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Welcome to Medicare
2
Jon LangmeadCenters for Medicare and Medicaid Services
Office of External Affairs
Philadelphia Regional Office
215-861-4174
3
Goals
Learn the basics of Medicare coverageDiscuss critical dates for Prescription Drug
Plans and Medicare Advantage PlansLearn about the Low Income SubsidyFind out how you or the people you work
with can get help with Medicare
What is CMS and Medicare?
5
Centers for Medicare and Medicaid Services
Federal Agency - Division of DHHSwww.medicare.gov (for consumers)www.cms.hhs.gov (for providers)Estimated 44.8 million enrollees
Over 1 million in Virginia
2007 Federal Outlays for CMS were 21% of the Federal Budget ($573.3 billion)
6
What Is Medicare?
Health insurance forPeople 65 years of age and olderPeople under age 65 with certain disabilitiesPeople of all ages with End-Stage Renal Disease
Sign-up: Handled by SSA or RRB
7
Medicare Parts A - D
Part A Part B Part C Part D
Hospital Insurance
Outpatient Care
Medicare Advantage
Prescription Drug
Coverage
Original Medicare
8
Medicare Partners
CMSAOA
FDAHRSAIHSNIH
SAMHSACDC
BOIVDASMPAOA
Senior Connections
9
Where To Go For Help
Federal Resources 1-800-Medicare and Medicare.gov Social Security (www.ssa.gov)
State and Other Resources Eldercare Locator BOI FQHCs Health Assistance Partnership (www.hapnetwork.org) Coordination of Benefits Contractor: 800-999-1118 QIO MyMedicareCommunity
10
Insurance Cards You May Encounter
Medicare Card (Red, White and Blue)Medicare Supplement Insurance
(Medigap)Medicare HMO, PFFS, PPOMedicare Part D Prescription PlanEmployer Retirement PlanDMASTRICARE
Medicare Parts A and B
12
Applying for Medicare
Initial Enrollment Period8 month period around 65th birthday
Enrollment automatically occurs at 65 if beneficiary is receiving Social Security or Railroad Retirement benefits
13
Exercise
1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare.
True
False
14
Exercise
1. People are automatically enrolled into Medicare when they turn 65.
True
False
15
Medicare Part AMost people don’t pay a monthly premium for
Part APeople with less than 10 years of Medicare-
covered workCan still get Part A
• Will pay a premiumFor information about Part A eligibility
Call Social Security Administration• 1-800-772-1213• TTY users call 1-800-325-0778
16
Part A Helps Pay for
Hospital inpatient careSkilled nursing facility (SNF) careHome health careHospice careBlood
17
Benefit Periods
The way that Medicare measures your use of Part A services
18
Paying for Hospital Stays (Part A)
For inpatient stays in 2009 you payDays 1 – 60: $1,068 deductible and no co-
paymentDays 61 – 90: $267 co-payment per dayEach Day After 90: $534 co-payment per
day ( Up to 60 lifetime reserve days)All costs for each day after Lifetime Reserve
Days
19
Paying for Hospice Care (Part A)
For hospice care in 2009 you pay$0A co-payment of up to $5 per prescription
for outpatient prescription drugs for pain and symptom management
5% of Medicare-approved amount for inpatient respite care
20
Paying for Skilled Nursing Facility Stays (Part A)
For skilled nursing facility stays in 2009 you pay:$0 for the first 20 days in each benefit period$133.50 per day for days 21 – 100 each
benefit period All costs for each day after day 100 in
benefit period
21
Paying for Home Health Care (Part A)
For home health care in 2009 you pay:$0$20% of the approved amount for DME
22
Enrolling in Medicare Part BYou choose whether or not to enroll in Part B
2009 Monthly premium: $96.40 Initial Enrollment Period (IEP)General Enrollment Period (GEP)
2323
Part B Enrollment PeriodsExample
Marie turned 65 on June 25, 2008. She will have group health coverage from her employer until she stops working on December 31, 2008.
Part B enrollment opportunities …
Enrollment period Begins Ends
IEP 3/1/08 9/30/08
SEP 10/1/08 8/31/09
GEP (each year) 1/1 3/31
2424
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
25
Paying for Part B Services
In Original Medicare you payYearly deductible ($135 in 2009)20% coinsurance for most services50% for most outpatient mental healthSome copayments
Some programs may help
26
Part B Coverage
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
27
Covered Preventive Services
“Welcome to Medicare” physical exam
Abdominal aortic aneurysm screening
Bone mass measurement Cardiovascular disease
screenings Colorectal cancer
screenings Diabetes screenings
Glaucoma tests Mammograms (screening) Pap test/pelvic exam/
clinical breast exam Prostate cancer screening Flu shots Pneumococcal shots Hepatitis B shots Smoking cessation
28
A/B Claims Processing
Medicare A/B Claims are handled by Medicare Administrative Contractors (MACs)
Viewing Beneficiary ClaimsQuarterly StatementsMyMedicare.gov
29
Medigap
Health insurance policySold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in Original Medicare
• Deductibles, coinsurance, copayments
• Does not work with Medicare Advantage Plans
Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin
• So you can compare easily
30
Benefits for Medicare Beneficiaries
Medical Benefits Original Medicare Medicare Advantage Plan (HMO, PFFS,
PPO)
Prescription Drug Benefits
Stand-Alone Part D Plan Through your MA Plan
Supplemental Insurance
Stand-Alone Medigap Plan N/A
Beneficiaries with both Medicare A and B
31
Benefits for Medicare Beneficiaries
Medical Benefits Original Medicare
Prescription Drug Benefits
Stand-Alone Part D Plan
Supplemental Insurance
Stand-Alone Medigap Plan
Beneficiaries with Medicare A or B
32
Additional Key Points
TravelMedigap and Original MedicareDelaying Enrollment in B
33
Key Things to Remember
Part B IEPVariety of ways to receive coverage
34
Exercise
1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare.
A. True
B. False
35
Exercise
2. Most people receive Part A premium free.
A. True
B. False
36
Exercise
3. The Part B premium for most people is $96.40 in 2008.
A. True
B. False
37
Exercise
To be entitled to Medicare, you must be at least 65 years of age and retired.
True
False
38
Exercise
A beneficiary can have both a Part C Plan and still be covered by a Medigap plan or employer plan.
True
False
39
Exercise
Some people can delay enrolling in Part B without paying a penalty.
True
False
40
Exercise
A beneficiary can have both a Medigap plan and a Part D Prescription Drug Plan.
True
False
Medicare Advantage Plans
Medicare Part C
42
How Medicare Advantage Plans Work
Usually get all Part A and B services through planMay have to use the plan’s providers
May get extra benefitsVision, hearing, dental servicesPrescription drug coverage
Still in Medicare programGet all Part A and Part B servicesHave Medicare rights and protections
43
Medicare Advantage Plans
Health Maintenance Organization (HMO) PlansSome have Point-of-Service option
Preferred Provider Organization (PPO) Plans Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans
Since 2007
44
Other Medicare Plans
Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the
Elderly (PACE)
45
Eligibility for Medicare Advantage
Live in plan’s service areaHave Medicare Part A and Part B
Continue to pay Part B premiumMay also pay monthly premium to plan
Don’t have ESRD at enrollmentSome exceptions
46
Enrolling in Medicare Advantage Plans
Generally done during the Initial, Annual, or Open Enrollment Periods
Apply directly with the plan, through a broker or agent, or through Medicare
47
MA Open Enrollment Period LimitsIf coverage is Can use OEP to get Cannot use OEP to get
Medicare Advantage Plan with prescription drug coverage (MA-PD)
A different MA-PD or
Original Medicare Plan and PDP or
MA-PFFS and a PDP
MA-only or
Original Medicare Plan only
(cannot drop drug coverage)
Medicare Advantage Plan with no prescription drug coverage (MA-only)
MA-only or
Original Medicare Plan only
MA-PD or
Original Medicare Plan and PDP (cannot add drug coverage)
Original Medicare Plan and a PDP
MA-PD or
MA-PFFS and the same PDP
MA-only or
A different PDP to use with Original Medicare Plan
(cannot drop drug coverage)
Original Medicare Plan only
MA-only MA-PD or
Original Medicare Plan and PDP (cannot add drug coverage)
10
Medicare Prescription Drug Plans
Medicare Part D
49
Medicare Prescription Drug Coverage
Coverage began January 1, 2006All people with Medicare can join a planProvided through
Medicare Prescription Drug PlansMedicare Advantage and other Medicare plansSome employers and unions
50
Specifics of Part D Definition of Part D covered drugs
Available only by prescription FDA approved drugs Used for a medically accepted indication
Includes supplies associated with injection of insulin Syringes, needles, alcohol swabs, gauze coveredTest strips and lancets not covered as available
under Part B Part D does not cover drugs already covered under
Part A or B (even if the person does not have Part A or Part B)
51
Part D Coverage
Part D Plan formularies must include “all or substantially all” drugs included in these categories:Cancer medicationsHIV/AIDS treatmentsAntidepressantsAntipsychotic medicationsAnticonvulsive treatments
• For epilepsy and other conditionsImmunosuppressants
52
Access to Part D Covered Drugs
Plans can manage access to covered drugsTiersPrior authorizationStep therapyQuantity limits
Plans must have processes in placeMembers must be provided all prescription
medications determined to be medically necessaryRequest coverage determinations and appeals
53
Part D Excluded Drugs Benzodiazepines Barbiturates Agents for anorexia, weight loss, or weight gain Fertility drugs Drugs for cosmetic purposes or hair growth Cough and cold medicine Prescription vitamins
Except prenatal and fluoride preparations Nonprescription drugs (over-the-counter drugs) Erectile dysfunction drugs
54
Access to Part D Covered Drugs
Plans can manage access to covered drugsTiersPrior authorizationStep therapyQuantity limits
Plans must have processes in placeMembers must be provided all prescription
medications determined to be medically necessaryRequest coverage determinations and appeals
55
Part D Excluded Drugs Benzodiazepines Barbiturates Agents for anorexia, weight loss, or weight gain Fertility drugs Drugs for cosmetic purposes or hair growth Cough and cold medicine Prescription vitamins
Except prenatal and fluoride preparations Nonprescription drugs (over-the-counter drugs) Erectile dysfunction drugs
56
Enrollment Periods
Initial Enrollment Period (IEP)7 monthsStarts 3 months before month eligible for Medicare
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)
57
Coverage Varies
Plans have formularies May not include every Part D drug
• Similar drug usually covered– Safe and effective
May have different cost levels (“tiers”)
Must cover range of drugs in each category
58
Access to Covered Drugs
Plans can manage access to drug coverage throughFormulariesPrior authorizationStep therapyQuantity limits
59
Medicare Drug Plan Costs
Monthly premiumVaries by planSome plans have no premium
Possible deductibleNo more than $275 in 2009
Copayments or coinsuranceMay depend on how much spent that year
60
Costs in 2009
Premium Generally less than $37 monthly
Deductible No more than $295
Drug Costs $295-$2,700
Beneficiary pays 25%
Drug Costs $2,700-$6,153
Beneficiary pays 100%
After spend $4,350 Beneficiary pays 5%
61
Coverage Gap in 2009
When member pays 100% of drug costsBegins after $2,700 in total drug costs
Initial coverage limit
Continues until out-of-pocket costs total $4,350May start earlier in some plans
After gap, pay 5% or small copaymentCatastrophic coverage
62
Late Enrollment Penalty
If you wait to enrollAdditional 1% of national base premium for
every month eligible but not enrolledMust pay the penalty as long as enrolled in a
Medicare drug plan
No penalty if you have other coverage at least as good as Medicare drug coverage
63
Exercise
1. You must have Medicare Part A and Medicare Part B to join Medicare Advantage plan with drug coverage.
A. TrueB. False
64
Exercise
2. The Annual Coordinated Election Period runs from November 1 through December 15 each year.
A. TrueB. False
65
Casework The beneficiary states that they were misled by an
agent or the plan and enrolled into a plan they did not want.
The beneficiary disenrolled from the plan or changed to direct bill, but premiums are still coming out of their SSA check or the beneficiary wanted premiums to come out of their SSA check and they are being billed directly.
The beneficiary enrolled or disenrolled in the plan, but the enrollment/disenrollment is not showing up at CMS.
The plan does not cover a medication the beneficiary needs.
Extra Help with Drug Plan Costs
67
Extra Help With Drug Costs
Sometimes called Low Income Subsidy (LIS)People with lowest income and resources
Pay no premiums or deductiblesHave small or no copayments
Those with slightly higher income and resourcesHave a reduced deductiblePay a little more out of pocket
No coverage gap for people who qualify for LIS
68
How People Qualify for Extra HelpPeople with Medicare and
BasisData Source
Changes During the Year
Medicaid benefits• Full Medicaid
benefits• Medicare Savings
Program
Automatically qualify
StatesQualify for a full
calendar yearGenerally only favorable
changes will occur
SSI benefits SSA
No Medicaid or SSI benefits
Must apply
SSA* or states
*almost all
Some events can impact status through the year
Extra help can increase, decrease, end
69
Continuing Eligibility for People who Applied with Social SecurityFour types of redetermination processes
InitialCyclical or recurringSubsidy-changing event (SCE)
70
Income and Resource Limits Income
Below 150% Federal poverty level• $1,300 per month for an individual* or• $1,750 per month for a married couple*• Based on family size
ResourcesUp to $11,990 (individual)Up to $23,970 (married couple)
• Includes $1,500/person funeral or burial expenses• Counts savings and stocks• Does not count home you live in
*Higher amounts for Alaska and Hawaii
2008 amounts
2008 amounts
71
MedicaidFederal and state program
For some people with limited income and resources If eligible, most health care costs coveredEach state decides
Who is eligibleHow people apply
Office names varySocial ServicesPublic AssistanceHuman Services
72
2009 LIS Guidelines
Annual Income
Monthly Income
Resources
73
Medicare and Full Medicaid
Auto-enrolled in a plan unlessAlready in a Part D planChoose and join own planCall plan or 1-800-MEDICARE to opt out
Coverage first month person has both Medicare and Medicaid
Will get auto-enrollment letter on yellow paperHave a continuous SEP
74
Others Qualified for Extra Help
Facilitated into a plan unlessAlready in a Part D planChoose and join own plan Enrolled in employer/union plan receiving subsidyCall plan or 1-800-MEDICARE to opt out
Coverage effective 2 months after CMS notifiedWill get facilitated enrollment letter on green paperHave continuous SEP
75
People New to Extra Help
People can apply for extra help any timeCan reapply if circumstances change
People in a Medicare drug plan who later qualify for extra helpPlan is notifiedPlan will refund costs back to effective date of
extra help• Premiums• Cost-sharing assistance
76
Auto- and Facilitated Enrollment
CMS identifies and enrolls people each monthPlans are randomly assigned
• From those with premiums at/below regional low-income premium subsidy amount
• May join MA plan meeting special needs
People already in MA planEnrolled in MA-PD, if offered
77
Enrollment Notices
CMS notifies people of enrollment in a PDP Auto-enrollment letter on yellow paperFacilitated enrollment letter on green paper
• Two versions– Full subsidy– Partial subsidy
• Includes list of plans in that region at/below regional low-income premium subsidy amount
MA plan sends notice if enrollment in MA-PD
78
Continuing Eligibility
People Who Automatically QualifyCMS re-establishes eligibility each fall for
next calendar yearPeople will receive letter from Medicare
• In September on gray paper– Those who no longer automatically qualify
– Includes SSA application
• In early October on orange paper– Those who will continue to automatically qualify but
with a different copayment level
79
Continuing Eligibility
People who applied with Social SecurityFour types of redetermination processes
• Initial• Cyclical or recurring• Subsidy-changing event (SCE)• Other event
– Any change other than SCE
80
Extra Help in 2008
Group 1 Group 2 Group 3
Premium $0 $0 Sliding scale based on income
Deductible $275/year
$0 $0 $56
Coinsurance up to $4,050 out of pocket
$1.05/$3.10 copay
$2.25/$5.60 copay
Up to 15% coinsurance
Catastrophic coverage
$0 $0 $2.25/$5.60 copay
81
Exercise
1. People with the lowest income and resources will pay no premiums or deductibles and have small or no co-payments for Part D coverage.
A. TrueB. False
82
Exercise
2. People can only apply for Extra Help during a the Open and Annual Enrollment Periods.
A. TrueB. False
83
Exercise
3. People who were automatically eligible for extra help for 2008 continue to qualify for the extra help through December 2008.A. TrueB. False
84
For More Information
1-800-MEDICARE (1-800-633-4227)TTY users call 1-877-486-2048
www.medicare.gov State Health Insurance Assistance
Program (SHIP)Medicare & You handbook
Other publications
85
CMS Complaints Procedure
Complete Complaint Tracking Form Available on VDA’s website:
http://vda.virginia.gov/pdfdocs/SHIP-Regional-Referral.doc
Email completed form to:[email protected] VICAP DirectorOlivia Claud (if BOI/agent issue involved)
86
Summary
Medicare coverage Original Medicare Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs