Welcome to Medicare

1
Welcome to Medicare
2

• Jon Langmead
• Centers for Medicare and Medicaid Services
• Office of External Affairs
• Philadelphia Regional Office
• jon.langmead_at_cms.hhs.gov
• 215-861-4174

3
Goals

• Learn the basics of Medicare coverage
• Discuss critical dates for Prescription Drug
  Plans and Medicare Advantage Plans
• Learn about the Low Income Subsidy
• Find out how you or the people you work with can
  get help with Medicare

4
What is CMS and Medicare?
5
Centers for Medicare and Medicaid Services

• Federal Agency - Division of DHHS
• www.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 for
• People 65 years of age and older
• People under age 65 with certain disabilities
• People 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
CMS AOA FDA HRSA IHS NIH SAMHSA CDC
BOI VDA SMP AOA 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, PPO
• Medicare Part D Prescription Plan
• Employer Retirement Plan
• DMAS
• TRICARE

11
Medicare Parts A and B
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Applying for Medicare

• Initial Enrollment Period
• 8 month period around 65th birthday
• Enrollment automatically occurs at 65 if
  beneficiary is receiving Social Security or
  Railroad Retirement benefits

13
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 A

• Most people dont pay a monthly premium for Part
  A
• People with less than 10 years of
  Medicare-covered work
• Can still get Part A
• Will pay a premium
• For information about Part A eligibility
• Call Social Security Administration
• 1-800-772-1213
• TTY users call 1-800-325-0778

16
Part A Helps Pay for

• Hospital inpatient care
• Skilled nursing facility (SNF) care
• Home health care
• Hospice care
• Blood

17
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 pay
• Days 1 60 1,068 deductible and no co-payment
• Days 61 90 267 co-payment per day
• Each 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
• 0
• A 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

20
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 B

• You choose whether or not to enroll in Part B
• 2009 Monthly premium 96.40
• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)

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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
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Paying the Part B Premium
Introduction

• Taken out of monthly payments
• Social Security
• Railroad retirement
• Federal government retirement
• For information about premiums
• Call SSA, RRB, or Office of Personnel Management
• If no monthly payments
• Billed every 3 months
• Medicare Easy Pay

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25
Paying for Part B Services

• In Original Medicare you pay
• Yearly deductible (135 in 2009)
• 20 coinsurance for most services
• 50 for most outpatient mental health
• Some 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 Claims
• Quarterly Statements
• MyMedicare.gov

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Medigap

• Health insurance policy
• Sold by private insurance companies
• Must 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

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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
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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

• Travel
• Medigap and Original Medicare
• Delaying Enrollment in B

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Key Things to Remember

• Part B IEP
• Variety of ways to receive coverage

34
Exercise
1. The Centers for Medicaid Medicaid Services
is responsible for enrolling most people in
Medicare.

1. True
2. False

35
Exercise

• 2. Most people receive Part A premium free.

1. True
2. False

36
Exercise

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

1. True
2. 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
41
Medicare Advantage Plans

• Medicare Part C

42
How Medicare Advantage Plans Work

• Usually get all Part A and B services through
  plan
• May have to use the plans providers
• May get extra benefits
• Vision, hearing, dental services
• Prescription drug coverage
• Still in Medicare program
• Get all Part A and Part B services
• Have Medicare rights and protections

43
Medicare Advantage Plans

• Health Maintenance Organization (HMO) Plans
• Some 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

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Other Medicare Plans

• Medicare Cost Plans
• Demonstrations/Pilot Programs
• Programs of All-inclusive Care for the Elderly
  (PACE)

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Eligibility for Medicare Advantage

• Live in plans service area
• Have Medicare Part A and Part B
• Continue to pay Part B premium
• May also pay monthly premium to plan
• Dont have ESRD at enrollment
• Some 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

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MA Open Enrollment Period Limits MA Open Enrollment Period Limits MA Open Enrollment Period Limits
If 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
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Medicare Prescription Drug Plans

• Medicare Part D

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Medicare Prescription Drug Coverage

• Coverage began January 1, 2006
• All people with Medicare can join a plan
• Provided through
• Medicare Prescription Drug Plans
• Medicare Advantage and other Medicare plans
• Some 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 covered
• Test 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 medications
• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments
• For epilepsy and other conditions
• Immunosuppressants

52
Access to Part D Covered Drugs

• Plans can manage access to covered drugs
• Tiers
• Prior authorization
• Step therapy
• Quantity limits
• Plans must have processes in place
• Members must be provided all prescription
  medications determined to be medically necessary
• Request 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 drugs
• Tiers
• Prior authorization
• Step therapy
• Quantity limits
• Plans must have processes in place
• Members must be provided all prescription
  medications determined to be medically necessary
• Request 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 months
• Starts 3 months before month eligible for
  Medicare
• Annual Coordinated Election Period (AEP)
• November 15 through December 31 each year
• Can 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 through
• Formularies
• Prior authorization
• Step therapy
• Quantity limits

59
Medicare Drug Plan Costs

• Monthly premium
• Varies by plan
• Some plans have no premium
• Possible deductible
• No more than 275 in 2009
• Copayments or coinsurance
• May 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 costs
• Begins after 2,700 in total drug costs
• Initial coverage limit
• Continues until out-of-pocket costs total 4,350
• May start earlier in some plans
• After gap, pay 5 or small copayment
• Catastrophic coverage

62
Late Enrollment Penalty

• If you wait to enroll
• Additional 1 of national base premium for every
  month eligible but not enrolled
• Must 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.

1. True
2. False

64
Exercise

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

1. True
2. 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.

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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 deductibles
• Have small or no copayments
• Those with slightly higher income and resources
• Have a reduced deductible
• Pay a little more out of pocket
• No coverage gap for people who qualify for LIS

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How People Qualify for Extra Help
People with Medicare and Basis Data Source Changes During the Year
Medicaid benefits Full Medicaid benefits Medicare Savings Program Automatically qualify States Qualify for a full calendar year Generally only favorable changes will occur
SSI benefits Automatically qualify SSA Qualify for a full calendar year Generally only favorable changes will occur
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 Security

• Four types of redetermination processes
• Initial
• Cyclical or recurring
• Subsidy-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
• Resources
• Up 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
Medicaid

• Federal and state program
• For some people with limited income and resources
• If eligible, most health care costs covered
• Each state decides
• Who is eligible
• How people apply
• Office names vary
• Social Services
• Public Assistance
• Human Services

72
2009 LIS Guidelines
Annual Income
Monthly Income
Resources
73
Medicare and Full Medicaid

• Auto-enrolled in a plan unless
• Already in a Part D plan
• Choose and join own plan
• Call plan or 1-800-MEDICARE to opt out
• Coverage first month person has both Medicare and
  Medicaid
• Will get auto-enrollment letter on yellow paper
• Have a continuous SEP

74
Others Qualified for Extra Help

• Facilitated into a plan unless
• Already in a Part D plan
• Choose and join own plan
• Enrolled in employer/union plan receiving subsidy
• Call plan or 1-800-MEDICARE to opt out
• Coverage effective 2 months after CMS notified
• Will get facilitated enrollment letter on green
  paper
• Have continuous SEP

75
People New to Extra Help

• People can apply for extra help any time
• Can reapply if circumstances change
• People in a Medicare drug plan who later qualify
  for extra help
• Plan is notified
• Plan 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 month
• Plans 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 plan
• Enrolled in MA-PD, if offered

77
Enrollment Notices

• CMS notifies people of enrollment in a PDP
• Auto-enrollment letter on yellow paper
• Facilitated 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 Qualify
• CMS re-establishes eligibility each fall for next
  calendar year
• People 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 Security
• Four 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.

1. True
2. False

82
Exercise

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

1. True
2. False

83
Exercise

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

1. True
2. False

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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 VDAs website http//vda.virginia.go
  v/pdfdocs/SHIP-Regional-Referral.doc
• Email completed form to
• PartDComplaints_RO3_at_cms.hhs.gov
• VICAP Director
• Olivia Claud (if BOI/agent issue involved)

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Summary

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