Health insurance for the following people: ◦ Those 65 and older ◦ Those younger than 65 with certain disabilities ◦ Those with End-Stage Renal Disease (permanent kidney failure)
Most outpatient prescription drugs Routine vision care Long-term care Routine dental care Dentures Hearing aids (exams and fittings) Routine foot care
Medicare Part A (Hospital Insurance) ◦ Inpatient care in hospitals ◦ Skilled nursing facility, hospice, and home health care Medicare Part B (Medical Insurance) ◦ Doctors’ services, hospital outpatient care and home health care ◦ Some preventive services
Medicare Part D ◦ Prescription drug option run by Medicare- approved private insurance companies ◦ Prescription drugs ◦ May help lower your prescription drug costs and help protect against higher costs in the future
Medicare Part C (Advantage Plan) ◦ Health plan managed by Medicare- approved private insurance companies ◦ Includes all benefits and services covered under Part A and Part B ◦ May include extra benefits and services for an extra cost ◦ Usually includes Medicare prescription drug coverage (Part D)
Premium remains $104.90 Part B deductible remains $147 Part A hospital inpatient ◦ deductible raised to $1260 for each benefit period (was $1216) ◦ Days 61-90: $315 per day coinsurance for each benefit period (was $304)
Annual deductible rises from $310 to $320 Number of plan choices will drop – some are being eliminated Average monthly premium will be $38.83 Doughnut hole is shrinking
First method Original Medicare ( Parts A & B) Prescription Drug Plan (Part D) Medicare Supplement or Medigap policy (identified by a letter) ◦ Supplements provide identical coverage, but vary widely in price
Second Method Medicare Advantage Plan (Part C) ◦ Includes Part A & B coverage Prescription Drug Coverage (Part D) ◦ Some advantage plans include prescription coverage
If you get retirement benefits from Social Security or the RRB, then you automatically get Parts A & B on 1 st day of month you turn 65 If you get disability benefits from Social Security or certain disability from the RRB, then you automatically get Parts A & B on the 1 st day of the 25 th month after your benefits begin
If your disability is ALS (Lou Gehrig’s disease), then you automatically get Parts A & B on 1 st day of month your disability benefits begin If you’re still working and not getting Social Security, then you’ll need to talk with your HR department about your choices related to Medicare. You may want to delay enrollment, which you’ll do online through www.ssa.gov.
When you first turn 65, you have 3 months before and after your birthday month Coverage begins based on your enrollment date If you don’t sign up for Medicare when you’re first eligible, then you may pay penalty for Part B as long as you receive benefits
Go from Original Medicare to Advantage Plan Go from Advantage Plan to Original Medicare Switch Medicare Advantage Plans Join Part D plan Switch Part D plans
Medicare Supplement might make sense if you ◦ Want flexibility in choosing your doctors ◦ Visit doctors frequently ◦ Travel extensively ◦ Have a chronic medical condition ◦ Don’t mind higher premiums to get lower out-of- pocket costs (predictability) 11 different plans
Medicare Advantage Plan might make sense if you ◦ Are willing to change doctors, if necessary ◦ Prefer all benefits from single plan & premium ◦ Visit doctors infrequently & don’t mind paying per-visit copayments and coinsurance ◦ Don’t mind researching your options annually ◦ Want lower premiums than supplements offer ◦ Are informed about your choices and don’t mind comparison shopping for plans ◦ Want options beyond what Medicare provides 19 different plans
Remember all that? Simple: buy the best insurance that you can afford – after doing your homework!
Two ways to get Part D ◦ Purchase Medicare prescription drug policy ◦ Choose a Medicare Advantage Plan that offers prescription drug coverage Even if you feel it’s not needed in your case, remember that you may pay a late enrollment penalty if you join a Part D plan later.
Monthly fee, varies by plan In addition to Part B cost of $104.90 Some Advantage Plans include Part D coverage in the cost Avoiding Part D Enrollment penalty ◦ Join drug plan when first eligible ◦ Don’t go 63 days or more without drug coverage Penalty = 1% of full uncovered months (pg 105)
Always be sure that your prescription drugs are in formulary of any plan you’re considering Check what “tier” drugs are in – each tier has different cost Do this every year during Open Enrollment! Call the plan for info or check plan’s website
Begins when total drug costs reaches $2,960 Includes what you & plan have paid Plan no longer covers drugs for rest of year You pay discounted amounts ◦ 45% on brand name drugs ◦ 65% on generic drugs Once you’ve paid $4,700 out of pocket you pay 5% of cost for covered drugs or copay of $2.65/generic, $6.60 for brand name drugs
Drug plans may include preferred and non-preferred pharmacies in their network You may pay less for drugs at preferred pharmacies
Program to help people pay Medicare prescription drug costs For single person, income less than $1,459 month and resources less than $13,440 per year For married person living with spouse, income less than $1,966 month and resources less than $26,860 per year
Apply through Social Security www.ssa.gov www.ssa.gov Helps with monthly drug plan premium, annual deductible, coinsurance and copayments Eliminates doughnut hole Switch plans at any time during year Same application used to get help from TN to pay your Medicare costs
Benefit period: begins day you’re admitted to hospital or skilled nursing facility (SNF) and ends when you haven’t received any inpatient hospital care or SNF skilled care for 60 days in a row Coinsurance: your share of cost for medical service or supply, expressed in percentage Copayment: set amount you pay as your share of cost for medical service or supply
Deductible: amount you pay for health care or prescriptions before Medicare or Advantage Plan or Drug Plan begins to pay Extra Help: helps those with limited income pay health care costs Formulary: list of drugs covered by prescription drug plan or other insurance plan Medically necessary: services or supplies needed to prevent, diagnose or treat illness, injury, condition, disease or its symptoms
Medicare-approved amount: payment accepted by doctor or supplier from Medicare Preferred Provider: doctor or supplier who is member of network for specific insurer’s HMO or PPO plan Preventive services: health care to prevent illness or detect at early stage Primary care doctor: person you see first for most health problems Referral: written order from primary care doctor for you to see specialist or get some medical services. Required in most HMOs.
Signing up too early or too late Not understanding difference between Medicare Supplement and Medicare Advantage Guessing when picking plan Not applying for extra help Not re-evaluating coverage yearly