version 12. 1. when medicare coverage begins 2. the four components of original medicare 3....

Welcome to

Medicare

SHIPTina Herrero-Backe

11.14.15

Version 12

1. When Medicare coverage begins

2. The four components of Original Medicare

3. Coordination of Benefits

4. Special focus on Part D and Immunosuppressants

11.14.15Understanding Medicare 2

Topics

a. Age: The 1st of the month in which you turn 65 *

b. Disability: The 25th month you receive disability benefits *

c. ESRD: The 4th month of dialysis*


When can Medicare begin?

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:

• 1st day of 4th month of dialysis

• Or 1st day of 1st month of home dialysis

Medicare ends:

• 12 months after the month dialysis stops or

• 36 months after the month of the kidney transplant

Part A Hospital

Insurance

Part B Medical

Insurance

Part C Medicare

Advantage Plans

HMO/PPO Includes Part

A, B, D DDDDsometimes Part D coverage

Part D Medicare Prescrip-tion Drug Coverage

11.14.15Getting Started5

What Does Medicare Cover?

Part A: Hospital CoverageFor 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 150

All Costs

11.14.15Getting Started 7

Part A: Skilled Nursing Facility

For Each Benefit Period in 2016

You Pay

Days 1-20 $0

Days 21-100 $161 per day

All days after 100 All Costs

◦Doctor’s visits◦Outpatient medical services◦Clinical lab tests◦Emergency Department Services◦Durable Medical Equipment◦Outpatient Chemotherapy


Part B – Medical Insurance

◦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”


Part B – Medical Insurance (cont’d)


Part B: Medical Coverage

2016 You Pay

Monthly Premium$104.90 (most people)

[$121.80]

Yearly Deductible (once)

$166.00

Medicare Covered Services

20%

(if provider accepts “Assignment”)


Medigap Plan TypesMedigap Plans

Benefits A B C D F/F* G K** L** M N

Medicare Part A deductible ($1288) X X X X X 50% 75% 50% X

Part A Skilled Nursing Coinsurance (after a 3 day inpatient hospital stay)

X X X X 50% 75% X X

Medicare Part B deductible ($166) X X

Part B Coinsurance (20%) X X X X X X 10%(you pay

10%)

15%(you pay

5%)

X X***

Medicare Part B excess charges X X

Part A Coinsurance (Days 61 – 150) X X X X X X X X X X

Part A additional days (up to an additional 365 days after Medicare benefits are used)

X X X X X X X X X X

Hospice Care Coinsurance X X X X X X 50% 75% X XBlood (first 3 pints if there is a charge) X X X X X X 50% 75% X XForeign travel emergency (up to plan limits) X X X X X X

* Plan F also offers a high-deductible plan, F*. In the F* option, also called High F, you pay for costs not covered by Medicare (including deductibles and coinsurances) up to the High F deductible of $2,180 in 2015 before your policy pays anything. **Plans K and L have an out-of-pocket yearly limit. *** Plan N Part B Coinsurance: You pay up to $20 for doctor visits and up to $50 for emergency room visits that do not result in an inpatient

Out-of-pocketlimit in 2015

$4,940 $2,470

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


Medigap Plans

Primary PayersSecondary PayersPayers of last resort

ESRD 30-month Coordination Period

Coordination of Benefits

Medicare is your only insurance

5/01/2015Coordination of Benefits 14

Medicare Is the Primary Payer If…

Medicare and Employer Plans 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

Medicare

and

ESRD

11.14.15

Medicare and ESRD Coverage Starts Under the Following Circumstances

1st day of the 4th month You get a regular course of dialysis in a facility

1st day of the month of the 1st 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

1st day of the month You get a kidney transplant

1st day of the month Admitted 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

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

ESRD and the 30-Month Coordination Period

05/01/2015 Medicare for People With End-Stage Renal Disease 18

Prescription Drug Coverage

11.14.15 Medicare Getting Started 19

Part A generally pays for all drugs during a covered inpatient stay

Drugs used in hospice care for symptom control and pain relief

20

Part A: Prescription Drug Coverage

• 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

Part B: Prescription Drug Coverage

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

Immunosuppressive Drugs


Part D Prescription Drug Plans

2016 You Pay

Monthly PremiumPlan 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)


The Donut Hole

You Pay:45% Brand Name58% Generic

Your cost

Total Drug Cost = $3,310

ENTEREXIT

Your TrOOP (deductible, coinsurances, Medicare’s 50% in coverage gap for brand names) = $4,850

Catastrophic Coverage

You Pay:5% or$7.40 Brand Name$2.95 Generic

The 2016 “Donut Hole”

Initial Stage

The Coverage GapYear What You Pay for Covered

Brand-Name Drugs in the Coverage Gap

What You Pay for Covered Generic Drugs in

the Coverage Gap

2015 45% 65%

2016 45% 58%

2017 40% 51%

2018 35% 44%

2019 30% 37%

2020 25% 25%

05/01/2015 Medicare Prescription Drug Coverage 25

Things to Consider:

1. Plan formularies2. Preferred v. standard pharmacies3. Pre-Authorizations4. Step Therapy


Part D: Which is the best plan?

Medicare’s Plan Finder

DateTitle 27

Open EnrollmentOctober 15 – December 7

Using immunosuppressants to do a 2016 Part D

search….

Part C: Advantage Plans

• 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

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


Medicare Savings Programs

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


Healthcare Fraud and Abuse

1. www.medicare.gov

2. www.insurance.maryland.gov• For Consumers•Medicare Related Information• Annual Premiums for Medicare Supplemental Policies


Useful Websites

http://www.medicare.gov/

http://www.insurance.maryland.gov/

State Health Insurance Assistance Program

Free Local Help for People with Medicare


Contact Your Local SHIP

version 12. 1. when medicare coverage begins 2. the four components of original medicare 3....

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