1. Medicare - the Basics Jeff Barlow – (949) 752-8300
Trillium Insurance Services, Inc.
Medicare Program Information

2. What is Medicare?
Federally sponsored individual health plan providing coverage for medically necessary procedures and services for individuals over age 65 (unless disabled or has ESRD).
Medicare coverage requires copays, coinsurance and deductible payments that are the responsibility of the beneficiary (or other secondary insurance).
Medicare is INDIVIDUAL coverage unlike private plans that may include family coverage. Married persons qualify on an INDIVIDUAL basis.
Medicare is an Insurance plan and requires out-of-pocket payments of the beneficiary when services are received.
Original Medicare is separated into two parts for claims processing purposes, Part A and Part B
The Medicare Program includes many different products that work together in different ways depending on how they are combined. The concept of primary and secondary insurance is part of the program and is a key element in understanding the overall program. Many of these products are sold and administered by private insurance companies.
Original Medicare: Parts A & B
Medicare Advantage: Part C
Medicare Prescription Drug Plans: Part D
Medicare Supplement Plans

3. The 4 Parts of Medicare

4. What Does Original Medicare Cover?
Medicare Part A
Medicare Part B
Inpatient Hospital Coverage
Skilled Nursing Care in a facility (requires a minimum 3 day prior hospitalization)
Home Health Care
Hospice
Blood
Following services are generally covered at 80%
Physician Services
Outpatient Surgery and Services
Durable Medical Equipment
Medicare benefits are administered by the Centers for Medicare and Medicaid Services (CMS)

5. What is NOT Covered by Original Medicare
Outpatient Prescription Medications
Routine Dental Care
Routine Vision Care and Eyeglasses
Hearing Aids
Foreign Travel
Cosmetic Procedures and Treatments
Long Term Care

6. What Does Original Medicare Cost?
Part A:
Most people qualify for premium-free Part A based on 40 quarters (equivalent to 10 years) of contribution to the Medicare system (paid through FICA taxes) by themselves or their spouse. For people with fewer than 40 quarters, Part A has a monthly premium.

7. What Does Original Medicare Cost?
Part B: The standard Part B monthly premium for 2019 is $ However, if you are single and your income is more than $85,000, or if married and your income is more than $170,000, you will pay more for your monthly premium.
Note: The Part B premium is typically automatically deducted from a person’s monthly Social Security Retirement benefit.

8. Medicare Part B premiums increase at higher incomes
Singles
Couples
Premium
< $85,000
< $170,000
$135.50
$85,001–$107,000
$170,001–$214,000
$189.60
$107,001–$133,500
$214,001–$267,000
$270.90
$133,501–$160,000
$267,001–$320,000
$352.20
$160,001–$500,000
$320,001–$750,000
$433.40
Source: Centers for Medicare & Medicaid Services. Income based on Modified Adjusted Gross Income (MAGI), which includes tax-exempt interest income. MAGI is based on income reported on the tax return from two years prior (e.g., for 2018, the 2016 tax return would apply). Existing beneficiaries who are receiving Social Security benefits may not see an increase in premiums in 2016 due to the “hold harmless” clause. A hold harmless provision in the Social Security Act disallows an increase in the Medicare Part B premium for qualifying Social Security recipients if their COLA is not large enough to cover the increase in the Part B premium

9. Initial Enrollment Period
If turning 65 and not collecting Social Security Retirement benefits.
Seven month period to enroll into Medicare without penalty.
Effective date for coverage will depend when enrollment occurs.

10. Special Enrollment Period
If a beneficiary or their spouse are “actively” working, they may be able to delay enrolling into Medicare Part B.
The Medicare beneficiary or their spouse is actively working for an employer providing the group health insurance coverage.
For a beneficiary older than 65, the employer must have 20 or more employees.
If the employer is paying first, they would enroll in Part A and delay enrollment into Part B. They would pick up Part B after they stop working/retire without penalty.
Note, it is necessary to enroll in Medicare Part B – it’s not automatic

11. Loss of Employer Coverage
Sign up for Part B and Part D as soon as you can
Part B – you have an 8-month SEP to enroll without penalty
The sooner you enroll in Part B, the sooner your coverage will begin
Enrolling in Part B also triggers your 6-month Medigap (Medicare Supplement) open enrollment period
Part D – you only have 63 days to enroll in Part D plan without penalty
Your plan will begin the first of the month following the month you enroll

12. How Do I Enroll?
Medicare enrollment is handled by the Social Security Administration.
Can be completed online at
Call
Appointments can be made for local offices through the above toll-free number

13. Medicare Supplement (Medigap Plans)
Standardized insurance plans designed to fill in the “gaps” in Medicare Part A and Part B coverage (deductibles, copayments, coinsurance, etc.).
Plans are designated by letter codes (A, B, C, D, F, Innov F, G, K, L, M, N).
All plans cover a basic group of benefits, with plans each covering a different group of “gaps”.
Coverage is the same from company to company, but premiums do vary.

14. Medicare Supplement (Medigap Plans)

15. Part C – Medicare Advantage
Health plan options approved by Medicare
Another way to get your Medicare coverage
Still part of the Medicare Program
Run by private companies
Medicare pays the plan an amount for each member’s care
May have to use network doctors or hospitals - ALWAYS check with your healthcare providers
Types of plans available vary from county to county

16. How They Work

17. Part D – Medicare Prescription Drug Coverage
Anyone covered by Medicare (Part A and/or Part B) is eligible to join a Part D plan.
Plans are sold by private insurance companies and require payment of monthly premiums.
Each plan covers a group of prescription medications (formulary list) and typically have copayments for prescriptions and possibly an annual deductible.
Plans and formulary lists may change annually.

18. When Can I Enroll in Part D Plan?
During your 7-month Initial Enrollment Period
During the yearly Open Enrollment Period
October 15th – December 7th each year
Coverage begins on January 1st
May be able to join at other times
Medicare Advantage Open Enrollment Period January 1 – March 31
Special Enrollment Period
For example, anytime you get Extra Help

19. Medicare Part D premiums increase at higher incomes
Singles
Couples
Premium
< $85,000
< $170,000 $0
$85,001–$107,000
$170,001–$214,000
$12.40
$107,001–$133,500
$214,001–$267,000
$31.90
$133,501–$160,000
$267,001–$320,000
$51.40
$160,001–$500,000
$320,001–$750,000
$70.90
Source: Centers for Medicare & Medicaid Services. Income based on Modified Adjusted Gross Income (MAGI), which includes tax-exempt interest income. MAGI is based on income reported on the tax return from two years prior (e.g., for 2018, the 2016 tax return would apply). Existing beneficiaries who are receiving Social Security benefits may not see an increase in premiums in 2016 due to the “hold harmless” clause. A hold harmless provision in the Social Security Act disallows an increase in the Medicare Part B premium for qualifying Social Security recipients if their COLA is not large enough to cover the increase in the Part B premium

20. Your Medicare Coverage Choices

21. Where Can You Get Help?
Social Security Administration – Enroll Medicare Part A & B
(toll free)
Medicare
(toll free)
Trillium Insurance Services, Inc.
Enroll in Medicare Supplement, Part D Rx, or Advantage Plan