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Medicare 101
First TN Area Agency on Aging & DisabilityLorrie WilsonDaris Morgan
04-26-07 2
Medicare 101
Introduction to Medicare Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs
04-26-07 3
What Is Medicare?
A health insurance program forPeople 65 years of age and olderPeople under age 65 with certain disabilitiesPeople with End-Stage Renal Disease (ESRD)
Administered by Centers for Medicare & Medicaid Services (CMS)
Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB)
Introduction
04-26-07 4
Applying for Medicare
Apply 3 months before age 65Don’t have to be retiredContact the Social Security Administration
Enrollment automatic if receiving Social Security or Railroad Retirement benefits
Introduction
04-26-07 5
Medicare
Medicare Basics
Part AHospital Insurance
Part BMedical Insurance
Prescription Drug Coverage (Part D)
Introduction
04-26-07 6
Medicare Coverage Basics
Part A
Inpatient hospital care Skilled nursing care Home health care Hospice care
Part B
Doctors’ services and outpatient care Preventive services Diagnostic tests Some therapies Durable medical equipment
Part D Outpatient prescription drugs
Introduction
04-26-07 7
Medicare Part A
Most people receive Part A premium free People with less than 10 years of Medicare-
covered employmentCan still get Part A
• Will pay a premium
For information about Part A entitlementCall SSA
• 1-800-772-1213• TTY users call 1-800-325-0778
Introduction
04-26-07 8
Enrolling in Medicare Part B Pay monthly Part B premium
$96.40 in 2008 Initial Enrollment Period (IEP)
7 months starting 3 months before month of eligibility
General Enrollment Period (GEP)January 1 through March 31 each yearCoverage effective July 1Premium penalty
• 10% for each 12-month period eligible but not enrolled• Paid for as long as the person has Part B• Limited exceptions
Introduction
04-26-07 9
Enrolling in Medicare Part B
Some people can delay enrolling in Part B with no penaltyIf covered under employer or union group
health plan• Based on current employment
– Person or spouse
• Will get a Special Enrollment Period (SEP)– Sign up within 8 months after coverage ends
Introduction
04-26-07 10
Part B Enrollment PeriodsExample
Marie turned 65 on June 25, 2007. She will have group health coverage from her employer until she stops working on December 31, 2007.
Part B enrollment opportunities …
Enrollment period Begins Ends
IEP 3/1/07 9/30/07
SEP 10/1/07 8/31/08
GEP (each year) 1/1 3/31
Introduction
04-26-07 11
Paying the Part B Premium
Taken out of monthly paymentsSocial SecurityRailroad retirementFederal government retirement
For information about premiumsCall SSA, RRB, or Office of Personnel Management
If no monthly paymentsBilled every 3 monthsMedicare Easy Pay
Introduction
04-26-07 12
Medicare Choices
Original Medicare PlanMedicare Advantage PlansOther Medicare PlansMedicare Prescription Drug Plans
Introduction
04-26-07 13
Original Medicare Plan Go to any health care provider that accepts
Medicare People are responsible for
Part A• $1,024 deductible in 2008 for hospital stays up to 60
days– Additional costs after 60 days
• Different costs for other Part A servicesPart B
• $135 annual deductible in 2008• 20% coinsurance or copayment for most Part B
services Some programs may help with costs
Original Medicare
04-26-07 14
The Medicare Card
Jane Doe
Original Medicare
04-26-07 15
Medigap
Health insurance policySold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in the Original Medicare Plan
• Deductibles, coinsurance, copayments• Does not work with Medicare Advantage Plans
Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin• So people can compare easily
Medigap
04-26-07 16
How Medigap WorksPeople can buy a Medigap policy
Within 6 months of enrolling in Part B• Must be age 65 or older
If they lose certain kinds of health coverage• Through no fault of their own
If they leave MA Plan under certain circumstancesWhenever the company will sell them one
Monthly premiumGenerally go to any doctor or specialist
Medigap
04-26-07 17
Medicare Advantage Plans
Health Maintenance Organization (HMO) PlansSome have Point-of-Service option
Preferred Provider Organization (PPO) PlansRegional PPOs new in 2006
Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans
New in 2007
Medicare Advantage and Other Medicare Plans
04-26-07 18
Other Medicare Plans
Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the
Elderly (PACE)
Medicare Advantage and Other Medicare Plans
04-26-07 19
Eligibility for MA Plans
Live in plan’s service areaEntitled to Medicare Part AEnrolled in Medicare Part B
Continue to pay Part B premiumMay also pay monthly premium to plan
Don’t have ESRD at enrollmentSome exceptions
Medicare Advantage and Other Medicare Plans
04-26-07 20
How MA Plans Work
Usually get all Part A and B services through planMay have to use providers in plan’s networkGenerally must still pay Part B premium
• Some plans may pay all or part May get extra benefits
Vision, hearing, dental servicesPrescription drug coverage
Still in Medicare programGet all Part A and Part B servicesHave Medicare rights and protections
Medicare Advantage and Other Medicare Plans
04-26-07 21
Medicare Prescription Drug Coverage
Coverage began January 1, 2006Available to all people with Medicare Provided through
Medicare Prescription Drug PlansMedicare Advantage and other Medicare plansSome employers and unions
Medicare Drug Coverage
04-26-07 22
Enrollment Periods
Initial Enrollment Period (IEP)7 monthsStarts 3 months before month of eligibility
Annual Coordinated Election Period (AEP)November 15 through December 31 each yearCan join, drop, or switch coverage
• Effective January 1 of following year
Special Enrollment Period (SEP)
Medicare Drug Coverage
04-26-07 23
Late Enrollment
People who wait to enroll may pay penaltyAdditional 1% of national base premium for
every month eligible but not enrolledMust pay the penalty as long as enrolled in a
Medicare drug planUnless they have other coverage at least
as good as Medicare drug coverage“Creditable coverage”
Medicare Drug Coverage
04-26-07 24
Prescription Drug Plans
At a minimum, must offer standard benefitIn 2008 members may pay
• Monthly premiums• Annual deductible, no more than $275• Copayments or coinsurance• Very little after $4,050 out-of-pocket
May offer supplemental benefits Plan information and costs available
www.medicare.gov1-800-MEDICARE (1-800-633-4227)
Medicare Drug Coverage
04-26-07 25
Extra Help With Drug Costs
Available for many people with limited income and resourcesIncome limit in 2007
• $1,276/month individual)• $1,711/month (married couple)
Resource limit• $11,710 (individual)• $23,410 (married couple)
Medicare Drug Coverage
04-26-07 26
Extra Help With Drug Costs
People with lowest income and resourcesPay no premiums or deductiblesHave small or no copayments
Those with slightly higher income and resourcesPay no or a reduced premiumHave a reduced deductiblePay a little more out of pocket
Medicare Drug Coverage
04-26-07 27
Eligibility for Extra Help
Some people may automatically qualifyPeople with Medicare who
• Get full Medicaid benefits• Get Supplemental Security Income (SSI)• Get help from Medicaid paying Medicare premiums
Others must apply and qualify
Medicare Drug Coverage
04-26-07 28
Medicaid
Joint Federal and state programFor some people with limited income and resources
If eligible, most health care costs covered Eligibility determined by state Application processes vary Office names vary
Social ServicesPublic AssistanceHuman Services
Medicaid and Medicare Savings Programs
04-26-07 29
Other Savings Programs
Medicare Savings ProgramsHelp from Medicaid paying Medicare expensesFor people with limited income and resourcesMay also pay deductibles and coinsurance
State-specific programsPACE
Medicaid and Medicare Savings Programs
04-26-07 30
For More Information
1-800-MEDICARE (1-800-633-4227)TTY users call 1-877-486-2048
www.medicare.gov www.cms.hhs.gov State Health Insurance Assistance
Program (SHIP) Medicare & You handbook
Other publications
04-26-07 31
Summary
Medicare coverage Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs
This training module provided by the
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www.cms.hhs.gov/NationalMedicareTrainingProgram
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