Medicare – Getting started June 11, 2016

What is SHIBA? 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’re an educational service We don’t sell anything! June 11, 2016Medicare – Getting started2

Today’s overview June 11, 2016Medicare – Getting started 3 Medicare basics: A, B, D or C How and when to enroll Medigaps (Medicare Supplement plans) Part D (prescription drug coverage) Medicare Advantage plans Do you need help paying for your plan? Next steps

Medicare decisions June 11, 2016Medicare – Getting started 4 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 plan? Can I get help with Medicare costs? Maybe?

Protect yourself! June 11, 2016Medicare – Getting started 5 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!

What is Medicare? June 11, 2016Medicare – Getting started 6 Health insurance for people: Age 65 and older Under age 65 and deemed disabled (SSDI) by SSA 24-month waiting period Any age with End-State Renal Disease (ESRD) or Lou Gehrig’s Disease (also known as ALS) No waiting period Who are a US citizen or legal permanent resident (LPR) If an LPR, must be for 5 continuous years

What is Medicare? June 11, 2016Medicare – Getting started 7 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

The four parts of Medicare June 11, 2016Medicare – Getting started 8 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

Original Medicare June 11, 2016Medicare – Getting started 9 Part A – Hospital insurance Hospital (inpatient) Skilled Nursing Facility Home health care Hospice care Part B – Medical insurance Doctor’s visits Outpatient hospital services Clinical lab tests Durable Medical Equipment Preventive services

Medicare doesn’t cover everything! June 11, 2016Medicare – Getting started 10 Routine eye exams, eyeglasses Only glasses after cataract surgery Routine dental care Cleanings, 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) June 11, 2016Medicare – Getting started 11 What does Part A cost? Most people get Part A premium free Based upon enrollee or spouse working and paying FICA taxes You can pay a premium to get Part A If you don’t have the work history It can cost $226 or $411/month depending on work credits

Medicare Part B (medical insurance) June 11, 2016Medicare – Getting started 12 What does Part B cost? This year – for most- Part B costs: $104.90/month Most people NEW to Medicare will pay $121.80/month Those with higher incomes may pay more Social Security notifies you of what you have to pay The amount may change yearly

Paying for Part A & B services June 11, 2016Medicare – Getting started 13 See chart in handouts In addition to Part B premiums and sometimes Part A premiums In Original Medicare, you pay: Part A Hospital deductible of $1,288 Part B yearly deductible of $166 20% coinsurance for most services THERE MAY BE OTHER COSTS! Programs may help pay these costs For people with limited income and resources

Enrolling in Medicare June 11, 2016Medicare – Getting started 14 Some people get Part A and B automatically: You already receive financial benefits from Social Security or the Railroad Retirement Board When you reach age 65 You’re under age 65 and disabled and receive financial benefits (SSDI) After 24 months of receiving SSDI You have ALS (Lou Gehrig’s disease) or End Stage Renal Disease (ESRD) Medicare starts right away

When enrollment is not automatic June 11, 2016Medicare – Getting started 15 Most people must enroll themselves – when you turn age 65 If you are not yet receiving Social Security or RRB benefits You need to enroll with Social Security Online at socialsecurity.gov Call Visit local Social Security office If you worked for the railroad, you enroll with RRB Call your local RRB office or

When can I enroll in Medicare? Initial Enrollment Period June 11, 2016Medicare – Getting started 16 The later you enroll, the later your coverage starts: Up to a 3-month wait 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

My spouse or I will keep working after age 65 Special Enrollment Period June 11, 2016Medicare – Getting started 17 Special Enrollment Period Occurs after Initial Enrollment Period ends For people who are covered by a group health plan based upon current employment The employment is your own, spouse’s, or sometimes other family member Can enroll in Medicare Any time still covered by the group plan During the 8-month period that starts with the month after employment ends or the coverage ends, whichever happens first

I missed enrolling in Medicare General Enrollment Period June 11, 2016Medicare – Getting started 18 General Enrollment Period If you missed your Initial Enrollment Period If you missed, or do not qualify for a Special Enrollment Period Can enroll from Jan. 1 through March 31 Medicare will start July 1 of that year Possible late enrollment surcharge on Medicare premiums

Should I keep/sign up for Part A? June 11, 2016Medicare – Getting started 19 Decision 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

Should I keep/sign up for Part B? June 11, 2016Medicare – Getting started 20 Decision 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.

Should I keep/sign up for Part B? June 11, 2016Medicare – Getting started 21 Decision If you don’t have coverage from active employment Yours or your spouses Delaying Part B may mean: Higher premiums Paying for your health care out-of-pocket If you do have coverage from 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

Should I keep/sign up for Part B? June 11, 2016Medicare – Getting started 22 Decision Sometimes you must have Part B if: You want to buy a Medigap policy You want to enroll in a Medicare Advantage plan You’re eligible for TRICARE Your employer coverage requires you have it Talk to your employer’s benefits administrator Talk to SSA or SHIBA if you have questions

Medicare card June 11, 2016Medicare – Getting started 23 Keep it and accept Medicare Parts A and B Return it to refuse Part B Follow instructions on back of card Jane Doe

June 11, 2016Medicare – Getting started 24 Decide how you want to get your Medicare

Medigaps Also called Medicare Supplement insurance June 11, 2016Medicare – Getting started25

What is a Medigap policy? June 11, 2016Medicare – Getting started 26 Medicare Supplement insurance policies sold by private companies Fills the gaps in Original Medicare Deductibles, coinsurance, copayments Standardized plans All plans with same letter Have same coverage Only the costs are different

Do I need a Medigap policy? June 11, 2016Medicare – Getting started 27 Decision Consider It only works with Original Medicare Do you have other supplemental coverage, such as a retiree plan? You might not need a Medigap Can you afford Medicare deductibles and copayments? What does the monthly Medigap premium cost?

When is the best time to buy a Medigap? June 11, 2016Medicare – Getting started 28 Usually during your Medigap Open Enrollment Period aka “Guaranteed Issue” Decision Consider: Your Medigap Open Enrollment Period starts when you’re age 65 or older AND enrolled in Part B Last 6 months You have protections – plans MUST sell you a plan You can buy a Medigap policy whenever a company agrees to sell you one In Washington state, very limited options and no guarantees of coverage for those under age 65

Which Medigap policy do I buy? June 11, 2016Medicare – Getting started 29 Decision Consider The coverage under each standardized plan The cost of each plan – be sure to shop Your individual health care needs

June 11, 2016Medicare – Getting started 30 Medigap Benefits Medigap Plans ABCDF*GK**L**MN 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% 30 *Plan F has a high-deductible option ** Plans K and L have out-of-pocket limits of $4,960 and $2,480 respectively Source: Page 101 of Medicare & You 2016

How do I find the right Medigap policy for me? June 11, 2016Medicare – Getting started 31 By computer or phone Call SHIBA: Call: MEDICARE ( ) TTY users call:

Medicare prescription drug plans Medicare Part D June 11, 2016Medicare – Getting started32

Part D – Medicare Rx drug coverage June 11, 2016Medicare – Getting started 33 Available for all people with Medicare Provided through: Medicare prescription drug plans Medicare Advantage plans Other Medicare plans

How Medicare Part D works June 11, 2016Medicare – Getting started 34 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 the deductibles and copayments There’s Extra Help to pay Part D costs If you have limited income and resources

Who can join Part D? June 11, 2016Medicare – Getting started 35 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

Should I enroll in a Part D plan? June 11, 2016Medicare – Getting started 36 Decision Consider Do you have creditable coverage? Coverage as good as Medicare’s Example: Coverage through an employer 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

Joining a Part D plan June 11, 2016Medicare – Getting started 37 You can join during: Your 7-month Initial Enrollment Period The Open Enrollment Period October 15 – December 7 Coverage stars January 1 Other special times Special Enrollment Period (SEP) Examples: move to a new area, gain or lose employer or retiree coverage, are eligible for Extra Help/Low Income Subsidy (LIS)

How do I choose a Part D plan? June 11, 2016Medicare – Getting started 38 Call or by computer Call SHIBA for help comparing plans Medicare Plan Finder at To join a Part D plan Enroll at Complete a paper enrollment form Call the plan Enroll on the plan’s website Call MEDICARE ( )

Medicare Advantage plans Medicare Part C – also called “Medicare Health Plans” June 11, 2016Medicare – Getting started39

Part C – Medicare Advantage June 11, 2016Medicare – Getting started 40 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 Choice of plans varies depending on what county you live in -- some counties don’t offer plans

How Medicare Advantage works June 11, 2016Document title 41 Still in Medicare with all rights and protections Still get Parts A and 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

Do I want to join a Medicare Advantage plan? June 11, 2016Medicare – Getting started 42 Decision Consider Most offer comprehensive coverage Including Part D 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 plans You must have Parts A and B to join You must live in the county where the plan is sold You can’t buy if you have End Stage Renal Disease

When can I enroll in a Medicare Advantage plan? June 11, 2016Medicare – Getting started 43 During the 7-month Initial Enrollment Period During the annual Open Enrollment Period October 15 – December 7 Coverage starts January 1 May be able to join at other times Special Enrollment Period (SEP) Examples: move to a new area, gain or lose employer or retiree coverage, are eligible for Extra Help/Low Income Subsidy (LIS) Contact the plan or Medicare to join Call their phone number Visit their website Find plan information at

Paying for Medicare June 11, 2016Medicare – Getting started44

What do I pay? June 11, 2016Medicare – Getting started 45 Costs vary and change yearly In Original Medicare Does the provider accept Medicare assignment? For Medicare Advantage, check with the plan For Medicare prescription drug plans, check with the plan

What help is there for people with limited income & resources? June 11, 2016Medicare – Getting started 46 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 coinsurance Extra Help Helps pay Part D costs

What is Medicaid? June 11, 2016Medicare – Getting started 47 Federal-state health insurance program For people with limited income/resources Certain people with disabilities If have both Medicare and Medicaid, covers most health care costs Eligibility determined by state In Washington state: DSHS- Department of Social & Health Services Apply if you MIGHT qualify

What are Medicare Savings Programs (MSPs)? June 11, 2016Medicare – Getting started 48 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? June 11, 2016Medicare – Getting started 49 Individual Monthly Income Limit Married Couple Monthly Income Limit Helps Pay Your Medicare Savings Program $1,337$1,802 Part 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)? June 11, 2016Medicare – Getting started 50 Help paying for prescription drug costs Social Security makes determination Some people automatically qualify Example: person qualifies for both Medicare AND Medicaid You or someone on your behalf can apply

Who can qualify for Extra Help? June 11, 2016Medicare – Getting started 51 Individual Monthly Income Limit Married Couple Monthly Income Limit Helps Pay Your Extra Help $1,485$2,003 Part D Premium, Deductibles and Co-pays Asset Limits: Individual $13,640 Couple$27,250

Should I apply for these programs June 11, 2016Medicare – Getting started 52 Decision Apply if you might qualify Social Security for Extra Help DSHS for Medicaid or Medicare Savings Programs SHIBA can help you

Key points to remember June 11, 2016Medicare – Getting started 53 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

Key points to remember June 11, 2016Medicare – Getting started 54 There are programs for people with limited income and resources Medicaid Medicare Savings Programs Extra Help Important: Make the right decisions and at the right times Get help if you need it

For more information June 11, 2016Medicare – Getting started 55 SHIBA: MEDICARE Medicare & You handbook

Medicare and mental health benefits June 11, 2016Medicare – Getting started56

What Medicare covers June 11, 2016Medicare – Getting started 57 Medicare Part A (hospital insurance) helps cover mental health care if you’re a hospital inpatient: Room Meals Nursing care Other related services and supplies

What Medicare covers June 11, 2016Medicare – Getting started 58 Medicare 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 your doctor orders May pay for partial hospitalization if you need intensive coordinated outpatient care

What Medicare covers June 11, 2016Medicare – Getting started 59 Medicare 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 condition, it’s important to find out whether a plan covers your drugs BEFORE you enroll. To find out, go to:

What Medicare does not cover June 11, 2016Medicare – Getting started 60 Medicare 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/from mental health services Support groups Testing/training for job skills that aren’t part of your mental health treatment

Medicare and the Affordable Care Act (ACA) June 11, 2016Medicare – Getting started61

How the ACA impacts Medicare June 11, 2016Medicare – Getting started 62 Does not cut Medicare benefits Does not eliminate Medicare Advantage plans Does not require people with Medicare to get more or different insurance Does improve Medicare benefits Does reduce Medicare costs

ACA Medicare benefits already in place June 11, 2016Medicare – Getting started 63 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

Key ACA Medicare provisions to control costs June 11, 2016Medicare – Getting started 64 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

Medicare & the insurance exchange June 11, 2016Medicare – Getting started 65 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? June 11, 2016Medicare – Getting started 66 The Office of the Insurance Commissioner can also help you with questions, information and complaints about all types of insurance, such as: Homeowner Auto Life Annuities Health And more! Call our Insurance Consumer Hotline: On the web at:

Help your community! June 11, 2016Medicare – Getting started 67 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!

More questions? June 11, 2016Medicare – Getting started 68 Please complete and return evaluation form Let us know if you want us to contact you to: Discuss you personal situation Learn more about becoming a volunteer THANK YOU!!!