1. New Mexico Aging and Long Term Services Department

2. New Mexico Aging and Long Term Services Department
* State Health Insurance Assistance Program
* NM Aging and Disability Resource Center
* Senior Medicare Patrol
* Medicare A, B, D, C
* Medigap
* Low income assistance

3. New Mexico State Health Insurance Assistance Program (SHIP)
* Federal partnership
* Counseling
* Education
* Outreach
* Free and Unbiased
* People on Medicare
* Family members
* Caregivers

4. New Mexico Aging and Disability Resource Center (ADRC) 1-800-432-2080
We are here to help
The ADRC connects people with resources to maximize personal choice and independence
It is the single point of entry for older adults, people with disabilities, their families and the general public to access:
* State and Federal benefits * Centennial Care
* Community Resources * Community based services

5. New Mexico Aging and Disability Resource Center (ADRC) 1-800-432-2080
Services
1. Benefits Counseling – guidance and problem solving for Medicare/Medicaid issues
2. Prescription Drug Assistance Programs
3. Community Services – home health care, caregiver support, adult day programs, legal services, healthcare fraud

6. Senior Medicare Patrol (SMP)
PROTECT DETECT REPORT
1. Protect yourself against Medicare fraud and abuse
2. Keep your Red White and Blue Medicare card SAFE

7. Senior Medicare Patrol (SMP)
PROTECT DETECT REPORT
3. Review your Medical Summary Notice
(MSN) - detect possible errors and
make sure you’re billed for the right
services
4. Report possible fraud to the ADRC

8. Senior Medicare Patrol (SMP)
Examples of Fraud and Abuse
* Billing for services and supplies that were not provided
* Submitting duplicate claims
* Obtaining your Medicare number for “free” services
* Improper coding to get a higher payment
* Claims for services or supplies that are not medically necessary -
excessive x-rays or lab tests

9. Senior Medicare Patrol (SMP)
Who is committing this crime?
* Physicians/Practitioners
* Physician’s employees
* Medical equipment suppliers
* Billing agencies
* Beneficiaries

10. Senior Medicare Patrol (SMP)
Protect yourself
Do:
* Use a journal to keep track of appointments and services
* Ask questions – you have a right to know everything about your
medical care
* Count your pills before leaving the pharmacy
Don’t:
* Let anyone persuade you to see a doctor for care you don’t
need
* Accept medical supplies from door-to-door salespeople,
Medicare does not make house calls or phone calls

11. Medicare Enrollment check - the month you turn 65
* Is automatic if you already receive a Social Security
check
* Enroll online or at the SSA office
- 3 months before you turn 65
- the month you turn 65
- 3 months after you turn 65

12. Medicare

13. Medicare Enrollment * Initial Enrollment Period - 7 months
* General Enrollment Period - Jan. 1 through Mar. 31
Coverage begins July 1
* Special Enrollment Period – moving, employer coverage
ends, entering or leaving a long term care facility

14. Part D: Prescription Drugs
Medicare
Part C:
Advantage Plan
Part A:
Hospital Insurance
Part B:
Medical Insurance
Part D: Prescription Drugs

15. Medicare 1. Decide how you want coverage Part C = Part A Part B Part D
Original Medicare OR Medicare Advantage
Part A Part B
Part D
Part C =
A + B + D

16. Medicare 3. Decide if you need supplemental coverage Medigap
Original Medicare OR Medicare Advantage
If you join a Medicare Advantage Plan, you do not need and cannot be sold a Medigap policy
Medigap
(pays 20%)

17. Part A Hospital Insurance - what it covers 1. Inpatient Hospital stay
2. Inpatient skilled nursing facility
3. Blood
4. Home health care
5. Hospice care

18. Part A Hospital Insurance - what it covers medication supplies
1. Inpatient Hospital stay - Covers everything administered during your stay in the hospital * once you’ve been admitted:
semi-private room meals general nursing equipment
medication supplies

19. Part A Hospital Insurance - what it covers
2. Skilled Nursing Facility - Covers skilled nursing and rehabilitative services and supplies that are medically necessary
Hospital stay condition 3 day stay as inpatient
Admit within 30 days Ambulance (limited)

20. Part A Hospital Insurance - what it covers
3. Home health care - Covers medically necessary part- time or intermittent skilled nursing care, physical therapy or speech pathology
Homebound Approved agency
Review every 60 days DME 20%

21. Part A Hospital Insurance - what it covers
4. Hospice Care - Covers medical needs when certified as terminally ill
Recertify 6 months Medication for pain
Respite care Medical equipment
Grief counseling Approved agency

22. Part A Hospital Insurance - what it covers * Free from blood bank
5. Blood – if you need blood while admitted as inpatient
* Free from blood bank
* If hospital has to pay
You pay for first 3 units
You or someone else can donate to replace

23. Part A Cost 1. Deductible = $1340.00 per benefit period (2018)
(begins the day you are admitted in a hospital, ends after 60 days)
2. Monthly premium = $0
* If you worked and paid Medicare Taxes for at least 10 years
* Call Social Security to determine your monthly premium if you
worked less than 10 years

24. Part A Cost 3. Co-pays/co-insurance =
a. Hospital stay – first 60 days = $0
days = $ per day (2018)
b. Skilled Nursing – first 20 days = $0
days = $ per day (2018)
c. Home healthcare - $0
d. Hospice Care - $0

25. Part B Medical Insurance – what it covers 1. Doctor visits
2. Outpatient surgery and supplies
3. Labs – X-rays, MRI, CT scan, EKG
4. Durable Medical equipment
5. Preventive services

26. Part B Preventive services – what it covers * Abdominal aortic
* Glaucoma
* Pneumococcal shot
aneurysm
* Hepatitis B shot
* Sexually
* Advanced Care
* Hepatitis C
transmitted
Planning
* HIV
infections
* Alcohol misuse
* Lung caner
* Tobacco cessation
* Bone mass
* Mammogram
* Welcome to
* Cardiovascular
* Medical
Medicare
* Colorectal
nutritional therapy
* Yearly Wellness
* Depression
* Obesity
visit
* Diabetes
* Pap test and pelvic
* Flu shot
exam

27. Part B Cost 1. Deductible = $183.00 (2018)
2. Monthly premium = $ (2018)
* You might be eligible to get help paying for the premium
with a Medicare Savings Program.
3. Co-pays/co-insurance = 20%

28. Part B
Cost
* Penalty for late enrollment = premium goes up 10% for each 12 month period; for the life of coverage
Example: $ x 10% = x 2 years = $26.80
= total Part B premium after 2 year penalty!

29. Part B Opt out * If covered by an employer plan or spouse
* Retiree plans -
Review guidelines with benefits administrator
* Creditable coverage

30. Medigap Policy AKA Supplemental Insurance
* A Medigap policy can be bought to cover your out of
pocket expenses with Original Medicare
* Some policies will pay for your deductibles, co-payments or
coinsurance
* Plans are identified by letters
* Sold by private insurance companies

31. Part D Eligibility Prescription Drug Insurance - What it covers
1. Must have Medicare part A and/or B
2. Must live in the service area
3. Join when your first eligible for Medicare
Prescription Drug Insurance - What it covers
1. Lower co-pays for medication
2. Choices of generic or brand name drugs

32. Part D Cost 1. Deductible = up to $405.00 (2018)
2. Monthly Premiums = vary by plan. The national average is $35.02 /month (2018)
3. Co-payments/co-insurance = depend on your prescriptions

33. Part D
Cost
* Penalty for late enrollment = 1% of the national base premium multiplied by each month you’re not enrolled; for the life of coverage
Example: $35.02 x 1% = .35 x 24 months = $ = total Part D premium with 2 year penalty!

34. AKA Medicare Advantage Plans
Part C
AKA Medicare Advantage Plans
Includes Medicare A, B and usually D
Eligibility
1. You must have Medicare Part A and B to join a Medicare Advantage Plan
2. You must live in the plan’s service area
3. Cannot have End Stage Renal Disease

35. *Call your plan for details about the cost on different services*
Part C
Cost
1. Annual deductible = each plan is different
2. Monthly premium = Part B premium ($ for 2018) + the monthly premium charged by the health plan
3. Co-pays and co-insurance = depends on the plan you choose
*Call your plan for details about the cost on different services*

36. Low Income Programs Social Security Administration (SSA)
1. Extra Help/Low Income Subsidy (LIS)
pays Part D deductible, premium and co-pays

37. EXTRA HELP Income Guidelines
Is means tested on income and resources. Depending on the percentage of FPL determines the ‘amount’ of extra help a beneficiary will receive.
Income guidelines range from 135% to 150% of FPL for any individual or couple:
135% = 100% extra help
140% = 75% extra help
145% = 50% extra help
150% = 25% extra help

38. EXTRA HELP 2018 Income Numbers 48 Contiguous States and DC
100% FPL individual = /month ( annually)
100% FPL couple = /month ( annually)
135% FPL individual = month ( annually)
135% FPL Couple = /month ( annually)
150% FPL Individual = /month ( annually)
150% FPL Couple = /month ( annually)

39. EXTRA HELP Individual Resource Limits
FULL Extra Help (PART D Premiums, deductibles, copays)
Individual 2018 Resource Limit:
Couple 2018 Resource Limit:
PARTIAL Extra Help (100% premium, but less help with deductibles/copays)
Individual 2018 Resource Limit
Couple Resource Limit

40. Medicare Savings Programs
State of New Mexico Medical Assistance Division
1. QMB - pays Medicare Part A deductible and premium
pays Medicare Part B deductible and premium
pays co-pay amounts
2. SLMB - pays Medicare Part B premium only
3. QI pays Medicare Part B premium only

41. Qualified Medicare Beneficiary (QMB)
* Pays Medicare Part B deductible, premium and co-pays
* Automatic help with Rx.
QMB INCOME LIMIT = 100% FPL
2018 Numbers:
Income : Individual = $
Couple = $
Resources: Individual = $
Couple = $

42. Specified Low Income Medicare Beneficiary (SLIMB)
* pays Medicare Part B premium
* automatic help with Rx
INCOME LIMITS SLIMB = greater than 100% FPL up to 120% FPL
2018 NUMBERS:
Income : Individual = $
Couple = $
Resources: Individual = $
Couple = $

43. Qualified Individual (QI1)
* pays Medicare Part B premium
* automatic help with Rx
Income limit QI1 between 120% and 135% FPL
2018 Numbers:
Income : Individual = $
Couple = $
Resources: Individual = $
Couple = $

44. Recap * State Health Insurance Assistance Program
* NM Aging and Disability Resource Center
* Senior Medicare Patrol
* Medicare A, B, D, C
* Medigap
* Low income assistance

45. 1-800-432-2080 Call the ADRC for confidential one-on-one counseling
Questions?
Call the ADRC for confidential
one-on-one counseling