_ _

Your guide to

Understanding Medicare

When you understand the

basics of Medicare, you’ll

be better able to choose

the coverage that works

best for you. This booklet

is packed with practical

information to help you

make sense of Medicare’s

various terms, parts, rules,

and enrollment periods.

Y0033_H5050_MA0001401-04-16Accepted 08-30-2016

What is Medicare? Medicare is a health insurance program introduced in 1965. It’s administered by the U.S. government through the Centers for Medicare & Medicaid Services (CMS). It is made up of four parts:

Part A Hospital

Insurance

Part B Medical

Insurance

Part C Medicare

Advantage Plans

Part D Prescription

Drug Coverage

Together, Parts A and B are known as “Original Medicare.”

Are you eligible? In general, you’re eligible for Medicare if you’re a U.S. citizen and fall into one of these categories:

• You’re age 65 or over, and you meet Social Security Administration guidelines.

• You’re under age 65 with certain disabilities and are receiving Social Security Disability Insurance benefits.

• You have end-stage renal disease.

• You meet other criteria (visit www.ssa.gov for specifics).

How to enroll If you’re receiving Social Security benefits, the Social Security Administration (SSA) will automatically sign you up and send you notification of enrollment. If you haven’t started receiving Social Security benefits, and are eligible for Medicare, you must sign up on your own, either online at www.ssa.gov or by visiting an SSA office.

2 YOUR GUIDE TO UNDERSTANDING MEDICARE

Part A: Hospital insurance Part A covers care received as an inpatient in a hospital. It has a “per benefit period” deductible—rather than an annual deductible—that must be paid before coverage begins. A benefit period starts on the day you go into a hospital or a skilled nursing facility, and ends after you haven’t received any hospital or skilled nursing care for 60 days.

If you’ve worked in the United States and paid Medicare taxes for at least 40 quarters (about 10 years), your Part A coverage is free. If you don’t qualify for free Part A, you can purchase this coverage from the government.

Some people who are already receiving Social Security benefits are automatically enrolled in Part A. Others need to apply when they become eligible for Medicare, or during the general enrollment period, Jan. 1 through March 31 each year. Coverage starts July 1.

For more details about benefit periods and their deductibles, visit medicare.gov.

Part A helps cover: • Inpatient care in hospitals (includes

critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)

• Skilled nursing facilities (not custodial or long-term care)

• Hospice care

• Home health care services

Part A doesn’t cover: • Nonskilled or custodial services, including

assistance in Activities of Daily Living (ADL)

• Benefits that are covered under Part B of Medicare

Part B: Medical insurance Medicare Part B is optional and has a monthly premium. This premium is deducted from your monthly Social Security check or billed quarterly if you’re not yet receiving Social Security benefits. A deductible and coinsurance apply when using Part B, and coverage is limited to services that are covered by Medicare.

If you don’t enroll in Part B when you’re first eligible for Medicare, and you decide to enroll later, your monthly Part B premium could go up 10 percent for each year that you could have had Part B but didn’t enroll.

If you have other coverage—such as an employer-sponsored plan—when you first become eligible for Medicare, you can defer your Medicare enrollment to a later time (up to 8 months after your other coverage ends) without penalty.

Visit medicare.gov to see if a test, item, or service you need is covered by Part B, or for details about penalties.

Part B covers: • Doctor services

• Outpatient care

• Some other services not covered by Part A

Part B doesn’t cover: • Long-term care (also called custodial care)

• Dental care (in most cases) and dentures

• Eye care (routine exam), eye refractions, and most eyeglasses

• Cosmetic surgery

• Alternative health care

• Hearing aids and exams for the purpose of fitting a hearing aid

• Hearing tests that haven’t been ordered by a doctor

• Routine foot care (with a few exceptions)

YOUR GUIDE TO UNDERSTANDING MEDICARE 3

Part C: Medicare Advantage plans Part C refers to Medicare Advantage plans, which combine your benefits from Parts A, B, and sometimes D (prescription drugs) in a single plan. Medicare Advantage plans are offered through private companies and must be approved by Medicare. These plans can provide additional benefits such as vision, hearing, and dental benefits, and health and wellness programs. Plans may use specific provider networks and preferred hospitals where you must receive your care to ensure that care is covered.

More details about Medicare Advantage plans:

• To qualify for these plans, you must be entitled to Part A and enrolled in Part B.

• You may pay a premium to the Medicare Advantage plan of your choice, and will continue to pay your Part B premium.

• You must maintain a permanent residence for six months or more in the service area of your Medicare Advantage plan.

• You may choose to enroll in a Medicare Advantage plan that does not include Part D prescription drug coverage. However, penalties may apply if you elect Part D prescription drug coverage at a later date.

Medicare Advantage plans feature: • No or minimal medical deductibles

• Simple copays for most covered services

• Limits on out-of-pocket expenses

• Coverage for urgent or emergency care when traveling outside the U.S.

• Fitness benefits

• Chiropractic care

Part D: Prescription drug coverage Medicare Parts A and B do not cover the cost of most prescription drugs. Medicare Part D is an optional prescription drug benefit that’s available through private companies and has a monthly premium. All Part D plans must be approved by Medicare and must meet certain standards set by the government. After that, plans can vary—with different premiums, drugs that are covered, and drug costs.

You can get Part D as a stand-alone drug plan, or as part of a Medicare Advantage plan that includes both your medical and prescription coverage. You are eligible for Part D if you have Medicare Part A and/or Part B, you live in your chosen plan’s service area, and you don’t already have prescription drug coverage through your employer or union, COBRA, or other means. You can only be enrolled in one Part D plan at a time. You will be disenrolled from a Medicare Advantage plan with or without Part D if you elect to enroll in a standalone Part D plan.

Visit medicare.gov to compare Medicare Part D prescription drug plans.

Part D covers:

• All outpatient drugs mandated by Medicare. Coverage rules such as limitations and prior authorizations may apply.

Part D doesn’t cover:

• Drugs not on the Medicare formulary.

• Certain drugs that are covered under Medicare Part B.

Financial assistance:

• If you have limited income or resources, you may qualify for Extra Help, a Medicare program to help pay prescription drug costs. For more information, go to medicare.gov and search “Extra Help.”

4 YOUR GUIDE TO UNDERSTANDING MEDICARE

How Part D prescription drug coverage works*

1 2 3 4

Deductible Initial Coverage

You pay fixed copays or

coinsurance until you reach the $3,700 total drug cost limit.

Coverage Gap Catastrophic Coverage

You pay You pay You pay 51% for generics, the greater of: all drug costs 40%† for brand names Generic $3.30 or 5%. until you meet until you reach your plan’s All other drugs: the $4,950deductible. $8.25 or 5%. out-of-pocket limit.

* This is a description of the standard 2017 Part D benefit. Your plan may vary. † Plus dispensing fee.

The four phases of Part D coverage

Part D coverage is designed in four phases, and your coverage changes from one phase to the next as your drug costs add up over the calendar year.

1. You pay all your drug costs out of pocket until you reach your plan’s deductible amount.

2. You just pay a copay or coinsurance until you reach $3,700 in covered drug costs. This total includes both what you’ve paid and what your plan has paid.

3. You have less coverage in this phase—known as the coverage gap or donut hole—until you reach $4,950 in out-of-pocket expenses. This total includes the value of any discounts you receive on brand-name drugs while in the coverage gap.

4. Your coverage increases and you pay a low coinsurance or fixed fee for the rest of the year.

On Jan. 1, your coverage starts over again in the deductible phase.

Penalties for late enrollment

If you don’t enroll in Part D when you’re first eligible for Medicare, and you decide to enroll later, you may be charged a higher monthly Part D premium— a penalty that you’ll pay for as long as you have Part D coverage.

For details on the penalty, go to medicare.gov and search “Part D late enrollment penalty.”

Before choosing a Medicare Part D plan, make sure the prescription drugs you currently take are on the plan’s formulary (list of covered drugs), and check the costs.

YOUR GUIDE TO UNDERSTANDING MEDICARE 5

Y0033_H5050_MA0001401-04-16Accepted 08-30-2016

Enrollment periods There are certain periods when you can join, change, or drop Medicare Parts A, B, C, and D.

Enrollment What it does When it is Considerations period

Initial Allows for Occurs the month you If your birthday is on the first Enrollment enrollment in turn 65 plus the three of the month, you’re eligible on Period (IEP) Parts A, B, C, months prior and the the first of the month prior to

and/or D. three months following. your 65th birthday.

Annual Allows for plan Occurs during the fourth More than one change is Enrollment changes, including quarter of the year. allowed, but the last one Period (AEP) dropping or adding This year, it is from during the AEP is the one that

Parts C and/or D. Oct. 15 to Dec. 7. Medicare recognizes and that becomes effective Jan. 1.

Medicare Allows Occurs from Advantage disenrollment Jan. 1 to Feb. 14. Disenrollment from Part C and/or D Period (MADP) and a return to

Original Medicare.

If you move from a Medicare Advantage plan back to Original Medicare, you may enroll in a stand-alone Part D prescription drug plan and a Medigap plan during this time. You may not enroll in or change to a Medicare Advantage plan during MADP.

Special Enrollment Periods (SEP)

These allow enrollment outside of AEP in specific situations.

Varies based on the qualifying event.

Examples of a qualifying event:

• Loss of group coverage

• Move from the plan service area

• Loss of eligibility due to change in chronic disease diagnosis

• Dual eligibility (Medicare and Medicaid)

6 YOUR GUIDE TO UNDERSTANDING MEDICARE

1

Other Medicare insurance Medicare

supplement plans

Employer retiree group plans

Also known as Medigap plans, these supplemental health insurance plans are sold by private insurance companies. They supplement Original Medicare and help “fill the gap”—covering coinsurance, copayments, and/or deductibles—for benefits that Original Medicare deems medically necessary, as well as other services not covered by Medicare.

More details:

• You must have Medicare Parts A and B in order to purchase a Medigap policy.

• There are standardized Medigap plans (A–N) and each plan has different benefits.

• You’ll pay a monthly premium for Medigap insurance, as well as your Part B premium.

• Electing Part B triggers a six-month Medigap open enrollment period, during which time coverage cannot be denied because of a pre-existing condition.

• Medigap plans aren’t the same as Medicare Advantage plans, Medicaid, employer or union plans, TRICARE, VA benefits, long-term-care insurance policies, or Indian Health Service, Tribal, or Urban plans.

• Currently, Medigap policies do not include prescription drug coverage. You may enroll in a stand-alone Medicare prescription drug plan (Part D) for this coverage.

Employers may offer group coverage for their retired employees with Medicare. Depending on the plan, the benefits can be a combination of an active employee plan and Medicare Advantage plan or a Medigap plan and may offer more comprehensive benefits than Original Medicare. Plan structures vary widely and once a beneficiary leaves the plan, they may not be able to re-enroll. If you think you’re eligible for retiree health benefits, contact your employer or retiree benefits administrator for further information.

There are special considerations for certain groups, such as federal employees. Check with your employee benefits manager to find out whether you are in such a group, then confirm this information with Medicare and Social Security. Keep notes on what information you are being given, when you get the information, and from whom.

YOUR GUIDE TO UNDERSTANDING MEDICARE 7

Group Health Nondiscrimination Notice and Language Access Services

GROUP HEALTH NONDISCRIMINATION NOTICE

Group Health Cooperative and Group Health Options, Inc. (“Group Health”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Group Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Group Health:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact the Group Health Civil Rights Coordinator.

If you believe that Group Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Group Health Civil Rights Coordinator, Group Health Headquarters, 320 Westlake Ave. N., Suite 100, GHQ-E2N, Seattle, WA 98109, 206-448-5819, 206-877-0645 (Fax), complianceoffice@ghc.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Group Health Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

LANGUAGE ACCESS SERVICES

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY：1-800-833-6388 / 711）。

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY：1-800-833-6388 / 711).

한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

© 2016 Group Health Cooperative and Group Health Options, Inc. Y0033_H5050_XB0001444-02-16 2017-XB-02_ACA_Notice_Taglines Accepted 08-21-2016

Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

ភាសាខ្មែរ (Khmer)៖ របយត័៖ េេបើ ិនអកនយខ្រ, េសជំ ិ ិ ឺ ំប់ ូ ូនួខយផក េយមនគតល គចនស បំេរអក។ ចរទរស័ព1-888-901-4636 (TTY: 1-800-833-6388 / 711។

日本語(Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-888-901-4636（TTY:1-800-833-6388 / 711）まで、お電話にてご連絡ください。

សិ

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS : 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

አማርኛ (Amharic)፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ن فارسی گفتگو می کنید، ر به زبااگ توجه:):فارسی گان برای شما فراهم می باشد. با يتسهیالت زبانی بصورت را

Farsi)

TTY: 1-800-833-6388 / 711) ( تماس 1-888-901-4636د. يبگیر

في ومعلومات مساعدة على الحصول حق لديكم :(Arabic)العربية إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية ملحوظة:

4636-901-888-1 اتصل برقم تتوافر لك بالمجان. (.6388-833-800-1 / 711)رقم هاتف الصم والبكم:

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਚ ਸਹਾਇਤਾ ਸੇਿਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। ਤਾਂ ਭਾਸਾ ਧਿੱ

ທ້ພີ

1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້ ່ ່ ົ ້ ໍາວາ ທານເວາພາສາລາວ, ການບ່ລິ ່ ື ້ ໍ ັ ່ ່ ້ ່ການຊວຍເຫຼອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມ ອມໃຫ ານ.

ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

For more information about how Medicare works, call the Social Security Administration at 1-800-772-1213 or visit www.ssa.gov.

Learn more about Group Health Medicare Advantage plans at medicare.ghc.org.

Group Health Cooperative is an HMO plan with a Medicare contract. Enrollment in Group Health HMO depends on contract renewal.

For more details about our plans, call Medicare Sales at 1-800-446-8882. (TTY users should call 1-800-833-6388 or 711.) Hours are Monday through Friday from 8 a.m. to 8 p.m. From Oct. 1 through Feb. 14, hours are 8 a.m. to 8 p.m., 7 days a week.