Welcome to Medicare. 2 Jon Langmead Centers for Medicare and Medicaid Services Office of External Affairs Philadelphia Regional Office [email protected].

Welcome to Medicare

2

Jon LangmeadCenters for Medicare and Medicaid Services

Office of External Affairs

Philadelphia Regional Office

[email protected]

215-861-4174

3

Goals

Learn the basics of Medicare coverageDiscuss critical dates for Prescription Drug

Plans and Medicare Advantage PlansLearn about the Low Income SubsidyFind out how you or the people you work

with can get help with Medicare

What is CMS and Medicare?

5

Centers for Medicare and Medicaid Services

Federal Agency - Division of DHHSwww.medicare.gov (for consumers)www.cms.hhs.gov (for providers)Estimated 44.8 million enrollees

Over 1 million in Virginia

2007 Federal Outlays for CMS were 21% of the Federal Budget ($573.3 billion)

6

What Is Medicare?

Health insurance forPeople 65 years of age and olderPeople under age 65 with certain disabilitiesPeople of all ages with End-Stage Renal Disease

Sign-up: Handled by SSA or RRB

7

Medicare Parts A - D

Part A Part B Part C Part D

Hospital Insurance

Outpatient Care

Medicare Advantage

Prescription Drug

Coverage

Original Medicare

8

Medicare Partners

CMSAOA

FDAHRSAIHSNIH

SAMHSACDC

BOIVDASMPAOA

Senior Connections

9

Where To Go For Help

Federal Resources 1-800-Medicare and Medicare.gov Social Security (www.ssa.gov)

State and Other Resources Eldercare Locator BOI FQHCs Health Assistance Partnership (www.hapnetwork.org) Coordination of Benefits Contractor: 800-999-1118 QIO MyMedicareCommunity

10

Insurance Cards You May Encounter

Medicare Card (Red, White and Blue)Medicare Supplement Insurance

(Medigap)Medicare HMO, PFFS, PPOMedicare Part D Prescription PlanEmployer Retirement PlanDMASTRICARE

Medicare Parts A and B

12

Applying for Medicare

Initial Enrollment Period8 month period around 65th birthday

Enrollment automatically occurs at 65 if beneficiary is receiving Social Security or Railroad Retirement benefits

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Exercise

1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare.

True

False

14

Exercise

1. People are automatically enrolled into Medicare when they turn 65.

True

False

15

Medicare Part AMost people don’t pay a monthly premium for

Part APeople with less than 10 years of Medicare-

covered workCan still get Part A

• Will pay a premiumFor information about Part A eligibility

Call Social Security Administration• 1-800-772-1213• TTY users call 1-800-325-0778

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Part A Helps Pay for

Hospital inpatient careSkilled nursing facility (SNF) careHome health careHospice careBlood

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Benefit Periods

The way that Medicare measures your use of Part A services

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Paying for Hospital Stays (Part A)

For inpatient stays in 2009 you payDays 1 – 60: $1,068 deductible and no co-

paymentDays 61 – 90: $267 co-payment per dayEach Day After 90: $534 co-payment per

day ( Up to 60 lifetime reserve days)All costs for each day after Lifetime Reserve

Days

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Paying for Hospice Care (Part A)

For hospice care in 2009 you pay$0A co-payment of up to $5 per prescription

for outpatient prescription drugs for pain and symptom management

5% of Medicare-approved amount for inpatient respite care

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Paying for Skilled Nursing Facility Stays (Part A)

For skilled nursing facility stays in 2009 you pay:$0 for the first 20 days in each benefit period$133.50 per day for days 21 – 100 each

benefit period All costs for each day after day 100 in

benefit period

21

Paying for Home Health Care (Part A)

For home health care in 2009 you pay:$0$20% of the approved amount for DME

22

Enrolling in Medicare Part BYou choose whether or not to enroll in Part B

2009 Monthly premium: $96.40 Initial Enrollment Period (IEP)General Enrollment Period (GEP)

2323

Part B Enrollment PeriodsExample

Marie turned 65 on June 25, 2008. She will have group health coverage from her employer until she stops working on December 31, 2008.

Part B enrollment opportunities …

Enrollment period Begins Ends

IEP 3/1/08 9/30/08

SEP 10/1/08 8/31/09

GEP (each year) 1/1 3/31

2424

Paying the Part B Premium

Taken out of monthly paymentsSocial SecurityRailroad retirementFederal government retirement

For information about premiumsCall SSA, RRB, or Office of Personnel Management

If no monthly paymentsBilled every 3 monthsMedicare Easy Pay

Introduction

25

Paying for Part B Services

In Original Medicare you payYearly deductible ($135 in 2009)20% coinsurance for most services50% for most outpatient mental healthSome copayments

Some programs may help

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Part B Coverage

Doctors’ services Outpatient medical and surgical services and

supplies Diagnostic tests Outpatient therapy Outpatient mental health services Some preventive health care services Other medical services

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Covered Preventive Services

“Welcome to Medicare” physical exam

Abdominal aortic aneurysm screening

Bone mass measurement Cardiovascular disease

screenings Colorectal cancer

screenings Diabetes screenings

Glaucoma tests Mammograms (screening) Pap test/pelvic exam/

clinical breast exam Prostate cancer screening Flu shots Pneumococcal shots Hepatitis B shots Smoking cessation

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A/B Claims Processing

Medicare A/B Claims are handled by Medicare Administrative Contractors (MACs)

Viewing Beneficiary ClaimsQuarterly StatementsMyMedicare.gov

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Medigap

Health insurance policySold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in Original Medicare

• Deductibles, coinsurance, copayments

• Does not work with Medicare Advantage Plans

Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin

• So you can compare easily

30

Benefits for Medicare Beneficiaries

Medical Benefits Original Medicare Medicare Advantage Plan (HMO, PFFS,

PPO)

Prescription Drug Benefits

Stand-Alone Part D Plan Through your MA Plan

Supplemental Insurance

Stand-Alone Medigap Plan N/A

Beneficiaries with both Medicare A and B

31

Benefits for Medicare Beneficiaries

Medical Benefits Original Medicare

Prescription Drug Benefits

Stand-Alone Part D Plan

Supplemental Insurance

Stand-Alone Medigap Plan

Beneficiaries with Medicare A or B

32

Additional Key Points

TravelMedigap and Original MedicareDelaying Enrollment in B

33

Key Things to Remember

Part B IEPVariety of ways to receive coverage

34

Exercise

1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare.

A. True

B. False

35

Exercise

2. Most people receive Part A premium free.

A. True

B. False

36

Exercise

3. The Part B premium for most people is $96.40 in 2008.

A. True

B. False

37

Exercise

To be entitled to Medicare, you must be at least 65 years of age and retired.

True

False

38

Exercise

A beneficiary can have both a Part C Plan and still be covered by a Medigap plan or employer plan.

True

False

39

Exercise

Some people can delay enrolling in Part B without paying a penalty.

True

False

40

Exercise

A beneficiary can have both a Medigap plan and a Part D Prescription Drug Plan.

True

False

Medicare Advantage Plans

Medicare Part C

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How Medicare Advantage Plans Work

Usually get all Part A and B services through planMay have to use the plan’s providers

May get extra benefitsVision, hearing, dental servicesPrescription drug coverage

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

43

Medicare Advantage Plans

Health Maintenance Organization (HMO) PlansSome have Point-of-Service option

Preferred Provider Organization (PPO) Plans Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans

Since 2007

44

Other Medicare Plans

Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the

Elderly (PACE)

45

Eligibility for Medicare Advantage

Live in plan’s service areaHave Medicare Part A and Part B

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

Don’t have ESRD at enrollmentSome exceptions

46

Enrolling in Medicare Advantage Plans

Generally done during the Initial, Annual, or Open Enrollment Periods

Apply directly with the plan, through a broker or agent, or through Medicare

47

MA Open Enrollment Period LimitsIf coverage is Can use OEP to get Cannot use OEP to get

Medicare Advantage Plan with prescription drug coverage (MA-PD)

A different MA-PD or

Original Medicare Plan and PDP or

MA-PFFS and a PDP

MA-only or

Original Medicare Plan only

(cannot drop drug coverage)

Medicare Advantage Plan with no prescription drug coverage (MA-only)

MA-only or

Original Medicare Plan only

MA-PD or

Original Medicare Plan and PDP (cannot add drug coverage)

Original Medicare Plan and a PDP

MA-PD or

MA-PFFS and the same PDP

MA-only or

A different PDP to use with Original Medicare Plan

(cannot drop drug coverage)

Original Medicare Plan only

MA-only MA-PD or

Original Medicare Plan and PDP (cannot add drug coverage)

10

Medicare Prescription Drug Plans

Medicare Part D

49

Medicare Prescription Drug Coverage

Coverage began January 1, 2006All people with Medicare can join a planProvided through

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

50

Specifics of Part D Definition of Part D covered drugs

Available only by prescription FDA approved drugs Used for a medically accepted indication

Includes supplies associated with injection of insulin Syringes, needles, alcohol swabs, gauze coveredTest strips and lancets not covered as available

under Part B Part D does not cover drugs already covered under

Part A or B (even if the person does not have Part A or Part B)

51

Part D Coverage

Part D Plan formularies must include “all or substantially all” drugs included in these categories:Cancer medicationsHIV/AIDS treatmentsAntidepressantsAntipsychotic medicationsAnticonvulsive treatments

• For epilepsy and other conditionsImmunosuppressants

52

Access to Part D Covered Drugs

Plans can manage access to covered drugsTiersPrior authorizationStep therapyQuantity limits

Plans must have processes in placeMembers must be provided all prescription

medications determined to be medically necessaryRequest coverage determinations and appeals

53

Part D Excluded Drugs Benzodiazepines Barbiturates Agents for anorexia, weight loss, or weight gain Fertility drugs Drugs for cosmetic purposes or hair growth Cough and cold medicine Prescription vitamins

Except prenatal and fluoride preparations Nonprescription drugs (over-the-counter drugs) Erectile dysfunction drugs

54

Access to Part D Covered Drugs

Plans can manage access to covered drugsTiersPrior authorizationStep therapyQuantity limits

Plans must have processes in placeMembers must be provided all prescription

medications determined to be medically necessaryRequest coverage determinations and appeals

55

Part D Excluded Drugs Benzodiazepines Barbiturates Agents for anorexia, weight loss, or weight gain Fertility drugs Drugs for cosmetic purposes or hair growth Cough and cold medicine Prescription vitamins

Except prenatal and fluoride preparations Nonprescription drugs (over-the-counter drugs) Erectile dysfunction drugs

56

Enrollment Periods

Initial Enrollment Period (IEP)7 monthsStarts 3 months before month eligible for Medicare

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)

57

Coverage Varies

Plans have formularies May not include every Part D drug

• Similar drug usually covered– Safe and effective

May have different cost levels (“tiers”)

Must cover range of drugs in each category

58

Access to Covered Drugs

Plans can manage access to drug coverage throughFormulariesPrior authorizationStep therapyQuantity limits

59

Medicare Drug Plan Costs

Monthly premiumVaries by planSome plans have no premium

Possible deductibleNo more than $275 in 2009

Copayments or coinsuranceMay depend on how much spent that year

60

Costs in 2009

Premium Generally less than $37 monthly

Deductible No more than $295

Drug Costs $295-$2,700

Beneficiary pays 25%

Drug Costs $2,700-$6,153

Beneficiary pays 100%

After spend $4,350 Beneficiary pays 5%

61

Coverage Gap in 2009

When member pays 100% of drug costsBegins after $2,700 in total drug costs

Initial coverage limit

Continues until out-of-pocket costs total $4,350May start earlier in some plans

After gap, pay 5% or small copaymentCatastrophic coverage

62

Late Enrollment Penalty

If you wait to enrollAdditional 1% of national base premium for

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

Medicare drug plan

No penalty if you have other coverage at least as good as Medicare drug coverage

63

Exercise

1. You must have Medicare Part A and Medicare Part B to join Medicare Advantage plan with drug coverage.

A. TrueB. False

64

Exercise

2. The Annual Coordinated Election Period runs from November 1 through December 15 each year.

A. TrueB. False

65

Casework The beneficiary states that they were misled by an

agent or the plan and enrolled into a plan they did not want.

The beneficiary disenrolled from the plan or changed to direct bill, but premiums are still coming out of their SSA check or the beneficiary wanted premiums to come out of their SSA check and they are being billed directly.

The beneficiary enrolled or disenrolled in the plan, but the enrollment/disenrollment is not showing up at CMS.

The plan does not cover a medication the beneficiary needs.

Extra Help with Drug Plan Costs

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Extra Help With Drug Costs

Sometimes called Low Income Subsidy (LIS)People with lowest income and resources

Pay no premiums or deductiblesHave small or no copayments

Those with slightly higher income and resourcesHave a reduced deductiblePay a little more out of pocket

No coverage gap for people who qualify for LIS

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How People Qualify for Extra HelpPeople with Medicare and

BasisData Source

Changes During the Year

Medicaid benefits• Full Medicaid

benefits• Medicare Savings

Program

Automatically qualify

StatesQualify for a full

calendar yearGenerally only favorable

changes will occur

SSI benefits SSA

No Medicaid or SSI benefits

Must apply

SSA* or states

*almost all

Some events can impact status through the year

Extra help can increase, decrease, end

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Continuing Eligibility for People who Applied with Social SecurityFour types of redetermination processes

InitialCyclical or recurringSubsidy-changing event (SCE)

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Income and Resource Limits Income

Below 150% Federal poverty level• $1,300 per month for an individual* or• $1,750 per month for a married couple*• Based on family size

ResourcesUp to $11,990 (individual)Up to $23,970 (married couple)

• Includes $1,500/person funeral or burial expenses• Counts savings and stocks• Does not count home you live in

*Higher amounts for Alaska and Hawaii

2008 amounts

2008 amounts

71

MedicaidFederal and state program

For some people with limited income and resources If eligible, most health care costs coveredEach state decides

Who is eligibleHow people apply

Office names varySocial ServicesPublic AssistanceHuman Services

72

2009 LIS Guidelines

Annual Income

Monthly Income

Resources

73

Medicare and Full Medicaid

Auto-enrolled in a plan unlessAlready in a Part D planChoose and join own planCall plan or 1-800-MEDICARE to opt out

Coverage first month person has both Medicare and Medicaid

Will get auto-enrollment letter on yellow paperHave a continuous SEP

74

Others Qualified for Extra Help

Facilitated into a plan unlessAlready in a Part D planChoose and join own plan Enrolled in employer/union plan receiving subsidyCall plan or 1-800-MEDICARE to opt out

Coverage effective 2 months after CMS notifiedWill get facilitated enrollment letter on green paperHave continuous SEP

75

People New to Extra Help

People can apply for extra help any timeCan reapply if circumstances change

People in a Medicare drug plan who later qualify for extra helpPlan is notifiedPlan will refund costs back to effective date of

extra help• Premiums• Cost-sharing assistance

76

Auto- and Facilitated Enrollment

CMS identifies and enrolls people each monthPlans are randomly assigned

• From those with premiums at/below regional low-income premium subsidy amount

• May join MA plan meeting special needs

People already in MA planEnrolled in MA-PD, if offered

77

Enrollment Notices

CMS notifies people of enrollment in a PDP Auto-enrollment letter on yellow paperFacilitated enrollment letter on green paper

• Two versions– Full subsidy– Partial subsidy

• Includes list of plans in that region at/below regional low-income premium subsidy amount

MA plan sends notice if enrollment in MA-PD

78

Continuing Eligibility

People Who Automatically QualifyCMS re-establishes eligibility each fall for

next calendar yearPeople will receive letter from Medicare

• In September on gray paper– Those who no longer automatically qualify

– Includes SSA application

• In early October on orange paper– Those who will continue to automatically qualify but

with a different copayment level

79

Continuing Eligibility

People who applied with Social SecurityFour types of redetermination processes

• Initial• Cyclical or recurring• Subsidy-changing event (SCE)• Other event

– Any change other than SCE

80

Extra Help in 2008

Group 1 Group 2 Group 3

Premium $0 $0 Sliding scale based on income

Deductible $275/year

$0 $0 $56

Coinsurance up to $4,050 out of pocket

$1.05/$3.10 copay

$2.25/$5.60 copay

Up to 15% coinsurance

Catastrophic coverage

$0 $0 $2.25/$5.60 copay

81

Exercise

1. People with the lowest income and resources will pay no premiums or deductibles and have small or no co-payments for Part D coverage.

A. TrueB. False

82

Exercise

2. People can only apply for Extra Help during a the Open and Annual Enrollment Periods.

A. TrueB. False

83

Exercise

3. People who were automatically eligible for extra help for 2008 continue to qualify for the extra help through December 2008.A. TrueB. False

84

For More Information

1-800-MEDICARE (1-800-633-4227)TTY users call 1-877-486-2048

www.medicare.gov State Health Insurance Assistance

Program (SHIP)Medicare & You handbook

Other publications

85

CMS Complaints Procedure

Complete Complaint Tracking Form Available on VDA’s website:

http://vda.virginia.gov/pdfdocs/SHIP-Regional-Referral.doc

Email completed form to:[email protected] VICAP DirectorOlivia Claud (if BOI/agent issue involved)

86

Summary

Medicare coverage Original Medicare Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs