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2. 1. When Medicare coverage begins 2. The four components of Original Medicare 3. Coordination of Benefits 4. Special focus on Part D and Immunosuppressants 11.14.15 Understanding Medicare2

3. a. Age: The 1 st of the month in which you turn 65 * b. Disability: The 25 th month you receive disability benefits * c. ESRD: The 4 th month of dialysis* 11.14.15 Understanding Medicare3

4. DISABILITY  Medicare begins 24 months after Social Security benefits begin Exception ALS (Lou Gehrig’s) – Medicare begins the month benefits begin Eligible for Medicare based on age at 65 ESRD Medicare begins: 1 st day of 4 th month of dialysis Or 1 st day of 1 st month of home dialysis Medicare ends: 12 months after the month dialysis stops or 36 months after the month of the kidney transplant

5. Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans HMO/PPO Includes Part A, B, D DDDDsometi mes Part D coverage Part D Medicare Prescrip- tion Drug Coverage 11.14.15 Getting Started 5

6. For Each Benefit Period in 2016 You Pay Part A Deductible$1,288 Days 0 - 60$0 Days 61 - 90$322 per day Days 91 – 150 $644 per day ( 60 lifetime reserve days) All days after 150All Costs

7. 11.14.15 Getting Started7 For Each Benefit Period in 2016 You Pay Days 1-20$0 Days 21-100$161 per day All days after 100All Costs

8. ◦ Doctor’s visits ◦ Outpatient medical services ◦ Clinical lab tests ◦ Emergency Department Services ◦ Durable Medical Equipment ◦ Outpatient Chemotherapy 11.14.15 Understanding Medicare8

9. ◦ Some home health services ◦ Kidney dialysis ◦ Mental health care ◦ Preventive services ◦ and more ◦ For a complete list of covered services see pp. 43-66 in 2016 “Medicare and You” 11.14.15 Understanding Medicare9

10. 11.14.15 Getting Started10 2016 You Pay Monthly Premium $104.90 (most people) [$121.80] Yearly Deductible (once) $166.00 Medicare Covered Services 20% (if provider accepts “Assignment”)

11. 11.14.15 Understanding Medicare11

12.  YOUR period of Guaranteed Issue Rights to purchase a Medigap:  The first 6 months you are at least 65 AND have Part B  For 63 days after an Advantage plan or an employer group health plan (including retiree or COBRA coverage) that pays after Medicare pays ends 11.14.15 Understanding Medicare12

13.  Primary Payers  Secondary Payers  Payers of last resort  ESRD 30-month Coordination Period

14.  Medicare is your only insurance 5/01/2015 Coordination of Benefits14

15. If You …Medicare Pays …. Or your spouse is actively working and has an EGHP Second …. Unless.. 65 or older with EGHP coverage through current employment (yours or your spouse’s) First if the employer has less than 20 employees Under 65 with a disability and have EGHP through current employment (yours or family member’s) First if the employer has less than 100 employees Eligible for Medicare due to End- Stage Renal Disease (ESRD) and you have EGHP coverage First when the 30-month coordination period ends, or if you had Medicare primary before the ESRD

16. 11.14.15

17. Coverage StartsUnder the Following Circumstances 1 st day of the 4 th monthYou get a regular course of dialysis in a facility 1 st day of the month of the 1 st month of dialysis You participate in a home dialysis training program during the first 3 months of the regular course of dialysis – w/ expectation to complete 1 st day of the monthYou get a kidney transplant 1 st day of the monthAdmitted to a Medicare-approved facility for a kidney transplant or procedures preliminary to a kidney transplant if transplant takes place in the same mo. or within the following 2 mos. 2 months before the month of your transplant if… Your transplant is delayed more than 2 months after you’re admitted to the hospital for the transplant or for health care services you need for the transplant

18.  If enrollment is based solely on ESRD ◦ Your GHP/employer coverage is the only payer during first 3 months  Medicare is the secondary payer during the 30-month coordination period  Separate coordination period each time enrolled based on ESRD ◦ No 3-month waiting period ◦ New 30-month coordination period if you have GHP coverage 05/01/2015 Medicare for People With End-Stage Renal Disease 18

19. 11.14.15Medicare Getting Started19

20.  Part A generally pays for all drugs during a covered inpatient stay  Drugs used in hospice care for symptom control and pain relief 20

21. Most injectable and infusible drugs given as part of a doctor’s service Drugs used at home with some durable medical equipment (DME) e.g. nebulizers and infusion pumps Certain oral anti-cancer Can cover immunosuppressive drugs under certain conditions 21

22. If You … Immunosuppressive Drugs Are entitled to Part A at time of transplant and  Medicare paid for your transplant and the transplant took place in a Medicare-approved facility or  Medicare was secondary payer but made no payment Are covered by Part B  Medicare pays 80%  You pay 20% Didn’t meet the transplant conditions above May be covered by Part D (unless you would be covered by Part B, but you haven't enrolled in Part B) 22

23. 11.14.15 Getting Started23 2016 You Pay Monthly Premium Plan premium (base price + income adj.) Yearly Deductible (once) $0 - $360 For drugs on the plan’s formulary Coinsurance (preferred network providers are usually more affordable)

24. 11.14.15 Understanding Medicare24 Initial Stage

25. The Coverage Gap YearWhat You Pay for Covered Brand-Name Drugs in the Coverage Gap What You Pay for Covered Generic Drugs in the Coverage Gap 201545%65% 201645%58% 201740%51% 201835%44% 201930%37% 2020 25% 05/01/2015Medicare Prescription Drug Coverage25

26. Things to Consider: 1. Plan formularies 2. Preferred v. standard pharmacies 3. Pre-Authorizations 4. Step Therapy 11.14.15 Understanding Medicare26

27. Date Title27 Open Enrollment October 15 – December 7 Using immunosuppressants to do a 2016 Part D search….

28. Part A and Part B services Usually includes prescription coverage The plan may have a monthly premium May include benefits not usually covered: Dental, vision, hearing Co-pays for appointments, services, hospital stays, etc. Costs may be higher out of network Medicare Advantage and Other Medicare Health Plans 28

29. SPDAP – Maryland Senior Prescription Drug Assistance Program Monthly income limits: $2942 /individual $3982/couple (no asset limit) Benefits: $40/month towards Part D premium One extra Part D switch per year 11.14.15 Understanding Medicare29

30. Step 1: Protect Yourself from Medicare Fraud and Abuse Step 2: Detect Medicare Fraud & Abuse Step 3: Report Suspected Medicare Fraud and Abuse SMP: Senior Medicare Patrol 11.14.15 Understanding Medicare30

31. 1. www.medicare.govwww.medicare.gov 2. www.insurance.maryland.govwww.insurance.maryland.gov For Consumers Medicare Related Information Annual Premiums for Medicare Supplemental Policies 11.14.15 Understanding Medicare31

32.  State Health Insurance Assistance Program  Free Local Help for People with Medicare 11.14.15 Understanding Medicare32