MEDICARE 101 BASICS Y0020_20_17102PRES_C_01302020
MEDICARE 101 BASICS
Y0020_20_17102PRES_C_01302020
Medicare Topics
After This Training, you will :
1. Understand the Four Parts of Medicare
2. Learn Medicare coverage options
3. Know the difference between Medicare
Supplements and Medicare Advantage Plans
4. Discover when you can enroll in Medicare
Advantage Plans
The Four Parts of Medicare
MEDICARE COVERAGE CHOICES
Medicare Advantage Plan
or
Original Medicare
Part A Hospital
Insurance
Part B Medical
Insurance
You can add
Medicare Supplement
Insurance (Medigap)
Policy
Part D Prescription
Drug Coverage
Part C Combines Part A and Part B
May include or you may add
Part D
Prescription Drug Coverage
(Most Part C plans cover
prescription drugs. You may be
able to add drug coverage to
some plan types if not already
included.)
Original Medicare
Original Medicare
Health care option run by the federal government
Provides your Part A and/or Part B coverage
See any doctor or hospital that accepts Medicare
You pay:
Part B premium (Part A is usually premium free)
Deductibles, coinsurance, or copayments
Can join a Part D plan to add drug coverage
Original Medicare = Part A & Part B
Covers Hospital stays and outpatient services
Original Medicare has a list of approved
services and makes approvals based on
“medical necessity”
There are certain services that Original
Medicare does not cover
NOT Covered By Part A and Part B
Long-term care
Routine dental care
Dentures
Cosmetic surgery
Acupuncture
Hearing aids and exams for fitting hearing
aids
Vision and eyewear
Other – check Medicare.gov
Original Medicare Costs
Monthly Part B premium
Part B deductible and coinsurance
Part A deductible
$144.60*
For those who are:
> Not collecting SSA
benefits
> New to Medicare in 2020
> Dual Eligibles-premium
paid by Medicaid
*Premium will be higher if your
income is higher than $87,000
single, $174,000 jointly
(Based on 2018 Tax Return)
What You Pay – Part B Premium
$135.50*
For those who are:
> Enrolled prior to 2019
> Beneficiaries who are
currently enrolled in Part B
> And having their premiums
deducted from SSA check
Paying for Inpatient Hospital Stays
For Each Benefit Period in 2020 You Pay
Days 1-60 $1,408 deductible
Days 61-90 $352 per day
Days 91-150 $704 per day
(60 lifetime reserve days)
All days after 150 All Costs
Paying for Skilled Nursing Facility Care
For Each Benefit Period in 2020 You Pay
Days 1-20 $0
Days 21-100 $176.00 per day
All days after 100 All Costs
Medicare Part B: Costs for
Most People
Yearly Deductible
$198.00
Coinsurance • 20% coinsurance for most covered for Part B services, like doctor’s services and Services some preventive services, if provider
accepts assignment
• $0 for some preventive services
• 20% coinsurance for outpatient mental health services, and copayments for hospital outpatient services
Original Medicare: No Limit to Costs
There is no limit (Maximum Out-of-Pocket)
to Original Medicare costs
You are responsible for coinsurance and
copayment costs regardless of how high
these costs go
Medigap Plans
Medigap Plans
Original Medicare
Part A Hospital
Insurance
Part B Medical
Insurance
You can add
Pay Additional Premium on top of
Part B premium
Medicare Supplement Insurance (Medigap)
Policy
Medigap Plans
Medigap explained:
Private health insurance
Supplements Original Medicare
Helps pay some health care costs that Original Medicare doesn’t cover (coverage “gaps”)
Medicare will pay its share of the Medicare-approved amounts for covered health care costs
– Then your Medigap policy pays its share
A Medigap policy covers one person
Medigap Costs
Medigap Cost (monthly premium) depends on
• Your age – premium costs can go up every year as you age
• Where you live (e.g., urban, rural, or ZIP Code)
• Company selling the policy
• Discounts (women, non-smokers, married couples)
• Medical underwriting
• Premiums may vary greatly for the same Medigap plan
Medigap Plans Do Not Cover Prescriptions
If you want drug coverage with a Medigap plan, you must get a stand-alone Part D prescription drug plan
The Part D plan will have a separate premium that you pay in addition to your Medigap premium
You will have 3 premiums to pay and 3 insurance cards to carry
Medigap Plan Card Part D Prescription
Drug Plan Card
Medicare Advantage Plans
Medicare Advantage Plans
What’s a Medicare Advantage (MA) Plan?
How MA Plans work
When you can join or switch plans
Medicare Advantage Plans
Health plan options
Approved by Medicare
Run by private companies
What’s a Medicare Advantage Plan?
Part of the Medicare program
Sometimes called Part C
Available across the country
Provide Medicare-covered benefits
May cover extra benefits
How Medicare Advantage Plans Work
Medicare Advantage Plans can have Medical and Prescription coverage all in one plan
Part C Combines Part A and
Part B
Part D Prescription Drug Coverage
(Most Part C plans cover prescription drugs. You may be able to add drug coverage to
some plan types if not already included.)
• You receive services through the plan
• Covers all Part A and Part B services
• Some plans may provide additional benefits
• Most plans include prescription drug coverage
• You may have to use network doctors/
hospitals
• May differ from Original Medicare
• Cost sharing may be different
How Medicare Advantage Plans Work
How Medicare Advantage Plans Work
You’re still in the Medicare program Medicare pays the plan every month for your care
You still have Medicare rights and protections
If the plan leaves Medicare you can -
Return to Original Medicare and a Med Supplement (Supplement may be subject to Medical Underwriting)
Medicare Health Maintenance Organization (HMO) Plan
Can you get your health care from any doctor or hospital?
No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).
Are prescription drugs covered?
Yes, when you join an HMO that includes prescription coverage
Do you need to choose a primary care doctor?
In most cases, yes.
Do you need a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.
What else do you need to know about this type of plan?
If your doctor or other health care provider leaves the plan, your plan will notify you and you can choose another plan doctor. If you get health care outside the plan’s network, you may have to pay the full cost. It’s important that you follow the plan rules. For example, the plan may require prior approval for certain services.
Medicare Preferred Provider Organization (PPO) Plan
Can you get your health care from any doctor or hospital?
In most cases, yes. PPOs have network doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.
Are prescription drugs covered?
In most cases, yes. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage. You may contact individual plans to find out if they offer prescription drug coverage.
Do you need to choose a primary care doctor? No.
Do you need a referral to see a specialist? In most cases, no.
What else do you need to know about this type of plan?
PPO plans aren’t the same as Original Medicare or Medigap.
Medicare PPO plans usually offer extra benefits (like dental or vision services) than Original Medicare, but you may have to pay extra for these benefits.
How Are Medigap Policies and MA Plans Different?
Medicare Supplement (Medigap) Insurance
Medicare Advantage Plans (Part C)
Offered by Private companies Private companies
Government oversight
State, but must also follow federal laws
Federal (plans must be approved by Medicare)
Works With Original Medicare Instead of Original Medicare Covers Gaps in Original Medicare
coverage, like deductibles, coinsurance, and copayments for Medicare-covered services.
All Part A- and Part B-covered services and supplies. May also cover things not covered by Original Medicare, like vision and dental coverage. Most plans include Medicare prescription drug coverage.
You must have Part A and Part B Part A and Part B Do you pay a premium
Yes. You pay a premium for the policy and you pay the Part B premium.
Yes. In most cases you pay a premium for the plan and you pay the Part B premium.
MA Can Include Part D Prescription Coverage
With a Medicare Advantage Plan, you can have
your medical benefits and prescription benefits
all together in one plan
You would have one premium, for one plan
and one card to carry
Medicare Advantage and Prescription Drug Plan Card
Part D Formulary Tiers
Tier 1:Preferred Generic
Tier 2:Generic
Tier: 3 Preferred Brand
Tier: 4 Non-Preferred
Tier: 5Specialty
The least expensive Drugsyour plan covers, Including allGeneric drugs and Select brand names
These drugs usually have a higher cost share than Tier 1 drugs and can include some preferred generic drugs and some brand name drugs
Brand name drugs that have proven to be the most effective in their class
Drugs considered non-preferred (brand names that are not the “most effective”) as well as preferred specialty drugs
The most expensive drugsBecause they are classified a brand name, specialty and not preferred
• Each tier has its own copay or coinsurance amount. Your plan will encourage you to use the lowest-cost drug to treat your medical condition.
• A drug on a lower tier will cost less than a drug on a higher tier.
Medicare Part D
The biggest difference in Medicare this year is the Medicare Part D coverage gap—also known as the “donut hole”—has been closed. Sort of.The gap refers to the maximum out-of-pocket (MOOP) costs incurred by reaching a certain benefit threshold on medications. While that has been addressed recently, it doesn’t mean your medications will be at no cost.
Medicare Part D
• Instead, Part D beneficiaries can expect a 25% copayment/coinsurance for drugs from the beginning of your plan year after meeting any plan deductible until you reach the 2020 maximum out-of-pocket (MOOP) spending limit of $6,350.
• After that, you’ll pay 0% - 5% of your drug costs. This maximum (MOOP) limit is significantly higher than it used to be, and provides even more reason to shop around and compare prices. Switching plans can save you money on out-of-pocket drug costs.
Additional MA Coverage
MA can cover services not covered by original
Medicare or Medigap:
Long-term care
Routine dental care
Dentures
Cosmetic surgery
Acupuncture
Hearing aids and exams for fitting hearing aids
Vision and eyewear
Other – check Medicare.gov
You still pay the monthly Part B premium. State assistance is available for some, you may pay an additional monthly premium which varies by plan
Plan deductibles, coinsurance, and copayments
Different from Original Medicare
Vary from plan to plan—often lower costs than Original Medicare, May be higher if out of network
Medicare Advantage Costs
Medicare Advantage Cost Limits
Medicare Advantage Plans limit how much you have to pay for services in any given year
This Maximum-Out-of-Pocket means that your copayments and coinsurances have a limit
Once this limit is reached, the Advantage Plan covers 100% of the costs of all your Medicare services
This limit can vary by plan Some plans may set it higher to provide catastrophic coverage
Some plans may set it very low so that beneficiaries quickly reach 100% coverage of their Medicare services
Who Can Join a Medicare
Advantage Plan?
Eligibility requirements—You must:
Be enrolled in Medicare Part A (Hospital Insurance)
Be enrolled in Medicare Part B (Medical Insurance)
Live in the plan’s service area
Be a United States (U.S.) citizen or lawfully present in the U.S.
Not be incarcerated
To join you must also:
Provide necessary information to the plan
Follow the plan’s rules
Can only belong to one plan at a time
Medicare Advantage Has No
Underwriting
Unlike Medicare Supplements, Medicare
Advantage plans have no underwriting
You can enroll in MA plans regardless of your
health with one exception:
Usually you can’t enroll if you have ESRD
There are limited exceptions to this rule
When You Can Join
or Switch MA Plans
Initial Enrollment Period
7-month period begins 3 months before the month you turn 65 Includes the month you turn 65 Ends 3 months after the month you turn 65
Important: If you delay Part B enrollment (for example, due to active employer group coverage), your time to enroll in an MA Plan may be more restricted.
You can only join 1 MA Plan at a time, and enrollment is generally for a calendar year.
When You Can Join
or Switch MA Plans
Medicare due to a Disability
7-month period begins 3 months before the 25th month of disability.
Ends 3 months after the 25th month of disability.
When You Can Join or
Switch MA Plans
Medicare “Annual • October 15—December 7 Election period” • Coverage begins January 1
Medicare “Open Enrollment Period”
••
3-month period begins Jan 1 - Mar 31Enrollment effective 1st of month following application
OEP Changes
MAPD to Original Medicare
MAPD to MAPD
MA Only plan to MA Only plan
January 1st–March 31st
OEP will be a one time use election period Limited to just one change during the 3 month window
Note: Effective dates will be first of the following month after the members signature date
When You Can Join or Switch Plans
Special Enrollment Period (SEP)
Move out of your plan’s service area You have Medicaid Plan leaves Medicare program or reduces its service area Leaving or losing employer or union coverage You enter, live at, or leave a long-term carefacility (like a nursing home) Losing your Extra Help status You join or switch to a plan that has a 5-star rating Retroactive notice of Medicare entitlement Other exceptional circumstances
Medicare Advantage Trial Rights and Medigap
Special Medigap rights for people who
join a Medicare Advantage Plan for the first time
When first eligible at 65 or
Leave Original Medicare and drop a
Medigap policy
Can disenroll during the first 12 months
Return to Original Medicare
Have guaranteed issue rights to return to
Medigap plan
Guaranteed Rights and
Protections
Get needed health care services
Get easy-to-understand information
Have personal medical information kept
private
Rights in Medicare Health Plans
Choice of health care providers
Access to health care providers (treatment plan)
Know how your doctors are paid
Fair, efficient, and timely appeals process
Grievance process
Coverage/payment information before service
Privacy of personal health information
Conclusion
Potential members have choices about how
to receive Medicare benefits
The key is to consider all options to see
what will work best for them
Resource Guide
Medicare Products Resources Resources “Medicare & You Handbook” CMS Product No. 10050
“Have You Done Your Yearly Medicare Plan Review?” CMS Product No. 11220
“Medicare Supplement Insurance, Getting Started” CMS Product No. 11575
“Your Guide to Medicare Private Fee-for-Service Plans” CMS Product No. 10144
“Understanding Medicare Enrollment Periods” CMS Product No. 11219
“Your Guide to Medicare Savings Account Plans” CMS Product No. 11206
“Your Guide to Special Needs Plans” CMS Product No. 11302
To access these products View and order single copies at
Medicare.gov/Publications. Order multiple copies (partners only) at productordering.cms.hhs.gov. You must register your organization.
Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.
Medicare.gov
CMS.gov
Social Security 1-800-772-1213. TTY users should call 1-800-325-0778. socialsecurity.gov
Railroad Retirement Board 1-877-772-5772. TTY users should call 1-312-751-4701. RRB.gov
Medicare Marketing Guidelines https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPart CMarketingGuidelines.html
Medicare Managed Care Manual
CMS.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-
Only-Manuals-IOMs-
Items/CMS019326.html
State Health Insurance Assistance Programs For telephone numbers call CMS 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. shiptacenter.org