Medicare 101

First TN Area Agency on Aging & DisabilityLorrie WilsonDaris Morgan

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Medicare 101

Introduction to Medicare Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs

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What Is Medicare?

A health insurance program forPeople 65 years of age and olderPeople under age 65 with certain disabilitiesPeople with End-Stage Renal Disease (ESRD)

Administered by Centers for Medicare & Medicaid Services (CMS)

Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB)

Introduction

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Applying for Medicare

Apply 3 months before age 65Don’t have to be retiredContact the Social Security Administration

Enrollment automatic if receiving Social Security or Railroad Retirement benefits

Introduction

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Medicare

Medicare Basics

Part AHospital Insurance

Part BMedical Insurance

Prescription Drug Coverage (Part D)

Introduction

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Medicare Coverage Basics

Part A

Inpatient hospital care Skilled nursing care Home health care Hospice care

Part B

Doctors’ services and outpatient care Preventive services Diagnostic tests Some therapies Durable medical equipment

Part D Outpatient prescription drugs

Introduction

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Medicare Part A

Most people receive Part A premium free People with less than 10 years of Medicare-

covered employmentCan still get Part A

• Will pay a premium

For information about Part A entitlementCall SSA

• 1-800-772-1213• TTY users call 1-800-325-0778

Introduction

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Enrolling in Medicare Part B Pay monthly Part B premium

$96.40 in 2008 Initial Enrollment Period (IEP)

7 months starting 3 months before month of eligibility

General Enrollment Period (GEP)January 1 through March 31 each yearCoverage effective July 1Premium penalty

• 10% for each 12-month period eligible but not enrolled• Paid for as long as the person has Part B• Limited exceptions

Introduction

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Enrolling in Medicare Part B

Some people can delay enrolling in Part B with no penaltyIf covered under employer or union group

health plan• Based on current employment

– Person or spouse

• Will get a Special Enrollment Period (SEP)– Sign up within 8 months after coverage ends

Introduction

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Part B Enrollment PeriodsExample

Marie turned 65 on June 25, 2007. She will have group health coverage from her employer until she stops working on December 31, 2007.

Part B enrollment opportunities …

Enrollment period Begins Ends

IEP 3/1/07 9/30/07

SEP 10/1/07 8/31/08

GEP (each year) 1/1 3/31

Introduction

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Paying the Part B Premium

Taken out of monthly paymentsSocial SecurityRailroad retirementFederal government retirement

For information about premiumsCall SSA, RRB, or Office of Personnel Management

If no monthly paymentsBilled every 3 monthsMedicare Easy Pay

Introduction

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Medicare Choices

Original Medicare PlanMedicare Advantage PlansOther Medicare PlansMedicare Prescription Drug Plans

Introduction

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Original Medicare Plan Go to any health care provider that accepts

Medicare People are responsible for

Part A• $1,024 deductible in 2008 for hospital stays up to 60

days– Additional costs after 60 days

• Different costs for other Part A servicesPart B

• $135 annual deductible in 2008• 20% coinsurance or copayment for most Part B

services Some programs may help with costs

Original Medicare

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The Medicare Card

Jane Doe

Original Medicare

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Medigap

Health insurance policySold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in the Original Medicare Plan

• Deductibles, coinsurance, copayments• Does not work with Medicare Advantage Plans

Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin• So people can compare easily

Medigap

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How Medigap WorksPeople can buy a Medigap policy

Within 6 months of enrolling in Part B• Must be age 65 or older

If they lose certain kinds of health coverage• Through no fault of their own

If they leave MA Plan under certain circumstancesWhenever the company will sell them one

Monthly premiumGenerally go to any doctor or specialist

Medigap

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Medicare Advantage Plans

Health Maintenance Organization (HMO) PlansSome have Point-of-Service option

Preferred Provider Organization (PPO) PlansRegional PPOs new in 2006

Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans

New in 2007

Medicare Advantage and Other Medicare Plans

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Other Medicare Plans

Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the

Elderly (PACE)

Medicare Advantage and Other Medicare Plans

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Eligibility for MA Plans

Live in plan’s service areaEntitled to Medicare Part AEnrolled in Medicare Part B

Continue to pay Part B premiumMay also pay monthly premium to plan

Don’t have ESRD at enrollmentSome exceptions

Medicare Advantage and Other Medicare Plans

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How MA Plans Work

Usually get all Part A and B services through planMay have to use providers in plan’s networkGenerally must still pay Part B premium

• Some plans may pay all or part May get extra benefits

Vision, hearing, dental servicesPrescription drug coverage

Still in Medicare programGet all Part A and Part B servicesHave Medicare rights and protections

Medicare Advantage and Other Medicare Plans

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Medicare Prescription Drug Coverage

Coverage began January 1, 2006Available to all people with Medicare Provided through

Medicare Prescription Drug PlansMedicare Advantage and other Medicare plansSome employers and unions

Medicare Drug Coverage

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Enrollment Periods

Initial Enrollment Period (IEP)7 monthsStarts 3 months before month of eligibility

Annual Coordinated Election Period (AEP)November 15 through December 31 each yearCan join, drop, or switch coverage

• Effective January 1 of following year

Special Enrollment Period (SEP)

Medicare Drug Coverage

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Late Enrollment

People who wait to enroll may pay penaltyAdditional 1% of national base premium for

every month eligible but not enrolledMust pay the penalty as long as enrolled in a

Medicare drug planUnless they have other coverage at least

as good as Medicare drug coverage“Creditable coverage”

Medicare Drug Coverage

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Prescription Drug Plans

At a minimum, must offer standard benefitIn 2008 members may pay

• Monthly premiums• Annual deductible, no more than $275• Copayments or coinsurance• Very little after $4,050 out-of-pocket

May offer supplemental benefits Plan information and costs available

www.medicare.gov1-800-MEDICARE (1-800-633-4227)

Medicare Drug Coverage

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Extra Help With Drug Costs

Available for many people with limited income and resourcesIncome limit in 2007

• $1,276/month individual)• $1,711/month (married couple)

Resource limit• $11,710 (individual)• $23,410 (married couple)

Medicare Drug Coverage

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Extra Help With Drug Costs

People with lowest income and resourcesPay no premiums or deductiblesHave small or no copayments

Those with slightly higher income and resourcesPay no or a reduced premiumHave a reduced deductiblePay a little more out of pocket

Medicare Drug Coverage

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Eligibility for Extra Help

Some people may automatically qualifyPeople with Medicare who

• Get full Medicaid benefits• Get Supplemental Security Income (SSI)• Get help from Medicaid paying Medicare premiums

Others must apply and qualify

Medicare Drug Coverage

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Medicaid

Joint Federal and state programFor some people with limited income and resources

If eligible, most health care costs covered Eligibility determined by state Application processes vary Office names vary

Social ServicesPublic AssistanceHuman Services

Medicaid and Medicare Savings Programs

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Other Savings Programs

Medicare Savings ProgramsHelp from Medicaid paying Medicare expensesFor people with limited income and resourcesMay also pay deductibles and coinsurance

State-specific programsPACE

Medicaid and Medicare Savings Programs

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For More Information

1-800-MEDICARE (1-800-633-4227)TTY users call 1-877-486-2048

www.medicare.gov www.cms.hhs.gov State Health Insurance Assistance

Program (SHIP) Medicare & You handbook

Other publications

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Summary

Medicare coverage Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid and Medicare Savings Programs

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