1. What is Medicare?
Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS). CMS is an agency within the Department of Health and Human Services (HHS). Social Security Offices process applications for Medicare and can also provide general information on the program.
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2. Medicare Eligibility Age 65 or older
Under age 65 with certain disabilities*
For all ages with end-stage renal disease (ESRD)
Medicare was created by Congress in 1965 and now covers about 48 million Americans. It is a health benefits program for U.S. citizens or permanent residents who are: (read slide bullets)
The Medicare program is administered by the Centers for Medicare & Medicaid Services (CMS).
However, when you enroll in Medicare, it is done through Social Security.
If you retired from the railroad, the Railroad Retirement Board will handle your enrollment.
*Includes citizens determined to be disabled with Amyotrophic Lateral Sclerosis (ALS), often referred to as Lou Gehrig’s Disease; or to be disabled based on exposure to environmental health hazards are entitled to Medicare the month they are deemed to be disabled
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3. Original Medicare Enrollment Periods
Initial Enrollment Period (IEP) begins three (3) months prior to turning age 65 and continues through the end of the third month after
General Enrollment Period allows individual who did not enroll in Part B during the IEP to enroll between January 1 – March 31 of each year for a July 1 effective date
Special Enrollment Period (SEP) allows individuals who delayed enrolling in Part B because they were receiving benefits through an employer as an active employee (or dependent of someone who is); SEP runs eight months from the time of retirement or loss of coverage
IEP (initial enrollment period) is a 7 month period
If you already get benefits from the Social Security Administration or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month that you turn 65. You do not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If you wait until you are 65, or sign up during the last three months of your initial enrollment period, your Medicare Part B start date will be delayed. (first of the month following enrollment)
GEP: can be assessed a 10% penalty for delayed enrollment to Part B
SEP: no set dates; based on situation
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4. Parts of Medicare Original Medicare includes:
Part A – hospital coverage
Part B – medical coverage
Both hospital and medical coverage can be obtained through private insurance companies under the Part C, also referred to as the Medicare Advantage Program.
Outpatient prescription drug coverage is available through private insurance companies under the Part D Program.
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5. Medicare Eligibility Part A – Hospital Coverage
No premiums are required for Part A coverage if the eligibility requirements below have been met:
An individual or his/her spouse has worked at least 10 years in Medicare-covered employment (paid Medicare taxes)
Aged 65 years or older
A US citizen or permanent resident
The federal government funds Part A costs through social security payroll tax deductions
If under 65, an individual can get Part A coverage without premiums if:
Received Social Security or Railroad Retirement Board disability benefits for 24 months
End-Stage Renal Disease and meets certain requirements
Is a disabled dependent whose parent qualifies based on work history

6. 1 Source: Medicare.gov, updated 2010.
Medicare Eligibility
Part B
Part B – Medical Coverage
Individuals must enroll in and pay a Part B premium
Part B premiums usually go up each year and are higher for individuals with higher incomes
Some people will pay a higher premium based on their modified adjusted gross income
Premiums can be deducted from a social security, railroad retirement, or civil service retirement check
The federal government funds Part B costs through the general tax revenues; beneficiary premiums cover 25% for Part B expenses1
Based on yearly income from 2014, if an individual has income of more than $85,000 ($170,000 for married couple), he/she will pay more for Part B coverage in 2014.
1 Source: Medicare.gov, updated 2010.

7. Medicare Eligibility Part B – Medical Coverage (cont.)
If an individual delays Part B enrollment after becoming eligible for benefits, a penalty may apply*
Part B premiums will go up 10% for each 12-month period during which Part B enrollment was delayed
The penalty is applied for all years going forward
If one did not enroll in Part B when first becoming eligible, enrollment is allowed during the General Enrollment Period
January 1 – March 31 of each year for a July 1 effective date
Enroll through Social Security Office
If Part B enrollment is completed during the General Enrollment Period, effective date will be July 1.
Part B enrollment can be delayed if individual is over age 65 and has group health insurance as a result of their current employment or their spouse’s current employment which provides group health insurance or is disabled and has group health insurance based on their or any family member’s current employment.
*A penalty for delaying Part B doesn’t apply to group covered individuals.

8. Medicare Benefits Part A Part B Inpatient hospital care
Physician services
Care in critical access hospitals
Outpatient hospital care
Skilled nursing care
Physical therapy
Hospice care
Ambulance
Home health care
Durable medical equipment
Prosthetics
Part B covered drugs

9. Basics of Original Medicare
Out of pocket costs under the Original Medicare program can be significant:
This costs represents outside same benefit period; therefore subject to a new Part A deductible
Services
Medicare Pays in 2017
Beneficiary Pays in 2017
Hospitalization on March 10th (5 days)
After $1,316 deductible, all costs
$1,316
Re-admitted on April 2nd (10 days)
All costs
$0 (deductible applied to same benefit period)
Admitted in August (8 days)
Total (not including Part B services)
$2,632
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10. Medicare Part A – Skilled Nursing
Services
In 2017 Medicare Pays
First 20 days
All approved amounts
Days
All but $ per day
After 100 days $0
Medicare Guidelines: in order for Medicare to allow SNF coverage, the beneficiary must have a prior hospital admission for a minimum of 3 days; the admission to the SNF has to be within 30 days of hospital discharge for the same condition they were originally treated for.
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11. Medicare Part B Enrollment
No coverage from active employment? Delaying Part B could mean:
Higher premiums -10% Penalty
Paying for your health care out-of-pocket
Still working (you or spouse)?
You may want to delay Part B
No penalty if you enroll while you have coverage or within 8 months of losing coverage
10% penalty is for a 12 month period of delayed enrollment with no creditable coverage
If you don’t have coverage from active employment
Yours or your spouses
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12. Medicare Part B Premium
Part B – Medical Coverage
If your Yearly Income is:
You Pay
File Individual Tax Return
File Joint Tax Return
$85,000 or below
$170,000 or below
$134.00
$85,001–$107,000
$170,001–$214,000
$187.50
$107,001–$160,000
$214,001–$325,000
$267.90
$160,001–$214,000
$325,001–$428,000
$348.20
above $214,000
above $428,000
$428.60
Based on yearly income from 2014, if an individual has income of more than $85,000 ($170,000 for married couple), he/she will pay more for Part B coverage in 2014.
New enrollees with an income of $85,000 as an individual or $170,000 as a married couple will pay the premium of $ per month.
Source: CMS.gov,

13. Medicare Part B In 2017 Medicare Pays Services
Part B – Physician services in or out of the hospital, supplies, physical/speech therapy, diagnostic tests, durable medical equipment
Excess Charges: Physicians who do not accept Medicare assignment can charge an additional 15% of Medicare- approved amounts. Original Medicare does not cover these excess charges. Excess charges or physician limiting charges are the Medicare beneficiary’s responsibility (in the states where these charges apply).
Outpatient Mental Health is 20%
Services
In 2017 Medicare Pays
First $183 of Medicare-approved amounts (Part B Deductible) $0
Remainder of Medicare-approved amount
80%
Part B Excess Charges
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14. Medicare Part B Preventive Services
Welcome to Medicare Physical Exam
Abdominal Aortic Aneurysm Screening
Bone Mass Measurements
Cardiovascular Screenings
Colorectal Cancer Screenings
Depression Screenings
Diabetes Screenings
EKG
Glaucoma Tests
HIV Screening
Mammogram Screening
Obesity Screening and Counseling
Pap Test and Pelvic Exam
Prostate Cancer Screening
Smoking Cessation Counseling
Flu Shots, Hepatitis B Shots and Pneumococcal Shot
Medicare covers a one-time preventive visit within the first 12 months that you have Medicare Part B. This visit is called the “Welcome to Medicare” preventive visit. It includes a review of your medical and social history related to your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed. The visit is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy.
Refer to Medicare Preventive Services Publication for guidelines or Medicare.gov
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15. Services Not Covered by Part A and B
Part A & B coinsurance and deductibles
Most outpatient prescription drugs
Dental care
Routine hearing exams, screenings, hearing aids
Routine eye exams, eyewear and contacts not associated with cataract surgery
Custodial care (unskilled) in a nursing home
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16. Common Medicare CoverageOR
Most people get their Medicare health care coverage in one of two ways:
1. Signing up for Original Medicare while possibly adding Part D and/or a Medicare Supplement. or
2. Getting a Medicare Advantage Plan that may or may not include Part D. Later on in the Medicare Advantage module we will discuss which MA plans include Part D as the only option for drug coverage option with MA, plans that may or may not have Part D with a Part D standalone option and plans that do not have Part D as an option at all and would have to be purchased separately if wanted.
Medicare Supplement and Medicare Advantage plans do not work together. A Medicare Supplement only follows Original Medicare and can not be purchased to fill gaps a Medicare Advantage plan leaves behind.
Some MA plans have Part D coverage built in while others don’t
There are three types of other Medicare plans that are not MA or Med Supp plans:
Medicare Cost Plans—similar to an HMO, but services received outside the plan are covered under Original Medicare,
Demonstrations/Pilot Programs—Demonstrations are special projects that test improvements in Medicare coverage, payments, and quality of care. They are usually for a specific group of people and/or are offered only in specific areas. There are also pilot programs for people with multiple chronic illnesses. These programs are designed to reduce health risks, improve quality of life, and provide savings.
PACE (Programs of All-inclusive Care for the Elderly)—PACE combines medical, social, and long- term care services for frail elderly people. This program can help them continue to live at home for as long as possible before moving to a nursing home. PACE is only available in states that have chosen to offer it under Medicaid, and the qualifications vary from state to state.

17. Medicare Supplement – Basics
Original Medicare program was not designed to cover 100% of health care costs. Unlike the MA program, which replaces Medicare, Medicare Supplement plans are secondary to original Medicare – filling in the coverage gaps. States (not CMS) administer and regulate private companies that offer Medicare Supplement plans sold to state residents; plans are portable and do not require state residence to stay in force. Medicare beneficiary retains their red, white, and blue Medicare ID card.
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18. Medicare ID Card
Front of Medicare ID card (Read card) then proceed to show back of card on next slide
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