MEDICARE 101 BASICS

Y0020_20_17102PRES_C_01302020

Medicare Topics

After This Training, you will :

1. Understand the Four Parts of Medicare

2. Learn Medicare coverage options

3. Know the difference between Medicare

Supplements and Medicare Advantage Plans

4. Discover when you can enroll in Medicare

Advantage Plans

The Four Parts of Medicare

MEDICARE COVERAGE CHOICES

Medicare Advantage Plan

or

Original Medicare

Part A Hospital

Insurance

Part B Medical

Insurance

You can add

Medicare Supplement

Insurance (Medigap)

Policy

Part D Prescription

Drug Coverage

Part C Combines Part A and Part B

May include or you may add

Part D

Prescription Drug Coverage

(Most Part C plans cover

prescription drugs. You may be

able to add drug coverage to

some plan types if not already

included.)

Original Medicare

Original Medicare

Health care option run by the federal government

Provides your Part A and/or Part B coverage

See any doctor or hospital that accepts Medicare

You pay:

Part B premium (Part A is usually premium free)

Deductibles, coinsurance, or copayments

Can join a Part D plan to add drug coverage

Original Medicare = Part A & Part B

Covers Hospital stays and outpatient services

Original Medicare has a list of approved

services and makes approvals based on

“medical necessity”

There are certain services that Original

Medicare does not cover

NOT Covered By Part A and Part B

Long-term care

Routine dental care

Dentures

Cosmetic surgery

Acupuncture

Hearing aids and exams for fitting hearing

aids

Vision and eyewear

Other – check Medicare.gov

Original Medicare Costs

Monthly Part B premium

Part B deductible and coinsurance

Part A deductible

$144.60*

For those who are:

> Not collecting SSA

benefits

> New to Medicare in 2020

> Dual Eligibles-premium

paid by Medicaid

*Premium will be higher if your

income is higher than $87,000

single, $174,000 jointly

(Based on 2018 Tax Return)

What You Pay – Part B Premium

$135.50*

For those who are:

> Enrolled prior to 2019

> Beneficiaries who are

currently enrolled in Part B

> And having their premiums

deducted from SSA check

Paying for Inpatient Hospital Stays

For Each Benefit Period in 2020 You Pay

Days 1-60 $1,408 deductible

Days 61-90 $352 per day

Days 91-150 $704 per day

(60 lifetime reserve days)

All days after 150 All Costs

Paying for Skilled Nursing Facility Care

For Each Benefit Period in 2020 You Pay

Days 1-20 $0

Days 21-100 $176.00 per day

All days after 100 All Costs

Medicare Part B: Costs for

Most People

Yearly Deductible

$198.00

Coinsurance • 20% coinsurance for most covered for Part B services, like doctor’s services and Services some preventive services, if provider

accepts assignment

• $0 for some preventive services

• 20% coinsurance for outpatient mental health services, and copayments for hospital outpatient services

Original Medicare: No Limit to Costs

There is no limit (Maximum Out-of-Pocket)

to Original Medicare costs

You are responsible for coinsurance and

copayment costs regardless of how high

these costs go

Medigap Plans

Medigap Plans

Original Medicare

Part A Hospital

Insurance

Part B Medical

Insurance

You can add

Pay Additional Premium on top of

Part B premium

Medicare Supplement Insurance (Medigap)

Policy

Medigap Plans

Medigap explained:

Private health insurance

Supplements Original Medicare

Helps pay some health care costs that Original Medicare doesn’t cover (coverage “gaps”)

Medicare will pay its share of the Medicare-approved amounts for covered health care costs

– Then your Medigap policy pays its share

A Medigap policy covers one person

Medigap Costs

Medigap Cost (monthly premium) depends on

• Your age – premium costs can go up every year as you age

• Where you live (e.g., urban, rural, or ZIP Code)

• Company selling the policy

• Discounts (women, non-smokers, married couples)

• Medical underwriting

• Premiums may vary greatly for the same Medigap plan

Medigap Plans Do Not Cover Prescriptions

If you want drug coverage with a Medigap plan, you must get a stand-alone Part D prescription drug plan

The Part D plan will have a separate premium that you pay in addition to your Medigap premium

You will have 3 premiums to pay and 3 insurance cards to carry

Medigap Plan Card Part D Prescription

Drug Plan Card

Medicare Advantage Plans

Medicare Advantage Plans

What’s a Medicare Advantage (MA) Plan?

How MA Plans work

When you can join or switch plans

Medicare Advantage Plans

Health plan options

Approved by Medicare

Run by private companies

What’s a Medicare Advantage Plan?

Part of the Medicare program

Sometimes called Part C

Available across the country

Provide Medicare-covered benefits

May cover extra benefits

How Medicare Advantage Plans Work

Medicare Advantage Plans can have Medical and Prescription coverage all in one plan

Part C Combines Part A and

Part B

Part D Prescription Drug Coverage

(Most Part C plans cover prescription drugs. You may be able to add drug coverage to

some plan types if not already included.)

• You receive services through the plan

• Covers all Part A and Part B services

• Some plans may provide additional benefits

• Most plans include prescription drug coverage

• You may have to use network doctors/

hospitals

• May differ from Original Medicare

• Cost sharing may be different

How Medicare Advantage Plans Work

How Medicare Advantage Plans Work

You’re still in the Medicare program Medicare pays the plan every month for your care

You still have Medicare rights and protections

If the plan leaves Medicare you can -

Return to Original Medicare and a Med Supplement (Supplement may be subject to Medical Underwriting)

Medicare Health Maintenance Organization (HMO) Plan

Can you get your health care from any doctor or hospital?

No. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

Are prescription drugs covered?

Yes, when you join an HMO that includes prescription coverage

Do you need to choose a primary care doctor?

In most cases, yes.

Do you need a referral to see a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a referral.

What else do you need to know about this type of plan?

If your doctor or other health care provider leaves the plan, your plan will notify you and you can choose another plan doctor. If you get health care outside the plan’s network, you may have to pay the full cost. It’s important that you follow the plan rules. For example, the plan may require prior approval for certain services.

Medicare Preferred Provider Organization (PPO) Plan

Can you get your health care from any doctor or hospital?

In most cases, yes. PPOs have network doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

Are prescription drugs covered?

In most cases, yes. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage. You may contact individual plans to find out if they offer prescription drug coverage.

Do you need to choose a primary care doctor? No.

Do you need a referral to see a specialist? In most cases, no.

What else do you need to know about this type of plan?

PPO plans aren’t the same as Original Medicare or Medigap.

Medicare PPO plans usually offer extra benefits (like dental or vision services) than Original Medicare, but you may have to pay extra for these benefits.

How Are Medigap Policies and MA Plans Different?

Medicare Supplement (Medigap) Insurance

Medicare Advantage Plans (Part C)

Offered by Private companies Private companies

Government oversight

State, but must also follow federal laws

Federal (plans must be approved by Medicare)

Works With Original Medicare Instead of Original Medicare Covers Gaps in Original Medicare

coverage, like deductibles, coinsurance, and copayments for 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 plans include Medicare prescription drug coverage.

You must have Part A and Part B Part A and Part B Do 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.

MA Can Include Part D Prescription Coverage

With a Medicare Advantage Plan, you can have

your medical benefits and prescription benefits

all together in one plan

You would have one premium, for one plan

and one card to carry

Medicare Advantage and Prescription Drug Plan Card

Part D Formulary Tiers

Tier 1:Preferred Generic

Tier 2:Generic

Tier: 3 Preferred Brand

Tier: 4 Non-Preferred

Tier: 5Specialty

The least expensive Drugsyour plan covers, Including allGeneric drugs and Select brand names

These drugs usually have a higher cost share than Tier 1 drugs and can include some preferred generic drugs and some brand name drugs

Brand name drugs that have proven to be the most effective in their class

Drugs considered non-preferred (brand names that are not the “most effective”) as well as preferred specialty drugs

The most expensive drugsBecause they are classified a brand name, specialty and not preferred

• Each tier has its own copay or coinsurance amount. Your plan will encourage you to use the lowest-cost drug to treat your medical condition.

• A drug on a lower tier will cost less than a drug on a higher tier.

Medicare Part D

The biggest difference in Medicare this year is the Medicare Part D coverage gap—also known as the “donut hole”—has been closed. Sort of.The gap refers to the maximum out-of-pocket (MOOP) costs incurred by reaching a certain benefit threshold on medications. While that has been addressed recently, it doesn’t mean your medications will be at no cost.

Medicare Part D

• Instead, Part D beneficiaries can expect a 25% copayment/coinsurance for drugs from the beginning of your plan year after meeting any plan deductible until you reach the 2020 maximum out-of-pocket (MOOP) spending limit of $6,350.

• After that, you’ll pay 0% - 5% of your drug costs. This maximum (MOOP) limit is significantly higher than it used to be, and provides even more reason to shop around and compare prices. Switching plans can save you money on out-of-pocket drug costs.

Additional MA Coverage

MA can cover services not covered by original

Medicare or Medigap:

Long-term care

Routine dental care

Dentures

Cosmetic surgery

Acupuncture

Hearing aids and exams for fitting hearing aids

Vision and eyewear

Other – check Medicare.gov

You still pay the monthly Part B premium. State assistance is available for some, you may pay an additional monthly premium which varies by plan

Plan deductibles, coinsurance, and copayments

Different from Original Medicare

Vary from plan to plan—often lower costs than Original Medicare, May be higher if out of network

Medicare Advantage Costs

Medicare Advantage Cost Limits

Medicare Advantage Plans limit how much you have to pay for services in any given year

This Maximum-Out-of-Pocket means that your copayments and coinsurances have a limit

Once this limit is reached, the Advantage Plan covers 100% of the costs of all your Medicare services

This limit can vary by plan Some plans may set it higher to provide catastrophic coverage

Some plans may set it very low so that beneficiaries quickly reach 100% coverage of their Medicare services

Who Can Join a Medicare

Advantage Plan?

Eligibility requirements—You must:

Be enrolled in Medicare Part A (Hospital Insurance)

Be enrolled in Medicare Part B (Medical Insurance)

Live in the plan’s service area

Be a United States (U.S.) citizen or lawfully present in the U.S.

Not be incarcerated

To join you must also:

Provide necessary information to the plan

Follow the plan’s rules

Can only belong to one plan at a time

Medicare Advantage Has No

Underwriting

Unlike Medicare Supplements, Medicare

Advantage plans have no underwriting

You can enroll in MA plans regardless of your

health with one exception:

Usually you can’t enroll if you have ESRD

There are limited exceptions to this rule

When You Can Join

or Switch MA Plans

Initial Enrollment Period

7-month period begins 3 months before the month you turn 65 Includes the month you turn 65 Ends 3 months after the month you turn 65

Important: If you delay Part B enrollment (for example, due to active employer group coverage), your time to enroll in an MA Plan may be more restricted.

You can only join 1 MA Plan at a time, and enrollment is generally for a calendar year.

When You Can Join

or Switch MA Plans

Medicare due to a Disability

7-month period begins 3 months before the 25th month of disability.

Ends 3 months after the 25th month of disability.

When You Can Join or

Switch MA Plans

Medicare “Annual • October 15—December 7 Election period” • Coverage begins January 1

Medicare “Open Enrollment Period”

••

3-month period begins Jan 1 - Mar 31Enrollment effective 1st of month following application

OEP Changes

MAPD to Original Medicare

MAPD to MAPD

MA Only plan to MA Only plan

January 1st–March 31st

OEP will be a one time use election period Limited to just one change during the 3 month window

Note: Effective dates will be first of the following month after the members signature date

When You Can Join or Switch Plans

Special Enrollment Period (SEP)

Move out of your plan’s service area You have Medicaid Plan leaves Medicare program or reduces its service area Leaving or losing employer or union coverage You enter, live at, or leave a long-term carefacility (like a nursing home) Losing your Extra Help status You join or switch to a plan that has a 5-star rating Retroactive notice of Medicare entitlement Other exceptional circumstances

Medicare Advantage Trial Rights and Medigap

Special Medigap rights for people who

join a Medicare Advantage Plan for the first time

When first eligible at 65 or

Leave Original Medicare and drop a

Medigap policy

Can disenroll during the first 12 months

Return to Original Medicare

Have guaranteed issue rights to return to

Medigap plan

Guaranteed Rights and

Protections

Get needed health care services

Get easy-to-understand information

Have personal medical information kept

private

Rights in Medicare Health Plans

Choice of health care providers

Access to health care providers (treatment plan)

Know how your doctors are paid

Fair, efficient, and timely appeals process

Grievance process

Coverage/payment information before service

Privacy of personal health information

Conclusion

Potential members have choices about how

to receive Medicare benefits

The key is to consider all options to see

what will work best for them

Resource Guide

Medicare Products Resources Resources “Medicare & You Handbook” CMS Product No. 10050

“Have You Done Your Yearly Medicare Plan Review?” CMS Product No. 11220

“Medicare Supplement Insurance, Getting Started” CMS Product No. 11575

“Your Guide to Medicare Private Fee-for-Service Plans” CMS Product No. 10144

“Understanding Medicare Enrollment Periods” CMS Product No. 11219

“Your Guide to Medicare Savings Account Plans” CMS Product No. 11206

“Your Guide to Special Needs Plans” CMS Product No. 11302

To access these products View and order single copies at

Medicare.gov/Publications. Order multiple copies (partners only) at productordering.cms.hhs.gov. You must register your organization.

Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.

Medicare.gov

CMS.gov

Social Security 1-800-772-1213. TTY users should call 1-800-325-0778. socialsecurity.gov

Railroad Retirement Board 1-877-772-5772. TTY users should call 1-312-751-4701. RRB.gov

Medicare Marketing Guidelines https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPart CMarketingGuidelines.html

Medicare Managed Care Manual

CMS.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-

Only-Manuals-IOMs-

Items/CMS019326.html

State Health Insurance Assistance Programs For telephone numbers call CMS 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. shiptacenter.org