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Medicare. Getting Started. SHIBA Statewide Health Insurance Benefits Advisors. A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner. What is SHIBA?. Statewide Health Insurance Benefits Advisors - PowerPoint PPT Presentation
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MedicareGetting Started
SHIBAStatewide Health Insurance Benefits Advisors
A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner
7/24/2015
What is SHIBA?
2
Statewide Health Insurance Benefits Advisors
A free program of the Office of the Insurance Commissioner
We provide unbiased and confidential information about Medicare and other health insurance
We are an educational service We don’t sell anything!
3
Medicare basics: A, B, D or C
How and when to enroll
Medigaps – Medicare Supplement plans
Part D – prescription coverage
Do you need help paying for your plan?
Medicare Advantage plans
Next steps
Today’s overview
Protect yourself!
4
As you research your options: Keep a notebook Write down the names of people you talk to,
the date and their contact information Note what was said in the conversation Keep copies of any paperwork Beware of fraud!
5
What is Medicare?
Health insurance for people:
• Age 65 and older• Under age 65 with certain disabilities• Any age with End-Stage Renal Disease (ESRD) or
Lou Gehrig’s Disease (also known as ALS)
6
What is Medicare?
It’s administered by:• Centers for Medicare & Medicaid Services (CMS)
But enrollment is done by:• Social Security Administration (SSA) for most• Railroad Retirement Board (RRB) railroad retirees
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The four parts of Medicare
Part A Hospital
Insurance
Part B Medical
Insurance
Part C Medicare
Advantage Plans (Includes Parts A & B and
sometimes Part D)
Part D Medicare
Prescription Drug
Coverage
OR
8
Original MedicareHas Part A – Hospital Insurance Hospital (Inpatient) Skilled Nursing Facility Home health care Hospice care
Has Part B – Medical Insurance Doctor’s visits Outpatient hospital services Clinical lab tests Durable Medical Equipment Preventive services
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Medicare does not cover everything!
Routine eye exams, eyeglasses• Only glasses after cataract surgery
Routine dental care• Cleaning, fillings, crowns, bridges, dentures
Hearing aids Most “alternative” medicine• Acupuncture, Naturopathy
Long-term care • Only skilled care in certain circumstances
Medicare Part A (Hospital Insurance)
What does Part A cost?• Most people get Part A premium free
• You can pay a premium to get Part A
• It can cost $224 or $407/mo. depending on work credits
10
Medicare Part B(Medical insurance)
11
What does Part B cost?• This year – for most – Part B costs: $104.90/month• Those who have higher incomes will pay
more May have penalty
Paying for Part A&B services See chart in handouts In addition to Part B premiums and sometimes Part A
premiums• In Original Medicare you pay:
o Part A Hospital deductible of $1,260o Part B yearly deductible of $147o 20% coinsurance for most serviceso THERE MAY BE OTHER COSTS!
Programs may help pay these costs• For people with limited income and resources
12
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How to enroll in Medicare Enrollment is automatic for most• If you get Social Security or RRB benefits
If enrollment is not automatic• For instance, you’re still actively working• You need to enroll with Social Security:
o Visit local officeo Call 1-800-772-1213o Online at socialsecurity.gov
If retired from Railroad, enroll with RRB• Call your local RRB office or 1 877 772 5772‑ ‑ ‑
14
Medicare card
Jane Doe
Keep it and accept Medicare Parts A and B Return it to refuse Part B• Follow instructions on back of card
Front Back
15
When can I enroll in Medicare?3 months before the month you
turn age 65
Medicare starts BD
month
2 months before
the month
you turn age 65
Medicare starts BD
month
1 month before
the month
you turn age 65
Medicare starts BD
month
Your birthday month
Medicare starts next
month
1 month after you turn age
65
Medicare starts in 2 months
2 months after you turn 65
Medicare starts in 3 months
3 months after you turn 65
Medicare starts in 3 months
The later you enroll, the later coverage starts: Up to a 3-month wait
16
Medicare decisions
Mayb
e?
Original Medicare? Should I keep/sign up for Part A? Should I take Part B? When? What about Part D? Do I need a Medigap policy? Do I want a Medicare Advantage Health plan? Can I get help
with Medicarecosts?
17
Decide how you want to get your Medicare coverage
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Decision Should I keep/sign up for Part A?
Consider• Get it automatically if getting
Social Security/RRB• Free for most people
If not free• Can pay for it if not enough work quarters
Yes
19
Decision Should I keep/sign up for Part B?
Consider
Is there active work involved?
NO ACTIVE work to consider. I’m ACTIVELY working and I’m covered by a health insurance
plan from my current job. I’m NOT ACTIVELY working, but my spouse is, and I’m covered
under his/her health insurance through their current job.
It Depends
20
DecisionShould I keep/sign up for Part B?
If you don’t have coverage from active employment• Yours or your spouses• Delaying Part B may mean:
o Higher premiumso Paying for your health care out-of-pocket
If you do have coverage through active employment• You may want to delay Part B • No penalty if you enroll while you have coverage or
within 8 months of losing coverage
Maybe Not
Probably
21
Decision Should I keep/sign up for Part B?
Sometimes you must have Part B• If you want to buy a Medigap policy• If you want to join a Medicare Advantage Plan• If you're eligible for TRICARE• If your employer coverage requires you have it
o Talk to your employer’s benefits administratoro Talk to SSA or SHIBA if questions
Medigaps Also called Medicare Supplement insurance
23
What is a Medigap policy? Medicare Supplement insurance policies• Sold by private companies
Fill the gaps in Original Medicare • Deductibles, coinsurance, copayments
Standardized plans All plans with same letter • Have same coverage• Only the costs are different
24
DecisionDo I need a Medigap policy?
Consider • It only works with Original Medicare• Do you have other supplemental coverage, such as
a retiree plan? o You might not need Medigap• Can you afford Medicare deductibles and
copayments?• What does the monthly Medigap premium cost?
Maybe
25
DecisionWhen is the best time to buy Medigap?
Consider:• Your Medigap Open Enrollment Period starts when
you're age 65 or older AND enrolled in Part Bo Lasts 6 monthso You have protections – plans MUST sell you a plan
• You can buy a Medigap policy whenever a company agrees to sell you one
Usually during your Medigap Open Enrollment Period
AKA “Guaranteed Issue”
26
DecisionWhich Medigap policy do I buy?
Consider• The coverage under each standardized plan• The cost of each plan – be sure to shop• Your individual health care needs
It Depends
Medigap BenefitsMedigap Plans
A B C D F* G K** L** M N
Part A Coinsurance Up to 365 Days Part B Coinsurance 50% 75% Blood 50% 75% Hospice Care Coinsurance Skilled Nursing Coinsurance 50% 75% Part A Deductible 50% 75% 50% Part B Deductible Part B Excess Charges Foreign Travel Emergency (Up to Plan Limits)
80% 80% 80% 80% 80% 80%
27
*Plan F has a high-deductible option ** Plans K and L have out-of-pocket limits of $4,940 and $2,470 respectively
Source: Page 93 of Medicare & You 2015
28
DecisionHow do I find the right Medigap policy for me?
By computer or phone• Call SHIBA 1-800-562-6900• Insurance.wa.gov • Call 1.800.MEDICARE (1-800-633-4227)• TTY users should call 1-877-486-2048
29
Medicare prescription drug plans
Medicare Part D
30
Part D – Medicare prescription drug coverage
Available for all people with Medicare Provided through:• Medicare prescription drug plans• Medicare Advantage plans• Other Medicare plans
31
How Medicare Part D works It’s optional • You can choose a plan and join
Plans have formularies • Lists of covered drugs• Must include range of drugs in each category
You pay the plan a monthly premium You pay deductibles and copayments There’s Extra Help to pay Part D costs• If you have limited income and resources
32
Who can join Part D?
You must have Part A and/or Part B You can’t live outside the U.S. You must actively enroll to join• In most cases no automatic enrollment
33
DecisionShould I enroll in a Part D plan?
Consider• Do you have creditable drug coverage?o Coverage as good as Medicare’s o For example through an employer plan
• Will that coverage end when you retire?• How much do your current drugs cost?• What do the premiums cost for Part D plans?
Without creditable coverage• Later enrollment may mean you pay a penalty
It Depends
34
Joining a Part D plan You can join:• During your 7 month Initial Enrollment Period• During the Open Enrollment Periodo October 15 – December 7 o Coverage starts January 1
• During other special timeso Special Enrollment Period
35
How do I choose a Part D plan? Call or by computer• Call SHIBA for help comparing plans• Medicare Plan Finder at:
www.medicare.gov/find-a-plan To join a Part D plan• Enroll on www.medicare.gov• Complete a paper enrollment form• Call the plan• Enroll on the plan’s website • Call 1-800-MEDICARE (1-800-633-4227)
36
Medicare Advantage plans Medicare Part C
Also called “Medicare Health plans”
37
Part C – Medicare Advantage Run by private companies Another way to get Medicare coverage Still part of the Medicare program Member may have a monthly
premium Medicare pays amount for each
member’s care May have to use network
doctors or hospitals
38
How Medicare Advantage works Still in Medicare with all rights and
protections Still get Part A and Part B services May include prescription drug coverage May include extra benefits • Like vision, dental, hearing & gym membership
Benefits and cost-sharing may be different per plan
39
DecisionDo I want to join a Medicare
Advantage plan?
Consider• Most offer comprehensive coverage
o Including Part D drug coverage
• May require you to use a network • You must pay Part B and monthly plan premium• May need a referral to see a specialist• Can only join/leave plan during certain periods• Doesn’t work with Medigap policies• You must have Part A and Part B to join• You must live in the county where the plan is sold• You can’t buy it if you have End Stage Renal Disease
It Depends
40
When can I enroll in an MA plan? During 7-month Initial Enrollment Period During the Open Enrollment Period• October 15 – December 7 each year• Coverage starts January 1
May be able to join at other times• Special Enrollment Period
Contact the plan or Medicare to join• Call their number• Visit their website• Plan information on www.medicare.gov
41
Paying for Medicare
42
What do I pay?
Costs vary and change yearly• In Original Medicare o Does the provider accept Medicare
Assignment?• In Medicare Advantageo Check with plan
• In Medicare prescription drug planso Check with plan
43
What help is there for people with limited income and resources?
Medicaid• For people with the lowest incomes, eligible
people pay little or nothing for their health care costs
Medicare Savings Programs• Helps pay Part B premiums and sometimes Part A
and Part B deductibles and co-insurance Extra Help• Helps pay Part D costs
44
What is Medicaid?
Federal-state health insurance program• For people with limited income/resources• Certain people with disabilities• If you have both Medicare and Medicaid, covers
most health care costs Eligibility determined by state In Washington: DSHS Apply if you MIGHT qualify
45
What are Medicare Savings Programs (MSPs)?
Help from Medicaid to pay Medicare costs• Pay Medicare premiums• May pay Medicare deductibles and coinsurance
Income amounts change each year
Who can qualify for MSP?
46
Individual Monthly Income
Limit
Married Couple
Monthly Income Limit
Helps Pay Your
Medicare Savings Program
$1, 324 $1,792Part B premiums, and sometimes Part A premiums, Medicare A & B deductibles and co-insurance
Asset Limits: Individual $ 7,280 Couple $10,930
What is Extra Help (Low Income Subsidy)?
Help paying prescription drug costs Social Security makes determination Some groups automatically qualify• Example: If they qualify for Medicare and
Medicaid You or someone on your behalf can apply
47
Who can qualify for Extra Help?
48
Individual Monthly Income
Limit
Married Couple
Monthly Income
Limit
Helps Pay Your
Extra Help $1,471 $1,991 Part D Premium, Deductibles and Co-pays
Asset Limits: Individual $13,640Couple $27,250
49
DecisionShould I apply for these programs?
Apply if you MIGHT qualify Social Security for Extra Help DSHS for Medicaid or Medicare Savings
Programs SHIBA can help you
Yes!
50
Key points to remember Medicare is a health insurance program It does not cover all of your health care costs
or types of care• You may want to find additional coverage• Or plan to pay out of pocket
Some plans change each year• You may need to review coverage during Open
Enrollment in the fall
51
There are programs for people with limited income and resources:• Medicaid• Medicare Savings Programs• Extra Help
Important:• Make the right decisions• Make them at the right times• Get help if you need it
Key points to remember
52
For more information
SHIBA: 1-800-562-6900 1-800-MEDICARE www.medicare.gov Medicare & You Handbook www.socialsecurity.gov www.washingtonconnection.org
53
Medicare and mental health benefits
54
What Medicare coversMedicare Part A (hospital insurance) helps cover mental health care if you’re a hospital inpatient:
Room Meals Nursing care Other related services and supplies
55
What Medicare coversMedicare Part B (medical insurance) helps cover mental health services you get from a doctor and other services you get outside of a hospital, such as:
Visits with a psychiatrist or other doctor Visits with a clinical psychologist or clinical social
worker Lab tests ordered by your doctor May pay for partial hospitalization if you need
intensive coordinated outpatient care
56
What Medicare coversMedicare Part D (prescription drug coverage) helps cover
Drugs you may need to treat a mental health condition
If you take Rx drugs for a mental health condition, it’s important to find out whether a plan covers your drugs before you enroll. Go to: medicare.gov/find-a-plan to find out which plans cover your drugs.
57
What Medicare does not coverMedicare Part A Private duty nursing Phone or TV in your room Personal items (i.e.,
socks, razors, etc. Private room
Medicare Part B Meals Transportation to and
from mental health services
Support groups Testing/training for job
skills that aren’t part of your mental health treatment
58
Medicare and theAffordable Care Act
(ACA)
59
How the ACA impacts Medicare
Does not cut Medicare benefitsDoes not eliminate Medicare Advantage
plansDoes not require people with Medicare to
get more or different insuranceDoes improve Medicare benefitsDoes reduce Medicare costs
60
ACA Medicare benefitsalready in place
Increased preventive benefits Many with no copay or deductibles Discounts in the Part D Donut Hole• Brand-name discount now & increasing
each year• Phasing it out by 2020
61
Key ACA Medicare provisions to control costs
Restructures payments to Medicare Advantage plans to bring costs more in line with Original Medicare plans
Reduces Medicare payments to hospitals with:• Too many patient readmissions• A high rate of patients who acquire infections while
hospitalized Requires competitive bidding for Durable Medical
Equipment New authority and resources to target waste,
fraud and abuse
62
Medicare & the insurance exchange
Medicare-eligible people cannot use the Washington Healthplanfinder.
SHIBA will continue to help Medicare-eligible people with their questions about health benefits under Medicare Parts A, B, D and C.
Need help with other insurance questions?
The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as:
Call our Insurance Consumer Hotline
1-800-562-6900
63
• Homeowner• Auto• Life
• Annuities• Health• And more!
Help your community! Did some of this make sense to you? Want to learn more? Want to make a difference for others? We would love to have you volunteer with
SHIBA!
64
65
More questions? Please complete and return evaluation form
Let us know if you want us to contact you to:• Discuss your personal situation• Learn more about becoming a volunteer
THANK YOU!!