Day 2 (&3) Chapter 3-MA (Part C)

Topics to Highlight

□ Review difference in plans □ Review enrollment periods □ Review SEP □ Stress counselors always need to look at client’s card □ Stress need for awareness of group vs. non-group

Handouts/Case Studies

□ Medicare Coverage Options (Excerpt from Medicare & You Handbook) □ Medicare Coverage Types (Excerpt from Medicare & You Handbook) □ List of Medicare Advantage Plans □ Case Study – Ty Juan On (Confusion over Medicare/MA) □ Case Study – Travis Tee (Part B) □ Case Study – Tyme Leeness (Medicare vs. MA plan) □ Case Study – Jan Itor (On MA plan – moving from out of state) □ Medicare Advantage Quiz □ Medical Insurance Explained for the HMO System (joke) □ Case Study – Ms. Heart (Medicare vs. MA plan) □ Case Study – Ms. Fran Chise (Pt. B delay while covered) □ Case Study – Mr. Will B. Gone (Wants MA – travels out of state) □ Case Study – Mr. Chad R. Boxx (MA – moved out of area) □ Case Study – Sal Lowe (Foreign Travel) □ Optional Handout – MRC’s Questions to Ask Before Joining a Medicare Private Health Plan

□ Homework: Read Chapter Four – Medicare Part D

55Section 4—Choose Your Health & Prescription Drug Coverage

What are my Medicare coverage choices? There are 2 main choices for how you get your Medicare coverage. Use these steps to help you decide.

In addition to the options listed above, you may be able to join other types of Medicare health plans. See pages 79–80. Some people may have other coverage like employer or union, Medicaid, military, or Veterans’ benefits. See pages 100–101 and 93–94.

Note: If you join a Medicare Advantage Plan, you can’t use Medicare Supplement Insurance (Medigap) to pay for out-of-pocket costs you have in the Medicare Advantage Plan. If you already have a Medicare Advantage Plan, you can’t be sold a Medigap policy. You can only use a Medigap policy if you disenroll from your Medicare Advantage Plan and return to Original Medicare. See page 67.

Decide if you want Original Medicare or a Medicare Advantage Plan

Original Medicare includes Part A (Hospital Insurance)

and/or Part B (Medical Insurance) ■ Medicare provides this coverage directly. ■ You have your choice of doctors, hospitals, and other providers that accept Medicare.

■ Generally, you or your supplemental coverage pay deductibles and coinsurance.

■ You usually pay a monthly premium for Part B.

See pages 57–63.

Decide if you want prescription drug coverage (Part D)

Decide if you want prescription drug coverage (Part D)

Decide if you want supplemental coverage

Medicare Advantage Plan (like an HMO or PPO)

Part C includes BOTH Part A (Hospital Insurance) and Part B (Medical Insurance) ■ Private insurance companies approved by Medicare provide this coverage.

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

■ You usually pay a monthly premium (in addition to your Part B premium) and a copayment or coinsurance for covered services.

■ Costs, extra coverage, and rules vary by plan.See pages 68–78.

■ If you want drug coverage, you must join a Medicare Prescription Drug Plan. You usually pay a monthly premium.

■ These plans are run by private companies approved by Medicare.

See pages 81–94.

■ If you want drug coverage, and it’s offered by your plan, in most cases you must get it through your plan.

■ In some types of plans that don’t offer drug coverage, you can join a Medicare Prescription Drug Plan.

See pages 74–75.

■ You may want to get coverage that fills gaps in Original Medicare coverage. You can choose to buy a Medicare Supplement Insurance (Medigap) policy from a private company.

■ Costs vary by policy and company. ■ Employers/unions may offer similar coverage.

See pages 64–67.

Step 2

Step 3

Step 2

56 Section 4—Choose Your Health & Prescription Drug Coverage

What should I consider when choosing or changing my coverage?

Coverage Does the plan cover the services you need?

Your other coverage

Do you have, or are you eligible for, other types of health or prescription drug coverage (like from a former or current employer or union)? If so, read the materials from your insurer or plan, or call them to find out how the coverage works with, or is affected by, Medicare. If you have coverage through a former or current employer or union or other source, talk to your benefits administrator, insurer, or plan before making any changes to your coverage. If you drop your coverage, you may not be able to get it back.

Cost

How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you pay out-of-pocket? Your costs vary and may be different if you don’t follow the coverage rules.

Doctor and hospital choice

Do your doctors and other health care providers accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?

Prescription drugs

Do you need to join a Medicare drug plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? How much will you have to pay for your prescription drugs under each plan? Are your drugs covered under the plan’s formulary? Are there any coverage rules that apply to your prescriptions? Is the pharmacy you use in the plan’s network?

Quality of care

Are you satisfied with your medical care? The quality of care and services given by plans and other health care providers can vary. Medicare has information to help you compare how well plans and providers work to give you the best care possible. See page 124.

Convenience

Where are the doctors’ offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records or prescribe electronically? Can you get an electronic copy of your information by email or to store in a personal health record? See page 125.

Travel Will you have coverage in another state or outside the U.S.?

74 Section 5—Get Information about Your Medicare Health Coverage Choices

How do Medicare Advantage Plans work? Health Maintenance Organization (HMO) Plan

Preferred Provider Organization (PPO) Plan

Can I get my health care from any doctor, other health care provider, or hospital?

No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

In most cases, yes. PPOs have network doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

Are prescription drugs covered?

In most cases, yes. Ask the plan. If you want Medicare drug coverage, you must join an HMO Plan that offers prescription drug coverage.

In most cases, yes. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?

In most cases, yes. No.

Do I have to get a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

In most cases, no.

What else do I need to know about this type of plan?

■ If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.

■ If you get health care outside the plan’s network, you may have to pay the full cost.

■ It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

■ PPO Plans aren’t the same as Original Medicare or Medigap.

■ Medicare PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

There may be several private companies that offer different types of Medicare Advantage Plans in your area. Each plan can vary. Read individual plan materials carefully to make sure you understand the plan’s rules. You may want to contact the plan to find out if the service you need is covered and how much it costs. Visit the Medicare Plan Finder at www.medicare.gov/find-a-plan, to find plans in your area. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

www.medicare.gov/find-a-plan

75Section 5—Get Information about Your Medicare Health Coverage Choices

Private Fee-for-Service (PFFS) Plan Special Needs Plan (SNP)

In some cases, yes. You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan’s terms, but you may pay more.

You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan (Part D) to get coverage.

Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

No. Generally, yes.

No. In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

■ PFFS Plans aren’t the same as Original Medicare or Medigap.

■ The plan decides how much you must pay for services. ■ Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before.

■ Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.

■ For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.

■ In an emergency, doctors, hospitals, and other providers must treat you.

■ A plan must limit membership to the following groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, ESRD, HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time if you’re eligible.

■ Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.

■ If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.

■ If you live in an institution, make sure that plan providers serve people where you live.

Day 2 – 2013 1

Case Study —Ty Juan On Ty Juan On calls you at the SHINE office. He has just become eligible for Medicare and received his card. He wants to know if he would need a referral from a primary care physician to access medical services when using Part A or B. Also, he heard that he needs to buy additional insurance - something called a Medicare Advantage Medigap plan. How would you help him?

Day 2 – 2013 2

Case Study —Travis Tee

Mr. Tee calls you at the SHINE office. He is 66 and retiring soon but does not plan to take Part B as his company will keep him on full insurance coverage for one year. A friend suggested he call the SHINE office to get information about Medicare. What questions would you ask Mr. Tee? What information would you give him?

Day 2 – 2013 3

Case Study— Mr. Tyme Leeness

Mr. Leeness comes to the SHINE office to get information on Medicare and Medicare HMO plans. He will be retiring in 3 months and wants to know when he can join a plan. He tells you that he spends 5 months of the year in Florida and the other 7 months in Massachusetts. How would you assist him?

Day 2 – 2013 4

Case Study - Jan Itor

Ms. Jan Itor calls you at the SHINE office. Her parents are moving to Massachusetts from Florida. They are enrolled in a Medicare Advantage plan in Florida. She wants to start the process of getting them insurance coverage in Massachusetts, but she knows nothing about Medicare or where to begin. How would you help her?

Day 2 – 2013 5

Medicare Advantage Quiz 1. Amanda is a 67 year old beneficiary enrolled in a Medicare Advantage plan. As a member of this plan Amanda has all the rights and protections guaranteed under Medicare.

___ True ____ False

2. When can a Medicare beneficiary join a Medicare Advantage plan? 3. Gordon has ESRD (End Stage Renal Disease) and belongs to an HMO through his employer. Gordon will be 65 next month and will retire from his employment. Gordon has been on Medicare for the past 7 months and wants to purchase a Medicare Advantage plan once he retires. Check all that apply. ____Gordon can purchase a Medicare Advantage plan if the employer HMO

offers a Medicare Advantage plan. ____Gordon cannot purchase a Medicare Advantage plan under any

circumstances because he has ESRD. ____Gordon can purchase any Medicare Advantage plan and all plans have to

accept him 4. Ms. King joined a Medicare Advantage plan 6 months ago when she first became eligible for Medicare. She wants to change to a new PCP (primary care physician) but learned he is not affiliated with her MA plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Annual Election Period to make a change. How would you assist her? 5. List the eligibility criteria to enroll in a Medicare Advantage plan.

Day 2 – 2013 6

Medical Insurance Explained for the HMO Systems Q. What does HMO stand for? A. This is actually a variation of the phrase, “HEY MOE” Its roots go back to a concept by Moe of the Three Stooges, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes. Q. I just joined a HMO. How difficult will it be to choose the doctor I want? A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. These doctors basically fall into two categories - those who are no longer accepting new patients and those who will see you, but are no longer participating in the plan. But don’t worry; the remaining doctor who is still in the plan, and accepting new patients, has an office just a half-day’s drive away. Q. Do all diagnostic procedures require pre-certification? A. No — only those you need. Q. Can I get coverage for my pre-existing conditions? A. Certainly, as long as they don’t require any treatment. Q. What happens if I want to try alternative forms of medicine? A. You’ll need to find alternative forms of payment. Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the Generic Medication, but it gave me a stomach ache. What should I do? A. Poke yourself in the eye. Q. What if I’m away from home and I get sick? A. You really shouldn’t do that.

Day 2 – 2013 7

Case Study - Ms. Heart Ms. Heart meets with you at the SHINE office. She has just retired from her job. She has Medicare A+B and wants to know what her options are for additional insurance over and above Medicare. She asks you to explain the differences between Medicare and a Medicare Advantage plan, and wants to know which is better. What would you tell her?

Day 2 – 2013 8

Case Study - Ms. Fran Chise Ms. Fran Chise meets with you at the SHINE office. She is 66 and has been retired for the past year. She did not sign up for Medicare Part B as her husband continued to work and she has been covered under his employer insurance plan. Her husband is retiring next month but the company will continue to provide full insurance coverage to both of them for six months after he stops working. Ms. Chise called Social Security to see when she must pick up Part B. Social Security told her she must pick up Part B immediately in order to avoid a penalty. Since she is covered in full for six months, she wanted to delay the Part B. What information would you give her?

Day 2 – 2013 9

Case Study - Mr. Will B. Gone Mr. Gone meets with you at the SHINE office to clarify questions about Medicare and other insurance. He will be turning 65 in a few months. He has a friend who belongs to a Medicare Advantage plan and is very pleased with the services he receives. Mr. Gone takes no medication and wants to enroll in the cheaper, non prescription plan. He doesn’t see why he should sign up for the prescription plan if he doesn’t take medication. Mr. Gone has already checked that his doctor participates, so he’s pretty well set on the plan. In discussing his upcoming retirement, Mr. Gone tells you of his plans to spend more time with family in Florida. What information would you give to Mr. Gone?

Day 2 – 2013 10

Case Study — Mr. Chad R. Boxx Mr. Boxx comes to see you at the SHINE office. He recently moved from another part of the state to live closer to his daughter. The Medicare Advantage plan he had is not available in his new location. He wants to know what his options are. How would you help him?

Day 2 – 2013 11

Case Study — - Mr. Sal Lowe Sal calls you to find out why a bill is not being paid by Medicare. He tells you that he became violently ill while traveling on a cruise ship to Greece and was treated by the ship’s doctor. He is surprised that the bill is not being paid since had a similar circumstance a few years earlier while on a cruise to Alaska. He explains that on the Alaska trip he had dinner on shore and became ill soon after returning to the ship. He was seen and treated by the ship’s doctor and the bill was paid. He doesn’t understand why Medicare is not covering this time. How would you help him?

Two Options for Supplementing Medicare

Original Medicare Part A & Part B

(must pay part B premium)

Medicare Advantage Plan Optional “Replacement”

Must maintain Part A and Part B and pay

monthly premium for Part B.

3 Types of Medicare Advantage Plans

HMO (Health Maintenance Organization)

May use network providers only

PPO (Preferred Provider Organization) Can go out of network for extra $$

SNP

(Special Needs Plans) HMOs for institutionalized individuals or

dual eligible

PFFS (Private Fee For Service)

Use only providers who accept plan

-Premiums range from $202 - $0/month -Covers some extra benefits -Usually need referrals to see specialists -May have co-pays and deductibles

Medigap Policy Covers “gaps” in Medicare

2 Different Types of Medigap Plans

Core

$96/mo* - covers most gaps

Supplement 1 $182/mo* - covers all gaps

- Free to choose any doctor or hospital - No referrals needed to see specialists - Does NOT include drug coverage

+ Prescription Drug Plan

Part D

(30 plans to choose from)

Prescription Advantage State Pharmacy Program (Optional)

Covers Part D Coverage Gap “Doughnut Hole” Supplements Part D Plan

FREE to Massachusetts seniors with moderate incomes

+

*Premium for least expensive Medigap program (sold by BCBS for Core and Fallon for Supplement 1). See Medigap Charts for other companies and premiums.

Day 2 What to Highlight and Handouts List1 Medicare Coverage Choices Excerpt from Medicare and You2013-medicare-and-you 552013-medicare-and-you 56

Medicare Advantage Types Excerpt from Medicare and you2013-medicare-and-you 742013-medicare-and-you 75

4 Medicare Rights Center - Questions to Ask Before Joining a MA plan3 - Day 2 Case Studies and QuizzesTwo Options for Supplementing Medicare