1. Dan Blyth State Health Insurance Assistance Program (SHIP)
MEDICARE Basics
Dan Blyth State Health Insurance Assistance Program (SHIP)
Housed within the Colorado division of insurance

2. SHIP Programs in all 50 states 16 sites in Colorado
Staff and volunteers
Funded by CMS
SHIP programs are housed in other agencies – like Councils of Governments, hospitals, agencies on aging.
An interesting feature is that much of the counseling work is done by volunteers. Three days of training, work with a mentor for several months volunteers in Colorado

3. Agenda Overview of Medicare How Medicare relates to Medicaid
Effect of Affordable Care Act on Medicare
Medicare resources
This presentation assumes that you have little knowledge of Medicare. It will give you an overview, but it won’t give you enough information to counsel someone on all the choices they have.
I know that many of your clients have both Medicare and Medicaid, and we’ll talk about how those two programs work, but I’ll confess that I’m not an expert on Medicaid.
Sitora asked that I cover the impact of the ACA on Medicare, so we’ll get to that.
And finally, and perhaps most importantly, I want you to know where you can go if one of your clients has a question about Medicare that yopu’;re not able4 to answer. And that happens to me a lot.

4. WHAT MEDICARE IS, AND WHAT IT ISN’T
Federal gov’t health insurance for:
Age 65 and older
Under age 65 with certain disabilities
Fundamentally, Medicare was established to be the health insurance for people in their retirement years. It is also available to people with disabilities, and for those with ESRD and ALS
Medicare isn’t mandatory

5. Medicare Isn’t: Medicaid Long Term Care Insurance
Nursing homes, assisted living
Medicaid is also health insurance, but for low income and people with disabilities. Medicaid eligibility is need-based, based on income & assets. Medicare is not. You can get Medicare whether you’re rich or poor.
Medicare is a federal program, so it is the same in all states. Medicaid is a joint federal and state program, so its eligibility and benefits can vary across states
Medicare also isn’t insurance for long term care. Medicare is halth insurance, but it doesn’t cover you if you need to enter a nursing home or assisted living.

6. Who’s Eligible for Medicare?
U. S. citizens, or
Lawful permanent residents with five consecutive years of residence in U.S.
Must have paid payroll taxes in the U.S. for 40 quarters
AND:
Age 65, or
Disabled, and on SSDI, for 24 months, or
No waiting period for Amyotrophic Lateral Sclerosis (ALS), or
End Stage Renal Disease (ESRD)
Busy slide.
Must be a U.S. citizen or a legal resident.
In addition to the citizenship and legal residence requirement, they must have paid Medicare taxes for 40 quarters ( ten years)
If a US citizen or legal resident hasn’t paid FICA taxes in the US for 40 years, they can purchase Medicare coverage from the govt. and the premium for Part A is on a sliding scale, up to $426/month
If you’re a U S citizen or a lawfully admitted immigrant, you must also be:
Age 65 or older, or disabled
If disabled, must have been on SSDI for two years, except those with ALS don’t have to wait 24 months
those with ESRD requiring dialysis or a transplant don’t have to be on SSDI

7. How Does Someone Enroll?
If already receiving Social Security Auto-enrolled into Medicare Part A and Part B when they turn 65, or in the 25th month of SSDI
If not auto-enrolled, they must take action to enroll
If covered by employer, they need not enroll in Medicare ( if coverage is ‘creditable’)
If, for example, someone retires at age 62 and starts receiving Social Security retirement, they must wait til age 65, and at that point they will receive notice from Social Security that they have been enrolled. But they will still have some choices to make.
If they aren’t receiving Social Security, enrollment isn’t automatic. They must enroll. They will get an enrollment packet 3 months before they turn 65 or in the 25th month of SSDI.
If they have “creditable coverage” , they can wait and enroll in Medicare when that other coverage stops.
There are different enrollment periods depending on an individual’s circumstances (for example, if they already have health insurance from their employer ). I’m not going to go through all those.

8. Once enrolled, they will get the card from Medicare
Once enrolled, they will get the card from Medicare. So if you’re not sure whether someone has Medicare, you can ask if they have a red, white and blue Medicare card.
Note that the card says that Jane Doe has Part A and Part B……

9. Medicare Parts and Costs (2014)
Part A = Hospital---
usually no monthly premium
$1,216 deductible
20% co-insurance
Part B = Outpatient--- office visits, X-rays, labs,
$104.90/month premium to Medicare, higher if income is >$85,000
$147 Deductible
20% co-insurance per visit
Different costs are paid by different “Parts” of Medicare.
Here are the general categories.
Part A pays for inpatient hospitalization, and also pays for skilled nursing care, some home health care, and hospice care
Part A is usually free for most people because they have paid in to Medicare for 10 years ( FICA taxes). If not, they can purchase Part A coverage, premium is $426 per month. Medicare pays 80%, and the patient is responsible for 20%
Part B covers outpatient medical services, like Dr. visits.
Part B has a monthly premium that the patient must pay to Medicare, and deductibles and co-payments to the Dr.’s office each visit.
I’ll note there are several exceptions to these rules about what part pays for what procedure, but I don’t want to get you bogged down in the arcane minutiae of Medicare rules.
So when someone enrolls in Medicare, they get their Medicare card, and can go to any doctor or hospital that accepts Medicare. If their regular family doctor accepts Medicare, they don’t have to change doctors when they enroll in Medicare. The doctor or hospital simply bills Medicare for 80% and the patient for 20%.
So you can see that with a major illness or injury, a person could be liable for huge bills, since they are liable for 20%. (The average Medicare hospital bill ( and that’s a lot less than the average hospital charge) is $9,000, 20% of that is $1800). For that reason, most people buy additional insurance coverage…..

10. Medicare Supplements (“Medigaps”)
Coverage by private insurers
Pays for some costs after Medicare
Not part of Medicare --- private insurance policies
Medicare Supplements, or “Medigap” plans are sold by private insurance companies to cover most of the costs that Medicare doesn’t cover. Think of it as secondary coverage behind Medicare. People shop for the plan and the company they want, and sign up with that company. They will pay a monthly premium. No one has to buy a Medicare Supplement, it’s optional.
So at this point, our hypothetical client, Jane Doe is enrolled in Medicare, has coverage for hospitals and doctor visits, and additional coverage for the 20% that Medicare doesn’t pay, but she doesn’t have an important insurance for her prescription medications, so she needs another Medicare Part….

11. Medicare Parts and Costs continued
Part D = Prescription Medications ---
Monthly premium
Co-pay or co-insurance per prescription
coverage by private insurers
Part D pays for those Drugs. And Part D plans are also offered by private insurers, and so Jane Doe has to shop for the plan she wants, and some plans cover more than others and cost more, and then she signs up with the company. She will pay a monthly premium to that company. Does she have to sign up for a Part D plan – no, but if she doesn’t, she will pay a penalty whenever in the future she decides she needs a drug plan.
There are many Part D Medicare insurance plans in Colorado, 39 actually, and they each have different prices and different co-pays, so it can be confusing for people to figure out which plan they should purchase. And, the plans change every year. That’s why they call us.

12. Medicare Parts and Costs continued
Hospital
(Part A)
Outpatient
(Part B)
Medication
(Part D)
So now Jane Doe has Inpatient, Outpatient and her medications covered, and her supplemental coverage, and to get this she is paying premiums to Medicare ( for Part A and Part B) , and to private insurance companies for Part D and for her Medigap plan. She can go to any doctor or clinic that accepts Medicare, and she can pick up her prescriptions at any pharmacy. And next time, she can go to a different doctor or clinic if she wants. This is how 2/3 of people get their Medicare.
The other 1/3 go a different route….
Medigap

13. Medicare Parts and Costs continued
Part C = Medicare Advantage
Combines Parts A, B and usually D
Private insurers
HMOs and PPOs
Special Needs Plans
Monthly premiums to Medicare and to the insurance carrier
Co-insurance or co-pay
Medicare Advantage plans are HMOs or PPOs . How many of you belong to Kaiser? Kaiser is an HMO and, for people on Medicare, it is a Medicare Advantage plan. It provides all the coverages that Medicare offers: Hospitalization, Office visits, medications, and no one needs a Medicare Supplement/Medigap. So instead of having separate A & B, plus a separate Drug plan and a separate Medicare Supplement, all those are packaged together in one insurance plan.
The trade-off is that you agree to use the company's network of providers, rather than going to any provider you want, you often need a referral from a PCP before you can see a specialist and you will pay co-pays for any services you use. Medicare Advantage Plans ( aka Medicare Health Plans) have “members”.
So you’ll pay the Medicare premium, like everyone else who’s on Medicare, and a premium to the insurer, and co-pays for your drugs and office visits.
A type of Medicare Advantage is a “Special Needs Plan”, and they limit membership to those who have a specific chronic condition or characteristic, for example, congestive heart failure, nursing home residents, or those who have both Medicare and Medicaid.
Everyone who has both Medicaid and Medicare is enrolled in one of the 4 Special Needs Plans in Colorado :
Kaiser, United Healthcare, Denver Health or Colorado Access

14. Other Medicare considerations
Enrollment periods
Penalties
How do I pick the right plan for me?

15. Medicare and Medicaid “Full Dual–Eligibles”
Medicaid pays the Medicare premiums and many (but not all) co-pays
Medicare pays first, then Medicaid pays for any additional costs
Medicare covers prescriptions
Almost all health care costs are covered
1 in 6 people in Colorado are on some form of Medicaid, and a substantial number of those are also on Medicare. They are the so-called “Dual Eligibles”, and there are two groups of Duals:
Full Dual Eligibles:
Virtually all their health care costs are covered by Medicare or Medicaid. Medicaid pays for them to be on Medicare, and covers the premiums and co-pays the patient would have to pay, and then they are covered by Medicare for hospital, outpatient, and prescription costs, and any Medicare-covered services.
There are other services that Medicaid covers that Medicare does not:…
If someone is on Medicaid when they become eligible for Medicare:
Medicaid will pay their Medicare costs --- premiums, co-pays.
Medicaid will cover costs for services that Medicare doesn’t cover, like eyeglasses, skilled nursing care, hearing aids
Dual eligibles are auto-assigned to Medicare Part D plans ( but they can change plans at any time)

16. Gaps in Medicare vs. Medicaid:
Routine dental care and dentures
D.M.E. for certain uses
Hearing aids and exams for fitting hearing aids
Transportation
Long-term care (nursing homes, assisted living, in-home care)
Certain drugs
Care Coordination
You’ll note that Medicare doesn’t cover some of the services that Medicaid covers , long term care, nursing homes, assisted living, like dental.
Medicaid will pay for these.
Drug coverage is perhaps the where the biggest changes are:
Once on Medicare, they no longer have Medicaid coverage for drugs, but have Medicare Part D. Medicare formularies are more restrictive than Medicaid

17. “Partial-Duals”: Medicaid pays the Medicare premiums and co- pays
Both “Full Duals” and “Partial Duals” should apply for the Low Income Subsidy, which helps them with Rx co-pays
The second group of Dual Eligibles are the “Partial- Duals” –people whose income is low, but not low enough to qualify for full Medicaid. Medicaid pays their Medicare premiums and co-pays. That’s all they get from Medicaid, but it is a significant benefit, because it saves them at least $ every month. It’s also known as the Medicare Savings Program, since it’s saving them on their Medicare costs.
They must re-certify every year, and if they don’t they will one day find that they are paying more co-pays, and the Medicare premium
I’ve noted here that people on Medicaid, whether full or dual, should apply to Social Security for the Low Income Subsidy (LIS), otherwise, they may face higher co-pays for their medications. Last week, letter went out to all those who are being removed from LIS (“gray letters”). We screen everybody, whether on Medicaid or not, for eligibility for LIS.

18. If on Medicaid when become eligible for Medicare:
Enroll in Medicare Parts A & B or Medicare Advantage Special Needs Plan
Auto enrolled in Part D Rx plan
Can change plans at any time

19. Accountable Care Collaborative
Demonstration project integrating care and financing across Medicare & Medicaid for 48,000 dual-eligibles
You may have heard of this demonstration project, the idea is to do a better job of coordinating care between Medicare and Medicaid, and also coordinate the payment better. 48,000 dual eligibles are assigned to one of the 7 the local RCCOs. ( Colorado Community Health Alliance is one of them, for Boulder, Jeffco, Gilpin, and Clear Creek. Denver RCCO is Colorado Access)
RCCOs pull together and contract with providers in primary care, acute care, medications, behavioral health, long term care & support.

20. Medicare and A.C.A. A.C.A. has little effect on Medicare.
If someone has Medicare, they don’t need (and can’t be sold) a marketplace insurance plan.
If someone has a private plan, they must cancel it and enroll in Medicare when they become eligible.
Medicare beneficiaries can buy a stand-alone dental plan.
If someone is on Medicare, nothing changes because of ACA. No cost changes, no coverage changes. No mandated coverage.
ACA has brought some new preventive health care screening to Medicare.
If someone has a health plan they purchased in the health care marketplace before they became eligible for Medicare, they should disenroll from that plan and enroll in Medicare when they become eligible for it; i.e., the transition to Medicare isn’t automatic. They could keep their individual plan, but they would lose any tax credits or subsidies that they are receiving from the exchange, and I don’t see that it would be worth it to them in any way. They’d be paying full price for a plan they don’t need.
If someone isn’t entitled to (“entitled” means receiving Soc Sec. benefits) Medicare Part A, and doesn’t have Part B, then they can purchase a marketplace insurance plan.

21. For Help 16 SHIP Locations 1 888 696-7213 (for Consumers)
en Español
State Office
Dora.colorado.gov/SHIP
Medicare is full of rules and regulations, that govern when people can enroll in the various parts of Medicare, the penalties if they don’t enroll when they should, what happens if they have other insurance, and so on. SHIP counselors are happy to work with individual clients to figure out what’s best for them, given their medical needs, where they live, etc.
Open Enrollment starts October 15, and is the only time everyone on Medicare can make changes to their coverage.
This is just the basic overview and doesn’t equip you to advise clients, but if you’d like that detail, we would be happy to set up webinars or other ways to give you the knowledge you need.
You can refer client to the number and the call will be answered by the local SHIP organization.
You can call or my office, or you can contact me. I’d ask that you don’t give my out to clients, because I wont be able to get to them all.