Understanding Medicare Module 1C Lessons * Program Basics * Your Medicare Coverage Choices * Original Medicare (Part A and Part B) * Medicare Advantage (Part C) and Other Medicare Plans * Medicare Prescription Drug Coverage (Part D) * Appeals * Programs for People with Limited Income and Resources Lesson 1 Program Basics * What is Medicare * Who is Eligible * Enrollment * How to Apply * The Four Parts of Medicare * What is not Covered What is Medicare? * Health insurance for three groups of people - 65 and older - Under 65 with certain disabilities - Any age with End-Stage Renal Disease (ESRD) * Administration - Centers for Medicare & Medicaid Services * Enrollment - Social Security Administration for most - Railroad Retirement Board (RRB) Automatic Enrollment Enrolling in Medicare * Some people need to sign up - Not getting Social Security or Railroad benefits - Enroll through Social Security (SSA) or - Railroad Retirement Board for railroad retirees * Apply 3 months before age 65 - Don't have to be retired * You have choices in how you get your Medicare health and drug coverage Lesson 2 - Your Medicare Coverage Choices * Original Medicare (Part A and Part B) * Medicare Advantage (Part C) and Other Medicare Plans * Medicare Prescription Drug Coverage (Part D) Medicare Part A Hospital Insurance * Costs * Coverage - Inpatient Hospital Stays - Skilled Nursing Facility Care - Home Health Care - Hospice Care - Blood Medicare Part A (Hospital Insurance) * Most people receive Part A premium free * Less than 10 years of Medicare-covered employment - Can pay a premium to get Part A * For information, call SSA at 1-800-772-1213 - TTY users call 1-800-325-0778 Benefit Period * Charges based on "benefit period" - Inpatient hospital care and skilled nursing facility (SNF) services - Begins day admitted to hospital - Ends when out of a hospital or SNF for 60 days in a row - You pay deductible for each benefit period - No limit to number of benefit periods Paying for Hospital Stays * For each benefit period in 2010 you pay - $1,100 total deductible for days 1 - 60 - $275 co-payment per day for days 61 - 90 - $550 co-payment per day for days 91 - 150 (60 lifetime reserve days) - All costs for each day beyond 150 days Skilled Nursing Facility Care * Must meet all conditions - Require daily skilled services * Not just long-term or custodial care - Inpatient in a hospital 3 consecutive days or longer - Admitted to the SNF within 30 days after leaving hospital - Care is for a condition that was treated in the hospital - Facility MUST be a Medicare participating SNF Skilled Nursing Facility Coverage * Semi-private room * Meals * Skilled nursing care * Physical, occupational, & speech-language therapy * Medical social services * Medications, medical supplies/equipment * Ambulance transportation (limited) * Dietary counseling Paying for Skilled Nursing Facility Care * For each benefit period in 2010 you pay - $0 for days 1 - 20 - $137.50 per day for days 21-100 - All costs after 100 days Home Health Care * Four conditions for home health coverage - Doctor must make a plan for your care at home - Must need specific skilled services - Must be homebound - Home health agency must be Medicare-approved Home Health Care Coverage * Part-time/intermittent skilled nursing care * Physical, occupational & speech-language therapy * Medical social services * Some home health aide services * Durable medical equipment, supplies Paying for Home Health Care * In Original Medicare you pay - Nothing for covered home health care services - 20% of Medicare-approved amount for durable medical equipment Hospice Care * Special care for terminally ill and family - Expected to live 6 months or less * Focuses on comfort, not on curing the illness * Doctor must certify for each "period of care" - Two 90-day periods, then unlimited 60-day periods * Hospice provider must be Medicare-approved Covered Hospice Services * Medical equipment and supplies * Drugs for symptom control and pain relief * Short-term hospital inpatient care (limited) * Respite care in a Medicare-certified facility - Up to 5 days each time with no limit to number of times * Home health aide and homemaker services * Social worker services * Dietary counseling * Grief counseling Paying for Hospice Care * In Original Medicare you pay - Nothing for hospice care - Up to $5 for prescription drugs for pain and symptom mgmt - 5% for inpatient respite care * Amount can change each year * You generally pay 100% for room and board in a facility Blood (Inpatient) * If the hospital gets blood free from a blood bank - You won't have to pay for it or replace it * If the hospital has to buy blood for you, you either - Pay the hospital costs for the first 3 units of blood you get in a calendar year or - Have the blood donated by you or someone else Medicare Part B Medical Insurance * Enrolling * Keeping Part B * Medicare and other coverage * Premium * Coverage * Part B costs * Assignment Monthly Part B Premium Paying the Part B Premium Part B Late Enrollment Penalty Part B Coverage * Doctors' services * Outpatient medical/surgical services and supplies * Diagnostic tests * Outpatient therapy * Outpatient mental health services * Some preventive health care services * Other medical services Covered Preventive Services * One time "Welcome to Medicare" physical exam * Physical Exam (yearly "Wellness Exam") Starts 2011 * Abdominal aortic aneurysm screening* * Bone mass measurement * Cardiovascular disease screenings * Colorectal cancer screenings * Diabetes screenings * EKG Screening* * Flu shots * Glaucoma tests * Hepatitis B shots * HIV Screening * Mammograms (screening) * Pap test/pelvic exam/clinical breast exam * Prostate cancer screening * Pneumococcal shots * Smoking cessation Paying for Part B Services * In Original Medicare you pay - Yearly deductible of $155 in 2010 - 20% coinsurance for most services - Some copayments * Some programs may help pay these costs Assignment * Medicare doctors/providers/ suppliers - Accept the Medicare-approved amount * As full payment for covered services * Only charge Medicare deductible/coinsurance amount - They submit your claim to Medicare directly * Applies to Original Medicare Part B claims * We say "accepts assignment" Providers who do NOT Accept Assignment * May charge more than Medicare-approved amount - Limit of 15% more for most services * "The limiting charge" * May ask you to pay entire charge at time of service * Providers sometimes must accept assignment - Medicare Part B-covered Rx drugs - Ambulance providers Private Contracts * Agreement between you and your doctor - Original Medicare and Medigap will not pay - Other Medicare plans will not pay - You will pay full amount for the services you get - No claim should be submitted - Cannot be asked to sign in an emergency What is not covered by Medicare Part A or Part B What's NOT Covered by Part A and Part B? * Items and services Medicare doesn't cover include, but aren't limited to: - Long-term care - Routine dental care - Dentures - Cosmetic surgery - Acupuncture - Hearing aids and exams for fitting hearing aids Exercise Exercise B. The Part B premium for most people is $96.40 in 2010. Original Medicare * What it is * Medicare Card * Medigap (Medicare Supplement Insurance) policies * Private contracts Original Medicare * Run by the Federal government * Provides your Part A and/or Part B coverage * Go to any doctor or hospital that accepts Medicare * You pay - Part B premium (Part A free for most people) - Deductibles, coinsurance or copayments * Can buy a Medigap policy to help pay some of these costs * Get Medicare Summary Notice (MSN) * Can join a Medicare Rx Plan to add drug coverage Medicare Card (front) Medigap * Medigap (Medicare Supplement Insurance) policies - Private health insurance for individuals - Sold by private insurance companies - Supplements Original Medicare coverage - Follow Federal/state laws that protect you - Must state "Medicare Supplement Insurance" Medigap * Costs vary by plan, company, and location * Medigap insurance companies can only sell a "standardized" Medigap policy - Identified in most states by letters - MA, MN, and WI standardize their plans differently * Does not work with Medicare Advantage * No networks except with a Medicare SELECT policy * You pay a monthly premium Medicare Advantage & Other Medicare Plans Medicare Advantage (MA) Plans (Part C) * What they are * Who can join * How the plans work * When to join and switch plans * MA Plan costs * Other Medicare plans What Are Medicare Advantage (MA) Plans? * Health plan options approved by Medicare * Run by private companies * Part of the Medicare program - Sometimes called "Part C" - Available in many areas of the country * Medicare pays a set amount to plan for your care If you join a Medicare Advantage Plan * You are still in Medicare the program * You still have Medicare rights and protections * You still get regular Medicare-covered services * You may get extra benefits - Such as vision, hearing, or dental care * You may be able to get prescription drug coverage Types of Medicare Advantage Plans * Health Maintenance Organization (HMO) * Preferred Provider Organization (PPO) * Private Fee-for-Service (PFFS) * Special Needs Plan (SNP) * Medicare Medical Savings Account (MSA) Medicare Advantage Eligibility Requirements * You must live in plan's service area * You must have Medicare Part A and Part B * You must not have ESRD at time of enrollment - Some exceptions How Medicare Advantage Plans Work * You get Medicare-covered services through the plan - All Part A and Part B covered services - Some plan may provide additional benefits * Most plans include prescription drug coverage * May have to go to network doctors or hospitals * Benefits and cost-sharing may be different than in Original Medicare Medicare Advantage Plan Costs * Must still pay Part B premium - Some plans may pay all or part for you - Some people may be eligible for state assistance * You may pay additional monthly premium to plan * You pay deductibles, coinsurance, and copayments - Different from Original Medicare - Varies from plan to plan Other Medicare Plans * Other types of Medicare plans that aren't MA plans - Medicare Cost Plans - Demonstrations/Pilot Programs - Programs of All-inclusive Care for the Elderly (PACE) * Only available in certain areas Exercise Exercise B. In 2011, the Medicare Advantage Open Enrollment Period is from January 1 through February 14. Medicare Prescription Drug Coverage (Part D) * What it is * Who can join * When you can join and switch * Part D plan costs * Extra Help * What is covered * How plans work Medicare Prescription Drug Coverage * Available for all people with Medicare * Provided through - Medicare Prescription Drug Plans - Medicare Advantage Plans - Other Medicare plans Who Can Join * You must have Medicare Part A and/or Part B * You must live in plan service area * You must enroll in a Medicare Rx plan * You can't live outside the U.S. or be incarcerated Late Enrollment Penalty * People who wait to enroll after their IEP - Pay additional 1% of base beneficiary premium * For every month eligible and not enrolled * For as long as they have Medicare drug coverage - Except those with other creditable drug coverage * At least as good as Medicare prescription drug coverage Prescription Drug Costs * Costs vary by plan * Most people will pay - Monthly premium - Deductible - Copayments or coinsurance - Very little after $4,550 out-of-pocket in 2010 * Extra Help if you have limited income/resources * One-time $250 rebate - During coverage gap in 2010 Extra Help with Drug Plan Costs * Help for people with limited income and resources * Social Security or state makes determination * Some groups are automatically eligible - People with Medicare and Medicaid - Supplemental Security Income (SSI) only - Medicare Savings Programs * Everyone else must apply Income and Resource Limits How to Apply for Extra Help * Multiple ways to apply - Paper application - www.socialsecurity.gov - State Medical Assistance office - Local organization * You or someone on your behalf can apply Medicare Prescription Drug Coverage * Must include a range of drugs in each Rx category - Generic and brand-name prescription drugs * Must cover all drugs in 6 classes - Anti-psychotics, anti-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS drugs * Don't have to cover certain drugs - Benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for erectile dysfunction Access to Covered Drugs * Coverage and rules vary by plan * Plans can manage access to drug coverage through - Formularies (list of covered drugs) - Prior authorization (doctor requests before service) - Step therapy (type of prior authorization) - Quantity limits (limits quantity for period of time) Formulary * A list of prescription drugs covered by the plan * May have "tiers" that cost different amounts Prior Authorization * Doctor must contact plan for prior authorization - Before prescription will be covered - Must show medical necessity for that particular drug * Ask plan for prior authorization requirements - Process for requests may vary by plan Drugs Not Covered by Part D * Excluded by law from Medicare coverage - Anorexia, weight loss or weight gain drugs - Barbiturates and benzodiazepines* - Erectile dysfunction drugs when used for the treatment of sexual or erectile dysfunction - Fertility drugs - Drugs for cosmetic or lifestyle purposes (e.g., hair growth) - Drugs for symptomatic relief of coughs and colds - Prescription vitamin and mineral products (except prenatal vitamins and fluoride preparations) - Non-prescription drugs *To be covered in 2014 Drugs Not Covered by Part D * Medicare Part A or Part B covered drugs - Unless you don't meet Part A or B coverage requirements * Plan may choose to cover excluded drugs - At their own cost, or - Share the cost with members Step Therapy * Type of prior authorization * Person must try a similar, less-expensive drug that has been proven effective * Doctor can request an exception if - Tried similar, less expensive drug and it didn't work, or - Step-therapy drug is medically necessary Quantity Limits * Plans may limit quantity of drugs they cover - Over a certain period of time - For reasons of safety and/or cost * Doctor may need to request an exception - Additional amount is medically necessary Exercise A. People who wait to enroll in a Part D plan after their Initial Enrollment Period may pay an additional 1% of the base beneficiary premium for every month they were eligible but not enrolled. Exercise B. You must have Medicare Part A and Part B to enroll in a Medicare prescription drug plan. Lesson 3 - Appeals * Part A and B appeals process * Part C appeals process * Part D appeals process Lesson 4 - Programs for People with Limited Income and Resources * Medicaid * Medicare Savings Programs * Help for People Who Live in the U.S. Territories Medicaid * Federal-state health insurance program - People with limited income and resources - Certain people with disabilities * If eligible, most health care costs covered * Eligibility determined by state * Application processes and benefits vary * Office names vary Medicare Savings Programs * Help from Medicaid paying Medicare premiums - For people with limited income and resources - May also pay Medicare deductibles and coinsurance - Programs include * Qualified Medicare Beneficiary (QMB) * Specified Low-income Medicare Beneficiary (SLMB) * Qualifying Individual (QI) Programs in U.S. Territories * Help people pay their Medicare costs * U.S. territories - Puerto Rico - Virgin Islands - Guam - Northern Mariana Islands - American Samoa * Programs vary - Contact Medical Assistance office Steps to Take * If you think you might qualify Review guidelines * Collect your personal documents * Get more information * Call your state Medical Assistance office * Call your local SHIP * Call your local Area Agency on Aging Complete application with state Medical Assistance office Exercise A. Medicaid eligibility requirements are set by each CMS Regional Office. For More Information * 1-800-MEDICARE (1-800-633-4227) - TTY users should call 1-877-486-2048 * Medicare & You handbook, CMS Pub. #10050 - Other Medicare publications on www.medicare.gov * www.medicare.gov * www.cms.gov * Your State Health Insurance Assistance Program (SHIP)