REACH National Medicare Training Program Speaker Name Group Name Date

2 All About Medicare in 2004 Module 1

3 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans –Formerly Medicare + Choice plans Medicare Savings Programs Key concepts MMA

4 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Plans Key concepts

5 CMS (Centers for Medicare & Medicaid Services) Federal agency within HHS Administers Medicare, Medicaid, SCHIP Spends over $360 billion a year Establishes policies for paying health care providers Conducts research Assesses quality Overview

6 Medicare A health insurance program for –People 65 years of age and older –Some people with disabilities –People with ESRD Administered by CMS Enrollment handled by SSA or RRB Prescription drug coverage Overview

7 Prescription Drug Coverage Medicare-approved drug discount card Prescription drug benefit in 2006 Medicare Advantage program Overview MMA

8 Applying for Medicare Apply 3 months before age 65 –Need not be retired Automatically enrolled if receiving Social Security or Railroad Retirement Benefits Overview

9 Medicare Health Plan Choices Original Medicare Plan Medicare Advantage plans –Medicare Managed Care plans Some have POS option –Medicare Preferred Provide Organization plans –Medicare Private Fee-for-Service plans –Medicare Specialty plans Overview

10 Some Interesting Statistics 2002 –Medicare paid 247 billion dollars 2003 –Over 41 million persons in Medicare 2030 –Projected 70.5 million persons over 65 Almost double in only 30 years Overview

11 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts

12 Medicare Medicare has two parts Part A Hospital Insurance Part B Medical Insurance Original Medicare

13 Paying for Medicare Part A Most people receive Part A premium free People with < 10 years of Medicare-covered employment will pay a Part A premium For information, call SSA – – for TTY users Original Medicare

14 Enrolling in Medicare Part B Initial Enrollment Period –7 months beginning 3 months before age 65 General Enrollment Period –January 1 through March 31 each year –Coverage effective July 1 –Premium increases 10% for each 12-month period you were eligible but did not enroll You carry this increase for the rest of your life Limited exceptions Original Medicare

15 Enrolling in Medicare Part B Special Enrollment Period –Sign up within 8 months of the end of employer or union group health plan coverage –No increased premium For questions, or to enroll, call SSA or RRB Original Medicare

16 Paying for Medicare Part B You pay –Monthly Medicare Part B premium $66.60 in 2004 –$100 per year deductible –20% coinsurance for most services –Some co-payments Some programs may help Original Medicare

17 Paying the Part B Premium Taken out of your monthly payment –Social Security –Railroad Retirement –Office of Personnel Management (OPM) For information about premiums –Call SSA, RRB or OPM May be billed every 3 months Medicare Easy Pay Original Medicare

18 The Original Medicare Plan Go to any provider that accepts Medicare Part A is premium free for most people You pay Medicare Part B premium You pay deductibles You pay coinsurance Original Medicare

19 Your Medicare Card (front) Jane Doe Original Medicare

20 Your Medicare Card (back) Original Medicare

21 Medicare Claims Contractors Medicare Carrier Durable Medical Equipment Regional Carrier Fiscal Intermediary Regional Home Health Intermediary Original Medicare

22 Other Insurance Employee coverage Retiree coverage Medigap insurance (Medicare Supplement Insurance) Original Medicare

23 Medigap Fills in gaps in the Original Medicare plan Must follow federal and state laws Ten standardized Medigap plans (A-J) in most states –Not Massachusetts, Minnesota, or Wisconsin May get little benefit from Medigap if in Medicare Advantage plan Will be changes in 2006 Original Medicare MMA

24 Buying Medigap Company must sell you a Medigap policy –Within 6 months of when you turn 65 and are enrolled in Part B –If you lose certain kinds of health coverage through no fault of your own –If you leave your Medicare Advantage plan Under certain circumstances Original Medicare

25 Your Medigap Rights Insurance company cannot –Deny you coverage –Place conditions on your policy –Charge you more because of health problems Different rules for those < 65 You may buy a policy any time the company will sell you one Original Medicare

26 Introducing Ben… You can call me Ben. But, I don’t like the nickname Benny. Hi! I’m Ben E. Ficiary.

27 What does Ben know…. Which government agency is directly responsible for administering the Medicare program? A.Social Security Administration B.Department of Health & Human Services C.Centers for Medicare & Medicaid Services D.Centers for Disease Control

28 Ben says… C. Centers for Medicare & Medicaid Services

29 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts

30 Medicare Part A Helps Pay for Hospital stays Skilled nursing facility (SNF) care Home health care Hospice care Blood For information, call MEDICARE Part A

31 Hospital Stays Covered services –Semi-private room –Meals –General nursing –Other hospital services and supplies Includes care in critical access hospitals 190 days in a lifetime for inpatient mental health Part A

32 A Benefit Period Medicare’s measure of hospital and SNF services Begins day admitted to hospital Ends when you have not received care in a hospital or SNF for 60 days in a row You pay deductible for each benefit period No limit to the number of benefit periods Part A

33 Paying for Hospital Stays For each benefit period in 2004 you pay –A total of $876 for a hospital stay of 1-60 days –$219 per day for days –$438 per day for days Part of your 60 Lifetime Reserve Days –All costs for each day beyond 150 days Part A

34 Skilled Nursing Facility Care Covered in full for the first 20 days –After a minimum 3-day qualifying hospital stay You pay $ per day for days You pay all costs after 100 days Does NOT include custodial care Part A

35 Skilled Nursing Facility Care Must meet all of the following conditions –Requires daily skilled services –Inpatient in a hospital at least 3 consecutive days –Admitted to SNF within 30 days after leaving hospital –Care in SNF is for a condition treated in the hospital –MUST be a Medicare participating SNF Part A

36 Skilled Nursing Facility Coverage Semi-private room Meals Skilled nursing care Physical, occupational and speech-language therapy Medical social services Medications, medical supplies/equipment Ambulance transportation Dietary counseling Part A

37 Home Health Care For as long as you are eligible –Limited hours per day –Limited days per week Four conditions –Doctor must make a plan for your care at home –Must need specific skilled services –Must be homebound –HHA must be approved by Medicare Part A

38 Home Health Care Covered services –Part-time skilled nursing care –Therapy Occupational Physical Speech-language –Some home health aide services –Durable medical equipment Part A

39 Paying for Home Health Care You pay –Nothing for covered home health care services –20% of the Medicare-approved amount for covered durable medical equipment Part A

40 Hospice Special care –People who are terminally ill –Families If you probably have less than 6 months to live Certification required for each “period of care” –Two 90-day periods –Unlimited 60-day periods Hospice must be Medicare-approved Part A

41 Covered Hospice Services Medical equipment and supplies Drugs for symptom control and pain relief Respite care in a Medicare-certified facility –Up to 5 days each time –No limit to number of times Home health aide and homemaker services Social worker services Dietary counseling Grief counseling Part A

42 Paying for Hospice Care You pay –Copayment up to $5 for outpatient prescription drugs –5% for inpatient respite care Amount you pay for respite care can change each year Part A

43 What does Ben know…. The benefit period for a hospital or SNF stay ends the day the beneficiary A.Has not received services in a hospital or SNF for 60 days in a row B.Is discharged from the hospital or skilled nursing facility C.Is released from his or her doctor’s care related to the hospital or skilled nursing facility stay

44 Ben says… A. Has not received hospital or SNF services for 60 days in a row

45 Ben looks at a case study… Bert was hospitalized for congestive heart failure on April 12, 2004, and was discharged on April 26. He was readmitted to the hospital on May 5, 2004, for an unrelated condition. Is he in a new benefit period? Why or why not?

46 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts

47 Part B Helps Pay for Doctors’ services Outpatient medical and surgical services and supplies Diagnostic tests Outpatient therapy Outpatient mental health services Some preventive health care services Other medical services Part B

48 Covered Preventive Services Bone mass measurement Colorectal cancer screening Diabetes services and some supplies Glaucoma testing Screening mammogram Pap test/pelvic exam/clinical breast exam Prostate cancer screening Vaccination (shots) Part B

49 New Covered Preventive Services Beginning January 2005 “Welcome to Medicare” physical Cardiovascular screening blood tests Diabetes screening tests Part B MMA

50 Part B Also Helps Pay for Clinical laboratory services Home health care Durable medical equipment (DME) Outpatient hospital services Blood Ambulance service –If other transportation would endanger your health Part B

51 Assignment Agreement between Medicare and physician/supplier –Physician/supplier agrees to accept Medicare- approved amount as payment in full –You pay coinsurance and deductible In some cases physician/supplier must accept assignment –For example, Medicare-covered ambulance service Part B

52 Assignment If assignment not accepted –Charges often higher –You pay more –Limit is 15% over approved amount Call MEDICARE ( ) –Copy of Does Your Doctor or Supplier Accept Assignment? Part B

53 Private Contracts Agreement between you and a doctor Medicare will not pay Medigap will not pay Medicare health plan will not pay You will pay charges No claim should be submitted Cannot be asked to sign in an emergency Part B

54 Therapy Limits Limits created by the BBA 1997 Moratorium effective until 2003 Moratorium reinstated through 2005 Part B MMA

55 What does Ben know…. Medicare Part B helps cover all of the following EXCEPT: A.Physical therapy B.Clinical lab services C.Doctor’s services D.Inpatient mental health services

56 Ben says… D. Inpatient mental health services

57 Ben looks at a case study… Conrad just left the hospital following his recovery from a stroke. He is scheduled to start a physical therapy program next week. Conrad thinks his hospital stay and physical therapy are covered benefits. Is he correct? If so, is it covered under Part A or Part B?

58 Ben looks at a case study… Mario is 65 years old and receives Social Security benefits. He is covered by the group health insurance policy provided by his wife’s employer. He wants to wait and enroll in Medicare Part B after his wife retires in 2 years. Will he have to pay an additional 10% for each year he could have been enrolled in Part B and wasn’t?

59 Ben looks at a case study… Robert is enrolled in the Original Medicare Plan and has no other insurance. He had a doctor’s appointment on 5/18/04. The doctor charged $75 (the Medicare-approved amount) for the office visit. Robert has not met any of his $100 Part B deductible. How much will Robert owe for his doctor’s visit?

60 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts MMA

61 Medicare Advantage Plans Medicare Managed Care plans –Some have POS option Medicare Preferred Provider Organization plans Medicare Private Fee-for-Service plans Medicare Specialty plans Medicare Advantage Plans

62 Eligibility Entitled to Medicare Part A Enrolled in Medicare Part B Live in plan’s service area Not have ESRD at the time of enrollment (with some exceptions) Medicare Advantage Plans

63 Important Information Still in Medicare program Continue to pay Medicare Part B premium Still have Medicare rights and protections Get all regular Medicare-covered services May pay additional monthly premium May receive additional benefits Medicare Advantage Plans

64 Medicare Managed Care Plans Offered by private companies Available in certain areas Plan can join or leave Medicare each year Providers can leave the plan Benefits may change each year Premiums may change each year Medicare Advantage Plans

65 How Does Managed Care Work? Usually go to only certain providers Generally need referral to see specialist May get extra benefits Some plans offer a Point-of-Service option –Can go to doctors and hospitals not on plan's list Medicare Advantage Plans

66 When Can You Join? When you first become eligible for Medicare Any time November 15 - December 31 Any time a plan is allowing new members to join Medicare Advantage Plans

67 Annual Enrollment November 15 - December 31 –Can choose new plan –New plan starts January 1 (in most cases) –Plan must accept new members Medicare Advantage Plans

68 Continuous Open Enrollment Continuous open enrollment through 2005 You can enroll or disenroll –At any time –For any reason Medicare Advantage Plans

69 What does Ben know…. All of the following are Medicare Advantage plans EXCEPT: A.Private Fee-for-Service plan B.Private Contract C.Managed Care plan

70 Ben says… B. Private Contract

71 Ben looks at a case study… In November 2004, Alan will choose the health plan he wants to join for the coming year. Enrollment in his new plan will begin January 1, Can Alan change plans on February 1 of that year?

72 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts

73 Medicaid Federal-State health insurance program –People with lower-income and limited resources –Certain disabled persons Eligibility determined by state Application processes vary –Social Services –Public Assistance –Human Services Medicare Savings

74 Programs to Help Pay Expenses Medicare-approved drug discount card –$600 credit Qualified Medicare Beneficiaries (QMBs) Specified Low-Income Medicare Beneficiaries (SLMBs) Qualifying Individuals (QIs) Qualified Disabled and Working Individuals (QDWIs) State-specific programs Medicare Savings

75 How to Apply If you think you might qualify –Review guidelines –Collect your personal documents –Get more information Call proper local agency Call your SHIP –Complete required paperwork Medicare Savings

76 How to Apply Locate the proper agency –Look in phone book –Call MEDICARE ( ) –Call your SHIP Produce your documents Complete the necessary application forms Medicare Savings

77 Session Topics Medicare overview Original Medicare Plan Medicare Part A Medicare Part B Medicare Advantage plans Medicare Savings Programs Key concepts

78 Information Channels MEDICARE Medicare & You handbook –Other publications Your local SHIP Key Concepts

79 Key Concepts Medicare is a health insurance program It is administered by CMS You may have choices about how you get your health care There are programs to help you with costs There are information sources available Key Concepts

80 Thanks for your attention…