1. 1 Medicare & the Medicare Modernization Act of 2003 Norma Lanier, State Outreach Coordinator First Coast Service Options, Inc. July 12, 2005

2. 2 Today’s Discussion Review of Medicare basics Medicare changes in 2005 and 2006 Preventive benefits covered by Part B Prescription Drug Benefit Medicare rights and protections Alzheimer’s and Medicare Program Evaluation

3. 3 First, the Basic Facts

4. 4 Medicare A health insurance program for –People 65 years of age and older –Some people with disabilities –People with ESRD Administered by CMS nationally Administered by private contractors locally

5. 5 Original Medicare Medicare has two parts Part A Hospital Insurance Part B Medical Insurance

6. 6 The Original Medicare Plan You may go to any provider that accepts Medicare Part A is premium free for most people You pay Medicare Part B premium You pay deductibles You pay coinsurance Original Medicare

7. 7 Medicare Part A Benefits Hospital stays Skilled nursing facility (SNF) care Home health care Hospice care Blood

8. 8 A Benefit Period Medicare’s measure of hospital and SNF services Begins day admitted to hospital Ends when you have not received care in a hospital or SNF for 60 days in a row You pay deductible for each benefit period No limit to the number of benefit periods Part A

9. 9 Paying for Hospital Stays For each benefit period in 2005 you pay –$912 deductible for a hospital stay of 1-60 days –$228 per day for days 61-90 –$456 per day for days 91-150 Part of your 60 Lifetime Reserve Days –All costs for each day beyond 150 days Part A

10. 10 Skilled Nursing Facility Care Covered in full for the first 20 days –After a minimum 3-day qualifying hospital stay You pay $114 per day for days 21-100 You pay all costs after 100 days Does NOT include custodial care Part A

11. 11 Skilled Nursing Facility Care Must meet all of the following conditions –Requires daily skilled services –Inpatient in a hospital at least 3 consecutive days –Admitted to SNF within 30 days after leaving hospital –Care in SNF is for a condition treated in the hospital –MUST be a Medicare participating SNF Part A

12. 12 Skilled Nursing Facility Coverage Semi-private room Meals Skilled nursing care Physical, occupational and speech-language therapy Medical social services Medications, medical supplies/equipment Ambulance transportation Dietary counseling Part A

13. 13 Home Health Care Covered services –Part-time skilled nursing care –Therapy Occupational Physical Speech-language –Some home health aide services –Durable medical equipment Part A

14. 14 Paying for Home Health Care You pay –Nothing for covered home health care services –20% of the Medicare-approved amount for covered durable medical equipment Part A

15. 15 Hospice Special care –People who are terminally ill –Families If a person has less than 6 months to live Certification required for each “period of care” –Two 90-day periods –Unlimited 60-day periods Hospice must be Medicare-approved Part A

16. 16 Covered Hospice Services Medical equipment and supplies Drugs for symptom control and pain relief Respite care in a Medicare-certified facility –Up to 5 days each time –No limit to number of times Home health aide and homemaker services Social worker services Dietary counseling Grief counseling Part A

17. 17 Part B Benefits Doctors’ services Outpatient medical and surgical services and supplies Diagnostic tests Outpatient therapy Outpatient mental health services Some preventive health care services Other medical services

18. 18 Enrolling in Medicare Part B Initial Enrollment Period –7 months beginning 3 months before age 65 General Enrollment Period –January 1 through March 31 each year –Coverage effective July 1 –Premium increases 10% for each year you were eligible but did not enroll You carry this increase for the rest of your life Original Medicare

19. 19 Enrolling in Medicare Part B Special Enrollment Period –Sign up within 8 months of the end of employer or union group health plan coverage –No increased premium For questions, or to enroll, call the Social Security Administration or Railroad Retirement Benefit Original Medicare

20. 20 Covered Preventive Services Bone mass measurement Colorectal cancer screening Diabetes services and some supplies Glaucoma testing Screening mammogram Pap test/pelvic exam/clinical breast exam Prostate cancer screening Vaccination (shots)

21. 21 Medigap Fills in gaps in the Original Medicare plan Must follow federal and state laws Standardized Plans A-J in most states –Except Minnesota, Massachusetts, Wisconsin Don’t need Medigap if in Medicare Advantage See Guide to Health Insurance for People with Medicare

22. 22 Let’s talk about more changes in Medicare…

23. 23 What We Heard People with Medicare want –More choices –Better benefits –Health care delivery options –Improved access to care Especially in rural areas

24. 24 Medicare Modernization Act of 2003 (MMA) 2004 Drug discount card Medicare Advantage 2006 Prescription drug plans Two new Medigap policies 2005 New preventive services Part B deductible $110-based on expenditures in future

25. 25 New Covered Preventive Services Beginning January 2005 “Welcome to Medicare” physical –Initial physical exam –Referral for screening and other preventive services Cardiovascular screening blood tests –Screening blood tests for cholesterol and other lipids or triglyceride levels Diabetes screening tests –Fasting plasma glucose test –Other tests appropriate for persons at high risk MMA

26. 26 Medicare Prescription Drug Plans Available January 2006 Offered through private prescription drug plans (PDPs) Can be offered by Medicare Advantage plans

27. 27 Eligibility and Enrollment Must be entitled to Part A and/or enrolled in Part B Enrollment is voluntary Increased premiums for people who wait –1 percent of the base premium for each month you don’t enroll After May 15, 2006 –Exception for those covered under other comparable insurance

28. 28 Why Join a Plan? Medical practice relies on new drug therapies to treat chronic conditions Out-of-pocket spending on drugs has increased Most people need or will need prescription drugs to stay healthy Medicare insurance coverage for prescription drugs will protect from high out-of-pocket costs For most people, joining when first eligible means paying the lowest monthly premiums

29. 29 Enrolling in a Plan People with Medicare can: Enroll directly with the plan Have a personal representative enroll them Ask others to help them enroll

30. 30 When to Enroll Join between November 15, 2005, and December 31, 2006 –Coverage will begin on January 1, 2006 Join between January 1, 2006, and May 15, 2006 –Coverage will begin the first day of the month after the month joined

31. 31 Medicare Prescription Drug Coverage Coverage begins January 1, 2006 Available for all people with Medicare Provided through: –Private prescription drug plans –Medicare health plans –Some employers and unions for retirees

32. 32 What it Costs…How it Works Pay a premium of about $37 each month –In addition to Part B premium –Enhanced benefit may cost more Pay a yearly deductible up to $250 Pay part of the cost of covered prescription drugs

33. 33 How it Works in 2006

34. 34 Lower-Income Assistance People with limited resources: –Get extra help with their Medicare drug plan cost Lowest incomes: –Pay no premiums or deductibles –Pay small or no copayments People with slightly higher incomes: –Pay reduced deductible –Pay a little bit more out of pocket.

35. 35 To Get Help Paying the Cost of Prescription Drug Plans Person with Medicare must: –Reside in the United States –Meet the income and resource requirements of the subsidy program –Be enrolled in Medicare

36. 36 To Get This Help Person does not have to do anything –If currently receiving benefits from both Medicaid and Medicare or –Receiving Supplemental Security Income benefits and Medicare Information will come in the mail from Medicare –Explaining eligibility for this coverage, and –What he/she should do this fall to enroll in a Medicare plan that offers prescription drug coverage

37. 37 To Get This Help Person with Medicare must have –Annual income less than $14,355 (single) –Annual income less than $19,245 (married) AND –Limited resources Application will come from Social Security Administration (SSA) Mail completed application to SSA For additional information, contact the SSA at 1-800- 772-1213

38. 38 Medicare Advantage Plans Another Way to Get Your Medicare Benefits MMA

39. 39 Medicare Advantage Plans New name for Medicare+Choice plans Medicare managed care plans Preferred Provider Organization plans (PPOs) Private-Fee-for-Service plans –Available in some states Medicare Specialty Plans

40. 40 If you join a Medicare Advantage Plan… You still have rights and protections You are still in the Medicare program You still get all your regular Medicare- covered services You may be able to get extra benefits –Coverage for extra days in the hospital

41. 41 Medicare Patients’ Rights Right to –Information about all treatment choices –Participate in treatment decisions –Get easy-to-understand information –Know what costs are paid by Medicare –Know how much you have to pay Overview

42. 42 Other Medicare Rights Right to –Receive emergency room services –Have your personal and health information kept private –Right to non-discrimination: You cannot be treated unfairly because of race, color, national origin. disability, age, sex, religion Overview

43. 43 Other Medicare Rights Right to –Know what to do if you have to file an appeal or a grievance (complaint) –An appeal is when Medicare does not pay Medicare does not pay enough You are not given a service –A grievance is about quality of care issues Overview

44. 44 Medicare and Alzheimer’s Medicare beneficiaries diagnosed with Alzheimer’s disease have the same rights and coverage than any other person with Medicare. Part A covers inpatient mental health services, including room, meals, nursing care and other related services Part B covers outpatient mental health services, including visits with health professionals such as doctors, clinical psychologists, clinical social workers, and clinical nurse specialists Part B also covers laboratory services and partial hospitalization

45. 45 For More Information National Sources Visit www.medicare.gov Call 1-800-MEDICARE (1-800-633-4227) –TTY 1-877-486-2048

46. 46 Please complete the Program Evaluation Form Thank You! Evaluation Form