1. Medicare: What else you should know SHIBA Statewide Health Insurance Benefits Advisors A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner 2/25/2015

2. What is SHIBA? 2 Statewide Health Insurance Benefits Advisors  A free program of the Office of the Insurance Commissioner  We provide unbiased and confidential information about Medicare and other health insurance  We are an educational service  We don’t sell anything!

3. 3  Medicare’s preventive benefits  How to pay for Medicare  Inpatient/outpatient (observation) SNF  Health Homes  Durable Medical Equipment (DME)  Transitioning from the Exchange to Medicare Today’s overview

4. 4 Medicare’s preventive benefits

5. Preventive services 5  Prevention is covered under Medicare Part B  Most preventive services are free – however some charge a coinsurance, copay  Check with your provider to make sure they accept Medicare

6. Types of preventive services 6  Health screening/exams  Counseling  Education  Immunizations Diagnostic tests may be ordered by the medical provider if you’re at risk, but these tests may have an out-of-pocket cost.

7. After you’re eligible for Part B 7  Get your Welcome to Medicare Preventive visit during your first 12 months of Part B coverage  What occurs during this visit – your doctor: Reviews your medical and family history Assesses any risk factors you may have Identifies risk factors that may make it necessary to get follow-up tests that have out-of-pocket costs Welcome to Medicare Preventive visit No cost if medical provider accepts Medicare

8. 8 After you’re eligible for Part B  The yearly Wellness visit takes place after your first 12 months of Part B eligibility (not as comprehensive)  Medicare covers this visit once every 12 months  Your provider will ask you to fill out a “Health Risk Assessment”  Anyone with Medicare is eligible  You pay nothing for the visit, unless you get additional tests or services that aren’t covered Wellness visit No cost if medical provider accepts Medicare

9. Examples of what’s covered 9  Flu, Hepatitis B and Pneumonia shots  Eyeglasses (limited)  Glaucoma tests  Diabetic supplies

10. 10  Flu shots: One per flu season starting in the fall  Hepatitis B shots: For people with medium or high risk; comes in a series of three for complete protection  Pneumonia shots: You can have any time of year, most people only need one in a lifetime High-risk people can get a pneumonia booster every 5 years Flu, Hepatitis B & Pneumonia shots

11. 11  One pair of eyeglasses with standard frames or one set of contact lenses from a supplier that accepts Medicare  After you have cataract surgery that implants an intraocular lens  You pay 20% of Medicare- approved amount and your Part B deductible applies Eyeglasses (limited)

12. Glaucoma tests 12 No cost if medical provider accepts Medicare  Medicare covers a Glaucoma screen by a doctor once every 12 months  You’re eligible if you’re: At high risk for diabetes African American over age 50 Hispanic and age 65 or older  Costs: You pay 20% of Medicare-approved amount after you meet the yearly Part B deductible

13. 13 Diabetic supplies  Covers: Blood sugar testing monitors and strips Lancet devices and lancets Blood sugar control solutions Therapeutic shoes (in some cases) Insulin (if medically necessary) if you use an external insulin pump  You pay 20% of Medicare-approved amount and Part B deductible applies

14. 14 Diabetic supplies (cont.)  No matter where you live, if you get your diabetic testing supplies delivered to your home, you must use a Medicare mail-order contract supplier – if you want Medicare to pay.  You can also buy supplies from any store that’s enrolled with Medicare (i.e., local pharmacy, storefront supplier)  This does not apply to insulin and external insulin pumps

15. Medicare preventive services resources  Medicare.gov  Call 1-800-MEDICARE (1-800-633-4227)  SHIBA pub: Understanding your Medicare preventive benefits 15

16. 16 How to pay for Medicare

17. 17 Help for people with limited income and resources  Medicaid For people with the lowest incomes, eligible people pay little or nothing for their health care costs  Medicare Savings Programs (MSPs) Helps pay Part B premiums and sometimes Part A and Part B deductibles and co-insurance  Extra Help Helps pay Part D (Rx drug) costs

18. 18 What is Medicaid?  Federal-state health insurance program For people with limited income/resources Certain people with disabilities If you have both Medicare and Medicaid, covers most health care costs  Eligibility determined by state  In Washington state: DSHS  Apply if you MIGHT qualify

19. 19 What are Medicare Savings Programs (MSPs)?  Help from Medicaid to pay for Medicare costs Pay Medicare premiums May pay Medicare deductibles and co-insurance  Income amounts change each year

20. 20 Who qualifies for MSP Individual Monthly Income Limit Married Couple Monthly Income Limit Helps Pay Your Medicare Savings Program $1,324$1,792 Part B premiums, and sometimes Part A premiums, Medicare A & B deductibles and co-insurance Asset Limits: Individual $ 7,280 Couple$10,930

21. 2/19/2013Getting Started21 What is Extra Help (Low Income Subsidy)?  Help paying prescription drug costs  Social Security makes determination  Some groups automatically qualify Example: If they qualify for Medicare and Medicaid  You or someone on your behalf can apply

22. 2/19/2013Getting Started22 Who qualifies for Extra Help? Individual Monthly Income Limit Married Couple Monthly Income Limit Helps Pay Your Extra Help $1,471$1,991 Part D Premium, Deductibles and Co-pays Asset Limits: Individual $13,640 Couple$27,250

23. 2/19/2013Getting Started23 Who should apply for these programs  Apply if you MIGHT qualify  Social Security for Extra Help  DSHS for Medicaid or Medicare Savings Programs  SHIBA can help you

24. 24 Inpatient/outpatient (observation) skilled nursing facility (SNF)

25. Hospital inpatient or outpatient 25  If you stay in a hospital overnight, you might still be considered outpatient  Your hospital status (hospital considers you an in- or outpatient) affects how much you pay for hospital services (i.e., x-rays, drugs, lab tests)  May also affect if Medicare will cover care you to get in an SNF following your hospital stay

26. Hospital inpatient or outpatient (cont.) 26  The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care.  An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care.

27. What you pay as an inpatient Medicare Part A  You pay a one-time deductible for all of your hospital services for the first 60 days Medicare Part B  Covers most of your doctor services  You pay 20% of Medicare-approved amount for doctor services after paying the Part B deductible 27

28. What you pay as an outpatient 28 Medicare Part B  Covers outpatient hospital services  You have a copay for each individual outpatient hospital service (amount may vary by service) Note: The copay for a single outpatient hospital service can’t be more than the inpatient hospital deductible  Generally Part B does not cover Rx and over-the- counter drugs in an outpatient setting

29. How hospital status affects the way Medicare covers your care in an SNF  Medicare will only cover care you get in an SNF if you first have a “qualifying inpatient hospital stay”  Your doctor must formally admit you to the hospital for at least 3 days in a row  Includes the day you were admitted as inpatient, but not the day of your discharge  If no 3-day inpatient hospital stay and you need care after your discharge, ask for care in another setting or if other programs can cover your SNF care 29

30. How hospital observation services affect SNF coverage  When you’re being observed in a hospital, you’re considered an outpatient  This means you cannot count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay 30

31. Where to get more help  Talk to your doctor or someone from the hospital discharge department  Medicare and You booklet  Call 1-800 MEDICARE  Read the handout Are you a hospital inpatient or outpatient? 31

32. Health Homes

33. What is a Health Home?  It’s a set of new care coordination services, provided by a care coordinator  He/she will work with you to increase coordination of all the services and supports you currently receive  Designed to support you with your ongoing chronic conditions and assist you with meeting your health goals  Examples of services include: Comprehensive care management Comprehensive and transitional planning Individual and family support services Referral to community and social support services 33

34. Who’s eligible for Health Home services  People with full Medicaid and Medicare coverage  These services support people with chronic conditions  The WA St. Health Care Authority will send you a letter to let you know you’re eligible  Your Health Home care coordinator will call you to talk about Health Home services  You can also contact Medicaid: 1-800-562-3022 34

35. Who provides Health Home services  Someone called a “care coordinator”  He/she works for Health Home lead organizations that contract with Medicare  A care coordinator will contact you to describe the Health Home services and answer your questions  You can stay with your current health care providers More information  Read the handout: Your Washington State Health Homes Booklet 35

36. 36 Durable Medical Equipment (DME)

37. What Medicare covers Durable medical equipment:  Oxygen equipment and supplies  Wheelchairs  Walkers  Hospital beds  Etc. 37

38. What Medicare covers (cont.)  Sometimes you must rent durable medical equipment  A doctor or other health care provider enrolled in Medicare must order for you to use in your home  You pay 20% of the Medicare-approved amount  Your Part B deductible applies 38 Important In all areas of the country, you must get your covered equipment, supplies, and replacement or repair services from a Medicare-approved supplier for Medicare to pay. See page 47 in the 2015 Medicare and You book

39. 39 Transitioning from the Exchange to Medicare

40. 40 Exchange to Medicare transition  When you become eligible for Medicare while on a health Exchange plan, Medicare will give you an initial enrollment period.  Once you’re entitled to Medicare, your health Exchange plan will automatically end your first day of Medicare coverage (WA state specific)  It’s to your advantage to sign up for Medicare because: Once you become Medicare eligible you can’t get lower costs for an Exchange plan based on your income If you wait to enroll in Medicare after your initial enrollment period, you may have to pay a late enrollment penalty for Part A and/or B

41. 41 Medicare fraud

42. 42 We all pay the price for Medicare fraud, abuse and waste! Watch out for these types of fraud:  You get billed for services or equipment you didn’t receive  You’re offered free testing or screening in exchange for your Medicare number  You’re charged for filling out claim forms OR – A medical provider:  Performs services that exceed what’s medically necessary  Offers/accepts referral fees from another provider for the referral  Misrepresents services that are billed to Medicare  Waives the 20% coinsurance or deductible Protect yourself from fraud

43. 43  Protect your Medicare number like you protect a bank account or credit card.  Review your Medicare payment notices and bills for errors.  Don ’ t do business with door-to-door or phone sales people, or online solicitations.  Always report suspicious activity. SHIBA is Washington state’s Senior Medicare Patrol project. We can help clients prevent, detect and report Medicare and Medicaid fraud and abuse. If you have questions or suspect fraud and abuse, call us at: 1-800-562-6900 Protect yourself from fraud

44. 44 Wrap up

45. Need help with other insurance questions? The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as: Call our Insurance Consumer Hotline 1-800-562-6900 45 Homeowner Auto Life Annuities Health And more!

46. Want to help your community?  Did some of this make sense to you?  Want to learn more?  Want to make a difference for others?  We would love to have you volunteer with SHIBA! 46

47. More questions?  Let us know if you want us to contact you to: Discuss your personal situation Learn more about becoming a volunteer THANK YOU!! 47