The Transition Network NEW TO MEDICARE Emma M Kalaidjian and Rae-Carole Fischer © November 13, Presented for TTN Chicago Chapter

NEW TO MEDICARE WHAT DO I NEED TO KNOW ???? Answers to Some Common Questions This program is intended for educational purposes and is not a solicitation to purchase insurance

MEDICARE – Q & A What is It? What’s Covered/What’s Not? How do I Apply? Can I Switch Plans? What does all of this Cost? What is Medigap? Where can I go for more help?

MEDICARE – WHAT IS IT? Health Insurance People 65+ (based on work credits/spouse’s) Disabled < 65 (received SSDI for 2 years) Anyone with End Stage Renal Disease

MEDICARE Is it one size fits all? Original Medicare: Government Plan Part A & B Fee-for-Service vs. Medicare Advantage Plans: Private HMO’S and PPO’S

MEDICARE What are the “Parts”? PART A (aka Hospital Insurance) Hospital “In-patient” (Caveat!) Skilled Nursing Facilities (Not Custodial) Hospice Care Home Health Care Services

MEDICARE What are the “Parts”? PART B (aka Medical Insurance) Doctors and Other Health Care Providers Outpatient care Durable Medical Equipment Preventive Services and Screenings

MEDICARE Part B Preventive Services PART B: FREE Preventive Services “Welcome to Medicare” Medicare & You §3 Annual “Wellness” visit Bone Density (24 months) Mammogram (12 months) Colorectal Cancer Screening (10 years) Shots “At-Risk” Diabetes Screening Depression/alcohol misuse/cardiac Screenings

MEDICARE Part B Preventive Services Preventive Services - With Cost Co-pay, co-insurance, deductible Cardio Blood Screening – Doctor’s Second Surgical Opinions Diabetes Related Management Training Doctor Ordered Hearing/Balance Exams “At Risk” Glaucoma Test Clinical Research Studies Other Tests – EKGs/MRIs/CT/X-RAYs

MEDICARE What is Not Covered? Services Not Covered Dental Care Hearing Aids Cosmetic Surgery Glasses Acupuncture Long-Term Care: Custodial Care Outside U.S.

MEDICARE What are the “Parts”? PART C - Medicare Advantage Private Plans: HMO’s/ PPO’s May Offer Extra Coverages Vision/Hearing/Dental Podiatry Services Wellness or Fitness Memberships Prescription Drug Coverage

MEDICARE What are the “Parts”? PART C - Medicare Advantage Advantages Single billing for premium Prescription coverage included Extra coverages Out-of-Pocket Expense Caps (No limit in Original Medicare)

MEDICARE What should I ask about Part C? PART C - Medicare Advantage Plans Things to Consider Coverage: Services? Location? Cost: Premium? Deductibles? Others? Choice: Network? Referrals Needed? Quality: Star Ratings? See Medicare & You 2013

MEDICARE What is Part D? PART D – Prescription Drug Program Run by approved private insurers Formulary Add to Original Medicare Sign up when first eligible How do I find a plan? medicare.gov/find-a-plan Medicare & You 2013

MEDICARE What is Part D? PART D – Prescription Drug Program What is the “donut hole”? Gap in coverage discounts available 52.5% on brands; 21% on generics Coverage Can I get help paying for prescriptions? Extra Help – Social Security 1/ State - SHIPs

WHEN CAN / MUST I APPLY? Part A & B People receiving Soc. Sec.- Automatic Apply online –quick/easywww.medicare.gov Not ready for retirement benefits? Social Security office in-person/on phone Year 65 Window (3 mos. before 65) Outside the Window / Penalties Special Enrollment Period - Employed

WHEN CAN / MUST I APPLY? Part C- same time as Part A & B Pt D (Drugs) – same as A & B Pt D Late Enrollment Penalty Medicare Supplement – Open Enrollment Window !

CAN I SWITCH PLANS? Once I’m enrolled, can I switch to a different plan? Drug/ Medicare Advantage/ Medigap Open Enrollment: Oct 15 – Dec 7 Move from Area; Switch to 5 Star Plan Special Enrollment: Advantage to Medicare only: Jan 1 – Feb 14

MEDICARE – WHAT IS THE COST OF THESE PLANS? See medicare.gov/cost PREMIUM $$ Part A is premium-free - if you paid Medicare taxes, otherwise $451/mo (2012); $441 in 2013) Part B - $99.90/mo in 2012 ($ in 2013); more for high income earners Part C (Medicare Advantage) – depends on carrier’s plan (medicare.gov/find-a-plan) Part D Prescription Drug Coverage – depends on plan ($15 up to $115/mo (IL) ; more for high income earners)

MEDICARE – COSTS: Co-Pays, Deductibles and Coinsurance Part A Deductible: $1156/benefit period + Co- Pays after 60 days’ stay ($1184 in 2013) Part B Deductible: $140/yr ($147 in 2013); Coinsurance 20%, except for some preventive services Part C (Medicare Advantage) – depends on carrier’s plan – out-of-pocket-caps Part D Prescription Drug Coverage – depends on plan Deductible: $0-$320; Co-Pays: $0-$95 (IL) Co-insurance: 15% - 40% → “Donut Hole”

MEDICARE COSTS How Does “Medigap” Work? Medicare Supplement Insurance: Private insurers (“A-N Plans”) See Chart in Medicare & You §5 Helps pay costs and some services that Original Medicare does not pay (ex. travel outside U.S.) Out-of-Pocket Expense Deductibles, Co-Pays, Co-insurance, Excess of Part A Lifetime Reserves, Physician “Excess Charges” One Person Coverage Cost varies by coverage and insurance company

MEDICARE SUPPLEMENT How Do I Select? Things to Consider When Shopping Around for “Medigap” ASK! (Choosing a Medigap Policy) Price and Ratings? “Community” or “No-age-rated” “Entry-age” or “Issue rated” “Attained age-rated” Discounts: Non-smokers/Women/ETF/ Pay-in-advance premium

When Can I Apply or Change Medigap Policies ? Open Enrollment – 65 th b.d. + 6 months Guaranteed Issue & Prior Creditable Coverage ↓ Late Enrollment / Switching Perils If no “prior creditable coverage” Pre-existing Conditions/ Up to 6 mo. wait “Medical Underwriting” Switching: if “Guaranteed Issue Right” Guaranteed Renewable – unless you default

“Medigap”- What Should I Watch Out For? Beware Illegal Practices Pressure/Mislead to Buy/Switch Sell a 2nd policy or one you don’t want Claim that it is a “Medicare” policy if private plan Claim to be a “Medicare Rep” Claim: government approved/recommended Sell Medicare Advantage when you said you wanted Original Sell Medigap policy when you have Medicaid or Medicare Advantage and you don’t want to switch Sell when not licensed in the state (medicare.gov/medigap)

MEDICARE – OTHER RESOURCES? More Help and Resources Employer plans and programs Medicare.gov 1/800- MEDICARE Social Security Administration Medicare & You Handbook, CMS Choosing a Medigap Policy publication “Extra Help” through Social Security 800/ State Medicaid SHIPs PACE Programs

MEDICARE – WHAT IS IT? THANKS FOR YOUR PARTICIPATION If you would like to contact Rae-Carole or Emma our addresses are: Emma: Rae-Carole:

Appendix ( Source medicare.gov/cost) Costs: MONTHLY MEDICARE PREMIUM 2012 Type of Monthly PremiumAmount of Monthly Premium Part A monthly premium (for people who pay a premium) $451 Part A Late Enrollment Penalty+10% Part B monthly premium$99.90 Higher-income consumers may pay more.Higher-income consumers may pay more Part B Late Enrollment Penalty +10% for each full 12-month period that you could have had Part B, but didn't sign up for it Part C monthly premiumVaries by plan Part D monthly premium Varies by plan Higher-income consumers may pay more Part D Late Enrollment Penalty Depends on how long you went without creditable prescription drug coverage

Appendix p 2 Part A Services/Costs Blood: In most cases, the hospital gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated. Home Health Care: You pay: $0 for home health care services Durable Medical Equipment: You pay: 20% of the Medicare-approved amount Hospice Care: You pay: $0 for hospice care. A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management; 5% of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest). Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home). Hospital Inpatient Stay: You pay: $1,156 deductible per benefit period; $0 for the first 60 days of each benefit period; $289 per day for days of each benefit period; $578 per "lifetime reserve day" after day 90 of each benefit period (up to a maximum of 60 days over your lifetime) Skilled Nursing Facility Stay: You pay: $0 for the first 20 days each benefit period;$ per day for days each benefit period.; all costs for each day after day 100 in a benefit period

Appendix p 3 Part B Services/Costs Deductible: You pay $140 per year. Blood: In most cases, the provider gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies. Clinical Laboratory Services: You pay $0 for Medicare-approved services. Home Health Services: You pay $0 for Medicare-approved services. You pay 20% of the Medicare-approved amount for durable medical equipment. Medical and Other Services: You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy*, and durable medical equipment. Mental Health Services: You pay 40% of the Medicare-approved amount for most outpatient mental health care. Other Covered Services: You pay copayment or coinsurance amounts. Outpatient Hospital Services: You pay: a coinsurance (for doctor services) or a copayment amount for most outpatient hospital services. The copayment for a single service can't be more than the amount of the inpatient hospital deductible.