1. Medicare Overview - September 2016 John Williams, SHIP Medicare Specialist

2. What Is Medicare & When It Is Available
Federal health insurance available at
Age 65 and older
Under age 65 after 24 months of SS or RR disability benefit entitlement
Under age 65 and entitled to SS or RR disability benefits due to ALS
Any age with ESRD
Administered by
Centers for Medicare & Medicaid Services (CMS)
Isn't the same as Medicaid

3. A-B-C-D Medicare has four parts Part A – Hospital Insurance
Part B – Medical Insurance
Part C – Medicare Advantage Plans
Part D – Prescription Drug Coverage

4. Medicare Options Original Medicare only (Parts A & B)
Original Medicare plus supplemental coverage - from former employer/union, Tricare for Life, for example
Original Medicare plus a Medigap plan
Original Medicare plus a Part D prescription drug plan
Medicare Advantage plan (Part C) with or without drug coverage

5. CHOICES
Original Medicare

6. Original Medicare Go to any provider that accepts Medicare Members pay
Part A premium - free for most people
Part B premium- amount generally changes annually
IRMAA Part B & D premium increases for people with high income
Deductibles - amounts generally change annually
Coinsurance or copayments
Program are available to help pay members' costs

7. Medicare – Initial Enrollment Period
Apply 3 months before age 65 if you want Medicare at age 65
Do not need to be retired
Benefits through employer/union - active employment plans Might not want to enroll in any or all parts of Medicare while working
Auto Enrollment in Parts A and B
If you already receive SS or RR benefits
Can refuse Part B

8. Medicare Part A – Hospital Coverage
Part A premium is free for most people
People with less than 10 years of Medicare-covered employment can pay a monthly premium to get Part A ($226 - $441)
Coverage
Hospital inpatient care, skilled nursing facility (SNF) care, home health care, hospice care, and blood work.
Charges based on “benefit period”
Inpatient hospital care and SNF services
Begins day admitted to hospital and ends when no care received in a hospital or SNF for 60 days in a row.
You pay deductible for each benefit period, but there is no limit to number of benefit periods

9. Paying for Inpatient Hospital Costs Part A
For inpatient Hospital stays in 2016 members pay
$1,288 total deductible for days 1 – 60
$0 co-payment per day for days
$322 co-payment per day for days 61 – 90
$644 co-payment per day for days 91 – 150 (60 lifetime reserve days)
All costs for each day beyond 150 days
Programs available to help pay costs

10. Medicare Part B - Medical Coverage
Enrollment in Part B is your choice
Initial Enrollment Period (IEP)
7 months beginning 3 months before age 65
Enrolled automatically if receiving SS or RR benefits
To keep Part B, keep the card
If you don’t want Part B, follow instructions with card

11. Medicare Part B - Paying the Premium
Taken out of your monthly payment
Social Security
Railroad Retirement
Federal Government retirement
Or billed every 3 months, if not receiving monthly payments
Programs available to help

12. Medicare Part B Premiums with High Income
Yearly Income Filed
Individual Tax Return
File Joint Tax Return
Premium
$85,000 or less
$170,000 or less
$104.90
$85,001-$107,000
$170,001-$214,000
$146.90
$107,001-$160,000
$214,001-$320,000
$209.80
$160,001-$214,000
$320,001-$428,000
$272.70
$214,001 or more
$428,001 or more
$335.70

13. Medicare Part B - Coverage
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
Clinical laboratory tests
Home health services (not covered under Part A)
Durable medical equipment
Outpatient hospital services
Blood Work
Ambulance service, if other transportation would endanger your health

14. Paying for Medical Costs Part B
In Original Medicare you pay
Yearly deductible
$166 in 2016
80% covered by Medicare, 20% co-pays for most services
Programs available to help pay Part B costs

15. Part B - Other Enrollment Periods
General Enrollment Period
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
Special Enrollment Period
Sign up within 8 months of the end of employer or union health plan coverage

16. Medigap Policies Health insurance policies
Sold by private insurance companies, plans are A through N
Follow Federal and state protection laws in every state
Policies must say “Medicare Supplement Insurance”
Cover “gaps” in Original Medicare
Costs may vary by state, must purchase a plan where you live

17. Medigap – How It Works Only works with Original Medicare
Can go to any doctor, hospital, or provider that accepts Medicare
Members pay a monthly premium
All Medigap plans must be approved by the IDOI
A list of all Medigap plans is located on the SHIP website (or via packet in the mail)

18. Medigap Plans-Enrollment
Guaranteed Issue Period - age 65 or older and Part B just starting - no medical underwriting for first 6 months
When you need coverage - with medical underwriting
Special Enrollment Periods - losing retiree coverage that pays secondary to Medicare - no medical underwriting

19. Part D – Prescription Drug Coverage
Private plans available for all people with Medicare
Approved by Medicare
Requirements:
Have Medicare Part A or Part B, or both
Live in plan service area
Programs are available to help pay members' costs
Medicare Prescription Drug Plans
Medicare Advantage Plans

20. Part D Costs Costs vary by plan, most people will pay:
Monthly premium - varies by plan
Annual deductible - varies by plan and generally changes annually
Initial coverage phase - members pays 25% of drug costs
Coverage gap (donut hole) - copays increase but drug costs are discounted - discounts increases annually until 2020 when coverage gap disappears
Catastrophic coverage - member pays 5% of drug costs
Programs available to help pay Part D costs

21. Medicare Part D – Making Changes
Annual Election Period (Open Enrollment Period )
Special Enrollment Periods
Permanently move out of plan service area
Lose creditable prescription drug coverage
Enter, reside in, or leave a long-term care facility
Like a nursing home
Qualify for Extra Help
Have other exceptional circumstances

22. Part D - Enrollment and Making Changes
When first eligible for Medicare
7 months beginning 3 months before first month of Medicare eligibility
During specific enrollment periods
Annual Election Period. -. October 15th - December 7th each year Coverage starts January first of next yeay
Special Enrollment Periods - move out of plan service area; lose creditable drug coverage; enter/reside in/leave a Long Term Care facility; eligible for Extra Help
Some people are enrolled automatically

23. Late Enrollment Surcharges/Penalties
The late enrollment penalty is calculated by multiplying 1% of the national base beneficiary premium ($34.10 in 2016) times the number of full, uncovered months that you were eligible but didn’t join a Medicare drug plan and went without other creditable prescription drug coverage.
This amount is rounded to the nearest $.10 and added to your monthly premium. You may have to pay this penalty for as long as you have a Medicare drug plan.

24. Medicare Advantage Plans - Overview
Health plan options approved by Medicare
Medicare benefits delivered through private companies approved by Medicare
Still in Medicare program
Still have Medicare rights and protections
Still get regular Medicare-covered services
May get extra benefits
Such as vision, hearing, or dental care
May be able to get prescription drug coverage (Part D)
Different Advantage Plans
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Private Fee-for-Service (PFFS)
Special Needs Plan (SNP)

25. Advantage Plans – Join or Switch Plans
When first eligible for Medicare
7 months beginning 3 months before first month of Medicare eligibility
Annual Election Period
October 15th – December 7th each year
Coverage starts January first of next year
Annual Disenrollment Period
January 1st – February 14th every year (coverage begins the first of the month after you switch)
May also join a Medicare Part D plan during change

26. Advantage Plans – How They Work
You may have to stay in a certain network of hospitals and providers
Co-pays and deductible are different than Original Medicare

27. Review - If You Are Eligible for Medicare
Decide if you want only Original Medicare; Original Medicare plus a Medigap Plan; or a Medicare Advantage Plan
Decide on a Prescription Drug Plan - Part D
Investigate policies and insurance companies
Choose a reasonable number of the plans and contact nsurance companies, brokers or independent agents for personal quotes.
Select coverage and enroll in plan(s)
Review your coverage every Fall during OEP and make needed enrollment changes

28. For More Information 1-800-MEDICARE (1-800-633-4227)
Medicare publications online
SHIP telephone:
SHIP:
SHIP counselors