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Medicare & the Medicare Modernization Act of 2003

Norma Lanier, State Outreach Coordinator

First Coast Service Options, Inc.

July 12, 2005

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Today’s Discussion

• Review of Medicare basics

• Medicare changes in 2005 and 2006

• Preventive benefits covered by Part B

• Prescription Drug Benefit

• Medicare rights and protections

• Alzheimer’s and Medicare

• Program Evaluation

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First, the Basic Facts

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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 nationally

• Administered by private contractors locally

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Original Medicare

Medicare has two parts

Part AHospital Insurance

Part BMedical Insurance

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The Original Medicare Plan

• You may 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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Medicare Part A Benefits

• Hospital stays

• Skilled nursing facility (SNF) care

• Home health care

• Hospice care

• Blood

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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 2005 you pay– $912 deductible for a hospital stay of 1-60 days– $228 per day for days 61-90– $456 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 $114 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

• 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 a person has 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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Part B Benefits

• 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

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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 year you were

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

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 the Social Security Administration or Railroad Retirement Benefit

Original Medicare

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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)

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Medigap

• Fills in gaps in the Original Medicare plan

• Must follow federal and state laws

• Standardized Plans A-J in most states– Except Minnesota, Massachusetts, Wisconsin

• Don’t need Medigap if in Medicare Advantage

• See Guide to Health Insurance for People with Medicare

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Let’s talk about more changes in Medicare…

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What We Heard

• People with Medicare want– More choices– Better benefits– Health care delivery options – Improved access to care

• Especially in rural areas

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Medicare Modernization Act of 2003 (MMA)

2004• Drug

discount card

• Medicare Advantage

2006• Prescription

drug plans

• Two new Medigap policies

2005• New

preventive services

• Part B deductible $110-based on expenditures in future

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New Covered Preventive ServicesBeginning January 2005

• “Welcome to Medicare” physical– Initial physical exam – Referral for screening and other preventive services

• Cardiovascular screening blood tests– Screening blood tests for cholesterol and other lipids or

triglyceride levels

• Diabetes screening tests– Fasting plasma glucose test– Other tests appropriate for persons at high risk

MMA

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Medicare Prescription Drug Plans

• Available January 2006

• Offered through private prescription drug plans (PDPs)

• Can be offered by Medicare Advantage plans

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Eligibility and Enrollment

• Must be entitled to Part A and/or enrolled in Part B

• Enrollment is voluntary• Increased premiums for people who wait

– 1 percent of the base premium for each month you don’t enroll

• After May 15, 2006

– Exception for those covered under other comparable insurance

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Why Join a Plan?• Medical practice relies on new drug therapies to

treat chronic conditions• Out-of-pocket spending on drugs has increased • Most people need or will need prescription drugs to

stay healthy• Medicare insurance coverage for prescription drugs

will protect from high out-of-pocket costs• For most people, joining when first eligible means

paying the lowest monthly premiums

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Enrolling in a Plan

People with Medicare can:

• Enroll directly with the plan

• Have a personal representative enroll them

• Ask others to help them enroll

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When to Enroll

• Join between November 15, 2005, and December 31, 2006– Coverage will begin on January 1, 2006

• Join between January 1, 2006, and May 15, 2006– Coverage will begin the first day of the month

after the month joined

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Medicare Prescription Drug Coverage

• Coverage begins January 1, 2006

• Available for all people with Medicare

• Provided through: – Private prescription drug plans– Medicare health plans– Some employers and unions for retirees

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What it Costs…How it Works• Pay a premium of about $37 each month

– In addition to Part B premium

– Enhanced benefit may cost more

• Pay a yearly deductible up to $250

• Pay part of the cost of covered prescription drugs

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How it Works in 2006

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Lower-Income Assistance

• People with limited resources:– Get extra help with their Medicare drug plan cost

• Lowest incomes:– Pay no premiums or deductibles

– Pay small or no copayments

• People with slightly higher incomes:– Pay reduced deductible

– Pay a little bit more out of pocket.

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To Get Help Paying the Cost of Prescription Drug Plans

• Person with Medicare must:– Reside in the United States– Meet the income and resource requirements

of the subsidy program– Be enrolled in Medicare

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To Get This Help

• Person does not have to do anything– If currently receiving benefits from both Medicaid

and Medicare or

– Receiving Supplemental Security Income benefits and Medicare

• Information will come in the mail from Medicare– Explaining eligibility for this coverage, and– What he/she should do this fall to enroll in a

Medicare plan that offers prescription drug coverage

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To Get This Help• Person with Medicare must have

– Annual income less than $14,355 (single)– Annual income less than $19,245 (married)

AND– Limited resources

• Application will come from Social Security Administration (SSA)

• Mail completed application to SSA

• For additional information, contact the SSA at 1-800-772-1213

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Medicare Advantage Plans

Another Way to Get Your Medicare Benefits

MMA

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Medicare Advantage Plans

• New name for Medicare+Choice plans

• Medicare managed care plans

• Preferred Provider Organization plans (PPOs)

• Private-Fee-for-Service plans– Available in some states

• Medicare Specialty Plans

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If you join a Medicare Advantage Plan…

• You still have rights and protections

• You are still in the Medicare program

• You still get all your regular Medicare-covered services

• You may be able to get extra benefits– Coverage for extra days in the hospital

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Medicare Patients’ Rights

• Right to– Information about all treatment choices– Participate in treatment decisions– Get easy-to-understand information – Know what costs are paid by Medicare – Know how much you have to pay

Overview

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Other Medicare Rights

• Right to– Receive emergency room services– Have your personal and health information kept

private – Right to non-discrimination: You cannot be

treated unfairly because of race, color, national origin. disability, age, sex, religion

Overview

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Other Medicare Rights

• Right to– Know what to do if you have to file an appeal

or a grievance (complaint)– An appeal is when

• Medicare does not pay

• Medicare does not pay enough

• You are not given a service

– A grievance is about quality of care issues

Overview

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Medicare and Alzheimer’sMedicare beneficiaries diagnosed with Alzheimer’s disease have the same rights and coverage than any other person with Medicare.

• Part A covers inpatient mental health services, including room, meals, nursing care and other related services

• Part B covers outpatient mental health services, including visits with health professionals such as doctors, clinical psychologists, clinical social workers, and clinical nurse specialists

• Part B also covers laboratory services and partial hospitalization

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For More InformationNational Sources

• Visit www.medicare.gov

• Call 1-800-MEDICARE (1-800-633-4227)– TTY 1-877-486-2048

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Please complete the Program Evaluation

Form

Thank You!

EvaluationForm