Advantage chart located in your tool kit, which lists the plans available in your region.
21 HMO Plans HMO (Health Maintenance Organization) Typically lower premium than other types of MA plansMost restrictive type of managed care planPlan “rules” must be followed for services to be paidMembers must use network providersReferrals from Primary Care Physician are requiredIf plan does not pay, original Medicare will NOT pay as back-upCare outside the service area for emergencies and urgent care situations ONLY (notification rules apply)May include extra benefits like vision, hearing or dentalMedicare HMO’s are an alternative choice to traditional health insurance. HMO’s are a form of managed care with each HMO plan having its own network of hospitals, skilled nursing facilities, doctors and other health care professionals to provide services to its members.Eligibility requirements to join a Medicare HMOMust be enrolled in Medicare Parts A AND B and continue to pay the Part B monthly premium.Must live in the HMO’s service area and NOT leave the service area for more than 6 consecutive months at a time.Cannot have ESRD at the time of application. If after joining a Medicare HMO plan, a person is medically determined to have ESRD, the plan is required to provide or arrange for all their medical care.A federally approved HMO is not allowed to deny membership to a Medicare beneficiary for any other health conditions (for example, cancer, heart disease, etc.) except ESRD. An HMO cannot require a health questionnaire be completed as a prerequisite to joining.How Medicare HMO’s WorkHMO’s contracting with the Medicare program must provide or arrange for the full range of Medicare Parts A, B and D services including hospitalization, physician services, skilled nursing, home health care and prescription coverage. Some HMO’s also provide benefits beyond what Medicare covers, such as routine services, limited dental care, hearing aids and eyeglasses.Medicare pays the HMO a monthly premium up front for each member.Like an insurance company, HMO’s cover health care costs in return for a monthly premium. Premiums vary from plan to plan and are subject to change annually. Medicare beneficiaries must also continue to pay the Part B monthly premium. They also commonly charge small co-payments for certain services (instead of the deductibles and co-insurance charged in original Medicare.Emergency/Urgent CarePrior authorization is NOT required for emergency care or services urgently needed while out of the plan’s service area. However, there are rules about notifying the plan of the need for such services.Emergencies= Those situations during which a person needs medical care immediately because of a sudden illness (or worsened illness) or injury, and the time needed to reach the HMO doctors or hospitals could increase the risk of serious harm or permanent damage. It is an unexpected or unforeseen condition. Examples include a fractured limb, suspected heart attack, excessive bleeding or stroke. The HMO will pay for out-of-plan emergency care, but the member may be charged a co-pay.
22 Advantages/Disadvantages to HMO Membership Quality of care enhanced due to coordination of servicesEasier to budget medical costs because premiums and co-pays are fixed amountsOther out-of-pocket expenses to enrollee minimal & predictableLess paperwork and no formsExtra benefits such as hearing, dental, routine exams, visionHealth promotion and disease prevention24 hour careRestriction on use of doctors, hospitals, health care providersMust have prior approval to see a specialist, have surgery, or obtain other medical servicesEnrollee may have to change from current physicianHMO facilities may not be easily accessibleLimitation on out-of-service area coverageOngoing treatment of chronic conditions may not be covered while outside the service area
23 HMO-POS Plans HMO-POS (HMO with Point-of-Service option) POS benefit allows the enrollee to use doctors, hospitals, and other providers who are not in the HMO or other plan networkMay have to pay deductible and any other fee Medicare does not cover for services received through POS optionMedicare Advantage Plans may offer a POS option as either:An additional benefit included in the plan’s basic premium ORA mandatory or supplemental benefit for which the plan will charge a higher premiumMedicare Advantage plans may offer a Point-of-Service option as either:An additional benefit (included in the plan’s basic premium), ORA mandatory or supplemental benefit for which the plan will charge a higher premium.How a HMO-POS works:The POS benefit allows the enrollee to use doctors, hospitals, and other providers who are not in the HMO or other plan network.The enrollee will likely have to pay a deductible and any part of the fee that Medicare does not cover for services received through a point-of-service option.
24 PPO Plans PPO (Preferred Provider Organization) Can have a higher monthly premiumCan go outside of network but will usually pay higher out-of-pocket costsPlan has network of providers (usually different than HMO network, even if same company)Generally does not require referrals from Primary Care PhysicianMay include extra benefits like vision, hearing, dentalA Medicare PPO Plan is offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.How a PPO works:The PPO receives a monthly payment per member from Medicare and must provide benefits to which the beneficiary is entitled.Some PPO’s require that the enrollee select a primary care physician who coordinates her/his care and who must refer the enrollee to a specialist.Some PPO’s may allow the enrollee to see any doctor within the network without getting a referral beforehand.Stand Alone PDP and HMO’s and PPO’s:If a beneficiary belongs to a Medicare Advantage HMO or PPO plan and wants new Medicare prescription drug coverage, she/he must get it from their Medicare Advantage HMO or PPO plan and may not get it from one of the “stand alone” Medicare Prescription Drug Plans (PDPs) being offered to Medicare beneficiaries in their area. All Medicare Advantage HMO and PPO plans must offer members at least one option which includes prescription drug coverage. They may also offer an option without prescription drug coverage.If a beneficiary joins a “stand alone” PDP, she/he will be dis-enrolled from the Medicare Advantage plan and returned to original Medicare.
25 PFFS Plans (PFFS) Private Fee-For-Service Beneficiary can go to any provider that agrees to the terms of the planNo referrals needed for specialistMay pay different amount for services under Part A & B but will get all the same services coveredMay pay extra for extra benefitsMedicare Private Fee-for-Service Plans are offered by a private insurance company and are only available in certain Massachusetts counties.Overview:Medicare pays a set amount of money every month to the private insurance company to provide health care coverage to people with Medicare on a fee-for-service arrangement. Also, the insurance company, rather than the Medicare Program, decides how much a beneficiary pays for the services they receive.Beneficiaries do not need to get a referral before going to a specialist. Although the amount paid for these services may not be the same as the original Medicare plan, beneficiaries will get all services covered under Medicare Parts A & B.There may be extra benefits for which the original Medicare plan does not pay, however, the beneficiary may have to pay extra for these benefits.Beneficiary will keep all the rights and protections under original Medicare except that she/he will not be protected against having to pay for services that the PFFS plan says are not medically necessary.EligibilityMust have Medicare Part A & Part BMust live in the service area of planBeneficiary still needs to pay the Part B premiumCannot have ESRDHow a Private Fee-For-Service Option might WorkGenerally, any Medicare-approved provider such as a doctor or hospital who, before treating a beneficiary, agrees to accept the Medicare PFFS plan’s terms and conditions of payment.The beneficiary must show their plan membership ID card every time they visit a health care provider. There is a telephone number or website on the card for the provider to find out about the plan’s terms and conditions of payment.This gives the provider the right to choose whether to accept the plan’s terms and conditions of payment. If a beneficiary is in need of emergency care, it is covered whether the provider accepts the plan’s payment terms or not.Not all providers will accept the plan’s payment terms or agree to treat a beneficiary. Prior to receiving any services, a beneficiary should ask the doctor or hospital if they are willing to contact the plan for payment information and accept the plan’s payment terms.
26 SNP Plans SNP (Special Needs Plan) Comprehensive program of medical care with membership limited to certain groups of people including:Those in certain institutions (like nursing homes)Those eligible for both Medicare & MassHealth (Duals)Those with certain chronic or disabling conditionsGenerally provides greater benefits to members including:Specialty care coordinationHospital case managementCommunication with caregiversRoutine patient visitsSpecial Needs Plans use a collaborative practice model to respond to the multiple needs of frail elderly residents of nursing facilities. The collaboration between the primary care physician and the nurse practitioner emphasizes preventing illness, early detection of disease and timely delivery of care in the nursing facility. A special needs plan is a comprehensive program of medical care that includes: Initial assessment of new membersRoutine patient visitsSpecialty care coordinationUrgent/unscheduled visitsHospital case managementCommunication with caregiversEligibilityEnrollee has Medicare A and B, andResides in a nursing home in the plan’s service areaDoes not have ESRD
27 Quick Reference: Pro’s of Medicare Advantage Plans Medicare Advantage Plans tend to attract people who are not high utilizers of medical services. They also attract people who want a lower premium planPro’s:Convenience of having only one plan (drug plan can be included)More choices available (HMO’s, PPO’s…)Lower premiums than Medigap plansPotential for better coordination of care (HMO’s provide this)Additional benefits such as hearing, dental, vision and annual examsThis quick reference is located on the backside of the handout, Two Options for Supplementing Medicare located in your tool kit.Additional Pro: No hospital stay required for SNF coverage benefit
28 Counseling Beneficiaries: Is Additional Coverage Needed? Does every Medicare beneficiary need additional Medicare coverage?Questions to ask beneficiary:Does she/he understand the “gaps” in Medicare coverage?Does she/he have other coverage to help pay for out-of-pocket costs associated with Medicare? (Retiree Coverage, Medigap plan, MassHealth)Can she/he afford to purchase additional coverage? (screen for Public Benefit programs)It is a common misconception that once one enrolls in Medicare one needs to additional coverage. Not everyone enrolled in Medicare needs Medicare Advantage or a Medigap plan (additional supplement option to be discussed in the next class).Beneficiaries who fall into one of the following categories MAY NOT need to purchase a Medicare Advantage plan.Retirees With Employer CoverageA retiree who has health insurance from her/his former employer may find it provides comprehensive coverage for a reasonable cost. Medicare Advantage may duplicate the hospital and medical benefits offered by the retiree plan and would be a waste of dollars in premiums each year. For retirees with very limited employer-sponsored health insurance benefits, Medicare Advantage may be necessary.Beneficiaries Who Qualify For Public BenefitsA beneficiary who qualifies for a public benefit program (See chapter entitled: Public Benefits) may not need the additional coverage that Medicare Advantage offers.Those Enrolled in MedigapA person would not need Medicare Advantage if they already have a Medigap supplement policy.
29 Medicare Advantage Review What is a Medicare Advantage Plan?What are the advantages of Medicare Advantage?What are the disadvantages of Medicare Advantage?Who can enroll in a Medicare Advantage Plan?When can a person enroll?What is the difference between an HMO and PPO?1. SLIDE 9: Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare to provide a beneficiary with their Part A and Part B benefits. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care.2. SLIDE 26:Convenience of having only one plan (drug plan can be included)More choices available (HMO’s, PPO’s…)Lower premiums than Medigap plansPotential for better coordination of care (HMO’s provide this)Additional benefits such as hearing, dental, vision and annual exams3. SLIDE 10 &12: Must live in plan area, may have to use network for providers, may need referrals4. SLIDE 12: Have Medicare Part A & Part B (must pay Part B premium)Cannot have ESRD (except if have coverage with a non-Medicare plan from the same company prior to being diagnosed)Must live in the plan’s service areaCannot be out of plan’s service area for more than 6 consecutive months5. SLIDE 13-18: Enrollment Periods6. SLIDE 21 (HMO), SLIDE 23 (PPO)
30 Case Study 1: Havvah Heart Havvah meets with you at the SHINE office. She has just retired from her job. She has Medicare A & B and wants to know what her options are for additional insurance over and above Medicare. She asks you to explain the differences between Medicare and a Medicare Advantage Plan, and wants to know which is better.What would you tell her?1. Original Medicare: Includes Parts A & B. Can purchase prescription drug coverage through Part D.(SLIDE 3) Original Medicare has gaps: Part A & B deductibles, Part A co-pays for some hospital care and SNF care, Part B co-insuranceSupplements such as Medigap plans (to be discussed next class) or Medicare Advantage plans which “replaces” Original Medicare by providing Part A & B along with additional coverage can fill these gaps.2. Explain Medicare Advantage (SLIDE 9 & 10): One way for a beneficiary to get additional Medicare coverage to cover the gaps in Original Medicare. Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare to provide a beneficiary with their Part A and Part B benefits. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. If a beneficiary is enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Beneficiaries may get additional benefits offered through the plan, including Medicare prescription drug coverage (Part D). Other extra benefits could include coverage for vision, hearing, dental care, and/or health and wellness programs.3. Medicare Advantage plans pro’s (SLIDE 27):Cover some of the gaps in Original MedicareLow premium (compared to Medigap plans)Most plans include prescription coverage so all services are conveniently in one planMay offer additional benefits such as hearing, dental, vision and annual exams5 types of Medicare Advantage plans to choose from including HMO’s (slide 21) , HMO-PPO’s (slide 23), PPO’s (slide 24) , PFFS’s (slide 25) offering people range of choices
31 Case Study 2: Tyme Leeness Tyme Leenes comes to the SHINE office to get information on Medicare and Medicare HMO plans. He will be retiring in 3 months and wants to know when he can join a plan. He tells you that he spends 5 months of the year in Florida and the other 7 months in Massachusetts.How would you assist him?1. Questions to ask: Is he married? If so if is spouse is actively working, can he join her/his employer plan? If not….2. Eligibility for MA plan (SLIDE 12):He must have Part A & B and pay Part B premium (will also need to pay MA premium if there is one)Must live in plan’s service area and cannot be out of the service area for more than 6 consecutive monthsCannot have ESRD3. HMO’s: (Advantage/disadvantages SLIDE 22, Pro’s SLIDE 27)Arrange for A, B & D services and provide additional benefits (routine services, limited dental, hearing aids, eye glasses) that Original Medicare doesn’t provide.Must use network of providers within service area and receive referrals for specialistsPrior authorization NOT required for emergency/urgent care while out of plans service area and plans will cover it (member may have to pay co-pay) under these conditions:Care received is unexpectedMember is temporarily outside of service area
32 Case Study 3: Ty Juan OnTy Juan On calls you at the SHINE office. He has just become eligible for Medicare and received his card. He wants to know if he would need a referral from a primary care physician to access medical services when using Part A or B. Also, he heard that he needs to buy additional insurance - something called a Medicare Advantage Medigap Plan.How would you help him?Confirm that Ty has Part A AND B (look at card to make sure)Explain Original Medicare (SLIDE 3) benefits and gaps (SLIDE 4 and 7-physician’s services, no routine physical covered). With Original Medicare, a beneficiary can go to any doctor, supplier, hospital, or facility that accepts Medicare and is accepting new Medicare patients, no referral needed.Ask if additional coverage is needed (SLIDE 28). If so, explain supplement options as 2 options, Medicare Advantage plans and Medigap plans. Discuss what supplement plans do (cover gaps in Original Medicare, offer additional benefits).Discuss Medicare Advantage in detail (SLIDE 9 & 10)
33 Case Study 4: Chad R. BoxxMr. Boxx comes to see you at the SHINE office. He recently moved to another part of the state to live closer to his daughter. The Medicare Advantage plan he had is not available in this new location. He wants to know what his options are.How would you help him?1. Discuss available Medicare Advantage plans in his new location (use chart). Discuss the options (available plan types SLIDE 21-25)2. Explain how to change plans: Automatic disenrollment from current plan when he signs up for a new plan (SLIDE 19)3. Review available Enrollment PeriodSEP (SLIDE 16): A special enrollment period (SEP) is a designated period of time when a beneficiary may make a change or election in coverage based on a special/qualifying event or circumstance. Refer to Medicare PDP/MA-PD SEP’s chart in tool kit to see if Mr. Boxx qualifies for any SEP.*Qualifitying SEP for Mr. Boxx= Recently moved out of the service area. Explain he has 2 months to do enroll in a new plan to qualify for this SEP.
34 Case Study 5: Will B. GoneMr. Gone meets with you at the SHINE office to clarify questions about Medicare and other insurance. He will be turning 65 in a few months. He has a friend who belongs to a Medicare Advantage Plan and is very pleased with the services he receives. Mr. Gone takes no medication and wants to enroll in the cheaper, non-prescription plan. He doesn’t see why he should sign up for the prescription plan if he doesn’t take medication. Mr. Gone has already checked that his doctor participates, so he’s pretty well set on the plan. In discussing his upcoming retirement, Mr. Gone tells you of his plans to spend more time with family in Florida.What information would you give to Mr. Gone?1. Questions to ask: How long does Mr. Gone plan to spend in Florida (if more than 6 consecutive months, not eligible for MA- SLIDE 12)2. Explain Medicare Advantage (SLIDE 9 & 10) including the different play types (SLIDES 21-25). PPO may be best for him so he can go out of network (if in Florida or traveling)3. Discuss MA drug coverage option and review the costs of plans with or without coverage.4. Discuss what his options would be if he takes a plan without drug coverage but later decides he does want coverage. Would need to enroll during available enrollment periodsExplain enrollment periods (SLIDE 14-18):Open (SLIDE 15): A beneficiary can switch to another MA Plan or to Original Medicare during the Open Enrollment Period, which runs from October 15th through December 7th each year, with coverage starting January 1st.MADP (SLIDE 18): Beneficiaries who belong to a Medicare Advantage (MA) Plan can switch to Original Medicare from January 1st through February 14th . If they go back to Original Medicare during this time, coverage under Original Medicare will take effect on the first day of the calendar month following the date on which the election or change was made.*SEP (SLIDE 16): A special enrollment period (SEP) is a designated period of time when a beneficiary may make a change or election in coverage based on a special/qualifying event or circumstance. Refer to Medicare PDP/MA-PD SEP’s chart in tool kit to see if Ima qualifies for any SEP.
35 Case Study 6: Fran ChiseMs. Fran Chise meets with you at the SHINE office. She is 66 and has been retired for the past year. She did not sign up for Medicare Part B as her husband continued to work and she has been covered under his employer insurance plan. Her husband is retiring next month but the company will continue to provide full insurance coverage to both of them for six months after he stops working. Ms. Chise called Social Security to see when she must pick up Part B. Social Security told her she must pick up Part B immediately in order to avoid a penalty. Since she is covered in full for six months, she wanted to delay the Part B.What information would you give her?1. Review Part B late enrollment penalty (SLIDE 6):Delaying or Rejecting Part B: An individual can reject Part B without facing a penalty in the future if she/he is covered by employer group health insurance through ACTIVE EMPLOYMENT, either through her/his own employment or the employment of a spouse. 8 month SEP after ending ACTIVE work to join BPenalty Notice For Delayed Part B Enrollment: A penalty will be assessed to an individual who rejects Part B when initially eligible and was NOT covered by an Employer Group Health Plan (EGHP) through active employment (either through her/his own employment or a spouse’s employment). Having a retiree plan or COBRA coverage does NOT protect an individual from the penalty.2. SEP is for 8 months so Fran could apply for Part B in the 5th month, a month before her husbands insurance coverage ends, so coverage begins in month 7.
36 Case Study 7: Jan ItorJan Itor calls you at the SHINE office. Her parents are moving to Massachusetts from Montana. They are enrolled in a Medicare Advantage Plan in Montana. She wants to start the process of getting them insurance coverage in Massachusetts, but she knows nothing about Medicare or where to begin.How would you help her?1. Provide Medicare 101 (SLIDES 3-5): Medicare NOT a comprehensive health insurance program (doesn’t pay for 100% of all health care costs). It forms the foundation for the beneficiary’s protection against heavy medical expenses. There are “gaps” in Medicare which require the beneficiary to pay a portion of her/his medical expenses.2. Discuss SEP eligibility (SLIDE 16): Parents eligible as they are moving out of their plans service area. They must notify the plan up to 12 months before, or 2 months after the move to be eligible for SEP.3. Explain Medicare Advantage options in Massachusetts (Overview SLIDES 9 & 10) (Plan types SLIDE 21-25)
37 Medical Insurance Explained for the HMO Systems Q. What does HMO stand for?This is actually a variation of the phrase, “HEY MOE” Its roots go back to a concept by Moe of the Three Stooges, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes.Q. Do all diagnostic procedures require pre-certification?No — only those you need.Q. Can I get coverage for my pre-existing conditions?Certainly, as long as they don’t require any treatment.Q. What happens if I want to try alternative forms of medicine?A. You’ll need to find alternative forms of payment.
38 Medical Insurance Explained for the HMO Systems, cont. Q. I just joined a HMO. How difficult will it be to choose the doctor I want?A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. These doctors fall into 2 categories - those who are no longer accepting new patients and those who will see you, but are no longer participating in the plan. But don’t worry; the remaining doctor who is still in the plan, and accepting new patients, has an office just a half-day’s drive away.Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the generic drugs, but it gave me a stomach ache. What should I do?A. Poke yourself in the eye.Q. What if I’m away from home and I get sick?A. You really shouldn’t do that.
39 Medicare Advantage Quiz Amanda is a 67 year old beneficiary enrolled in a Medicare Advantage Plan. As a member of this plan Amanda has all the rights and protections guaranteed under Medicare. Is this True or False?When can a Medicare beneficiary join a Medicare Advantage Plan?Ms. King joined a Medicare Advantage Plan 6 months ago when she first became eligible for Medicare. She wants to change to a new PCP (primary care physician) but learned he is not affiliated with her MA plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Open Enrollment Period to make a change. How would you assist her?1. True (SLIDE 10)2. Enrollment periods (SLIDE 14-18):Initial Enrollment Period (SLIDE 14): Begins 3 months immediately before their first entitlement to both Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).Open (SLIDE 15): A beneficiary can switch to another MA Plan or to Original Medicare during the Open Enrollment Period, which runs from October 15th through December 7th each year, with coverage starting January 1st.MADP (SLIDE 18): Beneficiaries who belong to a Medicare Advantage (MA) Plan can switch to Original Medicare from January 1st through February 14th . If they go back to Original Medicare during this time, coverage under Original Medicare will take effect on the first day of the calendar month following the date on which the election or change was made.SEP (SLIDE 16): A special enrollment period (SEP) is a designated period of time when a beneficiary may make a change or election in coverage based on a special/qualifying event or circumstance. Refer to Medicare PDP/MA-PD SEP’s chart in tool kit.3. SEP (SLIDE 16): A special enrollment period (SEP) is a designated period of time when a beneficiary may make a change or election in coverage based on a special/qualifying event or circumstance. Refer to Medicare PDP/MA-PD SEP’s chart in tool kit to see if Ima qualifies for any SEP. SEP: “Trial Period”- Beneficiaries can dis-enroll during the first 12 months of trying a Medicare Advantage Plan for the first time at age 65
40 Medicare Advantage Quiz, cont. Gordon has ESRD (End Stage Renal Disease) and belongs to an HMO through his employer. He will be 65 next month and will retire from his employment. He has been on Medicare for the past 7 months and wants to purchase a MA plan once he retires. He has Part A now and will enroll in Part B when he retires. Check all that apply.____ He can purchase a MA plan if the employer HMO offers a MA plan.____ He cannot purchase a MA plan under any circumstances because he has ESRD.____He can purchase any MA plan and all plans have to accept himList the eligibility criteria to enroll in a Medicare Advantage Plan.4. He can purchase a MA plan if the employer HMO offers a MA plan (SLIDE 12)Medicare Advantage (MA) Plans are available to most people with Medicare. To be eligible to join an MA Plan, a person must:People with ESRD usually can’t join an MA Plan or other Medicare plan. However, there are some exceptions.If a person with ESRD is a current member of a Health Maintenance Organization (HMO) plan when they first become eligible for Medicare and the plan has a Medicare contract, they will be able to change from their current plan to the Medicare HMO within the same company. The application to transfer enrollment must be made within 6 months of the effective date of their Medicare Part B.If a person with ESRD belongs to a Medicare Advantage plan and that plan moves out of the service area, the member will be allowed to join another Medicare Advantage plan.A beneficiary with ERSD can join a special ESRD MA plan if one is available.5. (SLIDE 12)