Presented by: Warren Coble Certified Senior Advisor

 Medicare  Federal program  Social Security  Earned benefit from working  Medicaid  State program  Social Services  Needs based benefit depends on income and assets

 Over 300 Different plans available in NC in 2013  Like everything these days, … such a wide variety. Make personal choice decisions based on:  Coverage needs  Cost you can afford  Convenience of use

 The unknown parts:  How sick are you going to get?  How often will you use it?  How will costs rise in the future?  If we had a crystal ball, we’d know the right decision to make every time. We don’t, so we have to make the best decision now based on the facts we have now.

 1. Age 65  2. Disability for 24 months  3. End-stage kidney failure  4. Lou Gehrig’s Disease  Have acquired sufficient work credits (40 quarters = 10 years)

 Receiving Social Security check? Enrolled automatically & premiums deducted  If not receiving Social Security, must apply up to 3 months ahead & premiums billed

Individuals turning age 65 who are NOT currently covered by Employer Group Health Plan based on ACTIVE employment

 Retiree coverage offered by employer is voluntary on their part and is subject to change – Supreme Court ruling in 03/2008  COBRA does not count for Medicare enrollment period purposes

 Compare employer cost/coverage (premium/deductible/co-pay/oop max) to Medicare cost/coverage  If your cost/coverage are reasonable, better off with employer coverage while working  If high cost ($250 month+) or only partial coverage (high deductibles/co-pays) may be better with Medicare/Supp/Advantage

 Parts of Medicare  A – HospitalC – Advantage  B - Medical D - Rx  Standardized A & B  Medicare Modernization Act of 2003 Mandated “Choices” & RX coverage

- Original - Medicare A & B usually go together, can add D (Managed by federal government) - Advantage - Medicare C alternative to A & B, may or may not include part D (Managed by private insurance companies)

See SHIIP Combo Form

 A – Hospital Insurance *Inpatient hospital/nursing home/hospice *Usually no premium (earned by paying Medicare tax while working) *$1184 deductible – per hospital stay Up to 60 days of inpatient coverage (Deductible waived on re-admission within 60 days) *Skilled nursing facility (short term only) – Days 1-20 in full (Special Requirements) - Days Medicare pays all but $ day *Hospice – Palliative care, including Rx *Home Health Care

 B – Medical Insurance  Outpatient hospital/physician care/medical equipment  Standard premium $ (2013) (higher for higher incomes)  $147 deductible per calendar year, then 80% Medicare/20% recipient co-pay  Based on “approved” charges

Not Covered By Medicare Or Supplement:  Long term care  Vision or dental care  Hearing aids  Eyeglasses  Private duty nursing

 Stand alone with original Medicare  Included with an advantage plan  Stand alone with an advantage plan

 See COMBO form  D – Rx prescription drug coverage  Operated by private companies Premium Deductible  5 Words: Co-Pay Gap Catastrophic

 1 – Premium$ $  2 – Deductible$ You pay 100%  3 – Initial coverage limit $ Includes deductible $ Co pay period Part D pays 75% up to $ You pay 25% of $ ($661.25)  4 - Coverage gap$ Discounts: 52.5% brand, 21% generic $ (deductable + 25 out of pocket % + gap)  5 - Catastrophic95/5%

 Annual preview period September 15–October 15 Assistance available to choose appropriate plans  Open enrollment October 15 - December 07  Changes effective January 1 each year

 Work with Original Medicare to fill in “gaps”  Cannot buy but one at a time.  Standardized/Regulated by N. C. Dept. of Insurance  Offered by individual companies  Will not work with Part C/Advantage

 Depending on Plan type chosen, designed to pay out of pocket expenses (deductibles, co- insurance, and co-pays) not paid by Medicare  See Plans Chart (SHIIP Combo Form)  Changed June 1, 2010 Gone - Plans E, H, I, J - New M, N 42 Plan “F” companies in North Carolina

Pricing method is important!!!  No-age rated  Issue-age-rated  Attained-age-rated  Price ranges from $ $ for Plan F (most common), 43 plan average is $ Find out company history/stability Discounts can confuse true cost

 Guaranteed renewable as long as premium is paid  Can never be cancelled due to health/excess use  Premiums will go up!!!!  Changing plans re-sets the starting age, often resulting in higher premiums

Medigap Open Enrollment Period:  Starts 1st day of month you are both age 65 or older and enrolled in Medicare Part B. Continues for 6 months.  Can apply up to 6 months in advance to have timely coverage at 65

 During open enrollment, cannot be denied coverage, regardless of health  Some companies apply pre-existing condition limitations up to 6 months  Deferring Medicare/Supplement to keep employer coverage will result in higher Supplement cost later

SEE GOLD SHEET Includes all benefits of regular Medicare  Hospital and medical coverage  Premiums/deductibles/co-pays vary by plan  May include extra benefits Vision, dental, hearing, gym membership  Not standardized  Not regulated by N. C. Dept. of Insurance (CMS)  Usually have a varied maximum out-of-pocket limit

 4 Basic plan types:  1. HMO – Health Maintenance Organization (in network)  2. PPO – Preferred Provider Organization (out of network)  3. SNP – Special Needs Plans  4. PFFS – Private Fee for Service

 Inpatient hospital ◦ Per day co-pay  $ $ per DAY  Surgery usually included in in-patient costs  Usually a limit on # of days you pay  Plans vary on yearly maximum out of pocket

 Skilled nursing facility Extremely varied co-pays Days $0 - $ per day Depends on plan and type Not accepted at all facilities

 Medical/doctor’s services Varied co-pays $10-$35 Primary care physician $10-$50 Specialist Verify your doctor/hospital will accept 30% % Out of network ! Each plan is different!

 Prescription drug (Rx)  May or may not be included  If not included, cannot buy stand-alone  Usually standard drug plan guidelines

 Original Medicare - $ (IRMMA)  Supplement – varied, $ $ average for Plan F $ month  Part D Rx – varied, $ $ average $35.00 per month  Advantage – varied, from $0 to $ per month

 See Road To 65  Initial, General, Special Enrollment periods  IEP – 3 months before, month of, 3 months after 65  Eligibility date depends on when you sign up  GEP – January – March each year, coverage begins July 1  SEP – Any time while covered by employer group health plan (cannot be during IEP)  Up to 8 months after employer group terminates

 Check options 4-6 months ahead of age 65.  If keeping employer coverage, check again 2-3 months before leaving employment.

 If eligible, and you need Medicare, failure to enroll timely can result in delays in coverage and costly premium penalties.  Although Cobra protects your Medigap/Supplement Enrollment period, it does not protect you for a Medicare Special Enrollment Period.

 Warren Coble & Associates  SHIIP –  MEDICARE –