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?

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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!

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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!

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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!

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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)

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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

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Original Medicare

Has 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

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Medicare Part B(Medical insurance)

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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

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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‑ ‑ ‑

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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

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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

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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?

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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

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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

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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

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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

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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

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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

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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”

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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%

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*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

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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

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Medicare prescription drug plansMedicare Part D

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Part D – Medicare prescription drug coverage

Available for all people with Medicare Provided through:• Medicare prescription drug plans• Medicare Advantage plans• Other Medicare plans

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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

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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

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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

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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

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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)

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Medicare Advantage plans Medicare Part C

Also called “Medicare Health plans”

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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

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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

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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

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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

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Paying for Medicare

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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

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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

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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

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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?

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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

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Who can qualify for Extra Help?

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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

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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!

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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

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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

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For more information

SHIBA: 1-800-562-6900 1-800-MEDICARE www.medicare.gov Medicare & You Handbook www.socialsecurity.gov www.washingtonconnection.org

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Medicare and mental health benefits

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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

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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

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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.

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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

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Medicare and theAffordable Care Act

(ACA)

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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

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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

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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

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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

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• 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!

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More questions?

Please complete and return evaluation form

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