Download - Understanding Medicare
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Understanding Medicare
Module 1
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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
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Medicare Basics
Module 1: Lesson 1
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Medicare BasicsLesson 1 Topics
Medicare overviewEnrollmentPart APart BMedicare plan choices
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Medicare Health insurance for people
Age 65 and olderUnder age 65 with certain disabilitiesAny age with End-Stage Renal Disease (ESRD)
Administered byCenters for Medicare & Medicaid Services (CMS)
Enroll throughSocial Security Administration (SSA) orRailroad Retirement Board (RRB)
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MedicareMedicare has
Part A – Hospital coveragePart B – Medical coveragePart 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
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Applying for Medicare
Apply 3 months before age 65Need not be retired
Automatically enrolled if receive Social Security or Railroad Retirement benefitsIf 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
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Paying for Medicare Part A
Most people receive Part A premium freePeople with less than 10 years of Medicare-
covered employmentCan pay a premium to get Part A
For information, call SSA1-800-772-1213TTY users call 1-800-325-0778
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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 yearCoverage effective July 1Premium 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
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Enrolling in Medicare Part B
Special Enrollment PeriodSign up within 8 months of the end of employer
or union health plan coverageNo increased premium
For questions or to enrollSSA: 1-800-772-1213RRB: 1-800-808-0772
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Paying for Medicare Part B Monthly Medicare Part B premium in 2007
Most people pay $93.50Programs available to help
If Your Yearly Income is You pay
File Individual Tax Return File 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 $200,000 Above $400,000 $161.40
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Paying the Part B Premium
Taken out of your monthly paymentSocial SecurityRailroad RetirementFederal Government retirement
For information about premiumsCall SSA or RRB
• Office of Personnel Management if a retired Federal employee
May be billed every 3 months Medicare Easy Pay
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Part A Helps Pay for
Hospital inpatient careSkilled nursing facility (SNF) careHome health careHospice careBlood
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Hospital Stays
Covered servicesSemi-private roomMealsGeneral nursingOther hospital services and supplies
Includes care in critical access hospitals190 days in a lifetime for inpatient mental
health care
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Skilled Nursing Facility Care
Must meet all of the following conditionsRequire daily skilled servicesHospital inpatient at least 3 consecutive days Admitted to SNF within 30 days after leaving
hospitalCare is for a condition treated in the hospitalMUST be Medicare participating SNF
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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
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Home Health Care
Covered servicesPart-time skilled nursing careTherapy
• Occupational
• Physical
• Speech-languageSome home health aide servicesDurable medical equipment
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Home Health Care
For as long as you are eligibleLimited hours per dayLimited days per week
Four conditionsDoctor must make a plan for your care at homeMust need specific skilled servicesMust be homeboundHome health agency must be Medicare-approved
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Hospice
Special care for terminally illAnd family
If you likely have less than 6 months to liveCertification required for each “period of care”
Two 90-day periodsUnlimited 60-day periods
Hospice provider must be Medicare-approved
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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 timeNo limit to number of times
Home health aide and homemaker services Social worker services Dietary counseling Grief counseling
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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
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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
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Part B Also Helps Pay for
Clinical laboratory testsHome health servicesDurable medical equipmentOutpatient hospital servicesBlood Ambulance service
If other transportation would endanger your health
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Medicare Plan Choices
Original Medicare PlanMedicare Advantage PlansOther Medicare plansMedicare drug plans
Medicare Prescription Drug PlansMedicare Advantage Plans and other Medicare
plans with prescription drug coverage
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Original Medicare Plan
Module 1: Lesson 2
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Original Medicare PlanLesson 2 Topics
What it is and how it worksYour costs in Original Medicare PlanAssignmentMedigap (Medicare Supplement Insurance)
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Original Medicare Plan
Red, white, and blue Medicare cardPart A and/or Part BGo to any provider that accepts MedicareYou pay
Part B premium• Part A free for most people
DeductiblesCoinsurance or copayments
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Medicare Card (front)
Jane Doe
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Medicare Card (back)
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Medicare Claims Contractors
Fiscal Intermediary (FI)Regional Home Health Intermediary (RHHI)Medicare CarrierDurable Medical Equipment Regional Carrier
(DMERC)Medicare Administrative Contractors (MAC)
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Original Medicare Plan—Part A
Charges based on “benefit period”Inpatient hospital care and SNF servicesBegins day admitted to hospitalEnds when no care received in a hospital or
SNF for 60 days in a row You pay deductible for each benefit periodNo limit to number of benefit periods
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Paying for Hospital Stays
For inpatient stays in 2007 you payDays 1 – 60 each benefit period
• $992 totalDays 61 – 90 each benefit period
• $248 per dayDays 91 – 150 (60 lifetime reserve days)
• $496 per day All costs for each day beyond 150 days
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Skilled Nursing Facility Care
For each benefit period in 2007 you payDays 1 – 20: $0Days 21 – 100: $124 per dayAll costs after 100 days
Must meet requirements for Medicare-covered stayDoes NOT include custodial care
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Paying for Home Health Care
In the Original Medicare Plan you payNothing for covered home health care services20% of the Medicare-approved amount for
covered durable medical equipment
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Paying for Hospice Care
In the Original Medicare Plan you payUp to $5 for prescription drugs5% for inpatient respite care
• Amount can change each year
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Paying for Part B
In the Original Medicare Plan you payMonthly Part B premium
• $93.50 in 2007 for most peopleYearly deductible
• $131 in 200720% coinsurance for most servicesSome copayments
Some programs may help
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Assignment
Agreement between you, doctor, and MedicareApplies to Original Medicare Plan Part B Claims
If providers accept assignment they agree toBe paid by MedicareGet only the amount Medicare approves for their
servicesOnly charge the Medicare deductible and/or
coinsurance amount
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Assignment
Providers who don’t accept assignment mayCharge more than Medicare-approved amount
• Limit of 15% more for most services
Ask you to pay entire charge at time of service
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Assignment
In some cases, providers must accept assignmentSome examples
• Medicare Part B-covered prescription drugs
• Ambulance providers
Doctors/providers generally have to file claimYou may have to file your claim for Part B-covered
drugs or supplies• If supplier or pharmacy not enrolled in Medicare
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Private Contracts
Agreement between you and doctorOriginal Medicare Plan will not payMedigap will not payOther Medicare plans will not payYou will pay chargesNo claim should be submittedCannot be asked to sign in an emergency
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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
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How Medigap Works
Only works with Original MedicareDon’t need Medigap policy in
• Medicare Advantage Plan
• Other Medicare plans
Can go to any doctor, hospital, or provider that accepts MedicareExcept with a Medigap SELECT policy
You pay a monthly premium
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Medicare Advantage Plans and Other Medicare Plans
Module 1: Lesson 3
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Medicare Advantage PlansLesson 3 Topics
What are Medicare Advantage Plans and other Medicare plans
Who can joinHow plans workJoining and switching plans
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What Are Medicare Advantage Plans?
Health plan options approved by Medicare Run by private companies Part of the Medicare program
Sometimes called “Part C”
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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)
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Other Medicare Plans
Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the
Elderly (PACE)
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Who Can Join?
Eligibility requirementsLive in plan’s service areaHave Medicare Part AHave Medicare Part BNot have ESRD at time of enrollment
• Some exceptions
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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
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Out-of-Pocket Costs
Generally must still pay Part B premiumSome plans may pay all or part
May pay additional monthly premiumPay other out-of-pocket costs
Different from Original Medicare PlanVary from plan to plan
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In a Medicare Advantage Plan
Still in Medicare programStill have Medicare rights and protectionsStill get all regular Medicare-covered servicesMay get extra benefits
Such as vision, hearing, or dental care
May be able to get prescription drug coverage
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Medicare HMO Plans
Copayment amounts set by planGenerally must get care and services from
plan’s networkUse 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
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Medicare HMO Plans (cont’d)
May need to choose primary care doctorUsually need a referral to see a specialistDoctors can join or leave
May get Medicare drug coverage
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Medicare PPO Plans
Can see any doctor or provider that accepts MedicareDon’t need referral to see specialistDon’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
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Medicare PFFS Plans Can see any Medicare-approved doctor or
hospital that accepts the planCan get services outside service areaDon’t need referral to see a specialistPlan sets copayment amounts
Can get emergency care anywhereWithout prior approval
If offered, can get Medicare prescription drug coverageIf not offered, can join a Medicare Prescription
Drug Plan
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Medicare MSA PlansNew in 2007Similar to Health Savings Account plansHave two parts
Medicare Advantage Plan with high deductible• Pays covered costs after you meet annual deductible
– Deductible varies by planMedical Savings Account
• Medicare deposits money the person may use– To pay health care costs
MSA demonstration available in some areas
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When Can You Join?
You can join a Medicare Advantage Plan or other Medicare planWhen first eligible for MedicareDuring specific enrollment periods
• Annual Coordinated Election Period
• Medicare Advantage Open Enrollment Period
• Special Enrollment Periods
• Limited Open Enrollment Period
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When Can You Switch?
Annual Election PeriodMedicare Advantage Open Enrollment PeriodSpecial circumstances
Move out of the plan’s service area and can’t stay in the plan
Plan leaves Medicare programOther special situations
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Annual Election Period
November 15 – December 31Can choose new plan
• Medicare Advantage Plan
• Medicare prescription drug plan
• Original Medicare PlanNew plan starts January 1
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Medicare AdvantageOpen Enrollment Period
January 1 – March 31, 2007Same period each yearChange effective first day of following monthCannot be used to start or stop Medicare
drug coverage
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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 inMedicare Medical Savings Account (MSA) PlansMA plans that offer Medicare prescription drug
coverage (MA-PDs)Medicare Prescription Drug Plans (PDPs)
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Medicare Prescription Drug Coverage
Module 1: Lesson 4
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Medicare Prescription Drug Coverage Lesson 4 Topics
OverviewEligibility and enrollmentExtra help
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Prescription Drug Coverage
Coverage began January 1, 2006Available for all people with Medicare Provided through
Medicare Prescription Drug PlansMedicare Advantage Plans and other
Medicare plans
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Prescription Drug Costs
Costs vary by planMost people will pay
Monthly premiumDeductibleCopayments or coinsuranceVery little after $3,850 out-of-pocket in 2007
Extra help available for people with limited income and resources
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Eligibility and Enrollment
You mustHave Medicare Part A, Part B, or bothLive in plan’s service areaEnroll in a Medicare prescription drug plan to
get coverage
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Enrollment Periods
Initial Enrollment Period (IEP)7 months beginning 3 months before the first
month of Medicare eligibility
Can change plansAnnual Coordinated Election Period
• November 15 – December 31 each yearSome special enrollment periods available
Some people are enrolled automatically
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Late Enrollment Penalty
People who wait to enroll after their IEPPay additional 1% of base beneficiary premium
• For every month eligible and not enrolled
• For as long as they have Medicare drug coverageExcept those with other creditable drug coverage
• Coverage at least as good as Medicare prescription drug coverage
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Special Enrollment Periods
For people whoPermanently move out of plan’s service areaLose creditable prescription drug coverage Enter, reside in, or leave a long-term care facility
• Like a nursing homeHave Medicaid or are in a Medicare Savings
Program• Have a continuous special enrollment period
Have other exceptional circumstances
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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
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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
ResourcesUp 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
2007 amounts
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How to Apply for Extra Help
Multiple ways to applyPaper applicationwww.socialsecurity.govState Medical Assistance officeLocal organization
You or someone on your behalf can apply
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Drug Plan Costs for People with Extra Help
Those below Federal poverty level save over 95% on average
People with lowest income and resourcesPay no premiums or deductiblesHave small or no copayments
Those with slightly higher income and resourcesHave a reduced deductiblePay a little more out of pocket
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Programs for People with Limited Income and Resources
Module 1: Lesson 5
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Programs for People with Limited Income and Resources
Lesson 5 TopicsMedicaidMedicare Savings Programs (MSP)Help for people living in U.S. territories
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Medicaid Federal-state health insurance program
People with limited income and resourcesCertain people with disabilities
If eligible, most health care costs covered Eligibility determined by state Application processes and benefits vary Office names vary
Social ServicesPublic AssistanceHuman Services
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Medicare Savings Programs
Help from Medicaid paying Medicare premiumsFor people with limited income and resourcesMay also pay Medicare deductibles and
coinsurancePrograms include
• Qualified Medicare Beneficiary (QMB)
• Specified Low-income Medicare Beneficiary (SLMB)
• Qualifying Individual (QI)
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Programs in U.S. Territories
Help people pay their Medicare costsU.S. territories
Puerto RicoVirgin IslandsGuamNorthern Mariana IslandsAmerican Samoa
Programs vary Contact Medical Assistance office
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If you think you might qualify …
1. Review guidelines2. Collect your personal documents3. 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
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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
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For More Information
1-800-MEDICARE (1-800-633-4227)TTY users should call 1-877-486-2048
Medicare & You handbookOther Medicare publicationswww.medicare.govwww.cms.hhs.govYour local SHIP
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This training module provided by the
For questions about training products, email [email protected]
To view all available NMTP materials or to subscribe to our listserv, visit
www.cms.hhs.gov/NationalMedicareTrainingProgram