Understanding Medicare Workbook 2019 › cms2019 › Presentations › ... · June 2019 Understanding Medicare 5. Notes . The parts of Medicare include . Part A (Hospital Insurance)

UNDERSTANDINGMEDICAREWORKBOOK 2019

ii

About This Workbook

This workbook is part of a training module that provides an overview of the basics of the Medicare Program, including Part A (Hospital Insurance), Part B (Medical Insurance), Medicare Supplement Insurance (Medigap) policies, Medicare Advantage (MA), Part D (Prescription Drug Coverage), appeals and programs to help people with limited income and resources, and related resources.

This training module was developed and approved by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace.

The information in this module was correct as of June 2019. To check for an updated version, visit CMSnationaltrainingprogram.cms.gov.

The CMS National Training Program (NTP) provides this as an informational resource for our partners. It isn’t a legal document or intended for press purposes. The press can contact the CMS Press Office at [email protected]. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

This training is provided by the CMS NTP.

To view all available NTP materials, or to subscribe to our email list, visit CMSnationaltrainingprogram.cms.gov.

Contact us at [email protected].

Follow us on Twitter @CMSGov #CMSNTP.

https://cmsnationaltrainingprogram.cms.gov/

mailto:[email protected]



.

iii

Contents

How to Use This Workbook............................................................................................................. 1

Lesson 1—Medicare Basics............................................................................................................ 3

Lesson 2—Medicare Eligibility and Enrollment ............................................................................... 11

Lesson 3—Introduction to Medicare Coverage Options .................................................................. 33

Lesson 4—Original Medicare (Part A and Part B) ........................................................................... 37

Lesson 5—Medicare Prescription Drug Coverage (Part D) ............................................................ 83

Lesson 6—Medicare Advantage (MA) Plans (Part C) ..................................................................... 96

Lesson 7—Appeals ......................................................................................................................... 112

Lesson 8—Medicare and Other Insurance ..................................................................................... 126

Lesson 9—Help for People with Limited Income and Resources .................................................... 135

Lesson 10—CMS Program-Related Resources .............................................................................. 144

Key Messages ................................................................................................................................ 151

Acronyms ........................................................................................................................................ 152

Appendixes

A—New Medicare Card .................................................................................................................. A-1

B—2019 Medicare Amounts ........................................................................................................... B-1

C—2019 Comparison of the Parts A, B, C, and D Appeal Processes ............................................. C-1

D—Answer Key ............................................................................................................................... D-1

1

How to Use This Workbook

The lessons in this module, “Understanding Medicare,” explain the benefits, costs, and enrollment for people with Medicare. It also includes information on appeals and helpful resources.

The materials are designed as a 1-day training for people learning about the program, and for use by experienced people to train others. Additional time may be needed for add-on activities.

The module consists of 156 PowerPoint slides with corresponding speaker’s notes. This companion workbook includes an appendix with helpful job aids.

Tips for using this workbook:

Take notes in the workbook during the training event. Retain the workbook as a quick reference tool. Use the activities in the workbook to check your understanding. Explore the resources mentioned in the workbook to further your knowledge about Medicare.

The electronic version of this workbook includes links to the online resources described in the workbook.

The icons shown below are used to indicate the parts of Medicare. Throughout the workbook, these icons are used for Part A, Part B, Part D, and Medicare Advantage (also called Part C).

Part A Hospital Insurance

Part B Medical Insurance

Part D Prescription Drug Coverage

Medicare Advantage

.

3

Lesson 1—Medicare Basics

What is Medicare? What are the parts of Medicare?How is Medicare funded?What agencies are responsible for Medicare?

Understanding Medicare 3June 2019

Notes

Lesson 1 provides background that explains

What is Medicare? What are the parts of Medicare? How is Medicare funded? What agencies are responsible for Medicare?

4

What Is Medicare?

Health insurance for people 65 and older Under 65 with certain disabilities

• ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease) without a waiting period

Any age with End-Stage Renal Disease (ESRD)

Note: To get Medicare, you must be a U.S. citizen or lawfully present in the U.S. Must reside in the U.S. for 5 continuous years. CMS Product No. 10050

June 2019 Understanding Medicare 4

Notes

Medicare currently provides health insurance for 59.7 million U.S. citizens. It’s health insurance for generally 3 groups of people:

Those who are 65 and older People under 65 with certain disabilities who have been entitled to Social Security Disability

Insurance (SSDI) benefits for 24 months—includes ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), without a waiting period

People of any age who have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare is also available to a very small subset of people who have an asbestos-related condition associated with a federally-declared environmental health hazard. Currently, it only applies to individuals affected by a hazard in Libby, Montana.

People who immigrate to the U.S. may qualify for Medicare if they’re in a lawful status. Generally, they must have resided in the U.S. for 5 continuous years to get Medicare.

The “Medicare & You” handbook (CMS Product No. 10050) pictured on the slide is sent (by mail or electronically) to every Medicare household each year in the fall. You can view it at Medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf. It’s sent to all newly enrolled people as well. It explains Medicare and provides information on Medicare health and drug plans in their geographic area.

For general Medicare enrollment information, visit CMS.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html.

https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html

5

What Are the Parts of Medicare?

Part A (Hospital Insurance) helps cover Inpatient care in hospitals Skilled nursing facility (SNF) care Hospice care Home health care BloodPart B (Medical Insurance) helps cover Services from doctors and other health care providers Outpatient care Home health care Durable medical equipment (DME) (like wheelchairs, walkers, hospital beds,

and other equipment and supplies) Many preventive services (like screenings, shots, and yearly wellness visits)

Part D (prescription drug coverage) Helps cover the cost of prescription drugs


Notes

The parts of Medicare include

Part A (Hospital Insurance) helps cover

Inpatient care in hospitals Skilled nursing facility (SNF) care Hospice care Home health care Blood (in most cases, if you need blood as an inpatient, you won’t have to pay to replace it)

Part B (Medical Insurance) helps cover

Services from doctors and other health care providers Outpatient care Home health care Durable medical equipment (DME) (like wheelchairs, walkers, hospital beds, and other equipment

and supplies) Many preventive services (like screenings, shots, and yearly wellness visits)

Part D (prescription drug coverage)

Helps lower the cost of prescription drugs

Part D plans are run by private insurance companies that follow rules set by Medicare.

6

How Is Medicare funded?

Medicare trust funds cover benefits and administrative costs Hospital Insurance (HI) Trust Fund

• Funded through payroll taxes paid by most employees, employers, and people who are self-employed; income taxes paid on Social Security benefits; interest earned on the trust fund investments; and Medicare Part A premiums from people who aren’t eligible for premium-free Part A

Supplementary Medical Insurance (SMI) Trust Fund • Funds authorized by Congress, Part B premiums and Part D

premiums


Notes

Medicare is paid for through 2 trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare.

1. The Hospital Insurance (HI) Trust Fund – Funded through payroll taxes paid by most employees, employers, and people who are self-employed, and other sources, like these: Income taxes paid on Social Security benefits Interest earned on the trust fund investments Medicare Part A premiums from people who have to pay a premium for Part A

It pays for Medicare Part A (Hospital Insurance) benefits, like inpatient hospital care, SNF care, home health care, and hospice care, and Medicare Program administration, like costs for paying benefits, collecting Medicare taxes, and fighting fraud and abuse.

2. The Supplementary Medical Insurance (SMI) Trust Fund – Funding is authorized by Congress, from the premiums of people enrolled in Medicare Part B (Medical Insurance) and Medicare prescription drug coverage (Part D), and other sources, like interest earned on the trust fund investments.

It pays for Part B and Part D benefits, and Medicare Program administration, like costs for paying benefits and for fighting fraud and abuse.

7

What Agencies Are Responsible for Medicare?

Handle Enrollment, Premiums

Social Security enrolls most people in Medicare

Railroad Retirement Board (RRB) enrolls railroad retirees in Medicare

Federal retirees’ premiums are handled by the Office of Personnel Management (OPM)

We Handle the Rest

Centers for Medicare & Medicaid Services (CMS) administers the Medicare Program


Notes

Agencies responsible for Medicare:

Social Security is responsible for enrolling most people in Medicare. The Railroad Retirement Board (RRB) is responsible for enrolling railroad retirees in Medicare. Social Security and RRB also collect premiums and determine the amounts of the Part A (if you

have to buy it) and Part B premiums. Medicare uses the name and address you have on file with Social Security. To change your name and/or address, visit your online My Social Security account.

If you retired from federal service, contact the Office of Personnel Management (OPM) regarding your premiums.

Medicare coverage, benefits, and payments are administered by the Centers for Medicare & Medicaid Services (CMS).

8

What CMS Does

Oversees and administers • Medicare • Health Insurance Marketplace

Works with states to administer• Medicaid• Children’s Health Insurance Program (CHIP)• State-Partnership Marketplaces

Maintains and monitors quality standards to assure quality health care through accountability and public disclosure

Fights fraud and abuse Explores quality-improvement and cost-saving advances by funding or

leading studies, demonstrations, and pilots CMS and its contractors process over 1 billion Medicare claims annually


Notes

CMS

Oversees and administers the Medicare Program and the Health Insurance Marketplace. Works with the states to administer Medicaid, the Children’s Health Insurance Program (CHIP),

and State-Partnership Marketplaces. Maintains and monitors quality standards to assure quality health care through accountability and

public disclosure. Fights fraud and abuse. Explores, tests, and, if worthwhile, implements quality-improvement or cost-saving measures

through awarding grants and funding or leading studies, demonstrations, and pilots. Maintains and shares its research, data, and findings.

CMS and its contractors process over 1 billion Medicare claims annually.

9

CMS’s 10 Regional Offices and Central Office


Notes

CMS was established in 1977. It’s headquartered in Baltimore, Maryland.

The 10 Regional Offices (ROs) divide the country into geographic areas to assist in field work for all states and territories. The 10 ROs are the agency’s state and local presence. Regional field staff work closely with people with Medicare, health care providers, state governments, CMS contractors, community groups, and others. They educate and train consumers, providers, partners, and local audiences on Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace.

The ROs are located in the following cities:

Region 1—Boston

Region 2—New York City

Region 3—Philadelphia

Region 4—Atlanta

Region 5—Chicago

Region 6—Dallas

Region 7—Kansas City

Region 8—Denver

Region 9—San Francisco

Region 10—Seattle

10

Medicare Basics—Questions


Notes

11

Lesson 2—Medicare Eligibility and Enrollment

How and when you can enroll in MedicareWhy enrolling on time is importantWhen enrollment is automatic The Medicare cardWhen enrollment isn’t automatic Enrollment periods


Notes

Lesson 2 provides information on

How and when you can enroll in Medicare Why enrolling on time is important When enrollment isn’t automatic The Medicare card When enrollment isn’t automatic Enrollment periods

How and When You Can Enroll in Medicare

If you get Social Security Disability

Insurance (SSDI) Social Security retirement

benefits, or Railroad Retirement Board

(RRB) benefits

Medicare enrollment rules and decisions vary depending on

Your age

Your other coverage, like from an employer

If you have End-Stage Renal Disease (ESRD)


Notes

Medicare enrollment rules and decisions vary by your age, other coverage (like from an employer), whether you have End-Stage Renal Disease (ESRD), and whether (and sometimes how long) you’re receiving Social Security or Railroad Retirement benefits.

12

Why Enrolling on Time Is Important

If you don’t enroll on time… Costs could be higher (late enrollment penalties) or you could pay more for a Medicare Supplement Insurance (Medigap) policy

Coverage might be affected, like having a gap in coverage or a waiting period for a pre-existing condition (Medigap)

You might not be able to buy a Medigap policy or may have to pay more

Premium Part A late enrollment penalty lasts 2X the number of years you could have had Part A but didn’t

Part B and Part D late enrollment penalties last your lifetime


Notes

If you don’t enroll on time

You may pay more for coverage (late enrollment penalties) for Part A (if you have to buy it), Part B, and Part D. The Part B and Part D penalties can last as long as you have Part B or Part D. If you’re eligible for Part A (but you have to buy it), and you don’t buy it when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could have had Part A, but didn’t sign up.

You may have a gap in coverage, or have a delay in coverage for a pre-existing condition. You might not be able to buy a Medicare Supplement Insurance (Medigap) policy, have to pay

more for it, or have a delay in coverage for a pre-existing condition.

13

14

Automatic Enrollment—Part A and Part B

Automatic enrollment for those who get Social Security benefits Railroad Retirement benefitsInitial Enrollment Period (IEP) Package Mailed 3 months before

• 65 or• 25th month of disability

benefits

Includes your Medicare card


Notes

If you’re already getting Social Security or Railroad Retirement Board (RRB) benefits (for example, getting early retirement benefits at least 4 months before you turn 65), you’ll be automatically enrolled in Medicare Part A and Part B without an additional application. You’ll get your Initial Enrollment Period (IEP) package, which includes your Medicare card and other information, about 3 months before you turn 65 (coverage begins the 1st day of the month you turn 65), or 3 months before your 25th month of disability benefits (coverage begins your 25th month of disability benefits). If your birthday is the 1st day of the month, your coverage begins the 1st day of the month before your 65th birthday.

If you aren’t getting retirement benefits from Social Security or the RRB, you must sign up to get Medicare.

Note: If you live in Puerto Rico and get benefits from Social Security or the RRB, you’ll automatically get Part A the 1st day of the month you turn 65, or after you get disability benefits for 24 months. However, if you want Part B, you’ll need to sign up for it. If you don’t sign up for Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. Visit Medicare.gov/Contacts to get the contact information for your local Social Security office or the RRB.

“Welcome to Medicare,” CMS Product No. 11095, is part of the IEP package. Visit Medicare.gov/Pubs/pdf/11095-Welcome-to-Medicare.pdf.

https://www.medicare.gov/Contacts/

https://www.medicare.gov/Pubs/pdf/11095-Welcome-to-Medicare.pdf

15

Your Medicare Card

Keep it to accept Part B To refuse Part B, follow instructions in the

“Welcome to Medicare” package Carry your card when away from home

• Let your doctor, hospital, or other health care provider see your card when you need health care

• Need a replacement card? Sign into your MyMedicare.gov account and

print an official copy

Call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048


Notes

If you choose to be in Original Medicare, you use your red, white, and blue Medicare card when you get health care services. The Medicare card shows the type of Medicare coverage (Part A and/or Part B) you have and the date the coverage started.

Your card has a Medicare Number that’s unique to you. It’s a unique combination of letters and numbers—the letters S, L, O, I, B, and Z are never used. This helps to protect your identity.

If you get your Medicare card in your IEP package and don’t want Part B, follow the directions and return the card.

If you choose to be in an MA Plan (like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)), your plan may give you a card to use when you get health care services and supplies. Your MA Plan ID card is your main card for Medicare. However, you also may be asked to show your Medicare card, so you should carry this card, too. Only give your Medicare Number to doctors, pharmacists, other health care providers, your insurers, or people you trust to work with Medicare on your behalf.

If you forget your card, you or your doctor or other health care provider may be able to look up your Medicare number online. Your doctor or other health care provider can use the secure Medicare Administrative Contractor (MAC) portal to look up your Medicare Number. You may also get your Medicare Number by logging on to myMedicare.gov.

https://www.mymedicare.gov/

16

You Must Take Action to Enroll in Medicare When it Isn’t Automatic

If you aren’t automatically enrolled in Part A and Part B (not getting Social Security or RRB benefits) 4 months before you turn 65 You need to enroll in Medicare with Social Security

• Visit socialsecurity.gov, or• Call 1-800-772-1213; TTY: 1-800-325-0778

Make an appointment to visit your local office To find your local office, visit secure.ssa.gov/ICON/main.jsp

If retired from a railroad, enroll with the RRB• Call your local RRB office at 1-877-772-5772


Note: The age for full Social Security retirement benefits is going up for people born in 1938 or later. Those born in 1960 and later will get full retirement benefits at 67. Medicare is still 65.

Notes

If you aren’t getting Social Security or RRB benefits at least 4 months before you turn 65 (for instance, because you’re still working), you’ll need to sign up for Part A (even if you’re eligible to get premium-free Part A) and Part B. To avoid a delay in coverage, you should contact Social Security to apply for Medicare 3 months before you turn 65. If you worked for a railroad, contact the RRB to sign up. You don’t have to be retired to get Medicare.

For people born in 1938 or later, their Social Security benefit may be affected by a provision that raises the age at which full Social Security benefits are payable. Starting with people born in 1938, the age at which full retirement benefits are payable increases gradually. Those born in 1960 and later will receive full retirement benefits at 67. (Medicare is still 65.) You can calculate your age for collecting full Social Security retirement benefits at socialsecurity.gov/retirement/ageincrease.html.

You can enroll online at socialsecurity.gov, or call 1-800-722-1213; TTY: 1-800-325-0778, or make an appointment at your local Social Security office. To find your local office, visit secure.ssa.gov/ICON/main.jsp.

Those who sign up for Social Security before they reach their full retirement age get partial retirement benefits. The earliest a person can start getting reduced Social Security retirement benefits remains 62.

For more information, visit https://www.ssa.gov/pubs/EN-05-10035.pdf.

Note: A “Welcome to Medicare” package will be sent to people who actively enroll in Part A and Part B. It’s mailed about 3–4 weeks after they apply for Medicare through Social Security. Included in the package is a Welcome to Medicare cover letter and a “Welcome to Medicare” pamphlet (CMS Product No. 12020). The package provides the person’s coverage start date (which is listed on the enclosed Medicare card). The pamphlet explains some important decisions the person with Medicare needs to make.

https://www.ssa.gov/planners/retire/ageincrease.html

https://www.ssa.gov/

https://secure.ssa.gov/ICON/main.jsp

https://www.ssa.gov/pubs/EN-05-10035.pdf

17

When You Can Sign Up for Medicare

If you don’t already have Medicare Initial Enrollment Period (IEP)

• 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65

• No late enrollment penalty Special Enrollment Period (SEP)

(in certain circumstances)• After IEP ends• Can enroll in Part B (or Part A if you have to buy it) if

you delayed enrolling because you were covered under a group health plan (with 20 or more employees) based on current employment (yours or your spouse’s)

• No late enrollment penalty


Notes

If you don’t have Medicare, and you’re eligible for premium-free Part A, you can enroll in Part A anytime you’re eligible. Your coverage will begin up to 6 months retroactive from the month you apply. However, you can enroll in Part B (and Part A if you have to buy it) only during specific enrollment periods. Your first opportunity to enroll is during your Initial Enrollment Period (IEP).

Initial Enrollment Period (IEP)

7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65

No late enrollment penalty If you don’t enroll in Part B during the IEP, you have to wait until the next General Enrollment Period (GEP). If you already have Medicare, you can make changes to your coverage during the yearly Open Enrollment Period (OEP), the Medicare Advantage OEP, a 5-star Enrollment Period, or in certain circumstances, during a Special Enrollment Period (SEP).

Special Enrollment Period (SEP) (in certain circumstances)

After IEP ends Can enroll in Part B (or Part A if you have to buy it) if you delayed enrolling because you were covered

under a group health plan (with 20 or more employees) based on current employment (yours or your spouse’s)

No late enrollment penalty If you don’t enroll in Part B during the IEP, you have to wait until the next General Enrollment Period (GEP). If you already have Medicare, you can make changes to your coverage during the yearly Open Enrollment Period (OEP), the Medicare Advantage OEP, a 5-star Enrollment Period, or in certain circumstances, during a Special Enrollment Period (SEP). Enrolling in Medicare or changing how you get your Medicare are important decisions. They must be done in a timely manner to avoid late enrollment penalties and to be sure you get the coverage you need, when you need it. These enrollment periods are explained on the following slides.

18

When You Can Sign Up for Medicare (continued)

If you didn’t sign up for Part A (if you have to buy it) and/or Part B during your IEP General Enrollment Period (GEP)

• If you don’t qualify for an SEP• You can sign up January 1–March 31 each year

Coverage begins July 1 of that year You may pay a higher Part A and/or Part B

premium for late enrollment


Notes

If you don’t enroll during your IEP, you have to wait until the next General Enrollment Period (GEP). You can enroll in Medicare Part A (if you have to buy it), and/or Part B during the GEP, which occurs each year from January 1–March 31. Your coverage would begin on July 1.

19

When You Can Join, Switch, or Drop Your Plan

Yearly Open Enrollment Period (OEP) for people with Medicare October 15–December 7 You can join, switch, or drop your

• Medicare Advantage (MA) Plan• Medicare Prescription Drug Plan (PDP)

You can return to Original Medicare


Notes

Each year, from October 15–December 7, you can join, switch, or drop your MA Plan or Medicare Prescription Drug Plan (PDP). You can return to Original Medicare. You should take advantage of this opportunity to review your present coverage and consider your future health needs. You can compare plans at Medicare.gov.

https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf

Automatic Enrollment Based on Disability

You’re enrolled automatically if you’re

Under 65 and disabled

and

Have been entitled to SSDI benefits for 24 months. If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), Medicare begins the first month you’re entitled to SSDI.


Notes

Medicare also covers 2 additional groups:

People under 65 with a disability who have been entitled to Social Security Disability Insurance (SSDI) benefits for 24 months.

People with ESRD who meet special Social Security earnings requirements. People with ESRD don’t need to be entitled to Social Security benefits to qualify for Medicare. However, if they’re also entitled to disability benefits, they may qualify under both programs. We’ll discuss ESRD on the next slide.

In most cases, you must be entitled to disability benefits for 24 months before Medicare can begin. Since there is a 5-month waiting period for SSDI, the earliest that Medicare can start is usually the 30th month after you become disabled. However, there are 2 exceptions:

The 5-month waiting period for cash benefits doesn’t apply to people who get childhood disability benefits or to some people who were previously entitled to disability benefits (in the past 5 years).

The 24-month Medicare waiting period doesn’t apply to people disabled by ALS, known as Lou Gehrig’s Disease. People with ALS get Medicare the first month they’re entitled to disability benefits.

20

21

Enrolling in Medicare Based onEnd-Stage Renal Disease (ESRD)

To enroll in Part A and Part B because you have ESRD

Get doctor/dialysis center to complete Form CMS-2728

Then, enroll at local Social Security office


Notes

You can enroll in Medicare Part A and Part B based on End-Stage Renal Disease (ESRD) at your local Social Security office. Social Security will need your doctor or the dialysis facility to complete Form CMS-2728 to document that you have ESRD and can get Medicare. If Form CMS-2728 is sent to Social Security before you apply, the office may contact you to ask if you want to complete an application. The form is available at CMS.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf.

Regardless of the number of employees and whether the coverage is based on current employment status, Medicare is the secondary payer of benefits for the first 30 months of Medicare eligibility (known as the 30-month coordination period) for people with ESRD who have employer or union group health plan (GHP) coverage. If your GHP coverage will pay for most or all of your health care costs (for example, if it doesn’t have a yearly deductible), you may want to delay enrolling in Part A and Part B until you’re getting near to the end of the 30-month coordination period. If you delay enrollment, you won’t have to pay the Part B premium for coverage you don’t need yet. After the 30-month coordination period, you should enroll in Part A and Part B.

If you’ll soon receive a kidney transplant, get the facts about eligibility and enrollment before deciding to delay because there are shorter time periods for eligibility and enrollment deadlines for transplant recipients.

Call Social Security at 1-800-772-1213, TTY: 1-800-325-0778 to make an appointment to enroll in Medicare based on ESRD.

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2728.pdf

Medicare and End-Stage Renal Disease (ESRD)—Medicare Coverage Choices

You Can Usually

Get Original Medicare

Join an ESRD Special Needs Plan (SNP) (if

available in your area)

You Can’t

Get Medicare Advantage* (with some exceptions)

*Effective January 1, 2021, people with ESRD can join an MA Plan with no restrictions


Notes

If you have ESRD and are new to Medicare, you’ll most likely get your health care through Original Medicare. You may also have the option of joining a Medicare Special Needs Plan (SNP), if one is available in your area for people with ESRD. There are only limited exceptions that allow a person with ESRD to enroll in a Medicare Advantage (MA) Plan (like an HMO or PPO). One example is if their current GHP has a Medicare option in their area.

Note: SEC. 17006 of the 21st Century Cures Act allows people with ESRD to join an MA Plan as of January 1, 2021.

22

23

When Coverage Starts for People with End-Stage Renal Disease (ESRD)

For most people, ESRDMedicare coverage begins…

Day 1 of 4th month of dialysis

If you’re covered by a group health plan (GHP), it may pay for the first 3 months of dialysis.

For some people with ESRD, if they get a kidney transplant or meet specific home dialysis conditions, Medicare coverage begins…

Immediately or Day 1 of 1st month of dialysis


Notes

When you enroll in Medicare based on ESRD and you’re getting a regular course of dialysis, Medicare coverage usually starts on the 1st day of the 4th month of your dialysis treatments. This waiting period will start even if you haven’t signed up for Medicare. For example, if you don’t sign up until after you’ve met all the requirements, your coverage could begin up to 12 months before the month you apply.

If you’re covered by a GHP, your Medicare coverage will still start the 4th month of dialysis treatments. Your GHP may pay the first 3 months of dialysis.

Medicare coverage can start as early as the 1st month of dialysis if you meet all of these conditions:

You take part in a home dialysis training program offered by a Medicare-certified training facility to teach you how to give yourself dialysis treatments at home

Your doctor expects you to finish training and be able to do your own dialysis treatments The regular course of dialysis is maintained throughout the waiting period that would otherwise

apply

If you’re getting a kidney transplant, Medicare coverage can begin the month you’re admitted to a Medicare-certified hospital for a kidney transplant (or for health care services that you need before your transplant) if your transplant takes place in that same month or within the next 2 months.

If you get a kidney transplant, you’ll need immunosuppressive drugs. Medicare will cover your immunosuppressive drugs only if, at the time of the transplant, you were enrolled in Part A. You’ll also need to enroll in Part B. This means you have 12 months from the time of the transplant to enroll in Medicare Part A and enroll in Part B.

Check Your Knowledge―Question 1

Why is your Medicare Initial Enrollment Period (IEP) important?

a. Missed enrollment deadlines could result in penalties

b. It’s your first opportunity to enroll in Medicare

c. When you enroll impacts when your coverage begins

d. All of the above


Notes


Why is your Medicare IEP important?

a. Missed enrollment deadlines could result in penalties b. It’s your first opportunity to enroll in Medicare c. When you enroll impacts when your coverage begins d. All of the above

See Appendix D for the answer.

24

Activity: Which Enrollment Period?

Help Dan, Lena, and Ralph understand when they can enroll in Medicare based on their situations.


Notes

On the next few slides, consider the person’s circumstances and name the enrollment period that the person may use.

25

Scenario—Dan

Dan is turning 65 in a few months.

What enrollment period is he approaching?


Notes



26

Dan can enroll during his….

IEPInitial Enrollment Period

7-Month Period

3 months before the month you turn 65

3 months after the month you turn 65

3 2 1

Coverage begins first of the month you turn 65

65th Birthday

First of next month

1 2 3

Delayed 2-3 months, Part A (if you have to buy it) and/or Part B

If he enrolls in a Medicare Advantage (MA) Plan during his IEP, he has an MA Open Enrollment Period (OEP) (3 months) to make a change if he wants to.


Notes

IEP



ANSWER: It’s his IEP.

The Initial Enrollment Period (IEP) is Dan’s first opportunity to enroll in Medicare. He’ll have 7 months to enroll. Remember, that’s the 3 months before the month he turns 65, the month he turns 65, and the 3 months after the month he turns 65. For people who’ve been getting Social Security Disability benefits for 24 months, their IEP would be the 7 months surrounding their 25th month of disability benefits.

If you enroll in any of the 3 months before you turn 65, your coverage begins the first of the month you turn 65. If you enroll the month of your 65th birthday, your coverage begins the first of the following month. If you wait until after the month you turn 65, your coverage is delayed 2–3 months.

People new to Medicare who enroll in an MA Plan during their IEP have 3 months of Medicare eligibility to use the MA Open Enrollment Period (OEP) to make a change if they so choose.

27

Scenario—Lena

Lena didn’t enroll in Medicare during her Initial Enrollment Period (IEP). She isn’t working, and she doesn’t have coverage. She isn’t getting Social Security benefits.

When will she next be able to enroll in Medicare?


Notes

Lena didn’t enroll in Medicare during her IEP. She isn’t working and she doesn’t have coverage. She isn’t getting Social Security benefits. When will she next be able to enroll in Medicare?

28

Lena can enroll during the…

GEPGeneral Enrollment Period for Part A (if she has to

buy it) and for Part BStartsJan 1

ContinuesFeb

EndsMar 31

Coverage BeginsJul 1

For Part A, anytime if she doesn’t have to buy it. Can be retroactive up to 6 months, but not before

the month she first qualified.June 2019 Understanding Medicare 29

Notes

GEP

Lena didn’t enroll in Medicare during her IEP. She isn’t working and has no other coverage. She isn’t getting Social Security benefits. When will she next be able to enroll in Medicare?

ANSWER: The GEP.

Since Lena isn’t working, has no other coverage, isn’t getting Social Security benefits, and she missed her IEP, she’ll have to wait until the next General Enrollment Period (GEP) to enroll in Medicare Part A (if she has to buy it,) and Part B. Her coverage won’t begin until July 1 of the same year. That means she’ll have a gap in coverage and may have late enrollment penalties too.

If she doesn’t have to pay for Part A, she can enroll in it at any time, and her coverage may be retroactive up to 6 months, but not before the month she first qualified.

29

30

Scenario—Ralph


Ralph is 68. He has Medicare Part A and a group health plan (GHP) from his current employer (with more than 20 employees). He plans to retire in 2 months. When can he enroll in Medicare Part B?

Notes

Ralph is 68. He has Medicare Part A and a group health plan (GHP) from his current employer (with more than 20 employees). He plans to retire in 2 months. When can he enroll in Medicare Part B?

Ralph can enroll during an…

SEPSpecial Enrollment Period for Part BMonth of

Retirement or GHP Coverage Ends

Mon

th

1 Mon

th

2 Mon

th

3 Mon

th

4 Mon

th

5 Mon

th

6 Mon

th

7 Mon

th

88-month period when you can enroll in Part B and choose

Original Medicare• Part D (Part A and/or Part B) within 63 days of loss of creditable prescription drug

coverage• You have 6 months from the Part B effective date to buy a Medigap policy

Medicare Advantage (MA) (must have Medicare Part A and Part B)


Notes

SEP

Ralph can enroll during a Special Enrollment Period (SEP) that will begin the month he retires, or that his group health plan (GHP) (with 20 or more employees) coverage ends (whichever comes first) and lasts for the next 8 months. During his SEP, he can sign up for Part B. Once he has Part A and Part B he can enroll in a Medicare Advantage (MA) Plan if he chooses.

If he had creditable prescription drug coverage (at least as good as Medicare Part D coverage), and loses it, he has 63 days to join a Medicare Prescription Drug Plan and won’t have a late enrollment penalty.

If he is enrolled in Original Medicare, he will have 6 months to buy a Medicare Supplement Insurance (Medigap) policy.

31

Medicare Eligibility and Enrollment Questions


Notes

32

Lesson 3—Introduction to Medicare Coverage Options

When you first enroll in Medicare, and during certain times of the year, you can choose how you get your Medicare coverage

There are 2 main ways to get Medicare

Original Medicare Medicare Advantage (MA)

Note: Medicare Supplement Insurance (Medigap) policies only work with Original Medicare.


Notes

When you first enroll in Medicare, and during certain times of the year, you can choose how you get your Medicare coverage. Medicare covers many types of services, and you have options for how you get your Medicare coverage.

There are 2 main ways to get Medicare:

Original Medicare (see Lesson 4) Medicare Advantage (MA) (also known as Part C) (see Lesson 6)

Medicare Supplement Insurance (Medigap) policies only work with Original Medicare.

33

34

Medicare Coverage Options

Original Medicare (Part A and Part B) You can add a Medicare Supplement Insurance

(Medigap) policy You can add Medicare prescription drug coverage

(Part D)Medicare Advantage (MA) Plan (also known as Part C) Usually includes Part D


Notes

Medicare coverage options and costs are explained in this lesson. Information is provided on the following:

Original Medicare (Part A and/or Part B) Add a Medicare Supplement Insurance (Medigap) policy Add Medicare prescription drug coverage (Part D) Medicare Advantage (MA) Plan (also known as Part C) Usually includes Part D

35

Decision Comparison Summary: How They Work

Original Medicare Medicare Advantage (MA) Plan (Part C)

Covers Part A and Part B benefits Medicare provides this coverage

directly You have your choice of doctors and

hospitals that are enrolled in Medicare and accepting new Medicare patients

Generally, you (or your supplemental coverage) pay deductibles and coinsurance

You usually pay a monthly premium for Part B

Covers Part A and Part B benefits and may cover additional benefits (like vision or dental)

Coverage provided by private insurance companies approved by Medicare

In most plans, you need to use plan doctors, hospitals, or other providers or you pay more or all of the costs

You may pay a monthly premium (in addition to your Part B premium) and a copayment or coinsurance for covered services


Notes

This chart helps you compare Original Medicare and MA Plans side by side.

Let’s start with how Original Medicare works: Covers Part A and Part B benefits Medicare provides this coverage directly You have your choice of doctors and hospitals that are enrolled in Medicare and accepting new

Medicare patients Generally, you or your supplemental coverage pays deductibles and coinsurance You usually pay a monthly premium for Part B

This is how MA works: Covers Part A and Part B benefits and may cover additional benefits (like vision or dental) Coverage provided by private insurance companies approved by Medicare In most plans, you need to use doctors, hospitals, or other providers that are in the plan’s network,

or you may pay more or all of the costs You may pay a monthly premium (in addition to your Part B premium) and a copayment or

coinsurance for covered services

36

How Are Medigap Policies and Medicare Advantage (MA) Plans Different?

Medicare Supplement Insurance (Medigap) Policies

Medicare Advantage (MA) Plans

Offered by Private companies Private companiesGovernment Oversight

State, but must also follow federal laws

Federal (plans must be approved by Medicare)

Works with Original Medicare N/ACovers Gaps in Original Medicare

coverage, like deductibles, coinsurance, and copaymentsfor Medicare-covered services

All Part A- and Part B-covered services and supplies. May also cover things not covered by Original Medicare, like vision and dental coverage. Most MA Plans include Medicare prescription drug coverage.

You must have Part A and Part B Part A and Part BDo you pay a premium?

Yes. You pay a premium for the policy and you pay the Part B premium.

Yes. In most cases you pay a premium for the plan and you pay the Part B premium.


Notes

This chart displays a side-by-side comparison of Medigap policies and MA Plans.

Both are offered by private companies. Government Oversight—Medigap must follow federal and state laws, but routine day-to-day

oversight of standardized Medigap policies is under the purview of the states. MA Plans must be approved by Medicare.

Medigap only works with Original Medicare. MA Plans don’t work with Medigap policies. If you join an MA Plan, you can’t use a Medigap policy to pay for out-of-pocket costs you have in the MA Plan.

Original Medicare pays for many, but not all, health care services and supplies. Private insurance companies sell Medigap policies to help pay for some of the out-of-pocket costs (“gaps”) that Original Medicare doesn’t cover. Medigap policies don’t pay your Medicare premiums. Most Medigap policies don’t cover out-of-pocket drug expenses, and you would need to consider a Part D plan. Some older policies (no longer sold) may have included some drug expense coverage (Plan I). MA Plans cover Part A- and Part B-covered services, may include Part D, and may cover certain non-covered benefits like vision and dental.

In both cases, you must have Part A and Part B to join. You pay a premium for a Medigap policy or an MA Plan, and you pay the Part B premium. If you already have an MA Plan, it’s illegal for anyone to sell you a Medigap policy unless you’re

disenrolling from your MA Plan to go back to Original Medicare. Contact your State Insurance Department for information.

Lesson 4—Original Medicare (Part A and Part B)

Includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) If you want drug coverage,

you can join a separate Part D plan To help pay your out-of-pocket

costs in Original Medicare (like your deductible and 20% coinsurance), you can also shop for and buy supplemental coverageJune 2019 Understanding Medicare 37

Notes

One of your Medicare options is Original Medicare:

Includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). If you want drug coverage, you can join a separate Part D plan. To help pay your out-of-pocket costs in Original Medicare (like your deductible and 20%

coinsurance), you can also shop for and buy supplemental coverage. (Some examples include coverage from a Medicare Supplement Insurance (Medigap) policy, or coverage from a former employer or union.)

37

38

Original Medicare Coverage and CostsPart A and Part B

Part A (Hospital Insurance) Coverage and costsPart B (Medical Insurance) Coverage and costs Delaying Part B


Notes

Original Medicare is one way you can get your Medicare coverage. It includes Part A (Hospital Insurance) and Part B (Medical Insurance). Information about coverage and costs helps answer these questions:

Should I take Part A and Part B? When? What do I need to do if I’m not retiring at 65 (delaying Part B)?

39

Original Medicare CoveragePart A (Hospital Insurance)

Part AHospital Insurance

Part A (Hospital Insurance) helps cover medically necessaryInpatient care in a hospital

• Semi-private room, meals, general nursing, other hospital services and supplies, as well as care in inpatient rehabilitation facilities and inpatient mental health care in a psychiatric hospital (lifetime 190-day limit)

Inpatient Skilled Nursing Facility (SNF) care• After a related 3-day inpatient hospital stay If you meet all the criteria


Notes

Medicare Part A (Hospital Insurance) helps cover medically necessary inpatient services.

Inpatient hospital care – Semi-private room, meals, general nursing, other hospital services and supplies, as well as care in inpatient rehabilitation facilities and inpatient mental health care in a psychiatric hospital (lifetime 190-day limit). All people with Part A are covered for inpatient hospital care when all of these are true: • A doctor makes an official order that says you need 2 or more midnights of medically

necessary care to treat your illness or injury and the hospital formally admits you • You need the kind of care that can be given only in a hospital • The hospital accepts Medicare • The Utilization Review Committee of the hospital approves your stay while you’re in a hospital

Inpatient Skilled Nursing Facility (SNF) care (not custodial or long-term care) if you meet certain criteria. Skilled care involves safe and effective care given by skilled nursing or rehabilitative staff. Skilled nursing and therapy staff includes registered nurses, licensed practical and vocational nurses, physical and occupational therapists, speech-language pathologists, and audiologists. You must first have a related 3-day* inpatient hospital stay, not including the day you are discharged.

Medicare doesn’t pay for your hospital or medical bills if you aren’t lawfully present in the U.S. Also, in most situations, Medicare doesn’t pay for your hospital or medical bills if you’re incarcerated.

Note: If you are in the hospital as an outpatient and then are admitted as an inpatient, Medicare Part A coverage can be retroactive up to 3 days.

*If your doctor is participating in an Accountable Care Organization (or other type of Medicare initiative) that’s approved for a SNF 3-Day Rule Waiver, you may not need to have a 3-day inpatient hospital stay before getting coverage.

40

Original Medicare Coverage Part A (Hospital Insurance) (continued)


Part A (Hospital Insurance) helps coverBlood (inpatient)Certain inpatient religious, nonmedical health care in

approved religious nonmedical health care institutions (RNHCIs)Home health careHospice care What isn’t covered?✖ Private-duty nursing✖ Private room (unless medically necessary)✖ Television and phone in your room (if there’s a

separate charge for these items)✖ Personal care items, like razors or slipper socks


Notes

Here’s more detail about what’s covered under Part A:

Blood – If the hospital gets blood from a blood bank at no charge, you won’t have to buy it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Certain inpatient health care services in approved religious nonmedical health care institutions (RNHCIs) – Medicare will only cover the inpatient non-religious, nonmedical items and services. Examples include room and board, or any items or services that don’t require a doctor’s order or prescription, like unmedicated wound dressings or use of a simple walker.

Home health care. Hospice care.

What isn’t covered?

Private-duty nursing, private room (unless medically necessary), a television and phone in your room (if there’s a separate charge for these items), and personal care items, like razors or slipper socks.

41

Paying for Medicare Part A

Most people don’t pay a premium for Part A • If you paid Federal Insurance Contributions Act

(FICA) taxes for at least 10 years If you paid FICA taxes less than 10 years, you

can pay a monthly premium to get Part A May have a penalty if you don’t enroll when

first eligible for Part A (if you have to buy it)• Your monthly premium may go up 10%• You’ll have to pay the higher premium for twice

the number of years you could’ve had Part A, but didn’t sign up


Notes

You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid enough Medicare taxes while working. This is sometimes called premium-free Part A. Federal Insurance Contributions Act (FICA) tax is a U.S. federal payroll (or employment) tax imposed on both employees and employers to fund Social Security and Medicare. About 99% of people with Medicare don’t pay a Part A premium since they’ve worked at least 40 quarters (10 years) of Medicare-covered employment. Enrollees 65 and over and certain persons with disabilities who have fewer than 40 quarters of coverage pay a monthly premium to get coverage under Part A, unless they can get benefits through a spouse or family member’s record. If you aren’t eligible for premium-free Part A, you may be able to buy Part A if you’re 65 or older, and you’ve enrolled in (or are enrolling in) Part B, and meet the citizenship and 5-year

residency requirements. Under 65, have a disability, and your premium-free Part A coverage ended because you returned to

work. If you’re under 65 and have a disability, you may continue to get premium-free Part A for up to 8 1/2 years after you return to work.

In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. The amount of the Part A premium depends on how long you or your spouse worked in Medicare-covered employment.

Social Security determines if you have to pay a monthly premium for Part A. In 2019, the Part A premium for a person who has worked less than 30 quarters of Medicare-covered employment is $437 per month. Those who have between 30 and 39 quarters of coverage may buy Part A at a reduced monthly premium rate, which is $240 for 2019.

If you aren’t eligible for premium-free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up 10% for every 12 months you didn’t have the coverage. You’ll have to pay the higher premium for twice the number of years you could’ve had Part A, but didn’t sign up.

If you have limited income and resources, your state may help you pay for Part A and/or Part B. Call Social Security at 1‑800‑772-1213; TTY: 1-800-325-0778 for more information about the Part A premium.

42

Part A—What You Pay in Original Medicare

Hospital Inpatient Stay

The $1,364 deductible and no coinsurance for days 1–60 of each benefit period

$341 per day for days 61–90 each benefit period $682 per “lifetime reserve day” after day 90 of each benefit period

(up to 60 days over your lifetime) All costs for each day after the lifetime reserve days Note: Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime

Skilled Nursing Facility (SNF) Care

$0 for the first 20 days of each benefit period $170.50 per day for days 21–100 of each benefit period All costs for each day after day 100 in a benefit period

Home Health Care Services

$0 for home health care services 20% of the Medicare-approved amount for durable medical equipment

Hospice Care Nothing for hospice care Up to $5 per Rx to manage pain and symptoms

• While at home 5% for inpatient respite care

Blood If hospital gets it from a blood bank at no charge, you have no chargeJune 2019 Understanding Medicare 42

Notes

There are costs you pay in Original Medicare. The actual dollar amounts are updated yearly. To see the most current amounts, visit Medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html. This is what you pay per benefit period (discussed on the next slide) for Part A-covered medically necessary services:

Hospital Inpatient Stay: Medicare.gov/coverage/hospital-care-inpatient.html – The deductible amount, $1,364 for days 1–60 (no coinsurance); $341 for coinsurance per day for days 61–90, $682 for coinsurance per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime); all costs for each day after the lifetime reserve days. Note: Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.

SNF Care: Medicare.gov/coverage/skilled-nursing-facility-care.html – $0 for first 20 days of each benefit period; $170.50 for coinsurance per day for days 21–100 of each benefit period, set by law at 1/8 of the inpatient hospital deductible amount for that calendar year; all costs after day 100 (see benefit periods on the next page)

Home Health Care Services: Medicare.gov/coverage/home-health-services.html – $0 for home health care services; 20% of the Medicare-approved amount (coinsurance) for durable medical equipment (DME) for providers accepting assignment

Hospice Care • Nothing for hospice care

• Up to $5 per Rx to manage pain and symptoms while at home

• 5% for inpatient respite care

Blood: If the hospital gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Note: If you can’t afford to pay these costs, there are programs that may help. These programs are discussed later in Lesson 9.

https://synergye365-my.sharepoint.com/personal/cmcclure_seiservices_com/Documents/Documents/2%20Medicare%20&%20Medicaid%202019/Day%201%20Workbook_PowerPoint/Medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html

https://synergye365-my.sharepoint.com/personal/cmcclure_seiservices_com/Documents/Documents/2%20Medicare%20&%20Medicaid%202019/Day%201%20Workbook_PowerPoint/Medicare.gov/coverage/hospital-care-inpatient.html

https://synergye365-my.sharepoint.com/personal/cmcclure_seiservices_com/Documents/Documents/2%20Medicare%20&%20Medicaid%202019/Day%201%20Workbook_PowerPoint/Medicare.gov/coverage/skilled-nursing-facility-care.html

https://synergye365-my.sharepoint.com/personal/cmcclure_seiservices_com/Documents/Documents/2%20Medicare%20&%20Medicaid%202019/Day%201%20Workbook_PowerPoint/Medicare.gov/coverage/home-health-services.html

43

Benefit Periods in Original Medicare

Measures use of inpatient hospital and SNF services• Begins the day you first get inpatient

care in hospital or SNF• Ends when not in a hospital/SNF 60 days

in a row Pay Part A deductible for each

benefit periodNo limit to number of benefit

periods you can have

Ends 60 days in a row here…

Home

Not here...

Hospital or SNF

Benefit periods can span across calendar years.June 2019 Understanding Medicare 43

Notes

A benefit period refers to the way that Original Medicare measures your use of hospital and SNF services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins.

You must pay the Part A inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods you can have. Benefit periods can span across calendar years.

44

Inpatient or Outpatient—The 2-Midnight Rule

Your hospital status affects how much you pay out-of-pocket, what is covered by Part A and/or Part B, and whether Medicare will cover subsequent SNF care

Part A coverage of outpatient (observation stays) retroactive up to 3 days prior to formal hospital admission by your doctor

Medicare Outpatient Observation Notice (MOON) – provided when in observation status longer than 24 hours, but before 36th

hourInpatient – When you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.

Outpatient – When the doctor hasn’t written an order to admit you, even if you spend the night.


Notes

Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs, and lab tests) and may also affect whether Medicare will cover care you get in a SNF following your hospital stay. You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.

You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.

An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care, but your doctor must order such admission and the hospital must formally admit you for you to become an inpatient. If you have an MA Plan (like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)), your costs and coverage may be different. Check with your plan.

If you’re formally admitted to the hospital with a doctor’s order after receiving care in a hospital emergency department (ED), Part A will pay for the inpatient stay and generally all related outpatient services provided by the hospital up to 3 days (stays during observation status) preceding the admission date. However, the days prior to actually being formally admitted wouldn’t count toward the 3-day inpatient qualifying hospital stay requirement for Part A SNF coverage.

For more information, read “Are You a Hospital Inpatient or Outpatient?” at Medicare.gov/Publications/11435.

The Medicare Outpatient Observation Notice (MOON) (Form CMS 10611-MOON) is a standardized notice to inform people with Medicare (including health plan enrollees) that they are outpatients receiving observation services and aren’t inpatients of a hospital or critical access hospital (CAH). The MOON is to be provided if observation is longer than 24 hours, but before the 36th hour of observation. For more information, visit CMS.gov/medicare/medicare-general-information/bni. The form is available at Arsystemsdayegusquiza.com/cms_moon_form.pdf.

https://www.cms.gov/medicare/medicare-general-information/bni/

http://arsystemsdayegusquiza.com/cms_moon_form.pdf

Home Health Care Coverage

Usually, a home health care agency coordinates the services your doctor orders for you.

Intermittent skilled nursing carePhysical therapySpeech-language pathology servicesContinued occupational services,

and moreMedicare doesn’t pay for

✖ 24-hour-a-day care at home✖Meals delivered to your home✖ Homemaker services ✖ Personal care


Notes

Covered home health services include the following:

Intermittent skilled nursing care Physical therapy Speech-language pathology services Continued occupational services, and more May also include medical social services, part-time or intermittent home health aide services,

medical supplies for use at home, durable medical equipment, or injectable osteoporosis drugs

Usually, a home health care agency coordinates the services your doctor orders for you.

Original Medicare doesn’t pay for the following:

✖ 24-hour-a-day care at home

✖ Meals delivered to your home

✖ Homemaker services

✖ Personal care

Some of these services could be covered by a Medicare Advantage (MA) Plan. Check with the plan.

45

46

5 Required Conditions for Home Health Care Coverage

1. Must be homebound 2. Must need skilled care on part-time or

intermittent basis3. Must be under the care of a doctor

• Receiving services under a plan of care4. Have face-to-face encounter with doctor

• Prior to start of care or within 30 days5. Services must be from a Medicare-

approved home health agency (HHA)


Part AHospital

Insurance

Notes

To be eligible for home health care services, you must meet all of these conditions:

1. You must be homebound. An individual is considered “confined to the home” (homebound) if the following 2 criteria are met: (1) The patient must either, because of illness or injury, need the aid of supportive devices like crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence, OR (2) have a condition such that leaving his or her home is medically contraindicated. If the patient meets only one of the 2 previous conditions, then the patient must ALSO meet these 2 additional requirements: (1) There must exist a normal inability to leave home, AND (2) leaving home must require a considerable and taxing effort. You may leave home for medical treatment or short, infrequent absences for nonmedical reasons, like attending religious services. You can still get home health care if you attend adult day care.

2. You must need skilled care on an intermittent basis, or physical therapy, or speech-language pathology, or have a continuing need for occupational therapy.

3. Your doctor must decide that you need skilled care in your home and must make a plan for your care at home.

4. Prior to certifying your eligibility for the Medicare home health benefit, the doctor must document that the doctor or a non-doctor practitioner has had a face-to-face encounter with you. The encounter must be done up to 90 days prior, or within 30 days after the start of care. The law allows the face-to-face encounter to occur via telehealth in rural areas, in an approved originating site. This means medical or other health services given to a patient using a communications system (like a computer, phone, or television), by a practitioner in a location different from the patient’s home.

5. The home health agency (HHA) caring for you must be approved by Medicare.

Note: Part B also may pay for home health care under certain conditions. For instance, Part B pays for home health care if an inpatient hospital stay doesn’t precede the need for home health care, or when the number of Part A-covered home health care visits exceed 100. For more information, read “Medicare and Home Health Care,” at Medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf. You can also visit CMS.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html.

https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf

https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

47

Paying for Home Health Care

In Original Medicare you payNothing for covered home health care

services 20% of the Medicare-approved

amount • For durable medical equipment (DME)

Covered by Part B

Plan of care reviewed every 60 daysCalled episode of care


Part AHospital

Insurance

Notes

In Original Medicare, you pay nothing for Part A-covered home health care services provided by a Medicare-approved home health agency.

Durable medical equipment (DME), when ordered by a doctor, is paid separately by Medicare. This equipment must meet certain criteria to be covered. Medicare usually pays 80% of the Medicare-approved amount for certain pieces of medical equipment, like a wheelchair or walker. If your HHA doesn’t supply DME directly, the HHA staff will usually arrange for a home equipment supplier to bring the items you need to your home.

Medicare pays your Medicare-certified HHA one payment for covered services you get during a 60-day period. This 60-day period is called an “episode of care.” The payment is based on your condition and care needs.

To find an HHA in your area, visit Medicare.gov and use the Home Health Compare tool, or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048.

Note: Part A covers post-institutional home health services furnished during a home health “spell of illness” for up to 100 visits. After you exhaust 100 visits of Part A post-institutional home health services, Part B covers the balance of the home health “spell of illness.” The 100-visit limit doesn’t apply to you if you’re only enrolled in Part A. If you’re enrolled only in Part B and qualify for the Medicare home health benefit, then all of your home health services are paid for under Part B. There’s no 100-visit limit under Part B.

https://www.medicare.gov/

48

What Is Hospice Care?

Interdisciplinary team provides services for those with a life expectancy of 6 months or less, and their family, usually at home Focus is on comfort and pain relief, not cure Sign election statement choosing hospice care instead

of routine Medicare-covered benefits to treat your terminal illness Doctor must certify each “election period”

• Two 90-day periods• Then unlimited 60-day periods • Face-to-face encounter required

Hospice provider must be Medicare approved


Part AHospital

Insurance

Notes

Part A also covers hospice care, which is a special way of caring for people who are terminally ill and their families, usually at home or a facility you live in. However, Medicare also covers short-term hospital care when needed. Hospice care is meant to help you make the most of the last months of life by giving you comfort and relief from pain. It involves a team that addresses your medical, physical, social, emotional, and spiritual needs. The goal of hospice is to care for you and your family, not to cure your illness.

You must sign an election statement choosing hospice care instead of routine Medicare-covered benefits to treat your terminal illness. However, medical services not related to your hospice condition would still be covered by Medicare.

You can get hospice care as long as your doctor certifies that you’re terminally ill, and probably have less than 6 months to live if the illness runs its normal course. Care is given in “election periods”—two 90-day periods, followed by unlimited 60-day periods. At the start of each election period, your doctor must certify that you’re terminally ill for you to continue getting hospice care.

Medicare also requires face-to-face visits. The doctor is required to meet with you within 30 days of hospice recertification, starting before the third election period and each subsequent recertification.

The hospice provider must be Medicare approved.

For more information, read “Medicare Hospice Benefits” at Medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF.

https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF

https://www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.PDF

49

Covered Hospice Services

Physician and nursing services Physical, occupational, and speech-language

therapy Medical equipment and supplies Drugs for symptom control and pain relief Short-term hospital inpatient care for pain and

symptom management Respite care in a Medicare-certified facility

• Up to 5 days each time, no limit to number of times

Hospice aide and homemaker services Social worker services Grief, dietary, and other counseling


Part AHospital

Insurance

Notes

In addition to the regular Medicare-covered services, like doctor and nursing care, physical and occupational therapy, and speech-language therapy, the hospice benefit also covers

Medical equipment (like wheelchairs or walkers). Medical supplies (like bandages and catheters). Drugs for symptom control and pain relief. Short-term care in the hospital, hospice inpatient facility, or SNF when needed for pain and

symptom management. Inpatient respite care, which is care given to you by another caregiver, so your usual caregiver can

rest. You’ll be cared for in a Medicare-approved facility, like a hospice inpatient facility, hospital, or nursing home. You can stay up to 5 days each time you get respite care, and there’s no limit to the number of times you can get respite care. Hospice care is usually given in your home (or a facility you live in). However, Medicare also covers short-term hospital care when needed.

Hospice aide and homemaker services. Social worker services. Other covered services as well as services Medicare usually doesn’t cover, like spiritual, grief,

dietary, and other counseling.

50

Paying for Hospice Care

In Original Medicare you pay Nothing for hospice care Up to $5 per Rx to manage pain and symptoms

• While at home

5% for inpatient respite careRoom and board may be covered in certain cases Short-term respite care For pain/symptom management that can’t be

managed at home If you have Medicaid and live in a nursing facility



Notes

For hospice care in Original Medicare, you pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while receiving routine or continuous care at home, and 5% of the Medicare-approved payment amount for inpatient respite care. For example, if Medicare has approved a charge of $150 per day for inpatient respite care, you’ll pay $7.50 per day. The amount you pay for respite care can change each year.

Room and board are only payable by Medicare in certain cases. Room and board are covered during short-term inpatient stays for pain and symptom management, and for respite care. Room and board aren’t covered if you receive general hospice services while a resident of a nursing home or a hospice’s residential facility. However, if you have Medicaid as well as Medicare, and reside in a nursing facility, room and board are covered by Medicaid.

To find a hospice program, call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048, or your state hospice organization. For more information, see the “Medicare Benefit Policy Manual,” Chapter 9, Coverage of Hospice Services under Hospital Insurance, at CMS.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf

51

Decision: Do I Need to Sign up for Part A?

Consider It’s free for most people You can buy it if your work history isn’t sufficient

• There may be a penalty if you delay

Talk to your benefits administrator if you (or your spouse) are actively working and covered by an employer plan

Stop contributions to your Health Savings Account (HSA) before your Medicare starts to avoid Internal Revenue Service tax penalties June 2019 Understanding Medicare 51

Notes

If you’re receiving Social Security or Railroad Retirement Board (RRB) benefits at least 4 months before you turn 65, you’ll be automatically enrolled in premium-free Part A.

If you don’t get Part A automatically, you should consider signing up for Part A when you’re first eligible (during your Initial Enrollment Period (IEP)). Most people don’t pay a monthly premium for Part A coverage because they or their spouse paid Medicare taxes while working.

If you aren’t eligible for premium-free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could’ve had Part A, but didn’t sign up. The 10% premium surcharge will apply only after 12 months have elapsed from the last day of the IEP to the last date of the enrollment period you used to enroll. In other words, if it’s less than 12 months, the penalty won’t apply. This penalty also won’t apply to you if you’re eligible for a Special Enrollment Period (SEP). Remember, you’re only eligible for an SEP, when first eligible for Medicare, if you or your spouse (or family member if you’re disabled) is actively working and covered by a group health plan (GHP) through the employer or union based on that work, or during the 8-month period that begins the month after the employment ends or the GHP coverage ends, whichever happens first. If you’re still working or have coverage through a spouse, talk to your employer benefits coordinator to learn how enrolling in Medicare (or delaying enrollment) will affect your employer coverage.

You can no longer contribute to a Health Savings Account (HSA) if you have Medicare. Talk to your company’s benefits administrator about when you should stop contributing to an HSA if you plan to sign up for Medicare. You may have to stop contributing to your HSA up to 6 months before your Medicare starts if you delay enrolling because your Part A may be retroactive up to 6 month. It can’t be effective earlier than your first month of eligibility. You can withdraw money from your HSA after you enroll in Medicare to help pay for medical expenses (like deductibles, premiums, copayments). If you contribute to your HSA after you have Medicare, you could be subject to a tax penalty by the Internal Revenue Service (IRS). See IRS Publication 969 for more information: IRS.gov/pub/irs-pdf/p969.pdf.

https://www.irs.gov/pub/irs-pdf/p969.pdf

https://www.irs.gov/pub/irs-pdf/p969.pdf

Scenarios—Alex

Alex went to the Emergency Department at his local hospital. He was there for 3 days before the doctor wrote an order to admit him as an inpatient. He was in the hospital for 2 more days.


Notes

Alex went to the Emergency Department at his local hospital. He was there for 3 days before the doctor wrote an order to admit him as an inpatient. He was in the hospital for 2 more days.

52

Activity

How many days were covered by Part A?

If his doctor wanted him to get skilled care at a skilled nursing facility (SNF), would Original Medicare cover it?


Notes

How many days were covered by Part A?

_____ days

If his doctor wanted him to get skilled care at a skilled nursing facility, would Original Medicare cover it?

Yes

No


This policy is outlined in the regulations at 42 CFR 412.2(c)(5) and Chapter 12 90.7 of the claims processing manual (CMS.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf).

Other guidance would be the MLN Matters article on the window (CMS.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1232.pdf), the FAQ document (CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/CR7502-FAQ.pdf), and a public memo we wrote (CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/JSMTDL-10382-ATTACHMENT.pdf).

A publication, “Are You an Inpatient or an Outpatient?,” is available at Medicare.gov/Pubs/pdf/11435-Are-You-an-Inpatient-or-Outpatient.pdf.

53

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1232.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1232.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/CR7502-FAQ.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/CR7502-FAQ.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/JSMTDL-10382-ATTACHMENT.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/JSMTDL-10382-ATTACHMENT.pdf

https://www.medicare.gov/Pubs/pdf/11435-Are-You-an-Inpatient-or-Outpatient.pdf

https://www.medicare.gov/Pubs/pdf/11435-Are-You-an-Inpatient-or-Outpatient.pdf


Medicare Part A helps pay for all of the following when medically necessary and requirements are met, EXCEPT for…

a. Doctor servicesb. An inpatient hospital stayc. An inpatient skilled nursing facility (SNF)

stayd. Hospice care


Notes


Medicare Part A helps pay for all of the following when medically necessary and requirements are met, EXCEPT for…

a. Doctor services b. An inpatient hospital stay c. An inpatient skilled nursing facility (SNF) stay d. Hospice care


54

55

Medicare Part A Questions


Notes

56

Original Medicare Part B (Medical Insurance)

Part B (Medical Insurance) helps cover medically necessary Doctors’ services Outpatient medical and surgical services and supplies Clinical lab tests DME (like walkers and wheelchairs) Diabetic testing equipment and supplies Preventive services (like flu shots and a yearly wellness

visit) Home health care Medically necessary outpatient physical and occupational

therapy, and speech-language pathology services Outpatient mental health care services

Part BMedical Insurance


Notes

Medicare Part B helps cover medically necessary

Doctors’ services Outpatient medical and surgical services and supplies – For approved procedures like X-rays or

stitches. Clinical laboratory services – Blood tests, urinalysis, and some screening tests. DME – like walkers, wheelchairs, and canes. Diabetic testing equipment and supplies – Blood sugar (glucose) testing monitors, blood sugar

test strips, insulin, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes or inserts.

Preventive services – Many exams, tests, screenings, and some shots to prevent, find, or manage a medical problem (like flu shots and a yearly wellness visit).

Home health services – You can use your home health benefits under Part A and/or Part B. Part B pays for home health care if an inpatient hospital stay doesn’t precede the need for home health care, or when the number of Part A-covered home health care visits exceed 100. For more information, see the “Medicare and Home Health Care” publication (Medicare Product No. 10969) at Medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf. You can also visit CMS.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html.

Medically necessary outpatient physical and occupational therapy, and speech-language pathology services

Outpatient mental health care services

To find out if Medicare covers a service not on this list, visit Medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227): TTY 1-877-486-2048. You can also download the “What’s Covered” mobile app. The app is available for free on both the App Store and Google Play.



https://www.medicare.gov/coverage

57

What You Pay—Part B Premiums

Monthly Premium Standard premium is $135.50

(may have to pay a higher amount depending on your income; see next slide)

Some people who get Social Security benefits pay less than this amount



Notes

You pay a premium for Part B each month. The standard Part B premium amount in 2019 is $135.50. You may have to pay a higher amount, depending on your income (see next slide). However, some people who get Social Security benefits pay less than this amount. For 2019, about 3.5% of people with Medicare will pay less than the full Part B standard premium due to the statutory hold harmless provision, which limits the increase in the Part B premium to be no greater than the increase in their Social Security benefits.

Remember: This premium may be higher if you didn’t choose Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t take it. An exception would be if you can enroll in Part B during an SEP because you or your spouse (or family member if you’re disabled) is still employed and you’re covered by a GHP through that employment.

You’ll pay the standard premium (or higher) in 2019 if you:

Enroll in Part B for the first time in 2019. Don’t get Social Security benefits. Are directly billed for your Part B premiums. Have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard

premium amount of $135.50 in 2019). Had a modified adjusted gross income (MAGI) as reported on your IRS tax return from 2 years

ago above a certain amount. If so, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium (see next slide).

Monthly Part B Standard Premium—Income Related Monthly Adjustment Amount (IRMAA) for 2019


Notes

People with Medicare with higher incomes pay higher Medicare Part B monthly premiums. These income- related monthly premium rates affect roughly 5% of people with Medicare. The total Medicare Part B premiums for people with higher income for 2019 are shown below:

For those whose income is

$85,000 or less, and file an individual tax return, file a joint tax return with a yearly income of $170,000 or less, or who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, the Part B premium is $135.50 per month

Above $85,000–$107,000, and file an individual tax return, file a joint tax return with a yearly income above $170,000 and less than $214,000, the Part B premium is $189.60 per month

Above $107,000–$133,500, and file an individual tax return, file a joint tax return with a yearly income of above $214,000 and less than $267,000, the Part B premium is $270.90 per month

Above $133,500–$160,000, and file an individual tax return, file a joint tax return with an income above $267,000 up to $320,000, the Part B premium is $352.20 per month

Above $160,000 and less than $500,000, and file an individual tax return, file a joint tax return with an income above $320,000 and less than $750,000, the Part B premium is $433.40 per month

$500,000 or above, and file an individual tax return, file a joint tax return with an income above $750,000, the Part B premium is $460.50 per month

For those people with Medicare who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses whose income is

Above $85,000 and less than $415,000, the Part B premium is $433.40 per month Above $415,000, the Part B premium is $460.50 per month

If you have to pay a higher amount for your Part B premium and you disagree (for example, if your income goes down), call Social Security at 1-800‑772-1213; TTY: 1‑800‑325‑0778.

Note: You may pay more if you have a Part B late enrollment penalty.

58

59

Part B—What You Pay in Original Medicare

Yearly Deductible

$185

Coinsurance for Part B Services

20% coinsurance for most covered services, like doctor’s services and some preventive services, if provider accepts assignment $0 for most preventive services 20% coinsurance for outpatient

mental health services, and copayments for hospital outpatient services


Notes

In addition to premiums, there are other costs you pay in Original Medicare. This is what you pay in 2019 for Part B-covered medically necessary services, which are services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice:

The annual Part B deductible is $185 in 2019. If you have Original Medicare, you pay the Part B deductible, which is the amount a person must pay for health care each calendar year before Medicare begins to pay. This amount can change every year in January. This means that you must pay the first $185 of your Medicare-approved medical bills in 2019 before Part B starts to pay for your care.

After you meet the annual deductible, you pay coinsurance for Part B services. In general, it’s 20% for most covered services for providers accepting assignment. Assignment is an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance (usually 20% of the approved amount). If the assignment isn’t accepted, providers can charge you up to 15% above the approved amount (called the “limiting charge”), and you may have to pay the entire amount up front.

Most preventive services have no coinsurance, and the Part B deductible doesn’t apply as long as the provider accepts assignment. You pay 20% for outpatient mental health services (visits to a doctor or other health care provider to diagnose your condition or monitor or change your prescriptions, or outpatient treatment of your condition (like counseling or psychotherapy) for providers accepting assignment).

If you can’t afford to pay these costs, there are programs that may help. These programs are discussed later in Lesson 9.

60

Part B and Active Employment

If you don’t have coverage from an employer group health plan (GHP) Delaying Part B may mean

• Higher premiums• Paying for your health care out-of-pocket• Waiting until the next General Enrollment Period (GEP) to

enroll (January 1–March 31) With coverage not starting until July 1

If you do have coverage through a GHP You may want to delay Part B No penalty if you enroll while you have

coverage or within 8 months of losing coverage or employment Contact your benefits administrator



Notes

If you don’t take Part B when you’re first eligible, you’ll have to pay a late enrollment penalty of 10% for each full 12-month period you could’ve had Part B but didn’t sign up for it, except in special situations. In most cases, you’ll have to pay this penalty for as long as you have Part B. You also may have to wait to sign up during the annual General Enrollment Period (GEP), which runs from January 1–March 31 of each year. Your coverage will be effective July 1 of that year.

Having coverage through an employer group health plan (GHP) (including federal or state employment, but not military service) or union while you or your spouse (or family member if you’re disabled) is still working can affect your Part B enrollment rights. If you or your spouse are covered through active employment, you may have an SEP. This means you can join Part B anytime that you or your spouse (or family member if you’re disabled) is working, and covered by a GHP through the employer or union based on that work, or during the 8-month period that begins the month after the employment ends or the GHP coverage ends, whichever happens first. Usually, you don’t pay a late enrollment penalty if you sign up during an SEP. SEPs don’t apply to people with End‑Stage Renal Disease (ESRD).

You should contact your employer or union benefits administrator to find out how your insurance works with Medicare and if it would be to your advantage to delay Part B enrollment.

61

Decision: Should I Keep/Sign up for Part B?

Consider Most people pay a monthly

premium• Usually deducted from Social

Security/Railroad Retirement Board (RRB) benefits• Amount depends on income

It may supplement employer coverage• Contact your benefits administrator to understand the

impact to your employer plan• If you don’t have other coverage, declining Part B will

mean you don’t have full coverage

Sometimes, you must have Part B (see next slide)



Notes

If you’re already getting Social Security benefits (for example, getting early retirement benefits) at least 4 months before you turn 65, you’ll automatically be enrolled in Medicare Part A and Part B without an additional application. You’ll get your IEP package, which includes your Medicare card and other information, about 3 months before you turn 65 (coverage begins the 1st day of the month you turn 65), or 3 months before your 25th month of disability benefits (coverage begins your 25th month of disability benefits).

The Part B premium is usually deducted from monthly Social Security, Railroad Retirement, or federal retirement payments. The amount depends on your income and when you enroll in Part B. If you delay enrollment, you may have to pay a lifetime penalty, which is added to your monthly Part B premium.

People who don’t get a retirement payment, or whose payment isn’t enough to cover the premium, get a bill from Medicare for their Part B premiums. The bill can be paid by credit card, check, or money order.

Having employer or union GHP coverage while you or your spouse (or family member if you’re disabled) is still working can affect your Part B enrollment rights. This includes federal and state employment, and TRICARE active-duty military service. You should contact your employer or union benefits administrator to find out how your insurance works with Medicare and if you should enroll in Part B during your IEP.

If you don’t have other coverage, declining Part B will mean you don’t have full coverage.

There are situations where you must have Part B (see next slide).

62

When You Must Have Part B

If you want to buy a Medigap policy If you want to join a Medicare Advantage (MA)

Plan If you’re eligible for TRICARE for Life (TFL) or

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

If your employer coverage requires you have it (less than 20 employees)• Talk to your employer or union benefits administrator


Note: Veterans Affairs (VA) benefits are separate from Medicare. With VA benefits, you may choose to not enroll in Part B, but you pay a penalty if you don’t sign up for Part B during your Initial Enrollment Period (IEP) and enroll later (visit VA.gov). If you have VA coverage, you won’t be eligible to enroll in Part B using the Special Enrollment Period (SEP).


Notes

You must have Part B if

You want to buy a Medicare Supplement Insurance (Medigap) policy. You must have Part A as well.

You want to join an MA Plan. You must have Part A as well. You’re eligible for TRICARE for Life (TFL) or Civilian Health and Medical Program of the

Department of Veterans Affairs (CHAMPVA). TFL provides expanded medical coverage to Medicare-eligible uniformed services retirees 65 or older, to their eligible family members and survivors, and to certain former spouses. You must have Part A and Part B to get TFL benefits. However, if you’re an active-duty service member, or the spouse or dependent child of an active-duty service member, you don’t have to enroll in Part B to keep your TRICARE coverage. When the active-duty service member retires and coverage changes to TFL, you must enroll in Part B to keep your TFL coverage. You can get Part B during an SEP if you have Medicare because you’re 65 or older, or you’re disabled. For more information, visit Tricare.mil/mybenefit.

Your employer coverage requires you or your spouse/family member to have it—fewer than 20 employees (talk to your employer or union benefits administrator).

Veterans Affairs (VA) benefits are separate from Medicare. With VA benefits, you may choose to not enroll in Part B, but you pay a penalty if you don’t sign up for Part B during your IEP and enroll later (visit VA.gov). If you have VA coverage, you won’t be eligible to enroll in Part B using the SEP.

You must have Part A and Part B to keep your CHAMPVA coverage. For more information, visit VA.gov/PURCHASEDCARE/programs/dependents/champva/CHAMPVA_eligibility.asp.

Note: View or download “Your Guide to Who Pays First,” at Medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf.

https://tricare.mil/mybenefit

https://www.va.gov/

https://www.va.gov/communitycare/site_redirect.asp

http://medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf

http://medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf


For Medicare Part B, in most cases, you pay _______.

a. A monthly premiumb. A yearly deductiblec. 20% coinsurance for most covered servicesd. All of the above


Notes


For Medicare Part B, in most cases, you pay _______.

a. A monthly premium b. A yearly deductible c. 20% coinsurance for most covered services d. All of the above


63

64

Part B Questions


Notes

65

What ISN’T covered by Part A and Part B?

Some of the items and services that Part A and Part B of Medicare don’t cover include:✖Most dental care✖ Eye exams related to prescribing glasses✖ Dentures✖ Cosmetic surgery✖ Routine physical exams✖Massage therapy✖ Acupuncture✖ Hearing aids and exams for fitting them✖ Long-term care ✖ Concierge care (also called concierge medicine, retainer-based medicine, boutique

medicine, platinum practice, or direct care)

They may be covered if you have other coverage, like Medicaid or a Medicare Advantage (MA) Plan that covers these services


Notes

What ISN’T covered by Part A and Part B?

Medicare doesn’t cover everything. If you need certain services that aren’t covered under Medicare Part A or Part B, you’ll have to pay for them yourself unless: You have other coverage (including Medicaid) to cover the costs You’re in a Medicare Advantage (MA) Plan that covers these services

Some of the items and services that Original Medicare doesn’t cover include:

✖ Most dental care ✖ Eye examinations related to prescribing glasses ✖ Dentures ✖ Cosmetic surgery ✖ Routine physical exams ✖ Massage therapy ✖ Acupuncture ✖ Hearing aids and exams for fitting them ✖ Long-term care ✖ Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine,

platinum practice, or direct care)

66

Scenario—Edgar

Edgar is getting Medicare-covered home health care. On Monday, his daughter took him to a doctor’s appointment. On Sunday, she took him to church. On Wednesdays and Fridays he is picked up for Adult Day Care. As long as he meets the other requirements to get home health care, he still qualifies for home health coverage even though he was able to leave his house.a. Trueb. False


Notes

Edgar is getting Medicare-covered home health care. On Monday, his daughter picked him up and took him to a doctor’s appointment. On Sunday, she picked him up and took him to church. On Wednesdays and Fridays, he is picked up for Adult Day Care. As long as he meets all the other requirements to receive home health care, he still qualifies for home health coverage even though he was able to leave his house.

a. True

b. False See Appendix D for the answer.

Activity—Original Medicare Coverage

Part AHospital

Insurance

Part BMedical

Insurance

Is it covered by Part A or Part B?


Notes

Identify whether an item or service is covered under Medicare Part A or Part B.

67

#1—Part A or Part B?

Medically necessary doctor’s care


Notes

Which covers medically necessary doctor’s care? Write your answer below.

_________________________


68


Medically necessary inpatient hospital stay


Notes

Which covers medically necessary inpatient hospital stays? Write your answer below.

_________________________


69



Notes

Which covers many preventive services, including colonoscopies?

Write your answer below.

_________________________


70


Routine Eye Exam


Notes

Which covers routine eye exams? Write your answer below.

Write your answer below.

_________________________


71


Home Health Care


Notes

Which covers home health care? Write your answer below.

_________________________


72

73

Medicare Supplement Insurance (Medigap) Policies

Sold by private insurance companies

Fills gaps in Original Medicare coverage• Deductibles, coinsurance, copayments

All plans with same letter • Have same coverage• Costs are different

Plans are different in Minnesota, Massachusetts, and Wisconsin

June 2019Understanding Medicare 73

Original Medicare

Notes

Now let’s talk about one way to help address some of the costs associated with Original Medicare coverage. A Medicare Supplement Insurance (Medigap) policy is health insurance sold by private insurance companies to fill gaps in Original Medicare. Medigap policies can help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services. Some Medigap policies also cover certain benefits Original Medicare doesn’t cover, like medical care if you travel outside the U.S.

Medigap policies don’t cover your share of the costs under other types of health coverage, including MA Plans, stand-alone Medicare Prescription Drug Plans (PDPs), GHPs (like from an employer or union), Medicaid, VA benefits, or TRICARE.

In all states except Massachusetts, Minnesota, and Wisconsin, Medigap policies must be one of the standardized Plans A, B, C, D, F, G, K, L, M, or N so they can be easily compared. Each plan has a set of benefits that are the same for any insurance company. It’s important to compare Medigap policies, because costs can vary. Each company decides which Medigap policies it will sell and the price for each plan, with state review and approval.

For more information on Medigap, see Module 3 in the Training Library at CMSnationaltrainingprogram.cms.gov/?q=global-search&search=Medigap+policies&combine=Medigap+policies.

Also, to learn more about choosing a Medigap policy, visit Medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html.

https://cmsnationaltrainingprogram.cms.gov/?q=global-search&search=Medigap+policies&combine=Medigap+policies

https://cmsnationaltrainingprogram.cms.gov/?q=global-search&search=Medigap+policies&combine=Medigap+policies

https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies

https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies

Medigap Plans

Standardized plans identified by a letter (except in MA, MN, WI (waiver states))

Plans with the same letter must offer all the same benefits

Companies don’t have to sell all plans

Plans Currently Sold Plans that Exist, But AreNo Longer Sold

A, B, C, D, F, G, K, L, M, and N E, H, I, and J

For help, contact your local State Health Insurance Assistance Program (SHIP) or your State Insurance Department


MedigapMedicare

Supplement Insurance

Notes

In most states, Medigap insurance companies can only sell you a standardized Medigap policy identified by letters A, B, C, D, F, G, K, L, M, and N. Plans D and G with an effective date on or after June 1, 2010, have different benefits than Plans D and G bought before June 1, 2010. Plans E, H, I, and J are no longer sold, but if you already have one, you can generally keep it. Plan F has a high-deductible option.

Medigap policies are standardized in a different way in Massachusetts, Minnesota, and Wisconsin. These are called waiver states.

The benefits in any Medigap plan identified with the same letter are the same regardless of which insurance company you purchase your policy from. Cost is usually the only difference between Medigap plans with the same letter sold by different insurance companies. You’re encouraged to shop carefully for a Medigap policy.

Insurance companies selling Medigap policies are required to make Plan A available. If they offer any other Medigap plan, they must also offer either Medigap Plan C or Plan F. Not all types of Medigap policies may be available in your state. Call your State Health Insurance Assistance Program (SHIP) (1-877-839-2675) or visit shiptacenter.org for more information and to locate the SHIP in your state.

Some people may still have a Medigap policy they purchased before the plans were standardized. If they do, they can keep them. If they drop them, they may not be able to get them back.

See slide 81 for upcoming Medigap changes.

74

https://www.shiptacenter.org/

Medigap Plans Basic Benefits

Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used)

The Part A hospice care coinsurance or

copayment

Blood (first 3 pints) Medicare Part B coinsurance or

copayment

All Medigap Plans Cover

MedigapMedicare



Notes

Each standardized Medigap plan must offer the same basic benefits, no matter which insurance company sells it. These include Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used), Medicare Part B coinsurance or copayments, blood (first 3 pints), and the Part A hospice care coinsurance or copayments.

75

Medigap Plan Coverage

*Plan F is also offered as a high-deductible plan by some insurance companies in some states. If you choose this option, this means you must pay for Medicare-covered costs (coinsurance, copayments, deductibles) up to the deductible amount of $2,300 before your policy pays anything. **For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible, $185, the Medigap plan pays 100% of covered services for the rest of the calendar year. ***Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.June 2019 Understanding Medicare

76

Notes

All Medigap policies cover a basic set of benefits, including the following:

All plans pay 100% of Medicare Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up. Plan F also offers a high-deductible plan in some states.

Plans A, B, C, D, F, G, M, and N pay 100% of the Medicare Part B coinsurance or copayment. Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits, and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission. Plan K pays 50% of the Medicare Part B coinsurance or copayment, with Plan L paying 75%.

Plans A, B, C, D, F, G, M, and N pay 100% of blood (first 3 pints). Plan K pays 50%, and Plan L pays 75%.

Plans A, B, C, D, F, G, M, and N pay 100% of the Part A hospice care coinsurance or copayment. Plan K pays 50% and Plan L pays 75%.

In addition, each Medigap plan covers different benefits:

• Plans C, D, F, G, M, and N cover 100% of the SNF care coinsurance; Plan K covers 50%; and Plan L covers 75%.

• Plans B, C, D, F, G, and N cover 100% of the Medicare Part A deductible; Plans K and M cover 50%; and Plan L covers 75%.

• Medigap Plans C and F cover 100% of the Medicare Part B deductible. • Medigap Plans F and G cover 100% of the Medicare Part B excess charges. • Medigap Plans C, D, F, G, M, and N cover 80% of foreign travel emergency costs up to the

plans’ limits. • In 2019, Plans K and L have out-of-pocket limits of $5,560 and $2,780, respectively.

76

Medigap Costs

Is medical underwriting

used?

Cost (Monthly Premium)

Varies Due To:

Is it a Medicare SELECT policy?

Are you in your

Medigap Open

Enrollment Period?

Where do you live (ZIP, rural, urban, etc.)?

Which company is

providing the policy/plan?

Your age, in some states, age-rated or

under 65.

MedigapMedicare



Notes

There can be big differences in the premiums that different insurance companies charge for exactly the same coverage. Costs can depend on your age. In some states, people under 65 can’t buy a Medigap policy, and some states allow companies to sell Medigap policies that could cost more if you’re older when you buy it (age-rated) or when you get older (attained-age rated), where you live (for example, urban, rural, or ZIP Code); the company selling the policy; and the plan you buy (for instance, if it’s a high-deductible Plan F or has more benefits). The cost of your Medigap policy may also depend on whether the insurance company does any of the following:

Offers discounts (like discounts for women, non-smokers, or people who are married; discounts for paying yearly; discounts for paying your premiums using electronic funds transfer; or discounts for multiple policies).

Uses medical underwriting (reviews your medical history to decide whether to accept your application, and add a waiting period for a pre-existing condition, if your state law allows it); or applies a different premium when you don’t have a guaranteed issue right; or aren’t in your Medigap Open Enrollment Period (OEP). If you buy it during your Medigap OEP, you get the best cost.

Sells Medicare SELECT policies that may require you to use certain providers. If you buy this type of Medigap policy, your premium may be less.

77

78

When Is the Best Time to Buy a Medigap Policy?

Consider Your Medigap Open Enrollment Period (OEP) begins the

month you’re 65 or older AND enrolled in Part B• Lasts 6 months minimum, may be longer in your state• You have protections

During your Medigap OEP, companies can’t do the following:• Refuse to sell you any Medigap policy they offer• Make you wait for coverage (there can be a waiting period for pre-

existing conditions if you don’t have creditable coverage before the OEP)• Charge more because of a past/present health problem

You can also buy a Medigap policy whenever a company agrees to sell you one• If later, there may be restrictions


Medigap Policy

Notes

Usually the best time to buy a Medigap policy is during your Medigap Open Enrollment Period (OEP). It begins when you’re 65 or older and enrolled in Part B for the first time. You must also have Medicare Part A to have a Medigap policy.

You have a 6-month Medigap OEP, which gives you a guaranteed right to buy a Medigap policy. Some states may have a longer period. Once this period starts, it can’t be delayed or repeated.

During your Medigap OEP, companies can’t do the following:

Refuse to sell you any Medigap policy they offer Make you wait for coverage (there can be a waiting period for pre-existing conditions if you don’t

have creditable coverage—previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under Medigap policy—before the OEP)

Charge more because of a past/present health problem

You may want to apply for a Medigap policy before your Medigap OEP starts if your current health insurance ends the month you become eligible for Medicare, or you reach 65, to have continuous coverage without any break.

You can also buy a Medigap policy whenever a company agrees to sell you one. However, there may be restrictions, like medical underwriting or a waiting period for pre-existing conditions.

Medical underwriting is a process used by insurance companies to try to figure out your health status when you’re applying for health insurance to determine whether to offer you coverage, at what price, and with what exclusions or limits.

79

Decision: Do I Need a Medigap Policy?

Consider It only works with Original Medicare Do you have other supplemental coverage?

• Like from an employer• If so, you might not need Medigap

Can you afford Medicare deductibles and copayments? What does the monthly Medigap premium

cost?


Medigap Policy

Notes

A Medigap policy only works with Original Medicare; Medigap doesn’t work with MA. If you have other coverage that supplements Medicare, like retiree coverage, you might not need

Medigap. You need to consider whether you can afford Medicare deductibles and copayments and weigh

this against how much the monthly Medigap premium costs.

80

How To Buy a Medigap Policy

Decide which Medigap plan (A–N) has the benefits you need• Compare plans by computer or phone

Visit Medicare.gov/find-a-plan and use the Medigap comparison tool Call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048

Find out which insurance companies sell Medigap policies in your state • Contact your State Health Insurance Assistance Program (SHIP) at

shiptacenter.org, your State Insurance Department, or visit Medicare.gov/find-a-plan

• Check if your state extends protections for those with a disability

Call the insurance companies and shop around for the best plan at a price you can afford

Once you choose the insurance company and the Medigap Plan, apply for the policy


Medigap Policy

Notes

To buy a Medigap policy, follow these steps:

Decide which Medigap plan (A–N) has the benefits you need. You can use the Medigap comparison tool on Medicare.gov/find-a-plan to compare your plans or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048.

Find out which insurance companies sell Medigap policies in your state by contacting your State Health Insurance Assistance Program (SHIP) at shiptacenter.org, or you can contact your State Insurance Department at Medicare.gov/Contacts/#resources/sids, or visit Medicare.gov/find-a-plan.

Federal Medigap protections aren’t offered for people with Medicare due to a disability, so contact your State Insurance Department to determine if your state extends protections to people under 65.

Call the insurance companies and shop around for the best plan at a price you can afford. Buy the Medigap policy. Once you choose the insurance company and the Medigap plan, apply

for the policy. The insurance company must give you a clearly worded summary of your Medigap policy when you apply.

For more information:

View the booklet “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” at Medicare.gov/Pubs/pdf/02110-Medicare-Medigap-guide.pdf.

Call your State Insurance Department. Visit Medicare.gov/contacts, or call 1‑800‑MEDICARE (1-800-633-4227); TTY 1-877-486-2048, to get the phone number.

https://www.medicare.gov/find-a-plan/questions/home.aspx


https://www.medicare.gov/Contacts/#resources/sids



https://www.medicare.gov/Pubs/pdf/02110-Medicare-Medigap-guide.pdf

https://www.medicare.gov/contacts/

81

2020 Medigap Changes

On or after January 1, 2020, no standardized Medigap policy may provide coverage of the Part B deductible Insurance companies can’t sell standardized Plans C

or F to people newly eligible for Medicare • Turning 65 as of January 1, 2020, or later• Getting premium-free Part A as of January 1, 2020, or later

A person who isn’t “newly eligible for Medicare” on January 1, 2020, or later can apply to buy Plan C or F, but this doesn’t qualify as a guaranteed issue right to buy it Insurance companies may sell Plans C or F to those

getting Medicare retroactively with Part A start date before January 1, 2020


Medigap Policy

Notes

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bipartisan legislation signed into law on April 16, 2015. It changed who’s eligible to purchase a Medigap policy that provides coverage of the Part B deductible.

Starting January 1, 2020, Medigap plans sold to new people with Medicare won’t be allowed to cover the Part B deductible. Because of this, Plans C and F won’t be available to people who are newly eligible for Medicare on or after January 1, 2020. If you already have either of these 2 plans (or the high-deductible version of Plan F), or are covered by one of these plans before January 1, 2020, you’ll be able to keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans.

A person who isn’t a “newly eligible Medicare beneficiary” on January 1, 2020, or later can apply to buy Plan C or F and the insurance company is allowed to sell the policy by MACRA. The insurance company isn’t required to sell the policy because a guaranteed issue right isn’t active.

Insurance companies can sell a Plan C or F to a person who gets retroactive Medicare premium-free Part A before January 1, 2020.

Plans C and F will remain active for people who already had them. Plans C and F are guaranteed renewable unless the premiums aren’t paid. There is no federal guaranteed issue right to transfer from Plans C or F to other plan types. Check with your state to see if it has more generous rules.

Check Your Knowledge—Question 4

Medigap policies may help pay for Medicare Prescription Drug Plan (PDP) copayments.

a. Trueb. False


Notes


Medigap policies may help pay for Part D prescription drug plan copayments.

a. True b. False


82

Lesson 5—Medicare Prescription Drug Coverage (Part D)

An optional benefit available to all people with Medicare

Run by private companies that contract with Medicare

Provided through• Medicare Prescription Drug Plans

(PDPs) (work with Original Medicare)

• Medicare Advantage Prescription Drug Plans (MA-PDs)

• Some other Medicare health plans Like Cost Plans


Can add to Original Medicare

Usually included in Medicare Advantage (MA)

Part DMedicare

prescription drug coverage

Notes

Medicare Part D is Medicare prescription drug coverage. It’s an optional benefit available to all people with Medicare. If you choose Original Medicare and you want prescription drug coverage, you must choose and join a Medicare Prescription Drug Plan (PDP). You usually pay a monthly premium.

These plans are run by private companies that contract with Medicare.

Part D coverage is provided through Medicare PDPs and Medicare Advantage (MA) Plans with Medicare prescription drug coverage (MA-PDs).

There are some other types of Medicare health plans that provide health care coverage that aren’t MA Plans, but are still part of Medicare, like Medicare Cost Plans and Programs of All-inclusive Care for the Elderly (PACE). Some of these plans provide Medicare Part A and Part B coverage, while others provide Part B coverage only. Some also provide Part D coverage. These plans have some of the same rules as MA Plans, as you’ll see later in this presentation. However, each type of plan has special rules and exceptions, so you should contact any plans you’re interested in to get more details.

For help choosing a Part D plan, contact your local State Health Insurance Assistance Program (SHIP). To find the contact information for your local SHIP, visit shiptacenter.org.

83


Medicare Drug Plan Costs—What You Pay in 2019

Part DMedicare


Costs vary by plan In 2019, most people will pay

• A monthly premium (varies by plan and income)

• A yearly deductible (if applicable)• Copayments or coinsurance• Percentage of cost while in the coverage gap,

beginning at $3,820• Very little after spending $5,100 out-of-

pocket—automatically get catastrophic coverage


Notes

Costs vary by plan

In 2019, most people will pay

A monthly premium (varies by plan and income) A yearly deductible (if applicable) Copayments or coinsurance Percentage of cost while in the coverage gap, beginning at $3,820 Very little after spending $5,100 out-of-pocket—automatically get catastrophic coverage

84

85

Monthly Part D Premium—Income Related Monthly Adjustment Amount (IRMAA) for 2019


Notes

In 2019, you pay only your plan premium if your yearly income in 2017 was $85,000 or less for an individual, or $170,000 or less for a married couple.

For 2019, if you reported a modified adjusted gross income (MAGI) of more than $85,000 (individuals) or $170,000 (married individuals filing jointly) on your 2017 IRS tax return (the most recent tax return information provided to Social Security by the Internal Revenue Service (IRS)), you’ll have to pay the Part D Income Related Monthly Adjustment Amount (IRMAA) in addition to your monthly Medicare drug plan premium (YPP).

It’s important to note that in 2018, the last income level for filing as an individual tax return was above $160,000, and filing a joint tax return was above $320,000. For 2019, an additional income level was added and the requirements changed for those who are married or separated and file separate tax returns.

Above $160,000 and less than $500,000, and file an individual tax return, file a joint tax return with an income above $320,000 and less than $750,000, you pay YPP and IRMAA of $70.90 per month.

$500,000 or above, and file an individual tax return, file a joint tax return with an income above $750,000, you pay YPP and IRMAA of $77.40 per month.

Social Security makes IRMAA determinations. If you disagree, or if your income changes for certain reasons, like divorce or retirement, you may be able to reduce your IRMAA. Visit https://www.ssa.gov/forms/ to view and print a copy of the “Medicare Income Related Monthly Adjustment Amount–Life-Changing Event form.”

https://www.ssa.gov/forms/

86

How Medicare Part D Works

Part DMedicare


It’s optional • You can choose a plan and join• May pay a lifetime penalty if you join late

Plans have formularies • Lists of covered drugs• Must include range of drugs in each category• Are subject to change—you’ll be notified

Your out-of-pocket cost may be lower if you use a preferred pharmacy

If you have limited income and resources, there’s Extra Help to pay Part D costs


Notes

Medicare contracts with private insurance companies that offer prescription drug plans to people with Medicare. Everyone with Medicare can get Medicare prescription drug coverage by enrolling in a Medicare drug plan. You may pay a penalty if you join later. You may get this coverage from an MA Plan (with prescription drug coverage), but to join an MA Plan you must have Part A and Part B.

Each plan has a formulary, or list of covered drugs. The formulary for each plan must include a range of drugs in the most commonly prescribed categories. This ensures that people with different medical conditions can get the treatment they need. All Medicare drug plans generally must cover at least 2 drugs in each category of drugs, but plans can choose which specific drugs are covered in each category.

Medicare drug plans must cover all drugs in 6 protected categories to treat certain conditions: Cancer drugs HIV/AIDS drugs Antidepressants

Antipsychotics Anticonvulsants Immunosuppressants

Also, Medicare drug plans must cover all commercially available vaccines, including the shingles shot (but not vaccines covered under Part B, like the flu and pneumococcal shots). You or your health care provider can contact your Medicare drug plan for more information about vaccine coverage and any additional information the plan may need. View the Code of Federal Regulations’ Access to covered Part D drugs, §423.120(d), ecfr.gov/cgi-bin/text-idx?SID=7805cfe316ca233ff673e2e02b0e6b74&mc=true&node=se 42.3.423_1120&rgn=div8. You or your provider can contact your Medicare drug plan for more information about vaccine coverage and any additional information the plan may need.

Formularies are subject to change and can be changed by the plan. Your plan will notify you of any formulary changes that affect drugs you’re taking. Plans may have preferred pharmacies. If you use a preferred pharmacy, your out-of-pocket costs may be lower.

People with limited income and resources may be able to get Extra Help paying for their Medicare drug plan costs. “Extra Help” is discussed in further detail later in the presentation.

https://ecfr.gov/cgi-bin/text-idx?SID=7805cfe316ca233ff673e2e02b0e6b74&mc=true&node=se%2042.3.423_1120&rgn=div8

https://ecfr.gov/cgi-bin/text-idx?SID=7805cfe316ca233ff673e2e02b0e6b74&mc=true&node=se%2042.3.423_1120&rgn=div8

Who Can Join Part D?

Part DMedicare


You must have Medicare Part A and/or Part B to join a Medicare Prescription Drug Plan (PDP)

You must have Medicare Part A and Part B to join a Medicare Advantage Plan with drug coverage (MA-PD)

You must have Medicare Part A and Part B or only Part B to join a Medicare Cost Plan with Part D coverage

You must live in the plan’s service area • You can’t be incarcerated• You can’t be unlawfully present in the U.S.• You can’t live outside the U.S.

You must join a plan to get drug coverage (in most cases)


Notes

To join a Medicare Prescription Drug Plan (PDP), you must have Medicare Part A and/or Part B. To join an MA Plan with prescription drug coverage (MA-PD), you must have both Medicare Part A and Part B. To join a Medicare Cost Plan with prescription drug coverage, you must have Medicare Part A and Part B, or have Medicare Part B only. A Medicare Cost Plan is a type of Medicare health plan that’s available in some areas. If you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Medicare Cost Plan pays for emergency services or urgently needed services).

Each plan has its own service area, which you must live in to enroll. People living in the U.S. territories, including Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa, can enroll. If you live outside the U.S. and its territories, or if you’re incarcerated, you’re not eligible to enroll in a plan. This means you can’t get Part D coverage. You must be lawfully present in the U.S. to be eligible to enroll in a plan.

Most people must join a Medicare drug plan to get coverage. So, while all people with Medicare can have this coverage, you need to take action to get it. If you qualify for Extra Help to pay for your prescription drugs, Medicare will enroll you in a Medicare drug plan unless you decline coverage or join a plan yourself. You can only be a member of one Medicare drug plan at a time.

87

88

Part D Late Enrollment Penalty

You may have to pay more if you wait to enroll Exceptions if you have

• Creditable drug coverage • Extra Help

You’ll pay the penalty for as long as you have coverage 1% for each full month eligible and without

creditable prescription drug coverage Multiply percentage by base beneficiary

premium ($33.19 in 2019) Amount changes every year


Part DMedicare


Notes

If you choose not to join a Medicare drug plan at your first opportunity, you may have to pay a late enrollment penalty in addition to your regular monthly premium if you enroll later. If you had other creditable drug coverage or if you qualify for Extra Help, you won’t have to pay a late enrollment penalty.

Medicare calculates the late enrollment penalty by multiplying 1% times the number of full, uncovered months you didn’t have Part D (once you were eligible) or creditable drug coverage times the current “national base beneficiary premium” ($33.19 in 2019). The final amount is rounded to the nearest $.10 and added to your plan’s monthly premium. The national base beneficiary premium may change each year, so the penalty amount may also change each year. You may have to pay this penalty for as long as you have a Medicare drug plan.

Your Medicare plan is required to tell you if you owe a penalty, and what your payment will be. The late enrollment penalty goes to the Medicare Trust Fund, not the plan. If you don’t agree with your late enrollment penalty, you may be able to ask Medicare for a review or reconsideration. You’ll need to fill out a reconsideration request form (that your plan will send you), and you’ll have the chance to provide proof that supports your case.

89

Part D Cost Considerations

Plans have formularies (lists of covered drugs)• Make sure the prescriptions you need are covered by

the plan• Can you use a preferred pharmacy?

You can choose a plan and join• May pay a lifetime penalty if you join later and didn’t

have creditable coverage (no more than a 63-day gap)

Costs vary by plan There’s Extra Help to pay Part D costs if you

have limited income and resources

Part DMedicare



Notes

Everyone with Medicare can get Medicare prescription drug coverage by enrolling in a Medicare drug plan. Each plan has a formulary, or list of covered drugs. Check that your prescriptions are covered, and compare the amount you’ll pay. You may have lower out-of-pocket costs if you have access to and use a preferred pharmacy.

You may pay a late enrollment penalty if you join later. You may get this coverage from an MA Plan (with prescription drug coverage), but you must have Part A and Part B.

Costs vary depending on the plan. All Medicare drug plans have to provide at least a standard level of coverage set by Medicare. However, some plans might offer more coverage and additional drugs, generally for a higher monthly premium.

For more information, visit CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf.

If you have limited income and resources, you may qualify for Extra Help to pay for your Medicare prescription drug coverage (see Lesson 9).

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf

90

When Can I Enroll in a Part D plan?

Part DMedicare


During your 7-month Initial Enrollment Period (IEP) During the yearly Open Enrollment Period (OEP)

• October 15–December 7 each year• Coverage begins January 1

If you get Part B for the first time during a General Enrollment Period (GEP) you can join a Part D plan from April 1–June 30 with coverage starting July 1

May be able to join at other times• MA OEP (January 1–March 31 each year)

Must be in an MA Plan already on January 1• Special Enrollment Period (SEP)

If you qualifyJune 2019 Understanding Medicare 90

Notes

You can join a Medicare drug plan when you first become eligible for Medicare, during your Initial Enrollment Period (IEP), which begins 3 months immediately before your first entitlement to both Medicare Part A and Part B.

The Annual Election Period (AEP)/Open Enrollment Period (OEP) – This period is from October 15–December 7. Any eligible person can join, switch, or drop a Medicare drug plan at this time. Each year, you have a chance to make changes to your MA or Medicare prescription drug coverage for the following year. Your coverage starts January 1. For most people, this is the one time each year that changes can be made. If you make a change during this time, your new coverage starts on January 1, if the plan gets your request by December 7. If you don’t have Medicare Part A coverage, and enroll in Medicare Part B during the General Enrollment Period (GEP) (January 1–March 31), you can sign up for a Medicare PDP from April 1–June 30. Your coverage begins on July 1.

The MA OEP is from January 1–March 31 each year. Your coverage begins the first day of the month after you enroll in the plan. You must be in an MA Plan already on January 1 to use this enrollment period. However, in certain situations you may join at other times, like when you switch from MA (MA OEP) to Original Medicare, you may add Part D coverage. Generally, you must stay enrolled for the calendar year.

You may be able to change your coverage mid-year if you qualify for a Special Enrollment Period (SEP) when certain events happen in your life. Check with your plan for more information.

91

Choosing a Part D Plan

Part DMedicare


Compare plans by computer or phone Use the Medicare Plan Finder at Medicare.gov/find-a-plan

• Updated Plan Finder available for those who want to try it

Call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048 Contact your State Health Insurance Assistance Program (SHIP)

for help comparing plans at shiptacenter.org

To join a Part D plan Enroll at Medicare.gov/find-a-plan Call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048 Enroll on the plan’s website or call the plan Complete a paper enrollment form The plan will notify you whether it has accepted or denied your

application• You can’t be denied based on health condition or the drugs you take


Notes

There’s help available to find the Medicare drug plan for you. You can use the Medicare Plan Finder at Medicare.gov/find-a-plan, or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048; or contact your State Health Insurance Assistance Program (SHIP) at shiptacenter.org for free counseling to help you compare Medicare drug plans.

After you pick a plan that meets your needs, call the company offering it and ask how to join. All plans must offer paper enrollment applications. Also, plans may let you enroll through their website or over the phone. Most plans also participate and offer enrollment through Medicare.gov/find-a-plan. An updated Plan Finder is available for those who want to try it. You can also call Medicare to enroll at 1-800-MEDICARE; TTY: 1-877-486-2048.

Plans must process applications in a timely manner. After you apply, the plan must notify you whether it has accepted or denied your application. Plans aren’t allowed to deny your application based on your health condition or the drugs you’re taking.




92

Decision: Should I Enroll in a Part D plan?

Part DMedicare


Consider Do you have creditable drug coverage?

• Coverage as good as Medicare’s For example, through an employer plan No penalty if you have creditable drug coverage and delay

enrolling in a Medicare drug plan

Will that coverage end when you retire? How much do your current drugs cost? What do the premiums cost for Part D plans?Without creditable coverage Later enrollment may mean you pay a penalty

• If you go 63 or more days in a row without creditable coverage


Notes

People who have another source of drug coverage, through a former employer for example, may choose to stay in that plan and not enroll in a Medicare drug plan. If your other coverage is at least as good as Medicare prescription drug coverage, called “creditable” coverage, you won’t have to pay a late enrollment penalty if you later join a Medicare drug plan. Your other plan will notify you to let you know if your coverage is creditable. This notice will explain your options. You can contact your plan’s benefits administrator for more information. Also, you may want to consider keeping your creditable prescription drug coverage rather than choosing a Medicare drug plan. It’s important to find out how Medicare coverage affects your current health insurance plan to be sure you don’t lose doctor or hospital coverage for yourself or your family members.

Some examples of coverage that may be considered creditable include group health plans (GHPs), Federal Employees Health Benefits (FEHB), State Pharmaceutical Assistance Programs (SPAPs), Veterans Affairs (VA) coverage, and military coverage, including TRICARE.

Even if you don’t take many prescriptions now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a lifetime late enrollment penalty if you join a plan later.

You may owe a late enrollment penalty if, at any time after your IEP is over, there’s a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. The cost of the late enrollment penalty depends on how long you went without creditable prescription drug coverage. After you join a Medicare PDP, the plan will tell you what your premium will be. If you don’t agree with the late enrollment penalty, you may be able to ask the plan for a reconsideration. Complete the form the plan sends you. Return it to the address provided or fax it to the number on the form within 60 days from the date on the letter telling you that you owe a late enrollment penalty. Include proof, like a copy of your notice of creditable coverage.


Medicare prescription drug coverage is also called _____.

a. Part A b. Part B c. Part D d. All of the above


Notes


Medicare prescription drug coverage is also called _____.

a. Part A b. Part B c. Part D d. All of the above


93


It’s July. You enrolled in Medicare last year but didn’t enroll in a Medicare drug plan. You don’t have creditable drug coverage. Generally, when is your next chance to enroll in Part D?a. Open Enrollment Period (OEP)b. Initial Enrollment Period (IEP)c. Your next birthdayd. 12 months after your IEP


Notes


It’s July. You enrolled in Medicare last year but didn’t enroll in a Medicare drug plan. You don’t have creditable drug coverage. Generally, when is your next chance to enroll in Part D?

a. Open Enrollment Period (OEP)

b. Initial Enrollment Period (IEP)

c. Your next birthday

d. 12 months after your IEP


94

95

Part D Questions


Notes

Lesson 6―Medicare Advantage (MA) Plans (Part C)

An MA Plan (like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)) is another way to get your Medicare coverage (sometimes called “Part C” or “MA Plans”) Offered by Medicare-approved private

companies that must follow rules set by Medicare If you join an MA Plan, you’ll still have

Medicare but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the MA Plan, not Original Medicare • You’ll need to use health care providers who

participate in the plan’s network (some plans offer out-of-network coverage)


Notes

A Medicare Advantage (MA) Plan (like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)) is another way to get your Medicare coverage. MA Plans, sometimes called “Part C,” are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join an MA Plan, you’ll still have Medicare but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the MA Plan, not Original Medicare. In most cases, you’ll need to use health care providers who participate in the plan’s network. Some plans offer out-of-network coverage.

If you choose an MA Plan, your plan will give you a card to use when you get health care services and supplies. Your MA Plan ID card is your main card for Medicare. However, you also may be asked to show your Medicare card, so you should carry this card, too. Only give your Medicare Number or other insurance information to doctors, pharmacists, other health care providers, your insurers, or people you trust to work with Medicare on your behalf.

96

How Medicare Advantage (MA) Plans Work

MedicareAdvantage

In an MA Plan you Are still in Medicare with all rights and protections Still get those services covered by Part A and

Part B, but the MA Plan covers those services May choose a plan that includes prescription drug

coverage Can be charged different out-of-pocket costs Can’t be charged more than Original Medicare for

certain services, like chemotherapy, dialysis, and skilled nursing facility (SNF) care

May choose a plan with extra benefits like vision, dental or fitness and wellness benefits

Have a yearly limit on your out-of-pocket costs


Notes

In an MA Plan you Are still in Medicare with all rights and protections Still get those services covered by Part A and Part B, but the MA Plan covers those services

instead of Original Medicare (must have both Part A and Part B to join an MA Plan) May choose a plan that includes prescription drug coverage Can be charged different out-of-pocket costs Can’t be charged more than Original Medicare for certain services, like chemotherapy, dialysis,

and skilled nursing facility (SNF) care May choose a plan that includes extra benefits like vision, dental, or fitness and wellness benefits

offered at the plan’s expense (not covered by Medicare) Have a yearly limit on your out-of-pocket costs

Note: MA Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other services that promote your health and wellness. Plans can also tailor their plan offerings to people with certain chronic health conditions. More details about these benefits are available in materials from the plan. This resulted from CMS’s reinterpretation of “primarily health related.” In order for CMS to approve a supplemental benefit, the benefit must focus directly on an enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not directly provided by one. Conditions most often included are diabetes, followed by congestive heart failure. Some plan-defined packages included cardiovascular disorders, chronic pain syndrome, chronic kidney disease, and opiate use disorder. For more Uniformity Flexibility information, visit CMS.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter.

97

https://www.cms.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter

https://www.cms.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter

98

How MA Plans Work (continued)

Each plan has a service area in which its enrollees must live

You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance (called an organization determination) • Contact your plan for more information

Each plan can charge different out-of-pocket costs and have different rules for how you get services • These rules can change each year

MA Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care

MA Plans have a yearly limit on your out-of-pocket costs for medical services

Hospice care is covered, but by Original MedicareJune 2019 Understanding Medicare 98

MedicareAdvantage

Notes

Each plan has a service area in which its enrollees must live. You (or a provider acting on your behalf) can request to see if an item or service will be covered by

the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” Contact your plan for more information.

Medicare pays a fixed amount for your coverage each month to the companies offering MA Plans. Each MA Plan can charge different out‑of‑pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan’s network for non‑emergency or non-urgent care). These rules can change each year.

MA Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care.

MA Plans have a yearly limit on your out‑of‑pocket costs for medical services. Hospice care is covered if you are enrolled in an MA Plan, but it is covered by Original Medicare.

99

MA Plan Notices

MedicareAdvantage

Plans send notices to members each year so you can see any changes Annual Notice of Change (ANOC)

(sent in September) Evidence of Coverage (EOC)

(sent by October 15)


Notes

Plans send notices to members, including “The Annual Notice of Change,” also known as the ANOC, and the “Evidence of Coverage,” also known as the EOC. These notices help you make decisions about your coverage. The ANOC includes changes in coverage, copayments, service area, and more that are effective

January 1. You’ll receive this in September. The EOC gives details about what is covered by the plan, how much you pay, and more. This

notice is sent by October 15.

If you don’t get either of these notices, contact the plan.

100

Who Can Enroll in an MA Plan?

To be eligible, you must Be enrolled in Medicare Part A (Hospital Insurance)

and Medicare Part B (Medical Insurance) Live in the plan’s service area Be a U.S. citizen or lawfully present in the U.S. Not be incarcerated In most cases, not have End-Stage Renal Disease

(ESRD) (restriction ends in 2021)To join, you must also Provide necessary information to the plan Follow the plan’s rules Only belong to one plan at a time


Notes

MA Plans are available to most people with Medicare. To be eligible to join an MA Plan, you must be enrolled in Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You must also live in the plan’s geographic service area. You must be a U.S. citizen or lawfully present in the U.S., and you can’t be incarcerated.

In most cases you can’t enroll in an MA Plan if you have End-Stage Renal Disease (ESRD). This restriction ends in 2021.

To join an MA Plan, you must also agree to

• Provide the necessary information to the plan, like your Medicare Number, address, date of birth, and other important information

• Follow the plan’s rules

• Belong to one MA Plan at a time

To find out which MA Plans are available in your area, visit Medicare.gov/find-a-plan or call 1-800-MEDICARE (1‑800‑633‑4227); TTY: 1‑877-486-2048.


101

When Can I Enroll in an MA Plan?

MedicareAdvantage

Generally, during your Initial Enrollment Period (IEP) If so, can change to another MA Plan (with or without drug

coverage) or go back to Original Medicare (with or without drug coverage) within the first 3 months you have Medicare

New yearly MA Open Enrollment Period (MA OEP) One-time change during January 1–March 31 each year with

coverage beginning the first of the following month Must already be enrolled in an MA Plan on January 1 to use the

MA OEP• You can switch to another MA Plan with or without drug coverage • You can disenroll from your plan and return to Original Medicare

If you return to Original Medicare, you can also join a Medicare Prescription Drug Plan (PDP) if you make this change


Note: If you drop a Medicare Supplement Insurance (Medigap) policy to join an MA Plan, you might not be able to get it back. Check with your state.

Notes

You can join an MA Plan when you first become eligible for Medicare, generally during your Initial Enrollment Period (IEP), which begins 3 months immediately before your first entitlement to both Medicare Part A and Part B.

Beginning in 2019, the MA OEP will allow individuals enrolled in an MA Plan to make a one-time election during the first 3 months of the calendar year (January 1–March 31) to switch MA Plans or to disenroll from an MA Plan and obtain coverage through Original Medicare. Coverage begins the first of the month following enrollment.

In addition, newly MA-eligible individuals (those with Part A and Part B) who enroll in an MA Plan also have the opportunity to also make a one-time election to change MA Plans or drop MA coverage and obtain Original Medicare (Trial Right). However, if you drop a Medicare Supplement Insurance (Medigap) policy to join an MA Plan, you might not be able to get it back. Rules can vary by state and your situation.

Changes to Part D coverage is limited to any individual who uses the MA OEP; however, the MA OEP doesn’t provide enrollment rights to any individual who’s not enrolled in an MA Plan during the applicable 3‑month period. Individuals who use the MA OEP to make changes to their MA coverage may also enroll in or disenroll from Part D coverage. For example, an individual enrolled in an MA-PD plan may use the MA OEP to switch to (1) another MA-PD Plan; (2) an MA-only Plan; or (3) Original Medicare with or without a PDP. The MA OEP will also allow an individual enrolled in an MA-only plan to switch to (1) another MA-only plan; (2) an MA-PD plan; or (3) Original Medicare with or without a PDP.

However, this enrollment period doesn’t allow for Part D changes for individuals enrolled in Original Medicare, including those with enrollment in stand-alone PDPs.

Note: If you have to pay for Part A and didn’t enroll during your IEP, you can enroll during the GEP. You may have a late enrollment penalty.

102

When Can I Enroll in an MA Plan?(continued)

MedicareAdvantage

During the yearly Open Enrollment Period (OEP) from October 15–December 7 each year

If you have Part A and enroll in Medicare Part B during a General Enrollment Period (GEP), you can enroll in an MA Plan from April 1–June 30 with coverage starting July 1

Special Enrollment Period (SEP) when certain events happen in your life


Notes

Each year, you have the chance to review your Medicare coverage and you can join, switch, or drop your plan. This is during the yearly Open Enrollment Period (OEP) that lasts from October 15–December 7 each year. You coverage would begin on January 1, as long as the plan had your request by December 7.

If you have Part A and enroll in Medicare Part B during a General Enrollment Period (GEP), you can enroll in an MA Plan April 1–June 30, with coverage starting July 1.

You may qualify for a Special Enrollment Period (SEP) when certain events happen in your life. Check with your plan for more information.

103

MA Plan Costs

Your out-of-pocket costs in an MA Plan vary depending on If the plan charges a monthly premium

• You pay the plan’s monthly premium (if any) in addition to the standard Medicare Part B premium—$135.50 in 2019

If the plan pays any of your monthly Medicare premium• Some MA Plans will help pay all or part of your Part B premium

(sometimes called a “Medicare Part B premium reduction”)

Whether the plan has a yearly deductible or any additional deductibles for certain services How much you pay for each visit or service (copayments

or coinsurance)


MedicareAdvantage

Notes

Your out-of-pocket costs in an MA Plan vary depending on

Whether the plan charges a monthly premium. You pay this in addition to the Medicare Part B premium. The standard monthly Part B premium in 2019 is $135.50. You may pay more depending on your income from 2 years ago, or if your MA Plan includes prescription drug coverage and you pay a late enrollment penalty for Part D.

Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advantage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction.”

Whether the plan has a yearly deductible or any additional deductibles for certain services. How much you pay for each visit or service (copayments or coinsurance). For example, the plan

may charge a copayment, like $10 or $20 every time you see a doctor.

104

MA Plan Costs(continued)

Your out-of-pocket costs in an MA Plan vary depending on The type of health care services you need and how often

you get them Whether you get services from a provider in the plan’s

network Whether you go to a doctor or supplier who accepts

assignment Whether the plan offers extra benefits that require an

extra premium The plan’s yearly limit on your out-of-pocket costs for all

medical services• Once you reach this limit, you’ll pay nothing for covered services

Whether you have MedicaidJune 2019 Understanding Medicare 104

MedicareAdvantage

Notes

Your out-of-pocket costs in an MA Plan vary depending on

The type of health care services you need and how often you get them. Whether you get services from a provider in the plan’s network. Whether you go to a doctor or supplier who accepts assignment. Assignment means that your

doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.

Whether the plan offers extra benefits that require an extra premium. The plan’s yearly limit on your out-of-pocket costs for all medical services. Once you reach this

limit, you’ll pay nothing for covered services. Whether you have Medicaid or get help from your state with health care or prescription drug costs.

Each year, plans set the amounts they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay the plan may change only once a year, on January 1. The ANOC and EOC notices you get in the fall describe these changes and costs.

105

How do I enroll in an MA Plan?

Use the Medicare Plan Finder• Updated Plan Finder available for those who want to

use it Visit the plan’s website to see if you can join

online Fill out a paper enrollment form

• Contact the plan to get an enrollment form, fill it out, and return it to the plan

• All plans must offer this option Call the plan you want to join

• Get your plan’s contact information from the Plan Finder

Call 1-800-MEDICARE (1-800-633-4227)


MedicareAdvantage

Notes

Not all MA Plans work the same way. Once you understand the plan’s rules and costs, here’s how to join:

Use the Medicare Plan Finder. An updated Plan Finder is available for those who want to use it. Visit the plan’s website to see if you can join online. Fill out a paper enrollment form. Contact the plan to get an enrollment form, fill it out, and return it

to the plan. All plans must offer this option. Call the plan you want to join. Get your plan’s contact information from the Plan Finder. Call 1-800-MEDICARE (1-800-633-4227).

Note: Medicare plans aren’t allowed to call you to enroll you in a plan, unless you specifically ask to be called. Also, plans should never ask you for financial information, including credit card or bank account numbers, over the phone.

106

Decision: Should I Join an MA Plan?

Consider You must have Part A and Part B to join Most offer comprehensive coverage

• Including Part D drug coverage

Some plans may require you to use a network You may need a referral to see a specialist You must pay the Part B and usually the monthly plan

premium You can only join/leave plan during certain periods It doesn’t work with Medigap policies It’s currently NOT available to MOST people with

ESRD


MedicareAdvantage

Notes

There are things to consider when deciding if you want to join an MA Plan:

Must have Part A and Part B to join Most plans offer comprehensive coverage including Part D drug coverage Some plans may require you to use a network You may need a referral to see a specialist You must pay the Part B premium and usually a monthly plan premium You can only join/leave the plan during certain periods MA Plans don’t work with Medigap policies It’s currently not available to most people with ESRD

• If you have ESRD, you can only join an MA Plan in certain situations: If you’re already in an MA Plan when you develop ESRD, you may be able to stay in your

plan or join another plan offered by the same company. If you’re already getting your health benefits (for example, through an employer health plan)

through the same organization that offers the MA Plan. If you had ESRD, but have had a successful kidney transplant, and you still qualify for

Medicare benefits (based on your age or a disability), you can stay in Original Medicare, or join an MA Plan.

You may be able to join a Medicare Special Needs Plan (SNP) that’s permitted to enroll people with ESRD if one is available in your area.

MA Plans are available to most people with Medicare. To be eligible to join an MA Plan, you must live in the plan’s geographic service area or continuation area, have Medicare Part A and Part B, be a U.S. citizen or lawfully present in the U.S. and not have ESRD. People with ESRD usually can’t join an MA Plan or other Medicare health plan. However, there are some exceptions.

107


Medicare Advantage Plans ________________.


a. Help pay for gaps in Original Medicareb. Must keep the same providers all yearc. Are private plans approved by each stated. Must cover all Medicare Part A and Part B

services

Notes


MA Plans __________.

a. Help pay for gaps in Original Medicare b. Must keep the same providers all year c. Are private plans approved by each state d. Must cover all Medicare Part A and Part B services



Generally, if you have End-Stage Renal Disease (ESRD) you can’t enroll in a Medicare Advantage (MA) Plan.

a. Trueb. False


Notes


Generally, if you have End-Stage Renal Disease (ESRD), you can’t enroll in a Medicare Advantage (MA) Plan.

a. True b. False


108

Tom

It’s January 5, 2020. Tom enrolled in a Medicare Advantage (MA) Plan in November during the Open Enrollment Period (OEP). He now thinks it isn’t a good choice for him. He isn’t sure if he’d like to change to a different MA Plan, or go back to Original Medicare. What’s the next enrollment period he could use?


Notes

It’s January 5, 2020, and Tom thinks that the Medicare Advantage (MA) Plan he enrolled in during the fall Open Enrollment Period (OEP) isn’t a good choice for him. He isn’t sure if he’d like to change to a different MA Plan, or go back to Original Medicare. What’s the next enrollment period he could use?

109

Tom can switch or drop his Medicare Advantage Plan (MA) next during the…

MA Open Enrollment Period (OEP)

Star

ts StartsJan 1 Co

ntin

ues

ContinuesFeb

Ends Ends

Mar 31

Cove

rage

Beg

ins

Coverage Begins 1st of month after you enroll


Notes

MA Open Enrollment Period (OEP)

It’s January 5, 2020, and Tom thinks that the Medicare Advantage (MA) Plan he joined during the Open Enrollment Period (OEP) isn’t a good choice for him. He’d like to change to a different MA Plan. What’s the next enrollment period he could use?

ANSWER: The MA OEP.

Remember, the MA OEP doesn’t provide a guaranteed issue right for a Medigap policy.

110

111

Medicare Advantage (MA)—Questions


Notes

Lesson 7—Appeals

Original Medicare Medicare Advantage (MA) Plan or

Other Health Plan Medicare Prescription Drug Plan (PDP)


Notes

Lesson 7, “Appeals,” explains that you have the right to request an appeal of certain decisions about your health care payment, coverage of services, or prescription drug coverage in Original Medicare, Medicare Advantage (MA) or other health plan, and in a Medicare Prescription Drug Plan (PDP).

For more information about appeals, visit Medicare.gov/claims-appeals/how-do-i-file-an-appeal. For help with filing an appeal, call the State Health Insurance Assistance Program (SHIP) in your state. To get the most up-to-date SHIP phone numbers, visit shiptacenter.org, or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048.

If you have an MA Plan, other Medicare health plan, or a Medicare PDP, your plan materials will have information on the appeals process.

112

https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal


Appeal Rights in Original Medicare

Request an appeal of health coverage or payment decisions. You can file an appeal if A service or item you got isn’t

covered and you think it should’ve been

Payment for a service or item is denied, and you think Medicare should’ve paid for it

You disagree with a Medicare coverage or payment decision (you can appeal the decision)

https://youtu.be/VXhtXKK-mn8


Original Medicare Appeals Video

Notes

You have the right to request an appeal of health coverage or payment decisions in Original Medicare. You have the right to a fair, timely, and efficient appeals process. You can file an appeal if

A service or item you got isn’t covered and you think it should’ve been Payment for a service or item is denied, and you think Medicare should’ve paid for it You disagree with a Medicare coverage or payment decision (you can appeal the decision)

113

How to Appeal in Original Medicare

The “Medicare Summary Notice” (MSN) will tell you• What Medicare paid• What you owe the provider or supplier• Medicare’s full or partial denial of your medical claim• Why Medicare didn’t pay• Your appeal rights, and who to contact if you need help filing an appeal• How and where to file your appeal• How much time you have to appeal

If you disagree with a Medicare coverage or payment decision, you can appeal the decision• Collect information that may help your case• Keep a copy of everything you send to Medicare

You may have the right to an expedited (fast) appeal in certain settings


Notes

In Original Medicare, you get a “Medicare Summary Notice” (MSN) in the mail or electronically (visit MyMedicare.gov to sign up) every 3 months if you get Part A- and Part B-covered items and services. The MSN will show you details of all items and services that have been billed to Medicare during the 3-month period, including

What Medicare paid What you owe the provider or supplier If Medicare has fully or partially denied your medical claim (this is the initial determination that is

made by the Medicare Administrative Contractor (MAC), which processes Medicare claims) Why Medicare didn’t pay Your appeal rights, and who to contact if you need help filing an appeal How and where to file your appeal How much time you have to file an appeal

If you disagree with a Medicare coverage or payment decision, you can appeal the decision. If you decide to appeal the decision, ask your doctor, health care provider, or supplier for any information that may help your case. Be sure to keep a copy of everything you send to Medicare as part of your appeal.

You may have the right to an expedited (fast) appeal in certain settings.

See the next slide for more information on expedited (fast) appeals.

114


Expedited (Fast) Appeals in Original Medicare

You have the right to an expedited appeal if you think• You’re being discharged too soon from your Medicare-covered inpatient

hospital stay• Your Medicare-covered services from the following are ending too soon

Skilled nursing facility (SNF) Home health agency (HHA) Comprehensive outpatient rehabilitation facility (CORF) Hospice

Ask your provider for any information that may help your case Request an expedited appeal

• Call the Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) in your region

• No later than the date listed on the notice

If you miss the deadline, you still have appeal rightsJune 2019 Understanding Medicare 115

Notes

You have the right to an expedited (fast) appeal if you think you’re being discharged too soon from your Medicare-covered inpatient hospital stay. Within 2 days of your hospital inpatient admission, you’ll get a notice called “An Important Message from Medicare about Your Rights” (sometimes called the “Important Message from Medicare” or the “IM”). This notice gives you Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) contact information and explains your rights.

You have the right to an expedited (fast) appeal if you think your Medicare-covered skilled nursing facility (SNF), home health agency (HHA), comprehensive outpatient rehabilitation facility (CORF), or hospice services are ending too soon. While you’re getting SNF, HHA, CORF, or hospice services, you should get a notice called the “Notice of Medicare-Non Coverage” (NOMNC) at least 2 days before covered services end. This notice explains the date your covered services end, what you may have to pay for, your rights, and how to request an expedited (fast) appeal.

You may ask your doctor or health care provider for any information that may help your case if you decide to file an expedited (fast) appeal.

You must call your regional BFCC-QIO to request an expedited (fast) appeal no later than the day you’re scheduled to be discharged from a Medicare-covered inpatient hospital, and no later than noon of the day after you get the “Notice of Medicare Non-Coverage” (NOMNC) for a Medicare-covered SNF, HHA, CORF, or hospice.

To get the BFCC-QIO phone number, visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048.

If you miss the deadline, you can still ask the BFCC-QIO to review your case, but different rules and time frames apply.

See “Medicare Appeals” (CMS Product No. 11525) for more details at Medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf.

115


https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf

https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf

Original Medicare Appeals Process: Part A & Part B (Fee-for-Service) Process

Chart footnote:2: The Appeals Amount in Controversy (AIC) requirement for all appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts.


Notes

There are 5 levels in the appeals process in Original Medicare (Part A and Part B) (fee-for-service).

Level 1: Redetermination by the Medicare Administrative Contractor (MAC) (by people at the MAC who weren’t involved with the first decision). If you disagree with the redetermination decision made by the MAC in level 1, you have 180 days after you get the “Medicare Redetermination Notice” (MRN) to request a reconsideration by a Qualified Independent Contractor (QIC), which is level 2. Details are on the MRN.

Level 2: Reconsideration by a QIC (a contractor who didn’t take part in the level 1 decision). If you disagree with the reconsideration decision in level 2, you have 60 days after you get the MRN to request a hearing by an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA), which is level 3.

Level 3: Decision by OMHA. The amount of your case must meet a minimum dollar amount, which is $160 for 2019. The ALJ will decide if your case meets the minimum dollar amount. You may be able to combine claims to meet the minimum dollar amount. Send the request to the OMHA office listed in the reconsideration notice. If you disagree with OMHA’s decision in level 3, you have 60 days after you get the decision to request a review by the Medicare Appeals Council, which is level 4.

Level 4: Review by the Appeals Council. Follow the directions in the decision letter you got from OMHA in level 3. There’s no minimum dollar amount to request Medicare Appeals Council review. If you disagree with the Appeals Council’s decision in level 4, you have 60 days after you get the Medicare Appeals Council’s decision to request judicial review by a Federal District Court, which is level 5.

Level 5: Judicial Review by a Federal District Court. To get judicial review in Federal District Court, the amount of your case must meet a minimum dollar amount, which is $1,630 for 2019. You may be able to combine claims to meet this dollar amount. Follow the directions in the Appeals Council’s decision letter you got in level 4.

Note: For a full-size copy of the Original Medicare (Part A and Part B) appeals process flowchart, visit CMS.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Downloads/Flowchart-FFS-Appeals-Process.pdf.

116

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Downloads/Flowchart-FFS-Appeals-Process.pdf

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Downloads/Flowchart-FFS-Appeals-Process.pdf

Rights When Filing MA and Other Health Plan Appeals

You have the right to Access your case file

• Call or write your plan• Plan may charge a reasonable fee for

Copying Mailing

Present evidence to support your case Ask for an expedited (fast) appeal

when supported by a doctor

Medicare Advantage Appeals Video

https://youtu.be/_7hQ7xd4yMo?list=PLaV7m2-zFKpjt7jXQYFjiy6fZ9qstPlxJ


Notes

If you’re in an MA Plan or other Medicare health plan and you’re filing an appeal, you have certain rights. You may want to call or write your plan and ask for a copy of your case file. To get the phone number or address of your plan, look at your “Evidence of Coverage,” (information from your plan that explains your rights) or the notice you get that explained why you couldn’t get the services you requested.

The plan may charge you a reasonable fee for copying this information and sending it to you. Your plan should be able to give you an estimate of how much it will cost based on the number of pages in the file, plus normal mail delivery.

The time frame for a plan to complete standard service coverage decisions is 14 days and may be extended by up to 14 additional days. The time frame may be extended if, for example, your plan needs more information from a non-contract provider to make a decision about the case, and the extension is in your best interest.

If you think your health could be seriously harmed by waiting the standard 14 days for a decision, ask your plan for a fast decision. You have the right to an expedited (fast) appeal when your request is supported by a doctor; or when applying the standard appeal time frame could seriously jeopardize your life or health, or your ability to regain maximum function. The plan must notify you of its decision within 72 hours. The 72 hours might be extended based on supporting documentation.

117

Expedited (Fast) Appeals Process―MA Planor Other Medicare Health Plan

You have the right to an expedited appeal if you think you’re being discharged too soon from your Medicare-covered inpatient hospital stay Within 2 days of your inpatient hospital admission, you should get

the “An Important Message from Medicare about Your Rights” notice, which will include BFCC-QIO contact information and an explanation of your rights Contact your BFCC-QIO no later than the day you’re scheduled to be

discharged from the hospital to ask for an expedited appeal• You’ll get a “Detailed Notice of Discharge” by noon the day after the

BFCC-QIO tells the hospital the decision If the BFCC-QIO decides you’re being discharged too soon, the plan will

continue to cover your Medicare-covered hospital stay If the BFCC-QIO decides you’re ready to be discharged, you won’t have to pay

the hospital charges until noon of the day after the BFCC-QIO decisionJune 2019 Understanding Medicare 118

Notes

You have the right to an expedited (fast) appeal if you think you’re being discharged too soon from your Medicare-covered inpatient hospital stay. Within 2 days of your inpatient hospital admission, you should get a notice called “An Important Message from Medicare about Your Rights” (sometimes called the “Important Message from Medicare” or the “IM”) with BFCC-QIO contact information and an explanation of your rights.

Contact your BFCC-QIO no later than the day you’re scheduled to be discharged from the hospital. When the BFCC-QIO gets your request, it will tell the plan and the hospital, and then the plan or your hospital will give you a “Detailed Notice of Discharge” by noon of the day after the BFCC-QIO tells the hospital. The notice will explain why your services are no longer covered, the applicable Medicare coverage rule or policy, and how the rule or policy applies to your specific situation.

If the BFCC-QIO decides that you’re being discharged too soon, the plan will continue to cover your Medicare-covered hospital stay as long as medically necessary (except for applicable coinsurance or deductibles).

If the BFCC-QIO decides that you’re ready to be discharged and you met the deadline for requesting a fast appeal, you won’t be responsible for paying the hospital charges (except for applicable coinsurance or deductibles) until noon of the day after the BFCC-QIO gives you its decision. If you get any inpatient hospital services after noon of that day, you may have to pay for them.

118

Expedited (Fast) Appeals Process—MA Plan or Other Medicare Health Plan (continued)

You have the right to an expedited appeal if you think your Medicare-covered services from an SNF, an HHA, or a CORF are ending too soon

Your plan must deliver the “Notice of Medicare Non-Coverage” (NOMNC) at least 2 days before covered services end

Contact your BFCC-QIO no later than noon the day after you get the “NOMNC” to request an expedited appeal

Provider will give you a “Detailed Explanation of Non-Coverage” by the end of the day that it gets the notice from the BFCC-QIO• If the BFCC-QIO decides that your services are ending too soon, your plan will continue

to cover your Medicare-covered SNF, HHA, or CORF services (except for applicable coinsurance or deductibles)

• If the BFCC-QIO decides that your services should end, you won’t be responsible for paying for any SNF, HHA, or CORF services provided before the termination date on the “NOMNC” that identified the date of termination of services


Notes

You have the right to a fast appeal if you think your services from a Medicare-covered SNF, HHA, or a CORF are ending too soon. Your provider or plan must deliver a “NOMNC” at least 2 days before covered services end. This notice explains the date your services end, what you have to pay for, your rights, and how to request an expedited (fast) appeal.

Contact the BFCC-QIO no later than noon of the day after you get the “NOMNC” to request an expedited (fast) appeal. See your notice for instructions on how to do this. When the BFCC-QIO gets your request, it will tell the plan and the provider. The provider will give you a “Detailed Explanation of Non-Coverage” by the end of the day that it gets the notice from the BFCC-QIO. The notice will explain why your plan intends to stop covering your services, the Medicare coverage rule or policy that applies to your situation, and any plan policy, contract provision, or reason on which your discharge decision was based.

If the BFCC-QIO decides that your services are ending too soon, your plan will continue to cover your Medicare-covered SNF, HHA, or CORF services (except for applicable coinsurance or deductibles).

If the BFCC-QIO decides that your services should end, you won’t be responsible for paying for any SNF, HHA care, or CORF services provided before the termination date on the “NOMNC.” If you continue to get services after the coverage end date, you may have to pay for those services.

119

Part C (Medicare Advantage) Appeals Process

• AIC = Amount in Controversy

• IRE = Independent Review Entity

Chart Footnotes1: Plans must process 95% of all clean claims from out-of-network providers within 30 days. All other claims must be processed within 60 days.2: The AIC requirement for all appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts. 4: Payment requests cannot be expedited.


Notes

This chart shows the appeals process for MA or other Medicare health plan enrollees. The time frames differ depending on whether you’re requesting a standard appeal, or if you qualify for an expedited (fast) appeal. If you ask your plan to provide or pay for an item or service and your request is denied, you can appeal the plan’s initial decision (the “organization determination”). You’ll get a notice explaining why your plan denied your request and instructions on how to appeal your plan’s decision. There are 5 levels of appeal. If you disagree with the decision made at any level of the process, you can go to the next level if you meet the requirements. First, your plan will make an Initial Determination. Pre-service time frames could possibly be extended 14 additional days. After each level, you’ll get instructions on how to proceed to the next level of appeal. The 5 levels of appeal are Level 1: Reconsideration from your plan. You must request the reconsideration within 60 days of the date of the notice of the organization determination. If your plan decides against you (fully or partially) or doesn’t meet the response deadline, your appeal is automatically sent to an Independent Review Entity (IRE), which is level 2. Level 2: Review by an Independent Review Entity (IRE). The IRE will review your plan’s decision and decide if they made the correct decision. If you disagree with the IRE’s decision, you have 60 days from the date of the IRE’s decision to request a hearing decision by OMHA, which is level 3. Level 3: Decision by Office of Medicare Hearings and Appeals (OMHA). The amount of your claim must meet a minimum dollar amount, which is updated yearly. The amount for 2019 is $160. If you disagree with OMHA’s decision, you have 60 days after you get OMHA’s decision to request a review by the Appeals Council, which is level 4. Level 4: Review by the Appeals Council. You can request that the Appeals Council review your case regardless of the dollar amount of your case. If you disagree with the Appeals Council’s decision, you have 60 days after you get the Appeals Council’s decision to request judicial review by a Federal District Court, which is level 5. Level 5: Judicial review by a Federal District Court. To get a review by a federal court, the remaining amount in controversy of your case must meet a minimum dollar amount which is updated yearly. The amount in 2019 is $1,630. Note: For a full-size copy of the MA appeals process flowchart, visit CMS.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Managed-Care-Appeals-Flow-Chart-.pdf.

120

https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Managed-Care-Appeals-Flow-Chart-.pdf

https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Managed-Care-Appeals-Flow-Chart-.pdf

Request a Part D Coverage Determination

A coverage determination is the initial decision made by a plan Which benefits you’re entitled to get How much you have to pay for a benefit You, your prescriber, or your appointed representative

can request it

Time frames for coverage determination requests Standard (decision within 72 hours) Expedited (decision within 24 hours)

• If life or health may be seriously jeopardized


Notes

A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your prescription drug benefits. This includes whether a certain drug is covered, whether you’ve met all the requirements for getting a requested drug, and how much you must pay for a drug.

You, your prescriber, or your appointed representative (CMS.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf) can ask for a coverage determination by calling your plan or writing them a letter. If you write to the plan, you can write a letter or use the “Model Coverage Determination Request” form available at CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/downloads/ModelCoverageDeterminationRequestForm.pdf.

There are 2 types of coverage determinations—standard or expedited. Your request will be expedited if the plan determines, or if your doctor tells the plan, that your life or health may be seriously jeopardized by waiting for a standard request.

A plan must give you its coverage determination decision as quickly as your health condition requires. After getting your request, the plan must give you its decision no later than 72 hours for a standard determination, or 24 hours for an expedited (fast) determination. If your coverage determination request involves an exception, the time clock starts when the plan gets your doctor’s supporting statement.

If a plan fails to meet these time frames, it must automatically forward the request and case file to the IRE (MAXIMUS) for review, and the request will skip over the first level of appeal (redetermination by the plan). MAXIMUS contact information is available at Medicarepartdappeals.com.

121

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/downloads/ModelCoverageDeterminationRequestForm.pdf


http://medicarepartdappeals.com/

Coverage and Formulary Exceptions

Plan must grant a formulary “exception” (type of coverage determination) if All formulary alternatives aren’t as effective and/or Drug would have adverse effects

Plan must grant an exception to a coverage rule if Coverage rule has been, or is likely to be, ineffective in

treating the enrollee’s condition, or It has caused, or is likely to cause, harm to the enrollee


Notes

A plan must grant a formulary “exception” (which is a type of coverage determination) when it determines that none of the formulary alternatives for treatment of the same condition would be as effective for the enrollee as the non-formulary drug and/or the drug would have an adverse effect. A plan must grant an exception to a coverage rule when it determines the coverage rule has been, or is likely to be, ineffective in treating the enrollee’s condition, or has caused, or is likely to cause, harm to the enrollee.

122

Requesting Part D Appeals

If your coverage determination or exception is denied, you can appeal the plan’s decision In general, you must make your

appeal requests in writing• Limited time frame to file an appeal

request (within 60 days or later with good cause)

• Plans must accept verbal expedited (fast) requests

An appeal can be requested by• You or your appointed representative• Your doctor or other prescriber

Medicare Prescription Drug Coverage Appeal Video

https://www.youtube.com/watch?v=_ZjBm_QmKN0


Notes

If you disagree with your Medicare drug plan’s coverage determination or exception decision, you have the right to appeal the decision. Your plan’s written decision will explain how you may file an appeal. Read this decision carefully and call your plan if you have questions. Most appeals must be requested within 60 days of the coverage determination or denial of an exception. However, this time frame may be extended for good cause (a circumstance that kept you from making the request on time or whether any actions by the plan may have misled you). For more information on good cause, visit CMS.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/index.html.

In general, you must make your appeal requests in writing. However, plans must accept verbal expedited (fast) redetermination requests. In addition, plans may choose to accept verbal standard redetermination requests. Check your plan materials or contact your plan to see if you can make verbal standard redetermination requests.

You or your appointed representative may ask for any level of appeal (CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/downloads/ModelCoverageDeterminationRequestForm.pdf). Your doctor or other prescriber can only ask for a redetermination or IRE reconsideration (level 1 or 2 appeal) on your behalf without being your appointed representative.

123

https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/index.html



Part D (Drug) Appeal Process

AIC = Amount in Controversy

IRE = Independent Review Entity

MA-PD = Medicare Advantage Plan with prescription drug coverage

PDP = Prescription Drug Plan

Chart Footnotes

2: The AIC requirement for all appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts.

3: A request for a coverage determination includes a request for a tiering exception or a formulary exception. The adjudication timeframes generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication timeframe begins when the plan sponsor receives the physician's supporting statement.

4: Payment requests cannot be expedited.


Notes

If you get an unfavorable initial decision, you have the right to appeal the decision. There are 5 levels of appeal: Level 1: Redetermination from your plan. If you disagree with your plan’s initial denial (coverage determination) or a coverage limitation under the plan’s drug management program, you can request a redetermination. You must request the redetermination within 60 days from the date of the coverage determination. If you disagree with the plan’s redetermination decision, you can request a reconsideration by an IRE, which is level 2, within 60 days from the date of the redetermination decision. Level 2: Reconsideration by an IRE. If you disagree with the IRE’s decision, you have 60 days after you get the IRE’s decision to request an ALJ hearing, which is level 3. Level 3: Decision by OMHA. The amount of your claim must meet a minimum dollar amount, which may change yearly. The amount for 2019 is $160. If you disagree with OMHA’s decision, you have 60 days after you get OMHA’s decision to request a review by the Appeals Council, which is level 4. Level 4: Review by the Appeals Council. You can request that the Appeals Council review your case, regardless of the dollar amount of your case. If you disagree with the Appeals Council’s decision, you have 60 days after you get the Appeals Council’s decision to request judicial review by a Federal District Court, which is level 5. Level 5: Judicial review by a Federal District Court. To get a review, the amount of your case must meet a minimum dollar amount. For 2019, the minimum dollar amount is $1,630 (may be able to combine claims to meet this dollar amount). Important: The Part D late enrollment penalty reconsideration process is unrelated to the appeals process flowchart—the appeals flowchart relates to benefit appeals. There’s only one level of independent review for late enrollment penalty disputes. For more information, contact your Medicare plan or your State Health Insurance Assistance Program (SHIP) at shiptacenter.org. Note: For a full-size copy of the Part D (Drug) appeals process flowchart, visit CMS.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Downloads/Flowchart-Medicare-Part-D.pdf.

124


https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Downloads/Flowchart-Medicare-Part-D.pdf

https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Downloads/Flowchart-Medicare-Part-D.pdf


If you’re in the hospital, you should get the “An Important Message from Medicare about Your Rights” notice within 4 days.

a. Trueb. False


Notes


If you’re in the hospital, you should get the “An Important Message from Medicare about Your Rights” notice within 4 days.

a. True

b. False


125

126

Lesson 8―Medicare and Other Insurance

Primary payer/secondary payer Who pays first? Medicare and the Marketplace


Notes

Lesson 8 provides an overview of Medicare when you have other coverage. Sometimes if you have other coverage, Medicare pays first (primary), it may pay second (secondary), and sometimes it may not pay at all.

For more detailed information, view National Training Program training module 5, “Coordination of Benefits (COB),” at https://cmsnationaltrainingprogram.cms.gov/sites/default/files/shared/2019_Mod%205_CoordinationofBenefits_v6_508_FINAL.pptx.

You may also download, view or print CMS Product No. 02179, “Your Guide to Who Pays First,” at Medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf.

https://cmsnationaltrainingprogram.cms.gov/sites/default/files/shared/2019_Mod%205_CoordinationofBenefits_v6_508_FINAL.pptx

https://cmsnationaltrainingprogram.cms.gov/sites/default/files/shared/2019_Mod%205_CoordinationofBenefits_v6_508_FINAL.pptx

https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf

127

Primary and Secondary Payers

How other insurance works with Medicare-covered services Insurance that pays first (primary payer) pays up to the

limits of its coverage Insurance that pays second (secondary payer) only pays if

there are costs the primary insurer didn’t cover The secondary payer (which may be Medicare) might not

pay all of the uncovered costs

If your employer insurance is the secondary payer, you might need to enroll in Part B before your insurance will pay


Notes

Here are some important facts to remember about how other insurance works with Medicare-covered services:

The insurance that pays first (primary payer) pays up to the limits of its coverage. The insurance that pays second (secondary payer) only pays if there are costs the primary insurer

didn’t cover. The secondary payer (which may be Medicare) might not pay all of the uncovered costs.

If your employer insurance is the secondary payer, you might need to enroll in Part B before your insurance will pay.

Who Pays First

If you… Who pays first?

Have retiree insurance (insurance from your or your spouse’s former employment)…

Medicare

Are 65 or older, have group health plan (GHP) coverage based on your or your spouse’s current employment and the employer has

• 20 or more employees…

• Fewer than 20 employees…

Your GHP

Medicare

Are under 65 and have a disability, have GHP coverage based on your or a family member’s current employment, and the employer has

• 100 or more employees…

• Fewer than 100 employees…

Your GHP

Medicare

Have Medicare because of End-Stage Renal Disease (ESRD)… Your GHP for the first 30 months after you become eligible to enroll in Medicare, then Medicare

Have Medicaid… MedicareJune 2019 Understanding Medicare 128

Notes

If you have retiree insurance (insurance from your or your spouse’s former employment), Medicare pays first.

If you are 65 or older, have group health plan (GHP) coverage based on your or your spouse’s current employment and the employer has 20 or more employees, your GHP pays first. However, if your employer has fewer than 20 employees, Medicare pays first.

If you are under 65 and have a disability, have GHP coverage based on your or a family member’s current employment, and the employer has 100 or more employees, your GHP pays first. However, if the employer has fewer than 100 employees, Medicare pays first.

If you have Medicare because of End-Stage Renal Disease (ESRD), your GHP pays first for the first 30 months (coordination period) after you become eligible to enroll in Medicare. After the coordination period, Medicare pays first.

If you have Medicaid, Medicare pays first.

For more information, visit Medicare.gov/Pubs/pdf/02179-medicare-coordination-benefits-payer.pdf to view the booklet “Medicare & Other Health Benefits: Your Guide to Who Pays First.” You can also call 1‑800‑MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

If you have other insurance or changes to your insurance, you need to let Medicare know by calling Medicare’s Benefits Coordination & Recovery Center (BCRC) at 1‑855‑798‑2627. TTY users can call 1‑855‑797‑2627.

128

https://www.medicare.gov/Pubs/pdf/02179-medicare-coordination-benefits-payer.pdf

129

Medicare and the Marketplace

It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan• Even if you only have Medicare Part A or Part B • Except through the Small Business Health Options

Program (SHOP) if you’re an active worker or a dependent of an active worker The size of the employer determines who pays first No late enrollment penalty if you enroll anytime you have SHOP

coverage, or within 8 months of losing that coverage

SHOP plans are available through issuers, agents, and brokers, not through HealthCare.gov


Notes

It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan. This is true even if you have only Part A or only Part B. The exception is a Marketplace plan through your employer (sold through the Small Business Health Options Program (called (SHOP)) if you’re an active worker or a dependent of an active worker.

SHOP coverage may pay first, before Medicare. If you delay enrollment because you have employer coverage through SHOP, you won’t have a late enrollment penalty if you enroll anytime you have SHOP Marketplace coverage, or within 8 months of losing that coverage (if employer has 20 or more employees). This doesn’t include COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage.

SHOP plans are available through issuers, agents, and brokers. They won’t be available through Healthcare.gov.

https://www.healthcare.gov/

130

Marketplace and Becoming Eligible for Medicare

You can keep a Marketplace plan after your Medicare coverage begins• Once your Medicare Part A coverage starts, you’ll no longer

be eligible for any premium tax credits or other cost savings you may be getting for your Marketplace plan You’ll have to pay full price for the Marketplace plan

Sign up for Medicare during your Initial Enrollment Period (IEP)• Or, if you enroll later, you may have to pay a late enrollment

penalty for as long as you have Medicare• Limited equitable relief until September 30, 2019, for Part B

late enrollment penaltyJune 2019 Understanding Medicare 130

Notes

If you have coverage through an individual Health Insurance Marketplace plan (not through an employer), you may want to terminate your Marketplace coverage and enroll in Medicare during your Initial Enrollment Period (IEP) to avoid the risk of a delay in future Medicare coverage and the possibility of a Medicare late enrollment penalty. Once you’re considered eligible for Part A, you won’t qualify for help paying your Marketplace plan premiums or other medical costs. No matter how you get Medicare, whether through Original Medicare or an MA Plan (like a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO)), you need to return to the Marketplace and end any subsidies, like premium tax credits or cost-sharing reductions, which are being paid on your behalf. If you continue to get help paying your Marketplace plan premium after you have Medicare, you might have to pay back the help you got when you file your taxes. Visit Healthcare.gov to connect to the Marketplace in your state and learn more. You can also find out how to terminate your Marketplace plan before your Medicare enrollment begins. Once you’re eligible for Medicare, you’ll have an IEP to sign up. For most people, their 7-month Medicare IEP starts 3 months before their 65th birthday and ends 3 months after their 65th birthday. If you enroll in Medicare after your IEP, you may have to pay a late enrollment penalty for as long as you have Medicare. If you have individual Marketplace coverage and only enroll in Part A during your IEP, you won’t be able to enroll in Part B later using the Special Enrollment Period (SEP). Note: You may have Medicare and Marketplace coverage concurrently, only if you had your Marketplace coverage before you had Medicare. It’s against the law for someone who knows you have Medicare to sell you a Marketplace plan. There’s no coordination of benefits between a Qualified Health Plan (QHP) and Medicare. You need to be aware of this if you decide to remain in a QHP after enrolling in Part A. It isn’t a secondary insurance. Also, drug coverage in a QHP may not be creditable and a penalty may result if you sign up for Part D later. For more information, visit Healthcare.gov/medicare/changing-from-marketplace-to-medicare/. Certain people who had Part A and a Marketplace plan and delayed enrolling in Part B may get to enroll in Part B without a late enrollment penalty through September 30, 2019. For more information, visit CMS.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Downloads/SHIP_and_Navigators_ER_Fact_Sheet.pdf.


https://www.healthcare.gov/medicare/changing-from-marketplace-to-medicare/

https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Downloads/SHIP_and_Navigators_ER_Fact_Sheet.pdf

https://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Downloads/SHIP_and_Navigators_ER_Fact_Sheet.pdf

131

Medicare for People With Disabilities and the Marketplace

You may qualify for Medicare based on a disability• You must be entitled to Social Security Disability Insurance

(SSDI) benefits for 24 months On the 25th month, you’re automatically enrolled in Medicare

Part A and Part B

If you’re getting SSDI, you can get a Marketplace plan to cover you during your 24-month waiting period • You may qualify for premium tax credits and reduced cost

sharing until your Medicare coverage starts


Notes

If you’re entitled to Social Security Disability Insurance (SSDI), you may qualify for Medicare. There’s a 24-month waiting period before Medicare coverage can start. During this waiting period, you can apply for coverage in the Marketplace. You can find out if you’ll qualify for Medicaid or for premium tax credits that lower your monthly Marketplace plan premium, and cost-sharing reductions that lower your out-of-pocket costs.

If you apply for lower costs in the Marketplace, you’ll need to estimate your income for 2019 for coverage in 2020. If you’re getting SSDI benefits and want to find out if you qualify for lower costs on Marketplace coverage, you’ll need to provide information about your Social Security payments, including disability payments.

Your Medicare coverage is effective on the 25th month of receiving SSDI. Your Medicare card will be mailed to you about 3 months before your 25th month of disability benefits. If you don’t want Part B, follow the instructions that are included with the card.

Once you’re eligible for Medicare, you won’t be able to get lower costs for a Marketplace plan based on your income. Once your Part A coverage starts, any premium tax credits and reduced cost sharing you may have qualified for through the Marketplace will stop. That’s because Part A is considered minimum essential coverage, not Part B.

Also, remember, the QHP isn’t required to pay any costs toward your coverage once you have Medicare.

132

Choosing Marketplace CoverageInstead of Medicare

You can choose Marketplace coverage instead of Medicare if you Are paying a premium for Part A—you can drop your Part A and

Part B coverage and get a Marketplace plan instead Only have Part B, and have to pay a premium for Part A—you

can drop Part B and get a Marketplace plan instead Are eligible for Medicare but haven’t enrolled in it because you:

• Would have to pay a premium for Part A• Have a medical condition that qualifies you for Medicare, like

ESRD, but haven’t applied for Medicare coverage• Are in your 24-month disability waiting period


Notes

You can choose Marketplace coverage instead of Medicare under the following conditions:

If you’re paying a premium for Part A—you can drop your Part A and Part B coverage and get a Marketplace plan instead

Only having Part B, and have to pay a premium for Part A—you can drop Part B and get a Marketplace plan instead

If you’re eligible for Medicare but haven’t enrolled because:

• You have to pay a premium for Part A

• You have a medical condition that qualifies you for Medicare, like End-Stage Renal Disease, but haven’t applied for Medicare coverage

• You’re in your 24-month disability waiting period

Note: Before choosing Marketplace coverage over Medicare, there are 2 important points to consider:

If you don’t enroll in Medicare when first eligible (during the IEP), you may have to pay late enrollment penalties if you later apply for both Part A (if you have to buy it) and Part B.

If you enroll in Medicare after your IEP ends, you can enroll in Medicare only during the Medicare General Enrollment Period (GEP) (from January 1–March 31), and coverage doesn’t begin until July of that year.

133

Scenario—Leslie

Leslie has individual Marketplace coverage. She’s turning 65 and wants to wait and enroll in Medicare Part B when she’s older because she and her husband have the same Marketplace coverage. Since she has worked long enough so that she doesn’t have to pay for Part A, she doesn’t have to worry about having a Part B late enrollment penalty. Having a Marketplace plan will allow her to enroll later without a late enrollment penalty.

a. True

b. False


Notes

Leslie has individual Marketplace coverage. She’s turning 65 and wants to wait and enroll in Medicare Part B when she’s older because she and her husband have the same Marketplace coverage. Since she has worked long enough to not have to pay for Part A, she doesn’t have to worry about having a Part B late enrollment penalty. Having a Marketplace plan will allow her to enroll later without a late enrollment penalty.

a. True

b. False


134

Medicare and Other Insurance Questions


Notes

135

Lesson 9—Help for People with Limited Income and Resources

Medicare Savings Programs• Help from your state paying Medicare costs, including

Medicare premiums, deductibles, and coinsurance Extra Help

• Help paying Part D prescription drug costs Medicaid

• Federal-state health insurance program For people with limited income/resources

Children’s Health Insurance Program (CHIP)• Covers uninsured children up to 19 and may cover

pregnant women If family’s income is too high for Medicaid


Notes

There are programs available to help people with limited income and resources pay their health care and/or prescription drug costs. These include Medicare Savings Programs, Extra Help, Medicaid, and the Children’s Health Insurance Program (CHIP). You should apply for these programs if you have limited income and resources. Even if you aren’t sure you qualify, you should apply. Visit Medicare.gov/contacts or call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048.

Medicare Savings Program: This program provides help from your state paying Medicare costs, including Medicare premiums, deductibles, and coinsurance. It often has higher income and resource guidelines than full Medicaid. Visit Medicare.gov/contacts/#resources/msps to see your state’s program.

Extra Help: This program helps people with limited income and resources with the costs of Medicare prescription drug coverage. It’s also called the low-income subsidy (LIS). Some people with Medicare must apply for Extra Help. You can apply by filling out a paper application, applying at socialsecurity.gov, or contacting your state Medical Assistance (Medicaid) office.

Medicaid: This program helps pay medical costs for some people with limited income and resources. It’s jointly funded by the federal and state governments and is administered by each state.

CHIP: This program provides low‑cost health insurance to children and some pregnant women in families who earn too much income to qualify for Medicaid, but not enough to buy private health insurance.

Federal Poverty Level (FPL) income limits are usually updated each February for the same calendar year and can be accessed at aspe.hhs.gov/poverty-guidelines.

https://www.medicare.gov/contacts/#resources/msps


https://aspe.hhs.gov/poverty-guidelines

136

Minimum Federal Eligibility Requirements for Medicare Savings Programs in 2019

Medicare Savings Program Individual Monthly Income Limits

Married Couple Income

Limits

Helps Pay Your

Qualified Medicare Beneficiary (QMB)

$1,061 $1,430 Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments)

Specified Low-Income Medicare Beneficiary (SLMB)

$1,269 $1,711 Part B premiums only

Qualifying Individual (QI) $1,426 $1,923 Part B premiums only

Qualifying Disabled & Working Individuals (QDWI)

$4,249 $5,722 Part A premiums only


Resource limits for QMB, SLMB, and QI are $7,730 for an individual and $11,600 for a married couple. Resource limits for QDWI are $4,000 for an individual and $6,000 for a married couple.

Notes

These amounts are federal minimum eligibility requirements for the 48 states. Limits are slightly higher in Alaska and Hawaii. If you qualify for the Qualified Medicare Beneficiary (QMB) program, you get help paying your Part A and Part B premiums, deductibles, coinsurance, and copayments. To qualify, you must be eligible for Medicare Part A and have an income not more than 100% of the FPL. This will be effective the first month after the month QMB eligibility is approved (can’t be retroactive). If you qualify for the Specified Low-Income Medicare Beneficiary (SLMB) program, you get help paying for your Part B premium. To qualify, you must be eligible for Medicare Part A and have an income that’s at least 100%, but isn’t more than 120% of the FPL. If you qualify for the Qualifying Individual (QI) program, and there are still funds available in your state, you get help paying your Part B premium. It’s fully federally funded. Congress only gave a limited amount of funds to each state. To qualify, you must be eligible for Medicare Part A because your income was too high and you lost your disability Part A and have an income not exceeding 135% of the FPL. If you qualify for the Qualifying Disabled & Working Individuals (QDWI) program, you get help paying your Part A premium. To qualify, you must be entitled to Medicare Part A because of a loss of disability-based Part A due to earnings exceeding substantial gainful activity (SGA), have an income not higher than 200% of the FPL and resources not exceeding twice the maximum for Supplemental Security Income (SSI) ($4,000 for an individual and $6,000 for married couple in 2019), and not be otherwise eligible for Medicaid. If your income is between 150% and 200% of the FPL, the state can ask you to pay a part of the Medicare Part A premium. The resource limits are $4,000 (individual) and $6,000 (married couple). In 2019, the resource limits for the QMB, SLMB, and QI programs are $7,730 for a single person and $11,600 for a married person living with a spouse and no other dependents. These resource limits are adjusted on January 1 of each year, based on the change in the annual consumer price index since September of the previous year (official in April of each year). For more Medicare Savings Program information, visit Medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html#collapse-2614. See Medicare.gov/contacts/#resources/msps to access your state’s Medicare Savings Program website. Note: The Medicare Savings Programs’ Income/Resource Limits information is typically released in January/February each year.

https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs#collapse-2614

https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs#collapse-2614

https://www.medicare.gov/contacts/#resources/msps

137

What Is Extra Help?

Part DMedicare


Program to help people pay for Medicare prescription drug costs (Part D)• Also called the low-income subsidy (LIS)

If you have lowest income and resources• Pay no premiums or deductible, and small or no

copayments

If you have slightly higher income and resources• Pay reduced deductible and a little more out of pocket

No coverage gap or late enrollment penalty if you qualify for Extra Help


Notes

Extra Help is a Medicare Program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

If you have the lowest income and resources, you’ll pay no premiums or deductible, and have small or no copayments. If you have slightly higher income and resources, you’ll have a reduced deductible and pay a little more out-of-pocket.

If you qualify for Extra Help, you won’t have a coverage gap or Part D late-enrollment penalty. Most people with Medicare can only make changes to their drug coverage certain times of the year. If you newly get, lose, or have a change in your Medicaid or Extra Help status, you may get a Special Enrollment Period to change drug plans. Check with your plan for more information.

Note: Residents of the U.S. territories aren’t eligible for Extra Help. Each of the territories helps its own residents with Medicare drug costs. This help is generally for residents who qualify for and are enrolled in Medicaid. This assistance isn’t the same as Extra Help.

See Guide to Consumer Mailings, which are issued in mid-May and late November, at CMS.gov/Medicare/Prescription-Drug-Coverage/LimitedIncomeandResources/Downloads/Consumer-Mailings.pdf.

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/LimitedIncomeandResources/Downloads/Consumer-Mailings.pdf

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/LimitedIncomeandResources/Downloads/Consumer-Mailings.pdf

Qualifying for Extra Help

Part DMedicare


You automatically qualify for Extra Help if you get Full Medicaid coverage (sometimes called “full dual”) Supplemental Security Income (SSI) Help from Medicaid paying your Part B premium (Medicare

Savings Program; sometimes called “partial dual”)

All others must apply Online at socialsecurity.gov/benefits/medicare/prescriptionhelp Call Social Security at 1-800-772-1213; TTY: 1-800-325-0778

• Ask for “Application for Help with Medicare Prescription Drug Plan Costs” (SSA-1020)

Contact your State Medical Assistance (Medicaid) office Work with a local organization, like a State Health Insurance

Assistance Program (SHIP)


Notes

You automatically qualify for Extra Help (and don’t need to apply) if you have Medicare and get full Medicaid coverage (sometimes called “full dual”), Supplemental Security Income (SSI) benefits, or help from Medicaid paying your Medicare Part B premiums (Medicare Savings Program; sometimes called “partial dual”).

If you don’t meet one of these conditions, you may still qualify for Extra Help, but you’ll need to apply for it. If you think you qualify but aren’t sure, you should still apply. You can apply for Extra Help at any time, and if you’re denied, you can reapply if your circumstances change. Eligibility for Extra Help may be determined by either Social Security or your State Medical Assistance (Medicaid) office.

You can apply for Extra Help by

Applying online at socialsecurity.gov/benefits/medicare/prescriptionhelp Completing a paper application you can get by calling Social Security at 1-800-772-1213;

TTY: 1-800-325-0778 Applying through your State Medical Assistance (Medicaid) office Working with a local organization, like a State Health Insurance Assistance Program (SHIP)

You can apply yourself, or someone with the authority (like with Power of Attorney) to act on your behalf can file your application, or you can ask someone else to help you apply.

If you apply for Extra Help, Social Security will transmit the data from your application to your State Medical Assistance (Medicaid) office to also initiate an application for a Medicare Savings Program, which can help you pay for your Medicare premiums.

Reference: socialsecurity.gov/pubs/EN-05-10525.pdf.

138

https://www.ssa.gov/benefits/medicare/prescriptionhelp/

https://www.ssa.gov/pubs/EN-05-10525.pdf

139

What Is Medicaid?

Joint federal and state program Helps pay health care costs for people with

limited income and resources Some people qualify for Medicare and Medicaid May cover services that Medicare may not or

may partially cover, like nursing home care, personal care, and home- and community-based services Covered 75.1 million people in 2018


Notes

Medicaid is a joint federal and state program that helps pay health care costs if you have limited income and/or resources and meet other requirements. Some people qualify for both Medicare and Medicaid.

If you have Medicare and full Medicaid coverage, most of your health care costs are covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage (MA) Plan (like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)).

If you have Medicare and/or full Medicaid coverage, Medicare covers your Part D prescription drugs. Medicaid may still cover some drugs that Medicare doesn’t cover.

People with Medicaid may get coverage for services that Medicare may not or may partially cover, like nursing home care, personal care, and home- and community-based services.

Medicaid is the largest source of funding for medical and health-related services for those with limited income and resources. Medicaid provides health coverage to an estimated 75.1 million people (in 2018), including children, pregnant women, parents, seniors, and individuals with disabilities. CHIP covered over 9.5 million children (in 2018).

For more information, visit Medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

140

Qualifying for Medicaid

Medicaid Programs vary from state to state• Each has different income and resource requirements

In some states, you may need to be enrolled in Medicare, if eligible, to get Medicaid Call your State Medical Assistance (Medicaid)

office for more information or to see if you qualify• Visit Medicare.gov/contacts, or call 1-800-MEDICARE

(1-800-633-4227); TTY: 1-877-486-2048


Notes

Medicaid Programs vary from state to state. They may also have different names, like “Medical Assistance” or “Medi-Cal.”

Each state has different income and resource requirements.

In some states, you may need to be enrolled in Medicare, if eligible, to get Medicaid.

Call your State Medical Assistance (Medicaid) office for more information and to see if you qualify. Visit Medicare.gov/contacts, or call 1-800-MEDICARE(1-800-633-4227); TTY: 1-877-486-2048.


141

How Are Medicare and Medicaid Different?

Medicare Medicaid

National program that’s consistent across the country

Statewide programs that vary among states

Administered by the federal government

Administered by state governments within federal rules (federal/state partnership)

Health insurance for people 65 and older, people under 65 with certain disabilities, or any age with End-Stage Renal Disease (ESRD)

Health insurance for people based on need—financial and non-financial requirements

Nation’s primary payer of inpatient hospital services to the disabled, elderly and people with ESRD

Nation’s primary public payer of acute health care, mental health, and long-term care services


Notes

Medicare and Medicaid are different in the following ways:

Medicare is a national program that’s consistent across the country. Medicaid consists of statewide programs that vary among states.

Medicare is administered by the federal government. Medicaid is administered by state governments within federal rules (federal/state partnership).

Medicare eligibility is based on age, disability, or End-Stage Renal Disease (ESRD). Medicaid eligibility is based on income and resources.

Medicare is the nation’s primary payer of inpatient hospital services to the disabled, elderly, and people with ESRD. Medicaid is the nation’s primary public payer of acute health, mental health, and long-term care services.

142

What Is the Children’s Health Insurance Program (CHIP)?

Health coverage for uninsured children in families earning too much to qualify for Medicaid, but too little for private insurance Jointly funded by federal and state governments Administered by statesOver 9.5 million children enrolled For CHIP information by state, visit

Medicaid.gov/chip/state-program-information /chip-state-program-information.html


Notes

Like Medicaid, the Children’s Health Insurance Program (CHIP) is a partnership between the states and the federal government that provides health coverage to eligible children, and some pregnant women, through both Medicaid and separate CHIP Programs. States administer CHIP within broad guidelines established by The Centers for Medicare & Medicaid Services (CMS), and the federal government provides matching funds to states to provide the coverage.

The federal matching rate for CHIP was typically about 15 percentage points higher than the Medicaid Federal Medical Assistance Percentage (FMAP) rate for that state. For example, a state with a 50% FMAP would typically have an “enhanced” CHIP matching rate of 65%. For 2016–2019, states receive a 23 percentage point increase to the CHIP FMAP, so CHIP matching rates range from 88% to 100%. In 2020, states will receive an 11.5 percentage point increase to the CHIP FMAP. Beginning in 2021, states will go back to receiving the regular enhanced CHIP matching rate. Unlike Medicaid, the money states get every year depends on the statute.

There are over 9.5 million children currently enrolled in the CHIP program.

To see CHIP information by state, visit Medicaid.gov/chip/state-program-information/chip-state-program-information.html.

143

Help for People with Limited Income and Resources—Questions


Notes

Lesson 10—CMS Program-Related Resources

CMS.gov – For partners, providers, and researchers; includes training• CMSnationaltrainingprogram.cms.gov – Partner training courses

and materials• cmsoc.service-now.com/pow/ – Product ordering for partners

Medicare.gov – For people with Medicare, caregivers, and partners (includes access to MyMedicare.gov)

“What’s Covered” App – Mobile app with Part A and Part B coverage information

Medicaid.gov – For people with Medicaid and caregivers InsureKidsNow.gov -Information on coverage for teens and

children in limited income and resource households


Notes

These websites have information you may need to help counsel a person with coverage from Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or through the Health Insurance Marketplace.

CMS.gov provides information on CMS’s programs for providers, partners, and researchers.

• CMSnationaltrainingprogram.cms.gov enables you to take courses, download documents, watch videos, and access other helpful tools.

• productordering.cms.hhs.gov enables you to order/pre-order multiple copies of available publications on such topics as Medicare, Medicaid, CHIP, and the Health Insurance Marketplace.

• Medicare.gov provides information on the Medicare Program for people with Medicare. It includes access to MyMedicare.gov. MyMedicare.gov is a free and secure way for you to: Sign up to get other Medicare resources electronically, like Medicare Summary Notices and

your “Medicare & You” handbook Print an official copy of your Medicare card Check your eligibility, enrollment, and other Medicare benefits View a calendar of your current and upcoming preventive services

If you don’t have an account, visit MyMedicare.gov, and select “Create an Account.”

The “What’s Covered” mobile app delivers reliable Part A and Part B coverage information right on your mobile device. You can download it for free on both the App Store and Google Play.

Medicaid.gov provides information on the Medicaid Program for people with Medicaid. It provides referrals to specific states since Medicaid is a joint federal/state program.

InsureKidsNow.gov provides information on coverage for teens and children in limited income and resource households from CHIP.

144

https://www.cms.gov/


https://cmsoc.service-now.com/pow/?id=pow_login




https://www.insurekidsnow.gov/

CMS Program-Related Resources

HealthCare.gov – Health Insurance Marketplace information for the general public

Marketplace.cms.gov – For partners, includes training socialsecurity.gov – Information on a broad range of Social

Security benefits and enrollment in the Medicare Program regulations.gov – The federal regulations website eCFR.gov – The electronic Code of Federal Regulations

website


Notes

HealthCare.gov is the website for the Health Insurance Marketplace. This site will refer you to states that have state-based Marketplaces.

Marketplace.cms.gov is the website for partners and stakeholders to get information and training on the Marketplace and consumer resources.

socialsecurity.gov provides information on a broad range of Social Security benefits and enrollment in the Medicare Program.

regulations.gov is the federal regulations website. eCFR.gov is the electronic Code of Federal Regulations website.

145


https://marketplace.cms.gov/


https://www.regulations.gov/

https://www.ecfr.gov/cgi-bin/ECFR?page=browse

Ordering Multiple Copies of CMS Publications

Returning User: Enter your username and

password in the designated fields, and then select the Login button

New User: Select the Request an Account

button to set up a new account

Enter the required information, then follow the prompts for setting up a new account, and select the Request Account button

productordering.cms.hhs.gov

Questions? Email your questions to: [email protected] 2019 Understanding Medicare 146

Notes

Partners seeking printed training materials may access the CMS Product Ordering Website. They need to create an account to order multiple copies of available publications at productordering.cms.hhs.gov. Topics include Medicare, Medicaid, CHIP, and the Health Insurance Marketplace. You may also have the opportunity to pre-order publications.

146

https://cmsoc.service-now.com/pow/?id=pow_login

Medicare “What’s Covered” App

Medicare’s free app Accurate cost, coverage, and

eligibility information right on your smartphone

For items and services covered by Medicare Part A and Part B

Available even when you’re offline

“What’s Covered” is available for download at both the App Store and Google Play

Medicare “What’s Covered” App Video

https://www.youtube.com/watch?v=G759n0EUV70


Notes

Not sure if Medicare will cover your medical test or service? Medicare’s free “What’s Covered” app delivers accurate cost and coverage information right on your smartphone. Now you can quickly see whether Medicare covers your service in the doctor’s office, the hospital, or anywhere else you use your phone.

“What’s Covered” is available for free on both the App Store and Google Play. Search for “What’s Covered” or “Medicare” and download the app to your phone. Once “What’s Covered” is installed, you can use it to get reliable Medicare information even when you’re offline.

The app delivers general cost, coverage, and eligibility details for items and services covered by Medicare Part A and Part B. Search or browse to learn what’s covered and not covered; how and when to get covered benefits; and basic cost information. You can also get a list of covered preventive services.

Easy access to accurate, reliable Medicare coverage information is just one new feature of the eMedicare initiative. To stay up to date on eMedicare improvements and other important news from Medicare, sign up for our email list and follow us on Facebook.

147

https://www.youtube.com/watch?v=YUiHOnmun8s&feature=youtu.be

https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_610

https://www.facebook.com/medicare/

Sections 504 and 508 Accessibility Support

Section 504 of the Rehabilitation Act “No qualified individual with a disability in the U.S. shall be excluded

from, denied the benefits of, or be subjected to discrimination under” any program or activity that either receives Federal financial assistance or is conducted by any Executive agency or the U.S. Postal Service

Section 508 of the Rehabilitation Act Section 508 establishes requirements for electronic and information

technology developed, maintained, procured, or used by the Federal government. Section 508 requires Federal electronic and information technology to be accessible to people with disabilities, including employees and members of the public.

For more information, visit ada.gov/cguide.htm


Notes

This section provides information about services offered through the Centers for Medicare & Medicaid Services (CMS) to provide information that is compliant with Sections 504 and 508 of the Rehabilitation Act of 1973.

Rehabilitation Act

The Rehabilitation Act prohibits discrimination on the basis of disability in programs conducted by Federal agencies, in programs receiving Federal financial assistance, in Federal employment, and in the employment practices of Federal contractors. The standards for determining employment discrimination under the Rehabilitation Act are the same as those used in Title I of the Americans with Disabilities Act.

Section 504 states that "no qualified individual with a disability in the U.S. shall be excluded from, denied the benefits of, or be subjected to discrimination under" any program or activity that either receives Federal financial assistance or is conducted by any Executive agency or the U.S. Postal Service.

Each Federal agency has its own set of section 504 regulations that apply to its own programs. Agencies that provide Federal financial assistance also have section 504 regulations covering entities that receive Federal aid. Requirements common to these regulations include reasonable accommodation for employees with disabilities; program accessibility; effective communication with people who have hearing or vision disabilities; and accessible new construction and alterations.

Section 508 establishes requirements for electronic and information technology developed, maintained, procured, or used by the Federal government. Section 508 requires Federal electronic and information technology to be accessible to people with disabilities, including employees and members of the public.

For more information, visit ada.gov/cguide.htm.

148

https://www.ada.gov/cguide.htm

149

The Customer Accessibility Resource Staff (CARS)

CARS is here to assist you with the following: Auxiliary aids for CMS documents, like

• Large print, Braille, audio, or data CD for persons who are blind or have low vision

• TTY or relay services for persons who are deaf or hard-of-hearing

Guidance and support on• Developing communication plans targeting individuals with

disabilities • Standard Operating Procedures (SOP) to incorporate the provision

and delivery of auxiliary aids in your organization

Best practices with large print, Braille and 508 standards


Notes

The Customer Accessibility Resource Staff (CARS) provides communications in accessible formats to make sure people with disabilities have an equal opportunity to participate in CMS services, activities, programs, and other benefits.

CARS is here to assist you with the following:

Auxiliary aids for CMS documents, like

• Large print, Braille, audio, or data CD for persons who are blind or have low vision

• TTY or relay services for persons who are deaf or hard-of-hearing Guidance and support on

• Developing communication plans targeting individuals with disabilities

• Standard Operating Procedures (SOP) to incorporate the provision and delivery of auxiliary aids in your organization

Best practices with large print, Braille and 508 standards

150

Request Alternate Formats

Contact CARS For Medicare information, call 1-800-MEDICARE

(1-800-633-4227); TTY: 1-877-486-2048 For Health Insurance Marketplace information, call

1-800-318-2596; TTY: 1-855-889-4325 By email at [email protected] By fax at 1-844-530-3676 A letter to

Centers for Medicare & Medicaid Services (CMS)Offices of Hearings & Inquiries (OHI)7500 Security Boulevard, Mail Stop S1-13-25Baltimore, MD 21244-1850Attn: Customer Accessibility Resource Staff


Notes

You may contact CARS to get free auxiliary aids and services to help you better communicate with people with disabilities. Auxiliary aids include materials in Braille, large print, data/audio files, relay services, and TTY communications.

Contact CARS:

For Medicare information, call 1-800-MEDICARE (1-800-633-4227); TTY: 1-877-486-2048 For Health Insurance Marketplace information, call 1-800-318-2596; TTY: 1-855-889-4325 By email at altformatrequest.cms.hhs.gov By fax at 1-844-530-3676 A letter to

Centers for Medicare & Medicaid Services (CMS) Offices of Hearings & Inquiries (OHI) 7500 Security Boulevard, Mail Stop S1-13-25 Baltimore, MD 21244-1850 Attn: Customer Accessibility Resource Staff

CARS’ scope of responsibilities applies to external communications and public-facing information only. Therefore, for questions regarding accessibility for internal CMS employees, please contact CMS’s Office of Equal Opportunity and Civil Rights. For questions regarding internal Section 508 compliance, please contact your Section 508 Clearance Officer. For questions regarding Section 1557 of the Affordable Care Act, including foreign language requests and for guidance on significant communication, please contact the Health and Human Services Office for Civil Rights.

Source: Medicare.gov/about-us/accessibility-nondiscrimination-notice.

mailto:altformatrequest.cms.hhs.gov

https://www.medicare.gov/about-us/accessibility-nondiscrimination-notice

Key Messages

Medicare is a health insurance program It doesn’t cover all of your health care costs You have choices in how you get coverage There are programs for people with limited

income and resources Decisions affect the type of coverage you get Certain decisions are time-sensitive You can get help if you need it


Notes

Here are some key messages to remember:

Medicare is a health insurance program. It doesn’t cover all of your health care costs. You have choices in how you get your coverage. There are programs for people with limited income and resources. You have choices to make. It’s important to know when you need to take action. Your decisions

affect the type of coverage you get. Certain decisions are time-sensitive. There’s help available if you need it.

151

152

Acronyms (AC-FE)

ACA Affordable Care ActALJ Administrative Law JudgeALS Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) ANOC Annual Notice of ChangeBCRC Benefits Coordination & Recovery CenterBFCC-QIO Beneficiary and Family Centered Care-Quality Improvement Organization CARS Customer Accessibility Resource StaffCEU Continuing Education Units

CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs CHIP Children’s Health Insurance Program CMS Centers for Medicare & Medicaid Services COBRA Consolidated Omnibus Budget Reconciliation ActCORF Comprehensive Outpatient Rehabilitation FacilityDME Durable Medical EquipmentEOC Evidence of CoverageESRD End-Stage Renal Disease FEHB Federal Employees Health Benefits


Notes

153

Acronyms (FI-MS)

FICA Federal Insurance Contributions Act FPL Federal Poverty Level GEP General Enrollment Period GHP Group Health Plan HHA Home Health AgencyHMO Health Maintenance Organization HSA Health Savings Account IEP Initial Enrollment Period IRE Independent Review EntityIRMAA Income Related Monthly Adjustment Amount IRS Internal Revenue Service

MA Medicare Advantage MA-PD Medicare Advantage Prescription Drug MAC Medicare Administrative ContractorMAGI Modified Adjusted Gross IncomeMEC Minimal Essential CoverageMLN Medicare Learning NetworkMOON Medicare Outpatient Observation NoticeMRN Medicare Redetermination NoticeMSA Medical Savings Account MSN Medicare Summary Notice


Notes

154

Acronyms (NO-SH)

NOMNC Notice of Medicare-Non CoverageNTP National Training Program OEP Open Enrollment Period OMHA Office of Medicare Hearings and AppealsOPM Office of Personnel ManagementPACE Programs of All-Inclusive Care for the Elderly PDP Prescription Drug Plan PFFS Private Fee-for-Service POS Point of Service PPO Preferred Provider Organization

QDWI Qualifying Disabled & Working IndividualsQHP Qualified Health Plan QI Qualified Individual QMB Qualified Medicare Beneficiary RNHCI Religious Nonmedical Health Care InstitutionsRO Regional OfficeRRB Railroad Retirement Board SEP Special Enrollment PeriodSGA Substantial Gainful ActivitySHIP State Health Insurance Assistance Program


Notes

Acronyms (SH-VS)

SHOP Small Business Health Options ProgramSLMB Specified Low-income Medicare Beneficiary SMI Supplemental Medical InsuranceSNF Skilled Nursing Facility SNP Special Needs Plan SOP Standard Operating ProceduresSPAP State Pharmaceutical Assistance ProgramSSDI Social Security Disability Insurance SSI Supplemental Security IncomeTFL TRICARE for Life

TTY Teletypewriter/Text Telephone VA U.S. Department of Veterans Affairs VSMI Variable Supplementary Medical Insurance


Notes

155

CMS National Training Program (NTP)

To view all available NTP training materials, or to subscribe to our email list, visit

CMSnationaltrainingprogram.cms.gov.

Stay connected. Contact us at [email protected], or

follow us @CMSGov #CMSNTP

Notes

This training is provided by the CMS National Training Program (NTP).

To view all available NTP materials, or to subscribe to our email list, visit CMSnationaltrainingprogram.cms.gov.

Contact us at [email protected].

Follow us @CMSGov #CMSNTP.



Appendix A New Medicare Card

A–1

Appendix B 2019 Medicare Amounts

B–1

(&is National Training Program

2019 MEDICARE AMOUNTS Part A - Hospital Insurance

Part A Standard Premium ■ No charge for most people {with at least 40 work quarters)

■ $437 per month for people with less than 30 work quarters

■ $240 per month for people with 30-39 work quarters

Part A Late Enrollment Penalty- If you aren't eligible for premium-free Part A, and you don't buy it when you're first eligible, your monthly premium may go up 10%. You'll have to pay the

higher premium for twice the number of years you could've had Part A, but didn't sign up.

Cost for You Pay Part A Deductible for Each Benefit ■ $1,364 Period

■ $0 for days 1-60 Hospital Inpatient Stay for Each ■ $341 a day for days 61-90 Benefit Period ■ $682 a day for days 91-150 {lifetime reserve days)

■ All costs for all days after 150

Skilled Nursing Facility Stay ■ $0 for days 1-20

■ $170.50 a day for days 21-100

■ All costs for all days after 100

Home Health Care ■ $0 for home health care services

■ 20% of the Medicare-approved amount for

durable medical equipment

Hospice Care ■ $0 for hospice care.

■ You may need to pay a copayment of no more

than $5 for each prescription drug and other similar products for pain relief and symptom

control while you're at home. In the rare case your

drug isn't covered by the hospice benefit, your

hospice provider should contact your Medicare

drug plan to see if it's covered under Part D.

■ You may need to pay 5% of the Medicare-approved

amount for inpatient respite care. ■ Medicare doesn't cover room and board when

you get hospice care in your home or another

facility where you live {like a nursing home).

Revised October 2018

B–2

Part B - Medical Insurance

Part B Deductible - $185 per year

Part B Coinsurance -After your deductible is met, you typically pay 20% of the Medicareapproved amount for most doctor services {including most doctor services while you're a

hospital inpatient), outpatient therapy, and durable medical equipment.

Part B Standard Premium - The standard Part B premium amount in 2019 is $135.50 {or higher depending on your income). However, some people who get Social Security benefits may pay

less than this amount.

Since 2007, people with Medicare with higher incomes have paid higher Medicare Part B monthly premiums. These income-related monthly adjustment amounts {IRMAA) affect roughly 5% of people with Medicare.

Your Part B premium in 2019 based on your 2017 tax return:

File Individual Tax File Joint Tax Return

File Married & Separate You Return Tax Return pay

$85,000 or less $170,000 or less $85,000 or less $135.50

Above $85,000 up to Above $170,000 up to Not applicable $189.60 $107,000 $214,000



Above $160,000 and less Above $320,000 and less Above $85,000 and less $433.40 than $500,000 than $750,000 than $415,000

$500,000 or above $750,000 and above $415,000 and above $460.50

Part B Late Enrollment Penalty - If you don't sign up for Part B when you're first eligible, or if you drop Part Band then get it after you're first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% (.10) for each full 12-month period that you could've had Part B, but didn't sign up for it.

B–3

Part D - Medicare Prescription Drug Coverage

Part D Base Beneficiary Premium - $33.19 {used to determine any late enrollment penalty amount).

Listed below are the 2019 Part D monthly income-related premium adjustment amounts

people with Medicare who file an individual tax return {including those who are single, head of

household, qualifying widow{er) with dependent child, or married filing separately who lived

apart from their spouse for the entire taxable year), or a joint tax return pay.

Your Part D premium in 2019 based on your 2017 tax return:

File Individual Tax Return

$85,000 or less

Above $85,000 up to

$107,000

Above $107,000 up

to $133,500

Above $133,500 up

to $160,000

Above $160,000 and

less than $500,000

$500,000 or above

File Joint Tax Return

$170,000 or less

Above $170,000 up

to $214,000

Above $214,000 up

to $267,000

Above $267,000 up

to $320,000

Above $320,000 and

less than $750,000

$750,000 and above

File Married & Separate Tax Return

$85,000 or less

Not applicable

Not applicable

Not applicable

Above $85,000 and

less than $415,000

$415,000 and above

* IRMAA is adjusted each year, as it's calculated from the annual beneficiary base premium

You pay Incomerelated monthly adjustment amount + your plan premium (YPP)

ypp

$12.40 + YPP*

$31.90 + YPP*

$51.40 + YPP*

$70.90 + YPP*

$77.40 + YPP*

Part D Deductibles, Copayments, and Coinsurance - The amount you pay for Part D

deductibles, copayments, and/or coinsurance varies by plan . Look for specific Medicare drug

plan costs , and then call the plans you're interested in to get more details.

Part D Late Enrollment Penalty - If you don't sign up for Part D when you're first eligible, or if you drop Part D and then get it after you're first eligible, you may have to pay a late enrollment

penalty for as long as you have Part D. The cost of the late enrollment penalty depends on how

long you didn't have creditable prescription drug coverage. The late enrollment penalty is

calculated by multiplying 1% {.01) of the national base beneficiary premium {$33.19 in 2019)

times the number of full, uncovered months that you were eligible but didn't join a Medicare

Prescription Drug Plan and went without other creditable prescription drug coverage. This final

amount is rounded to the nearest $.10 and added to your monthly premium. The national base beneficiary premium may increase each year, so the penalty amount may also increase each

year.

Appendix C 2019 Comparison of the Parts A, B, C, and D

Appeal Processes

C–1

Parts A & B (Fee-for-Service) Process

Initial Determination

Standard Process

Medicare Administrative Conuaclor (MAC)


120 days to file

First Level of Appeal

MAC Redetermination: 60-day time limit

180 days to file

Second Level of Appeal

Qualified Independent Contractor (QIC) Reconsideration:

60-day time limit

60 days to file

Third Level of Appeal

Office of Medicare Hearings and Appeals Amount in

Controversy (AIC)=> $1602

90-day time limit

I 60 days to file

Fourth Level of Appeal

Medicare Appeals Council 90-day time limit

r 60 days to file

Fifth Level of Appeal

(Judicial Review}

Federal District Court AIC => $1,6302

1: Plans must process 95% of all dean claims from out-of-network providers within 30 days. All other claims must be processed within 60 days. 2: The A IC requirement for au appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts. 3: A request for a coverage determination includes a request for a tiering exception or a formulary exception. The adjudication timeframes generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication timeframe begins when the plan sponsor receives the physician's supporting statement. 4: Payment requests cannot be expedited.

Comparison of the Parts A, B, C, and D Appeal Processes Revised April 2019

C–2

Part C (Medicare Advantage) Process


Standard Process

Pre-Service: 14-day time limit Payment: 60-day time limit1 Organization

Determination

Expedited Process4

+ Pre-Service: 72-hour time limit


Health Plan Reconsideration Pre-Service: 30-day time limit

Payment: 60-day time limit

60 days to file Health Plan Reconsideration: 72-hour time limit


lnilepenilent Review Entity (IRE) Reconsideration Pre-Service:

30-day limit Payment:

60-da time limit

Automatic IRE review if plan

upholds denial

IRE Reconsideration: 72-hour time limit


60 days to file

Office of Medicare Hearings and Appeals AIC => $16o2

No statutory time limit for processing


60 days to file

Medicare Appeals Council No statutory time limit for processing


(Judicial Review)

60 days to file r Federal District Court

AIC => $1,

' L- l

i- i

~

6302

1: Plans must process 95% of all clean claims from out-of-network providers within 30 days. All other claims must be processed within 60 days. 2: The AIC requirement fOf all appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts. 3: A request for a coverage determination includes a request for a tiering exception or a formu1ary exception. The adjudication timeframes generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication timeframe begins when the plan sponsor receives the physician's supporting statement. 4: Payment requests cannot be expedited.


C–3

Part D (Drug) Process


Standard Process

72-hour time limit3

Expedited Process 4

24-hour time limit3


Prescription Drug Plan (PDP)/Medicare Advantage Prescription Drug Plan

(MA-PD) Redetermination 7-day time limit (benefits)

14-day time limit (J)ayments)

60 days to file PDP/MA-PD Redetermination: 72-hour time limit


IRE Reconsideration 7-day time limit (benefits)

14-day time limit (payments) 60 days to file IRE Reconsideration:

72-hour time limit


Office of Medicare Hearings and Appeals

Standard Decision AIC => $1602

90-day time limit

60 days to file

Office of Medicare Hearings and

Appeals Expedited Decision

AIC => $1602

10-day time limit


Medicare Appeals Council Standard Decision 90-day time limit

60 days to file Medicare Appeals Council

Expedited Decision 10-day time limit


(Judicial Review)

60 days to file

Federal District Court AIC => $1 ,6302

+ I

+

+

........_

~

+

+

/

/

1: Plans must process 95% of all clean claims from out-of.network providers within 30 days. All other claims must be processed within 60 days. 2: The AIC requirement for all appeals at the Office of Medicare Hearings and Appeals (OMHA) and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects the CY 2019 AIC amounts. 3: A request for a coverage determination includes a request for a tiering exception or a formulary exception. The adjudication timeframes generally begin when the request is received by the plan sponsor. However, if the request involves an exception request, the adjudication timeframe begins when the plan sponsor receives the physician's supporting statement. 4: Payment requests cannot be expedited.


Appendix D Answer Key

D–1

Answer Key

p. 24 (Check Your Knowledge Question 1)—d. All of the above. The Initial Enrollment Period (IEP) lasts for 7 months (3 months before your 65th birthday, the month of your 65th birthday, and 3 months after your birthday). It’s your first opportunity to enroll. When you sign up impacts the date your coverage starts, and delaying enrollment after becoming eligible could result in late enrollment penalties.

p. 53 (Alex)—5 days. His Part A coverage would be retroactive up to 3 calendar days. No. He wasn’t actually an inpatient for 3 consecutive days.

p. 55 (Check Your Knowledge Question 2)—a. Doctor services. Medicare Part A covers inpatient care (hospital and Skilled Nursing Facility) and hospice care and more. Doctor services are covered under Medicare Part B (Medical Insurance).

p. 63 (Check Your Knowledge Question 3)—d. All of the above. For Medicare Part B, most people will pay a monthly premium, the Part B yearly deductible, and 20% coinsurance for most covered services. These Part B amounts change yearly.

p. 66 (Edgar)—b. True. You may leave home for medical treatment or short, infrequent absences for nonmedical reasons, like attending religious services. You can still get home health care if you attend adult day care.

p. 68 (#1 Part A or Part B?)—Part B covers medically necessary doctor’s care.

p. 69 (#2 Part A or Part B?)—Part A covers medically necessary inpatient hospital stays.

p. 70 (#3 Part A or Part B?)—Part B covers many preventive services, including colonoscopies.

p. 71 (#4 Part A or Part B?)—Routine eye exams aren’t covered by Original Medicare. Medicare doesn’t cover everything. For instance, Original Medicare also doesn’t cover routine dental services, hearing aids, or cosmetic surgery. They may be covered if you have other coverage, like Medicaid or an MA Plan that covers these services.

p. 72 (#5 Part A or Part B?)—Home health care can be covered by Part A and/or Part B, depending on the circumstances. Part A generally covers home health care. However, Part B also may pay for home health care under certain conditions. For instance, Part B pays for home health care if an inpatient hospital stay doesn’t precede the need for home health care, or when the number of Part A-covered home health care visits exceed 100. For more information, read “Medicare and Home Health Care” at Medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf. You can also visit CMS.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html.

p. 82 (Check Your Knowledge Question 4)—b. False. Medigap policies cover gaps in Original Medicare coverage, like deductibles, coinsurance, and copayments for Medicare-covered services.



D–2

p. 93 (Check Your Knowledge Question 5)—c. Part D. Medicare prescription drug coverage is also called Part D. Part D coverage is provided through Medicare PDPs, Medicare Advantage Plans with Medicare prescription drug coverage (MA-PDs), and Cost Plans.

p. 94 (Check Your Knowledge Question 6)—a. OEP. Generally, the soonest you could join a Part D plan is the next Open Enrollment Period (OEP), from October 15–December 7. Each year, you have a chance to make changes to your Medicare prescription drug coverage for the following year. For most people, this is the one time each year that changes can be made. If you make a change during this time, your new coverage starts on January 1.Note: You may owe a late enrollment penalty if, at any time after your IEP is over, there’s a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. The cost of the late enrollment penalty depends on how long you went without creditable prescription drug coverage.

p. 107 (Check Your Knowledge Question 7)—d. Must cover all Medicare Part A and Part B services. They offer all Part A and Part B covered services, but may cover additional benefits not covered by Original Medicare, like vision and dental.

p. 108 (Check Your Knowledge Question 8)—a. True. If you have End-Stage Renal Disease (ESRD), you’ll usually get your health care through Original Medicare. Note: SEC. 17006 of the 21st Century Cures Act allows people with ESRD to join a Medicare Advantage Plan as of January 1, 2021.

p. 125 (Check Your Knowledge Question 9)—b. False. You have the right to an expedited appeal if you think you’re being discharged too soon from your Medicare-covered inpatient hospital stay. Within 2 days of your inpatient hospital admission, you should get the “An Important Message from Medicare about Your Rights” notice, which will include Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) contact information and an explanation of your rights.

p. 133 (Leslie)—b. False. An individual Marketplace plan isn’t considered creditable coverage for the purpose of Medicare enrollment. If she misses her IEP, she may have to pay a late enrollment penalty for Part B.