1. Understanding Medicare Module 1

2. 04-26-072 Lessons 1.Medicare Basics (Part A and Part B) 2.Original Medicare Plan 3.Medicare Advantage Plans (Part C) and other Medicare plans 4.Medicare prescription drug coverage (Part D) 5.Programs for people with limited income and resources

3. Medicare Basics Module 1: Lesson 1

4. 04-26-074 Medicare Basics Lesson 1 Topics Medicare overview Enrollment Part A Part B Medicare plan choices

5. 04-26-075 Medicare Health insurance for people Age 65 and older Under age 65 with certain disabilities Any age with End-Stage Renal Disease (ESRD) Administered by Centers for Medicare & Medicaid Services (CMS) Enroll through Social Security Administration (SSA) or Railroad Retirement Board (RRB)

6. 04-26-076 Medicare Medicare has Part A – Hospital coverage Part B – Medical coverage Part C – Medicare Advantage Plans (like HMOs and PPOs) Part D – Prescription drug coverage You have choices in how you get your Medicare health and drug coverage

7. 04-26-077 Applying for Medicare Apply 3 months before age 65 Need not be retired Automatically enrolled if receive Social Security or Railroad Retirement benefits If don’t already receive benefits, apply 3 months before age 65 Call SSA at 1-800-772-1213 –TTY users call 1-800-325-0778

8. 04-26-078 Paying for Medicare Part A Most people receive Part A premium free People with less than 10 years of Medicare- covered employment Can pay a premium to get Part A For information, call SSA 1-800-772-1213 TTY users call 1-800-325-0778

9. 04-26-079 Enrolling in Medicare Part B Initial Enrollment Period (IEP) 7 months beginning 3 months before age 65 General Enrollment Period (GEP) January 1 through March 31 each year Coverage effective July 1 Premium increases 10% for each 12-month period you were eligible but did not enroll Pay this penalty as long as you have Part B Limited exceptions

10. 04-26-0710 Enrolling in Medicare Part B Special Enrollment Period Sign up within 8 months of the end of employer or union health plan coverage No increased premium For questions or to enroll SSA: 1-800-772-1213 RRB: 1-800-808-0772

11. 04-26-0711 Paying for Medicare Part B Monthly Medicare Part B premium in 2007 Most people pay $93.50 Programs available to help If Your Yearly Income isYou pay File Individual Tax ReturnFile Joint Tax Return $80,000 or less$160,000 or less$93.50 $80-001-$100,000$160,001-$200,000$105.80 $100,001-$150,000$200,000-$300,000$124.40 $150,001-$200,000$300,001-$400,000$142.90 Above $200,000Above $400,000$161.40

12. 04-26-0712 Paying the Part B Premium Taken out of your monthly payment Social Security Railroad Retirement Federal Government retirement For information about premiums Call SSA or RRB Office of Personnel Management if a retired Federal employee May be billed every 3 months Medicare Easy Pay

13. 04-26-0713 Part A Helps Pay for Hospital inpatient care Skilled nursing facility (SNF) care Home health care Hospice care Blood

14. 04-26-0714 Hospital Stays Covered services Semi-private room Meals General nursing Other hospital services and supplies Includes care in critical access hospitals 190 days in a lifetime for inpatient mental health care

15. 04-26-0715 Skilled Nursing Facility Care Must meet all of the following conditions Require daily skilled services Hospital inpatient at least 3 consecutive days Admitted to SNF within 30 days after leaving hospital Care is for a condition treated in the hospital MUST be Medicare participating SNF

16. 04-26-0716 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

17. 04-26-0717 Home Health Care Covered services Part-time skilled nursing care Therapy Occupational Physical Speech-language Some home health aide services Durable medical equipment

18. 04-26-0718 Home Health Care For as long as you are eligible Limited hours per day Limited days per week Four conditions Doctor must make a plan for your care at home Must need specific skilled services Must be homebound Home health agency must be Medicare-approved

19. 04-26-0719 Hospice Special care for terminally ill And family If you likely have less than 6 months to live Certification required for each “period of care” Two 90-day periods Unlimited 60-day periods Hospice provider must be Medicare-approved

20. 04-26-0720 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

21. 04-26-0721 Part B Helps Pay for 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

22. 04-26-0722 Covered Preventive Services “Welcome to Medicare” physical exam Abdominal aortic aneurysm screening Bone mass measurement Cardiovascular screenings Colorectal cancer screenings Diabetes screenings Glaucoma tests Mammograms (screening) Pap test/pelvic exam/ clinical breast exam Prostate cancer screening Flu shots Pneumococcal shots Hepatitis B shots Smoking cessation

23. 04-26-0723 Part B Also Helps Pay for Clinical laboratory tests Home health services Durable medical equipment Outpatient hospital services Blood Ambulance service If other transportation would endanger your health

24. 04-26-0724 Medicare Plan Choices Original Medicare Plan Medicare Advantage Plans Other Medicare plans Medicare drug plans Medicare Prescription Drug Plans Medicare Advantage Plans and other Medicare plans with prescription drug coverage

25. Original Medicare Plan Module 1: Lesson 2

26. 04-26-0726 Original Medicare Plan Lesson 2 Topics What it is and how it works Your costs in Original Medicare Plan Assignment Medigap (Medicare Supplement Insurance)

27. 04-26-0727 Original Medicare Plan Red, white, and blue Medicare card Part A and/or Part B Go to any provider that accepts Medicare You pay Part B premium Part A free for most people Deductibles Coinsurance or copayments

28. 04-26-0728 Medicare Card (front) Jane Doe

29. 04-26-0729 Medicare Card (back)

30. 04-26-0730 Medicare Claims Contractors Fiscal Intermediary (FI) Regional Home Health Intermediary (RHHI) Medicare Carrier Durable Medical Equipment Regional Carrier (DMERC) Medicare Administrative Contractors (MAC)

31. 04-26-0731 Original Medicare Plan—Part A Charges based on “benefit period” Inpatient hospital care and SNF services Begins day admitted to hospital Ends when no care received in a hospital or SNF for 60 days in a row You pay deductible for each benefit period No limit to number of benefit periods

32. 04-26-0732 Paying for Hospital Stays For inpatient stays in 2007 you pay Days 1 – 60 each benefit period $992 total Days 61 – 90 each benefit period $248 per day Days 91 – 150 (60 lifetime reserve days) $496 per day All costs for each day beyond 150 days

33. 04-26-0733 Skilled Nursing Facility Care For each benefit period in 2007 you pay Days 1 – 20: $0 Days 21 – 100: $124 per day All costs after 100 days Must meet requirements for Medicare- covered stay Does NOT include custodial care

34. 04-26-0734 Paying for Home Health Care In the Original Medicare Plan you pay Nothing for covered home health care services 20% of the Medicare-approved amount for covered durable medical equipment

35. 04-26-0735 Paying for Hospice Care In the Original Medicare Plan you pay Up to $5 for prescription drugs 5% for inpatient respite care Amount can change each year

36. 04-26-0736 Paying for Part B In the Original Medicare Plan you pay Monthly Part B premium $93.50 in 2007 for most people Yearly deductible $131 in 2007 20% coinsurance for most services Some copayments Some programs may help

37. 04-26-0737 Assignment Agreement between you, doctor, and Medicare Applies to Original Medicare Plan Part B Claims If providers accept assignment they agree to Be paid by Medicare Get only the amount Medicare approves for their services Only charge the Medicare deductible and/or coinsurance amount

38. 04-26-0738 Assignment Providers who don’t accept assignment may Charge more than Medicare-approved amount Limit of 15% more for most services Ask you to pay entire charge at time of service

39. 04-26-0739 Assignment In some cases, providers must accept assignment Some examples Medicare Part B-covered prescription drugs Ambulance providers Doctors/providers generally have to file claim You may have to file your claim for Part B-covered drugs or supplies If supplier or pharmacy not enrolled in Medicare

40. 04-26-0740 Private Contracts Agreement between you and doctor Original Medicare Plan will not pay Medigap will not pay Other Medicare plans will not pay You will pay charges No claim should be submitted Cannot be asked to sign in an emergency

41. 04-26-0741 What Is Medigap? Health insurance policies Sold by private insurance companies Follow Federal and state laws that protect you Must say “Medicare Supplement Insurance” Cover “gaps” in Original Medicare Plan 12 standardized policies, plans A – L Except in Massachusetts, Minnesota, Wisconsin Costs may vary By plan By company Where you live

42. 04-26-0742 How Medigap Works Only works with Original Medicare Don’t need Medigap policy in Medicare Advantage Plan Other Medicare plans Can go to any doctor, hospital, or provider that accepts Medicare Except with a Medigap SELECT policy You pay a monthly premium

43. Medicare Advantage Plans and Other Medicare Plans Module 1: Lesson 3

44. 04-26-0744 Medicare Advantage Plans Lesson 3 Topics What are Medicare Advantage Plans and other Medicare plans Who can join How plans work Joining and switching plans

45. 04-26-0745 What Are Medicare Advantage Plans? Health plan options approved by Medicare Run by private companies Part of the Medicare program Sometimes called “Part C”

46. 04-26-0746 Medicare Advantage Plans Medicare Health Maintenance Organization (HMO) Medicare Preferred Provider Organization (PPO) Medicare Private Fee-for-Service (PFFS) Medicare Special Needs Plan (SNP) Medicare Medical Savings Account (MSA)

47. 04-26-0747 Other Medicare Plans Medicare Cost Plans Demonstrations/Pilot Programs Programs of All-inclusive Care for the Elderly (PACE)

48. 04-26-0748 Who Can Join? Eligibility requirements Live in plan’s service area Have Medicare Part A Have Medicare Part B Not have ESRD at time of enrollment Some exceptions

49. 04-26-0749 How Do Medicare Advantage Plans Work? Generally get all Medicare-covered services through the plan Can include prescription drug coverage May have to see certain doctors or go to certain hospitals to get care Benefits and cost-sharing may be different from those in Original Medicare Plan

50. 04-26-0750 Out-of-Pocket Costs Generally must still pay Part B premium Some plans may pay all or part May pay additional monthly premium Pay other out-of-pocket costs Different from Original Medicare Plan Vary from plan to plan

51. 04-26-0751 In a Medicare Advantage Plan Still in Medicare program Still have Medicare rights and protections Still get all regular Medicare-covered services May get extra benefits Such as vision, hearing, or dental care May be able to get prescription drug coverage

52. 04-26-0752 Medicare HMO Plans Copayment amounts set by plan Generally must get care and services from plan’s network Use doctors and hospitals that join the plan May have to pay in full for care outside plan’s network Covered if emergency or urgently needed care Point-of-Service option allows visits to “out-of- network” providers

53. 04-26-0753 Medicare HMO Plans (cont’d) May need to choose primary care doctor Usually need a referral to see a specialist Doctors can join or leave May get Medicare drug coverage

54. 04-26-0754 Medicare PPO Plans Can see any doctor or provider that accepts Medicare Don’t need referral to see specialist Don’t need referral to see out-of-network provider Copayment amounts set by plan Will usually pay more for out-of-network care May get Medicare drug coverage

55. 04-26-0755 Medicare PFFS Plans Can see any Medicare-approved doctor or hospital that accepts the plan Can get services outside service area Don’t need referral to see a specialist Plan sets copayment amounts Can get emergency care anywhere Without prior approval If offered, can get Medicare prescription drug coverage If not offered, can join a Medicare Prescription Drug Plan

56. 04-26-0756 Medicare MSA Plans New in 2007 Similar to Health Savings Account plans Have two parts Medicare Advantage Plan with high deductible Pays covered costs after you meet annual deductible –Deductible varies by plan Medical Savings Account Medicare deposits money the person may use –To pay health care costs MSA demonstration available in some areas

57. 04-26-0757 When Can You Join? You can join a Medicare Advantage Plan or other Medicare plan When first eligible for Medicare During specific enrollment periods Annual Coordinated Election Period Medicare Advantage Open Enrollment Period Special Enrollment Periods Limited Open Enrollment Period

58. 04-26-0758 When Can You Switch? Annual Election Period Medicare Advantage Open Enrollment Period Special circumstances Move out of the plan’s service area and can’t stay in the plan Plan leaves Medicare program Other special situations

59. 04-26-0759 Annual Election Period November 15 – December 31 Can choose new plan Medicare Advantage Plan Medicare prescription drug plan Original Medicare Plan New plan starts January 1

60. 04-26-0760 Medicare Advantage Open Enrollment Period January 1 – March 31, 2007 Same period each year Change effective first day of following month Cannot be used to start or stop Medicare drug coverage

61. 04-26-0761 Limited Open Enrollment Period Only people in Original Medicare Plan Can join an MA-only plan Plan without Medicare prescription drug coverage During 2007 and 2008 Does NOT allow enrollment in Medicare Medical Savings Account (MSA) Plans MA plans that offer Medicare prescription drug coverage (MA-PDs) Medicare Prescription Drug Plans (PDPs)

62. Medicare Prescription Drug Coverage Module 1: Lesson 4

63. 04-26-0763 Medicare Prescription Drug Coverage Lesson 4 Topics Overview Eligibility and enrollment Extra help

64. 04-26-0764 Prescription Drug Coverage Coverage began January 1, 2006 Available for all people with Medicare Provided through Medicare Prescription Drug Plans Medicare Advantage Plans and other Medicare plans

65. 04-26-0765 Prescription Drug Costs Costs vary by plan Most people will pay Monthly premium Deductible Copayments or coinsurance Very little after $3,850 out-of-pocket in 2007 Extra help available for people with limited income and resources

66. 04-26-0766 Eligibility and Enrollment You must Have Medicare Part A, Part B, or both Live in plan’s service area Enroll in a Medicare prescription drug plan to get coverage

67. 04-26-0767 Enrollment Periods Initial Enrollment Period (IEP) 7 months beginning 3 months before the first month of Medicare eligibility Can change plans Annual Coordinated Election Period November 15 – December 31 each year Some special enrollment periods available Some people are enrolled automatically

68. 04-26-0768 Late Enrollment Penalty People who wait to enroll after their IEP Pay additional 1% of base beneficiary premium For every month eligible and not enrolled For as long as they have Medicare drug coverage Except those with other creditable drug coverage Coverage at least as good as Medicare prescription drug coverage

69. 04-26-0769 Special Enrollment Periods For people who Permanently move out of plan’s service area Lose creditable prescription drug coverage Enter, reside in, or leave a long-term care facility Like a nursing home Have Medicaid or are in a Medicare Savings Program Have a continuous special enrollment period Have other exceptional circumstances

70. 04-26-0770 Extra Help Help with drug plan costs for people with limited income and resources Eligibility determined by SSA or state Income and resources are counted Some groups are automatically eligible People with Medicare and Medicaid Supplemental Security Income only Medicare Savings Programs Everyone else must apply

71. 04-26-0771 Income and Resource Limits Income Below 150% Federal poverty level $1,276.25 per month for an individual* or $1,711.25 per month for a married couple* Based on family size Resources Up to $11,710 (individual) Up to $23,410 (married couple) Includes $1,500/person funeral or burial expenses Counts savings and stocks Does not count home you live in *Higher amounts for Alaska and Hawaii 2007 amounts

72. 04-26-0772 How to Apply for Extra Help Multiple ways to apply Paper application www.socialsecurity.gov State Medical Assistance office Local organization You or someone on your behalf can apply

73. 04-26-0773 Drug Plan Costs for People with Extra Help Those below Federal poverty level save over 95% on average People with lowest income and resources Pay no premiums or deductibles Have small or no copayments Those with slightly higher income and resources Have a reduced deductible Pay a little more out of pocket

74. Programs for People with Limited Income and Resources Module 1: Lesson 5

75. 04-26-0775 Programs for People with Limited Income and Resources Lesson 5 Topics Medicaid Medicare Savings Programs (MSP) Help for people living in U.S. territories

76. 04-26-0776 Medicaid Federal-state health insurance program People with limited income and resources Certain people with disabilities If eligible, most health care costs covered Eligibility determined by state Application processes and benefits vary Office names vary Social Services Public Assistance Human Services

77. 04-26-0777 Medicare Savings Programs Help from Medicaid paying Medicare premiums For people with limited income and resources May also pay Medicare deductibles and coinsurance Programs include Qualified Medicare Beneficiary (QMB) Specified Low-income Medicare Beneficiary (SLMB) Qualifying Individual (QI)

78. 04-26-0778 Programs in U.S. Territories Help people pay their Medicare costs U.S. territories Puerto Rico Virgin Islands Guam Northern Mariana Islands American Samoa Programs vary Contact Medical Assistance office

79. 04-26-0779 If you think you might qualify … 1.Review guidelines 2.Collect your personal documents 3.Get more information Call your state Medical Assistance office Call your local State Health Insurance Assistance Program (SHIP) Call your local Area Agency on Aging 4.Complete application with state Medical Assistance office

80. 04-26-0780 Module 1 Lessons 1.Medicare Basics (Part A and Part B) 2.Original Medicare Plan 3.Medicare Advantage Plans (Part C) and other Medicare plans 4.Medicare prescription drug coverage (Part D) 5.Programs for people with limited income and resources

81. 04-26-0781 For More Information 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048 Medicare & You handbook Other Medicare publications www.medicare.gov www.cms.hhs.gov Your local SHIP

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