medicare education by ray mcpherson
TRANSCRIPT
Medicare 101…a bare bones look
Inpatient Hospital Ins.
Outpatient Medical Ins.
Part A
Part B
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
Part A
Part B
Most oftenincluded
Part DRx – Prescription Drugs[Stand Alone Plans]
Part D
Medi-Gaps
Medicare ADVANTAGE
Original MedicareFederal Gov’t
2 Ways To Get Medicare
10 Letter Plans in Washington
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
GAPS
GAPS
Part C
Medicare… in more detail.
Inpatient Hospital Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Part A
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
Medicare ADVANTAGE
Part C
Outpatient Medical Ins.
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part B
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
Inpatient Hospital Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Part A
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
Inpatient Hospital Ins.
Outpatient Medical Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part A
Part B
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
[Monthly Changeable][Network: Any provider that accepts Medicare]Medi-Gaps
10 Letter Plans in Washington
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
NF
100%
$179-$188100%
K
50%
$57$4940 MOOP
$128Pt. B $147
Doc/$20 - ER/$50
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
Inpatient Hospital Ins.
Outpatient Medical Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part A
Part B
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
G$158
Pt. B $147
[Monthly Changeable][Network: Any provider that accepts Medicare]Medi-Gaps
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
Rx – Prescription Drugs[Stand Alone Plans]
Part D
1% Penalty
Avg. $33.13/ mo.
Formulary – Rx ListTiers 1 -5
Inpatient Hospital Ins.
Outpatient Medical Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
NF
100%
$188/mo.100%
K
50%
$57-mo.$4940 MOOP
$128/mo.Pt. B $147
Doc/$20 - ER/$50
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part A
Part B
A
BGAPS
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
G$158/mo.Pt. B $147
[Monthly Changeable][Network: Any provider that accepts Medicare]Medi-Gaps
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
Rx – Prescription Drugs[Stand Alone Plans]
Part D
1% Penalty
Avg. $33.13/ mo.
1. Formulary - a list of prescription drugs covered by a Plan.2. Tier level determines what your copay will be for a given drug. Higher tier = higher
cost3. 90-Day Supply4. Step Therapy – Some drugs require you to try another drug first.5. Exceptions6. Network Pharmacies – unless emergency7. Low Income Subsidy
Stage 1.Yearly Deductible
You Pay 100%
$0 to $320
Stage 3.Coverage Gap – “Donut Hole”
Brand-name
Stage 2.Initial Benefit
Period Copays
Insurance PaysBalance
You Pay Copays
ManufacturerProvides
50%discount
Insurance Pays 5%
You Pay45%
Of Drug Value
You Pay65%
Of Drug Value
Insurance Pays35%
Of Drug Value
Generic
Stage 4.Catastrophic Coverage
You pay Greater of | 5% or $2.65 generic / $6.60 Brand
Medicare Pays80%
Of Drug Value
Insurance Pays15% of Drug Value
TrOOP When YOU have paid $4700 (including Mfg. 50% disc.) then…
In 2015, when in Stage 3 Coverage Gap, 95 percent of the full price of a brand name and 65 percent of the full price of a generic goes toward True Out of Pocket expense (TrOOP). Once this amount reaches $4700, then Stage 4 – Catastrophic coverage is reached.
(Monthly Premiums are in addition to cost shown below.)Part D – Standard Benefit, what you pay for drugs.
When You + Insurance Pays = $2960
Inpatient Hospital Ins.
Outpatient Medical Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
NF
100%
$188/mo.100%
K
50%
$57-mo.$4940 MOOP
$128/mo.Pt. B $147
Doc/$20 - ER/$50
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part A
Part B
$104.90/mo.
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
G$158/mo.Pt. B $147
Part A
Part B
Most oftenincluded
Part DRx – Prescription Drugs[Stand Alone Plans]
Part D
1% Penalty
Avg. $33.13/ mo.
Formulary – Rx ListTiers 1 -5
[Monthly Changeable][Network: Any provider that accepts Medicare]Medi-Gaps
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Inpatient Hospital Ins.
Outpatient Medical Ins.
Prem: $104.90/mo.
HMO – Get your care in NetworkYou choose your doctorLow to No Monthly PremiumsCopays more predictable
PCP copaysSpecialist copaysOutpatient Surgery
Worldwide Emergency Care Additional Benefits
- Dental- Vision- Health Club
1. Review maximum cost exposureAccumulation of copays
2. Review Recurring CostsDoctor VisitsLab VisitsPhysical Therapy RX CostsMonthly Premium
3. Trial Right
Formulary – Rx ListTiers 1 -5
Part A
Part B
$104.90/mo.
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
Part A
Part B
Most oftenincluded
Part DRx – Prescription Drugs[Stand Alone Plans]
Part D
Medi-Gaps
ELIGIBILITYPart A & BESRD6 months in service area
Election PeriodsAEP: Oct 15 – Dec 7MADP: Jan 1 – Feb 14SEP: common examples Leave employer coverage Moving out of area LIS
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C
Inpatient Hospital Ins.
Outpatient Medical Ins.
Ded. $1260/Stay (Benefit Period Day 1-60)
Prem: $104.90/mo.Ded: $147/yr.Co-Ins. You – 20% & Medicare – 80%
NF
100%
HMO – Get your care in NetworkYou choose your doctorLow to No Monthly PremiumsCopays more predictable
PCP copaysSpecialist copaysOutpatient Surgery
Worldwide Emergency Care Additional Benefits
- Dental- Vision- Health Club
1. Review maximum cost exposureAccumulation of copays
2. Review Recurring CostsDoctor VisitsLab VisitsPhysical Therapy RX CostsMonthly Premium
3. Trial Right
Formulary – Rx ListTiers 1 -5
$188/mo.100%
K
50%
$57-mo.$4940 MOOP
$128/mo.Pt. B $147
Doc/$20 - ER/$50
[Doctor, Outpatient Surgery, Ambulance, etc.]
Part A
Part B
$104.90/mo.
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
BGAPS
[Hospital, Hospice, Homecare, Skilled Nursing, etc.]
G$158/mo.Pt. B $147
Part A
Part B
Most oftenincluded
Part DRx – Prescription Drugs[Stand Alone Plans]
Part D
1% Penalty
Avg. $33.13/ mo.
Formulary – Rx ListTiers 1 -5
[Monthly Changeable][Network: Any provider that accepts Medicare]Medi-Gaps
Original MedicareFederal Gov’t
2 Ways To Get Medicare
Medicare ADVANTAGE
Part C