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Medicare: What else you should know
SHIBAStatewide Health Insurance Benefits Advisors
A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner
2/25/2015
What is SHIBA?
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Statewide Health Insurance Benefits Advisors
A free program of the Office of the Insurance Commissioner
We provide unbiased and confidential information about Medicare and other health insurance
We are an educational service We don’t sell anything!
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Medicare’s preventive benefits
How to pay for Medicare
Inpatient/outpatient (observation) SNF
Health Homes
Durable Medical Equipment (DME)
Transitioning from the Exchange to Medicare
Today’s overview
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Medicare’s preventive benefits
Preventive services
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Prevention is covered under Medicare Part B
Most preventive services are free – however some charge a coinsurance, copay
Check with your provider to make sure they accept Medicare
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Types of preventive services
Health screening/exams Counseling Education Immunizations
Diagnostic tests may be ordered by the medical provider if you’re at risk, but these tests may have an out-of-pocket cost.
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After you’re eligible for Part B
Get your Welcome to Medicare Preventive visit during your first 12 months of Part B coverage
What occurs during this visit – your doctor:• Reviews your medical and family history • Assesses any risk factors you may have• Identifies risk factors that may make it necessary to get
follow-up tests that have out-of-pocket costs
Welcome to Medicare Preventive visit
No cost if medical provider accepts Medicare
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After you’re eligible for Part B
The yearly Wellness visit takes place after your first 12 months of Part B eligibility (not as comprehensive)
Medicare covers this visit once every 12 months Your provider will ask you to fill out a “Health Risk
Assessment” Anyone with Medicare is eligible You pay nothing for the visit, unless you get
additional tests or services that aren’t covered
Wellness visit
No cost if medical provider accepts Medicare
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Examples of what’s covered
Flu, Hepatitis B and Pneumonia shots Eyeglasses (limited) Glaucoma tests Diabetic supplies
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Flu shots: One per flu season starting in the fall Hepatitis B shots: For people with medium or high
risk; comes in a series of three for complete protection
Pneumonia shots: You can have any time of year, most people only need one in a lifetime• High-risk people can get a pneumonia booster every 5 years
Flu, Hepatitis B & Pneumonia shots
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One pair of eyeglasses with standard frames or one set of contact lenses from a supplier that accepts Medicare
After you have cataract surgery that implants an intraocular lens
You pay 20% of Medicare-approved amount and your Part B deductible applies
Eyeglasses (limited)
Glaucoma tests
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No cost if medical provider accepts Medicare
Medicare covers a Glaucoma screen by a doctor once every 12 months
You’re eligible if you’re:• At high risk for diabetes• African American over age 50• Hispanic and age 65 or older
Costs:• You pay 20% of Medicare-approved amount after you meet the
yearly Part B deductible
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Diabetic supplies
Covers:• Blood sugar testing monitors and strips• Lancet devices and lancets• Blood sugar control solutions• Therapeutic shoes (in some cases)• Insulin (if medically necessary) if you use an external
insulin pump You pay 20% of Medicare-approved amount and
Part B deductible applies
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Diabetic supplies (cont.) No matter where you live, if you get your diabetic
testing supplies delivered to your home, you must use a Medicare mail-order contract supplier – if you want Medicare to pay.
You can also buy supplies from any store that’s enrolled withMedicare (i.e., local pharmacy,storefront supplier)
This does not apply to insulin and external insulin pumps
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Medicare preventive services resources
Medicare.gov Call 1-800-MEDICARE (1-800-633-4227) SHIBA pub: Understanding your Medicare
preventive benefits
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How to pay for Medicare
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Help for people with limited income and resources
Medicaid• For people with the lowest incomes, eligible people pay
little or nothing for their health care costs Medicare Savings Programs (MSPs)• Helps pay Part B premiums and sometimes Part A and Part
B deductibles and co-insurance Extra Help• Helps pay Part D (Rx drug) costs
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What is Medicaid?
Federal-state health insurance program• For people with limited income/resources• Certain people with disabilities• If you have both Medicare and Medicaid, covers most
health care costs Eligibility determined by state In Washington state: DSHS Apply if you MIGHT qualify
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What are Medicare Savings Programs (MSPs)?
Help from Medicaid to pay for Medicare costs• Pay Medicare premiums• May pay Medicare deductibles and co-insurance
Income amounts change each year
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Who qualifies for MSP
Individual Monthly Income
Limit
Married Couple
Monthly Income
Limit
Helps Pay Your
Medicare Savings Program
$1,324 $1,792Part B premiums, and sometimes Part A premiums, Medicare A & B deductibles and co-insurance
Asset Limits: Individual $ 7,280Couple $10,930
Getting Started 212/19/2013
What is Extra Help(Low Income Subsidy)?
Help paying prescription drug costs Social Security makes determination Some groups automatically qualify• Example: If they qualify for Medicare and Medicaid
You or someone on your behalf can apply
Getting Started 222/19/2013
Who qualifies for Extra Help?
Individual Monthly Income
Limit
Married Couple
Monthly Income
Limit
Helps Pay Your
Extra Help $1,471 $1,991 Part D Premium, Deductibles and Co-pays
Asset Limits: Individual $13,640Couple $27,250
Getting Started 232/19/2013
Who should apply for these programs
Apply if you MIGHT qualify Social Security for Extra Help DSHS for Medicaid or Medicare Savings Programs SHIBA can help you
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Inpatient/outpatient (observation) skilled nursing facility (SNF)
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Hospital inpatient or outpatient
If you stay in a hospital overnight, you might still be considered outpatient
Your hospital status (hospital considers you an in- or outpatient) affects how much you pay for hospital services (i.e., x-rays, drugs, lab tests)
May also affect if Medicare will cover care you to get in an SNF following your hospital stay
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Hospital inpatient or outpatient (cont.)
The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care.
An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care.
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What you pay as an inpatient
Medicare Part A You pay a one-time deductible for all of your hospital
services for the first 60 days
Medicare Part B Covers most of your doctor services You pay 20% of Medicare-approved amount for
doctor services after paying the Part B deductible
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What you pay as an outpatient
Medicare Part B Covers outpatient hospital services You have a copay for each individual outpatient
hospital service (amount may vary by service)Note: The copay for a single outpatient hospital service can’t be more than the inpatient hospital deductible
Generally Part B does not cover Rx and over-the-counter drugs in an outpatient setting
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How hospital status affects the way Medicare covers your care in an SNF
Medicare will only cover care you get in an SNF if you first have a “qualifying inpatient hospital stay”
Your doctor must formally admit you to the hospital for at least 3 days in a row
Includes the day you were admitted as inpatient, but not the day of your discharge
If no 3-day inpatient hospital stay and you need care after your discharge, ask for care in another setting or if other programs can cover your SNF care
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How hospital observation services affect SNF coverage
When you’re being observed in a hospital, you’re considered an outpatient
This means you cannot count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay
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Where to get more help
Talk to your doctor or someone from the hospital discharge department
Medicare and You booklet Call 1-800 MEDICARE Read the handout Are you a hospital inpatient
or outpatient?
Health Homes
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What is a Health Home? It’s a set of new care coordination services, provided by
a care coordinator He/she will work with you to increase coordination of
all the services and supports you currently receive Designed to support you with your ongoing chronic
conditions and assist you with meeting your health goals
Examples of services include:• Comprehensive care management• Comprehensive and transitional planning• Individual and family support services• Referral to community and social support services
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Who’s eligible for Health Home services
People with full Medicaid and Medicare coverage These services support people with chronic
conditions The WA St. Health Care Authority will send you a
letter to let you know you’re eligible Your Health Home care coordinator will call you to
talk about Health Home services You can also contact Medicaid: 1-800-562-3022
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Who provides Health Home services
Someone called a “care coordinator” He/she works for Health Home lead organizations
that contract with Medicare A care coordinator will contact you to describe the
Health Home services and answer your questions You can stay with your current health care providersMore information Read the handout: Your Washington State Health
Homes Booklet
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Durable Medical Equipment (DME)
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What Medicare covers
Durable medical equipment: Oxygen equipment and supplies Wheelchairs Walkers Hospital beds Etc.
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What Medicare covers (cont.)
Sometimes you must rent durable medical equipment
A doctor or other health care provider enrolled in Medicare must order for you to use in your home
You pay 20% of the Medicare-approved amount Your Part B deductible applies
ImportantIn all areas of the country, you must get your covered equipment, supplies, and replacement or repair services from a Medicare-approved supplier for Medicare to pay.See page 47 in the 2015 Medicare and You book
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Transitioning from the Exchange to Medicare
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Exchange to Medicare transition When you become eligible for Medicare while on a health
Exchange plan, Medicare will give you an initial enrollment period.
Once you’re entitled to Medicare, your health Exchange plan will automatically end your first day of Medicare coverage (WA state specific)
It’s to your advantage to sign up for Medicare because:• Once you become Medicare eligible you can’t get lower costs for an
Exchange plan based on your income• If you wait to enroll in Medicare after your initial enrollment period, you
may have to pay a late enrollment penalty for Part A and/or B
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Medicare fraud
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We all pay the price for Medicare fraud, abuse and waste! Watch out for these types of fraud:
You get billed for services or equipment you didn’t receive You’re offered free testing or screening in exchange for
your Medicare number You’re charged for filling out claim forms
OR – A medical provider:
Performs services that exceed what’s medically necessary Offers/accepts referral fees from another provider for the
referral Misrepresents services that are billed to Medicare Waives the 20% coinsurance or deductible
Protect yourself from fraud
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Protect your Medicare number like you protect a bank account or credit card.
Review your Medicare payment notices and bills for errors.
Don’t do business with door-to-door or phone sales people, or online solicitations.
Always report suspicious activity.
SHIBA is Washington state’s Senior Medicare Patrol project. We can help clients prevent, detect and report Medicare and Medicaid fraud and abuse. If you have questions or suspect fraud and abuse, call us at:
1-800-562-6900
Protect yourself from fraud
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Wrap up
Need help with other insurance questions?
The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as:
Call our Insurance Consumer Hotline
1-800-562-6900
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• Homeowner• Auto• Life
• Annuities• Health• And more!
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Did some of this make sense to you? Want to learn more? Want to make a difference for others? We would love to have you volunteer with
SHIBA!
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