MEDICARE BENEFITS AND UPDATES FOR

2012

Senior Health Insurance Program800-548-9034

WHAT IS SHIP? Senior Health Insurance Program Established in 1988 Free Medicare Counseling Program Sponsored by the State of Illinois

Illinois Department of Insurance Does not sell or solicit insurance Dedicated to educating people with

Medicare SHIP trains volunteer counselors throughout

Illinois Provide one-on-one counseling

With Medicare Beneficiaries, family members and caregivers

Through community based sites

MEDICARE Medicare has four parts

Part A – Hospital Insurance

Part B – Medical Insurance

Part C – Medicare Advantage

HMO, PPO, PFFS, SNP, and MSA

Also know as Managed care

Part D – Prescription Drug Coverage

Medicare Supplement Insurance

Not to be confused with secondary insurance

Original Medicare

PART A – COVERED SERVICESInpatient Hospital Care

Skilled Nursing Facility Care

Home Health Care

Hospice Care

PART A COSTS FOR INPATIENT HOSPITAL STAYS

5

For each benefit period in 2012

You Pay

Days 1-60 $1,156 deductibleDays 61-90 $289 per dayDays 91-150 $578 per day (60

lifetime reserve days)All days after 150

All Costs

PART A COSTS FOR

SKILLED NURSING FACILITY CARE

For each benefit period in 2012

You Pay

Days 1-20 $0

Days 21-100 $144.50 per day

All days after 100 All Costs

PART B – COVERED SERVICES

Medical Expenses

Home Health Care

Outpatient Hospital Services

Durable Medical Equipment (DME)

2012 PART B AMOUNTS

Part B Annual Deductible - $140 Part B Monthly Premium

06

/22

/20

11

8

DR

AF

T M

ed

icare

Cu

rren

t To

pics

If your income is $85K or less and you paid this in

2011

You pay this in 2012

$96.40, $110.50, $115.40 $99.90

INCOME-RELATED PART B PREMIUM Part B premium income thresholds

Frozen at 2010 levels through 2019 06

/22

/20

11

9

DR

AF

T M

ed

icare

Cu

rren

t To

pics

If your Yearly Income in 2010 wasIn 2012

You Pay*

File Individual Tax Return

File Joint Tax Return

$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

*Higher if you have a late enrollment penalty

MEDICARE PART C Medicare Advantage (MA)

Provided through private insurance companies Offered through

HMO, PPO, PFFS, MSA an SNP

Must offer all services covered under Medicare Part A and Part B May be able to offer extra services

May include Drug Coverage No need to have a Supplement plan Must live in plans service area Must follow plans guidelines for coverage

MEDICARE PART D

Began in 2006 Offered by private companies contracted

with Medicare to provide prescription drug coverage

Available to anyone enrolled in MedicarePart A and/or Part B

Coverage offeredStand-alone Prescription Drug Plan (PDP)As part of a Medicare Advantage Plan (MA-PD)

MORE AFFORDABLE PRESCRIPTION DRUGS

Discounts for 2012 50% discount on brand-name drugs and 14%

discount on generic-drugs during the donut hole.

Elimination of the Donut Hole by 2020 Your cost-share should be approximately 25%

during the plan year.

COST SHARING FOR BRAND-NAME DRUGS IN THE MEDICARE PART D COVERAGE GAP,

2010-2020

COST SHARING FOR GENERIC DRUGS IN THE MEDICARE PART D COVERAGE GAP, 2010-

2020

SPECIAL PART D CO-PAY STRUCTURE

NEW FOR 2012 For dual eligibles receiving Home and

Community Based Waiver Services (HCBS) $0 co-pay for prescriptions Similar to co-pay structure for duals in a

nursing home Must keep dual eligible status

NEW

HOME AND COMMUNITY BASED WAIVER SERVICES

There are 9 HCBS programs in Illinois: Http://www.hfs.illinois.gov/hcbswaivers/

Includes DRS Home Services Program

Includes Department on Aging Community Care Program

HOME AND COMMUNITY BASED WAIVER SERVICES CONTINUED

HCBS “status” works like Medicaid dual eligible status

If you have HCBS enrollment in any month of the year, you get $0 Part D co-pays for the rest of the year

If you have HCBS enrollment in July or later, you get $0 co-pays for the following year

Must keep the dual eligible status Most people will have the waiver program

and be a dual eligible as waiver programs now count toward meeting spend-down

ENROLLMENT PERIODS Annual Open Enrollment Period

Oct. 15th – Dec. 7th, 2011Join, switch, or drop

Plan effective Jan. 1, 2012Dual eligibles have continuous enrollment

options throughout the year

Special Enrollment PeriodSpecial circumstance that allows you to

enroll outside the normal time frame

ANNUAL ENROLLMENT PERIOD EXTENDED

Elections may be made through December 10

AEP extended to advocates such as SHIP, MIPPA grantees, ADRCs, and the Aging Network

During enrollment use code AEP2012

MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP)

Begins Jan. 1 and end Feb. 14 each year May disenroll from Medicare Advantage Plan

(MA Plan) or from MA-Prescription Drug Plan (MA-PD) May NOT enroll into another MA plan during

MADP May return to Original Medicare May choose a Part D plan regardless if

moving from a MA-only or a MA-PD New plan choice effective the first day of the

following month

INITIAL ENROLLMENT PERIOD

Seven-month period when a beneficiary is entitled to enroll into Medicare Part A, B, D and/or C

Starts 3 months prior to eligibility month (3) Includes the month of eligibility (1) End 3 months after the eligibility month (3) Referred to as the 3 – 1 – 3 rule

SPECIAL ENROLLMENT PERIOD (SEP) FOR THOSE LOSING ‘CURRENT’ EGHP

SEP begins when beneficiary’s primary status in an Employer Group Health Plan ends Eight month period beginning with the first

month employment is no longer ‘Current’ Coverage in EGHP could be from a spouse

Enroll in Medicare Part B at this time to avoid late enrollment penalty

Avoid part D penalty by enrolling in a part D plan no later than 63 days after employment ends

MEDICARE GENERAL ENROLLMENT PERIOD

Begins Jan. 1 and ends March 31 of every year

May enroll into parts A and/or B Coverage effective date is July 1 of same

year For those who must pay premiums for

Medicare Part A This could include those who declined Part B

and now wish to enroll Penalties for late enrollment usually apply

MEDICARE PREVENTIVE SERVICES Implemented January 1, 2011

Elimination of Part B Deductible and Coinsurance

You pay nothing for most preventive services

When a doctor or health care provider accepts assignment

Example: Bone Mass Measurement

In 2010 you pay 20% after Part B deductible

In 2011 you pay no deductible or copay

PREVENTIVE SERVICE – COSTThe amount you pay varies and

depends on whether you get your Medicare benefits through Original Medicare (fee-for-service); or

Medicare Advantage Plan (HMO, PPO, etc)

Some services are completely free

MEDICARE PREVENTIVE SERVICES…..CONT.

Physical Exams“Welcome to Medicare” physical exam

A one-time exam available to new Medicare beneficiaries within first 12 months of Medicare Part B enrollment

Annual “Wellness” Exam Available to beneficiaries who’ve been

enrolled into Medicare Part B for more than 12 months

Medicare-covered Preventive Services

Abdominal Aortic Aneurysm (AAA) Screening

A one-time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your one-time "Welcome to Medicare" physical exam. Before January 1, 2011, you pay 20% of the Medicare-approved amount. Starting January 1, 2011, you pay nothing for the screening if the doctor accepts assignment.

Bone Mass Measurements

Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment

Cardiovascular Screening

Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the tests, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.

Flu Shots

Helps prevent influenza or flu virus. Generally covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor or other health care provider accepts assignment for giving the shot. Note: Medicare Part B also covers administration of the H1N1 flu shot. You pay nothing if your doctor accepts assignment for giving the shot.

Glaucoma Test

Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you also pay the hospital a copayment

Medicare-covered Preventive Services

Hepatitis B Shots

This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. Starting January 1, 2011, you pay nothing for the shot if the doctor accepts assignment.

HIV Screening

Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. You pay nothing for the test, but you generally have to pay the doctor 20% of the Medicare approved amount for the doctor’s visit.

Breast Cancer Screening (Mammograms)

Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39. January 1, 2011, you pay nothing for the test if the doctor accepts assignment.

Medicare Nutrition Medical Therapy Service

Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for the test if the doctor accepts assignment

Pap Test & Pelvic Exams (includes clinical breast exams)

Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. Starting January 1, 2011, you pay nothing for Pap test specimen collection, and pelvic and breast exams if the doctor accepts assignment.

Medicare-covered Preventive Services

Pneumococcal Shot

Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.

Prostate Cancer Screening

Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50 (coverage for this test begins the day after your 50th birthday). You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor's visit. You pay nothing for the PSA test. In a hospital outpatient setting, you also pay the hospital a copayment.

Smoking Cessation

Includes up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.

Note: Medicare coverage of smoking cessation counseling is now considered a covered preventive service if you haven’t been diagnosed with an illness caused or complicated by tobacco use. Starting January 1, 2011, you pay nothing for the counseling sessions.

Diabetes Screening

These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Test may also cover if you have two or more of the following ; Are you age 65 or older, or are you overweight, or have a family history of diabetes (parents, siblings), or have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds. Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.

Medicare-covered Preventive Services

Colon Cancer Screening (Colorectal)

Colorectal cancer is usually found in people age 50 or older, and the risk of getting it increases with age. Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer. Treatment works best when colorectal cancer is found early.One or more of the following tests may be covered.

Fecal Occult Blood Test — Once every 12 months if 50 or older. You pay nothing for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.

Flexible Sigmoidoscopy — Generally, once every 48 months if 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment.

Colonoscopy — Generally, you can get this procedure once every 120 months, or 48 months after a previous flexible sigmoidoscopy. If your doctor says you’re at high risk, you can get it every 24 months. There’s no minimum age required for you to get a colonoscopy. Starting January 1, 2011, you’ll pay nothing for the procedure if your doctor accepts assignments.

Barium Enema — Once every 48 months if 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare approved amount for the doctor’s services. In a hospital outpatient setting, you also pay the hospital a copayment.

MEDICARE PRESCRIPTION DRUG COVERAGE PREMIUM

Higher income individuals pay a higher Part D premium Uses same thresholds used to compute income-

related adjustments to the Part B premium As reported on your IRS tax return from 2 years ago

Must pay if you have Part D coverage

06

/22

/20

11

31

DR

AF

T M

ed

icare

Cu

rren

t To

pics

ACA

INCOME-RELATED ADJUSTMENT TO PART D PREMIUM

06

/22

/20

11

32

DR

AF

T M

ed

icare

Cu

rren

t To

pics

If your Yearly Income in 2010 was

In 2012 You Pay

File Individual Tax Return

File Joint Tax Return

$85,000 or below $170,000 or below Base Premium (BP)

$85,000.01 – $107,000 $170,000.01 – $214,000

BP + $11.60

$107,000.01 – $160,000

$214,000.01 – $320,000

BP + $29.90

$160,000.01 – $214,000

$320,000.01 – $428,000

BP + $48.10

$214,000.01 or higher $428,000.01 or higher BP + $66.40

ACA

USE MEDICARE.GOV FOR RESOURCES

Top 7 Services on Medicare.gov Find out what Medicare costs in 2012 Find health and drug plan, compare and enroll! Apply on-line for Medicare now Find out if Medicare covers your tests, items,

services Get Extra Help with prescription drug costs Find out how Medicare works with your other

insurance Get a new Medicare card Link to MyMedicare.gov

RESOURCE AND PUBLICATION SHIP

Medicare Supplement Premium Comparison Guide 800-548-9034 www.insurance.illinois.gov

Medicare Medicare & You 2012 handbook 1-800-633-4227 www.medicare.gov www.mymedicare.gov TTY 1-877-486-2048

Social Security Administration “Extra Help” application 800-772-1213 www.ssa.gov

Dept on Aging - (Illinois Cares Rx) 800-252-8966 www.cbrx.il.gov