Navigating Your Benefits and Healthcare System
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What we will cover today:
• Medicare Overview• Enrolling in Medicare• Managing Your Medicare• Resources to Help pay Medicare Premiums
and Co-insurance• Resources to Help with Medication Costs• Long Term Care and Tools to Help You Plan for
Long Term Care
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www.agewiseconnection.com
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Qualifying for MedicareUS citizens or resident VISA holders who have lived in the US for five consecutive years and
• 65 years or older; eligible for Social Security or Railroad Retirement Benefits
• 65 or older; married to someone eligible for Social Security/Railroad retirement
• Have received Social Security Disability income for at least 24 months
• Have ESRD (kidney failure) or ALS (Amyotrophic Lateral Sclerosis)
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Applying for Medicare Initial Enrollment Period
Apply 3 months before age 65, the month of 65th birthday, or 3 months after month of 65th birthday*Need not be retired
Automatically enrolled if receiving Social Security or Railroad Retirement Benefits
Received Social Security Disability Benefits (SSDI) for 24 Months
Apply through the Social Security Administration (SSA)or Railroad Retirement Board (RRB)
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Medicare Basics
Medicare
Part AHospital
Part BMedical
Part DPrescription
Part C Medicare Advantage
Medicare Health Plans (PPO, HMO, PFFS,
SNP)
Known as Original Medicare
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The Original Medicare Plan
• Part A and/or Part B
• Go to any provider that accepts Medicare
• Pay Medicare Part B premium
• Pay deductibles
• Pay co-insurance
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Medicare Part AOverview
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Medicare Part A – Eligibility and Premiums
• Awarded at age 65 or if a person has received disability payments for 24 months
• $0 premium for those who have 40 quarters of Medicare-covered Employment (or from a spouse)
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Medicare Part A – Hospital Insurance – Helps Pay for
• Hospital stays
• Skilled nursing facility (SNF) care
• Home health care
• Hospice care
• Blood
Deductibles, Co-Payments For Part A (Hospitalization)
• $1,068 deductible Per Benefit Period
• $267 Per day for days 61-90
• $534 Per day for 91-150(Lifetime Reserve Days)
• All costs for each day beyond 150 days
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Medicare Part BOverview
Part B - MedicalOut-patient/Physician Insurance Helps Pay
for:• Doctor Services• Outpatient therapy • Outpatient mental health services• Some preventive health care services• Clinical laboratory services• Durable medical equipment (DME)• Outpatient hospital services • Blood • Ambulance service
– If other transportation would endanger health
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Enrolling in Medicare Part B
Initial Enrollment Period
• 7 months beginning 3 months before age 65
• Enrollment after 24 months of Social Security disability
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Paying for Medicare Part B – Outpatient Services
• $96.40 monthly premium
• $135 per year deductible in 2009
• 20% co-insurance for most services
Medicare Prescription Drug Coverage
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Medicare Part D: Prescription Drug
Coverage
• Medicare drug coverage• Must enroll in Part D within 90 days of Medicare
eligibility – else a penalty will apply– Penalty – 1% of the national average premium times as many
months you could have been enrolled– Penalty waived if you have “creditable” coverage by another
insurance – Part D enrollment needs to be within 63 days of loss of creditable coverage
• People to receive Part D benefits through stand alone PDP plan or Medicare Advantage Plan (MAPD)
Part D Eligibility Requirements
• Medicare Part A and/or Part B– Part A and Part B to join Medicare Advantage
plan with drug coverage
• Live in plan’s service area• Enroll in a plan
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Enrolling in Part D
Enrollment Periods for PDP • Initial Enrollment Period (7 mos. surrounding
Medicare effective date) • Annual Coordinated Election Period (AEP Nov. 15th-
Dec. 31st)-Can choose PDP or MA-PD• Special Enrollment Period (SEP)
Open enrollment period for MA-PD (OEP Jan. 1st-Mar. 31st)
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What is the Medicare prescription “donut hole” or “gap?”
• Getting into the gap:– You pay copays or coinsurance for each
prescription filled; the plan pays the remainder until drug costs (retail) reach $2,700
• The gap:– You pay 100% of drug costs until out of
pocket for the calendar year equal $4,350
• After the Gap (Catastrophic Coverage)– Small coinsurance charged for each drug until
end of year
*Note: excluded drugs do not help contribute towards out of pocket costs to be out of the gap
Choosing a Part D Plan• For assistance choosing a
Part D plan visit www.medicare.gov
• The following information is needed to compare plans:
-Name-Date of birth-Medicare card-Zip code-County-List of medications
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www.medicare.govPrescription Drug Plan Finder
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Part C -Medicare AdvantagePrivate Health Plans
Medicare
Medicare Advantage Plan
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Pays plan to provide Part A and B coverage
Pays company $$ per person enrolled
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Medicare Advantage (Part C)• Replaces the manner in which benefits for Original
Medicare are provided
• Offered through private companies
• May offer extra benefits including Part D coverage
• Most require additional premium in additional to annual Medicare premium
• Coinsurance/Co-pays
• May offer some vision or basic dental benefits
• For enrollment, MUST:– Have Medicare Part A and Part B
– Live in plan’s geographical service area
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What are Medicare Advantage Plan Options?
• Medicare Managed Care Plans (HMOs) – Health Maintenance Organizations
• Medicare Preferred Provider Organization (PPOs) – Preferred Provider Organizations
• Private Fee-for-Service Plans (PFFSs)
• Special Needs Plans (SNPs)
Why choose an Advantage Plan?• Generally includes Physical
Exam annually
• May include some Dental, Vision or Hearing Coverage
• Often, fixed copay for doctor services
• Sometimes, lower hospitalization costs
• Often, a lower monthly premium than Medigap
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What’s the Advantage?
• Can result in cost savings for medical care for some people
• Can offer additional services not covered by Original Medicare
• Any Medicare beneficiary can enroll and receive benefits – no pre-existing condition exclusion or waiting period for coverage
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Is Medicare Advantage right for you?• A Medicare Advantage Plan is NOT a replacement for
your Medigap policy.• Before you enroll in a Medicare Advantage Plan, answer
the following questions:– 1. Are my doctors and hospitals covered by the plan? That
is, do they accept the plan’s terms and conditions?– 2. Do I need a referral to see a specialist?– 3. Can I get care outside the plan's service area or
network? If so, how?– 4. What costs are involved in the plan (premium,
deductible, copayments)?– 5. Are my prescriptions covered by the plan?– 6. What are copayment requirements for lab tests,
diagnostic tests, x-rays, MRI scans, or CT scans?
Medicare Advantage Enrollment:General Periods
• When first eligible for Medicare
• Open Enrollment PeriodJanuary – March
• If plan has Part D coverage, additional period:November 15th - December 31st
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What card do I use?
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Medicare Advantage Enrollment
• You can use the Medicare Plan Comparison tool on Medicare.gov to find and compare plans
• You can enroll online
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Medicare Advantage Enrollment
To enroll, call: Medicare Private Insurance Company
Or, online: www.medicare.gov
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Financial Assistance for Medicare Health Costs
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Medicaid – Medicare Savings Programs (QMB, SLMB, and QI)
• Pays Medicare premiums and possibly additional coinsurances
• Savings Program eligibility varies state to state:• Georgia 2009 Eligibility
Coverage Single income limit
Single asset limit
Married Income limit
Married asset limit
QMB Part B premiums + coinsurances
$903 $4,000 $1,214 $6,000
SLMB Part B premiums $1,083 $4,000 $1,457 $6,000
QI1 Part B premiums $1,218 $4,000 $1,639 $6,000
Burial Allowance: $10,000 per person:
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Extra Help for Prescriptions/ Low Income Subsidy
• Who is eligible?Income < $0-1,354 Single
< $0-1,821 Married Assets (Resources)
$12,510 Single $25,010 Married
• What are the benefits?– No/low premiums for those with
limited incomes– No/low deductible– Small copayment or coinsurance for
each prescription
Resources for Bridging the Coverage Gap
http://www.medicare.gov/bridging-the-gap.asp
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Resources for Bridging the Coverage Gap
• Needy Medswww.needymeds.org
• Partnership For Prescription Assistancewww.pparx.org
• RxAssistwww.rxassist.org
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Benefits CheckUpwww.benefitscheckup.org
Find Benefits Programs For:• Prescription drugs • Nutrition (SNAP/Food Stamps) • Energy assistance • Financial • Legal • Health care • Social Security • Housing • In-home services • Tax relief • Transportation • Educational assistance • Employment • Volunteer services
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What is Medigap ?• Sold by private insurance
companies
• Fills in the “GAPS” for Medicare
• 12 standardized plans (A through L)
• Must have Part A & B
• Medigap SELECT policies may require use of certain physicians and hospitals
Medicare Primary
Medigap/
Supplement Insurance
Secondary
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Enrolling in a MedigapOpen Enrollment Period
• 6 months following enrollment in Medicare Part B
• Cannot be turned down for any reason
• Cannot charge more because of health problem
• Cannot make beneficiary wait for all coverage to start– May wait for coverage of pre-existing
conditions – unless creditable coverage
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How Medigap Works
• Only works with Original Medicare– Won’t work with
• Medicare Advantage Plans • Other Medicare plans
• Can go to any doctor, hospital, or provider that accepts Medicare– Unless have Medigap SELECT policy
Medigap Is Not
• Medicare Advantage Plans• Medicare Part B• Medicare Prescription Drug
Plans• Medicaid• Employer or union plan• TRICARE• Veterans’ benefits
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Who Can Buy Medigap?• Must have Medicare Parts A
and B• May not be able to buy
Medigap under 65 – People with a disability– People with End-Stage Renal
Disease• Guaranteed right to buy a
Medigap policy– In your Medigap open
enrollment period– Covered under a Medigap
protection
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Why Buy Medigap?
• Original Medicare does not pay all costs
• Medigap policy may help
– Lower out-of-pocket costs
– Get more health insurance coverage
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Medigap Toolwww.medicare.gov
Provides:• Information on
different types of Medigap policies by area
• Contact information on the companies that offer them
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Once you are enrolled in Medicare, you can use www.mymedicare.gov to:
• View claim status (excluding Part D claims) • Order a duplicate Medicare Summary Notice (MSN) or replacement
Medicare card • View eligibility, entitlement and preventive services information • View enrollment information including prescription drug plans • View or modify your drug list and pharmacy information • View address of record with Medicare and Part B deductible status • Access online forms, publications and messages sent to you by CMS
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www.mymedicare.gov
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Mymedicare.gov Virtual Tourhttp://www.mymedicare.gov/WBTMain.asp
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www.medicareinteractive.org
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For More Information….
• Medicare 1-800-633-4227www.medicare.gov
• Social Security Administration 1-800-772-1213
www.ssa.gov
• Georgia Cares1-800-669-8387
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What is Long-Term Care?
How is it paid for?
Long-Term Care
About 2/3 of those over age 65 will need some LTC, for an average of 3 years
Nearly 1 in 4 people provide long-term care to friends and relatives
Long-Term Care
Activities of Daily Living (ADL’s)
Instrumental Activities of Daily Living (IADLs)
Bathing
Dressing
Eating
Using the Toilet
Transferring
Continence
Grocery Shopping
Laundry
Preparing Meals
Housework
Managing Medication
Transportation
Levels of Long Term Care
Skilled Care – medical or nursing care and therapies
Personal or Custodial Care – help with ADLs
Supervisory Care – monitoring, supervision and stand-by help with ADLs
Long Term Care Settings
Informal Care Formal Care
Unpaid Caregivers
Family & Friends
Caregiver Support
Home Care Services
Community-Based Services
Residential Care
Why Plan?
More control and choice
Better access to options
Preservation of assets and income
Fewer burdens on loved ones
www.medicare.gov/LTCPlanning
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www.agewiseconnection.com/retirement
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www.agewiseconnection.com/benefitsYou will find:• Resources to help you
navigate the Medicare system• Information on getting help
paying for prescriptions• Resources to help you plan for
Long Term Care• Resources to help you learn
more about health conditions• Tool to help navigate the
healthcare system – transition from one care setting to another
All in one place!61
Atlanta Regional CommissionArea Agency on Aging
www.agewiseconnection.com
404.463.3333
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