Understanding Medicare Basics with edits by Illinois SHIP Module 1B

November 16, What is Medicare? A health insurance for people –65 and older –Under 65 with certain disabilities –Any age with End-Stage Renal Disease (ESRD) Administration –Centers for Medicare & Medicaid Services Enrollment –Social Security Administration for most –Railroad Retirement Board (RRB) Understanding Medicare

Different Parts of Medicare Medicare Has four Parts –Part A: Hospital Insurance –Part B: Medical Insurance –Part C: Medicare Advantage HMO, PPO, Private-Fee-For-Service, Special Needs Plan o Also referred to has Medicare Health Plans –Part D: Prescription Drug Coverage November 16, 2010 Understanding Medicare 3 Original Medicare

November 16, 2010 Understanding Medicare 4 Part A & B Some will include Part D Part – B Part – A Part – D or Secondary MedSup or Secondary Ways to receive Medicare Original Medicare Medicare Advantage (HMO, PPO, etc)

Social Security Administration Responsible for eligibility and enrollment –People aged 65yrs or older Contributed into FICA 40 quarters (10yrs) Married and receiving benefits under a spouses work record Must have been married a minimum of 10yrs to receive benefits under a former spouse –Under age 65yrs Receiving disability benefits under SSA or Railroad retirement systems for 24 months –Any Age Receiving regular dialysis Amyotrophic Lateral Sclerosis (ALS) o a.k.a Lou Gehrigs Disease November 16, 2010 Understanding Medicare 5

Medicare for Disabled Individuals Disability Defined: –Inability to work –Expected to last for 1 year or result in death Can be the result of blindness o Visual acuity 20/200 or less with correcting lens in better eye OR o Visual field of 20 degrees or less Note: SSA is responsible for disability determination November 16, 2010 Understanding Medicare 6

Qualifying for Disability Benefits Meet requirements –Definition of disability –Work credits Or relationship to someone with work credits 5-month waiting period –Exceptions People eligible for childhood disability benefits Some people previously entitled to disability benefits November 16, 2010 Understanding Medicare 7

Applying for Disability Benefits Call SSA at Necessary documentation needed –Social security number –Proof of age –Health-care provider information –Medical records –Work history Including W-2 for the past two years Dont wait to apply November 16, 2010 Understanding Medicare 8

Qualifying for Medicare due to Disability 24-month waiting period –Exceptions for people with ALS No additional waiting period Medicare starts with first month of benefits Medicare usually begins 30 th month after disability began o 5 months + 24 months = 29 month wait November 16, 2010 Understanding Medicare 9

ESRD Disability For Medicare Coverage begins: –Fourth month of dialysis First month if certain conditions are met –Month you receive kidney transplant –Month you are admitted to approved hospital For transplant of procedures preliminary to transplant –2 months before month of transplant If transplant is delayed more than 2 months November 16, 2010 Understanding Medicare 10

Enrollment Periods Initial Enrollment Period (IEP) –3month before, month of, 3months after Persons 65 th birthday 30 th month for Medicare due to disability General Enrollment Period (GEP) –January 1 st through March 31 st of each year –Medicare coverage begins July 1 st of same year Penalties will usually apply Special Enrollment Period (SEP) –Working or covered by a working spouse Medicare Part B – 8 months from when retirement begins Medicare Part D – 63days from when retirement begins o Only if already enrolled into Medicare Part A November 16, 2010 Understanding Medicare 11

Original Medicare Go to any provider that accepts Medicare Enrolled into Medicare Part A –Premium free for most people Paid 40 quarters (10yrs) into FICA –Others may be able to purchase If a U.S. citizen; or Legal U.S. resident of 5 continuous years or more Enroll into Medicare Part B –Pay monthly premium Starting in 2007 some individuals have their premiums based on their taxable income Pay Part A and Part B –Deductible –Coinsurance or co-payment November 16, 2010 Understanding Medicare 12

November 16, Medicare Card (front) Jane Doe Understanding Medicare

Medicare Part A - Covered Services Inpatient Hospital Care Semi-private room and board, general nursing, meals, and the other hospital services and supplies Skilled Nursing Facility Care Full-time inpatient nursing and rehabilitative services (Custodial Care not covered) Home Health Care Part-time skilled nursing care, home health aids, physical and occupational therapy, speech and language pathology Hospice Care Support services from a Medicare- approved hospice, includes drugs for system control and pain relief November 16, 2010 Understanding Medicare 14

November 16, Benefit Period Part A (Hospital Insurance) charges are based on benefit period –Inpatient hospital care and skilled nursing facility (SNF) services –Begins first day of inpatient hospital care –Ends when you have been out of a hospital or SNF for 60 days in a row –Benefit period is not based on a calendar year –You pay deductible for each benefit period –No limit to number of benefit periods Understanding Medicare

Medicare Part B - Covered Services Medical Expenses Physician services, some diagnostic test, physical and speech therapy, ambulance, observation stay in the hospital…etc. Home Health Care Part-time skilled nursing care, home health aids, physical and occupational therapy, speech and language pathology Outpatient Hospital Services Outpatient surgery, diagnostic procedures, emergency room, partial hospitalization…etc. Durable Medical Equipment (DME) Walkers, wheelchairs, hospital beds, insulin pump, some medication associated with a DME…etc. November 16, 2010 Understanding Medicare 16

Medicare Part B – Preventive Services Welcome to Medicare Physical Exam – Available only to new Part B beneficiaries Annual Wellness Exam – Available to everyone on Medicare beginning Jan. 1, 2011 Bone Mass Measurements Cardiovascular Screening Colorectal Cancer Screening Diabetes Screening Hepatitis B Shots Glaucoma Screening Pneumococcal Shot Pap Test and Pelvic Exam Screening Mammograms Prostate Cancer Screening Smoking Cessation Counseling Flu Shot November 16, 2010 Understanding Medicare 17

Paying the Part B Premium Taken out of one of the following monthly payments: –Social Security –Railroad Retirement –Federal Government Retirement For information about premiums –Call SSA or RRB Office of Personnel Management if a retired Federal employee Will be billed every 3 months –If not receiving SSA or RRB benefits November 16, 2010 Understanding Medicare 18

Medicare Penalties Part A –Penalty will only apply if a beneficiary has to purchase Medicare Part A 10% a year for twice the number of years Example: Mrs. Robinson has delayed enrollment into Part A for 2 years, her penalty will be 10% a year for 4 years. Part B –If a person delayed enrollment into Part B, their penalty will be 10% for each year and will remain with them for as long as they are on Medicare Example: Ms. Debbie has delayed enrollment into Part B for 3 years, she will have to pay a 30% penalty including her monthly premium for as long as she is on Medicare. November 16, 2010 Understanding Medicare 19

Medicare Supplement Insurance November 16, 2010Understanding Medicare20

2010s MedSup Policy – Core Benefit Core Benefits for Plans A, B, C, D, F, G, M, N include: All Part A coinsurance expenses for : $283 per day for 61st through 90th day; $566 per day for 91st through 150th day; Part A Hospice coinsurance Upon exhaustion of Part A hospitalization benefits, full coverage of an additional 365 days per lifetime; Part B coinsurance or copayment; including Part B Preventive Services First three pints of blood each calendar year *Core benefits for Plan K and L are the same as listed above with the exception of 50% (Plan K) and 75% (Plan L) payment for the Part A deductible, Part B coinsurance, the blood deductible, hospice care coinsurance and Skilled Nursing Facility coinsurance. November 16, 2010 Understanding Medicare 21

2010s Medicare Supplement Policies effective June 1, 2010 and currently available Benefits Included Plan A Plan B Plan C Plan D Plan F Plan G Plan K Plan L Plan M Plan N Core Benefits ** * Skilled Nursing Facility * (50%) * (75%) Part A Deductible * (50%) * (75%) * (50%) Part B Deductible Part B Excess (100%) Foreign Travel Out-of Pocket Maximum $4620$ November 16, 2010 Understanding Medicare

What is a MedSup Policy? Health insurance policy –Provided by private insurance companies Used with Original Medicare only –Must have both Medicare Part A and Part B –Covers the major gaps in Medicare Medicare-approved charges All policies are standardized –Each policy will be identical from company to company Except in Massachusetts, Minnesota, and Wisconsin November 16, 2010 Understanding Medicare 23

2010s Medicare Supplement Policies effective June 1, 2010 and currently available Benefits Included Plan A Plan B Plan C Plan D Plan F Plan G Plan K Plan L Plan M Plan N Core Benefits ** * Skilled Nursing Facility * (50%) * (75%) Part A Deductible * (50%) * (75%) * (50%) Part B Deductible Part B Excess (100%) Foreign Travel Out-of Pocket Maximum $4620$ November 16, 2010 Understanding Medicare

High Deductible Option Another variation of a Medicare Supplement Policy offered is a high-deductible option Offered only with a standardize Plan F Plan will not pay its portion of benefits until deductible has been met –$2,000 in 2011 Deductible is adjusted each year November 16, 2010 Understanding Medicare 25

What is a MedSelect Policy? Health Insurance Policy –Provided by private insurance companies Used with Original Medicare only –Must have both Medicare Part A and Part B –Covers the major gaps in Medicare Medicare-approved charges Conforms to the Standardize plans –Each policy will be identical from company to company Except in Massachusetts, Minnesota, and Wisconsin Must use specific hospital contract with MedSelect plan –For inpatient hospital services –May have to use specific physicians Must live within 30 miles of a contracted hospital November 16, 2010 Understanding Medicare 26

Medicare Supplement Open Enrollment One-time 6-month window –Have or enrolling into Part A –Enrolling into Part B for first time Including those enrolling due to disability Cannot be denied a policy –Join any plan from any company May require a pre-existing condition waiting period –No more than 6 months November 16, 2010 Understanding Medicare 27

Medicare Disabled Beneficiary Illinois Public Act –Began June 1, 2008 –Provided same open enrollment rights for Medicare Supplement Insurance 6 months Open Enrollment Period (OEP) upon entitlement to Medicare Part B To purchase any policy from almost any company, regardless of health history –Company cannot charge a rate higher then their highest rate Registered with the Illinois Department of Insurance –Once a beneficiary turns 65 yrs-old, they will be entitled to a new 6 months OEP November 16, 2010 Understanding Medicare 28

Medicare Disabled Beneficiary 2011 Guarantee Enrollment Period Guaranteed enrollment for disabled Medicare beneficiaries - November 15 through December 31 Guaranteed issue of a Medigap with 3 companies AARP/ United Healthcare, Blue Cross Blue Shield, and Health Alliance. November 16, 2010 Understanding Medicare 29

Rights and Guarantees Loss of Medicare Supplement –Company pulls out of the market Must be provided with another policy Loss of other coverage –Employer group health plan 63-day Guaranteed Issue May purchase Plan A, B, C, F, K or L Medicare Advantage (MA) –Leave MA plan with first 12 months of first enrollment –Plan is pulled from the market November 16, 2010 Understanding Medicare 30

1990s Medicare Supplement Policies Policies sold prior to June 1, 2010 Benefits Included Plan A Plan B Plan C Plan D Plan E Plan F Plan G Plan H Plan I Plan J Plan K Plan L Core Benefits ** Skilled Nursing Coinsurance (50% (75%) Part A Deductible (50%) (75%) Part B Deductible Part B Excess (100%) Part B Excess (80%) Foreign Travel Emergency At Home Recovery November 16, 2010 Understanding Medicare 31

What is Secondary Insurance? Secondary insurance is other insurance that is provided by –Employment sponsored health and/or drug coverage –Retirement health and/or drug coverage –Union sponsored health and/or drug coverage Not offered by or contracted with Medicare Company may choose; –Who they will cover –How and what coverage will be offered –if it will provide any additional coverage for Medicare beneficiaries Note: Medicare beneficiaries should contact their benefits office to see how it will work with Medicare. November 16, 2010 Understanding Medicare 32

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