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What is Medicare Qualifying for Medicare

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					         Medicare 101 and Health Care Reform




    Atlanta Regional Commission, Area Agency on Aging




        What is Medicare?
   Health insurance for people
     Age 65 and older

     Under age 65 with certain disabilities

     Any age with End-Stage Renal Disease
      (ESRD)
     ALS

   Administered by
     Centers for Medicare & Medicaid Services

      (CMS)
   Enroll through
     Social Security or

     Railroad Retirement Board (RRB)




                                                             2




        Qualifying for Medicare
    US citizens or resident VISA holders who
    have lived in the US for five consecutive
    years and

    •   65 years or older; eligible for Social Security or
        Railroad Retirement Benefits
    •   65 or older; married to someone eligible for
        Social Security/Railroad retirement
    •   Have received Social Security Disability income
        for at least 24 months
    •   Have ESRD (kidney failure) or ALS
        (Amyotrophic Lateral Sclerosis)




                                                             3




                                                                 1
Applying for Medicare

                               Initial Enrollment Period
                                Apply 3 months before age 65, the
                                month of 65th birthday, or 3 months
                                after month of 65th birthday
                                 Need
                                *Need not be retired

                               Automatically enrolled if receiving
                                Social Security or Railroad
                                Retirement Benefits
                               Received Social Security Disability
                                Benefits (SSDI) for 24 Months


                                                                      4




Medicare Basics

                        Medicare

                                                Part C
                                          Medicare Advantage
                                          PRIVATE Medicare
                                          Health Plans (PPO,
                                           HMO, PFFS, SNP)



 Part A                   Part B                    Part D
 Hospital                 Medical                 Prescription
               Known as:
            Original Medicare
                                                                      5




             Medicare Part A
               Overview




                                                                      6




                                                                          2
Medicare Part A – Eligibility and
Premiums
   Awarded at age 65 or if a person
    has received disability payments for
    24 months
   $0 premium for those who have 40
    quarters of Medicare-covered
    employment (or from a spouse)
       $450/month for those with less than 30
        quarters of Medicare covered
        employment
       $248/month for those with 30-39
        quarters of Medicare-covered
        employment

                                                                   7




Medicare Part A – Hospital
Insurance – Helps Pay for
                                       Hospital stays
                                       Skilled nursing facility
                                        (SNF) care
                                       Home health care
                                       Hospice care
                                       Drugs that are part of
                                        inpatient care


                                                                   8




Deductibles, Co-Payments For
Part A (Hospitalization)

       $1132 Per Benefit Period
       $283 Per day for days 61-90
       $566 Per day for 91-150
          (Lifetime Reserve Days)
       All costs for each day beyond
        150 days




                                                                   9




                                                                       3
Deductibles, Co-Payments For
Part A (Skilled Nursing Facility)
   Days 1-20: $0 copay

   Days 21-100: $141.50 per day

   Aft 100 days: No
    After     d   N
     benefits
   Must Meet Requirements for
    Medicare covered stay
       No custodial care




                                                        10




                   Medicare Part B
                     Overview




                                                        11




Enrolling in Medicare Part B
   General Enrollment Period (GEP)
       January 1 through March 31 each year
       Coverage effective July 1
       Premium increases 10% for each 12-month period
        eligible,but did not enroll
           Penalty i effect f lifetime
            P    l in ff     for lif i
           Limited exceptions
   Special Enrollment Period
       Sign up within 8 months of the end of employer or
        union health plan coverage
       No increased premium




                                                             4
Paying for Medicare Part B –
Outpatient Services
                            Costs
                                  Monthly Medicare Part B premium
                                    $110.50

                                       $115.40 - 2011
                                       May be higher depending on
                                        income
                                  $162 per year deductible in 2011
                                  20% co-insurance for most services




                                                                      13




Part B - Medical Out-patient/Physician
Insurance Helps Pay for:
   Doctor Services
   Outpatient therapy
   Outpatient mental health services
   Some preventive health care
         i
    services
   Clinical laboratory services
   Durable medical equipment (DME)
   Outpatient hospital services
   Blood
   Ambulance service
     If other transportation would

       endanger health
                                                                      14




Ambulance Services (Part B)
                             Medicare covers if:
                              Other modes of transportation
                               would jeopardize health
                              Used for transportation to or from
                               hospital or SNF
                              Sudden illness or person’s health
                               is in danger
                               i i d
                              Doctor determines medically
                               necessary if not an emergency

                             *Medicare pays for ambulance
                              services to nearest facility that can
                              provide care


                                                                      15




                                                                           5
Services NOT Covered Under Part B

   Nursing Home Care

   Acupuncture

   F i H lth C
    Foreign Health Care
    (Except for Limited
    Situations in Canada and
    Mexico)




                                                        16




Services NOT Covered Under Part B

                                  Eyeglasses or Eye
                                   Exams
                                   (Except for Cataracts)
                                  Hearing Aids or Exams
                                  Immunizations (Except
                                   Flu and Pneumonia)
                                  Cosmetic surgery
                                  Custodial Care or
                                   Homemaker Services


                                                        17




        Medicare Part D




                                                             6
     Medicare Part D:
Prescription Drug Coverage

        Sold by private health insurance companies that contract
         with Medicare

        People may receive Part D benefits through a stand
         alone Medicare Prescription Drug Plan (PDP) or a
         Medicare Advantage Plan (MAPD)

        Otherwise people can continue to receive their drug
         coverage through retiree/union health plans

                                                                  19




         Medicare Part D:
    Prescription Drug Coverage


        Part D Enrollment:
                                                     p
             Initial Enrollment Period – same 7 month period as
             Medicare A&B eligibility – may be penalized for
             waiting

            Annual Election Period-Nov. 15th-Dec. 31st

            Special Enrollment Period

                                                                  20




    Part D Costs
       Monthly Premium - varies

       May or may not include a deductible

       Drug costs range from flat copay
        amount to percentage of total drug
        cost
       Total out of pocket (not including
        premium) of $4550




                                                                  21




                                                                       7
    What is the Medicare prescription
    “donut hole” or “gap?”
   Getting into the gap:
        Bennie pays copays or coinsurance for
         each prescription filled; the plan pays the
         remainder until drug costs (retail) reach
         $2,840
   The gap:
        Bennie pays 100% of drug costs until out
         of pocket for the calendar year equal
         $4,550
   After the Gap (Catastrophic Coverage)
        Small coinsurance charged for each drug
         until end of year


        Note: excluded drugs do not help contribute towards out of pocket
        costs to be out of the gap
                                                                            22




    Medicare Prescription Drug Coverage

        Available only for prescriptions
        Prescription drugs, biologicals, insulin
        Medical supplies associated with injection of
         insulin
        A PDP or MA-PD may not cover all drugs
        Brand name and generic drugs will be in
         each formulary




    Medicare Advantage (Part C)


                            Medicare
                              Pays private plans
                              to provide health
                              coverage – the
                              coverage differs
                              from Medicare!


               Medicare Advantage Plan

                                                                            24




                                                                                 8
    Medicare Advantage (Part C)
                          Replaces Original Medicare coverage
                          Offered through private companies
                          May offer extra benefits including Part D
                           coverage
                          Some require additional premium in additional to
                           monthly Medicare premium
                          Coinsurance/Co-pays

                          For enrollment, MUST:
                              Have Medicare Part A and Part B
                              Live in plan’s geographical service area

                              Not have ESRD

                                                                          25




    Medicare Advantage Enrollment
                                       Initial Enrollment Period-
                                          7 month surrounding Part B
                                          effective date
                                       Annual Election Period-
                                         November 15th-December
                                         31st

                                       Special Enrollment Period-
                                         Special Needs Plans and
                                         certain exceptional
                                         circumstances




                                                                          26




    What are Medicare Advantage Plan
    Options?
   Medicare Managed Care Plans
    (HMOs) – Health Maintenance
    Organizations
   Medicare Preferred Provider
    Organization (PPOs) –
    Preferred Provider
    Organizations
   Private Fee-for-Service Plans
    (PFFSs)
   Special Needs Plans (SNPs)


                                                                          27




                                                                               9
        Why choose an Advantage Plan?

    May include some Dental,
     Vision or Hearing Coverage
    Often, fixed copay for doctor
     services
    Sometimes, lower
     hospitalization costs
    Often, a lower monthly premium
     than Medigap




        What’s the Advantage?
    Can result in cost savings for
     medical care for some people
    Can offer additional services
     not covered by Original
     Medicare
    Any Medicare beneficiary can
     enroll and receive benefits – no
     pre-existing condition exclusion
     or waiting period for coverage




    Is Medicare Advantage the right choice?
   A Medicare Advantage Plan is NOT a replacement
    for a Medigap policy.
   Before enrollment in a Medicare Advantage Plan,
    answer the following questions:
       1. Are the doctors and hospitals covered by the plan?
        That is, do they accept the plan’s terms and
        conditions?
       2. Is a referral needed to see a specialist?
       3. Can the plan be utilized outside the plan's service
        area or network? If so, how?
       4. What costs are involved in the plan (premium,
        deductible, copayments)?
       5. Are needed prescriptions covered by the plan?
       6. What are copayment requirements for lab tests,
        diagnostic tests, x-rays, MRI scans, or CT scans?
                                                                 30




                                                                      10
What is Medigap ?
                                          Sold by private insurance
                                           companies

                                          Fills in the “GAPS” for
                                           Medicare

                                          10 standardized plans (A
                                           through N)

Medicare           Primary                Must have Part A & B

                                          Medigap SELECT policies
Medigap/           Secondary               may require use of certain
Supplement                                 physicians and hospitals
Insurance


                                                                     31




Enrolling in a Medigap
Open Enrollment Period


                                  6 months following enrollment in
                                   Medicare Part B

                                  Cannot be turned down for any
                                   reason

                                  Cannot charge more because of
                                   health problem

                                  Cannot make beneficiary wait for all
                                   coverage to start



                                                                     32




Enrolling In Medigap

Under age 65:
• Do not have guaranteed
  issue rights
• Will be subject to prexisting
     diti
  conditions
• Company not required to
  sell beneficiary policy
• Will be given OEP at age 65




                                                                     33




                                                                          11
Why Buy Medigap?

    Original Medicare does
     not pay all costs
    Medigap policy may help
        Lower out-of-pocket
            t
         costs
        Get more health
         insurance coverage




                                                                              34




      Additional Information: Financial
     Assistance for Medicare Health Costs




                                                                              35




Medicaid – Medicare Savings Programs
(QMB, SLMB, and QI)
    Pays Medicare premiums and
     possibly additional coinsurances
    Savings Program eligibility varies
     state to state:
    Georgia 2010 Eligibility
    Apply through DFCS
         Coverage            Single income   Single   Married   Married
                             limit           asset    Income    asset limit
                                             limit    limit
QMB      Part B premiums +   $903            $6,600   $1,214    $9,910
         deductibles and
         coinsurance
SLMB     Part B premiums     $1,083          $6,600   $1,457    $9,910

QI       Part B premiums     $1,218          $6,600   $1,639    $9,910



              Burial Allowance: $10,000 per person:                           36




                                                                                   12
Extra Help for Prescriptions/ Low Income
Subsidy
                                 Who is eligible?
                                  Income
                                      < $0-1,354 Single
                                      < $0-1,821 Married
                                  Assets (Resources)
                                       $8100-$12,510 Single
                                       $ ,     $ ,
                                       $12,910-$25,010 Married

                              Apply through SSA

                                 What are the benefits?
                                   No/low premiums for those with limited
                                    incomes
                                   No/low deductible

                                   Small copayment or coinsurance for
                                    each prescription
                                                                       37




Now that you know the basics,
what has changed?




                                                                       38




Overview

    Health reform through two bills (March 2010)
        Patient Protection and Affordable Care Act (H.R. 3590)
        Health Care and Education Reconciliation Act of 2010
         (H.R. 4872)
            Collectively called the “Affordable Care Act (ACA)”

    The Affordable Care Act strengthens Medicare
        Improves some benefits
        Guarantees Medicare benefits
        Extends Medicare’s financial solvency




                                                                       1




                                                                             13
Overview

     •   The Affordable Care Act protects and improves
         guaranteed Medicare benefits
         –   Provides that nothing in the Act shall result in a
             reduction of guaranteed benefits under Medicare
         –      q                g generated for Medicare under
             Requires that savings g
             the Act are used to:
             •   extend the solvency of the Medicare trust funds;
             •   reduce Medicare premiums and other cost-sharing for
                 beneficiaries; and
             •   improve or expand guaranteed Medicare benefits and
                 protect access to Medicare providers




                                                                                    2




Medicare Part D
    Closes the coverage gap over time

        Provides a $250 rebate to those who enter the gap (or
         “doughnut hole”) in 2010
            CMS automatically sends a rebate check when a
             beneficiary’s Part D spending reaches the coverage gap
                Checks are issued each month through mid-2011
                Checks are issued within 75 days of the quarter in which the
                 beneficiary enters (or hits) the gap
            Two groups do NOT receive the $250 rebate
                LIS enrollees
                Enrollees in a qualified retiree drug plan




                                                                                    3




Medicare Part D
     •   Closes the coverage gap over time
         –   Medicare Coverage Gap Discount Program
             •   Begins on January 1, 2011
                 –   Receive up to a 50% discount on Part D covered brand-
                     name drugs and a 7% discount on generic drugs (2011)
             •   Gradually reduces the out-of-pocket costs for brand-
                 name and generic drugs
             •   Gap will be “closed” by 2020
                 –   Beneficiaries still liable for 25% co-insurance between the
                     initial coverage limit (ICL) and the catastrophic coverage
                     level
                 –   Reduces the catastrophic coverage level; it currently stands
                     at $6,440 in total annual Part D drug costs.



                                                                                    4




                                                                                        14
Medicare Part D
      Annual Enrollment Period (October 15 –
       December 7)
          Moves and extends the dates
          Effective in 2011 for the 2012 plan year


      TrOOP (True Out-of-Pocket) Costs
          Drugs provided by AIDS Drug Assistance Programs (ADAP)
           or the Indian Health Service count as TrOOP
          Effective January 1, 2011




                                                                             5




Medicare Advantage

      Special Needs Plans
          Extends the Special Needs Plan (SNP) program until 2014
      Cost-sharing
          Prohibits MA plans from imposing higher cost-sharing
                                                       benefits
           requirements for some Medicare covered benefits,
           including chemotherapy, dialysis services, and skilled
           nursing care, than those charged under Original Medicare
           (effective in 2011)
          Requires MA plans that provide extra benefits to give
           priority to cost-sharing reductions, wellness and preventive
           care, and lastly, benefits not covered under Medicare
           (effective in 2011)


                                                                            11




Medicare Advantage
      Disenrollment
          Beginning in 2011, eliminates the Open
           Enrollment Period (January 1 - March 31)

                      2011,
           Starting in 2011 provides a 45-day disenrollment
           period to MA enrollees (January 1 - February 14)
              Referred to as the Medicare Advantage
               Disenrollment Period (MADP)
                  Return to Original Medicare and enroll in a stand-alone PDP
                  Not allowed to switch to another MA plan during the
                   disenrollment period



                                                                            12




                                                                                 15
Preventive Services

     •    New Annual Wellness visit
          –   Beneficiaries receive personalized prevention plan services
              (PPPS)
          –   Visit must do the following:
              •    Establish or update the individual’s medical and family history
              •    List individual’s current medical providers and suppliers and all
                   prescribed medications
              •    Record measurements of height, weight, body mass index,
                   blood pressure and other routine measurements
              •    Detect any cognitive impairment
              •    Establish a screening schedule for the next 5 to 10 years
              •    Provide personal health advice and coordinate appropriate
                   referrals and health education




                                                                                   18




Preventive Services



         Eliminates cost-sharing for Medicare-covered
          preventive services
                 Annual Part B deductible and 20% coinsurance
                 Effective January 1, 2011

         Eliminates the Part B deductible for tests that
          begin as colorectal cancer screening tests, but
          based on findings from the test, become
          diagnostic or therapeutic services

                                                                                   19




                        Online Resources


        Part D and Medicare Advantage
         Comparisons:
         www.medicare.gov
        Low Income Subsidy Application
         www.ssa.gov




                                                                                  48




                                                                                        16
For More Information

                   Call GeorgiaCares
                    1-800-669-8387
                   1-800-MEDICARE
                    (1 800 633 4227)
                    (1-800-633-4227)
                   Social Security
                    Administration
                    1-800-772-1213
                   www.medicare.gov


                                        49




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