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2. We Are NOT Medicare
We do NOT represent Medicare, Medicaid or CMS Center for Medicare Services in any form or fashion
We are Broker Agents that represent ALL the Major Carriers in Texas
We have our own Agency in Garland TX
We have 6 years in the Medicare field
All License information is on website

3. When you call Medicare
Part A is assigned when you turn 65, 3 months before, during, and 3 months after (7 months total) to enroll into Medicare
Part B you enroll into that is deducted from your Social Security Check
Part C or Advantage Plans, also called HMO’s, PPO’s and Special Needs Plans
Part D is prescription plans

4. Things to know Traditional Medicare pays Part A & B or 80%
A Medical Supplement Plan covers the 20% but it’s not mandated to buy
If you get a Med Sup it may or may not have Part D built into the plan
You are required to get Part D
Most Advantage Plans include Part D and cover the 20% gap plus include dental, hearing and vision

5. Medical Supplements Med Sups are NOT the same as Advantage Plans
Med Sups may or may not have Part D
Med Sups do not include Dental, Hearing or Vision in the plan
Med Sups cost money and will rate up meaning go higher with age
All Med Sups are the same so a Plan F has the same benefits with each carrier only the price is different between carriers

6. Most people get Part A premium-free
You can get premium-free Part A at 65 if:
You already get retirement Benefits from Social Security or the Railroad Retirement Board.
You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.
You or your spouse had Medicare-covered government employment.
Worked more than 40 quarters

7. Part A premiums
If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $437. If you paid Medicare taxes for quarters, the standard Part A premium is $240.
In most cases, if you choose to buy Part A, you must also:
Have Medicare Part B (Medical Insurance)
Pay monthly premiums for both Part A and Part B

8. Part A Premium-free
If you're under 65, you can get premium-free Part A if:
You got Social Security or Railroad Retirement Board disability benefits for 24 months.
You have End-Stage Renal Disease (ESRD) and meet certain requirements.

9. Part A hospital inpatient deductible and coinsurance
$1,364 deductible for each benefit period
Days 1-60: $0 coinsurance for each benefit period
Days 61-90: $341 coinsurance per day of each benefit period
Days 91 and beyond: $682 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
Beyond lifetime reserve days: all costs

10. Part B costs
Some people automatically get Medicare Part B (Medical Insurance), and some people need to sign up for Part B
If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.
Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these: Social Security, Railroad Retirement Board, Office of Personnel Management

11. Part B premium in 2019 is $
If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA).
IRMAA is an extra charge added to your premium. Max amount $460.50/month

12. Part B deductible & coinsurance
You pay $185 per year in 2019 for your Part B Deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these:
Most doctor services (including most doctor services while you're a hospital inpatient)
Outpatient therapy
Durable medical equipment (DME)

13. Part C Advantage Plans, HMO, PPO & DSNP Dual Special Needs Plans
Health Maintenance Organization (HMO)
In most HMOs you can only go to the hospitals, doctors, and other health care providers that have agreements with the plan except in an emergency. You may also need to get a referral from your primary care doctor before seeing a specialist.
HMO’s have ZERO PREMIMUM COST
Primary Doctor ZERO COST in network
Dental, Hearing and Vision built into the plan

14. Preferred Provider Organization (PPO)
A type of Medicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network.
You can use doctors, hospitals, and providers outside of the network for an additional cost
Some have a ZERO PREMIMUM
See any Primary Doctor accepting Medicare
No Referral for Specialist

15. Special Needs Plan (SNP)
Medicare Special Needs Plans are a type of Medicare Advantage Plan designed for certain types of people with Medicare.
Some Special Needs Plans are for people with certain chronic diseases and conditions like Diabetes and Heart Conditions or have been on disability longer than 24 months

16. Part D Drug Plan
When turning 65 and enrolling in Medicare you must get a prescription plan within 63 days or risk being penalized for life unless:
Your plan has creditable coverage
You’re a Veteran
Qualify for LIS

17. Drug Tiers
Drugs on a formulary are often organized into different drug "tiers"
Tier 1 – Preferred Generic drugs
Tier 2 -Generic drugs
Tier 3 - Preferred brand-name drugs
Tier 4- Non-preferred brand name drugs
Tier 5- Specialty tier

18. Step Therapy
In some cases, plans require you to first try one drug to treat your medical condition before they will cover another drug for that condition.
If a drug has step therapy restrictions, you may work with the plan and your doctor to get an exception.

19. True out-of-pocket (TrOOP)
True out-of-pocket (TrOOP) costs are amounts you pay for covered Part D drugs that count towards your drug plan’s out-of-pocket threshold.
Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of-pocket limit. The limit doesn’t include the drug plan’s premium.

20. Drug Coverage Gap or “Donut Hole”
Medicare drug plans may have a "coverage gap," which is sometimes called the "donut hole." This means that after you and your drug plan have spent a certain amount of money for covered drugs, you may have to pay more for your drugs (until you reach the out-of-pocket threshold) ICP Initial Coverage Period where you have copay of 25% on Name Brand Meds or 37% for Generic until you reach Catastrophic Coverage where you pay the greater of 5% of drug cost or $3.40 Generic or $8.50 all others.
Note: If you get extra help paying your drug costs, you won't have a coverage gap. However, you will probably still have to pay a small copayment or coinsurance amount.

21. Donut Hole Example 2019
You take 6 generic meds costing $ total the plan pays for the meds and you pay $0 for months 1-8 but triggers ICP at $3,800
Months 9-11 you pay 37% of drugs costing you $ (Generic) for next 3 months but triggers Catastrophic Coverage $5,100 in month 12 or 5% of drug costing you $23.88
You paid $382 on meds costing $5730

22. LIS Qualification Low Income Subsidy is income based to qualify.
Single person $1561
Married Couple $2114
Asset limits:$7,730 Individual
$11,600 Couple
This is combined income including retirement income, 401K’s, IRA’s or any income reported on your taxes.

23. Full Extra Help QMB/DSNP
QMB will qualify for Medicaid automatically
People who qualify for the full low-income subsidy for Medicare prescription drug coverage.
People who get full Extra Help pay $0 for their monthly Medicare drug plan premium, $0 deductible, and no more than $3.40 (generic) or $8.50 (brand) for their prescriptions.

24. QMB/DSNP/Medicaid
Qualified Medicare Beneficiary (QMB): Gross monthly income limits: (100% Federal Poverty Level or FPL + $20**)
$1,061 –Individual
$1,430 –Couple
Asset limits:$7,730 –Individual
$11,600 –Couple
You must apply every year for QI Benefits.

25. SLMB Pays Part B
Specified Low-Income Medicare Beneficiary (SLMB): Gross monthly income limits: (120% FPL + $20)
$1,269 –Individual
$1,711 –Couple Asset limits:
$7,730 –Individual
$11,600 –Couple
Some plans will count SLMB as Full QMB

26. Qualifying Individual (QI) Program
Qualifying Individual (QI): Gross monthly income limits: (135% FPL + $20)
$1,426 –Individual
$1,923 –Couple Asset limits:
$7,730–Individual
$11,600 –Couple

27. Qualified Disabled and Working Individuals (QDWI) Program
The QDWI program helps pay Part A premiums only
You're a working disabled person under 65
You lost your premium-free Part A when you went back to work
You aren't getting medical assistance from your state
Individual $4,249 resource limit $4,000
Married $5,722 resource limit $6,000

28. LIS Resources Including
What items are included in the Medicare Savings Program resource limits?
Money in a checking or savings account
Stocks
Bonds

29. LIS Resources NOT Included
Your home
One car
Burial plot
Up to $1,500 for burial expenses or Life Insurance if you have put that money aside
Furniture
Other household and personal items

30. Spend Down Program
Some people make a little to much to qualify for LIS, the solution is to buy a health insurance product like Hospital Indemnity policy or Final Expense policy. This can be used to qualify a person for some level of LIS to get the benefit of saving of the MSP Medicare Savings Program

31. SOA Scope of Appointment
Agents may represent Part D, Medicare Advantage, and Medigap plans, but they should only present information about the products you are interested in.
You must complete a scope of appointment form before your appointment.
Every face-to-face meeting requires a Scope of Appointment. Additionally, SOAs must be filled out for one-on-one phone conversations.
Per CMS, agents must keep SOA forms on file for at least 10 years, even if the appointment didn't end in a sale

32. SEP Special Election Period
You can make changes to your Medicare Plans and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage.
These chances to make changes are called Special Enrollment Periods (SEPs)

33. SEP Qualifications You have Diabetes or chronic conditions
I moved to a new address that isn't in my plan's service area.
I moved to a new address that’s still in my plan's service area, but I have new plan options in my new location.
I moved back to the U.S. after living outside the country.
I just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital).
I'm released from jail.

34. SEP Qualification You lose your current coverage
I'm no longer eligible for Medicaid.
I left coverage from my employer or union (including COBRA coverage).
I involuntarily lose other drug coverage that's as good as Medicare drug coverage (creditable coverage), or my other coverage changes and is no longer creditable.
I had drug coverage through a Medicare Cost Plan and I left the plan.
I dropped my coverage in a Program of All-inclusive Care for the Elderly (PACE) plan.

35. SEP Qualification You have a chance to get other coverage if
You have a chance to enroll in other coverage offered by my employer or union.
You have or am enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage).
You enrolled in a Program of All-inclusive Care for the Elderly (PACE) plan.

36. SEP Qualification Your plan changes its contract with Medicare
Medicare takes an official action (called a "sanction") because of a problem with the plan that affects me.
Medicare ends (terminates) my plan's contract.
My Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan's contract with Medicare isn't renewed.

37. SEP Qualification I'm eligible for both Medicare and Medicaid.
I qualify for Extra Help paying for Medicare prescription drug coverage.
I'm enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility.
I dropped a Medigap policy the first time I joined a Medicare Advantage Plan.
I have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with my condition.
I'm enrolled in a Special Needs Plan (SNP) and no longer have a condition that qualifies as a special need that the plan serves.

38. SEP Qualification
I joined a plan, or chose not to join a plan, due to an error by a federal employee.
I wasn't properly told that my other private drug coverage wasn't as good as Medicare drug coverage (creditable coverage).
I wasn't properly told that I was losing private drug coverage that was as good as Medicare drug coverage (creditable coverage).

39. Medicare Facts FACT – ALL Medicare Plans change each year
The government tells you to shop your plan each year for changes that may effect you
Each carrier has different plans with specific benefits and health conditions
Certain plans are designed for Chronic Conditions like Diabetes or Heart Conditions
70% of most Seniors could get a better plan

40. Conclusion
As your Broker we can contact you during the year of plan changes effecting your coverage
We can also inform you of new plans that may benefit you or your family
Your situation changes qualifying you for a SEP and plan change
If you or someone you know has a question or problem contact us for a personal one on one consultation