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Innovative Solutions. Enduring Principles.
License No. 0451271
Assembling the Puzzle
Medicare 101
&
Kaiser Permanente Senior Advantage
Karyn Goodsite, Sr. Account Manager
Sylvia Weathers, Sr. Service Representative
Keenan & Associates
Agenda
•
Welcome & Introductions
•
Medicare 101
•
Age-In Campaign
•
Monthly Billing & Medicare Activity Report
License No. 0451271
Innovative Solutions. Enduring Principles.
Medicare 101
Group Medicare
Medicare 101
What is Medicare?
■
Federally funded national health program that pays for
Seniors
Disabled
Individuals with end-stage renal (kidney) disease (ESRD)
■
Part of President Lyndon Johnson’s Great Society Initiative
Signed into law in 1965
■
Administered by the Centers for Medicare & Medicaid Services
Medicare 101
Medicare eligibility
■
Beneficiaries include:
Seniors: Individuals 65 or older
If they or their spouse are eligible for Social Security
Disabled: Individuals under 65, but disabled
If eligible for Social Security disability
After two-year waiting period
Individuals with end-stage renal disease (ESRD)
Medicare 101
Closer look at Medicare Part A
■
Purpose: Provides inpatient insurance
Hospital, Skilled Nursing Facility (SNF), Hospice, Home Health
■
Eligibility
First day of the month that retiree turns 65
Two years after becoming disabled
Soon after renal dialysis begins
■
Cost
No premium if beneficiary or spouse have worked 40 quarters
of Medicare-covered employment
Medicare 101
Closer look at Medicare Part B
■
Purpose: Provides outpatient insurance
Physician services (inpatient and outpatient), outpatient
surgery, lab, radiology, durable medical equipment (DME),
dialysis, etc.
■
Enrollment
Optional plan: Individuals responsible for their own
enrollment
Enroll with Social Security Administration
Medicare 101
Closer look at Medicare Part B
■
Monthly premium, usually deducted from Social Security
■
Premium goes up 10% for each 12-month period that
individual declines coverage
Known as Late Enrollment Penalty (LEP)
Not imposed if individual continues to work for, and
receives his or her health coverage from, a Group plan of
20 or more eligibles
If initial enrollment is missed, they can enroll during
Medicare’s Open Enrollment Period (January 1 to March 31
with coverage effective July 1
■
In 2009, Part B premium will range from $96.40 to
$308.30, depending on income
Medicare 101
2009 Monthly Premiums for Medicare Part B
Above $426,000 Above $213,000 $308.30 $320,001-$426,000 $160,001-$213,000 $250.50 $214,001-$320,000 $107,001-$160,000 $192.70 $170,001-$214,000 $85,001-$107,000 $134.90 $170,000 or less $85,000 or less $96.40 Married Couple Single
If Your Yearly Income is You Pay Above $128,000 $308.30 $85,001-$128,000 $250.50 Under $85,000 or less $96.40
If You Are Married but You File a Separate Tax Return From Your Spouse and
Medicare 101
When to purchase Medicare Part B
■
Option 1
A person over 65 actively working can postpone purchasing Part B until they decide to
retire.
There would be no Late Enrollment Penalty (LEP) if the member postpones enrollment in
Part B due to primary coverage through an employer group.
■
Option 2
A person, still working, can purchase Part B. This is where Medicare becomes secondary
payer. This person does not assign their Medicare to Kaiser Permanente, instead uses
providers that accept Medicare. This may be more expensive for the individual.
■
Option 3
Medicare 101
Medicare Advantage (aka Medicare Part C)
■
Legislation: Balanced Budget Act (BBA) of 1997
■
Purpose: Expanded the role of managed care plans
Created private plan options for how beneficiaries receive Medicare
coverage
Option One: Original Medicare Plan through the Centers for
Medicare & Medicaid Services (CMS)
Option Two: Original Medicare Plus Medicare Supplement
Plans “Medigap”
Option Three: Through a private insurer plan, such as an HMO
These plans were first known as Medicare Risk plans
Then renamed Medicare + Choice plans
Medicare 101
65, retired, has
Medicare A & B
Option 1:
Original Medicare
: I can go to any
doctor, specialist that accepts Medicare.
(Deductibles and Coinsurance apply)
How am I going to use my Medicare?
Option 2:
Original Medicare plus Medicare
Supplement Plans (Medigap)
: I can go to any
doctor, specialist that accepts Medicare and
purchase Medigap Plans A-L to help pay for
my deductibles and coinsurances.
Medicare 101
Medicare Part C: Relationship between
CMS and Medicare Advantage plans
■
MA plans are “at risk” plans, as opposed to “cost” plans that are
guaranteed to be paid their costs
■
CMS pays the insurer a monthly capitation
Based on the beneficiary’s county of residence
Amount is adjusted over time, based on:
Fee-for-service” national per capita growth rates update the county
rates
Payments to plans based on their bids relative to the county rates
■
In order for the insurer to be paid capitation by CMS, the member
must exclusively assign his or her benefits to the insurer
Medicare 101
Medicare Part D
■
Legislation: Medicare Modernization Act (MMA) of 2003
■
Purpose: Provides outpatient prescription drug coverage
This prescription drug benefit became available to eligible individuals
beginning January 1, 2006.
■
Options for enrollment in Part D:
Private insurer plan, like Kaiser Permanente
Prescription Drug Plan (PDP): A new plan type (created by the legislation)
that offers prescription drugs only
Medicare 101
Enrollment in Part D
■
Periods when members are eligible for initial enrollment:
Age-in: When member turns 65 (7-month period)
■
Late Enrollment Penalty (LEP)
Like Part B, beneficiaries must obtain Part D as soon as they are eligible or be
charged a penalty
Medicare 101
Low-income subsidy (LIS) - extra help
■
For those with limited income and resources
■
Provides help with Part D premiums and outpatient drug
copayments
Degree of help depends on income and resources
■
Additional facts about LIS:
Apply at Social Security or through CMS
Administered by the member’s plan, for CMS
Medicare 101
Group Medicare
Medicare 101
Medicare Plans and Products
■
Kaiser Permanente Senior Advantage (KPSA)
KPSA for Groups
Medicare 101
Kaiser Permanente Senior Advantage
■
Kaiser Permanente’s offering for the “Medicare Advantage”
(MA) program enabled by Part C
■
May be offered with a Part D component (MA-PD)
■
Available to both Group and Individual Plan members
Individual Plan members must have Parts A and B to join
Group Plan members must have Parts A and B to join.
Some Group plans will accept members with Part B only entitlement
Medicare 101
Senior Advantage: CMS Reimbursement
■
Members “lock-in” their benefits with KP
■
Assign their Medicare benefits to KP
■
KP “at risk” for all medical services
■
CMS pays a monthly capitation to KP
Member
CMS Reimbursement
Monthly capitation, based on:
Medicare 101
Group Medicare
Medicare 101
Age-in strategy
Our campaign includes a series of
six mailings that are sent over the
year between members’ 64
thand 65
thbirthdays.
Medicare 101
64 years old
Medicare 101
64 and 4 months
Medicare 101
64 and 7 months
At 64 and 7 months, members
are sent a self-mailer that lists
key information about
Medicare, and highlights the
advantages of staying with
Kaiser Permanente. We also
send a handy refrigerator
magnet with our phone
Medicare 101
64 and 9 months: complete enrollment packet
At 64 and 9 months (the age at which most members can enroll in
Medicare), members receive a complete Senior Advantage enrollment
Medicare 101
THANK YOU
Maria Harlan
Medicare Retiree Consultant
Kaiser Permanente
Kaiser Permanente
License No. 0451271
Innovative Solutions. Enduring Principles.
Examples of changes that can impact premiums are:
Higher – over age 65,
non-Medicare premium
Over age 65 retired not enrolled in
Senior Advantage
Under age 65
Higher – over age 65,
non-Medicare premium
Retired over age 65 disenrolled
from Senior Advantage
Retired over age 65 enrolled in
Senior Advantage
Lower –Senior Advantage premium
Over age 65 retired enrolled in
Senior Advantage
Under age 65
Impact:
Change To:
Change From:
**For customers who have composite premiums, the number of over 65 non-Medicare retirees will affect premiums at
renewal.
Assembling the Puzzle
Innovative Solutions. Enduring Principles.
MONTHLY MEDICARE ACTIVITY REPORT
MONTHLY MEDICARE ACTIVITY REPORT
MONTHLY MEDICARE ACTIVITY REPORT
MONTHLY MEDICARE ACTIVITY REPORT
PID: XXXXXXXXX
Enrollment Unit(s): All
Section 1
Section 1
Section 1
Section 1 –––– SUMMARY OF MEMBER STATUS CHANGES
SUMMARY OF MEMBER STATUS CHANGES
SUMMARY OF MEMBER STATUS CHANGES
SUMMARY OF MEMBER STATUS CHANGES
Section 2: Section 2: Section 2:
Section 2: MEMBERS CURRENTLY IN THE SENIOR ADVANTAGE SOLICITATION PROCESSMEMBERS CURRENTLY IN THE SENIOR ADVANTAGE SOLICITATION PROCESSMEMBERS CURRENTLY IN THE SENIOR ADVANTAGE SOLICITATION PROCESSMEMBERS CURRENTLY IN THE SENIOR ADVANTAGE SOLICITATION PROCESS 11113333 Members turning age 64 years and 9 months next month
Members turning age 64 years and 9 months next month Members turning age 64 years and 9 months next month
Members turning age 64 years and 9 months next month 2222 Members turning age 64 years and 10 months next month
Members turning age 64 years and 10 months next month Members turning age 64 years and 10 months next month
Members turning age 64 years and 10 months next month 2222 Members turning age 64 years and 11 months next month
Members turning age 64 years and 11 months next month Members turning age 64 years and 11 months next month
Members turning age 64 years and 11 months next month 5555 Members turning age 65 years next month
Members turning age 65 years next month Members turning age 65 years next month
Members turning age 65 years next month 4444 Section 3A:
Section 3A: Section 3A:
Section 3A: NEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERS 11111111 Section 3B:
Section 3B: Section 3B:
Section 3B: NEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERS WITH PART D LATE ENNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERS WITH PART D LATE ENNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERS WITH PART D LATE ENNEWLY ENROLLED MAPD SENIOR ADVANTAGE MEMBERS WITH PART D LATE ENROLLMENTROLLMENTROLLMENTROLLMENT 0000 PENALTY PENALTY PENALTY PENALTY Section 3C: Section 3C: Section 3C:
Section 3C: MAPD SENIOR ADVANTAGE MEMBERS NEWLY ENTITLED TO LOW INCOME SUBSIMAPD SENIOR ADVANTAGE MEMBERS NEWLY ENTITLED TO LOW INCOME SUBSIMAPD SENIOR ADVANTAGE MEMBERS NEWLY ENTITLED TO LOW INCOME SUBSIMAPD SENIOR ADVANTAGE MEMBERS NEWLY ENTITLED TO LOW INCOME SUBSIDYDYDYDY 0000 Section 3D:
Section 3D: Section 3D:
Section 3D: NEWLY ENROLLED MA SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MA SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MA SENIOR ADVANTAGE MEMBERSNEWLY ENROLLED MA SENIOR ADVANTAGE MEMBERS 0000 Section 3E:
Section 3E: Section 3E:
Section 3E: NEWLY ENROLLED DOUBLE COVERED NON PLAN OF RECORD COMMERCIAL MEMBNEWLY ENROLLED DOUBLE COVERED NON PLAN OF RECORD COMMERCIAL MEMBNEWLY ENROLLED DOUBLE COVERED NON PLAN OF RECORD COMMERCIAL MEMBNEWLY ENROLLED DOUBLE COVERED NON PLAN OF RECORD COMMERCIAL MEMBERSERSERSERS 0000 Section 4:
Section 4: Section 4:
Section 4: MEMBERS WHO HAVE NOT ENROLLED IN SENIOR ADVANTAGEMEMBERS WHO HAVE NOT ENROLLED IN SENIOR ADVANTAGEMEMBERS WHO HAVE NOT ENROLLED IN SENIOR ADVANTAGEMEMBERS WHO HAVE NOT ENROLLED IN SENIOR ADVANTAGE 6666 Section 5:
Section 5: Section 5:
Section 5: SENIOR ADVANTAGE DENIALS AND SENIOR ADVANTAGE COST DISENROLLMENSENIOR ADVANTAGE DENIALS AND SENIOR ADVANTAGE COST DISENROLLMENSENIOR ADVANTAGE DENIALS AND SENIOR ADVANTAGE COST DISENROLLMENSENIOR ADVANTAGE DENIALS AND SENIOR ADVANTAGE COST DISENROLLMENTSTSTSTS 6666 Section 6:
Section 6: Section 6:
Section 6: DECEASED MEMBERSDECEASED MEMBERSDECEASED MEMBERSDECEASED MEMBERS 0000 Section 7:
Section 7: Section 7:
Section 7: MEMBERS AGE 64 YEARS AND 10 MONTHS LIVING OUTSIDE OF THE KAISERMEMBERS AGE 64 YEARS AND 10 MONTHS LIVING OUTSIDE OF THE KAISERMEMBERS AGE 64 YEARS AND 10 MONTHS LIVING OUTSIDE OF THE KAISERMEMBERS AGE 64 YEARS AND 10 MONTHS LIVING OUTSIDE OF THE KAISER PERMANENTE CALIFORNIA PERMANENTE CALIFORNIA PERMANENTE CALIFORNIA PERMANENTE CALIFORNIA 0000 SERVICE AREA SERVICE AREA SERVICE AREA SERVICE AREA Section 8: Section 8: Section 8:
Section 8: MEMBERS WHO HAVE TURNED 65 LIVING OUTSIDE OF THE KAISER PERMANENMEMBERS WHO HAVE TURNED 65 LIVING OUTSIDE OF THE KAISER PERMANENMEMBERS WHO HAVE TURNED 65 LIVING OUTSIDE OF THE KAISER PERMANENMEMBERS WHO HAVE TURNED 65 LIVING OUTSIDE OF THE KAISER PERMANENTE CALIFORNIATE CALIFORNIATE CALIFORNIATE CALIFORNIA 0000 SERVICE AREA SERVICE AREA SERVICE AREA SERVICE AREA Section 9: Section 9: Section 9:
Section 9: MEMBERS OVER 65 NOT ENROLLED IN A MEDICARE PLANMEMBERS OVER 65 NOT ENROLLED IN A MEDICARE PLANMEMBERS OVER 65 NOT ENROLLED IN A MEDICARE PLANMEMBERS OVER 65 NOT ENROLLED IN A MEDICARE PLAN 99993333 Section 10:
Section 10: Section 10:
Section 10: PART D LATE ENROLLMENT PENALTY MEMBERSPART D LATE ENROLLMENT PENALTY MEMBERSPART D LATE ENROLLMENT PENALTY MEMBERSPART D LATE ENROLLMENT PENALTY MEMBERS 0000 Section 11:
Section 11: Section 11:
Section 11: LOW INCOME SUBSIDY MEMBERSLOW INCOME SUBSIDY MEMBERSLOW INCOME SUBSIDY MEMBERSLOW INCOME SUBSIDY MEMBERS 2222 Section 12:
Section 12: Section 12:
License No. 0451271
Innovative Solutions. Enduring Principles.
Assembling the Puzzle
Kaiser Monthly Medicare Activity Report
ACTION REQUIRED:
This is a comprehensive list of all members over the age of 65 who are not enrolled in a Medicare plan (including members appearing in Sections 4, 5, 6 and 8 of this month’s report). The customer will continue to incur the over 65, non-Medicare premium for retired members. Retired members can enroll in a Medicare plan, or the customer can terminate their membership or pay the substantially increased premium. Please verify working status shown. If a member continues to work for the customer after age 65, there will be not impact on the customer’s premium.
All Enrollment Unit(s):
XXXXXXXXXX PID:
Section 9 – MEMBERS OVER 65 NOT ENROLLED IN A MEDICARE PLAN
