Norvax University Online Training: Medicare 101: Introduction to Medicare

Agenda Medicare Eligibility & Enrollment Overview of Medicare Coverage Options Benefits & Cost of Original Medicare Medicaid Medicare Resources for More Information

What is Medicare? Medicare is a federal program which provides health insurance benefits for people who meet one of 3 categories: 65 or Older Those with End Stage Renal Disease (ESRD) Those under 65 with certain disabilities Administration Centers for Medicare & Medicaid Services (CMS) CMS is an agency within the Department of Health and Human Services (HHS) Medicare covers 49 million Americans

What is Medicare? The Social Security Act established both the Medicare and Medicaid programs in 1965. Original Medicare is a “fee-for-service” system, where a Medicare beneficiary is charged a fee for each health care service/supply received. Beneficiaries can see any provider that is approved by the Medicare program. Fun Fact: Who was the first Medicare beneficiary? Answer: Former President Harry S. Truman.

Medicare Prescription Drug Coverage Four Parts of Medicare Part A Hospital Insurance Part B Medical Insurance There are 4 parts to Medicare: Original Medicare includes hospital coverage under Part A and medical coverage under Part B. Both hospital and medical coverage can be obtained through private insurance companies under Part C, also referred to as the Medicare Advantage program. Outpatient prescription drug coverage is available through private insurance companies under the Part D program. For today’s discussion, we’ll be discussing Part A and Part B. Part D Medicare Prescription Drug Coverage Part C Medicare Advantage

Enrollment Automatic for those receiving Social Security benefits Railroad Retirement Board benefits Initial Enrollment Period Package Mailed 3 months before 25th month of disability benefits Age 65

Enrolling in Medicare Some people need to sign up Those not automatically enrolled Enroll through Social Security Railroad Retirement Board for railroad retirees Apply 3 months before age 65 Do not have to be retired

Enrollment Periods Initial Enrollment Period (IEP) Begins 3 months prior to the month of turning age 65 and continues through the end of the third month after General Enrollment Period (GEP) Allows individuals who did not enroll in Part B during the IEP to enroll between January 1 – March 31 of each year for a July 1 effective date Special Enrollment Period (SEP) Allows individuals who delayed enrolling in Part B because they were receiving benefits through an employer as an active employee (or dependent of someone who is); SEP runs eight months from the time of retirement or loss of coverage

Medicare Card Keep it and accept Medicare Parts A and B Return it and refuse Part B Follow instructions on back of card FRONT BACK

Medicare Options

Overview of Medicare Options The choice of options to be considered are: Premium Cost Cost Sharing Network Providers Prescription Drug Coverage Value-Added Benefits

Original Medicare A&B

Medicare Part A (Hospital Insurance) Premium Most people receive Part A premium free If you paid FICA taxes for at least 10 years If you paid FICA taxes less than 10 years Can pay a premium to get Part A 30 or more quarters - $248/month in 2012 Less than 30 quarters - $451/month in 2012 May receive penalty if not bought when first eligible The federal government funds Part A costs through social security payroll tax deductions

Medicare Part A Coverage Inpatient Hospital Stays Semi-private room, meals, general nursing, and other hospital services and supplies Care in critical access hospitals and inpatient rehabilitation facilities Inpatient mental health care in psychiatric hospital (lifetime 190-day limit) Generally covers all drugs provided during an inpatient stay received as part of treatment Skilled Nursing Facility Care Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies

Medicare Part A Coverage Home Health Care Services Can include part-time or intermittent skilled care Physical therapy, speech-language pathology, continuing need for occupational therapy Some home health aide services, medical social services, medical supplies Hospice Care For terminally ill and includes drugs, medical care, and support services from a Medicare-approved hospice Blood Received during inpatient care

Part A Cost Sharing Inpatient Hospitalization Skilled Nursing Facility Deductible for 2012: $1,156 (first 60 days) Day 61-90: $289/day After 90 days using lifetime reserve days (60 days): $578/day After lifetime reserve days are used: No Coverage Skilled Nursing Facility First 20 days: No cost sharing Day 21-100: $144.50/day After 100 days: No Coverage

Part A Cost Sharing Home Health Care Hospice Care Blood $0 for Skilled HHC Services 20% for Durable Medical Equipment (DME) Hospice Care 5% for inpatient respite care Room and board, in some cases $5 for prescription drugs Blood 100% first 3 pints 20% for additional pints

Monthly Part B Premium Yearly Income in 2010 You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $99.90 $85,001 - $107,000 $170,001 - $214,000 $139.90 $107,001 - $160,000 $214,001 - $320,000 $199.80 $160,001 - $214,000 $320,001 - $428,000 $259.70 Above $214,000 Above $428,000 $319.70 Individuals must enroll in and pay a Part B premium. Part B premiums usually go up each year and are higher for individuals with higher incomes. The federal government funds Part B costs through the general tax revenues; beneficiary premiums cover 25% for Part B expenses

Paying the Part B Premium Deducted monthly from Social Security Railroad Retirement Benefit Federal retirement payments If not deducted Billed every 3 months Medicare Easy Pay to deduct from bank account Contact SSA, RRB, or OPM about premiums

Part B Late Enrollment Penalty Penalty for not signing up when first eligible 10% more for each 12-month period May have penalty as long as you have Part B Sign up during a Special Enrollment Period (SEP) Usually no penalty Part B premiums will go up 10% for each 12-month period during which Part B enrollment was delayed. The penalty is applied for all years going forward. If one did not enroll in Part B when first becoming eligible, enrollment is allowed during the General Enrollment Period – January 1 – March 31 for a July 1 effective date

Part B & Employer or Union Coverage May affect your Part B enrollment rights You may want to delay enrolling in Part B if: You have employer or union coverage and You or your spouse, or family member if you are disabled, is still working See how your insurance works with Medicare Contact your employer/union benefits administrator

When Employer/Union Coverage Ends When your employment ends You may get a chance to elect COBRA You may get a Special Enrollment Period Sign up for Part B without a 10% penalty

Paying for Part B Services In Original Medicare you pay Yearly deductible of $140 in 2012 20% coinsurance for most services Some programs may help pay these costs

Medicare Part B Coverage Doctors’ Services Medically necessary services (includes outpatient and some doctor services you receive when an inpatient) or covered preventive services Except for certain preventive services, you pay 20% of the Medicare-approved amount (if the doctor accepts assignment) and the Part B deductible applies Outpatient Medical & Surgical Services and Supplies For approved procedures (like X-rays, a cast, or stitches) You pay 20% of the Medicare-approved amount for the doctor’s services (if the doctor accepts assignment) You also pay a copayment for each service and the Part B deductible applies

Medicare Part B Coverage Home Health Care Services Medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, occupational therapy Medically necessary part-time or intermittent home health aide services, medical social services, and medical supplies Durable medical equipment and an osteoporosis drug are also covered You pay nothing for covered services Durable Medical Equipment Items such as oxygen, equipment and supplies, wheelchairs, walkers, and hospital beds for you in the home. Some items must be rented. You pay 20% of the Medicare-approved amount and Part B deductible applies

Medicare Part B Coverage Other Services (including but not limited to) Medically necessary medical services and supplies, such as: Clinical laboratory services Diabetes supplies Kidney dialysis services and supplies Mental health care Limited outpatient prescription drugs Diagnostic X-rays, MRIs, CT scans, and EKGs Transplants Costs vary

Part B Covered Preventive Services One-time “Welcome to Medicare” physical exam Annual wellness visit after 12 mos. enrolled in Part B Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1 Abdominal aortic aneurysm screening – one time, with referral Bone mass measurement – every 24 months for certain conditions Cardiovascular screening blood tests – every five years for all persons Colorectal cancer screening – four different tests, vary in frequency Diabetes screenings – up to two per year for those with risk factors EKG screening – one time, with referral Glaucoma testing – once per year for those at high risk HIV screening Mammogram – annual screening for most women Pap test and pelvic exam – every 24 months Prostate cancer screening – every 12 months for men over age 50 Smoking cessation counseling

NOT Covered by Part A and Part B Acupuncture Dental care/dentures Cosmetic surgery Custodial care Health care while traveling outside the U.S. Hearing aids Orthopedic shoes Outpatient prescription drugs (covered under Part D) Routine foot care Routine eye care and eyeglasses Vaccines, except as previous listed (covered under Part D)

What is Original Medicare? Health care option run by the Federal government Provides Part A and/or Part B coverage See any doctor that accepts Medicare Beneficiary pays: Part B premium (Part A free for most people) Deductibles, coinsurance or copayments Can join a Part D plan to add drug coverage Can join a Medigap plan to pick up the “gaps”

Assignment Doctor, provider, or supplier accepts assignment Signed an agreement with Medicare Or is required by law Accept the Medicare-approved amount As full payment for covered services Only charge Medicare deductible/coinsurance amount Most accept assignment They submit your claim to Medicare directly

Supplier and Assignment Suppliers that don’t accept assignment May charge you more The limiting charge is 15% more May have to pay entire charge at time of service Providers sometimes must accept assignment Medicare Part B-covered prescription drugs Ambulance suppliers Physicians who don’t accept Medicare assignment can charge an additional 15% of Medicare-approved amounts. Original Medicare does not cover these excess charges. These are the beneficiary’s responsibility.

Medicaid

Medicaid Federal-state health insurance program For people with limited income and resources Certain people with disabilities Most costs covered for Medicare/Medicaid Called “dual eligible” Eligibility determined by state Application process and benefits vary Office names vary Office names vary: Social Services, Public Assistance, Humana Services

Medicare Savings Programs Help from Medicaid paying Medicare costs For people with limited income and resources Programs include Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Qualifying Individual (QI) Qualified Disabled & Working Individuals (QDWI) See state websites for more information Out-of-pocket costs that must be paid by Medicaid: QMB only: Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits SLMB only: Medicare Part B premium QI: Medicare Part B premium QDWI: Part A premium There is also the QMB Plus, SLMB Plus, and Other FBDE – Full Benefit Dual Eligible (Medicare part B premium; Full Medicaid benefits)

Medicare Resources Resources Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048) www.medicare.gov www.CMS.gov Social Security 1-800-772-1213 (TTY 1-800-325-0778) www.socialsecurity.gov Railroad Retirement Board 1-877-772-5772 www.rrb.gov State Health Insurance Assistance Programs (SHIPs)* *For telephone numbers call CMS Affordable Care Act www.healthcare.gov/center/authorities/patient_protection_affordable_care_act_as_passed.pdf

Upcoming Webinar Medicare Advantage September 6th 12:00pm CST *Annual Election Period (AEP) is October 15th – December 7th

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