Norvax University Online Training: Medicare 101: Introduction to Medicare

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Agenda•Medicare Eligibility & Enrollment•Overview of Medicare Coverage

Options•Benefits & Cost of Original Medicare•Medicaid•Medicare Resources for

More Information

What is Medicare?• Medicare is a federal program which provides

health insurance benefits for people who meet one of 3 categories:– 65 or Older – Those with End Stage Renal Disease (ESRD)– Those under 65 with certain disabilities

• Administration– Centers for Medicare & Medicaid Services (CMS)– CMS is an agency within the Department of

Health and Human Services (HHS)

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What is Medicare?• The Social Security Act established both the

Medicare and Medicaid programs in 1965.• Original Medicare is a “fee-for-service” system,

where a Medicare beneficiary is charged a fee for each health care service/supply received.

• Beneficiaries can see any provider that is approved by the Medicare program.

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Four Parts of Medicare

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Part AHospital

Insurance

Part BMedical

Insurance

Part CMedicare

Advantage

Part DMedicare

Prescription Drug Coverage

Enrollment• Automatic for those receiving– Social Security benefits– Railroad Retirement Board benefits

• Initial Enrollment Period Package–Mailed 3 months before• 25th month of disability benefits • Age 65

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Enrolling in Medicare• Some people need to sign up

– Those not automatically enrolled• Enroll through Social Security

– Railroad Retirement Board for railroad retirees

• Apply 3 months before age 65– Do not have to be retired

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Enrollment Periods• Initial Enrollment Period (IEP)

– Begins 3 months prior to the month of turning age 65 and continues through the end of the third month after

• General Enrollment Period (GEP)– Allows individuals who did not enroll in Part B during the IEP to

enroll between January 1 – March 31 of each year for a July 1 effective date

• Special Enrollment Period (SEP)– Allows individuals who delayed enrolling in Part B because they were

receiving benefits through an employer as an active employee (or dependent of someone who is); SEP runs eight months from the time of retirement or loss of coverage

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Medicare Card• Keep it and accept Medicare Parts A and B• Return it and refuse Part B– Follow instructions on back of card

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FRONT BACK

Medicare Options

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Overview of Medicare Options• The choice of options to be considered are:– Premium Cost– Cost Sharing– Network Providers– Prescription Drug Coverage– Value-Added Benefits

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Original MedicareA&B

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Medicare Part A (Hospital Insurance)Premium• Most people receive Part A premium free– If you paid FICA taxes for at least 10 years

• If you paid FICA taxes less than 10 years– Can pay a premium to get Part A– 30 or more quarters - $248/month in 2012– Less than 30 quarters - $451/month in 2012

• May receive penalty if not bought when first eligible

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Medicare Part A Coverage• Inpatient Hospital Stays

– Semi-private room, meals, general nursing, and other hospital services and supplies

– Care in critical access hospitals and inpatient rehabilitation facilities– Inpatient mental health care in psychiatric hospital (lifetime 190-day

limit)– Generally covers all drugs provided during an inpatient stay received

as part of treatment• Skilled Nursing Facility Care

– Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies

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Medicare Part A Coverage• Home Health Care Services

– Can include part-time or intermittent skilled care– Physical therapy, speech-language pathology, continuing need for

occupational therapy– Some home health aide services, medical social services, medical

supplies• Hospice Care

– For terminally ill and includes drugs, medical care, and support services from a Medicare-approved hospice

• Blood– Received during inpatient care

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Part A Cost Sharing• Inpatient Hospitalization– Deductible for 2012: $1,156 (first 60 days)– Day 61-90: $289/day– After 90 days using lifetime reserve days (60 days):

$578/day– After lifetime reserve days are used: No Coverage

• Skilled Nursing Facility– First 20 days: No cost sharing– Day 21-100: $144.50/day– After 100 days: No Coverage

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Part A Cost Sharing• Home Health Care– $0 for Skilled HHC Services– 20% for Durable Medical Equipment (DME)

• Hospice Care– 5% for inpatient respite care– Room and board, in some cases– $5 for prescription drugs

• Blood– 100% first 3 pints– 20% for additional pints

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Monthly Part B PremiumYearly Income in 2010 You Pay

File Individual Tax Return File Joint Tax Return

$85,000 or below $170,000 or below $99.90

$85,001 - $107,000 $170,001 - $214,000 $139.90

$107,001 - $160,000 $214,001 - $320,000 $199.80

$160,001 - $214,000 $320,001 - $428,000 $259.70

Above $214,000 Above $428,000 $319.70

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Paying the Part B Premium• Deducted monthly from– Social Security– Railroad Retirement Benefit– Federal retirement payments

• If not deducted– Billed every 3 months– Medicare Easy Pay to deduct from bank account

• Contact SSA, RRB, or OPM about premiums

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Part B Late Enrollment Penalty• Penalty for not signing up when first eligible– 10% more for each 12-month period– May have penalty as long as you have Part B

• Sign up during a Special Enrollment Period (SEP)– Usually no penalty

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Part B & Employer or Union Coverage• May affect your Part B enrollment rights– You may want to delay enrolling in Part B if:

• You have employer or union coverage and• You or your spouse, or family member if you are disabled, is still

working

• See how your insurance works with Medicare– Contact your employer/union benefits administrator

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When Employer/Union Coverage Ends• When your employment ends– You may get a chance to elect COBRA– You may get a Special Enrollment Period• Sign up for Part B without

a 10% penalty

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Paying for Part B Services• In Original Medicare you pay– Yearly deductible of $140 in 2012– 20% coinsurance for most services

• Some programs may help pay these costs

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Medicare Part B Coverage• Doctors’ Services

– Medically necessary services (includes outpatient and some doctor services you receive when an inpatient) or covered preventive services

– Except for certain preventive services, you pay 20% of the Medicare-approved amount (if the doctor accepts assignment) and the Part B deductible applies

• Outpatient Medical & Surgical Services and Supplies– For approved procedures (like X-rays, a cast, or stitches)– You pay 20% of the Medicare-approved amount for the doctor’s

services (if the doctor accepts assignment)– You also pay a copayment for each service and the Part B deductible

applies

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Medicare Part B Coverage• Home Health Care Services

– Medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, occupational therapy

– Medically necessary part-time or intermittent home health aide services, medical social services, and medical supplies

– Durable medical equipment and an osteoporosis drug are also covered– You pay nothing for covered services

• Durable Medical Equipment– Items such as oxygen, equipment and supplies, wheelchairs, walkers,

and hospital beds for you in the home. Some items must be rented.– You pay 20% of the Medicare-approved amount and Part B deductible

applies

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Medicare Part B Coverage• Other Services (including but not limited to)– Medically necessary medical services and supplies, such

as:• Clinical laboratory services• Diabetes supplies• Kidney dialysis services and supplies• Mental health care• Limited outpatient prescription drugs• Diagnostic X-rays, MRIs, CT scans,

and EKGs• Transplants

– Costs vary

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Part B Covered Preventive Services• One-time “Welcome to Medicare” physical exam• Annual wellness visit after 12 mos. enrolled in Part B• Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1• Abdominal aortic aneurysm screening – one time, with referral• Bone mass measurement – every 24 months for certain conditions• Cardiovascular screening blood tests – every five years for all persons• Colorectal cancer screening – four different tests, vary in frequency• Diabetes screenings – up to two per year for those with risk factors• EKG screening – one time, with referral• Glaucoma testing – once per year for those at high risk• HIV screening• Mammogram – annual screening for most women• Pap test and pelvic exam – every 24 months• Prostate cancer screening – every 12 months for men over age 50• Smoking cessation counseling

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NOT Covered by Part A and Part B• Acupuncture• Dental care/dentures• Cosmetic surgery• Custodial care• Health care while traveling outside

the U.S.• Hearing aids• Orthopedic shoes• Outpatient prescription drugs (covered under Part D)• Routine foot care• Routine eye care and eyeglasses• Vaccines, except as previous listed (covered under Part D)

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What is Original Medicare?• Health care option run by the Federal government• Provides Part A and/or Part B coverage• See any doctor that accepts Medicare• Beneficiary pays:– Part B premium (Part A free for most people)– Deductibles, coinsurance or copayments

• Can join a Part D plan to add drug coverage• Can join a Medigap plan to pick up the “gaps”

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Assignment• Doctor, provider, or supplier accepts assignment

– Signed an agreement with Medicare– Or is required by law– Accept the Medicare-approved

amount• As full payment for covered

services• Only charge Medicare

deductible/coinsurance amount

• Most accept assignment– They submit your claim to Medicare directly

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Supplier and Assignment• Suppliers that don’t accept assignment–May charge you more• The limiting charge is

15% more• May have to pay entire

charge at time of service

• Providers sometimes must accept assignment–Medicare Part B-covered prescription drugs– Ambulance suppliers

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Medicaid

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Medicaid• Federal-state health insurance

program– For people with limited income

and resources– Certain people with disabilities

• Most costs covered for Medicare/Medicaid– Called “dual eligible”

• Eligibility determined by state• Application process and benefits vary• Office names vary

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Medicare Savings Programs• Help from Medicaid paying Medicare costs– For people with limited income and resources– Programs include• Qualified Medicare Beneficiary (QMB)• Specified Low-Income Medicare Beneficiary (SLMB)• Qualifying Individual (QI)• Qualified Disabled & Working

Individuals (QDWI)

• See state websites for moreinformation

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Medicare ResourcesResourcesCenters for Medicare & Medicaid Services (CMS)

1-800-MEDICARE(1-800-633-4227)(TTY 1-877-486-2048)www.medicare.govwww.CMS.gov

Social Security 1-800-772-1213(TTY 1-800-325-0778)www.socialsecurity.gov

Railroad Retirement Board 1-877-772-5772www.rrb.gov

State Health Insurance Assistance Programs (SHIPs)*

*For telephone numbers call CMSwww.medicare.gov

Affordable Care Act www.healthcare.gov/center/authorities/patient_protection_affordable_care_act_as_passed.pdf

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Upcoming Webinar• Medicare Advantage– September 6th 12:00pm CST

*Annual Election Period (AEP) is October 15th – December 7th

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Questions?

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