1. Medicare 101

2. Agenda Understanding the basics of Medicare What is Medicare?
Who qualifies?
How do you obtain it?
How does it work?
What are the different coverage options?
Medicare Advantage vs. Medicare Supplement
Medicare Advantage
HMO, PPO, HMO-POS, PFFS
Medicare Supplements
Plans A-N
Formularies & Provider Directories
What are they? Why do I need to check them?
Prescription Drugs
Part D Coverage Gap/Donut Hole
Election Periods

3. Understanding the basics of Original Medicare
What is Medicare?
A national fee-for-service insurance program, administered by the U.S. federal government. Medicare is a sub-agency of Social Security.
Part A (Hospital Insurance)
Part B (Medical Insurance)
Who Qualifies?
Aged 65 or disabled
U.S. Citizen and resident
You must have paid into the system for 10 years (or 40 quarters of taxes).
You OR your spouse. Even divorcees will get Medicare, as long as their spouse worked for 10 years and had SS taxes withheld.
If disabled…
Must be receiving SSDI benefits for 24 consecutive months to qualify.
“Original Medicare”

4. How do you obtain Medicare?
Some people get Part A & Part B automatically
You may qualify automatically if one of the following applies to you:
I’m already getting benefits from SS or the Railroad Retirement Board (RRB)
I’m under 65 and have a disability
I have Lou Gehrig’s disease
*If you’re automatically enrolled, you will receive your Red, White, and Blue Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability.
- If you don’t get your card in the mail, call Social Security at
Some people need to sign up for Part A & Part B
You need to sign up for Part A and Part B if the following applies to you:
You aren’t getting SS or RR benefits (for example, because you’re still working)
You qualify for Medicare because you have ESRD

5. Parts A & B When can I first enroll? What if I’m late to enroll?
The three months before your 65th birthday, the month of, and the three months after
Enrollment in Part A is automatic if you are already receiving SS Benefits.
What if I’m late to enroll?
For Part A, usually no penalties (unless you didn’t pay enough into SS)
For Part B, premiums will be higher after the Initial Enrollment Period (unless you qualify for an exception) You’ll pay a 10% penalty for each full 12-month period you wait to enroll.

6. What if you don’t want Part B?
If your Medicare hasn’t started yet, there are 2 ways to drop Part B:
1. If you were automatically enrolled in Part A & Part B and sent a Medicare card, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will pay Part B premiums.
2. If you signed up for Medicare through SS, contact Social Security.

7. Examples of Medicare Card #’s:
- Medicare RR Card:
A (the letter is at the FRONT, not at the end) Make sure to write that # on the app exactly as it appears on their card
- Spouse receiving benefits: B
- Spouse – Divorced: D
- Widowed – Child Dependent:
WCD

8. There are 2 Medicare Choices:1 2
ORIGINAL MEDICARE (Part A & B)
Part A
Hospital
Most people don’t pay a monthly premium for Part A
If you have to buy Part A, you will pay $411/month
Skilled Nursing – SNF (days 1-20, you pay $0; days , you pay $161 per day)
After 100 days, you move into Long Term Care (LTC)
Home Health/Hospice (You pay $0)
Inpatient Care (You pay the deductible $1,288. Days 1-60: $0, Days 61-90: $322 coinsurance per day)
Some blood transfusions
Part B
Doctor & Outpatient visits
Premium change for 2016: $ (remember, this amount can go up each year)
Deductible: $166 per year (having a deductible makes people think twice about seeing a doctor.)
Ambulance
Medical equipment
Certain Drugs (Chemo, Radiation)
Covers 80% (as soon as you’ve paid your premium).
You’ll pay 20% of the Medicare Approved Amount (after your deductible is met.)
MEDICARE ADVANTAGE Plan (Part C)
Combines Part A and Part B and, in many cases, includes prescription drug coverage
MAPD – Comprehensive Plan
Offered by Private Insurance companies
Premium varies by plan. Some plans offer a $0 premium
Your $ Part B deductible now goes to the private ins co.
You must continue to pay your Part B premium
It changes how you receive your Medicare
You won’t lose your Part A & B
Advantages: Dental, Vision, Hearing, Wellness Services, Gym membership, Good plan for healthy people, low premium.
Disadvantages: HMO plan may have a Gatekeeper process, the plan premiums, benefits and co-payments may change every year.

9. Medicare Advantage: HMO, PPO, HMO-POS, PFFS
HMO (Health Maintenance Org): Generally, a PCP arranges your healthcare in the plan’s network. Some HMO plans have a Gatekeeper/Referral process.
PPO (Preferred Provider Org): You can go out of network, but you’re going to pay much more. “Balance billing” by Dr’s can occur.
Balance billing is when Dr’s charge you a lot more money for services since out of network services aren’t covered by the insurance carrier.
HMO-POS: The Dr chooses to accept out of network patients. (No one is really an HMO-POS nowadays)
PFFS: (Private Fee-for-Service): The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. Not in Utah anymore.
Not all Providers will agree to treat you. They can opt out anytime.

10. Medicare Supplement/Medigap Policies
Provides coverage after your Medicare stops
Helps cover some of what Medicare Parts A & B don’t – such as coinsurance, copayments and deductibles
You’ll typically pay anywhere between $70 - $279/month depending on the plan, state and insurance carrier. Average amount is $140/month. Rates can go up every year.
Offered by private insurance companies
Remember: Supplements have nothing to do w/Medicare
Plans A – N (A, B, C, D, F, G, K, L, M, N)
Most common: F, G, N (Refer to page 101 in Medicare & You handbook)
Plan F is the Cadillac of plans.
Part G is $20 - $30 cheaper than Plan F
Part N: premiums are significantly less

12. MedSupp continued…. Eligibility:
Generally must be enrolled in Medicare Parts A & B
Resident of the state in which you are applying for coverage
Age 65+ (or under age 65 with certain disabilities in some states)
People of any age with end-stage renal disease
Advantages:
Great for those who travel
Can see any provider nationwide that accepts Medicare
Great for someone with a lot of health issues
Peace of mind knowing that you’re fully covered (no co-pays, etc…)
Cons:
Can be expensive

13. Medicare Advantage vs. Medicare Supplement
Concerns of Seniors
Medicare
Advantage
Supplement
Restrictive Network of Doctors and Hospitals
YES NO
Co-Payments to Providers
Health Plan decides what tests and procedures are approved for you
Can your plan be cancelled?
Plans are approved yearly and can be dropped
Can’t be cancelled as long as premiums are paid
Prescription coverage

14. Formularies What is a formulary?
A list of Prescription Drugs that your health plan covers. It lists both brand-name and generic prescription drugs.
All drugs are tiered. (T1, T2, T3, T4, T5) The higher the tier, the more money you’ll pay
Tier 1: Preferred Generics
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Brand
Tier 5: Specialty Tier
*** Plug in their prescriptions on Medicare.gov to see which plan has the best tiers.
***Always check the GoodRx app to find the lowest price on prescriptions.

15. Provider Directories:
Lists all providers and hospitals that are covered by the plan.
You can request a hard copy of the Provider Directory OR you can search for providers using the lookup tool for each carrier.
You can also download an electronic version of the directory and save it to your desktop. Simply hit Ctrl+F to open a search box. Type in the Provider’s name or hospital and it will take you to that exact page.

16. Part D Rx coverage Only offered by private insurance companies
$ $162.10/month. Most people pay around $50/month.
Deductibles, Tiers, Formularies
You must be entitled to Part A or have Part B
You must continue to pay your Part B Premium
Each plan has a list of drugs that it covers (Formulary)
90 days vs 30 days for prescriptions
Make sure their drugs are covered:
- Plug in their prescriptions on Medicare.gov to see which plan offers the best Tiers (Generally, the lower the tier, the lower your copay)
- Check the GoodRx app
Enrollment:
Coverage is NOT automatic
Penalties may apply if you enroll late. 1% each moth you go without credible coverage

17. Donut Hole/Coverage Gap
Keep in mind that you’ll get dinged if you say “Donut Hole”. The acceptable term is “Coverage Gap”
4 Phases of the Coverage Gap: 1 2 3 4
Deductible Phase
Initial Coverage
Coverage Gap
Catastrophic
$360 (standard amount)
Up to $3,310
Up to $4,850 5%
Now you’ll pay co-pays
You’ll now pay 45% of the cost of brand name drugs
You stay in this stage for the rest of the plan year.
Tier 1: $ or %
You’ll now pay 58% of the cost of generic drugs
Tier 2
T.R.O.O.P (True real out of pocket costs)
Tier 3
Tier 4
Tier 5
Only $ you’ve paid out of pocket will contribute to your Coverage Gap

18. Election Periods Initial Enrollment Period (IEP)
3 months before your birthday month, birthday month, and 3 months after birthday month. (7-month window)
Open/Annual Enrollment Period (AEP)
October 15th – December 7th
Special Enrollment Period (SEP)
Move? Get married? Lose coverage? Retire? 63 days before and after
LIS: can change plan anytime
Dual: anytime
Loss EGHP: loss of employer group (voluntary or involuntary)
SNF: if you go in or out of a skilled nursing facility, it opens up an SEP
General Enrollment Period (GEP)
Every JULY
Never took Part B
You can only call back from Jan 1st – April 30th
Policy takes effect July 1st
***You can only enroll them the 2 months PRIOR to July 1st. (So May and June)
Medicare Advantage Disenrollment Period (MADP)
January 1st – February 14th

19. Helpful Resources Medicare & You handbook Medicare.gov GoodRx App
This should be considered your Bible as a Medicare agent
Pay special attention to Pages 17, 101
Medicare.gov
Compare prescription costs by plan
GoodRx App
Find lowest cost for prescriptions
Social Security:
Medicare: MEDICARE