MEDICARE BASICS WHAT TO KNOW AND WHAT TO EXPECT WITH MEDICARE

MEDICARE BASICS

WHAT TO KNOW AND WHAT TO EXPECT WITH MEDICARE

AGENDA

•

What is original Medicare?

•

The A, B, C, and D’s of Medicare

•

Enrollment periods

•

Medicare Advantage star rating system

•

Where you can find more information

ORIGINAL MEDICARE

• Part A and Part B from Original Medicare.

PART A: HOSPITAL INSURANCE

What it Covers…

• In-patient hospital care

• Hospice care

• Home health services

• In-patient skilled nursing

How you qualify…

• You already get retirement

benefits from Social Security or the Railroad Retirement Board.

• You're eligible to get Social

Security or Railroad benefits but haven't filed for them yet.

• For premium free Part A, you or your spouse must have worked for at least 40 quarters of

coverage (varies is applying due to age or disability)

PART B: MEDICAL INSURANCE

What It Covers…

• Doctor’s visits

• Outpatient care

• Durable Medical Equipment

• Preventative screenings

If You Decide To Enroll…

• You can sign up through

the Social Security offices

• Pay a monthly premium

• Social Security check deduction

• Quarterly billing from Social Security

ORIGINAL MEDICARE ENROLLMENT PERIODS

• Initial Enrollment Period (IEP)

• General Enrollment Period (GEP)

• Special Election Period (SEP)

PART C: MEDICARE ADVANTAGE

What I s I t ^?

• Private insurance plans,

approved by

Medicare

• Combine Part A and Part B

• May or may not include Part D (prescription coverage)

• In most plans, you need to use plan doctors, hospitals, and other providers or you pay more or all of the costs.

How to Qualify

• You have Medicare Part A and Part B

• You live in the service area of the plan, if applicable

• You don’t have end-stage renal disease (exceptions apply)

• You enroll when the plan is accepting enrollment

PART C: MEDICARE ADVANTAGE

• Types of Plans

• Health Maintenance Organization (HMO)

• Point-of-Service (POS)

• Preferred Provider Organization (PPO)

• Private Fee-for-Service (PFFS)

• Special Needs Plans (SNP)

PART D: PRESCRIPTION DRUG COVERAGE

What Is It?

• Outpatient prescription drug coverage

• Medicare approved formulary

How Do I Get One?

• Join a Medicare Advantage or Medicare Cost plan that includes Part D in their coverage

• Acquire a separate Part D plan from a private insurance company,

approved by Medicare

• Each plan can vary in cost and drugs covered

Coverage Gap Brand Discount

Enrollees pay 45% of the costs for Brand Name Drugs (plus a portion of the

dispensing fee). The balance of the cost is paid by the manufacturer and the health plan as indicated above. Catastrophic Coverage Stage

80% Paid by Medicare 15% Plan Contribution 5% Enrollee Coinsurance

This coverage ensures that once you have paid a certain amount of your covered Part D drugs, you only pay a small share of the cost for the rest of the calendar year.

Coverage Gap Stage

45% Enrollee Brand Discount Payment

50% Pharmaceutical

Manufacturer Brand Discount 5% Plan Brand Contribution 65% Enrollee Generic Payment

35% Plan Generic Contribution You stay in this stage until

your True Out-of-Pocket (TrOOP) costs reach $4,700.

2015 STANDARD MEDICARE PART D

$320 ENROLLEE DEDUCTIBLE

Initial Coverage Stage

75% Plan Contribution 25% Enrollee Coinsurance When the total paid by you and the plan reaches $2,960 the Coverage Gap Stage begins.

*CAN CHANGE ON AN ANNUAL BASIS ON JANUARY 1.

MEDICARE PART C & PART D

ENROLLMENT PERIODS

• Initial Coverage Election Period (ICEP)

• Annual Election Period (AEP)

• Part D Initial Enrollment Period (IEP)

• Special Election Period (SEP)

• Disenrollment Period (MADP)

MEDICARE STAR QUALITY RATINGS

• Objective ratings on Medicare plans

• Rated on a scale 1-5 from over 50

measures, grouped into different

categories

• Rated on an annual basis

• Allows a one time switch to a 5 Star

plan during the year (SEP)

• Find these ratings at

www.medicare.gov

M EDICARE

MEDIGAP: MEDICARE SUPPLEMENT PROGRAM

What Is It?

• An extension of Original

Medicare to help cover

some of the extra costs

• Copay’s

• Coinsurance

• Deductibles

• Owned by private

insurance companies

How It Works…

• When you receive care, the provider will bill Medicare using your Original Medicare

coverage.

• Then the provider bills the Medigap insurance for the remainder

• The beneficiary is responsible for any outstanding charges incurred after both payments have been made

TYPES OF MEDIGAP PLANS

WHAT YOU NEED TO KNOW ABOUT MEDIGAP

• Medigap doesn’t cover everything

• Generally don’t cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing

• You must have Medicare Part A and Part B

• You cannot have a Medicare Advantage plan and a Medigap plan at the same time

• The Medigap policy only covers one person.

• Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage.

• Any standardized Medigap policy is guaranteed renewable even if you have health problems.

• Medigap plans are not contracted with Medicare

• Medigap plans do not have a network of providers

• Doesn’t include Emergency Room or Ambulance

FOR MORE INFORMATION

• 1-800-MEDICARE toll free at 1-800-633-4227 (TTY 1-877-486-2048), 24 hours a day, seven days a week

• medicare.gov

• socialsecurity.gov

• Statewide Health Insurance Benefits Advisors (SHIBA)

• Social Security toll free at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday from 7 a.m. to 7 p.m.

• Medicare & You Handbook

THANK YOU!