Turning 65

1
Turning 65
2
Presented By

• Maribeth Stein
• Outreach Specialist
• maribeth.stein_at_ageoptions.org
• 1-800-699-9043
• 1-708-383-0258

3
Area Agencies on Aging

• Area Agencies across the nation are your
  convenient starting points.
• We are responsible for
• -planning and funding services for older
  adults
• -coordinating the services of local senior
  service organizations to ensure high quality
  and access
• -advocating by educating policy makers on the
  needs of older persons.

4
Programs and Services Supported by AgeOptions

• Case Management to assess a loved ones
  condition and find services
• Elder Abuse Intervention
• Caregiver Support Services
• Long Term Care Ombudsman Program to assist
  nursing home residents and their families
• Senior Nutrition Programs meals served at
  community sites and delivered to the home
• Chore / and Homemaker Services
• Housing Assistance/ and Home Repair

5
What well cover today

• The Medicare Program
• Eligibility
• Enrollment
• Benefits
• Other Options
• Where to get help

6
What is Medicare?

• A federal health insurance program
• Run by the Centers for Medicare and Medicaid
  Services (CMS)
• Benefit decisions controlled by the U.S. Congress
• Social Security Administration handles enrollment
  eligibility

7
Who is eligible for Medicare?

• Age work history
• Age 65 and eligible for benefits under either
  Soc. Sec. or Railroad Ret., or federal, state or
  local employee
• 40 quarters (10 years) of Soc Sec covered
  employment eligible for Social Security AND
  Medicare Part A
• Persons with disabilities
• Receiving disability benefits under Soc. Sec. or
  Railroad Ret. for 24 months or more

8
Others eligible for Medicare

• ESRD (End-stage renal disease)
• Receiving regular dialysis or received transplant
  due to kidney failure
• Spouses and widows age 65, but not eligible based
  on their own work records
• Not automatically enrolled must apply

9
Others may purchase Medicare coverage

• Age 65, but not enough qualified work history
• May purchase coverage
• 30-39 quarters- 216 per month
• 29 quarters or less- 393 per month
• Must be age 65 and a U.S. resident
• U.S. citizen or legal permanent resident living
  in the U.S. for 5 continuous years

10
Enrollment Periods

• Initial Enrollment
• 7 months (3-1-3)
• Special Enrollment
• Delay enrollment if working
• Must enroll within 8 months after work terminates
• Note Penalties if dont enroll when first
  eligible

11
Medicare was never intended to pay 100 of
healthcare bills

• Protection against basic and large medical
  expenses
• Focus on acute careillness or injury
• Leaves gaps where the consumer must pay
• Does not cover
• Long-term care in a nursing home
• Routine physicals, vision, hearing, dental, or
  foot care
• Health care outside the U.S.

12
Original Medicare

• Red, white and blue card
• Pay-per-service system
• Almost any doctor, anywhere in U.S.
• Limits on doctor and hospital fees
• Covers most medical needs
• Medicare Summary Notices are now sent on a
  quarterly basis

13
The Medicare Card
Original Medicare
Jane Doe
14
Medicare Parts A B

• Part A
• Hospital Insurance
• Hospital, skilled nursing facility, home health,
  hospice
• Part B
• Medical Insurance
• Doctors, outpatient services, preventative
  services, lab tests, ambulance services,
  equipment and supplies

15
Medicare Part D

• Everyone with Medicare may join Part D
• Can sign up every November and December
• If turning 65 can sign up before and after
  birthday
• There is extra help for people with limited
  income
• Low Income Subsidy ( Federal Program)
• Illinois Cares Rx ( State Program)
• Penalty if dont sign up when first eligible

16
Part A Benefits

• Hospital stays
• Semi-private room, meals, nursing, supplies,
  medications
• Skilled Nursing Facility
• Up to 100 days with 3-day hospital stay
• Skilled level care only (short-term,rehabilitative
  )
• Home Health Care
• Part-time skilled nursing care, therapies, aide
  services, supplies
• Hospice
• Pain and symptom relief and supportive services
  for terminally ill

17
What are your Part A costs?

• Hospital deductible 1068 in 2009
• each benefit period (may be more than once per
  year)
• for longer stays, you pay daily coinsurance
• days 1-60 0
• days 61-90 267 per day
• days 91-150 534 per day
• Skilled nursing facility
• days 1-20 0
• days 21-100 133.50 per day
• over 100 days, you pay all

18
Part B Benefits

• Doctors services inpatient and outpatient,
  medical and surgical
• Physical, occupational and speech therapy
• Lab services, diagnostic tests
• Ambulance
• Durable medical equipment
• Outpatient hospital services
• Some home health care

19
Your Part B Costs

• Monthly premium 96.40 in 2008- you must pay
  this in addition to any private insurance or
  Managed Care Plan you buy
• Annual Deductible 135 in 2008- this amount will
  increase every year
• Medicare usually pays 80 of the Medicare
  approved amount for doctors services you pay
  the difference (20 coinsurance)

20
Income-Related Part B Premium Increase

• Beginning January 2007
• Higher premium increase for those with income
  over
• 82,000 (individual tax return)
• 164,000 (joint tax return)

21
Additional Part B Costs

• 50 outpatient mental health
• Outpatient emergency room, hospital and surgery
  services are a fixed amount, depending on the
  service

22
Preventive Care Benefits

• Abdominal Aortic Aneurysm Screening
• Bone Mass Measurement
• Cardio Vascular screening
• Colon cancer screening
• Diabetes screenings
• Diabetic self-management
• Immunizations (flu, pneumonia and Hepatitis B
  shots)

23
Preventive Care Benefits

• Glaucoma Examination
• Mammogram screening
• Medical Nutrition Therapy Services
• Physical Exam (a one-time Welcome to Medicare
  exam
• Prostate cancer screening
• Pap Smears
• Smoking Cessation (counseling to stop smoking)
• New services covered for 2008

24
New Benefits

• Ultrasound screening for abdominal aortic
  aneurysms. Referred during Welcome to Medicare
  exam. No deductible
• No deductible for colorectal cancer screening

25
Diabetes Screening

• Testing for people at risk
• Includes fasting blood glucose test
• Talk with you doctor about frequency- up to twice
  in a 12 month period
• No deductible or coinsurance in Original Medicare

26
Doctor Charge Limits

• Doctors who take assignment
• Agrees to take Medicare approved rate as payment
  in full
• Medicare pays 80 of that rate
• Doctors who dont take assignment
• Can charge no more than 15 above Medicares
  approved rate
• Doctors who opt out
• Patient signs private contract to pay in full
• Cannot submit any claim to Medicare

27
Medigap Plans/Medicare Supplement Plans to Fill
the Gaps

• Private health insurance
• Regulated by Illinois Department of Financial and
  Professional Regulation (www.idfpr.com)
• 12 standardized Medigap
• Plans A-L
• Monthly premiums range widely
• Variations on standard A-L
• Medicare Select plans
• High deductible plans (F or J) for 2008 1,900

28
Other Supplemental Coverage

• Retiree benefits from former employer or union
• Spouses employer group health plan

29
Who May Join a Medicare Advantage Plan?

• Must be enrolled in both Parts A B
• Live in plans service area
• Must accept everyone on Medicare except people
  with ESRD
• Fill out sign application form
• Agree to follow rules
• Can be in hospice program

30
How Medicare Advantage Plans Work

• Usually get all Medicare Part A and Part B
  services through the plan
• Usually have to use providers that are approved
  by the plan
• HMO, PPO
• May get extra benefits
• May get vision, hearing, dental services
• May get prescription drug coverage
• Still in Medicare program
• Part A and Part B services are provided by a
  private company that contracts with Medicare
• Have Medicare rights and protections
• Always covered for emergency and urgent care

31
How Medicare Part D Works

• Offered by private plans contracting with
  Medicare
• Each plan has a list of drugs it covers called a
  formulary and a list of pharmacies you may use
• 2 types of plans to choose from
• An insurance plan that only covers drugs (PDP)
  or
• A Medicare advantage plan (HMO or PPO) that
  covers drugs and your other health benefits

32
Part D/ Exceptions to the Penalty

• You may keep your current coverage and join a
  Medicare drug plan later with no penalty if the
  benefits in your current plan are considered as
  good as the new plans called creditable
  coverage
• Be sure to check with your employer/union
• To see if current coverage is considered
  creditable
• VA coverage is considered creditable you may
  keep it without penalty
• You may also join a part D plan and/or Illinois
  cares rx

33
What Drugs Are Covered?

• Each plan has its own list of covered drugs
  (formulary)
• Includes at least two drugs from each category of
  drugs
• 220 illness categories included
• Prescription drugs, insulin
• Brand name and generic drugs
• Plan must give 60-day notice if formulary changes
  but it can change throughout the year

34
Exceptions and Appeals

• You may request an exception if the plan
• Doesnt cover a drug that is medically
  necessary for you
• Requires trying a different drug first
• Has a limit on the amount prescribed
• By phone or written request
• Will usually need a doctors statement
• Plan must respond quickly
• 72 hours for most requests
• 24 hours if an emergency
• If denied, you may appeal
• First to the plan
• Several levels of appeals

35
Switching Plans

• Next chance to switch is November 15-December
  31, 2008 to take effect in January 2009
• People with both Medicare and Medicaid may switch
  plans any month

36
Benefit for 2008

• Average monthly premium about 40 a month
• Range from 17.70 to 97.50 in Cook County
• May be a deductible of 275 plans vary
• Between 0 and 2,510 in drug costs- Plan co-pays
• The plan pays 75 and you pay 25
• Between 2,510 and 5,726.25 you pay all
• No benefit, sometimes called the donut hole
• After 5,726.25 the plan pays 95
• You will have paid 4,050 out of your pocket
  (plus the premiums)
• Exceptions to donut hole
• State of Illinois program
• Low Income Subsidy program
• Part D plan that covers gap

37
Assistance for Individuals With Limited Income

• Medicaid
• Medicare Savings Programs
• The Qualified Medicare Beneficiary (QMB) Program
  
• Specified Low-income Medicare Beneficiary (SLMB)
  Program
• Qualified Individual (QI-1) Program

38
Consider the Options Based on Whats Most
Important to You

• Choice of doctors / specialists
• Monthly costs
• Predictable costs
• Benefits
• Convenience
• Coverage when traveling away from home

39
Health Benefits for Veterans

• Veterans only are eligible, not spouses or
  survivors
• In 2008, income must be less than 28,429 for a
  single vet
• In 2008, income must be less than 34,117 for a
  vet with a single dependent
• Must enroll in the program
• Get medications through VA hospitals or clinics
• Co-payments of 8 for a 30 day supply
• Call 1-877-222-8387 for an application

40
Illinois Cares Rx

• New name for SeniorCare and Circuit Breaker
  Pharmaceutical Assistance Programs
• One application for Prescription coverage,
  license plate discount and real estate grant
  check
• One application for both must be renewed each
  year
• Can apply online- even first time filers

41
Illinois Cares Rx Benefits - Summary

• You pay
• No premium (the state pays it for you)
• No deductible for covered drugs
• No coverage gap (donut hole) for covered drugs
• Pays up to 2,510 worth of covered drugs, then
  you pay 20 plus your original co-pay
• For each prescription you fill between 0 and
  2510 you pay
• 2.25 generic
• 5.60 preferred brand name
• 15 Non preferred drugs
• Between 2,510 and 5,726.25 worth of drugs, you
  pay 20 plus co-pays
• After 5,726.25 worth of drugs, you pay 5
• 25 per month rebate instead of benefits if you
  already have insurance coverage for drugs. Your
  coverage should be creditable otherwise you are
  much better off with the Illinois Cares Rx full
  benefit instead of the rebate

42
Illinois Cares Rx Plus(Formerly SeniorCare)

• Age 65 years and over
• Covers most types of prescription medications
• Covers some prescribed over-the-counter drugs
• Yearly income less than
• 23,225 household of 1
• 31,264 household of 2

43
Illinois Cares Rx Basic

• Age 65 years and over or on disability
• (age 16 or over)
• Pays for medications for 10 specific illnesses
  plus a special benefit for HIV
• Alzheimer's disease
• arthritis
• cancer
• diabetes
• glaucoma
• heart and blood pressure problems
• lung and smoking-related illnesses
• osteoporosis
• Parkinsons disease
• multiple sclerosis
• HIV/AIDS (new in 2007)

44
Illinois Cares Rx Basic (Cont.)

• Yearly income less than
• 24,808 household of 1
• 32,916 household of 2
• 41,023 household of 3
• For medications for the 11 covered conditions,
  you pay
• 2.25 most generic drugs, 5.60 preferred brand
  name
• 15 (non-preferred brands and specialty drugs)
• Up to 2,510,00 then you pay 20 plus co-pays
• After 5,726.25 worth of drugs, you pay 5
• For other prescriptions, you pay your Part D
  plans co-pays
• 25 per month rebate instead of benefits if you
  already have insurance coverage for drugs

45
Medicaid Basics

• Medicaid is a program designed to assist low
  income individuals pay for their medical care.
• Medicaid is a state administered program and each
  state sets its own guidelines regarding
  eligibility and services.
• Managed by the Dept.of
• Human Services.

46
Medicaid Eligibility

• Monthly Income for an individual 892 with an
  asset limit of 2,000.00 or less
• Monthly income for a couple 1,192.00 with an
  asset limit of 3,000.00 or less

47
Medicaid Programs

• Aid to Aged, Blind and Disabled (AABD)
• Medicare Savings Program
• QMB, SLMB, Q/I
• Food Stamps

48
Medicaid Enrollment

• The best place to get help with enrollment is at
  your local senior center. They have benefit
  counselors available to help you navigate the
  Medicaid system
• North Shore Senior Services
• 161 Northfield Road
• Northfield, Il
• Ph [phone]

49
Medicaid Enrollment

• You can enroll on site at
• DHS Family Community Resource Center in Cook
  County - Northern
• Family Community Resource Center
• 8020 St Louis Ave Skokie, IL 60076
• Phone [phone]TTY [phone]Fax
  [phone]
• At this site you can receive applications for
  Cash, Food Stamps, and Medical benefits
  Assistance by fax, mail or in person
• On the internet www.dhs.state.il.us

50
Dont Become a Victim of Fraud!

• Tips
• No door-to-door marketing allowed
• Cant sign you up over the phone unless you call
  them
• Must follow Do Not Call rules get on the list
• You cannot buy any of the new Medicare plans
  until November
• Dont enroll in anything until youve compared
  your options
• Dont give out your Medicare or Social Security
  number
• Keep track of your mail
• There is reliable and free help available you
  should not have to pay for it
• Report any suspicious marketing practices at
  1-800-699-9043

51
Dont Hesitate to Call for Answers

• AgeOptions
• 1-800-789-0003
• SHIP
• 1-800-548-9034
• 1-800-Medicare
• 1-800-633-4227
• Social Security
• 1-800-772-1213

52
Dont Hesitate to Call for Answers

• Progress Center for Independent Living
• 1-708-209-1500
• North Shore Senior Center
• 1-847-784-6000

53
If you use the internet

• www.medicare.gov
• Compare plans - costs, benefits, pharmacies
• Information on the Extra Help program and new
  Medicare benefits
• www.benefitscheckup.org
• Fill out a confidential questionnaire
• Find out all the programs you qualify for,
  including Illinois Cares Rx and Extra Help
• Applications and information to help you apply,
  links to other sites
• www.ssa.gov
• Application and information for Extra Help
• www.cbrx.il.gov
• Application and information about Illinois Cares
  Rx and Circuit Breaker
• Check the status of your Illinois Cares
  RX/Circuit Breaker application

54

• Thank You!
• Maribeth Stein