Medicare 101 Missouri State Health Insurance Assistance Program SHIP CL This material has been created or produced by CLAIM with financial assistance, in whole or part, through a grant from the Administration for Community Living. Funding is administered through the Missouri Department of Insurance Financial Institutions and Professional Registration and service is provided by Primaris Foundation, a non-profit organization.

What is CLAIM? Community Leaders Assisting the Insured of Missouri Missouri’s SHIP State Health Insurance Assistance Program Nationwide network Meets needs of the local Medicare population

Creation of SHIPs (1990) Created by Congress as part of Medigap reform package Provide Medicare education Help understand Medicare Make informed decisions about benefits Resolve problems in paying for healthcare Give feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS)

Funding Missouri Department of Insurance Financial Institutions & Professional Registration (DIFP) received the first federal grant in Primaris has been awarded the contract through the DIFP since Primaris Foundation is a non-profit organization.

How are clients’ needs met? Volunteers are trained and certified Relate to the questions and needs of clients Volunteers have access to staff support, CMS, and other professionals Currently 300 volunteers statewide and 180 community partners

Examples of Who We Serve A 70-year-old widow A 45-year-old disabled person A daughter taking care of her mom and dad A social worker helping a very sick client A 64-year-old retiring in 3 months Someone who recently lost benefits A professional or caregiver who needs information A person who needs help enrolling in Part D

Services How CLAIM Counselors Can Help Enrollment and billing Medicare Advantage Plans Medigap and supplemental insurance Medicare Prescription Drug Program Long-term care insurance Public benefits Appeals and grievances Suspected waste, fraud, and abuse

President Lyndon B. Johnson at the signing ceremony July 30, 1965, at the Truman Library in Independence, Missouri.

Qualifying for Medicare Beneficiary reaches age 65 (“Age in”) Determined by age and credits SSA determined beneficiary is disabled 24 month waiting period after payments start ESRD One month on home dialysis Three months on facility dialysis

Enrollment *Late enrollment penalty may apply. Have 40 credits? Don’t have 40 credits or not sure? Automatic Enrollment Apply for Benefits at the Local Social Security Administration Office*

Optional Enrollment Part A Required for automatic enrollees Manual enrollees Part B Optional for all enrollees May be declined without penalty in some circumstances i.e. still employed Late Enrollment Penalties may apply

Enrollment Periods Initial enrollment period (3-1-3) Automatic enrollment – receiving Social Security benefits Manual enrollees – not yet drawing Social Security benefits, still working, or not enough credits General enrollment period – January, February, or March every year Effective July

What are the Four Parts of Medicare? Four Parts of Medicare Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans, like HMOs and PPOs. Includes Part A & B, usually Part D coverage Part D Prescription Drug Coverage

Part A Hospital Insurance

Medicare Part A Coverage: Inpatient Hospital Care Skilled Nursing Facility (SNF) Home Health Hospice Blood

Paying for Part A Premiums paid by Medicare taxes Must have 40 credits Those without 40 credits pay pro-rated premium Hospital must accept “Medicare Assignment” for services Deductible for each benefit period 2016 deductible is $1,288 Co-Pays may also apply

Benefit Periods Measures use of inpatient hospital and skilled nursing facility (SNF) services Begins the day you first receive inpatient hospital care Ends when not in hospital/SNF 60 days in a row Pay Part A deductible for each benefit period $1,288 in 2016 No limit to number of benefit periods

Part B Medical Insurance

Medicare Part B Coverage: Doctor’s office visits Outpatient hospital services Home health Ambulance transportation Therapy Physical Occupational Speech Clinical Lab Services Durable Medical Equipment P reventative Services

Paying for Part B Monthly premium Current 2016 premium is $ Previous enrollees with SSA withdrawal pay $ Premium paid by beneficiary is 25% of actual cost Late enrollment penalties Normally withheld from Social Security benefit Annual Deductible: $ for 2016 May increase annually Co-pays and deductibles may apply

Part B Covered Preventive Services “Welcome to Medicare” visit Annual “Wellness” visit Abdominal aortic aneurysm screening Alcohol misuse screening and counseling Behavioral therapy for cardiovascular disease Bone mass measurement Cardiovascular disease screenings Colorectal cancer screenings Depression screening Diabetes screenings Diabetes self-management training

Part B Covered Preventive Services Flu shots Glaucoma tests Hepatitis B shots HIV screening Mammograms (screening) Obesity screening and counseling Pap test/pelvic exam/clinical breast exam Pneumococcal pneumonia shot Prostate cancer screening Sexually transmitted infection screening (STIs) and high-intensity behavioral counseling to prevent STIs Smoking cessation

Supplemental Insurance Medigaps and Employer Plans

Purpose of Supplements Gaps Medicare was not designed to pay all health care costs Medicare coverage has gaps Medical Care Cost Costs of medical care outpaced coverage Individual Percentage of income that people pay for health care continues to increase Medicare cost-sharing has increased since 1965

Medigap Policies Medigap - Medicare Supplement Insurance policies Private health insurance for individuals Sold by private insurance companies Supplement Original Medicare coverage Follow Federal/State laws that protect you Medigap Open Enrollment Period Sign up for Part B Once started, cannot be delayed or repeated

Medigap Policies 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 Monthly premiums

Employer Insurance Part B coverage is optional if a person is: Employed Covered under active employer medical plan; or Covered under a working spouse’s active medical plan Secondary Payer Rule Company must have 20 or more employees for someone 65 or older and, 100 employees for under 65 for the employer insurance to be primary; otherwise, it is secondary to Medicare

When Employer or Union Coverage Ends Options: May be a chance to elect COBRA May get a Special Enrollment Period Sign up for Part B without a penalty Can enroll in a Medigap, PDP, or Medicare Advantage Plan within certain time frames of coverage ending.

Medicare Part C Medicare Advantage Plans

Part C: Medicare Advantage Plans Alternative method of obtaining benefits Administered by private insurance companies Another way to receive Medicare Coverage Must provide coverage found in Original Medicare Can provide additional benefits Part D Hearing Vision Dental

Medicare Advantage Plan Costs M ust still pay Part B premium S ome plans may pay all or part for you P lan may have monthly premium Deductibles, coinsurance, and copayments may apply D ifferent from Original Medicare Varies from plan to plan Plans have out of pocket maximums

Medicare Advantage Eligibility Requirements Live in plan’s service area Enroll in Medicare Part A and Part B Must not have ESRD at the time of enrollment Some exceptions Must provide necessary information May only belong to one plan at a time

How Medicare Advantage Plans Work Still enrolled in Medicare with all rights and protections Benefits and cost-sharing differ and are set by the plan and approved by Medicare Co-payments for certain services and cost sharing for other services (20%) Plans may require prior authorization for services.

Part D Medicare Prescription Drug Plans

Medicare Part D Administered through private insurance coverage in conjunction with Medicare Must be enrolled in Part A and/or B Two sources of coverage Medicare Prescription Drug Plans (PDPs) Medicare Advantage Plans with (MA-PDs)

Paying for Part D Premiums $15.70 and up Penalties apply for late enrollment Deductible Cost-sharing and deductibles determined by: the type of medication terms of the plan selected Gap

Enrollment Periods for Prescription Drug Programs Initial Enrollment Period (IEP)  7 month period  Starts 3 months before month of eligibility Annual Enrollment Period Oct. 15 – Dec. 7 Annual Medicare Advantage Disenrollment Period  Between Jan. 1–Feb. 14, you can leave an MA plan and switch to Original Medicare. If you make this change, you may also join a Part D plan to add drug coverage. Coverage begins the first of the month after the plan gets the enrollment form.

Prescription Drug Costs Costs vary by plan In 2016, most people will pay: A monthly premium – average $34.10 An annual deductible – no more than $360 Copayments or coinsurance may apply

Part D Late Enrollment Penalty Higher premium for some who wait to enroll Additional 1% of base national average premium Every month eligible and not enrolled For as long as they have Medicare drug coverage No penalty with creditable drug coverage Coverage at least as good as Medicare drug coverage

Access to Covered Drugs Coverage and rules vary by plan Plans manage access to drug coverage Formularies (list of covered drugs) Prior authorization (doctor contacts plan) Step therapy (type of prior authorization) Quantity limits (limits quantity for period of time)

Stretching Your Health Care Dollars

Stretching Health Care Dollars Low Income Subsidy (LIS) Extra Help through Social Security Administration May qualify for zero premium for Part D Drug Plan Reduced co-payments/co-insurance Qualify for continuous open enrollment to change plans Eligibility and level of help determined by income and resources Application available through Social Security or CLAIM Online at

Stretching Health Care Dollars Medicare Savings Programs Federal and State funding through MO HealthNet to assist with: Medicare premiums Deductibles and coinsurance (QMB only) Auto enrolled in Part D Extra Help Income and resources determines assistance- QMB SLMB Qualifying Individual Enrollment - Missouri Family Support Division

Missouri SMP Program Statewide volunteer program whose mission is to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect and report healthcare fraud, errors, and abuse through outreach, counselling and education. Program funded through Administration on Aging and administer by Care Connection Missouri

myMedicare.gov View claim status(excluding Part D claims) Order a duplicate Medicare Summary Notice or replacement Medicare card View eligibility, entitlement and preventive service info View or modify your drug list & pharmacy info View address of record with Medicare & Part B deductible status Access online forms, publications & messages sent to you by CMS

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