Medicare Medicare Benefit Benefit ReviewReview

What is Medicare? What is Medicare?

Medicare is Health Insurance Medicare is Health Insurance For people 65 or olderFor people 65 or olderFor people under 65 with certain disabilitiesFor people under 65 with certain disabilitiesFor people at any age with EndFor people at any age with End--Stage Renal Stage Renal Disease (permanent kidney failure requiring Disease (permanent kidney failure requiring dialysis or a kidney transplant)dialysis or a kidney transplant)

Medicare Has Different PartsMedicare Has Different Parts

Medicare Part AMedicare Part A –– Hospital InsuranceHospital Insurance

Medicare Part BMedicare Part B –– Medical InsuranceMedical Insurance

Medicare Part CMedicare Part C –– Medicare Advantage PlansMedicare Advantage Plans

Medicare Part DMedicare Part D –– Prescription Drug CoveragePrescription Drug Coverage

Medicare Part A Medicare Part A (Hospital Insurance)(Hospital Insurance)

Medicare Part A covers partially or totally:Medicare Part A covers partially or totally:Inpatient care in hospitals (partially)Inpatient care in hospitals (partially)Skilled nursing facility (partially)Skilled nursing facility (partially)Hospice (totally)Hospice (totally)Home Health Care (totally)Home Health Care (totally)

Medicare Part BMedicare Part B (Medical Insurance)(Medical Insurance)

Helps cover medicallyHelps cover medically--necessary servicesnecessary servicesDoctorDoctor’’s servicess servicesOutpatient careOutpatient careSome preventive services to help maintain health and Some preventive services to help maintain health and to keep certain illnesses from getting worseto keep certain illnesses from getting worse

Medicare Part C Medicare Part C –– Advantage PlansAdvantage Plans

Another way to have Medicare benefitsAnother way to have Medicare benefitsCombines Medicare Part A & B & sometimes Part D Combines Medicare Part A & B & sometimes Part D coveragecoverageMedicare Advantage Plans are managed by private Medicare Advantage Plans are managed by private insurance companies approved by Medicareinsurance companies approved by MedicareThe plans must cover medicallyThe plans must cover medically--necessary services but necessary services but may charge different comay charge different co--payments, coinsurance or payments, coinsurance or deductibles for these servicesdeductibles for these services

Medicare Part DMedicare Part D –– Prescription DrugsPrescription DrugsHelps cover Helps cover prescription drugs. prescription drugs. May help lower May help lower prescription costs and prescription costs and help protect against help protect against higher costs in the higher costs in the futurefuture

MedicareMedicare’’s Covered Servicess Covered Services

MedicareMedicare’’s Part A Covered Servicess Part A Covered ServicesHospital StaysHospital Stays

Covers a semiCovers a semi--private room, meals, general nursing, private room, meals, general nursing, drugs as a part of inpatient treatment, procedures, drugs as a part of inpatient treatment, procedures, surgery, other hospital services and supplies. surgery, other hospital services and supplies. Inpatient mental health care in a psychiatric hospital is Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.limited to 190 days in a lifetime.

Blood Blood -- starting with the 4starting with the 4thth pint (the first 3 pints arenpint (the first 3 pints aren’’t t covered)covered)

MedicareMedicare’’s Part A Covered Services, s Part A Covered Services, cont.cont.

Skilled Nursing FacilitySkilled Nursing Facility (SNF) (SNF) After a 3After a 3--day minimum inpatient hospital stay for a day minimum inpatient hospital stay for a related illness or injuryrelated illness or injuryCovers a semiCovers a semi--private room, meals, skilled nursing and private room, meals, skilled nursing and rehabilitative services, and other services and supplies rehabilitative services, and other services and supplies Care in a SNF requires skilled care like intravenous Care in a SNF requires skilled care like intravenous injections or physical therapy. injections or physical therapy. Medicare Medicare does notdoes not cover longcover long--term care or custodial term care or custodial

care in a SNFcare in a SNF

MedicareMedicare’’s Part A Covered Services, s Part A Covered Services, cont.cont.

Home Health ServicesHome Health Services ((Reasonable and Reasonable and necessary partnecessary part--time or intermittent skilled care) time or intermittent skilled care)

Nursing (Skilled service)Nursing (Skilled service)Physical Therapy (Skilled service)Physical Therapy (Skilled service)Speech Therapy (Skilled service)Speech Therapy (Skilled service)Occupational Therapy (If a skilled service is required)Occupational Therapy (If a skilled service is required)Medical Social Work (If a skilled service is required)Medical Social Work (If a skilled service is required)Home Health Aide (If a skilled service is required)Home Health Aide (If a skilled service is required)Durable Medical equipment (Wheelchairs, hospital beds, oxygen, wDurable Medical equipment (Wheelchairs, hospital beds, oxygen, walkers) alkers) Medical SuppliesMedical Supplies

MedicareMedicare’’s Part A Covered Services, s Part A Covered Services, cont.cont.

Hospice CareHospice Care –– for people with a terminal illness for people with a terminal illness who are expected to live 6 months or less if the disease who are expected to live 6 months or less if the disease runs its normal courseruns its normal course

DrugsDrugsMedical servicesMedical servicesSupport servicesSupport servicesSome shortSome short--term inpatient stays (for pain & symptom term inpatient stays (for pain & symptom management)management)Inpatient respite (to provide the caregiver with rest)Inpatient respite (to provide the caregiver with rest)Bereavement servicesBereavement services

Medicare's Part B Covered ServicesMedicare's Part B Covered Services

Covers medicallyCovers medically--necessary services like necessary services like doctordoctor’’s services, outpatient care and other s services, outpatient care and other medical services that Part A doesnmedical services that Part A doesn’’t cover.t cover.Part B has a premium each month. In 2008 the Part B has a premium each month. In 2008 the standard premium amount is $96.40standard premium amount is $96.40There is also a yearly deductible before Medicare There is also a yearly deductible before Medicare starts to pay itstarts to pay it’’s share. In 2008 the deductible s share. In 2008 the deductible amount is $135amount is $135

Medicare's Part B Covered Services,Medicare's Part B Covered Services, cont.cont.

Medicare B covers a great many services. Some Medicare B covers a great many services. Some examples follow:examples follow:

Ambulance servicesAmbulance servicesAmbulatory surgeryAmbulatory surgeryClinical laboratory servicesClinical laboratory servicesDisease screenings, colorectal cancer, diabetes, cardiovascular Disease screenings, colorectal cancer, diabetes, cardiovascular disease, glaucoma, mammogram disease, glaucoma, mammogram Emergency room servicesEmergency room servicesDiabetes suppliesDiabetes suppliesDoctor servicesDoctor services

Medicare's Part B Covered Services,Medicare's Part B Covered Services, cont.cont.

Ongoing durable medical equipmentOngoing durable medical equipmentImmunizations Immunizations –– flu, hepatitis B, pneumoniaflu, hepatitis B, pneumoniaFoot exams and treatmentFoot exams and treatmentPhysical, Occupational, & SpeechPhysical, Occupational, & Speech--Language therapyLanguage therapyProsthetic/Orthotic ItemsProsthetic/Orthotic ItemsSecond surgical opinionsSecond surgical opinionsSurgical dressing servicesSurgical dressing servicesTests Tests –– XX--Ray, MRIs, CT scans, EKGsRay, MRIs, CT scans, EKGsTransplantsTransplants

What is What is NOTNOT covered by Medicare covered by Medicare Parts A & BParts A & B

AcupunctureAcupunctureCosmetic surgeryCosmetic surgeryCustodial care & long term careCustodial care & long term careDental careDental careRoutine eye careRoutine eye careRoutine foot careRoutine foot careTests that havenTests that haven’’t been ordered by the doctort been ordered by the doctorPhysical examsPhysical examsAdditional items & services as identified in the Medicare Additional items & services as identified in the Medicare handbookhandbook

Medicare Part CMedicare Part C

Medicare Advantage Plans are health plan options (like Medicare Advantage Plans are health plan options (like HMOs and HMOs and PPOsPPOs) approved by Medicare and run by ) approved by Medicare and run by private companies. private companies. Medicare pays an amount for your care every month Medicare pays an amount for your care every month those private health plans. those private health plans. Medicare Advantage Plans must follow rules set by Medicare Advantage Plans must follow rules set by Medicare. Medicare. Medicare Advantage Plans Medicare Advantage Plans are notare not supplimental supplimental insurance. insurance.

Medicare Part C, Medicare Part C, cont.cont.

Medicare Advantage Plans provide all of the Medicare Medicare Advantage Plans provide all of the Medicare Part A & B benefits and must cover at least all of the Part A & B benefits and must cover at least all of the medicallymedically--necessary services that the original Medicare necessary services that the original Medicare plan provides. plan provides. Medicare Advantage plans can charge different coMedicare Advantage plans can charge different co--payments, coinsurance and deductibles.payments, coinsurance and deductibles.Medicare Advantage Plans may offer extra benefits such Medicare Advantage Plans may offer extra benefits such as vision, hearing, dental, and/or health and welfare as vision, hearing, dental, and/or health and welfare programs. Most include prescription drug coverage programs. Most include prescription drug coverage (usually for an extra cost)(usually for an extra cost)

Medicare Part C, Medicare Part C, cont.cont.

Medicare Advantage Plans usually have provider Medicare Advantage Plans usually have provider networks.networks.This means that the individual will probably have to see This means that the individual will probably have to see a doctor who belongs to the plan or go to a certain a doctor who belongs to the plan or go to a certain hospital to receive covered services. hospital to receive covered services. The individual may need a referral to see specialists. The individual may need a referral to see specialists. If the individual uses providers who are not in the If the individual uses providers who are not in the network he may have to pay the full amount of the network he may have to pay the full amount of the charges. charges.

Medicare Part C, Medicare Part C, cont.cont.

Individuals considering a Medicare Advantage Plan Individuals considering a Medicare Advantage Plan should understand the plan and itshould understand the plan and it’’s limitations and s limitations and should discuss options with a knowledgeable person (not should discuss options with a knowledgeable person (not just the person who represents the plan in question)just the person who represents the plan in question)An individual enrolled in a Medicare Advantage Plan is An individual enrolled in a Medicare Advantage Plan is still in the Medicare program with Medicare rights and still in the Medicare program with Medicare rights and protections including the right to appealprotections including the right to appealAn individual may opt out of the plan and go back to An individual may opt out of the plan and go back to traditional Medicare coverage. Contact Medicare for the traditional Medicare coverage. Contact Medicare for the timeframe for changing plans.timeframe for changing plans.

Medicare Part D Medicare Part D (Prescription Drugs Coverage)(Prescription Drugs Coverage)

Medicare offers prescription drug coverage for Medicare offers prescription drug coverage for everyone with Medicare. everyone with Medicare. To get prescription drug coverage the individual To get prescription drug coverage the individual must join a Medicare drug plan.must join a Medicare drug plan.Medicare drug plans are run by insurance Medicare drug plans are run by insurance companies and other private companies approved companies and other private companies approved by Medicare. by Medicare. Each plan can vary in cost and drugs covered.Each plan can vary in cost and drugs covered.

Medicare Part DMedicare Part DThere are two ways to get Medicare prescription drug There are two ways to get Medicare prescription drug coverage coverage

Join a Medicare Prescription Drug PlanJoin a Medicare Prescription Drug PlanJoin a Medicare Advantage Plan Join a Medicare Advantage Plan

Things to consider when comparing plansThings to consider when comparing plansCoverageCoverage –– check to see if the plan covers the drugs taken by check to see if the plan covers the drugs taken by the individualthe individualCostCost –– Check to see how much the prescription drugs cost in Check to see how much the prescription drugs cost in each planeach planConvenience Convenience –– Make sure the planMake sure the plan’’s pharmacies include the s pharmacies include the ones the individual wants to useones the individual wants to use

Medicare Part DMedicare Part D

Costs vary depending on the drugs the individual uses, Costs vary depending on the drugs the individual uses, the plan chosen, and qualification for extra help to pay the plan chosen, and qualification for extra help to pay for Part D costsfor Part D costsPayments made to a Medicare drug plan include:Payments made to a Medicare drug plan include:

Monthly premium Monthly premium –– paid in addition to the Part B premiumpaid in addition to the Part B premiumYearly deductible Yearly deductible –– Amount paid for prescriptions before the Amount paid for prescriptions before the plan begins to payplan begins to payCoCo--payment or coinsurance payment or coinsurance –– Amounts paid for prescriptions Amounts paid for prescriptions after the deductible.after the deductible.

Medicare Part D Plans vary so the individual Medicare Part D Plans vary so the individual must compare plans prior to making a choicemust compare plans prior to making a choice..

Getting Help to Compare PlansGetting Help to Compare PlansVisit Visit www.medicare.govwww.medicare.gov on the web. Under on the web. Under ““Search ToolsSearch Tools”” select select ““Compare Medicare Compare Medicare Prescription Drug PlansPrescription Drug Plans””..Call 1Call 1--800800--MEDICARE MEDICARE ((11--800800--633633--42274227))TTY users should call TTY users should call 11--877877--486486--20482048Call the State Health Insurance Assistance Call the State Health Insurance Assistance Program (SHIP) Program (SHIP) 11--800800--548548--90349034 (toll free in (toll free in Illinois)Illinois)

MedicareMedicare’’s Quality Monitoring at s Quality Monitoring at www.medicare.govwww.medicare.gov

To compare certified facilities visit:To compare certified facilities visit:““Compare Dialysis Facilities in Your AreaCompare Dialysis Facilities in Your Area””““Compare Home Health Facilities in Your AreaCompare Home Health Facilities in Your Area””““Compare hospitals in Your AreaCompare hospitals in Your Area””““Compare Nursing Homes in Your AreaCompare Nursing Homes in Your Area””

To compare Medicare Health Plans and To compare Medicare Health Plans and MedigapMedigap(Medicare supplemental insurance) visit: (Medicare supplemental insurance) visit: ““Medicare Medicare Options CompareOptions Compare””To compare Medicare drug coverage visit: To compare Medicare drug coverage visit: ““Medicare Medicare Prescription Drug Plan FinderPrescription Drug Plan Finder””

Questions?Questions?