understanding medicare basics with edits by illinois ship module 1b

Understanding Medicare Basics with edits by Illinois SHIP

Module 1B

November 16, 2010 2

What is Medicare?

A health insurance for people– 65 and older– Under 65 with certain disabilities– Any age with End-Stage Renal Disease (ESRD)

Administration– Centers for Medicare & Medicaid Services

Enrollment – Social Security Administration for most– Railroad Retirement Board (RRB)

Understanding Medicare

Different Parts of Medicare

Medicare Has four Parts– Part A: Hospital Insurance

– Part B: Medical Insurance

– Part C: Medicare Advantage• HMO, PPO, Private-Fee-For-Service, Special Needs Plan

o Also referred to has Medicare Health Plans

– Part D: Prescription Drug Coverage

November 16, 2010 Understanding Medicare 3

“Original Medicare”


Part A & B

Some will include Part D

Part – B

Part – A

Part – D or Secondary

MedSup

or

Secondary

Ways to receive Medicare

Original MedicareMedicare Advantage

(HMO, PPO, etc)

Social Security Administration Responsible for eligibility and enrollment

– People aged 65yrs or older• Contributed into FICA 40 quarters (10yrs)• Married and receiving benefits under a spouse’s work record• Must have been married a minimum of 10yrs to receive

benefits under a former spouse

– Under age 65yrs• Receiving disability benefits under SSA or Railroad

retirement systems for 24 months

– Any Age• Receiving regular dialysis• Amyotrophic Lateral Sclerosis (ALS)

o a.k.a Lou Gehrig’s Disease


Medicare for Disabled Individuals

Disability Defined:– Inability to work– Expected to last for 1 year or result in death

• Can be the result of blindnesso Visual acuity 20/200 or less with correcting lens in better eye

ORo Visual field of 20 degrees or less

Note: SSA is responsible for disability determination


Qualifying for Disability Benefits

Meet requirements– Definition of disability– Work credits

• Or relationship to someone with work credits

5-month waiting period– Exceptions

• People eligible for childhood disability benefits• Some people previously entitled to disability benefits


Applying for Disability Benefits

Call SSA at 800-772-1213 Necessary documentation needed

– Social security number– Proof of age– Health-care provider information– Medical records– Work history

• Including W-2 for the past two years

Don’t wait to apply


Qualifying for Medicare due to Disability

24-month waiting period– Exceptions for people with ALS

• No additional waiting period• Medicare starts with first month of benefits

Medicare usually begins 30th month after disability begano 5 months + 24 months = 29 month wait


ESRD Disability For Medicare

Coverage begins:– Fourth month of dialysis

• First month if certain conditions are met

– Month you receive kidney transplant– Month you are admitted to approved hospital

• For transplant of procedures preliminary to transplant

– 2 months before month of transplant• If transplant is delayed more than 2 months


Enrollment Periods Initial Enrollment Period (IEP)

– 3month before, month of, 3months after• Person’s 65th birthday• 30th month for Medicare due to disability

General Enrollment Period (GEP)– January 1st through March 31st of each year– Medicare coverage begins July 1st of same year

• Penalties will usually apply

Special Enrollment Period (SEP)– Working or covered by a working spouse

• Medicare Part B – 8 months from when retirement begins• Medicare Part D – 63days from when retirement begins

o Only if already enrolled into Medicare Part A


Original Medicare Go to any provider that accepts Medicare Enrolled into Medicare Part A

– Premium free for most people• Paid 40 quarters (10yrs) into FICA

– Others may be able to purchase• If a U.S. citizen; or

• Legal U.S. resident of 5 continuous years or more

Enroll into Medicare Part B– Pay monthly premium

• Starting in 2007 some individuals have their premiums based on their taxable income

Pay Part A and Part B– Deductible– Coinsurance or co-payment


November 16, 2010 13

Medicare Card (front)

Jane DoeUnderstanding Medicare

Medicare Part A - Covered Services

Inpatient Hospital CareSemi-private room and board, general nursing, meals, and the other hospital services and supplies

Skilled Nursing Facility CareFull-time inpatient nursing and rehabilitative services (Custodial Care not covered)

Home Health Care

Part-time skilled nursing care, home health aids, physical and occupational therapy, speech and language pathology

Hospice CareSupport services from a Medicare-approved hospice, includes drugs for system control and pain relief


November 16, 2010 15

Benefit Period Part A (Hospital Insurance) charges are based on

“benefit period”– Inpatient hospital care and skilled nursing facility (SNF)

services– Begins first day of inpatient hospital care– Ends when you have been out of a hospital or SNF for

60 days in a row – Benefit period is not based on a calendar year– You pay deductible for each benefit period– No limit to number of benefit periods

Understanding Medicare

Medicare Part B - Covered Services

Medical Expenses

Physician services, some diagnostic test, physical and speech therapy, ambulance, observation stay in the hospital…etc.

Home Health Care

Part-time skilled nursing care, home health aids, physical and occupational therapy, speech and language pathology

Outpatient Hospital ServicesOutpatient surgery, diagnostic procedures, emergency room, partial hospitalization…etc.

Durable Medical Equipment (DME)

Walkers, wheelchairs, hospital beds, insulin pump, some medication associated with a DME…etc.


Medicare Part B – Preventive Services

“Welcome to Medicare” Physical Exam – Available only to new Part B beneficiaries

Annual “Wellness Exam” – Available to everyone on Medicare beginning Jan. 1, 2011

Bone Mass Measurements Cardiovascular Screening

Colorectal Cancer Screening Diabetes Screening

Hepatitis B Shots Glaucoma Screening

Pneumococcal Shot Pap Test and Pelvic Exam

Screening Mammograms Prostate Cancer Screening

Smoking Cessation Counseling Flu Shot


Paying the Part B Premium

Taken out of one of the following monthly payments:– Social Security

– Railroad Retirement

– Federal Government Retirement

For information about premiums– Call SSA or RRB

• Office of Personnel Management if a retired Federal employee

Will be billed every 3 months– If not receiving SSA or RRB benefits


Medicare Penalties Part A

– Penalty will only apply if a beneficiary has to purchase Medicare Part A

• 10% a year for twice the number of years

Example: Mrs. Robinson has delayed enrollment into Part A for 2 years, her penalty will be 10% a year for 4 years.

Part B– If a person delayed enrollment into Part B, their

penalty will be 10% for each year and will remain with them for as long as they are on Medicare

Example: Ms. Debbie has delayed enrollment into Part B for 3 years, she will have to pay a 30% penalty including her monthly premium for as long as she is on Medicare.


Medicare Supplement Insurance


2010’s MedSup Policy – Core Benefit

Core Benefits for Plans A, B, C, D, F, G, M, N include: All Part A coinsurance expenses for : $283 per day for 61st through 90th day; $566 per day for 91st through 150th day; Part A Hospice coinsurance Upon exhaustion of Part A hospitalization benefits, full coverage of an

additional 365 days per lifetime; Part B coinsurance or copayment; including Part B Preventive Services First three pints of blood each calendar year

*Core benefits for Plan K and L are the same as listed above with the exception of 50% (Plan K) and 75% (Plan L) payment for the Part A deductible, Part B coinsurance, the blood deductible, hospice care coinsurance and Skilled Nursing Facility coinsurance.


2010’s Medicare Supplement Policieseffective June 1, 2010 and currently available

Benefits IncludedPlan

APlan

BPlan

CPlan

DPlan

FPlan

GPlan

KPlan

LPlan

MPlan

N

Core Benefits √ √ √ √ √ √ √* √* √ √*

Skilled Nursing Facility √ √ √ √ √*

(50%)

√*(75%)

√ √

Part A Deductible √ √ √ √ √ √*(50%)

√*(75%)

√*(50%)

√

Part B Deductible √ √

Part B Excess (100%) √ √

Foreign Travel √ √ √ √ √ √

Out-of Pocket Maximum

$4620 $2310 22November 16, 2010 Understanding Medicare

What is a MedSup Policy? Health insurance policy

– Provided by private insurance companies

Used with “Original Medicare” only– Must have both Medicare Part A and Part B– Covers the major gaps in Medicare

• Medicare-approved charges

All policies are standardized– Each policy will be identical from company to company

• Except in Massachusetts, Minnesota, and Wisconsin


2010’s Medicare Supplement Policieseffective June 1, 2010 and currently available

Benefits IncludedPlan

APlan

BPlan

CPlan

DPlan

FPlan

GPlan

KPlan

LPlan

MPlan

N

Core Benefits √ √ √ √ √ √ √* √* √ √*

Skilled Nursing Facility √ √ √ √ √*

(50%)

√*(75%)

√ √

Part A Deductible √ √ √ √ √*(50%)

√*(75%)

√*(50%)

√

Part B Deductible √ √

Part B Excess (100%) √ √

Foreign Travel √ √ √ √ √ √

Out-of Pocket Maximum

$4620 $2310 24November 16, 2010 Understanding Medicare

High Deductible Option

Another variation of a Medicare Supplement Policy offered is a “high-deductible option”

Offered only with a standardize Plan F Plan will not pay it’s portion of benefits until

deductible has been met– $2,000 in 2011

Deductible is adjusted each year


What is a MedSelect Policy? Health Insurance Policy

– Provided by private insurance companies

Used with “Original Medicare” only– Must have both Medicare Part A and Part B

– Covers the major gaps in Medicare• Medicare-approved charges

Conforms to the Standardize plans– Each policy will be identical from company to company

• Except in Massachusetts, Minnesota, and Wisconsin

Must use specific hospital contract with MedSelect plan– For inpatient hospital services

– May have to use specific physicians

Must live within 30 miles of a contracted hospital


Medicare Supplement Open Enrollment

One-time 6-month window– Have or enrolling into Part A– Enrolling into Part B for first time

• Including those enrolling due to disability

Cannot be denied a policy– Join any plan from any company

May require a pre-existing condition waiting period

– No more than 6 months


Medicare Disabled Beneficiary Illinois Public Act 95-0436

– Began June 1, 2008– Provided same open enrollment rights for Medicare Supplement

Insurance• 6 months Open Enrollment Period (OEP) upon entitlement to

Medicare Part B

• To purchase any policy from almost any company, regardless of health history

– Company cannot charge a rate higher then their highest rate• Registered with the Illinois Department of Insurance

– Once a beneficiary turns 65 yrs-old, they will be entitled to a new 6 months OEP


Medicare Disabled Beneficiary2011 Guarantee Enrollment Period

Guaranteed enrollment for disabled Medicare beneficiaries - November 15 through December 31

Guaranteed issue of a Medigap with 3 companies

AARP/ United Healthcare, Blue Cross Blue Shield, and Health Alliance.


Rights and Guarantees Loss of Medicare Supplement

– Company pulls out of the market• Must be provided with another policy

Loss of other coverage– Employer group health plan

• 63-day Guaranteed Issue• May purchase Plan A, B, C, F, K or L

Medicare Advantage (MA)– Leave MA plan with first 12 months of first enrollment– Plan is pulled from the market


1990’s Medicare Supplement PoliciesPolicies sold prior to June 1, 2010

Benefits Included

PlanA

PlanB

Plan

CPlan

DPlan

EPlan

FPlan

GPlan

HPlan

IPlan

JPlan

KPlan

L

CoreBenefits

√ √ √ √ √ √ √ √ √ √ √* √*

Skilled NursingCoinsurance

√ √ √ √ √ √ √ √√

(50%

√(75%)

Part ADeductible

√ √ √ √ √ √ √ √ √

√(50%) √

(75%)

Part BDeductible

√ √ √

Part BExcess (100%)

√ √ √

Part BExcess (80%)

√

Foreign Travel Emergency

√ √ √ √ √ √ √ √

At HomeRecovery

√ √ √ √


What is Secondary Insurance? Secondary insurance is other insurance that is provided by

– Employment sponsored health and/or drug coverage– Retirement health and/or drug coverage– Union sponsored health and/or drug coverage

Not offered by or contracted with Medicare Company may choose;

– Who they will cover– How and what coverage will be offered– if it will provide any additional coverage for Medicare beneficiaries

Note: Medicare beneficiaries should contact their benefits office to see how it will work with Medicare.


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understanding medicare basics with edits by illinois ship module 1b

Documents

medicare card

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original medicare slide

understanding medicare

medicare health plans

year medicare coverage

medicare approved hospice

working spouse medicare