MEDICARE

OVERVIEW

MEDICARE

OVERVIEW

Program Manager

800-234-7119

Pam Roberts

402- 444-6617

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What is Medicare & Who Runs the Medicare Program?

Medicare is the federal health insurance program for people age 65 or older. It also covers persons under age 65 with disabilities and people with End-Stage Renal Disease (ESRD)

The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that runs Medicare. CMS is part of the U.S. Department of Health and Human Services (HHS)

Today’s Medicare is about CHOICE. Original Medicare Plan

Fee-For-Service (pay-per-visit) health plan that lets people go to any doctor, hospital or other health care provider who accepts Medicare. Medigap policies are Medicare supplement insurance sold by

private insurance companies to fill “gaps” in Original Medicare Plan coverage.

Medicare Advantage Plans Health Plan options that are approved by Medicare but

run by private companies. They are part of the Medicare Program and sometimes called “Part C”.

Prescription Drug Coverage Open to everyone with Medicare, but you must join a

drug plan to get this coverage.

Medicare has three parts

Part AHospital Insurance

Most people do not have to pay for Part A.

Part BMedical Insurance

Most people pay monthly for Part B.

Part DPrescription Drug

InsuranceProvided through private

insurance companies

Part A Inpatient Hospital Stays Skilled Nursing Facility (SNF) Care Home Health Care Hospice Care

D5

Original MedicarePart A Beneficiary Costs in 2007

In-Patient Hospitalization: $992. deductible for a hospital stay of 1-60 days $248. per day copayment for days 61-90 $496. per day copayment for days 91-150 All costs for each day beyond 150 days Blood deductible -- first three pints

Skilled Nursing Facility Costs: Days 1-20: Medicare pays 100 (approved) Days 21-100: $124. copayment per day Beyond 100 days: Beneficiary pays all costs

D7

Original MedicarePart A Beneficiary Costs in 2007

Home Health Care: Medicare pays 100% for Home Health Care covered

services – You pay 0%. 20% of the Medicare-approved amount for covered

Durable Medical Equipment Hospice Care:

Medicare pays 100% for services – You pay 0% Beneficiary pays:

No more than $5 for each prescription drug and other similar products

5% of Medicare approved amount for inpatient respite care

D16

Part BMonthly Premium – Generally, $93.50 in 2007 Doctors Services Outpatient Hospital & Emergency Room Durable Medical Equipment Clinical Lab Services Other Services & Supplies

E5

Original Medicare - Part BBeneficiary Liability

Yearly Deductible - $131.00 in 2007

Coinsurance Amounts 20% of Medicare approved amount for physician services; 50%

of Medicare approved amount for outpatient mental health services; Set co-payment amount for hospital outpatient services

Excess Charges generally limited to 15% over Medicare approved amount;

exceptions include durable medical equipment, flu shots, & some drugs

Noncovered Items

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Part B Preventive Services Available to Help you Stay Healthy “Welcome to Medicare”

physical exam Bone mass measurement Cardiovascular screening Colorectal cancer screening Diabetes screening,

services, and supplies

Glaucoma screening Pap test and pelvic exam

with clinical breast exam Prostate cancer screening Screening mammogram Smoking cessation

counseling Vaccinations (shots)

Medicare Supplement Insurance Sometimes referred to as a “Medigap” Policy, this is health

insurance sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage.

Medigap policies help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services

Medigap policies DO NOT work with Medicare Advantage plans

Insurance companies in NE can sell you a policy from 12 “standardized” Medigap policies (Medigap A through L). These Medigap policies must all have specific benefits.

Costs vary by policy and company. An employer/union/retiree plan may offer similar coverage

Medicare Advantage Basics A unique alternative to Original Medicare

Sometimes referred to as Medicare + Choice or Part C Approved by Medicare and administered by private

companies, so MA Plans provide ALL of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services.

You must have Medicare Parts A & B to join Operates under an annual contract with Medicare Usually includes coverage for prescription drugs (MAPD) May offer extra benefits, i.e. vision, hearing or dental care Must accept all Medicare beneficiaries, even those on

Medicare due to disability, and cannot have a waiting period for pre-existing conditions. The exception are those with End-Stage Renal Disease (ESRD)

In a Medicare Advantage Plan, be aware that….

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You must continue to pay Part A (if necessary) and Part B premiums Some Medicare Advantage Plans charge a monthly premium in addition

to your Part A/Part B premium. Costs vary by plan and the services you use.

You must live in area where plan is offered You are responsible for the co-payments

Plans determine their own rates & charges.Co-pays vary according to plan

Medigap (supplement) Plans do not work with Medicare Advantage Plans Your current provider may or may not accept the plan you

choose as these plans often have networks Doctors or hospitals are not required to accept payment from MA plans.

If the provider does NOT accept the plan, you may be responsible for the entire payment!

Important MA Considerations: Does your provider accept the plan?

You may have to see doctors who accept the plan or go to certain hospitals to get covered services—are you willing to change?

In most Medicare Advantage Plans, if your plan offers Medicare prescription drug coverage and you want drug coverage, you must get it from your plan. Are your prescriptions covered under this plan?

Can you cover the maximum out of pocket? i.e. in-patient hospital co-pays

Rules for enrollment and disenrollment Annual Co-ordinated Election Period (AEP)

November 15 through December 31—Coverage begins January 1

Medicare Advantage open enrollment period January 1 through March 31 each year—lateral move only

Twelve Month Trial Run Can leave the MA plan at any point during

first 12 months If enrolled when turned 65:

Can go to Original Medicare and buy any Medigap plan A-L (OR)

If left Medigap and original Medicare: Can return to Original Medicare and get their Medigap

policy back, if still available, or pick another one (A,B,C,F,K or L) from any issuer

Medicare Prescription Drug Coverage--Part D--

Began January 1, 2006 Offered by private plans approved by Medicare Available for all people with Medicare

Part A, Part B, or both Must join a Medicare drug plan to get coverage

Part D Enrollment & Penalties Initial Enrollment Period (IEP)

7 months Starts 3 months before month of eligibility

Annual Coordinated Election Period (AEP) Special Enrollment Period (SEP) People who wait to enroll may pay penalty

Additional 1% of national base premium for every month eligible but not enrolled

November 15 – December 31 every year People who don’t have a Medicare drug plan can

enroll People who currently have a Medicare drug plan can

switch Changes are effective January 1, 2008 Special Enrollment Period (SEP) may apply in

special circumstances

Annual Coordinated Election Period (AEP)

Annual Notice of Change All Part D plans send to all members

By October 31, 2007 Will include information for 2008

Summary of Benefits Formulary Any changes

Premium Copayment/coinsurance

Basic Standard Coverage

2008 BASIC STANDARD COVERAGE

Your DrugCosts

You Pay MedicarePays

Your Total Out-Of-Pocket Costs Per

Year*

Deductible $0- $275 100% ($275) $0 $275

Coinsurance $276-$2,510 25% ($558.75) 75% ($1,676.25)

$833.75

GAPor Doughnut

Hole

$2,511-$5,726.25

 

100% ($3,216.25)

$0 $4050.

Catastrophic Benefit

Over $5,726.25

5% 95% $4050. + 5% of costs above $5,726.25

*Does not include premium cost

Part D Plan Finder Tool and MyMedicare.gov

Both available at: www.medicare.gov

Part D Plan Finder Tool Allows beneficiaries to personalize their search for

prescription drug coverage that best meets their needs Compare plans Use preferences to narrow results Provides information on Prescription Drug Plans &

Medicare Advantage Prescription Plans MyMedicare.gov

Secure online service for accessing your personal Medicare information

Limited Income and Resources? What is Medicaid? What is the Medicare Savings

Program? What is Medicare’s Extra Help?

Low Income Subsidy

Reevaluation and Enrollment Events Begin November 16th, 2007 Call VAS office for list of events close to you Can come into VAS office for one-on-one

1941 South 42nd Street, Suite 502 The Center 444-6617