MedicareThe Basics

CMS: Who Are We More than 100 million Americans receive

care that is financed through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP)

Focused on transforming the U.S. health care system through ◦ Better care that is seamless and coordinated◦ Improved health of the population◦ Reduced rates of growth in health care spending

through improvement.

CMS: Who are we 10 Regional Offices

◦ Audit State and Contractor Operations◦ Coordinate Outreach Activities

Central site in Baltimore, MD◦ Writes regulations and guidance◦ Coordinates national strategies for program

implementation◦ Oversees “Centers” responsible for key policy and

operational areas

Getting Started 4

Health insurance for three groups of people◦ 65 and older◦ Under 65 with certain disabilities◦ Any age with End-Stage Renal Disease (ESRD)

Administration◦ Centers for Medicare & Medicaid Services (CMS)

Enrollment ◦ Social Security Administration (SSA) for most◦ Railroad Retirement Board (RRB) railroad

retirees

What is Medicare?

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Getting Started 5

Part AHospital

Insurance

Part B Medical

Insurance

Part C Medicare

Advantage (like HMOs and PPOs)

Part D Medicare

Prescription Drug

Coverage

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The Four Parts of Medicare

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Has Part A – Hospital Insurance◦ Hospital◦ Skilled Nursing Facility◦ Home health care◦ Hospice care

Has Part B – Medical Insurance◦ Doctor’s visits◦ Outpatient hospital services◦ Clinical lab tests◦ Preventive services

Original Medicare

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Getting Started 7

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

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Medicare Card

Jane Doe

Keep it and accept Medicare Parts A and B

Return it to refuse Part B– Follow instructions on back of card

Front Back

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Getting Started 9

Enrollment is not automatic◦ If you don’t get Social Security or RRB benefits◦ For instance, you are still actively working

Enroll with Social Security◦ Visit local office◦ Call 1-800-772-1213◦ Online at socialsecurity.gov

If retired from Railroad enroll with RRB◦ Call your local RRB office or 1‑877‑772‑5772

How to Enroll in Medicare

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Getting Started 10

You don’t have to be retired Your initial enrollment period lasts 7 months

◦ Begins three months before your 65th birthday ◦ Includes the month you turn 65◦ Ends three months after you turn 65

There are other times you may enroll◦ But you may pay a penalty if you delay enrolling

When to Enroll in Medicare

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Consider◦ Get it automatically if getting Social Security/RRB◦ Free for most people◦ Can pay if work history is not sufficient

There may be a penalty if you delay◦ If you/your spouse is actively working and

covered by employer plan Contact Social Security to sign up

Decision Should I keep/sign up for Part A?

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Yes

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Consider◦ Automatic if getting Social Security/RRB benefits◦ Most people pay a monthly premium

Usually deducted from SS/RRB benefits Amount depends on income (see Attachment C)

◦ It may supplement employer coverage

Decision Should I keep/sign up for Part B?

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Getting Started 13

Sometimes you must have Part B◦ If you want to buy a Medigap policy◦ If you want to join a Medicare Advantage Plan◦ If you are eligible for TRICARE◦ If your employer coverage requires you have it

Talk to your employer’s benefits administrator With Veterans benefits it’s optional

◦ But you pay a penalty if you sign up late If you don’t sign up during your initial enrollment period

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Decision Should I keep/sign up for Part B?

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If you don’t have coverage from active employment◦ Yours or your spouses◦ Delaying Part B may mean

Higher premiums Paying for your health care out-of-pocket

If you do have coverage through active employment◦ You may want to delay Part B ◦ No penalty if you enroll while you have coverage

or within 8 months of losing coverage

Decision Should I keep/sign up for Part B?

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Maybe Not

Probably

Getting Started 15

Policies sold by private companies Fill the gaps in Original Medicare

◦ Deductibles, coinsurance, copayments Standardized plans in all but three states

◦ Minnesota, Massachusetts, Wisconsin All plans of same letter have same coverage

◦ Only costs are different

What is Medigap?

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Getting Started 16

Consider◦ Do you have Original Medicare?

Medigap doesn’t work with Medicare Advantage◦ Do you have other coverage that supplements

Medicare? You might not need Medigap

◦ Can you afford Medicare deductibles and copayments?

◦ How much will the monthly Medigap premium cost?

DecisionDo I need a Medigap policy?

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Maybe

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Medigap BenefitsMedigap Plans

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

Part A Coinsurance

Up to 365 Days

Part B Coinsurance

Blood

Hospice Care Coinsurance

Skilled Nursing Coinsurance

50% 75%

Part A Deductible 50% 75% 50%

Part B Deductible

Part B Excess Charges

Foreign Travel Emergency (Up to Plan Limits)

*Plan F has a high-deductible option ** Plans K and L have out-of-pocket limits of $4,640 and $2,320 respectively

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By phone or computer◦ Call 1 800 MEDICARE◦ Visit medicare.gov and use the compare tool◦ Call your SHIP◦ The process

Choose standardized plan, like a Plan C, for example Compare costs of all Plan C policies

The coverage is the same – the costs may be different

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DecisionHow do I find the right Medigap policy for me?

Getting Started 19

Health plan options approved by Medicare Run by private companies Medicare pays amount for each member’s

care Another way to get Medicare coverage Part of the Medicare program May have to use network doctors or hospitals

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Part C – Medicare Advantage

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During 7 month initial enrollment period Can join during annual fall open enrollment

◦ October 15 – December 7 each year◦ Coverage begins January 1

May be able to join during other special times

Contact the plan to join◦ Call their number◦ Visit their website◦ Plan information is available on

www.medicare.gov

When can I enroll in a MA plan?

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Getting Started 21

Still in Medicare with all rights and protections

Still get Part A and Part B services Plan may include prescription drug

coverage May include extra benefits like vision or

dental Benefits and cost-sharing may be

different

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How Medicare Advantage Works

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Consider◦ Most offer comprehensive coverage

Including Part D drug coverage◦ May require you to use a network ◦ You must pay monthly premium to plan

Still must pay Part B premium◦ May need a referral to see a specialist◦ Can only join/leave plan during certain periods◦ Doesn’t work with Medigap policies◦ Must have Part A and Part B to join

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DecisionDo I want to join a Medicare Advantage Plan?

Getting Started 23

See Appendix C for costs ◦ In Original Medicare (Part A and Part B)

Make sure your doctor accepts “assignment” ◦ In Medicare Advantage

Check with plan◦ In Medicare Prescription Drug Plans

Check with plan Costs change yearly

◦ Updates are in Medicare & You handbook Mailed every fall

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What Do I Pay?

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Available for all people with Medicare Provided through

◦ Medicare Prescription Drug Plans◦ Medicare Advantage Plans◦ Other Medicare plans

Must include range of drugs in each category

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Part D – Medicare Prescription Drug Coverage

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You must have Medicare Part A and/or Part B You must live in the plan’s service area You can’t live outside the U.S. You can’t be incarcerated You must enroll in a Medicare Part D plan

◦ In most cases no automatic enrollment◦ You must fill out an application

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Who Can Join Part D?

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Can join during 7 month initial enrollment period

Can join during annual fall open enrollment◦ October 15 – December 7 ◦ Coverage starts January 1

Can join during other special times Contact plan to join

◦ Call◦ Visit website

Joining a Part D Plan

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Getting Started 27

Consider◦ Do you have creditable drug coverage?

Coverage as good as Medicare’s For example through an employer plan

◦ Will that coverage end when you retire?◦ What is the cost of drugs you currently take?◦ What is the cost of premiums for Part D plans?◦ You may pay a penalty if you don’t take Part D

when first eligible Unless you have creditable coverage

DecisionShould I enroll in a Part D plan?

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Call or by computer◦ 1-800-MEDICARE◦ Plan Finder Tool at www.medicare.gov◦ Call SHIP for help comparing plans

To join a Part D Plan◦ Complete a paper application◦ Call the plan◦ Enroll on the plan’s Web site ◦ Enroll on www.medicare.gov ◦ Call 1-800-MEDICARE (1-800-633-4227)

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DecisionHow do I choose a Part D plan?

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Medicaid Extra Help Medicare Savings Programs

What help is there for people with limited income and resources?

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Federal-state health insurance program◦ For people with limited income and resources◦ Certain people with disabilities

Most costs covered for Medicare/Medicaid◦ Called “dually eligible”

Eligibility determined by state Application processes and benefits vary State office names vary Apply if you MIGHT qualify

What is Medicaid?

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Help paying prescription drug costs Social Security or state makes

determination Some groups automatically qualify

◦ People with Medicare and Medicaid◦ Supplemental Security Income (SSI) only◦ Medicare Savings Programs

You or someone on your behalf can apply

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What is Extra Help?

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Help from Medicaid paying Medicare costs◦ Pay Medicare premiums◦ May pay Medicare deductibles and coinsurance

Often higher income/resource guidelines Income amounts change each year Some states offer their own programs

What are Medicare Savings Programs?

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Getting Started 33

Apply if you MIGHT qualify Your SHIP can help you

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DecisionShould I apply for these programs?

Yes

Getting Started 34

Medicare is a health insurance program It does not cover all health care costs for

enrollees There are other ways to get coverage within

the program Important

◦ Make the right decisions◦ Make them at the right times◦ Get help if you need it

Key Points to Remember

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Getting Started 35

Focus on Prevention, Improved Quality, Improved Access to Care, and Reducing Waste◦ Elimination of Co-Insurance and Deductibles for

most preventive tests◦ Partnership for Patients, Center for Medicare and

Medicaid Innovation◦ New coverage options for the uninsured◦ Increased criminal penalties for fraud, increased

resources to combat it◦ Effort to make Medicare Advantage (Part C) more

cost effective and competitive

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The Affordable Care Act

Improving Quality and Care Coordination Why?

◦ 2,000 deaths/year from unnecessary surgery◦ 7000 deaths/year from medication errors in

hospitals Medication errors are among the most common,

harming at least 1.5 million people, costing $3.5 billion

◦ 20,000 deaths/year from other errors in hospitals ◦ 80,000 deaths/year from infections in hospitals◦ 13% of Hospital Readmissions are avoidable

Cost $45 Billion/year

Coverage for the Uninsured with Pre-Existing Conditions Early Retiree Reinsurance Program

◦ Provides financial relief for employers so retirees can get quality, affordable insurance

Pre-Existing Condition Plans Provide Access to coverage for those who cannot afford it◦ A plan is in each state. Information can be found

on www.pcip.gov◦ The New York Plan is called the NY Bridge Plan.

Its website is www.nybridgeplan.com

Resources You Should Know

www.healthcare.gov◦ Tool that can help the uninsured determine what

coverage they may be eligible for◦ Detailed Information on the Affordable Care Act

Resources you should knowEPIC – New York’s Prescription Plan for

Seniors Supplements Part D 1-800-332-3742

HIICAP Program Provides Health Insurance Counseling to Medicare Beneficiaries

1-800-701-0501

Resources you should knowGeneral Medicare Questions and Complaints:1-800-MEDICARE

Coordination of Benefits Issues1-800-999-1118

Community Health Advocates888-614-5400

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Medicare & You Handbook National Medicare Training Program

◦ cms.hhs.gov/NationalMedicareTrainingProgram

More Information

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