LOST IN THE MEDICARE MAZE...Part B (medical) has a base premium for 2020 of $144.60 per month. The Part B premium can be adjusted by Social Security and the IRS using your AGI from

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LOST IN THE MEDICARE MAZE

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WHEN CAN I GET MY MEDICARE?Medicare is available to all those 65 and older who qualify for coverage.

Medicare is also available to persons under 65 who are disabled or have ESRD.

There are multiple election periods for which a person will start their Medicare coverage.

Initial Enrollment Period or Initial

Coverage Enrollment

Annual Enrollment Period

Special Enrollment Period

Open Enrollment Period

IEP/ICEP AEP SEP OEP

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If you are already receiving Social Security disability or retirement, your enrollment in Part A and Part B is automatic.

If you are new to Medicare you can go to www.ssa.gov and create an account to sign up for Part A or Part B online.

WHEN CAN I GET MY MEDICARE?

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WHAT ARE THE ELECTION PERIODS?

IEP/ICEP – First eligible for Medicare either by aging into Medicare (turning 65) or receiving disability for 24-consecutive months.

AEP – A period in the year when those with Original Medicare, Medicare Advantage Plans, or drug plans are permitted to make changes or renew those plans. (October 15 – December 7)

SEP – Enrollment given to individuals due to certain qualifying events; involuntary loss of employer coverage, moving out of a plan’s coverage area are just a couple of examples.

OEP – A period where individuals with a new Medicare Advantage can make another change to their newly elected plan.

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http://www.ssa.gov/

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HOW MUCH DOES IT COST?If you worked 40 quarters (10 years) and paid into Social Security during this time, you will qualify for Part A (hospital) at $0 cost.

Part B (medical) has a base premium for 2020 of $144.60 per month. The Part B premium can be adjusted by Social Security and the IRS using your AGI from your last 2-years of tax returns.

If you make over the minimum threshold, your Part B can be adjusted. This tax is referred to as the IRMAA (income-related monthly adjusted amount) – it will affect the Part D (Rx coverage) of Medicare.

Think of it as a penalty for making too much money. If you believe your income for the year your are eligible for Medicare is less than what the AGI shows, you will have the right to appeal the decision. IRMAA is calculated each year and adjusted accordingly.

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SINGLE MARRIEDFILING JOINTLY

MARRIEDFILING SEPARATELY

PART B PREMIUM PER INDIVIDUAL MEMBER

PART D IRMAA PER INDIVIDUAL MEMBER

$87,000 or less $174,000 or less $87,000 or less $144.60 $0 + your plan premium

$87,001 to $109,000

$174,001 to $218,000 Not Applicable $202.40 $12.20 + your plan premium

$109,001 to $136,000


$136,001 to $163,000


$163,001 and under $500,000

$326,001 and under $750,000

$87,001 and under $413,000 $462.70 $70.00 + your plan premium

$500,001 and above

$750,001 and above $413,001 and above $491.60 $76.40 + your plan premium

2020 IRMAA SCHEDULE

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SHOULD I ENROLL IN MEDICARE?There are a number of factor to consider when making a decision:

1. Do you currently have a creditable coverage health plan* through a current employer?

2. What type of plan do you have; is it a HDHP** with a HSA or do you have a standard PPO or HMO health plan?

If you enroll in Part A, it is important to understand you or your employer will no longer be eligible to contribute to your HSA. You may still use up the balance of funds for any medical costs and even may use it to pay your Part B premium (if you enrolled), Part D premium, a Medicare Advantage premium, or a long-term care premium.

* Expected to pay on Average as much as Medicare** High Deductible Health Plans with Health Savings Account

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THE 4 PARTS OF MEDICARE

Hospital Medical Medicare Advantage

Prescription

PART A PART B PART C PART D

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INPATIENT HOSPITAL CARE

MEDICARE PART A: HOSPITAL COVERAGE

SKILLED NURSING FACILITY HOSPICE CARE

HOME HEALTH CARE

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MEDICARE PART A: HOSPITAL COVERAGE

EACH BENEFIT PERIOD 60 DAYS YOUR RESPONSIBILITY

Days 1-60 $1,408.00 Part A Deductible

Days 61-90 $352.00 Co-pay per Day

After 90 days you will use part of 60 lifetime reserve days (optional) $704.00 Co-pay per Day

After reserve days are exhausted All costs (no cap on expenses)

60-60-60 RULE

ALWAYS VERIFY YOUR STATUS DURING YOUR STAY E.G. INPATIENT, REHABILITATIVE, OR OBSERVATION

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MEDICARE PART A: HOSPITAL INPATIENT CARE

Medicare Part A deductible benefit period• Hospital Admittance

• Can pay the deductible more than once during the year.

Part A Deductible $1408 (No more than 60 nights between stays)

Jan 1-7 Jan 20-24 Mar 17-23 May 4-15

Part A Deductible $1408 (More than 60 nights between stays)

Jan 1-7 ($1408) May 4-15 ($1408)

Part A Deductible with co-pay after 60 nights (combined)

Jan 1-15 (14) Feb 11-28 (16) Mar 2-31 Apr 1-4 (31) Total 61 nights

$1408 + $352 co-pay per day

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MEDICARE PART A: HOSPITAL INPATIENT CAREMedicare covers semi-private rooms (private rooms if deemed medically necessary)

General nursing services

Rx’s as part of your inpatient care and treatment

Other hospital services and supplies e.g. meals, general housekeeping, most cases a T.V.

Included are acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care

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MEDICARE PART A: SKILLED NURSING FACLIITY• Medicare covers after a minimum three night medically necessary inpatient hospital stay

• Member pays $0 first 20 days of each benefit period

• Member pays $176.00 days 21-100

• Member pays all costs after day 100

*Doctor will determine if member is to continue under SNF care**Observation services do not count towards the minimum 3 night stay

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MEDICARE PART A: HOSPICE CARE• Doctor must certify the member is

terminally ill with less than 6 months to live and if necessary, recertify after those 6 months the member is still terminal

• Coverage includes all items and services needed for pain relief and symptom management

• Member pays nothing for hospice care services

*May have co-pay of up to $5 for Rx

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MEDICARE PART A: HOME HEALTH CAREDoctor must order members care and must be provided by a Medicare certified home health agency

Medicare will cover the first 100 visits once the required conditions have been met

1. Must have been a hospital inpatient for at least 3 nights2. Must have received home health care services within 14 days of being discharged from the hospital or SNF

Member pays nothing for covered home health care services and 20% of Medicare approved amount for durable medical equipment

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MEDICARE PART B: MEDICAL SERVICES• Original Medicare Part B helps cover

medically necessary doctor services (inpatient/outpatient), outpatient care, home health services, durable medical equipment, and other medical services

• The member pays a co-insurance for each individual outpatient hospital service

• Under Original Medicare member must meet the yearly $198 deductible

• Medicare pays 80% and member is expected to pay $20% after deductible

*No yearly limit to what member will pay out-of-pocket

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MEDICARE PART B: MEDICAL SERVICES

AMBULANCE SERVICEMember pays 20% after Part B deductible, if not already met for year

AMBULATORY SURGICAL CENTERSMember pays 20% of Medicare approved services after Part B deductible, if not already met for year

BLOODMember pays the first 3 pints in the calendar year, unless you have the blood donated by you or someone you know

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MEDICARE PART B: HOME HEALTH CARE• If member requires more than the 100 visits under Part A, B begins

covering in place of Part A

• Covers all visits if member does not meet Part A requirements

• The home health agency should tell member how much Medicare will pay and what services member may me responsible for if not covered by Medicare

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MEDICARE PREVENTATIVE SERVICES

Medicare Part B covers many preventative services at $0 cost if provider accepts Medicare assignment:Abdominal aortic aneurysm screening – 1 timeAlcohol misuse screening and counseling – annualBone density – every 2 yearsMammograms – annualCardiac rehabilitation – case by caseBehavioral therapy (Cardiovascular) – annualCardiovascular disease screenings – every 5 yearsCervical and vaginal screenings – every 2 yearsColorectal cancer screening testing - ??Depression – annualDiabetes screenings – bi-annual (if needed) Diabetes self-management training – up to 10 hours

Flu shots – 1x during flu seasonGlaucoma test – annualHepatitis C screening test – determined by PCPHIV screening – annualMedical nutrition therapy service – PCP referredObesity screening and counseling – PCP referred Pneumococcal shot – determined by PCP STD screening and counseling – annualWelcome to Medicare preventative visit – 1 timeYearly wellness visit – annualCPAP therapy – after diagnosis 3 month therapy

Please note: Medicare has some time restrictions as to the frequency you may use these preventative services

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ORIGINAL MEDICARE BILLING• Important for member to understand in relation to provider billing• All billing from provider goes to Medicare first • Medicare determines how much the provider will receive for services • Member receives a Medicare Summary Notice (MSN) every 3 months*• The MSN explains how much was paid in claims & what the member may owe the

provider (if anything)*If any Part A or B services were used

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HOW MUCH SHOULD A MEMBER EXPECT TO PAY IN HEALTH CARE EXPENSES?The average 65-year-old couple can expect to pay out over the rest of their lifetime an estimated $404,000.

This is why enrolling in either a Medicare Advantage or Supplement plan can be a good choice versus just keeping OM by itself

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MEDICARE PART C: MEDICARE ADVANTAGEMedicare Advantage is a Part C plan through a private insurance company with a Medicare contract*

Plan type available:• HMO – Health Maintenance Organization• PPO – Preferred Provider Organization• PFFS – Private Fee For Service • HMOPOS – Point of Service • SNP – Special Needs Plans• MSA – Medicare Savings Account Plans

*As good as or better than Original Medicare

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MEDICARE ADVANTAGE PLANS: CHARACTERISTICS

HMO• Network Healthcare

• PCP required

• Lower Premiums

• Referrals required (most of the time)

• Lower co-pays

• Out-of-pocket cost limits (in network only)

• With or without Rx plan (rules permitting)

PPO• No network, use any provider

(Medicare participant)

• PCP not required

• No referrals required

• Out-of-pocket cost limits (in network and out of network)

• With or without Rx plan (rules permitting)

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PFFS• Like OM go to any provider

• Plan determines how much it will pay providers

• How much member pays in co-pays and coinsurance

• Plans may include Rx coverage or member may choose individual PDP

• For each service that the member gets, provider must agree to plan’s payment terms each time*

HMOPOS• HMO plans which may allow members

to get some services out-of-network for a higher co-payment or coinsurance

• Member may need to get a referral from primary care doctor

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SPECIAL NEEDS PLAN (SNP)*

• Provide focused and specialized health care for specific groups of members, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic conditions

MEDICARE SAVINGS ACCOUNT PLANS*

• Combination of high-deductible health plan and bank account. Medicare deposits money into the account. Can use money for any health services throughout the year. Member must purchase a separate PDP

*Plans subject to availability in members’ service area

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MEDICARE ADVANTAGE BILLING• Unlike OM all billing from the provider goes to the

insurance company

• The member is responsible to pay the provider any co-pay or coinsurance as required

• All claim issues are settled through the insurance company through appeals

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MEDICARE PART D:PRESCRIPTION DRUG PLANS (PDP)

• Medicare approved Part D coverage through private insurance company with a Medicare contract

• Deductible $435.00 for 2020

• Plans can be with or without deductibles

• Formulary – list of drugs covered by the plan

• Tier levels – drugs groups together by amount of co-pay or coinsurance for each prescription• Tier 1 – Preferred generics• Tier 2 – Non-preferred generics• Tier 3 – Preferred brand• Tier 4 – Non-preferred brand• Tier 5 – Specialty

• 3 Coverage Levels• Initial• Coverage Gap (Donut Hole)• Catastrophic Change

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MEDICARE PART D: PDP COVERAGE LEVELS

After the deductible (if applicable) has been met now begins the Initial Coverage Level:

• Member pays a co-pay or may pay a % of the drug’s cost. Currently the plan pays 75% and the member pays 25%

• Each Part D provider plan can determine what % or co-pay paid by plan and member. Co-pay and coinsurance limitations apply

• The total retail cost of the covered medications determines the members True Out-of-Pocket (TrOOP) cost, not what the member pays at the “counter”

• Member pays this until total retail drug costs reach $4,020 (member + plan) after which the member goes into the coverage gap

*Important note: Member’s premium does not count towards TrOOP

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MEDICARE PART D:PDP COVERAGE LEVELS

Coverage Gap (Donut Hole)• While in the coverage gap the manufacturer pays 70% and the government pays 5% with

the member paying 25% the cost of drugs and getting a 95% credit towards the TrOOPcost. The government’s discount on generic drugs is 75% (does not count towards the member’s TrOOP

• Manufacturers and government provide a 50% discount on brand-name plan covered drugs along with the 35% (85%) towards TrOOP

• 100% of member responsibility and manufacturer discounts count toward catastrophic coverage

• Coverage Gap ends at $6,350 TROOP cost, after which the member will begin the Catastrophic Coverage Level

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MEDICARE PART D:PDP COVERAGE LEVELS

Catastrophic Coverage – considered a government “safety-net’• Insurer and Medicare pay 95% of costs• Member pays the greater of 5% coinsurance or $3.60 for generic and $8.95 for all other

drugs

What costs count towards Catastrophic Coverage?• Member’s deductible• What member paid during the initial coverage level• Almost the full cost of the brand name drug counts (including the manufacturer’s discount)• Amounts paid by others (family, charities, or other on your behalf)• State Pharmaceutical Assistance Programs (SPAP) if available, AIDS Drug Assistance

Programs, and Indian Health Service

*Not all Rx plans are created equal

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MEDICARE PART D• What if I cannot afford my drugs?

• Other options to assist seniors with paying for Rx• Medicaid / Low Income Subsidy (LIS)

• State Pharmacy Assistance Programs (SPAP)

• Pharmaceutical Assistant Programs

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MEDICARE PART D:PDP ASSISTANCE• Medicaid - Joint federal and state

program helps pay medical costs if you have limited income and resources and meet other requirements

• If you have both Medicare and full Medicaid most of your healthcare and Rx costs are covered

• Some Medicare beneficiaries may only partially qualify for Medicaid; known as “dual eligible”

*Call 1.800.633.4227 to check on requirements to qualify

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MEDICARE PART D: PDP ASSISTANCE• State Pharmacy Assistance Programs – Help Medicare members pay

for Rx drugs based on financial need, age, or medical need. State makes its own rules on how to provide coverage to its members

• Not all states offer this program

*Not available in WV

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MEDICARE PART D: PDP ASSISTANCE• Low Income Subsidy (LIS) – Social Security Administration (SSA) and

Centers for Medicare and Medicaid Services (CMS) operate the program

• If a member does not qualify for Medicaid assistance, then the member may be eligible for an LIS; this has different qualification requirements than Medicaid

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MEDICARE PART D:PDP ASSISTANCE• Pharmaceutical Assistant

Programs – Some higher costing drugs’ manufacturers have grants or discount programs available to assist Medicare eligible in acquiring some Rx at little to no cost

*Call manufacturer directly for information

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MEDICARE SUPPLEMENT AKA MEDI-GAPOriginal Medicare does not provide comprehensive coverage, there are gaps Medicare eligible are expected to pay like deductibles, co-pays, and co-insurance

Insurance companies offer plans covering all or some of these gaps in coverage

These are individual plans working in tandem with Original Medicare

Important to note these plans only cover Medicare approved claims

All Medicare Supplement plans are standardized by the government

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MEDICARESUPPLEMENTThe following charts show the benefits included in each of the standard Medicare Supplement plans. Every company must make available Plan “A.” Some plans may not be available in your state.

BASIC BENEFITS

• Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end

• Medical Expenses – Part B coinsurance (generally 20% of Medicare approved expenses) or copayments for hospital outpatient services. Plans K,L, and N require insureds to pay a portion of coinsurance or copayments.

• Blood – First three pints of blood each year Hospital – Part A coinsurance

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A B C D G K L M NBasic,

including 100% Part B coinsurance

Basic, including

100% Part B coinsurance

Basic, including


Basic, including


Basic, including


Hospitalization and

preventative care paid at 100%; other

benefits paid at 50%

Hospitalization and

preventative care paid at 100%; other

benefits paid at 75%

Basic, including


Basic, including 100%

Part B coinsurance, except up to

$20 copayment for office visit and up to $50 copayment

for ER

Skilled Nursing Facility

coinsurance


coinsurance


coinsurance

50% Skilled Nursing Facility coinsurance

75% Skilled Nursing Facility coinsurance


coinsurance


coinsurance

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible



Part A Deductible

Part B Excess (100%)

Foreign Travel

Emergency

Foreign Travel Emergency


Foreign Travel

Emergency


Out-of-Pocket Limit $[4940]; paid at 100%

after limit reached

Out-of-Pocket Limit $[2470]; paid at 100%

after limit reached

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MEDICARE SUPPLEMENT: BENEFITS• No network healthcare

• Additional 365 days of coverage after Medicare benefits exhausted under Part A

• Completely portable; no travel restrictions within the United States

• Household discounts available with most carriers

• Foreign travel coverage of 80% after the $250 deductible, coverage up to $50,000 lifetime limit

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MEDICARESUPPLEMENTHow does a Medicare Supplement plan coordinate with Medicare and provider?

As described earlier, Medicare is the only insurance the member has if they do not have a Medicare Advantage plan, employer, or other government insurance plan

A Medicare Supplement plan is not a secondary insurance!

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WHAT IS NOT COVERED BY MEDICARE?

• Dental, Vision, and Hearing

• Long term care (LTC) outside of hospice

• Burial expense except a lump sum death payment of $255

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MEDICARE DECISIONS• What kind of coverage plan should I choose?

• Should I sign up for Medicare Part B?• If not, when should I sign up?

• What about Part D?

• Do I need a Medicare Supplement plan?

• Can I get help with my Medicare costs?

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Documents

LOST IN THE MEDICARE MAZE...Part B (medical) has a base premium for 2020 of $144.60 per month. The Part B premium can be adjusted by Social Security and the IRS using your AGI from