1. Norvax University Online Training:
Medicare 101: Introduction to Medicare

2. Agenda Medicare Eligibility & Enrollment
Overview of Medicare Coverage Options
Benefits & Cost of Original Medicare
Medicaid
Medicare Resources for More Information

3. What is Medicare?
Medicare is a federal program which provides health insurance benefits for people who meet one of 3 categories:
65 or Older
Those with End Stage Renal Disease (ESRD)
Those under 65 with certain disabilities
Administration
Centers for Medicare & Medicaid Services (CMS)
CMS is an agency within the Department of Health and Human Services (HHS)
Medicare covers 49 million Americans

4. What is Medicare?
The Social Security Act established both the Medicare and Medicaid programs in 1965.
Original Medicare is a “fee-for-service” system, where a Medicare beneficiary is charged a fee for each health care service/supply received.
Beneficiaries can see any provider that is approved by the Medicare program.
Fun Fact: Who was the first Medicare beneficiary? Answer: Former President Harry S. Truman.

5. Medicare Prescription Drug Coverage
Four Parts of Medicare
Part A
Hospital Insurance
Part B
Medical Insurance
There are 4 parts to Medicare: Original Medicare includes hospital coverage under Part A and medical coverage under Part B. Both hospital and medical coverage can be obtained through private insurance companies under Part C, also referred to as the Medicare Advantage program. Outpatient prescription drug coverage is available through private insurance companies under the Part D program. For today’s discussion, we’ll be discussing Part A and Part B.
Part D
Medicare Prescription Drug Coverage
Part C
Medicare Advantage

6. Enrollment Automatic for those receiving
Social Security benefits
Railroad Retirement Board benefits
Initial Enrollment Period Package
Mailed 3 months before
25th month of disability benefits
Age 65

7. Enrolling in Medicare Some people need to sign up
Those not automatically enrolled
Enroll through Social Security
Railroad Retirement Board for railroad retirees
Apply 3 months before age 65
Do not have to be retired

8. Enrollment Periods Initial Enrollment Period (IEP)
Begins 3 months prior to the month of turning age 65 and continues through the end of the third month after
General Enrollment Period (GEP)
Allows individuals who did not enroll in Part B during the IEP to enroll between January 1 – March 31 of each year for a July 1 effective date
Special Enrollment Period (SEP)
Allows individuals who delayed enrolling in Part B because they were receiving benefits through an employer as an active employee (or dependent of someone who is); SEP runs eight months from the time of retirement or loss of coverage

9. Medicare Card Keep it and accept Medicare Parts A and B
Return it and refuse Part B
Follow instructions on back of card
FRONT
BACK

10. Medicare Options

11. Overview of Medicare Options
The choice of options to be considered are:
Premium Cost
Cost Sharing
Network Providers
Prescription Drug Coverage
Value-Added Benefits

12. Original Medicare A&B

13. Medicare Part A (Hospital Insurance)
Premium
Most people receive Part A premium free
If you paid FICA taxes for at least 10 years
If you paid FICA taxes less than 10 years
Can pay a premium to get Part A
30 or more quarters - $248/month in 2012
Less than 30 quarters - $451/month in 2012
May receive penalty if not bought when first eligible
The federal government funds Part A costs through social security payroll tax deductions

14. Medicare Part A Coverage
Inpatient Hospital Stays
Semi-private room, meals, general nursing, and other hospital services and supplies
Care in critical access hospitals and inpatient rehabilitation facilities
Inpatient mental health care in psychiatric hospital (lifetime 190-day limit)
Generally covers all drugs provided during an inpatient stay received as part of treatment
Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies

15. Medicare Part A Coverage
Home Health Care Services
Can include part-time or intermittent skilled care
Physical therapy, speech-language pathology, continuing need for occupational therapy
Some home health aide services, medical social services, medical supplies
Hospice Care
For terminally ill and includes drugs, medical care, and support services from a Medicare-approved hospice
Blood
Received during inpatient care

16. Part A Cost Sharing Inpatient Hospitalization Skilled Nursing Facility
Deductible for 2012: $1,156 (first 60 days)
Day 61-90: $289/day
After 90 days using lifetime reserve days (60 days): $578/day
After lifetime reserve days are used: No Coverage
Skilled Nursing Facility
First 20 days: No cost sharing
Day : $144.50/day
After 100 days: No Coverage

17. Part A Cost Sharing Home Health Care Hospice Care Blood
$0 for Skilled HHC Services
20% for Durable Medical Equipment (DME)
Hospice Care
5% for inpatient respite care
Room and board, in some cases
$5 for prescription drugs
Blood
100% first 3 pints
20% for additional pints

18. Monthly Part B Premium Yearly Income in 2010 You Pay
File Individual Tax Return
File Joint Tax Return
$85,000 or below
$170,000 or below
$99.90
$85,001 - $107,000
$170,001 - $214,000
$139.90
$107,001 - $160,000
$214,001 - $320,000
$199.80
$160,001 - $214,000
$320,001 - $428,000
$259.70
Above $214,000
Above $428,000
$319.70
Individuals must enroll in and pay a Part B premium.
Part B premiums usually go up each year and are higher for individuals with higher incomes.
The federal government funds Part B costs through the general tax revenues; beneficiary premiums cover 25% for Part B expenses

19. Paying the Part B Premium
Deducted monthly from
Social Security
Railroad Retirement Benefit
Federal retirement payments
If not deducted
Billed every 3 months
Medicare Easy Pay to deduct from bank account
Contact SSA, RRB, or OPM about premiums

20. Part B Late Enrollment Penalty
Penalty for not signing up when first eligible
10% more for each 12-month period
May have penalty as long as you have Part B
Sign up during a Special Enrollment Period (SEP)
Usually no penalty
Part B premiums will go up 10% for each 12-month period during which Part B enrollment was delayed. The penalty is applied for all years going forward.
If one did not enroll in Part B when first becoming eligible, enrollment is allowed during the General Enrollment Period – January 1 – March 31 for a July 1 effective date

21. Part B & Employer or Union Coverage
May affect your Part B enrollment rights
You may want to delay enrolling in Part B if:
You have employer or union coverage and
You or your spouse, or family member if you are disabled, is still working
See how your insurance works with Medicare
Contact your employer/union benefits administrator

22. When Employer/Union Coverage Ends
When your employment ends
You may get a chance to elect COBRA
You may get a Special Enrollment Period
Sign up for Part B without a 10% penalty

23. Paying for Part B Services
In Original Medicare you pay
Yearly deductible of $140 in 2012
20% coinsurance for most services
Some programs may help pay these costs

24. Medicare Part B Coverage
Doctors’ Services
Medically necessary services (includes outpatient and some doctor services you receive when an inpatient) or covered preventive services
Except for certain preventive services, you pay 20% of the Medicare-approved amount (if the doctor accepts assignment) and the Part B deductible applies
Outpatient Medical & Surgical Services and Supplies
For approved procedures (like X-rays, a cast, or stitches)
You pay 20% of the Medicare-approved amount for the doctor’s services (if the doctor accepts assignment)
You also pay a copayment for each service and the Part B deductible applies

25. Medicare Part B Coverage
Home Health Care Services
Medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, occupational therapy
Medically necessary part-time or intermittent home health aide services, medical social services, and medical supplies
Durable medical equipment and an osteoporosis drug are also covered
You pay nothing for covered services
Durable Medical Equipment
Items such as oxygen, equipment and supplies, wheelchairs, walkers, and hospital beds for you in the home. Some items must be rented.
You pay 20% of the Medicare-approved amount and Part B deductible applies

26. Medicare Part B Coverage
Other Services (including but not limited to)
Medically necessary medical services and supplies, such as:
Clinical laboratory services
Diabetes supplies
Kidney dialysis services and supplies
Mental health care
Limited outpatient prescription drugs
Diagnostic X-rays, MRIs, CT scans, and EKGs
Transplants
Costs vary

27. Part B Covered Preventive Services
One-time “Welcome to Medicare” physical exam
Annual wellness visit after 12 mos. enrolled in Part B
Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1
Abdominal aortic aneurysm screening – one time, with referral
Bone mass measurement – every 24 months for certain conditions
Cardiovascular screening blood tests – every five years for all persons
Colorectal cancer screening – four different tests, vary in frequency
Diabetes screenings – up to two per year for those with risk factors
EKG screening – one time, with referral
Glaucoma testing – once per year for those at high risk
HIV screening
Mammogram – annual screening for most women
Pap test and pelvic exam – every 24 months
Prostate cancer screening – every 12 months for men over age 50
Smoking cessation counseling

28. NOT Covered by Part A and Part B
Acupuncture
Dental care/dentures
Cosmetic surgery
Custodial care
Health care while traveling outside the U.S.
Hearing aids
Orthopedic shoes
Outpatient prescription drugs (covered under Part D)
Routine foot care
Routine eye care and eyeglasses
Vaccines, except as previous listed (covered under Part D)

29. What is Original Medicare?
Health care option run by the Federal government
Provides Part A and/or Part B coverage
See any doctor that accepts Medicare
Beneficiary pays:
Part B premium (Part A free for most people)
Deductibles, coinsurance or copayments
Can join a Part D plan to add drug coverage
Can join a Medigap plan to pick up the “gaps”

30. Assignment Doctor, provider, or supplier accepts assignment
Signed an agreement with Medicare
Or is required by law
Accept the Medicare-approved amount
As full payment for covered services
Only charge Medicare deductible/coinsurance amount
Most accept assignment
They submit your claim to Medicare directly

31. Supplier and Assignment
Suppliers that don’t accept assignment
May charge you more
The limiting charge is 15% more
May have to pay entire charge at time of service
Providers sometimes must accept assignment
Medicare Part B-covered prescription drugs
Ambulance suppliers
Physicians who don’t accept Medicare assignment can charge an additional 15% of Medicare-approved amounts. Original Medicare does not cover these excess charges. These are the beneficiary’s responsibility.

32. Medicaid

33. Medicaid Federal-state health insurance program
For people with limited income and resources
Certain people with disabilities
Most costs covered for Medicare/Medicaid
Called “dual eligible”
Eligibility determined by state
Application process and benefits vary
Office names vary
Office names vary: Social Services, Public Assistance, Humana Services

34. Medicare Savings Programs
Help from Medicaid paying Medicare costs
For people with limited income and resources
Programs include
Qualified Medicare Beneficiary (QMB)
Specified Low-Income Medicare Beneficiary (SLMB)
Qualifying Individual (QI)
Qualified Disabled & Working Individuals (QDWI)
See state websites for more information
Out-of-pocket costs that must be paid by Medicaid:
QMB only: Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits
SLMB only: Medicare Part B premium
QI: Medicare Part B premium
QDWI: Part A premium
There is also the QMB Plus, SLMB Plus, and Other FBDE – Full Benefit Dual Eligible (Medicare part B premium; Full Medicaid benefits)

35. Medicare Resources Resources
Centers for Medicare & Medicaid Services (CMS)
1-800-MEDICARE
( )
(TTY )
Social Security
(TTY )
Railroad Retirement Board
State Health Insurance Assistance Programs (SHIPs)*
*For telephone numbers call CMS
Affordable Care Act

36. Upcoming Webinar Medicare Advantage
September 6th 12:00pm CST
*Annual Election Period (AEP) is October 15th – December 7th

37. Questions?