Making Sense of Medicare

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1 Making Sense of Medicare Stephanie M. Turnbull Manager, Member Benefits 1 Highlights Medicare Eligibility Types of Medicare Coverage Medicare Part A Medicare Part B Medicare Part C Medicare Part D Medicare Medigap Coverage Applies to Part A and Part B Only Medicare Low Income Subsidy (LIS) Medicare Enrollment 2 1

2 Eligibility 65 or older Under 65 with certain disabilities Any age with End Stage Renal Disease (ESRD) Individual coverage Specific enrollment deadlines Red, White & Blue Card 3 Medicare Part A Inpatient Coverage Inpatient Coverage Hospital Hospice Skilled Nursing Facility No premiums if Medicare taxes were paid while working Patient payment responsibility varies depending on the type of service received 4 2

3 Medicare Part B Outpatient Coverage Outpatient Coverage Physician Services Home Health Durable Medical Equipment (DME) Clinical Laboratory Services Premium based on current income 2011 Deductible: $162 20% Co Insurance/Patient Responsibility 5 Medigap Medicare Supplement Medicare supplement insurance Sold by private companies Covers the gaps in Original Medicare Benefits Part A and Part B such as co payments, co insurance and deductibles Several policies labeled A N which vary in coverage Does not apply to Medicare Part C or Part D 6 3

4 Medicare Part C Medicare Advantage Medicare Advantage Plan Combines Medicare A, B and sometimes D into one plan Offered by private insurance companies approved by Medicare Plan may include vision, hearing, dental and/or health and wellness programs Must pay Part B and Part C Premium Out of Pocket may be reduced 7 Medicare Part D Prescription Drugs Medicare Prescription Drug Coverage Insurance companies contract with Medicare to manage prescription drug benefit Patients must have Medicare Part A and/or Part B Medicare Part C beneficiaries qualify Medicare Part D Formulary Coverage Gap or Donut Hole Changes in co payment structure 8 4

5 Medicare Part D Prescription Drugs Deductible $ 310 $310 Initial coverage Limit Coverage Gap $2830 $2840 Member responsibility:100% of the coverage gap; $250 rebate for reaching coverage gap Out of Pocket $4550 $4550 Catastrophic Coverage Generic: 5% or $2.50 Brand: 5% or $6.30 Member responsibility:50% on brand name drugs, 93% on generic drugs. Full retail cost of drug will apply to gap Generic: 5% or $2.50 Brand: 5% or $ Brand Coverage Gap Discount Projection 10 5

6 Medicare Coverage Gap Discount Program Brand manufacturers must have a Signed Discount Agreement with Center for Medicare and Medicaid Services (CMS) Brand drugs will be taken off the Medicare Part D formulary if the manufacturer chooses not to participate Coverage Gap Discount applies to the portion of cost that falls into the coverage gap 11 Generic Coverage Gap Discount Projection 12 6

7 Medicare Low Income Subsidy LIS What is it? Assistance with drug plan premiums, yearly deductible, coinsurance, and co payments Medicare Part D coverage gap does not apply Apply through Social Security Administration website or by calling Medicare LIS Eligibility Single Person: Income less that $16,335 and resources less than $12,640 Married Person: Income less than $22,065 and resources less than $25,260 Resources Include Checking, Savings, Stocks, and Bonds Automatically Qualify if you meet one of the following conditions Full Medicaid Coverage Assistance with Part B Premiums from State Medicaid Program Supplemental Security Income (SSI) Benefit 14 7

8 Important Enrollment Dates Medicare A and B Enrollment Dependant on date of birth and qualifying new diagnosis Medicare D Open Enrollment Mid November End of December New coverage and cost changes begin January 1 Medicare Part C Enrollees May Switch to Original Medicare January 1 st February 15 th of the current year 15 Additional Information on Medicare Medicare.gov Basics of Medicare My Eligibility Part D Plan Finder Online Enrollment Medicare & You MEDICARE ( ) 16 8

9 Summary Medicare Plan Types A: Inpatient Coverage B: Outpatient Coverage C: Medicare Advantage D: Prescription Drug Coverage Medicare D 2011 Coverage Gap Discounts Medicare Low Income Subsidy Medicare Enrollment 17 Additional Information Health Care Reform Act Manufacturers Signed Discount Agreement a.asp#topofpage 18 9

10 Question & Answer 19 References "Medicare & You 2011." Centers for Medicare and Medicaid Services, Sept Web. Feb <http://www.medicare.gov/publications/pubs/pdf/10050.pdf>."medicare Prescription Drug Coverage: How to Join a Medicare Drug Plan." Medicare.gov. Centers for Medicare and Medicaid Services, Sept Web. Feb <www.medicare.gov/publications/pubs/pdf/11111.pdf>. "Closing the Coverage Gap Medicare Prescription Drugs Are Becoming More Affordable." Centers for Medicare and Medicaid Services, Nov Web. Feb <www.medicare.gov/publications/pubs/pdf/11464.pdf>. "Information Pharmacists Can Use On: Closing the Coverage Gap." Centers for Medicare and Medicaid Services, Nov Web. Feb <www4.cms.gov/partnerships/downloads/11522 P.pdf>. "Bridging the Coverage Gap in 2011." Centers for Medicare and Medicaid Services, Jan Web. Feb <www.medicare.gov/publications/pubs/pdf/11213.pdf>. "Re Determination of Low Income Subsidy (LIS) Eligibility for 2011." Centers for Medicare and Medicaid Services, Oct Web. Feb <https://www.cms.gov/.../downloads/lisundeemedplan1letter2011.pdf>. Nothing contained in this power point is to be considered as the rendering of legal advice for specific cases. Readers/attendees are responsible for obtaining such advice from their own legal counsel. The power point and any forms herein are intended for educational and informational purposes only. Information contained in this power point is not a guarantee and official determinations are made by the Centers for Medicare and Medicaid Services (CMS)

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