MEDICARE

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MEDICARE YOU

• Fitting the Pieces Together

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Introduction

• Sue Brown and Leda Welke, Elder Benefit
  Specialists
• Aging and Disability Resource Center
• 721 Oxford Avenue, Room 1550
• Eau Claire WI 54703
• Email us adrc_at_co.eau-claire.wi.us 
• Call us  715-839-4735, Toll free
   1-888-338-4636 
•  tty use Relay (711)
• Web site http//www.co.eau-claire.wi.us (click
  on ADRC link on home page)
• If a page number follows a particular section in
  this Power Point, it is referring to
  corresponding information in the Medicare You
  2013 book

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MEDICARE

• The federal government healthcare coverage for
  people 65 and older, or, those (if under 65)
  found disabled by the Social Security
  Administration. Eligibility does NOT depend on
  income or assets.
• Medicare year is from January thru December
• If you are already receiving Social Security
  retirement benefit prior to age 65, you will
  receive a Medicare card by mail with your Part A
  Part B start date. You MUST notify Social
  Security if you do NOT want Part B starting at
  that time. (P. 17)
• If you are not receiving Social Security
  retirement benefit, YOU must contact Social
  Security before your 65th birthday. You can
  enroll on-line. (P. 18)

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Medicare Part A hospital/inpatient

• Inpatient hospitalization, skilled nursing
  facility, inpatient psychiatric care (190 day),
  hospice, some home healthcare
• Premium free if you have enough Social Security
  work quarters. If not, you will be assessed a
  premium (p. 24)
• Deductible of 1,184.00 (2013) per benefit period
  (60 days)
• Initial Enrollment period 3 months before, the
  month of, and 3 months after turning 65 (P. 19)

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Medicare Part B - Medical/outpatient

• Doctor visits, Outpatient services, and services
  Part A does not cover
• Enrollment periods (P. 19)
• Initial 3 months before, the month of, 3 months
  after turning 65
• Special enrollment period - when group coverage
  thru employment ends (P. 19)
• General - Between January 1 and March 31 each
  year coverage begins July 1

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Medicare Part B

• May have late enrollment penalty if you do not
  sign up when first eligible AND do not have other
  creditable coverage.
• Monthly premium 104.90 (2013)
• Annual deductible 147.00 (2013) changes every
  year
• Pays approx 80 of approved amount for almost all
  reasonable necessary medical services

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Medicare Part B

• Premiums higher for persons with income over
  85,000/single 170,000/joint
• Premium deducted from Social Security benefit or,
  if not receiving a benefit yet, beneficiary will
  be billed quarterly
• Assistance available for premium payment if
  income/asset guidelines met (P. 99)

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Medicare supplement insurance

• Medicare supplement aka Medigap (P. 64)
• Private secondary health insurance designed to
  fill in the gaps after Original Medicare pays
  according to State and Federal laws
• example deductibles, co-insurance, and
  co-payments
• Costs vary depending on insurance company
  (average between 150 - 300/m)
• Guaranteed renewable for life unless you commit
  fraud or you dont pay the premiums

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Guaranteed issue rights

• Insurance companies are required to accept your
  application for a Medicare supplement policy
• Cant deny you coverage
• Must cover pre-existing conditions
• Cant charge you more for pre-existing, past or
  present health conditions
• GUARANTEED ISSUE RIGHTS 6 month open enrollment
  when Part B first becomes effective, when you
  turn 65 OR 24 months after date of disability
  determination. (disabled persons receive a
  second open enrollment when they turn 65)
• GUARANTEED ISSUE RIGHTS up to 63 days when loss
  of coverage is involuntary, includes
  employer/retiree groups, medical assistance, or
  Medicare Advantage

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MEDICARE SUPPLEMENT COVERAGE

• Basic Benefits
• Covers the 20 gap in coverage after Medicare
  Part B
• Covers co-payments for hospitalizations and
  skilled nursing care
• Additional Inpatient Psychiatric Care (175 days
  lifetime)
• First 3 pints of blood
• Additional 40 home health care visits

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Wisconsin Mandated Benefits

• Applies ONLY to policies purchased in Wisconsin
• Coverage for usual and customary cost of
  non-Medicare covered chiropractic care
• Coverage for 30 days non-Medicare SKILLED
  nursing facility care with no prior
  hospitalization required (per benefit period)
• 120 Preventive Health Care Benefits to cover
  routine services such as physical examinations,
  immunizations, and health screenings

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OPTIONAL BENEFITS

• Part A deductible rider (covers the 1,184.00
  deductible)
• Part B deductible rider (147.00 annual
  deductible)
• Part B excess charges rider (covers the excess
  charges a provider can charge over the approved
  Medicare amount if provider doesnt accept
  Medicare Assignment)

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Optional benefits

• Additional Home Health Care (up to 365 visits per
  year)
• Foreign travel emergency
• New optional benefits (effective June, 2010)
• Part B 100 deductible with co-pays for office
  and ER visits
• Part A 50 deductible (no out-of-pocket maximum)

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TYPES OF MEDICARE SUPPLEMENTS

• Free Standing Traditional Medicare Supplement
  Policies
• Medicare Select Policies (defined network of
  providers)
• Cost-Sharing Supplemental Policies (K L new
  for 2006)
• K Plans share in costs after Medicare at 50
  rate
• L Plans share in costs after Medicare at 25
  rate

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MEDICARE ADVANTAGE PLANS

• What is an Advantage Plan?
• Private Medicare Replacement plans, replace
  original Medicare AB (P. 68)
• Enrollments Periods (must have Parts AB to
  enroll)
• Initial Enrollment 3 months prior, the month
  of, 3 months after starting Medicare
• Open Enrollment October 15 December 7
• Special Enrollment i.e. relocation, trial
  period, loss of group.
• Disenrollment January 1 February 14

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Advantage plans

• Lock-in You will be locked into your plan of
  choice for the calendar year (can only change
  during open enrollment stated above)
• Trial Periods May be allowed to disenroll back
  to Original Medicare during initial 12 months
• No health care questions except for end stage
  renal disease

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TYPES OF ADVANTAGE PLANS

• Private Fee for Service (PFFS)
• Preferred Provider (PPO)
• Managed Care (HMO) (some plans have POS/point of
  service option)
• Special Needs Plans (for persons with chronic
  diseases or for persons on Medical Assistance or
  for persons in institutional settings)
• Medicare Savings Accounts (coverage under an
  Advantage plan once deductible is met Savings
  account with deposited from Medicare. May have
  income tax ramifications)

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PREMIUMS/COSTS ADVANTAGE PLANS

• Must continue to pay the Part B premium
• Premiums vary by plan (range 0 - 286.00 per
  month for plans available in Eau Claire County
  for 2013)
• Medicare pays the Advantage plan a set amount
  every month to cover Medicare services you share
  in the cost with co-pays/co-insurance
• Co-pays for every covered service with most
  Advantage plans
• Maximum out of pocket limits may vary by plan

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ADVANTAGE PLANS

• Plans can change premiums/co-pays, coverage
  options on a yearly basis pending CMS approval
• Plans send Annual Notice of Change each year in
  the fall
• (VERY IMPORTANT)
• Providers may choose to Balance Bill up to 15
  to beneficiaries enrolled in PFFS

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Employee/retiree group health coverage

• Includes coverage thru employer (p. 93)
• Active employee health coverage, retiree
  coverage, COBRA Continuation Coverage, Federal
  Employer Health Benefits
• Each plan has its own premiums/co-pays associated
  with the approved contract purchased by the
  employer
• Contract may change at any time
• May include creditable drug coverage. (ask
  before enrolling in Part D)
• May provide Primary (if actively working and
  number of employees are 20 for 65 and up or
  100 for disabled) OR Secondary coverage to
  Original Medicare

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OTHER SECONDARY HEALTH COVERAGE

• Heath Insurance Risk Sharing Plan (HIRSP)
• Wisconsin HIRSP plan makes insurance available to
  Wisconsin residents who have either (1) lost
  their employer sponsored group health insurance
  OR (2) are unable to find adequate health
  insurance in the private market due to their
  medical condition(s).
• 1-800-828-4777 Web site www.hirsp.org
• Federal high risk pool is a program for people
  who have been without health insurance for at
  least 6 months AND who have a pre-existing
  condition, which prevents them from obtaining
  health insurance in the private market.
• 1-888-253-2698 Web site www.hirsp.org

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MILITARY COVERAGE

• Veterans Benefits (VA facilities only) (P. 94)
• Prescription coverage is creditable
• Does not coordinate with Medicare
• Need to meet priority level of coverage
• May want to purchase additional insurance

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Military coverage

• TRICARE for Life/Champ VA (P. 94)
• Prescription coverage is creditable
• Does coordinate with Medicare
• No additional insurance needed (acts as a
  Medicare supplement)

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MEDICAL ASSISTANCE (MEDICAID)

• Benefits received are dependent on gross income
  and cash assets. Benefits range from full MA to
  help with paying Medicare Part B premiums.
  Apply at county Department of Human Services or
  the Aging and Disability Resource Center.

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PRESCRIPTION COVERAGE OPTIONS

• Medicare Part D Prescription Plan (P. 81)
• Anyone on Medicare is eligible
• Began 1/1/2006
• Enrollments (can only make one selection per
  period)
• Initial Enrollment Period 3 months prior, month
  of, 3 months after starting Medicare
• Open Enrollment Period October 15 thru December
  7
• Special Enrollment Periods for specific
  circumstances

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Part D plan costs

• Costs
• Premiums vary according to plan (15 -
  119.70/month)
• Co-pays vary per drug, per plan, per pharmacy
• Standard plan (P. 85)
• Deductible 0 - 325 (2013)
• 25 of the first 2,970.00 in drug costs
  (initial coverage limit)
• Pay 79 for generic meds and 47.5 for brand name
  meds in the coverage gap up to 6,733.75
• Pay 5 of costs thereafter (catastrophic)

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Costs continued

• May be assessed a penalty if not enrolled in a
  Part D drug plan OR have other creditable drug
  coverage (P. 88)
• For 2013 penalty of months without
  creditable coverage x 0.31
• Enrollees will receive an Annual Notice of Change
  each year in the fall.
• VERY IMPORTANT INFORMATION
• Low Income Subsidy EXTRA HELP (P. 95)
• Assistance available for persons with low
  income/limited resources
• Automatically eligible if on any Medicaid program
• Apply through Social Security

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MEDICARE. GOV HOME PAGE
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SENIORCARE

• Eligible if age 65 and over and Wisconsin
  resident
• Recognized by Medicare as creditable coverage
  for drugs
• Cost 30 (application fee) per person for 12
  months coverage
• Benefits received depends on income, four levels
  of coverage
• Complete application on your own no special
  enrollment period

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OTHER CREDITABLE RX COVERAGE

• Employer/Retiree Groups Prescription coverage
  (check with employer)
• Military/Veterans Prescription coverage
• Will NOT incur penalty with Part D if you have
  creditable RX coverage
• NON-CREDITABLE PRESCRIPTION PROGRAMS
• Discount Programs (Badger RX)
• Canadian/Mexico mail-order
• Pharmaceutical Patient Assistance Programs
• NACO Prescription Discount Card Programs

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MAKING YOUR COVERAGE DECISION

• The decision to purchase insurance is a personal
  choice and should be based on your personal
  health care needs
• There are many options to consider for best
  possible care
• Keep in mind the potential outof-pocket costs if
  insurance decisions are not made in a timely
  manner
• Medigap counselors are available for your
  assistance to help you with possible options
  available to you call 1-800-242-1060 for
  further questions

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• Prepared by
• Vicki Buchholz, Lead Medigap Insurance counselor
  
• Sue Brown and Leda Welke, Elder Benefit
  Specialists