1. What is a Medigap? Health insurance policy
Sold by private insurance companies
Must say “Medicare Supplement Insurance”
Costs vary by plan, company and location
Deductibles, coinsurance, copayments
Does not work with Medicare Advantage Plans
Medigap is also known and a Medicare Supplement.
Original Medicare pays for many health care services and supplies, but it doesn’t pay all of a person’s health care costs. A Medigap policy is a health insurance policy sold by private insurance companies to fill the “gaps” in coverage under Original Medicare, like deductibles, coinsurance, and copayments. Some Medigap policies also cover benefits that Medicare doesn’t cover, like emergency health care while traveling outside the U.S.
The insurance companies that sell these policies must follow Federal and state laws that protect people with Medicare. The Medigap policy must be clearly identified as “Medicare Supplement Insurance.”
A Medigap policy only works with Original Medicare. If you join a Medicare Advantage Plan or other Medicare plan, your Medigap policy can’t pay any deductibles, copayments, or other cost-sharing under your Medicare plan.

2. Common Medicare CoverageOR
Most people get their Medicare health care coverage in one of two ways:
1. Signing up for Original Medicare while possibly adding Part D and/or a Medicare Supplement. or
2. Getting a Medicare Advantage Plan that may or may not include Part D. Later on in the Medicare Advantage module we will discuss which MA plans include Part D as the only option for drug coverage option with MA, plans that may or may not have Part D with a Part D standalone option and plans that do not have Part D as an option at all and would have to be purchased separately if wanted.
Medicare Supplement and Medicare Advantage plans do not work together. A Medicare Supplement only follows Original Medicare and can not be purchased to fill gaps a Medicare Advantage plan leaves behind.
Some MA plans have Part D coverage built in while others don’t
There are three types of other Medicare plans that are not MA or Med Supp plans:
Medicare Cost Plans—similar to an HMO, but services received outside the plan are covered under Original Medicare,
Demonstrations/Pilot Programs—Demonstrations are special projects that test improvements in Medicare coverage, payments, and quality of care. They are usually for a specific group of people and/or are offered only in specific areas. There are also pilot programs for people with multiple chronic illnesses. These programs are designed to reduce health risks, improve quality of life, and provide savings.
PACE (Programs of All-inclusive Care for the Elderly)—PACE combines medical, social, and long-term care services for frail elderly people. This program can help them continue to live at home for as long as possible before moving to a nursing home. PACE is only available in states that have chosen to offer it under Medicaid, and the qualifications vary from state to state.

3. Basics of Original Medicare
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Basics of Original Medicare
Out of pocket costs under the Original Medicare program can be significant:
Services
Medicare Pays in 2017
Beneficiary Pays in 2017
Hospitalization on March 10th (5 days)
After $1,316 deductible, all costs
$1,316
Re-admitted on April 2nd (10 days)
All costs
$0 (deductible applied to same benefit period)
Admitted in August (8 days)
Total (not including Part B services)
$2,632
This costs represents outside same benefit period; therefore subject to a new Part A deductible

4. Medicare Part A – Skilled Nursing
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Medicare Part A – Skilled Nursing
Services
In 2017 Medicare Pays
First 20 days
All approved amounts
Days
All but $ per day
After 100 days $0
Medicare Guidelines: in order for Medicare to allow SNF coverage, the beneficiary must have a prior hospital admission for a minimum of 3 days; the admission to the SNF has to be within 30 days of hospital discharge for the same condition they were originally treated for.

5. Medicare Part B Services In 2017 Medicare Pays
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Medicare Part B
Part B – Physician services in or out of the hospital, supplies, physical/speech therapy, diagnostic tests, durable medical equipment
Services
In 2017 Medicare Pays
First $183 of Medicare-approved amounts (Part B Deductible) $0
Remainder of Medicare-approved amount
80%
Part B Excess Charges
Excess Charges: Physicians who do not accept Medicare assignment can charge an additional 15% of Medicare-approved amounts. Original Medicare does not cover these excess charges. Excess charges or physician limiting charges are the Medicare beneficiary’s responsibility (in the states where these charges apply).
Outpatient Mental Health is 20%

6. Medicare Exclusions
Ask: Does Medicare Cover everything? What are some things you think Medicare may not cover?
Turn to next slide for a list of exclusions

7. Medicare Supplement – Basics of Original Medicare
Some of the things NOT covered by Parts A and B are:
Part A & B coinsurance and deductibles
Most outpatient prescription drugs
Routine dental care
Routine hearing exams, screenings, hearing aids
Routine eye exams, most eye wear, contacts
Custodial care (unskilled) in a nursing home
Some of the things not covered by Original Medicare are:
Part A & B coinsurance and deductibles
Most outpatient prescription drugs
Routine dental care
Routine hearing exams, screenings,hearing aides
Routine eye exams, most eye wear, contacts
Custodial care (unskilled) in a nursing home

8. Medicare Supplement – Basics
Medicare beneficiary retains their red, white, and blue Medicare ID card
There is no network requirement; Medicare beneficiaries can see any Medicare approved provider in the Medicare program
Providers bill Medicare as they normally would
Medicare carriers and intermediaries process claims, generally pay the provider 80% of the Medicare allowable amount after applicable deductibles are applied -- claims are then sent to Medicare Supplement carriers to cover any amounts payable by the plan
Plans are guaranteed renewable – cannot be canceled
Except for non-payment of premium and misrepresentation

9. Medicare Supplement – Basics
Original Medicare program was not designed to cover 100% of health care costs
Medicare Supplement plans are supplementary to original Medicare – filling in the coverage gaps
In 1992, the federal government established the 10 Standard Plans A-J with varying coverage options for Part A and B deductibles and coinsurance followed in all states except for Wisconsin, Minnesota, and Massachusetts
Includes High Deductible Plans F & J
In 2006, Plans K & L were added
States (not CMS) administer and regulate private companies that offer Medicare Supplement plans sold to state residents; plans are portable and do not require state residence to stay in force
Standard plans were available for new enrollment from 1992 up to June 1, 2010.
Pre-standardized plans were available for new enrollment prior to 1992

10. Choosing a Medigap Chart
Refer to Choosing a Medigap Publication
Plan K OOP limitation is $4960 for 2016 (cost sharing plan)
Plan L OOP limitation is $2480 for 2016 (cost sharing plan)
Plan F High deductible is $2, for 2015
***Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.
Plan K OOP limitation is $4,960 for 2016 (cost sharing plan)
Plan L OOP limitation is $2,480 for 2016(cost sharing plan)
Plan F High deductible is $2, for 2016
***Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

11. WellPoint Medicare Supplement Plans – Comparison
Medicare Supplement Benefits
Plan F
Plan G
Plan N*
Medicare Part A Coinsurance plus coverage for 365 additional days after Medicare benefits end
Medicare Part B Coinsurance
Blood (First 3 pints) and
Hospice (under Part A Coinsurance) X
Skilled Nursing Facility Care Coinsurance
Medicare Part A Deductible
Medicare Part B Deductible
Medicare Part B Excess Charges
100%
Foreign Travel Emergency
Here are the plans WellPoint offers in its portfolio (with exception of WI) Note: If you are under age 65 and qualify for Medicare due to disability, your choice of plans may be limited. See Outline of Coverage for available plans.
Note: There are no Med Supp plan offerings in NY for 2016
This slide lays out a chart that allows you to compare the plans and benefits for WellPoint offering effective 6/1/ This chart can also be located in the Sales Brochure of the Marketing kit
Reminder: INPT Mental Health has 190 day lifetime max in a psychiatric hospital. (lifetime reserve days do not apply)
* 100% Part B coinsurance, except up to $20 copayment for certain office visit and up to $50 copayment for ER.
Internal Use Only – Any redistribution or other use is strictly forbidden. Not for distribution to the general public; nor for solicitation purposes.

12. Eligibility Criteria Applicant must: Have Medicare Parts A and B*
Be a permanent resident of the state in which the application is taken
Be replacing an existing Medicare Supplement, if applicable
To buy a Medigap policy, you generally must have Medicare Part A and Part B.
If you are under age 65 and have a disability or End-Stage Renal Disease (ESRD), you may or may not be able to buy a Medigap policy until you reach age 65. We will cover Medigap policies for people under age 65 later in this presentation.
Medicare Supplement plans are portable, and they are guaranteed renewable. There are no contracts. As long as you continue to pay your premium, they will not be cancelled.

13. Enrollment Period Open Enrollment Period
Medicare Supplement Open Enrollment Period begins the first day of the month in which a beneficiary is both 65 years old and enrolled in Part B and continues for 6 months
Individual has guaranteed issue for all plans during this period
Insurance plan cannot charge additional premium for existing health conditions during this time
You may buy a Medigap policy any time an insurance company will sell you one, but some times are better than others to ensure your best choice, coverage, and cost.
Generally, the best time to buy a Medigap policy is during your Medigap open enrollment period because companies can’t:
Refuse to sell any Medigap policy it sells
Make you wait for coverage (exception below)
Charge more because of a past/present health problem
A company can make you wait for coverage if you have a pre-existing condition but you don’t have creditable coverage
You may want to apply for a Medigap policy before your Medigap open enrollment period starts, if your current health insurance coverage ends the month you become eligible for Medicare OR you reach age 65 to have continuous coverage without any break.
If you are 65 or older, your Medigap open enrollment period begins when you enroll in Part B.
It can’t be changed or repeated, although some states have more generous rules.
As long as you pay your Medigap premium, your policy is automatically renewed each year or “guaranteed renewable.”
NOTE: In some states, insurance companies may legally refuse to renew Medigap policies that were bought before 1990.

14. Underwriting Guidelines
Health underwriting is the assessment of the medical history and current health status of an applicant to determine the appropriate risk classification. In many states, individuals applying outside of their Medicare Supplement open enrollment period may be subject to health underwriting, unless exercising a Guaranteed Issue situation. Consult your state specific Medicare Supplement Marketing Kit for specific underwriting guidelines.
Underwriting is used to determine acceptance or not to issue a policy based on health questions located on the application.

15. When is a Medigap Policy Guaranteed Issued?
Individuals that meet any of the qualifying events are candidates for guaranteed issue* into Medigap Plans offered by the carrier.
These provisions apply only to individuals who are 65 and older
The rights of the member must be communicated by the insurer providing prior coverage
The application must be received by the insurance company within 63* days of disenrollment
Proof of disenrollment from the applicant’s prior carrier may be required
*Certain states have Guaranteed Issue without regard to qualifying events. In addition, some states allow for more than a 63 day break in coverage.
Medicare recognizes instances when extra time will be allowed to make a choice about enrollment in a new plan. Maine=90 days
Also there may be state to state differences in what may be allowed in terms of extra time to enroll.

16. Under 65 and Disabled
Individuals may have Medicare before age 65 due to a Medicare qualifying disability or End Stage Renal Disease (ESRD). ESRD is permanent kidney failure requiring dialysis or a kidney transplant. Federal law does not require insurance companies to sell Medigap policies to individuals under the age of 65. Some states require Medigap insurance companies to sell a Medigap policy even if the beneficiary is under age 65.
Federal law doesn’t require insurance companies to sell Medigap policies to people under age 65.
The following states do require Medigap insurance companies sell to people under 65:
California*, Colorado, Connecticut, Delaware**, Florida, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts*, Michigan, Minnesota, Mississippi, Missouri, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Texas, Vermont*, Wisconsin.
Even if your state isn’t on this list:
Some insurance companies may voluntarily sell Medigap policies to some people under age 65.
Some states require that people under age 65 who are buying a Medigap policy be given the best price available.
Generally, Medigap policies sold to people under age 65 may cost more than policies sold to people over age 65.
If you live in a state that has a Medicare open enrollment period for people under age 65, you will still get another Medicare open enrollment period when you reach age 65, and you will be able to buy any Medigap policy sold in your state.
*Medigap not available to people with ESRD under age 65.
**Medigap only available to people with ESRD.

17. Select Plan – Provider Network Hospital
Network Hospital Restrictions Disclosure: When you require health care services in a hospital on an inpatient basis, you may choose any hospital you wish.
However, benefits are conditioned on whether you use
A participating hospital OR
A non-participating hospital
Only Ohio and Kentucky Medicare Supplement Plans offers a Medicare SELECT option.
If you buy a Medicare SELECT policy, you are buying one of the 11 current standard Medigap Plans A through N sold on or after June 1, A Medicare SELECT plan is an exact copy of the standard plan, but with Facility requirements for full benefits.
You need to use specific hospitals to get full insurance benefits (except in an emergency).
For this reason, Medicare SELECT policies generally cost less.
If you do not use a Medicare SELECT provider for non-emergency services, you may have to pay what Medicare does not pay. Medicare will pay its share of approved charges as long as your provider participates.
The full benefits of your coverage will be paid anywhere if hospitalization is for Emergency Care. Emergency Care is defined as care, which is needed immediately because of an injury or sickness of sudden and unexpected onset.
Referrals
There are no restrictions on referrals to other hospitals if referred by a network hospital and this referral is approved by us.
Remember we have negotiated rates established with these facilities in order to keep the costs down.
If you use the services of a participating hospital, the Medicare Part A inpatient hospital deductible amount will be waived by the hospital.

18. Select Plan – Provider Network Hospital (cont.)
If you use the services of a non-participating hospital, the hospital will not waive, and we will not pay, the Medicare Part A inpatient hospital deductible amount, unless:
You are hospitalized for symptoms requiring Emergency Care or hospitalization is immediately required for an unforeseen sickness, injury or condition;
It is not reasonable for you to obtain services through a participating hospital; or
You require covered services that are not available through a Participating Hospital
These network hospital restrictions apply only to the inpatient hospital confinement deductible benefit. These restrictions do not apply to any other benefit in your Policy.

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Medicare Assignment
Providers who accept “Medicare Assignment,” agree to:
Receive payment from Medicare for covered services; and
Accept Medicare rates for covered services.
Those providers that do NOT accept Medicare assignment but still accept Medicare can bill the beneficiary for “excess charges,” or up to 15% of the Medicare allowed amount.
Medicare requires that the “limiting charge” is 15% (may be lower in some states).
Provider Claim Forms do have “assignment” indicator for providers to check to verify if they do or do not accept Medicare Assignment

20. See state-specific brochures for factors influencing premium rates.
Premiums can be determined by:
Plan selection
Age
County of residency, zip code
Gender of the applicant
Tobacco use
See state-specific brochures for factors influencing premium rates.
Plan Selection: Plan F is higher than High Ded Plan F for example
Age (if not community rated) and rating methodologies will be discussed next