Presented by: Warren Coble

Certified Senior Advisor

MedicareFederal programSocial SecurityEarned benefit from working

Medicaid State program Social Services Needs based

benefit depends on income and assets

Over 300 Different plans available in NC in 2013

Like everything these days, … such a wide variety. Make personal choice decisions based on:

Coverage needs Cost you can afford Convenience of use

The unknown parts: How sick are you going to get? How often will you use it? How will costs rise in the future? If we had a crystal ball, we’d know the

right decision to make every time. We don’t, so we have to make the best decision now based on the facts we have now.

1. Age 65 2. Disability for 24 months 3. End-stage kidney failure 4. Lou Gehrig’s Disease

Have acquired sufficient work credits (40 quarters = 10 years)

Receiving Social Security check? Enrolled automatically & premiums deducted

If not receiving Social Security, must apply up to 3 months ahead & premiums billed

Individuals turning age 65 who are NOT

currently covered by Employer Group Health

Plan based on ACTIVE employment

Retiree coverage offered by employer is voluntary on their part and is subject to change – Supreme Court ruling in 03/2008

COBRA does not count for Medicare enrollment period purposes

Compare employer cost/coverage (premium/deductible/co-pay/oop max) to Medicare cost/coverage

If your cost/coverage are reasonable, better off with employer coverage while working

If high cost ($250 month+) or only partial coverage (high deductibles/co-pays) may be better with Medicare/Supp/Advantage

Parts of Medicare A – Hospital C – Advantage B - Medical D - Rx

Standardized A & B 1966-2003 Medicare Modernization Act of 2003

Mandated “Choices” & RX coverage

- Original - Medicare A & B usually go together, can add D

(Managed by federal government)

- Advantage - Medicare C alternative to A & B, may or may not include part D (Managed by private insurance companies)

See SHIIP Combo Form

A – Hospital Insurance *Inpatient hospital/nursing home/hospice*Usually no premium (earned by paying

Medicare tax while working)*$1184 deductible – per hospital stay

Up to 60 days of inpatient coverage(Deductible waived on re-admission

within 60 days)*Skilled nursing facility (short term only)

– Days 1-20 in full (Special Requirements)- Days 21-100 Medicare pays all but $148.00 day

*Hospice – Palliative care, including Rx *Home Health Care

B – Medical Insurance Outpatient hospital/physician

care/medical equipment Standard premium $104.90 (2013)

(higher for higher incomes) $147 deductible per calendar year,

then 80% Medicare/20% recipient co-pay

Based on “approved” charges

Not Covered By Medicare Or Supplement: Long term care Vision or dental care Hearing aids Eyeglasses Private duty nursing

Stand alone with original Medicare

Included with an advantage plan

Stand alone with an advantage plan

See COMBO form

D – Rx prescription drug coverage

Operated by private companies

Premium Deductible

5 Words: Co-Pay Gap Catastrophic

1 – Premium $15.00 - $116.80

2 – Deductible $325.00You pay 100%

3 – Initial coverage limit $2970.00Includes deductible $325.00Co pay periodPart D pays 75% up to $1983.75You pay 25% of $2645.00 ($661.25)

4 - Coverage gap $3763.75 Discounts: 52.5% brand, 21% generic

$4750.00 (deductable + 25 out of pocket % + gap)

5 - Catastrophic 95/5%

Annual preview period September 15–October 15Assistance available to choose

appropriate plans Open enrollment

October 15 - December 07 Changes effective January 1 each year

Work with Original Medicare to fill in “gaps” Cannot buy but one at a time. Standardized/Regulated by N. C. Dept. of

Insurance Offered by individual companies Will not work with Part C/Advantage

Depending on Plan type chosen, designed to pay out of pocket expenses (deductibles, co-insurance, and co-pays) not paid by Medicare

See Plans Chart (SHIIP Combo Form) Changed June 1, 2010

Gone - Plans E, H, I, J - New M, N42 Plan “F” companies in North Carolina

Pricing method is important!!! No-age rated Issue-age-rated Attained-age-rated Price ranges from $122.50 - $253.60 for

Plan F (most common), 43 plan average is $155.19

Find out company history/stabilityDiscounts can confuse true cost

Guaranteed renewable as long as premium is paid

Can never be cancelled due to health/excess use

Premiums will go up!!!! Changing plans re-sets the starting age,

often resulting in higher premiums

Medigap Open Enrollment Period:

Starts 1st day of month you are both age 65 or older and enrolled in Medicare Part B. Continues for 6 months.

Can apply up to 6 months in advance to have timely coverage at 65

During open enrollment, cannot be denied coverage, regardless of healthSome companies apply pre-existing condition limitations up to 6 monthsDeferring Medicare/Supplement to keep employer coverage will result in higher Supplement cost later

SEE GOLD SHEET

Includes all benefits of regular Medicare Hospital and medical coverage Premiums/deductibles/co-pays vary by plan

May include extra benefitsVision, dental, hearing, gym

membership Not standardized Not regulated by N. C. Dept. of Insurance (CMS) Usually have a varied maximum out-of-pocket limit

4 Basic plan types: 1. HMO – Health Maintenance

Organization (in network) 2. PPO – Preferred Provider

Organization (out of network) 3. SNP – Special Needs Plans 4. PFFS – Private Fee for Service

Inpatient hospital◦ Per day co-pay

$140.00 - $290.00 per DAY Surgery usually included in in-patient costs Usually a limit on # of days you pay Plans vary on yearly maximum out of

pocket

Skilled nursing facilityExtremely varied co-paysDays 1-100 - $0 - $137.50 per dayDepends on plan and typeNot accepted at all facilities

Medical/doctor’s servicesVaried co-pays $10-$35 Primary care physician$10-$50 SpecialistVerify your doctor/hospital will accept

30% - 100 % Out of network ! Each plan is different!

Prescription drug (Rx)

May or may not be included If not included, cannot buy stand-alone Usually standard drug plan

guidelines

Original Medicare - $104.90 (IRMMA) Supplement – varied, $122.50 - $253.60

average for Plan F $155.19 month Part D Rx – varied, $15.00 - $116.80 -

average $35.00 per month Advantage – varied, from $0 to $169.80 per

month

See Road To 65 Initial, General, Special Enrollment periods IEP – 3 months before, month of, 3 months

after 65 Eligibility date depends on when you sign up GEP – January – March each year, coverage

begins July 1 SEP – Any time while covered by employer group

health plan (cannot be during IEP) Up to 8 months after employer group terminates

Check options 4-6 months ahead of age 65.

If keeping employer coverage, check again 2-3 months before leaving employment.

If eligible, and you need Medicare, failure to enroll timely can result in delays in coverage and costly premium penalties. Although Cobra protects your Medigap/Supplement Enrollment period, it does not protect you for a Medicare Special Enrollment Period.

Warren Coble & Associates

SHIIP – 1-800-443-9354

1-800-MEDICARE – 1-800-633-4227