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Title: Welcome to the MEDICARE TRAINING


1
Welcome to the MEDICARE TRAINING
A Continuing Education Course presented
by UNICARE Life and Health Insurance
Company Course 36387CA020
2
Course Objective
  • To make Medicare coverage, guidelines and
    co-insurance issues easier to understand.
  • To educate you so that you can better assist and
    educate your clients.

3
Benefit to Attendees
  • You will experience a "user-friendly,
    easy-to-understand" approach to an otherwise
    complex subject.
  • You will better understand the senior citizen
    situation when seeking a quality Medicare
    Supplement.

4
Seminar Agenda
  • What is Medicare and Who is Entitled
  • Centers for Medicare and Medicaid Services (CMS)
  • Major Changes in Medicare
  • Who Pays for Medicare
  • Medicare Eligibility and Enrollment
  • Part A -Benefits and Purchasing
  • Part B - Benefits
  • Medicare Assignment and Payment
  • New Preventative Benefits

5
Seminar Agenda (continued)
  • Supplemental Insurance
  • Supplement Open Enrollment
  • Plans A-J
  • Standardization and Medicare Select
  • Remaining Gaps in Medicare
  • Balance Budget Act of 1997
  • Guarantee Issue Provision
  • New Health Care Options

6

History of Medicare
  • Through out history there have been many
    significant events that led to the enactment of
    Medicare.
  • Medicare is the result of many attempts by union
    groups, congress and presidents to implement
    socialized medicine in the United States.
  • Most efforts to block socialized medicine came
    from medical groups and hospital organizations

7
What is Medicare and Who is Entitled?
  • Medicare is federal health program for the aged
    and disabled
  • It was established as part of the Social Security
    Act of 1965
  • Medicare was introduced in 1966, when only 50of
    the nations elderly population had any health
    insurance.
  • Today, only about 1 of the elderly are uninsured.

8

What is Medicare and Who is Entitled?
  • When first implemented in 1966 Medicare covered
    19 million beneficiaries nation wide
  • Medicare originally covered only most people age
    65 and older
  • In 1999 Medicare covered about 39 million
    enrollees at an annual cost of about 213 billion
  • The average calendar year cost was about 5500.
    per enrollee

9
What is Medicare and Who is Entitled?
  • Medicare expanded in 1973 to cover persons who
    were entitled to Social Security or Railroad
    Retirement disability for at least 24 months and
    persons with end-stage renal disease requiring
    continuing kidney dialysis or a kidney
    transplant. (End-stage renal disease now 6
    months)

10
Health Care Financing Administration
  • In 1977, the Health Care Finance Administration
    was established under the Department of Health
    and Human Services to administer the Medicare
    program.
  • In 2001 (HCFA) name was changed to Centers for
    Medicare Medicaid Services

11
Centers for Medicare Medicaid Services
  • (CMS) is the federal agency within the Department
    of Health and Human Services that administers
    Medicare and regulates the Senior Risk (HMO)
    Industry
  • (CMS) responsibilities for Medicare include
    formulation of policy and guidelines, contract
    oversight and operations, maintenance and review
    of utilization records and the general financing
    of Medicare

12
Major Changes in Medicare
  • Part A
  • Prospective Payment/DRGs for Hospital Care
  • Medicare-Approved HMOs
  • Part B
  • Physicians Assignment
  • Medicare Catastrophic Coverage Act
  • Passed in 1988, Repealed 1989.
  • Home Health Care adopts DRGs

13
Who Pays For Medicare?
  • Medicare Part A is financed through mandatory
    payroll deduction (FICA tax).
  • The FICA tax is 1.45 of earnings (paid by both
    the employee and employer), and 2.9 for
    self-employed persons. This tax is paid on all
    covered wages and self-employed income without a
    limit

14
Who Pays For Medicare?
  • Medicare beneficiaries also contribute in part by
    paying deductibles, coinsurance and premiums.
  • For those people who are eligible due to age or
    medical conditions, but have not paid into Social
    Security, Medicare PART A is available at a
    premium.

15
Who Pays For Medicare?
  • For most people, the monthly premium for Hospital
    PART A is 319, if they have paid FICA tax for 30
    to 39 quarters the monthly premium is reduced to
    175.

16
Who Pays For Medicare?
  • Medicare PART B is financed through
  • monthly premiums paid by beneficiaries these
    premiums cover about 25 of expenditures
  • monthly premium is 54.00
  • contributions from the Federal Governments
    general fund.

17
Medicare Eligibility
  • To be eligible for Medicare, you
  • or your spouse must have worked for at least ten
    years in Medicare covered employment.
  • must be 65 years of age and a citizen or
    permanent resident of the United States.
  • or a person younger than 65 with a disability or
    a chronic kidney disease.

18
Medicare Enrollment
  • Automatic Enrollment
  • If already getting Social Security benefits when
    you turn 65, you will automatically be enrolled
    in Medicare Parts A and B.
  • You will receive your card about three months
    before your 65th birthday.

19
Medicare Enrollment
  • Automatic Enrollment (continued)
  • If disabled, you will automatically get a
    Medicare card in the mail after receiving Social
    Security Benefits for 24 months.

20
Medicare Enrollment
  • Applying for Medicare
  • If not receiving Social Security benefits, you
    must apply by contacting any Social Security
    Administration office three months prior to your
    65th birthday.

21
Medicare Enrollment
  • Initial Enrollment Period
  • Seven months, starting 3 months before the month
    in which you turn 65. If you do not enroll
    during this period, you must wait until the next
    general enrollment period.
  • General Enrollment Period
  • January 1st to March 31st each year
  • Your Medicare coverage will be effective the
    following July 1st.

22
Medicare Enrollment
  • Late Enrollment Consequences
  • If you wait 12 months or more to enroll and you
    do not have group health insurance as a result of
    your or your spouses current employment, Part B
    premiums increase 10 for each 12 months that you
    do not enroll.
  • If you have to pay a premium for Part A,
  • the cost increases is limited to10
  • no matter how late you enroll.

23
Medicare Enrollment
  • Extenuating Circumstances
  • You can delay Part B enrollment if
  • you are over 65 and have group health insurance
    through you or your spouses current employment,
    or...
  • you are disabled and have group health insurance
    through you or your spouses current employment.

24
Medicare Enrollment
  • Extenuating Circumstances (continued)
  • You may enroll while you are covered by a group
    health plan or wait till your group coverage
    ends.
  • A special 8-month enrollment period begins the
    month your coverage ends.
  • If you do not enroll by the end of this period,
    you will have to wait until the Medicares next
    general enrollment period.

25
What Is a Medicare Card?
  • A Medicare Card is issued to every Medicare
    Beneficiary
  • Card shows name of beneficiary
  • Card shows Medicare claim number
  • Card also shows if the beneficiary has Hospital
    (Part A) and Medical (Part B) insurance, as well
    as the effective dates of coverage.

26
Health Insurance Claim Number
  • Claim number usually is the beneficiaries Social
    Security number followed by an A
  • If beneficiary is receiving benefits through
    their spouse, the claim number would be the
    spouses Social Security number followed by a B.
  • If the beneficiary is receiving benefits through
    a deceased spouse the card would have the
    spouses Social Security number followed by a D

27
MEDICARE BENEFITS
28
Medicare consists of two parts
  • Hospital Insurance protection - PART A
  • Medical Insurance protection - PART B

29
MEDICARE BENEFITSPART A
30
Medicare PART A provides institutional care,
including
  • PART A
  • Medicare helps pay for
  • care in a hospital
  • skilled nursing facility
  • home health care
  • hospice care

31
Part A Benefits
  • Benefit Period
  • Coverage is measured in a Benefit Period which
    begins the day you are admitted to a hospital and
    ends when you have been out of a hospital or
    skilled nursing facility for 60 consecutive days.
  • If you go back to the hospital after 60 days a
    new benefit period starts
  • There is no limit on the number of benefit
    periods you can have in a year.

32
Part A Hospital Covered Services
  • Semi-private room and board
  • General nursing care
  • Operating and recovery room
  • Intensive care
  • Inpatient prescription drugs
  • Lab and X-Ray services
  • All other medical necessary services and supplies
    provided in the hospital.

33
Part A Hospital Benefits
  • For each benefit period you pay
  • Day 1 through 60 - Medicare pays all covered
    costs except a 812 in patient hospital
    deductible. Hospital deductible must be met each
    benefit period.
  • Day 61 through 90 - Medicare pays all covered
    costs except 203 per day coinsurance.

34
Part A Hospital Benefits
  • Day 91 through 150 Lifetime Reserve Days.
    Medicare pays all covered costs except 406 per
    day.
  • The 60 lifetime reserve days never renew.
  • Beyond 151 days Medicare pays nothing

35
Part A Skilled Nursing Facility
  • A skilled nursing facility is different from a
    nursing home. It is a special kind of facility
    that primarily furnishes skilled and
    rehabilitation services.
  • It may be a separate facility or a distinct part
    of another facility such as a hospital.

36
Part A Skilled Nursing Facility
  • Qualifications
  • You require daily skilled care, which can only
    be provided on an inpatient
    basis
  • You must be hospitalized for at least 3
    consecutive days
  • Be admitted for the same condition for which you
    were hospitalized
  • Be admitted within 30 days of your discharge from
    the hospital
  • Certified as medically necessary

37
Part A Skilled Nursing Facility
  • Medicare will help pay for this care for up to
    100 days per benefit period...
  • Day 1 through 20 - Medicare pays all covered
    costs.
  • Day 21 through 100 - Medicare pays all covered
    costs except 99 per day.
  • Day 101 - you pay full cost.

38
Part A Home Health Care
  • Medicare will pay the full cost of medically
    necessary home health care visits provided by a
    Medicare approved home health care agency
  • A home health agency is a public or private
    agency that provides skilled nursing care,
    physical therapy speech therapy and other
    therapeutic services

39
Part A Home Health Care
  • Qualifications
  • You must be hospitalize for at least 3
    consecutive days.
  • Home health services must be initiated within 14
    days of discharge from the hospital or skilled
    nursing home.
  • Finding of Medical Necessity and prescribed by
    physician.

40
Part A Home Health Care
  • Qualifications
  • Patient is receiving intermittent skilled nursing
    care, physical therapy or speech therapy.
  • Patient is confined to their home.
  • Care is not primarily custodial.

41
Part A Home Health Services Cover
  • Part-time or intermittent skilled nursing care
  • Part-time or intermittent home health aide
    services
  • Physical therapy, speech therapy, occupational
    therapy
  • Medicare Social Services
  • Durable medical equipment has a 20 coinsurance

42
Part A Home Health Care Benefits
  • The first 100 home health visits are financed
    under Part A as post institutional home health
    services.
  • If home health not initiated within 14 days
    benefits are covered under Part B.

43
Part A Home Health Care Benefits
  • If all 100 visits are exhausted under Part A then
    Part B finances home health care visits.
  • If you do not have a qualifying hospital stay
    then all home health care is financed by Part B
    without a visit limit.

44
Custodial Care
  • Medicare will NOT cover care in a skilled nursing
    facility or pay home health benefits if the care
    is primarily custodial - as defined by Medicare

45
Part A Hospice Care
  • Medicare pays for hospice care if you are
    terminally ill with a life expectancy of 6 months
    or less and you choose to receive it, instead of
    the standard Medicare benefits for your illness.
  • If you choose hospice care and require treatment
    for an illness other than a terminal condition,
    standard Medicare benefits apply.

46
Part AHospice Care
  • 100 Medicare payments for
  • Physicians services
  • Nursing care
  • Medical appliances and supplies
  • Physical, occupational and speech therapy
  • Dietary and social counseling
  • Home health aide and homemaker services
  • Unlimited benefit period.

47
Part A Hospice Care
  • Nearly 100 Medicare payments for
  • Prescription drugs for pain and symptom relief
    (5 but not to exceed 5 for each prescription)
  • Respite care for care givers
    (cost of about 5 per day)

48
MEDICARE BENEFITS PART B
49
Part B Benefits
  • Helps pay doctor bills and outpatient hospital
    care.
  • The monthly premium is 54.00, deducted from your
    Social Security, or Civil Service Retirement
    check.
  • If not receiving checks, they pay the premium
    directly to the Government usually on a quarterly
    basis.

50
Part B Covered Services
  • Doctors services
  • Outpatient hospital services
  • Ambulance services
  • Durable medical equipment
  • Lab, X-ray and radiation therapy
  • Other health-related services

51
Part B Physician Services
  • Part B Deductible and Coinsurance
  • you must pay the first 100 each year of the
    charges approved by Medicare.
  • After the deductible has been met, Medicare will
    pay 80 of Medicare-approved charges.
  • Outpatient mental health services are covered at
    50 of Medicare-approved charges.

52
New Preventive Benefits
  • New Medicare-covered benefits for 1998 edition
  • Yearly mammogram and pap smear, including pelvic
    and breast exam, for which there is no Part B
    deductible (effective 1/1/98)
  • Diabetes glucose monitoring and diabetes
    education for which there is no Part B deductible
    (effective 7/1/98)

53
New Preventive Benefits
  • New Medicare-covered benefits for 1998 edition
  • Colon cancer screening (effective 1/1/98)
  • Bone mass measurement (effective 7/1/98)
  • Flu and pneumococcal pneumonia shots are covered
    100 if the physician accepts assignment.

54
Part B Benefit Limits
  • Therapeutic shoes - once a year.
  • Durable medical equipment - must be prescribed by
    a doctor for use at home and be supplied by a
    Medicare-approved supplier.
  • Ambulance services - must meet Medicare
    requirements.

55
Part B Medicare Assignment
  • Medicare has a fee schedule that lists the dollar
    amount that Medicare considers to be the
    reasonable charge for each of the services
    provided by a physician.
  • Physicians that accept assignment are physicians
    that accept these fee schedules as full payment.

56
Part B Medicare Assignment
  • If a physician accepts Medicare assignment as
    payment in full, Medicare pays 80 of allowable
    charges to doctor.
  • Your co-payment will never be more than
  • 20 of charges.

57
Part B Medicare Assignment
  • If physician does not accept assignment
  • they may charge up to an additional 15 above the
    Medicare approved amount
  • You owe doctor the 20 of the approved charges
    PLUS excess charges of up to15 of the original
    Medicare approved amount

58
Lets ReviewThe Gaps In Medicare
59
Gaps In Hospital Part A
  • 812 hospital deductible for the first 60 days
  • 203 daily coinsurance for days 61 through 90
  • 406 daily coinsurance for days 91 through 150
    (lifetime reserve days)
  • All cost after 150 in the hospital
  • First 3 pints of blood

60
Gaps In Hospital Part A
  • Private hospital room unless medically necessary
  • Private duty nursing
  • Personal convenience items such as telephone or
    television in your room.
  • For care received outside the United States
    even if an emergency

61
Gaps In Skilled Nursing
  • 101.50 daily coinsurance for days 21 through 100
  • All costs after 100 days
  • All cost for care that is less than that of
    skilled care. (intermediate and custodial care)
  • The first 3 pints of blood

62
Gaps In Skilled Nursing
  • All costs if you were not transferred to a
    skilled nursing facility in a timely manner after
    a qualifying hospital stay
  • Personal convenience items that you request, such
    as a television or telephone in your room
  • Private duty nursing

63
Gaps In Home Health Care
  • 24-hour nursing care at home
  • Self-administered drugs and medications
  • Meals delivered to home
  • Homemaker services
  • Blood transfusions
  • 20 for durable medical equipment

64
Gaps In Medical Part B
  • 100 annual deductible
  • The 20 coinsurance
  • The permissible excess charges above Medicare
    approved amount (15)
  • 50 of the Medicare approved amounts for most
    outpatient mental health treatment
  • Charges for most self-administered prescription
    drugs

65
Gaps In Medical Part B
  • Homemaker services that are primarily to assist
    you in meeting personal care or house keeping
    needs
  • Most dental care and dentures.
  • Charges for acupuncture treatment
  • All charges for routine eye examinations and
    eyeglasses except prosthetic lenses after
    cataract surgery

66
Gaps In Medical Part B
  • Hearing aids or routine hearing loss examinations
  • All charges for care outside the United States
    (except limited in Mexico and Canada)
  • Charges for routine foot care except when a
    medical condition affecting the lower limbs (such
    as diabetes) requires care by a medical
    professional
  • The cost of the first 3 pints of blood

67
Standardization andMedicare Supplement
Medigap Policies
68
Standardization
  • In 1992 the National Association of Insurance
    Commissioners in conjunction with Health Care
    Financing Administration formulated 10 standard
    Medicare Supplements Plans that could be sold to
    the public.
  • These standardized plans must have a letter
    designation of A through J

69
Standardization
  • Benefits do not vary by company an A Plan is a A
    Plan, a C Plan is a C Plan, F is a F and so on.
    If they have the same letter designation the
    benefits are identical.
  • Plans were designed to make the purchasing of a
    Medigap policy easier for senior citizens to
    understand
  • Standardization is nationwide, Plans do not vary
    from state to state.

70
Standardization
Medicare Select is a type of standardized plan
  • The only difference between Medicare Select and
    Standard plans is the insurance company has
    specific hospitals and in some cases specific
    doctors in order to be eligible for full
    benefits.
  • Full benefits are paid in case of emergency
  • Generally has a lower premium in comparison to
    other Medigap policies

71
Standardization
  • Every company selling Medicare
    Supplements must offer Plan A.
  • Companys may then offer any of the remaining
    plans (B through J)

72
Standard Plan A The Basic Benefits included in
all plans
  • Part A coinsurance 203 per day for the 61st
    through the 90th day of hospitalization
  • Part A coinsurance 406 per day for the 91st
    through 150th day (lifetime deserve days)
  • After Medicare hospital benefits are exhausted,
    covers 100 of hospital expenses for an extra 365
    days

73
Standard Plan A The Basic Benefits included in
all plans
  • Coverage under parts A and B for the cost of the
    first 3 pints of blood.
  • Coverage for the coinsurance amount for Part B
    services (20 of approved amount for physicians
    services and 50 of approved amount for
    outpatient mental health services) after the 100
    annual deductible is met

74
Standard Plan B
  • Includes Basic Plan A Benefits
  • Pays Medicare Part A Inpatient Hospital
    Deductible (812 per 60 day benefit period)

75
Standard Plan C
  • Includes Basic Plan A Benefits
  • Part A Deductible (812)
  • Coverage for Skilled Nursing Facility Coinsurance
    amount (101.50 per day for days 21 through 100
    per benefit period)
  • Coverage for the Medicare Part B 100 Deductible
  • Foreign Travel Emergency 80 coverage after a
    250 deductible with a lifetime maximum of
    50,000

76
Standard Plan D
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Foreign Travel Emergency
  • Coverage for At Home Recovery. The at home
    recovery benefit pays up to 1,600 per year for
    short-term, at home assistance with activities of
    daily living (like bathing, dressing, personal
    hygiene, etc.) for those recovering from an
    illness, injury or surgery

77
Standard Plan E
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Foreign Travel Emergency
  • Coverage for Preventive Medical Care. The
    preventive medical care benefit pays up to 120
    per year for things like a physical examination,
    serum cholesterol screening, hearing tests,
    diabetes screening and thyroid function tests

78
Standard Plan F
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Part B Deductible (100)
  • Foreign Travel Emergency
  • Coverage for 100 of Medicare Part B Excess
    Charges (maximum of 15 above approved amount)

79
Standard Plan G
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Foreign Travel Emergency
  • Coverage for At Home Recovery. (1,600 per year)
  • Coverage for 80 of Medicare Part B Excess
    Charges (maximum of 15 above approved amount)

80
Standard Plan H
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Foreign Travel Emergency
  • Basic Drug Benefit after a 250 annual deductible
    plan pays 50 of prescriptions with a maximum
    annual benefit of 1250

81
Standard Plan I
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Foreign Travel Emergency
  • Coverage for At Home Recovery. (1,600 per year)
  • 100 of Medicare Part B Excess Charges
  • Basic Drug Benefit (1250 Limit)

82
Standard Plan J
  • Includes Basic Plan A Benefits
  • Part A Deductible(812)
  • Skilled Nursing Coinsurance (101.50)
  • Part B Deductible (100)
  • 100 of Medicare Part B Excess Charges
  • Foreign Travel Emergency

83
Standard Plan J
  • Includes Basic Plan A Benefits
  • Coverage for At Home Recovery. (1,600 per year)
  • Preventive Care (120)
  • Extended Drug Benefit after a 250. annual
    deductible plan pays 50 of prescriptions with a
    maximum annual benefit of 3000.

84
Medicare Open Enrollment
  • State and Federal laws guarantee that for a
    period of 6 months from the date you are enrolled
    in Medicare Part B and age 65 or older, you have
    a right to buy the Medigap policy of your choice
    regardless of any health problems you may have.

85
Medicare Open Enrollment
  • During this 6 month period you may purchase any
    Medigap sold by any insurer selling Medigap
    insurance in your state.
  • The company cannot deny coverage, place wavers or
    charge you additional premiums because of your
    health history

86
Medicare Open Enrollment
  • The company can, however, impose as much as 6
    months waiting period for preexisting conditions
  • Preexisting conditions are generally health
    problems that you have seen a physician within
    the last 6 months before the policy effective
    date.

87
Balance Budget Act of 1997
  • Guaranteed issue Medicare supplement protection
    when other health insurance ends or is lost.
    Effective July 1, 1998
  • To qualify you must apply for a new policy within
    63 days of loosing your other health coverage

88
Balance Budget Act of 1997You qualify if
  • You were enrolled in an employer group health
    plan with benefits that supplemented your
    Medicare benefits and the plan stopped providing
    those benefits.

89
Balance Budget Act of 1997You qualify if
  • You were enrolled in a Medicare Health
    Maintenance Organization or Medicare SELECT
    policy and your enrollment ended when you moved
    outside of the plans service area, or your plans
    contract with Medicare ended.

90
Balance Budget Act of 1997You qualify if
  • You were enrolled in a Medigap policy and
    coverage stopped because of the insolvency of the
    company, because of other involuntary termination
    of coverage or the company violated or
    misrepresented a provision of your policy.

91
Balance Budget Act of 1997
  • The guarantee applies to you if
  • You had a Medigap policy and dropped it to enroll
    in a Medicare HMO or care SELECT policy for the
    first time. You then decided to disenroll from
    the Medicare HMO or Medicare SELECT policy within
    12 months of first enrolling.

92
Balance Budget Act of 1997
  • Under this guarantee, companies selling Medicare
    supplemental insurance must sell you one of 4
    guaranteed issue Medigap policies, Medicare
    Supplement Plans A, B, C or F.
  • Medigap companies may not deny you coverage or
    charge you additional premium because of any
    health conditions.

93
Balance Budget Act of 1997
  • Creates new health care options called Medicare
    Choice
  • Health Maintenance Organization (HMO)
  • Health Maintenance Organizations with Point of
    Service options (HMOs With POS)
  • Provider Sponsored Organizations (PSOs)
  • Preferred Provider Organizations (PPOs)

94
Balance Budget Act of 1997
  • Creates new health care options called Medicare
    Choice
  • Private Fee-for-Service Plan
  • Medicare Medical Savings Account (MSA)
  • Religious Fraternal Benefit Society Plans
  • High Deductible Plans F and J
    (1500 deductible)

95
Thank you for attending today's seminar on
Medicare!
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