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MedicareUnit 7
Medicare Part A Payment PlanBeneficiary Pays (2009)
Hospital Stays
1-60 days $1068
61-90 days $267/day
91-150 days $534/day
151+ days all costs
Monthly premium $244
SNF
1-20 days nothing
21-100 days $133.50 per day
max
101+ days all costs
Annual deductible $1,068
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Medicare Part A Payment PlanBeneficiary PaysHome Health Care
Nothing for approved home health care services
20% of approved durable medical equipment
Hospice
Co-payment of $5 for prescription drugs
5% of Medicare-approved amount for respite care
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Medicare Part BBeneficiary Pays
Medical & Other
$135 deductible
$96.40 per mo. premium
20% of Medicare approved physician cost
20% outpatient physical, occupational, & speech-language therapy
50% outpatient mental health care
Home Health Care
Nothing for Medicare-approved services
20% of Medicare-approved durable medical equipment
Premium higher for singles with incomes of $85,000 + & incomes of $170,00 +
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Medicare Part BBeneficiary Pays
Clinical Lab Services
Nothing for Medicare-approved services
Outpatient Hospital Services
20% of billed amount after deductible
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Other Part B Coverage Insurance Company incentive - $12 billion in
subsidies to private insurers that offer health plans to Medicare beneficiaries.
Beginning 2010 Medicare will face competition among private insurance plans.
Medicare savings accounts – tax shelters for individuals with deductibles above $1,000 for singles & $2,000 for couples.
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Prescription Drug Benefit (2009) Premium - $450/yr Deductible - $250 Coverage – 75% of drug costs up to $250; 25% $259 - $2,250 Gap – no coverage between $2,250 – $5,100 After $5,100 Medicare pays drug costs Low-income subsidies – premium, deductible, & coverage gap
waived for those at 135% FPL & lower ($22,588 for couples) & have less than $6,000 liquid assets
Company incentive – tax-free subsidies to employers who maintain to insurance companies
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Medicare Advantage + Choice Plans Beneficiary Pays
Part A Same payments
Part B $58.70/mo. premium + additional Choice Plan’s premium (?)
Choice Plan’s co-payments for services
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“Accepting Assignment”Payment to Physician
Medicare pays Beneficiary pays
Physicians accepting assignment
80% of approved charge
20% of co-payment
Physicians not accepting assignment
80% of approved charge
20% co-payment + 15% of additional cost
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Example of Accepting Assignment
Medicare pays Beneficiary pays
Physician accepting
$100 per visit
$80 $20
Physician not accepting
$120 per visit
$80 $20 + $3
(15% of $20)
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Medicaid Monthly income of $1,737 for single Spend down to $2,000 liquid assets for
institutionalized spouse
• Entire SSI goes to pay for institutionalization Community spouse can have between $95,100 in
assets
• Maximum monthly income $1,737
• Window – 3 yrs from date of institutionalization or 5 yrs for transfers to trust
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Main Problems in Providing Care for Elderly Limited coverage under Medicare
−homebound status
−skilled nursing 1.4% or $13/mo increase in SSI – 1/3 of this will go for
increase in Medicare premiums Private insurance option at cost to elderly Cost of home health care services expensive Cost of long-term care expensive Problems with managed care plans
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