2004 REACH National Medicare Training Program

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2004 REACH National Medicare Training Program

Speaker NameGroup Name

Date

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All About Medicare in 2004

Module 1

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Session Topics

• Medicare overview• Original Medicare Plan• Medicare Part A• Medicare Part B• Medicare Advantage plans

– Formerly Medicare + Choice plans

• Medicare Savings Programs• Key concepts

MMA

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Session Topics

• Medicare overview• Original Medicare Plan• Medicare Part A• Medicare Part B• Medicare Advantage plans• Medicare Savings Plans• Key concepts

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CMS(Centers for Medicare & Medicaid Services)

• Federal agency within HHS

• Administers Medicare, Medicaid, SCHIP

• Spends over $360 billion a year

• Establishes policies for paying health care providers

• Conducts research

• Assesses quality

Overview

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Medicare

• A health insurance program for– People 65 years of age and older– Some people with disabilities– People with ESRD

• Administered by CMS

• Enrollment handled by SSA or RRB

• Prescription drug coverage

Overview

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Prescription Drug Coverage

• Medicare-approved drug discount card

• Prescription drug benefit in 2006

• Medicare Advantage program

Overview

MMA

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Applying for Medicare

• Apply 3 months before age 65– Need not be retired

• Automatically enrolled if receiving Social Security or Railroad Retirement Benefits

Overview

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Medicare Health Plan Choices

• Original Medicare Plan

• Medicare Advantage plans– Medicare Managed Care plans

• Some have POS option

– Medicare Preferred Provide Organization plans– Medicare Private Fee-for-Service plans– Medicare Specialty plans

Overview

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Some Interesting Statistics

• 2002– Medicare paid 247 billion dollars

• 2003– Over 41 million persons in Medicare

• 2030– Projected 70.5 million persons over 65

• Almost double in only 30 years

Overview

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Session Topics

Medicare overview

• Original Medicare Plan• Medicare Part A• Medicare Part B• Medicare Advantage plans• Medicare Savings Programs• Key concepts

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Medicare

Medicare has two parts

Part AHospital Insurance

Part BMedical Insurance

Original Medicare

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Paying for Medicare Part A

• Most people receive Part A premium free

• People with < 10 years of Medicare-covered employment will pay a Part A premium

• For information, call SSA – 1-800-772-1213– 1-800-325-0778 for TTY users

Original Medicare

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Enrolling in Medicare Part B

• Initial Enrollment Period– 7 months beginning 3 months before age 65

• General Enrollment Period– January 1 through March 31 each year– Coverage effective July 1– Premium increases 10% for each 12-month period

you were eligible but did not enroll• You carry this increase for the rest of your life• Limited exceptions

Original Medicare

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Enrolling in Medicare Part B

• Special Enrollment Period– Sign up within 8 months of the end of employer

or union group health plan coverage– No increased premium

• For questions, or to enroll, call SSA or RRB

Original Medicare

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Paying for Medicare Part B

• You pay– Monthly Medicare Part B premium

• $66.60 in 2004

– $100 per year deductible– 20% coinsurance for most services– Some co-payments

• Some programs may help

Original Medicare

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Paying the Part B Premium

• Taken out of your monthly payment– Social Security– Railroad Retirement– Office of Personnel Management (OPM)

• For information about premiums– Call SSA, RRB or OPM

• May be billed every 3 months• Medicare Easy Pay

Original Medicare

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The Original Medicare Plan

• Go to any provider that accepts Medicare

• Part A is premium free for most people

• You pay Medicare Part B premium

• You pay deductibles

• You pay coinsurance

Original Medicare

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Your Medicare Card(front)

Jane Doe

Original Medicare

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Your Medicare Card(back)

Original Medicare

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Medicare Claims Contractors

• Medicare Carrier

• Durable Medical Equipment Regional Carrier

• Fiscal Intermediary

• Regional Home Health Intermediary

Original Medicare

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Other Insurance

• Employee coverage

• Retiree coverage

• Medigap insurance (Medicare Supplement Insurance)

Original Medicare

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Medigap

• Fills in gaps in the Original Medicare plan• Must follow federal and state laws• Ten standardized Medigap plans (A-J) in

most states– Not Massachusetts, Minnesota, or Wisconsin

• May get little benefit from Medigap if in Medicare Advantage plan

• Will be changes in 2006

Original Medicare

MMA

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Buying Medigap

• Company must sell you a Medigap policy– Within 6 months of when you turn 65 and are

enrolled in Part B– If you lose certain kinds of health coverage

through no fault of your own– If you leave your Medicare Advantage plan

• Under certain circumstances

Original Medicare

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Your Medigap Rights

• Insurance company cannot– Deny you coverage– Place conditions on your policy– Charge you more because of health problems

• Different rules for those < 65

• You may buy a policy any time the company will sell you one

Original Medicare

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Introducing Ben…

You can call me Ben.

But, I don’t like the

nickname Benny.

Hi!I’m Ben E.

Ficiary.

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What does Ben know….

Which government agency is directly responsible for administering the Medicare program?

A. Social Security AdministrationB. Department of Health & Human ServicesC. Centers for Medicare & Medicaid

ServicesD. Centers for Disease Control

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Ben says…

C. Centers for Medicare & Medicaid Services

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Session Topics

Medicare overviewOriginal Medicare Plan

• Medicare Part A• Medicare Part B• Medicare Advantage plans• Medicare Savings Programs• Key concepts

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Medicare Part A Helps Pay for

• Hospital stays

• Skilled nursing facility (SNF) care

• Home health care

• Hospice care

• Blood

• For information, call 1-800-MEDICARE

Part A

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Hospital Stays

• Covered services– Semi-private room– Meals– General nursing– Other hospital services and supplies

• Includes care in critical access hospitals• 190 days in a lifetime for inpatient mental

health

Part A

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A Benefit Period

• Medicare’s measure of hospital and SNF services

• Begins day admitted to hospital

• Ends when you have not received care in a hospital or SNF for 60 days in a row

• You pay deductible for each benefit period

• No limit to the number of benefit periods

Part A

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Paying for Hospital Stays

• For each benefit period in 2004 you pay– A total of $876 for a hospital stay of 1-60 days– $219 per day for days 61-90– $438 per day for days 91-150

• Part of your 60 Lifetime Reserve Days

– All costs for each day beyond 150 days

Part A

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Skilled Nursing Facility Care

• Covered in full for the first 20 days– After a minimum 3-day qualifying hospital stay

• You pay $109.50 per day for days 21-100

• You pay all costs after 100 days

• Does NOT include custodial care

Part A

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Skilled Nursing Facility Care

• Must meet all of the following conditions– Requires daily skilled services– Inpatient in a hospital at least 3 consecutive days – Admitted to SNF within 30 days after leaving

hospital– Care in SNF is for a condition treated in the

hospital– MUST be a Medicare participating SNF

Part A

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Skilled Nursing Facility Coverage

• Semi-private room• Meals• Skilled nursing care• Physical, occupational and speech-language

therapy• Medical social services• Medications, medical supplies/equipment• Ambulance transportation• Dietary counseling

Part A

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Home Health Care

• For as long as you are eligible– Limited hours per day– Limited days per week

• Four conditions– Doctor must make a plan for your care at home– Must need specific skilled services– Must be homebound– HHA must be approved by Medicare

Part A

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Home Health Care

• Covered services– Part-time skilled nursing care– Therapy

• Occupational

• Physical

• Speech-language

– Some home health aide services– Durable medical equipment

Part A

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Paying for Home Health Care

• You pay– Nothing for covered home health care services– 20% of the Medicare-approved amount for

covered durable medical equipment

Part A

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Hospice

• Special care – People who are terminally ill

– Families

• If you probably have less than 6 months to live• Certification required for each “period of care”

– Two 90-day periods

– Unlimited 60-day periods

• Hospice must be Medicare-approved

Part A

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Covered Hospice Services

• Medical equipment and supplies• Drugs for symptom control and pain relief• Respite care in a Medicare-certified facility

– Up to 5 days each time– No limit to number of times

• Home health aide and homemaker services• Social worker services• Dietary counseling• Grief counseling

Part A

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Paying for Hospice Care

• You pay– Copayment up to $5 for outpatient prescription

drugs– 5% for inpatient respite care

• Amount you pay for respite care can change each year

Part A

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What does Ben know….The benefit period for a hospital or SNF stay ends the day the beneficiary

A. Has not received services in a hospital or SNF for 60 days in a row

B. Is discharged from the hospital or skilled nursing facility

C. Is released from his or her doctor’s care related to the hospital or skilled nursing facility stay

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Ben says…

A. Has not received hospital or SNF services for 60 days in a row

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Ben looks at a case study…

Bert was hospitalized for congestive heart failure on April 12, 2004, and was discharged on April 26. He was readmitted to the hospital on May 5, 2004, for an unrelated condition. Is he in a new benefit period? Why or why not?

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Session Topics

Medicare overviewOriginal Medicare PlanMedicare Part A

• Medicare Part B• Medicare Advantage plans• Medicare Savings Programs• Key concepts

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Part B Helps Pay for

• 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

Part B

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Covered Preventive Services

• Bone mass measurement• Colorectal cancer screening• Diabetes services and some supplies• Glaucoma testing• Screening mammogram• Pap test/pelvic exam/clinical breast exam• Prostate cancer screening• Vaccination (shots)

Part B

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New Covered Preventive Services

• Beginning January 2005

• “Welcome to Medicare” physical

• Cardiovascular screening blood tests

• Diabetes screening tests

Part B

MMA

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Part B Also Helps Pay for

• Clinical laboratory services• Home health care• Durable medical equipment (DME)• Outpatient hospital services• Blood • Ambulance service

– If other transportation would endanger your health

Part B

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Assignment

• Agreement between Medicare and physician/supplier– Physician/supplier agrees to accept Medicare-

approved amount as payment in full– You pay coinsurance and deductible

• In some cases physician/supplier must accept assignment– For example, Medicare-covered ambulance service

Part B

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Assignment

• If assignment not accepted– Charges often higher – You pay more– Limit is 15% over approved amount

• Call 1-800-MEDICARE (1-800-633-4227)– Copy of Does Your Doctor or Supplier Accept

Assignment?

Part B

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Private Contracts

• Agreement between you and a doctor

• Medicare will not pay

• Medigap will not pay

• Medicare health plan will not pay

• You will pay charges

• No claim should be submitted

• Cannot be asked to sign in an emergency

Part B

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Therapy Limits

• Limits created by the BBA 1997

• Moratorium effective until 2003

• Moratorium reinstated through 2005

Part B

MMA

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What does Ben know….

Medicare Part B helps cover all of the following EXCEPT:

A. Physical therapyB. Clinical lab servicesC. Doctor’s servicesD. Inpatient mental health services

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Ben says…

D. Inpatient mental health services

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Ben looks at a case study…

Conrad just left the hospital following his recovery from a stroke. He is scheduled to start a physical therapy program next week. Conrad thinks his hospital stay and physical therapy are covered benefits. Is he correct? If so, is it covered under Part A or Part B?

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Ben looks at a case study…Mario is 65 years old and receives Social Security benefits. He is covered by the group health insurance policy provided by his wife’s employer. He wants to wait and enroll in Medicare Part B after his wife retires in 2 years. Will he have to pay an additional 10% for each year he could have been enrolled in Part B and wasn’t?

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Ben looks at a case study…

Robert is enrolled in the Original Medicare Plan and has no other insurance. He had a doctor’s appointment on 5/18/04. The doctor charged $75 (the Medicare-approved amount) for the office visit. Robert has not met any of his $100 Part B deductible. How much will Robert owe for his doctor’s visit?

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Session TopicsMedicare overviewOriginal Medicare PlanMedicare Part AMedicare Part B

• Medicare Advantage plans• Medicare Savings Programs• Key concepts

MMA

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Medicare Advantage Plans

• Medicare Managed Care plans– Some have POS option

• Medicare Preferred Provider Organization plans

• Medicare Private Fee-for-Service plans

• Medicare Specialty plans

Medicare Advantage Plans

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Eligibility

• Entitled to Medicare Part A

• Enrolled in Medicare Part B

• Live in plan’s service area

• Not have ESRD at the time of enrollment (with some exceptions)

Medicare Advantage Plans

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Important Information

• Still in Medicare program

• Continue to pay Medicare Part B premium

• Still have Medicare rights and protections

• Get all regular Medicare-covered services

• May pay additional monthly premium

• May receive additional benefits

Medicare Advantage Plans

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Medicare Managed Care Plans

• Offered by private companies

• Available in certain areas

• Plan can join or leave Medicare each year

• Providers can leave the plan

• Benefits may change each year

• Premiums may change each year

Medicare Advantage Plans

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How Does Managed Care Work?

• Usually go to only certain providers

• Generally need referral to see specialist

• May get extra benefits

• Some plans offer a Point-of-Service option– Can go to doctors and hospitals not on plan's

list

Medicare Advantage Plans

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When Can You Join?

• When you first become eligible for Medicare

• Any time November 15 - December 31

• Any time a plan is allowing new members to join

Medicare Advantage Plans

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Annual Enrollment

• November 15 - December 31– Can choose new plan– New plan starts January 1 (in most cases)– Plan must accept new members

Medicare Advantage Plans

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Continuous Open Enrollment

• Continuous open enrollment through 2005

• You can enroll or disenroll– At any time– For any reason

Medicare Advantage Plans

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What does Ben know….

All of the following are Medicare Advantage plans EXCEPT:

A. Private Fee-for-Service planB. Private ContractC. Managed Care plan

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Ben says…

B. Private Contract

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Ben looks at a case study…

In November 2004, Alan will choose the health plan he wants to join for the coming year. Enrollment in his new plan will begin January 1, 2005. Can Alan change plans on February 1 of that year?

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Session Topics

Medicare overviewOriginal Medicare PlanMedicare Part AMedicare Part BMedicare Advantage plans

• Medicare Savings Programs• Key concepts

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Medicaid

• Federal-State health insurance program– People with lower-income and limited resources– Certain disabled persons

• Eligibility determined by state• Application processes vary

– Social Services– Public Assistance– Human Services

Medicare Savings

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Programs to Help Pay Expenses

• Medicare-approved drug discount card– $600 credit

• Qualified Medicare Beneficiaries (QMBs)• Specified Low-Income Medicare Beneficiaries

(SLMBs)• Qualifying Individuals (QIs)• Qualified Disabled and Working Individuals

(QDWIs)• State-specific programs

Medicare Savings

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How to Apply

• If you think you might qualify– Review guidelines– Collect your personal documents– Get more information

• Call proper local agency

• Call your SHIP

– Complete required paperwork

Medicare Savings

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How to Apply

• Locate the proper agency– Look in phone book– Call 1-800-MEDICARE (1-800-633-4227)– Call your SHIP

• Produce your documents

• Complete the necessary application forms

Medicare Savings

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Session Topics

Medicare overviewOriginal Medicare PlanMedicare Part AMedicare Part BMedicare Advantage plansMedicare Savings Programs

• Key concepts

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Information Channels

• 1-800 MEDICARE

• Medicare & You handbook– Other publications

• www.medicare.gov

• Your local SHIP

Key Concepts

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Key Concepts

• Medicare is a health insurance program

• It is administered by CMS

• You may have choices about how you get your health care

• There are programs to help you with costs

• There are information sources available

Key Concepts

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Thanks for your attention…