Medicare 101

Medicare 101

Christian Reformed Church

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Medicare 101 Introduction to Medicare Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid Question and Answers

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What Is Medicare?A health insurance program for

People 65 years of age and olderPeople under age 65 with certain disabilitiesPeople with End-Stage Renal Disease (ESRD)

Administered by Centers for Medicare & Medicaid Services (CMS)

Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB)

Introduction

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Applying for MedicareApply 3 months before age 65

Don’t have to be retiredContact the Social Security Administration

Enrollment automatic if receiving Social Security or Railroad Retirement benefits

Introduction

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MedicareMedicare Basics

Part AHospital Insurance

Part BMedical Insurance

Prescription Drug Coverage (Part D)

Introduction

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Medicare Coverage Basics

Part A

Inpatient hospital care Skilled nursing care Home health care Hospice care

Part B

Doctors’ services and outpatient care Preventive services Diagnostic tests Some therapies Durable medical equipment

Part D Outpatient prescription drugs

Introduction

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Medicare Part A Most people receive Part A premium free People with less than 10 years of Medicare-

covered employment or anyone not paying Medicare Tax (i.e. clergy)Can still get Part A, but will pay premium

($451/month in 2012) If over 65 (on Part A) actively working and on

employer’s group medical planMay receive some Part A benefit to supplement

covered services not paid by active plan

Introduction

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Enrolling in Medicare Part B Pay monthly Part B premium

$99.90 in 2012 – higher income consumers pay more Initial Enrollment Period (IEP)

7 months starting 3 months before month of eligibility General Enrollment Period (GEP)

January 1 to March 31 each year - Coverage effective July 1

Premium penalty• 10% for each 12-month period eligible but not enrolled

Introduction

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Enrolling in Medicare Part B Some people can delay enrolling in Part B

with no penaltyIf covered under employer group health plan

that is considered “creditable coverage”• Based on current employment

– Person or spouse• Will get a Special Enrollment Period (SEP)

when employer group coverage ends– Sign up within 8 months after coverage ends

Introduction

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Part B Enrollment PeriodsExample

Marie turned 65 on June 2, 2012. She will have group health coverage from her employer until she stops working on December 31, 2012.

Part B enrollment opportunities …

Enrollment period Begins Ends

IEP 3/1/12 9/30/12

SEP 10/1/12 8/31/13

GEP (each year) 1/1 3/31

Introduction

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Paying the Part B Premium

Taken out of monthly Social Security payments

If no monthly paymentsBilled every 3 monthsMedicare Easy Pay

Introduction

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Medicare ChoicesOriginal Medicare PlanMedicare Advantage PlansOther Medicare PlansMedicare Prescription Drug Plans

Introduction

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Original Medicare Plan Can access any health care provider that accepts

Medicare People are responsible for:

Part A• In 2012, $1,156 deductible per benefit period for

hospital stays up to 60 days– Additional costs after 60 days

• Different costs for other Part A servicesPart B

• $140 annual deductible in 2012• 20% coinsurance or copayment for most Part B

services Some programs may help with costs

Original Medicare

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The Medicare Card

Jane Doe

Original Medicare

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Medicare Coverage Outside U.S.For most situations, Basic Medicare won’t

pay for health care or Rx outside U.S.Must have either:

Medicare Supplement plan that covers foreign travel

Some Medicare Advantage plans include itInternational Travel Insurance

Visit www.medicare.gov/Coverage/ to learn more about what Medicare covers.

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MedigapHealth insurance policy

Sold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in the Original Medicare Plan

• Deductibles, coinsurance, copayments• Does not work with Medicare Advantage Plans

Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin• So people can compare easily

Medigap

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How Medigap WorksPeople can buy a Medigap policy

Within 6 months of enrolling in Part B• Only some plans are guarantee-issue

If they lose certain kinds of health coverage• Through no fault of their own

If they leave MA Plan under certain circumstancesWhenever insurance company will sell them one

Monthly premiumGenerally go to any doctor or specialist

Medigap

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Medicare Advantage Plans Health Maintenance Organization (HMO) Plans

Some have Point-of-Service option Preferred Provider Organization (PPO) Plans

Regional PPOs Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans

Not very common

Medicare Advantage and Other Medicare Plans

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Eligibility for MA Plans

Live in plan’s service areaEntitled to and Enrolled in Medicare Part AEnrolled in Medicare Part B

Continue to pay Part B premiumMay also pay monthly premium to plan

Don’t have ESRD at enrollmentSome exceptions

Medicare Advantage and Other Medicare Plans

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How MA Plans Work Usually get all Part A and B services through plan

May have to use providers in plan’s networkGenerally must still pay Part B premium

• Some plans may pay all or part May get extra benefits

Vision, hearing, dental servicesPrescription drug coverage

Still in Medicare programGet all Part A and Part B servicesHave Medicare rights and protections

Medicare Advantage and Other Medicare Plans

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Medicare Prescription Drug Coverage

Medicare “D” program began Jan 1, 2006Available to all people with Medicare Provided through

Medicare Prescription Drug PlansMedicare Advantage and other Medicare plansSome employers and unions

Medicare Drug Coverage

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Enrollment Periods

Initial Enrollment Period (IEP)7 monthsStarts 3 months before month of eligibility

Annual Coordinated Election Period (AEP)November 15 through December 31 each yearCan join, drop, or switch coverage

• Effective January 1 of following year

Special Enrollment Period (SEP)

Medicare Drug Coverage

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Late Enrollment

People who wait to enroll may pay penaltyAdditional 1% of national base premium for

every month eligible but not enrolledMust pay the penalty as long as enrolled in a

Medicare drug planUnless they have other coverage at least

as good as Medicare drug coverage“Creditable coverage”

Medicare Drug Coverage

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Prescription Drug Plans At a minimum, must offer standard benefit

In 2012 members may pay• Monthly premiums• Annual deductible, no more than $320• Copayments or coinsurance

Coverage Gap (donut hole)Begins when reach coverage limit ($2,930 in 2012)

and ends when you spend $4,700 TROOP (True Out-of-Pocket costs).

In “donut hole”, 50% manufacturer-paid discount on covered brand-name drugs. 14% discount for generic

After TROOP max, minimal cost sharing (5%)

Medicare Drug Coverage

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Medicaid Joint Federal and state program

For some people with limited income and resources If eligible, most health care costs covered Eligibility determined by state Application processes vary Office names vary

Social ServicesPublic AssistanceHuman Services

Medicaid and Medicare Savings Programs

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For More Information 1-800-MEDICARE (1-800-633-4227)

TTY users call 1-877-486-2048 www.medicare.gov Social Security Administration (1-800-772-1213) www.cms.hhs.gov State Health Insurance Assistance Program

(SHIP) Medicare & You handbook

Other publications

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Summary Medicare coverage Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid

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Questions?Thanks for your time!Presented by:

Kevin CumingsVice-President of BenefitsBuiten & Associates, LLC5738 Foremost Dr.Grand Rapids, MI [email protected]