Medicare Overview

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Medicare Overview
SMP Volunteer Foundations Training
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Objectives of Volunteer Foundations Training

• At the end of this training, participants will be
  able to
• Describe the background and mission of the
  national SMP program
• Identify the three roles of the SMPs
• Identify components and benefits of Medicare
  programs
• Describe eligibility and enrollment requirements
  of Medicare, Medicaid, and other assistance
  programs
• Review sample MSNs against case files for
  accuracy
• Describe how Medicare programs are subject to
  fraud, waste, and abuse and
• Identify strategies to combat fraud, waste,
  error, and abuse.

Chapter 1
Chapter 2
Chapter 3
Refer to H-1a-b
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Agenda

• Welcome, Introductions, Objectives of Training
• History of Medicare
• Medicare Basics
• Eligibility for Medicare
• The A,B,C,Ds of Medicare
• Medicare Supplement Insurance (Medigap)
• Enrollment in Medicare
• Reading the Medicare Summary Notice (MSN)
• Extra Help for People with Limited Income
• Resources for Beneficiaries
• Evaluation and Wrap-Up

Refer to H-2
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Medicare Today and Tomorrow

• Managed by
• Centers for Medicare and Medicaid Services (CMS)
• Oversight provided by the U.S. Administration on
  Aging
• Extent of Medicare
• In 2008, Medicare spent 468 billion for health
  care costs of more than 45 million beneficiaries.
• In the next ten years, Medicare spending will
  more than double.

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The Good News

• Since 1996, when the government increased
• its focus on Medicare fraud and abuse,
• AoAs SMP program has made a significant impact
  in efforts to fight fraud
• A large part of the solution to the problem of
  health care fraud and abuse is the use of
  volunteers!

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The Bad News

• Fraud, errors and abuse cost the Medicare program
  billions of dollars in 2008.

Bottom Line The Federal government and taxpayers
lose billions of dollars each year as a result
of Medicare and Medicaid fraud and abuse.
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You Are Part of the Good News!

• SMP Volunteers help play an important role in
• Educating Medicare and Medicaid beneficiaries,
  and
• Reducing and preventing
  health care fraud and abuse.
• And THATs why its important for SMP volunteers
  to understand Medicare Basics.

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Medicare Basics
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Medicare Program

• Program created by Congress in 1965
• The federal health insurance program for
• Persons 65 years and older
• Some persons under 65 years who have disabilities
  
• Persons with end-stage renal disease (ESRD)
• Administered by the Centers for Medicare and
  Medicaid Services (CMS)
• Not intended to pay 100 of medical bills

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Eligibility for Medicare

• Must be U.S. Citizen OR individual with resident
  visa who has lived in the U.S. for 5 consecutive
  years.
• In addition,
• Must be 65 years old or older AND receive or be
  eligible to receive Social Security or Railroad
  Retirement Benefits (or a spouse of someone who
  meets these criteria)
• OR
• Have been receiving disability benefits for at
  least 24 months
• OR
• Have kidney failure, End-Stage Renal Disease
  (ESRD)
• OR
• Approved for Social Security Disability with a
  diagnosis of ALS (Lou Gehrigs disease).

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Parts of Medicare
Part A Hospital Insurance
Part B Outpatient Insurance
Part C Medicare Advantage
Part D Prescription Drugs
Medicare Supplement Insurance MEDIGAP Not part
of Medicare
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Do You Know
the Parts of Medicare?
Refer to H-3. Match the Medicare Part listed in
the left-hand column to its appropriate
description in the right-hand column by drawing a
line from the Medicare program to its description.
Refer to H-3
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Jigsaw Learning the Parts of Medicare

• What better way to learn about the Parts of
  Medicare than to teach it to someone else?
• Refer to Handout H-4 and read the instructions
• Person 1 Read about Medicare Part A on page 5
• Person 2 Read about Medicare Part B on pages
  6-8
• Person 3 Read about Medicare Part C on page 9
• Person 4 Read about Medicare Part D on page 10
• Person 5 Read about Medigap Insurance on pages
  11-12
• When all the Experts have completed teaching,
  everyone in your group will have learned key
  points of the five Medicare Parts.

Refer to H-4
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Learning the Parts of Medicare (Cont.)

• Part A
• Benefits
• Costs
• Non-covered services
• Your rights in the hospital
• Part B
• Benefits
• Costs
• Non-covered services
• Assignment

Note Assignment is the term used to indicate
that a doctor or supplier has agreed to accept
the Medicare-approved amount as full payment. See
example on Chapter 2, p. 8 .
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Learning the Parts of Medicare (Cont.)

• Part C
• Eligibility
• Costs
• 5 types of Medicare Advantage plans
• Part D
• Eligibility
• Costs

Note A beneficiary who joins a Medicare
Advantage Plan (Part C) but who isnt happy with
the plan has the right to return to Original
Medicare (Parts A B) within the first 12 months
of joining.
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Medicare Supplement Insurance (Medigap)

• Eligibility
• Key points
• Costs

Note Medigap is not a Medicare program.
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Parts of Medicare Test your Knowledge

• Refer to H-5ab Review the statements, which
  come directly from Chapter 2 of your Volunteer
  Training Manual.
• Test your knowledge by filling in the blanks.
• You may refer to Chapter 2 to help you with this
  exercise.

Refer to H-5a-b
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Medicare Enrollment

• Enrollment handled through Social Security
  Administration or Railroad Retirement Board
• Automatic enrollment
• Initial Enrollment
• General Enrollment
• Special Enrollment

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1. Automatic Enrollment
Enrollment in Medicare Parts A and B occurs automatically for individuals who Enrollment will take place and benefits will begin
Have already been receiving benefits from Social Security or the Railroad Retirement Board before age 65 On the first day of the month individual turns 65
Have a disability, are under age 65, and has been receiving Social Security Disability Insurance for at least 24 months After individual has received SSDI or certain disability benefits from the RRB for 24 months
Notes Individuals not eligible for automatic
enrollment will need to sign up for Parts A and
B. Automatic enrollment does not apply to Parts
C, D, or Medigap. These plans will begin only if
the beneficiary initiates them.
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2. Initial Enrollment

• If automatic enrollment does not apply, the best
  time to enroll in all parts of Medicare is during
  initial enrollment, when individual first becomes
  eligible for Medicare.
• Parts A-D 7 months surrounding 65th birthday
• Medigap must be 65 AND have Part B
• 10 Penalty for delayed enrollment in Part B.

Advice for beneficiaries Enroll 1-3 months
before birthday month to ensure that coverage
begins by the time individual reaches age 65.
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3. General Enrollment

• Timeframes for enrolling and making changes to
  plans are different for each Medicare Part and
  for Medigap.
• Beneficiaries who miss the initial enrollment
  period can enroll during the general enrollment
  period for each of the Medicare plans, as
  outlined in the SMP Volunteer Manual.

Can a beneficiary get out of their plan? See page
15 of the SMP Volunteer Manual.
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4. Special Enrollment
Special enrollment situations Special enrollment timeframe Individual may sign up
Individual or spouse (or other family member, if individual is disabled) is working and has group health plan coverage through the employer or union. Any time individual or spouse is still covered by a plan through current or active employment. During the 8-month period beginning when individual (or spouse) retires or loses health insurance.
Individual is serving as a volunteer in a foreign country. For details, see the Medicare and You Handbook (described on p. 17 of the Volunteer Manual).
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How to Enroll

• \
• The enrollment process differs for each Part of
  Medicare.
• Beneficiaries are responsible for their own
  enrollment however, SMPs may assist
  beneficiaries with general information and
  resources

Note See the SMP Volunteer Training Manual (p.
17) for descriptions re how to enroll and where
to get more information on Medicare and
enrollment.
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Check Your Knowledge about Medicare Basics
Check Your Knowledge

• See how much you know about Medicare Basics!
• Turn to H-6 and read each statement.
• Determine whether the statement is True or False.
  
• For each false statement, write the corrected
  statement in the space provided.
• As the answers are reviewed, circle any that you
  missed or want to read/learn more about. Use
  this as your study sheet for future reviews.

Refer to H-6
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Medicare Statements and Claims
Tracking

• Medicare Summary Notices (MSNs)
• Key tool to help beneficiaries track medical
  information
• Helps beneficiaries and SMPs to catch errors and
  potential fraud and abuse
• Not all Medicare programs send out MSNs.
• Sometimes, statement has different name, e.g.,
• Medicare Part D plans send an Explanation of
  Benefits (EOB).
• Medicare Advantage plans (Part C) send statements
  that are not standardized like other Medicare
  programs.

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Examining the Medicare Summary Notice (MSN)

• MSNs are a valuable resource. It is important
  that you become familiar with the MSN, both to
  explain the format to beneficiaries, and to
  examine it for potential errors, fraud, and
  abuse.
• Examining the Medicare Summary Notice
• Refer to pages 2130 in Chapter 2 of the
  Volunteer Manual and refer to H-7 in the
  participant handouts
• Review the MSN on pages 21-22 as you answer the
  questions on H-7

Refer to H-7
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www.MyMedicare.gov

• A valuable, real-time tool to combat fraud and
  abuse
• Allows registered users to track health care
  services received
• Users can
• View most recent MSNs
• Check Part B deductible status
• View eligibility information
• Track available preventive services
• Find Medicare health or prescription drug plans.
• Encourage beneficiaries to sign up for the site,
  where they can keep track of their personal
  information
• www.MyMedicare.gov

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Extra Help for Persons with Limited Income and
Resources
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Extra Help for Persons with Limited Income and
Resources

• Categories of individuals who may be eligible for
  extra help
• Underserved, disadvantaged, or hard-to-reach
  populations
• Ethnic or cultural minorities
• Frequently targeted by scam artists, resulting
  in millions of dollars lost to fraud and abuse!
• Types of assistance programs available
• Medicaid
• Medicare Savings Programs
• Programs of All-Inclusive Care for the Elderly
  (PACE)
• Help with Prescription Drugs
• Supplemental Security Income (SSI)

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1. Medicaid

• Joint federal/state program helps pay medical
  costs for some individuals with limited income
  and resources
• Dual-eligibles Persons eligible for both
  Medicare and Medicaid most health costs are
  covered
• Programs may cover services not fully covered by
  Medicare, e.g., nursing home and home health care
• State Medical Assistance (Medicaid) office
  responsible for determining eligibility and
  enrollment.

Refer to H-8
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2. Medicare Savings Programs

• Helps pay Medicare Premiums and, in some cases,
  Medicare Part A and B deductibles and
  co-insurance.
• Persons eligible for Medicare Savings Programs
  must have Medicare Part A and have limited
  resources set annually by Medicare
• State Medical Assistance (Medicaid) office
  responsible for determining eligibility and
  enrollment.

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3. Programs of All-Inclusive Care for
the Elderly (PACE)

• Combines medical, social, and long-term care
  services for frail elderly people who live in and
  get health care in the community
• Provides all medically necessary services and
  prescription drugs may prove a better choice
  than care through a nursing home
• State Medical Assistance (Medicaid) office
  responsible for determining eligibility and
  enrollment.

Note Not all areas have PACE Refer to SMP
Volunteer Manual p. 33 for details
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4. Help with Prescription Drug Costs (Medicare
Extra Help)

• Assists limited-income beneficiaries with
  premiums, deductibles, and co-payments for
  prescription drug plans
• State Pharmacy Assistance Programs (SPAPs)
  available in some states also help with payment
  for prescription drugs.

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5. Supplemental Security Income
(SSI) Benefits

• Monthly amount paid by Social Security to
  individuals with limited income and resources who
  are disabled, blind, or age 65 or older.
• Provide cash to meet basic needs for food,
  clothing, and shelter.
• SSI benefits ? Social Security benefits

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Extra Help for Persons with Limited Income and
Resources

• Five common types of assistance programs
• Medicaid
• Medicare Savings Program
• SSI
• PACE
• Help with Prescription Drug Costs
• Can you describe them?
• On H-9, match the type of assistance program with
  its description

Refer to H-9
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Resources for Beneficiaries

• Who can help with Medicare questions?
• SHIP
• 1-800-MEDICARE
• Social Security
• Web sites
• www.MyMedicare.gov -sign up for own personal
  account
• www.Medicare.gov -Consumer Web site for
  information about Medicare
• Materials
• My Medicare and You Handbook (www.Medicare.gov)
• Personal Health Care Journal (PHCJ)Provided by
  local SMP

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Self-CheckChapter 2

• Turn to H-10 and take the self-check inventory to
  assess how much youve learned about Chapter 2
  content.
• Refer to the SMP Volunteer Manual to help you
  find the answers.
• When you have finished the self-check, your
  workshop facilitator will provide you
  with the answer key.

Refer to H-10
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Your Thorough Understanding of Medicare
will help you to prevent,
detect, and report
Medicare fraud and abuse
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Chapter 2 Wrap-up
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