1. Teresa Hatfield Extension Agent Family & Consumer Sciences
Adult Development and Aging

2. What is Medicare?
Federal health insurance that covers some of your medical and inpatient hospital costs if you:
Are age 65 or over
Are under age 65
Receiving Social Security Disability
Have End Stage Renal Disease
Have Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig’s Disease
Medicare was enacted in 1965 as Title 18 of the Social Security Act, which created a comprehensive health insurance program for Older Americans
Medicare is a federal health insurance program. It covers some medical costs if you are in one of the groups mentioned on the slide. (Review the groups with participants.)
People with disabilities:
Must have Social Security Disability Insurance (SSDI)
Have 24-month waiting period
Have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig’s Disease)
ESRD = Kidney disease requiring dialysis or kidney transplant.
Medicare pays some medical costs, but not all!
Medicare is not the same as Medicaid. Medicaid is medical coverage for people with low income and assets, and some people may qualify for both Medicare and Medicaid. But Medicare is open to all those mentioned.
To qualify for either Medicare or Medicaid, you must be a U.S. citizen or permanent legal resident (with green cards) who has lived in the U.S. for 5 consecutive years before applying.
We are now going to talk about the Basics of Medicare and the choices you will have to make in deciding how you want to use your Medicare.

3. What are the components of Medicare?

4. Original Medicare Part A & B
Part A—Hospital Insurance
Inpatient Hospital
Skilled Nursing
Hospice Care
Part B—Medical Insurance
Healthcare Providers
Medical Equipment
Labs
Outpatient Hospital

5. Medicare Parts C & D Part C---Medicare Advantage Plans
Private insurance
Manages your Medicare
HMO’s, PPO’s, PFFS
Part D—Prescription Drug Coverage
Private Insurance

6. Premium Costs of Original Medicare
Part A is free if:
My spouse or I earned enough work credits
If I am using my spouses employment record for eligibility my spouse must be 62 or older
Part B premium in 2018 for most people
New to Medicare $134
*Premiums may change each year
Most people will not pay a monthly premium for Medicare Part A. If they or their spouse has worked at least 40 credits (10 years) in social security covered employment. If you have to pay for Part A, it will cost you $422 each month in 2018 if you have less than 30 work quarters. It will cost you $232 if you have between work quarters.
Part B: Premium $109 per month for those drawing a Social Security benefit and already on Medicare, and $ for those new to Medicare or those who are not drawing a Social Security Benefit, and a $ deductible.

7. When Do I enroll in Medicare?

8. When can I join Original Medicare?
Enrollment Periods
Initial: Seven months around your 65th birth month or your Medicare eligibility date
Special: Up to eight months after your job-based plan ends – not when COBRA ends!!!
General: Every year from January - March (coverage starts July 1)
Let’s talk about when you join Medicare.
Initial Enrollment Period (IEP):
For most people, this is the three months before your 65th birthday month, your birthday month, and the three months after. The date you enroll affects the date your Medicare starts.
Special Enrollment period (SEP):
If you or your spouse work and have health insurance benefits through that job, you may delay joining Medicare. COBRA does not count as employer coverage!
You must notify SSA when the job or the insurance ends. You have 8 months to join Medicare, after the month the job or coverage ends.
If you think you may delay joining Medicare, talk to Social Security before you make your decision! Write down the name of the person you speak with, their phone number, the date, and what you discuss.
General Enrollment Period (GEP):
If you miss initial or special enrollments, you may join Medicare from January 1-March 31 of each year. Coverage starts July 1 of that year.
Many people who sign up for Medicare during this time will have to pay a permanent late-enrollment penalty. The penalty is a 10% premium increase for each full 12-month period you could have had Part B but didn’t sign up for it. Medicare waives the penalty for some people with lower incomes and assets.
NOTE:  If a person turns 65 on the first of the month, Medicare will start on the first of the month BEFORE the birthday month.  Anyone with a birthday on the first  of a month should take that into consideration.
Example: Birthday is May 1.  Use April as the Birthday month – Medicare will begin on April 1.

9. Example
Marie will turn age 65 on July 17, She has health insurance from her job until she retires on December 31, 2018.
Her Medicare enrollment opportunities are …
Enrollment period
Starts
Ends
Initial
Apr 1, 2018
Oct 31, 2018
Special
Jan 1, 2019
Aug 31, 2019
General (yearly)
Jan 1
Mar 31

10. Enrollment Part A and Part B
Automatic enrollment for those getting
Social Security benefits
Railroad Retirement Board benefits
Initial Enrollment Package
Mailed 3 months before
Your 65th birthday
25th month of disability benefits
Includes your Medicare card
Most people must enroll in Medicare, especially if they are not yet receiving financial benefits from Social Security (or RRB). You can do this in person at your local Social Security office, over the phone, or at ssa.gov.
There are some exceptions, where you don’t have to enroll themselves.
If you are already getting Social Security benefits, generally the Social Security Administration will work with Medicare to sign you up:
If you have a disability and receive Social Security Disability Insurance, or SSDI benefits, for 24 months, SSA will automatically enroll you in Medicare Parts A and B effective the 25th month of disability.
If you are getting Social Security Retirement or Railroad Retirement benefits when you turn age 65, SSA also automatically enrolls you. SSA will send you forms a few months before your 65th birthday. These forms will allow you to defer parts of Medicare if that’s what you need to do.
If you worked five or more years for the railroad:
Apply for Medicare through the Railroad Retirement board
Call

11. Enrollment Non Automatic
If you’re not automatically enrolled
You need to enroll with Social Security
Visit socialsecurity.gov
Call
Visit your local office
If retired from the Railroad, enroll with the Railroad Retirement Board (RRB)
Call your local RRB office or 1‑877‑772‑5772
Apply 3 months before you turn 65
Don’t have to be retired to get Medicare

12. When will my Medicare Start?
You sign up:
Your coverage starts:
The month you turn 65
1 month after you sign up
1 month after you turn 65
2 months after you sign up
2 months after you turn 65
3 months after you sign up
3 months after you turn 65
During the January 1–March 31 General Enrollment Period
July 1

13. Premiums for Higher Incomes
If your yearly income in 2016(for what you pay in 2018) was
You pay each month (in 2018)
File individual return
File joint tax return
File married & separate return
$85,000 or less
$170,000 or less
$134
Above $85,000 up to $107,000
Above $170,000 up to $214,000 NA
$187.50
Above $107,000 up to $133,000
Above $214,000 up to $267,000
$267.90
Above $133,000 up to $160,000
Above $267,000 up to $320,000
$348.30
Above $160,000
Above $320,000
Above $85,000
$428.60
Those making over 85,000 as an individual or 170,000 as a couple will pay , those individuals making over 107, 000 and couples making over 214,000 will pay $267.90, individuals above $160,000 up to $214,000, and couples above $320,000 up to $428,000 will pay $348.30, individuals above $214,000, and couples above $428,000 will pay $

14. Penalty
Part B
10% of premium for each full 12 month period that you could have had Part B but didn’t sign up for it
If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it.

15. Ways to have your Medicare
How do you want to get coverage?
Medicare Advantage Plans
HMO, PPO, PFFS
Part C of Medicare
Combines Hospital, Medical and possibly
Prescription Drug Coverage
Original Medicare (Your Primary Insurance)
Part A: Hospital
Part B: Medical
Part D: Drug Coverage
(Private Insurance)
Medigap or Supplemental Coverage
You can’t use or be sold a Medicare Supplemental (Medigap) policy.

16. Original Medicare Medicare (Parts A & B) pay:
Part of the total Medicare approved amount for covered services (often 80%)
If you have Original Medicare, you pay:
Medicare premiums and deductibles
Copays and coinsurance (often 20%)
15% more if provider won’t accept assignment
Medicare doesn’t cover (dental, routine vision, etc.)
Get out Overview of Cost Sheet
Medicare does not pay:
-the full cost of all Medicare covered services.
-What most providers bill. Medicare pays a percentage of a Medicare-”approved amount,” which may be less than what providers bill.
Besides monthly Medicare premiums, those with only Original Medicare must also pay (show the Medicare Part A/B Covered Services chart) certain amounts that may change yearly, including:
Part A deductible for inpatient hospital stays up to 60 days. You must pay the deductible before Medicare pays. This is $1,288 in 2016 per benefit period.
A Part B deductible, which is $183 for 2018.
Copays or coinsurance for Part B services. This is often a percentage of the Medicare-approved amount (20% in most cases).
Excess charges: Some providers who treat people with Medicare do not “accept assignment.” This means these providers may charge you up to15% more than the Medicare-approved amount.
Services Medicare doesn’t cover. If all you have is Part A and B, you may want to think about how you will pay for out-of-pocket costs.

17. Medigap/Supplemental Insurance
Run by private insurance companies
Plans A-N (not the same as Medicare Parts A-D)
Fill gaps in Original Medicare
May pay copays, coinsurance, deductibles
Does Not cover prescription drugs
If you don’t have other insurance besides Medicare, one option is to buy an insurance plan that works with Original Medicare. These insurance plans are called Medicare Supplement plans, or sometimes Medigaps (because they fill the gaps in Original Medicare).
Medigaps each have a Plan letter (A-N). This is different from the Parts of Medicare (A-D)!
In most cases, medical providers bill Medicare directly, and then Medicare sends any remaining portion of the bill to the Medigap. Medigaps may be used nationwide anytime you are seeing a provider who treats Medicare patients.

18. Medigap (Supplemental Insurance)
Federal government sets benefits
Each plan letter must cover the same benefits
Example:
Jones Company sells Plan G for $150/month.
Smith Company sells Plan G for $175/month.
Both plans provide the same benefit, no matter how much you pay for the premium.
Medigap: Medigap plans are supplemental insurance plans that can help cover the expenses that come with Original Medicare. These costs include things like, coinsurance, copayments, and deductibles.
When you think about buying a Medigap, here are a few things to consider:
All Medigaps are standardized. This means the federal government defines what each Plan letter (A-N) must cover. The 10 Standardized Plans chart shows benefits for each plan letter.
Insurance companies may not change the benefits under any of these plans.
So if you are shopping for a Medigap, as you decide where to buy, you might want to compare companies by price and customer service.

19. Purchasing a Medigap You have “guaranteed issue” to buy your Medigap:
Six months of when you sign up for Medicare Part B or
60 days of losing creditable Medical coverage if you already have Part B
“Guaranteed issue” means the plan must:
Accept you with no health screening
Charge you the same rate they charge other customers
Insurers must sell you a Medigap with no health screening in your first six months with Medicare Part B at age 65 or over. This is sometimes called “guaranteed issue,” or the Medigap “Open Enrollment Period.” During this time, the insurer:
Must accept you regardless of your health
May not charge you higher rates than other people
If you are under age 65 and on Medicare due to a disability, you will not get this guaranteed issue period until you turn age 65. In Kansas insurance companies are required to sell all types of Medigap policies to Medicare beneficiaries who are under age 65, including those with disabilities.
Medigaps do not have a yearly open enrollment period. State law allows you to change your plan in some cases, but most of the time when you buy a Medigap, as long as you pay your premium the plan stays in effect and the benefits of the plan never change.
When the guaranteed issue time period is up insurers may require you to pass a written health screening before they sell you a Medigap.

20. What to look for in a Part D Plan

21. Prescription Drug Coverage Part D
Part D – Optional (run by private insurance companies)
Have Part A, B, or both
Live in the plan’s service area
Can purchase regardless of health status
May have only one Part D or Prescription drug plan at a time
Will cost more for those with higher incomes
Medicare Supplements do not cover the cost of Prescription Drugs. You will have to purchase a separate Part D policy to cover these costs. (Review Slide)

22. When can I join Part D?
Initial Enrollment Period for Medicare (seven months around your 65th birth month or Medicare eligibility date
Open Enrollment -October 15 - December 7
January 1 effective date
Special Enrollment Period-2 months after a life changing event (loss of employer coverage)
If you are new to Medicare, your initial enrollment period for Part D is the same as for Medicare – the seven months around your 65th birthday. This includes the month of your birthday, plus the three months before and the three months after.

23. Things to Consider Cost Coverage Convenience Premiums
Co-pays/Co-insurance
Deductibles
Coverage
Does it cover all your medications?
Convenience
Which Pharmacies can you use
Preferred pharmacies
Part D plans are not all the same! (Review text on slide)
Kansas has 22 Part D Prescription Drug plans for 2017.
Part D plans have monthly premiums. For 2018 in KS these range from $ national average premium=about $35.00.
Some Part D plans have a yearly deductible, which you must pay before the plan pays. The deductible in 2018 may be up to $405.
Most Part D plans require you to pay some share of the Rx costs – either a copay (a flat rate) or coinsurance (a percentage). The amount varies based on your plan, your meds, and your pharmacy.
Many Part D plans also have a donut hole or coverage gap, which is like a second deductible you may have to meet mid-year. By 2020, Medicare is phasing out the donut hole and changing Part D plans so they cover about 75% of Rx costs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2018, once you and your plan have spent $3750 on covered drugs (the combined amount plus your deductible), you're in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap
Once you enter the coverage gap, you get a 60% manufacturer-paid discount on covered brand-name drugs. Although you'll only pay 40% of the price for that brand-name drug, the entire price will count as out-of-pocket costs which will help you get out of the coverage gap. You'll also pay 51% of the plan's cost for covered generic drugs until you reach the end of the coverage gap.
Once you've spent $4,950 out-of-pocket for the year, you're out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get "catastrophic coverage." It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.
Items that count towards the coverage gap
Your yearly deductible , coinsurance, and copayments
The discount you get on brand-name drugs in the coverage gap minus government subsidies
What you pay in the coverage gap
Items that don't count towards the coverage gap
The drug plan premium
Pharmacy dispensing fee
What you pay for drugs that aren’t covered
Discounts Medicare provides in the coverage gap, 42% toward generics, and 5% on brand name drugs
Coverage: Most plans have a formulary, or a list of drugs the plan covers. Plans have rules about how they cover various drugs.
Convenience: Drug plans work with some, but not necessarily all, pharmacies in every area. The plans may charge you lower costs for using certain pharmacies. Some plans also have a mail-order option.
But the best place to compare plans is online at You can go to that site yourself, or have a SHICK counselor help you.

24. Do I need Part D? Enrollment is optional.
Do I have other “creditable” drug coverage?
If yes, I may keep my current drug coverage with no penalty
If no, and I join Part D later than my initial enrollment period, I may pay a penalty
Will joining Part D end other coverage I have?
Plans we know are as good as Medicare Part D include: TRICARE for Life, VA drug coverage, and IHS drug coverage.
If you have other prescription drug coverage, such as through a job or retiree plan, find out if it is as good as Part D, to help you decide whether you need Part D or not.
Your plan must send you information each fall that tells you whether your plan’s drug coverage is as good as Part D. If it is, you will not be penalized if you don’t join Part D.
Your plan must also notify you if your drug coverage ends or changes so that it is not as good as Part D. If this happens, you may join Part D with no penalty within 63 days.
If you don’t get information from your plan, or can’t find it, contact the plan and ask for the information in writing.
Save all these letters from your current plan!
If you have a job-based or retiree plan and want to join Part D, be especially careful! Joining Part D may end your entire job-based or retiree plan, and you may lose all rights to get it back. Leaving your job-based or retiree plan may also affect other benefits through your current or former employer, and end health coverage for your family members. Read all letters your employer or union sends you, and contact the benefits administrator with any questions.

25. Part D Penalty
You could have a penalty if do not have another form of creditable drug coverage and decide not to take out a plan.
When you do decide to take a Part D plan the penalty will go into effect.
Penalty is based on how many months you could have had a Part D and didn’t

26. Where to Shop?

27. Medicare Part C
Medicare Advantage Plans (run by private insurance companies)
Optional – replaces Original Medicare (Parts A&B) while you have the plan
May contain prescription drug coverage
The other way to have Medicare is to join a private insurance plan that replaces Medicare as long as you have the plan. These optional private insurance plans are called Medicare Advantage plans. They are also sometimes called Medicare Health Plans, Medicare Part C, and Medicare+Choice.
If you join a Medicare Advantage plan, you are still in Medicare, but you no longer get Original Medicare. Instead, the federal government pays the Medicare Advantage plan to manage your care. Don’t throw out your red, white & blue Medicare card! Keep it in a safe place. If you leave the MA plan, you will return to Original Medicare. You will also still need your Medicare card to run the Plan Finder on Medicare.gov.
The Medicare Advantage substitutes for Original Medicare as long as you have the MA plan. This means the plan, and not Original Medicare, decides how much you pay, how much it pays your doctors, and resolves any problems you may have.
The Medicare Advantage plan must provide all Medicare-covered services from Parts A and B to you. The way it provides those services may be different than under Original Medicare (i.e. you may pay different out-of-pocket costs, but your out-of-pocket costs for some services may not exceed costs under Original Medicare, due to the Affordable Care Act). Medicare Advantage plans may or may not include Part D drug coverage. They may also require you to buy Part D coverage from that same insurer, to keep the MA plan.

28. How They Work Receive services through the plan
All Part A- and Part B-covered services
Some plans may provide additional benefits
Most plans include prescription drug coverage
You may have to use network doctors/hospitals
May differ from Original Medicare in
Benefits
Cost sharing

29. Medicare Advantage Plans
Health Maintenance Organizations (HMOs)
HMO Point of Service
Preferred Provider Organization (PPOs)
Private Fee-For-Service (PFFS)
Special Needs Plans
There are three main types of Medicare Advantage Plans:
HMOs: People who choose HMOs must get care from providers in the plan’s network. Often a primary care doctor coordinates your care, and the plan requires you to have referrals from that doctor to see specialists.
PPOs: PPOs also have a network of providers. But the plan will cover some costs if you see providers outside the network. You usually pay more outside the network.
PFFSs: These plans let you see any provider who accepts Medicare and takes the plan. But they don’t contract with providers, so providers may change their minds from visit to visit about whether to accept this coverage. We recommend you check with your providers before each medical visit, to ensure they still take this coverage. Most PFFS plans must provide you a network of doctors who accept the plan.
For all plans, it may be helpful to ask about any limits on who you can see and the process of seeing specialists or other providers. Learn all the rules before you sign up.

30. Medicare Advantage Costs
I pay:
My Medicare Part B premium
My Medicare Part A premium (if any)
Medicare Advantage (MA) plan monthly premium.
Deductible and copays or coinsurance.
See to estimate costs
Speaker Notes: Review text on the slide with Ps. And use Medicare Part C with holes page.
In 2018, Medicare Advantage plan premiums in Kansas range from $0-196/month.
Some plans have higher premiums when Part D drug coverage is included, and others don’t.
Some plans with lower premiums have higher costs elsewhere, such as higher deductibles and copays or coinsurance.
Every plan is different!
If you are interested in a Medicare Advantage plan, the website allows you to get an estimate of costs for specific plans in your county. You can explore that site on your own, or make an appointment with a SHICK counselor who can help you review that information.
Most MA plans in 2018 have no deductible for medical coverage; but they may have a deductible for drug coverage if they include Part D.
There are no insurance plans for sale that fill the gaps in Medicare Advantage. For example, you can’t get a Medigap to fill what Medicare Advantage does not cover.

31. Who Can Join? Medicare Beneficiaries: With both Medicare Parts A and B
Who live in the plan’s service area
With any health conditions except End-Stage Renal Disease (ESRD)
If you have End-Stage Renal Disease (ESRD), which is kidney failure requiring dialysis or a transplant, you usually can’t join a Medicare Advantage Plan. But there are some exceptions, such as if you are already in a Medicare Advantage plan and then develop ESRD.
Otherwise, your health status does not affect your ability to join a Medicare Advantage plan.
This may be an option for people under age 65 who can’t afford a Medigap, or who aren’t likely to pass the Medigap’s health screening.

32. Protect Yourself Guard your Medicare number
Review your Medicare Summary Notice
Don’t do business with door to door, phone sales, or online solicitors.
Report any discrepancies or fraudulent activity
Protect documents that contain personal information

33. Next steps What are your next steps?
Do you need personal help with your situation?
Contact SHICK for an appointment!
Local number: