Medicare 101
Christian Reformed Church
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Medicare 101
Introduction to Medicare Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid Question and Answers
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What Is Medicare?
A health insurance program forPeople 65 years of age and olderPeople under age 65 with certain disabilitiesPeople with End-Stage Renal Disease (ESRD)
Administered by Centers for Medicare & Medicaid Services (CMS)
Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB)
Introduction
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Applying for Medicare
Apply 3 months before age 65Don’t have to be retiredContact the Social Security Administration
Enrollment automatic if receiving Social Security or Railroad Retirement benefits
Introduction
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Medicare
Medicare Basics
Part AHospital Insurance
Part BMedical Insurance
Prescription Drug Coverage (Part D)
Introduction
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Medicare Coverage Basics
Part A
Inpatient hospital care Skilled nursing care Home health care Hospice care
Part B
Doctors’ services and outpatient care Preventive services Diagnostic tests Some therapies Durable medical equipment
Part D Outpatient prescription drugs
Introduction
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Medicare Part A
Most people receive Part A premium free People with less than 10 years of Medicare-
covered employment or anyone not paying Medicare Tax (i.e. clergy)Can still get Part A, but will pay premium
($451/month in 2012) If over 65 (on Part A) actively working and on
employer’s group medical planMay receive some Part A benefit to supplement
covered services not paid by active plan
Introduction
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Enrolling in Medicare Part B
Pay monthly Part B premium$99.90 in 2012 – higher income consumers pay more
Initial Enrollment Period (IEP)7 months starting 3 months before month of eligibility
General Enrollment Period (GEP)January 1 to March 31 each year - Coverage effective
July 1Premium penalty
• 10% for each 12-month period eligible but not enrolled
Introduction
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Enrolling in Medicare Part B
Some people can delay enrolling in Part B with no penaltyIf covered under employer group health plan
that is considered “creditable coverage”• Based on current employment
– Person or spouse
• Will get a Special Enrollment Period (SEP) when employer group coverage ends
– Sign up within 8 months after coverage ends
Introduction
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Part B Enrollment PeriodsExample
Marie turned 65 on June 2, 2012. She will have group health coverage from her employer until she stops working on December 31, 2012.
Part B enrollment opportunities …
Enrollment period Begins Ends
IEP 3/1/12 9/30/12
SEP 10/1/12 8/31/13
GEP (each year) 1/1 3/31
Introduction
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Paying the Part B Premium
Taken out of monthly Social Security payments
If no monthly paymentsBilled every 3 monthsMedicare Easy Pay
Introduction
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Medicare Choices
Original Medicare PlanMedicare Advantage PlansOther Medicare PlansMedicare Prescription Drug Plans
Introduction
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Original Medicare Plan Can access any health care provider that accepts
Medicare People are responsible for:
Part A• In 2012, $1,156 deductible per benefit period for
hospital stays up to 60 days– Additional costs after 60 days
• Different costs for other Part A servicesPart B
• $140 annual deductible in 2012• 20% coinsurance or copayment for most Part B
services Some programs may help with costs
Original Medicare
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The Medicare Card
Jane Doe
Original Medicare
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Medicare Coverage Outside U.S.
For most situations, Basic Medicare won’t pay for health care or Rx outside U.S.
Must have either:Medicare Supplement plan that covers foreign
travelSome Medicare Advantage plans include itInternational Travel Insurance
Visit www.medicare.gov/Coverage/ to learn more about what Medicare covers.
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Medigap
Health insurance policySold by private insurance companiesMust say “Medicare Supplement Insurance”Covers “gaps” in the Original Medicare Plan
• Deductibles, coinsurance, copayments• Does not work with Medicare Advantage Plans
Up to 12 standardized plans A – L• Except in Massachusetts, Minnesota, Wisconsin• So people can compare easily
Medigap
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How Medigap WorksPeople can buy a Medigap policy
Within 6 months of enrolling in Part B• Only some plans are guarantee-issue
If they lose certain kinds of health coverage• Through no fault of their own
If they leave MA Plan under certain circumstancesWhenever insurance company will sell them one
Monthly premiumGenerally go to any doctor or specialist
Medigap
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Medicare Advantage Plans
Health Maintenance Organization (HMO) PlansSome have Point-of-Service option
Preferred Provider Organization (PPO) PlansRegional PPOs
Private Fee-for-Service (PFFS) Plans Special Needs Plans Medicare Medical Savings Account (MSA) Plans
Not very common
Medicare Advantage and Other Medicare Plans
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Eligibility for MA Plans
Live in plan’s service areaEntitled to and Enrolled in Medicare Part AEnrolled in Medicare Part B
Continue to pay Part B premiumMay also pay monthly premium to plan
Don’t have ESRD at enrollmentSome exceptions
Medicare Advantage and Other Medicare Plans
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How MA Plans Work
Usually get all Part A and B services through planMay have to use providers in plan’s networkGenerally must still pay Part B premium
• Some plans may pay all or part
May get extra benefitsVision, hearing, dental servicesPrescription drug coverage
Still in Medicare programGet all Part A and Part B servicesHave Medicare rights and protections
Medicare Advantage and Other Medicare Plans
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Medicare Prescription Drug Coverage
Medicare “D” program began Jan 1, 2006Available to all people with Medicare Provided through
Medicare Prescription Drug PlansMedicare Advantage and other Medicare plansSome employers and unions
Medicare Drug Coverage
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Enrollment Periods
Initial Enrollment Period (IEP)7 monthsStarts 3 months before month of eligibility
Annual Coordinated Election Period (AEP)November 15 through December 31 each yearCan join, drop, or switch coverage
• Effective January 1 of following year
Special Enrollment Period (SEP)
Medicare Drug Coverage
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Late Enrollment
People who wait to enroll may pay penaltyAdditional 1% of national base premium for
every month eligible but not enrolledMust pay the penalty as long as enrolled in a
Medicare drug plan
Unless they have other coverage at least as good as Medicare drug coverage“Creditable coverage”
Medicare Drug Coverage
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Prescription Drug Plans At a minimum, must offer standard benefit
In 2012 members may pay• Monthly premiums• Annual deductible, no more than $320• Copayments or coinsurance
Coverage Gap (donut hole)Begins when reach coverage limit ($2,930 in 2012)
and ends when you spend $4,700 TROOP (True Out-of-Pocket costs).
In “donut hole”, 50% manufacturer-paid discount on covered brand-name drugs. 14% discount for generic
After TROOP max, minimal cost sharing (5%)
Medicare Drug Coverage
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Medicaid
Joint Federal and state programFor some people with limited income and resources
If eligible, most health care costs covered Eligibility determined by state Application processes vary Office names vary
Social ServicesPublic AssistanceHuman Services
Medicaid and Medicare Savings Programs
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For More Information
1-800-MEDICARE (1-800-633-4227)TTY users call 1-877-486-2048
www.medicare.gov Social Security Administration (1-800-772-1213) www.cms.hhs.gov State Health Insurance Assistance Program
(SHIP) Medicare & You handbook
Other publications
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Summary
Medicare coverage Original Medicare Plan Medicare Supplement Insurance (Medigap) Medicare Advantage and other Medicare plans Medicare prescription drug coverage Medicaid
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Questions?
Thanks for your time!Presented by:
Kevin CumingsVice-President of BenefitsBuiten & Associates, LLC5738 Foremost Dr.Grand Rapids, MI [email protected]
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