Medicare and the Health Insurance Marketplaces

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1 Medicare and the Health Insurance Marketplaces Information for Professionals who work with Medicare Beneficiaries

2 Medicare Rights Center The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives Page 2

3 This training will cover The Marketplaces Marketplace plans for individuals Medicare beneficiaries and individual Qualified Health Plans (QHPs) Consequences of late enrollment and strategies for resolving Medicare enrollment mistakes The Small Business Health Options Program (SHOP) Medicare beneficiaries and the Small Business Health Options Program (SHOP) plans Making decisions about Medicare drug coverage Page 3

4 The Marketplaces Page 4

5 The Marketplaces Forums where businesses and individuals can shop for health coverage Insurance for individuals is called Qualified Health Plans (QHPs) Insurance for businesses are called Small Business Health Options Plans (SHOP) Marketplaces permit comparison of available plan options based on price, benefits, services, and quality Marketplaces are also called Exchanges Page 5

6 The Marketplaces Marketplaces will operate in every state and the District of Columbia How state Marketplaces get run varies Some states run their own Marketplaces Some partner with the federal government Some rely on the federal government to run their Marketplaces Page 6

7 Paying for QHP coverage People with incomes between 100 percent and 400 percent of the federal poverty level (FPL) can receive tax credits to pay for the QHP premiums Some groups never qualify for tax credits People who are eligible for Medicaid People who are eligible for Medicare Page 7

8 Requirement for health coverage Starting January, 1, 2014, US residents must have a minimum level of health coverage, called minimum essential health coverage This requirement is known as the Individual Mandate Minimum essential health coverage includes: Medicare Medicaid, employer insurance and QHPs People who fail to obtain minimum essential coverage need to pay a fee unless they can t afford health coverage Page 8

9 Do the Marketplaces affect Medicare? The Marketplaces do not affect Medicare coverage Medicare will operate the same way it has always operated Medigap policies, Medicare Advantage plans and stand-alone Part D drug coverage will not be sold through the Marketplaces People with Medicare should not use the Marketplaces to change their coverage Page 9

10 Open Enrollment Periods The Marketplace Open Enrollment Period overlaps with Medicare s Fall Open Enrollment Period Medicare Fall Open Enrollment Period (October 15 - December 7) Marketplace Open Enrollment period (November 15 - February 15) People with Medicare should use Medicare s Fall Open Enrollment Period to examine their Medicare plans and make changes based on coverage needs Page 10

11 People with Medicare and the Marketplaces People with Medicare, should not switch to a QHP It is illegal for a Marketplace representative to enroll a person with any part of Medicare into a QHP People with QHPs who become eligible for Medicare can keep their QHPs, but it is not typically a good idea to do so May provide little to no coverage, and carry expensive premiums Page 11

12 People with Medicare and the Marketplaces Medicare provides the most cost- effective coverage Premiums for Medicare Parts A and B, Medigap and Part D plans should cost less than QHPs and provide more coverage Most people who qualify for Medicare will not qualify for low income tax credits to help pay QHP premiums Medicare Part A fulfills the minimum essential coverage requirement Medicare Part B does not count as minimum essential health coverage by itself Page 12

13 Transitioning to Medicare from a QHP If people have an QHP, they should take Medicare once they become eligible and drop their QHP People should make sure to enroll in Medicare Parts A, B and D during their Initial Enrollment Period They should keep track of when they first qualify for Medicare They should enroll themselves if not automatically enrolled People should notify a representative of their QHP at least 14 days before their Medicare coverage begins They should tell the representative to end their QHP coverage Page 13

14 Why take/keep Medicare? If people are eligible for Medicare, they will likely need to pay the full premium of a QHP Will not usually qualify for tax credits to help pay for QHPs QHP premiums will be more expensive than Medicare coverage options without tax credit assistance If they delay Medicare enrollment, Will likely pay higher Medicare premiums for the rest of their lives Will have to wait for Medicare to start if they decide to enroll later There is no guarantee that a QHP will pay for a person s health care if they are eligible for Medicare but fail to enroll A QHP may pay very little toward a person s health care, even though they are paying the full premium Page 14

15 Consequences of not enrolling People who don t enroll in Medicare when they should may face these problems: Premium penalties Their existing coverage may not pay for care May have to pay the full cost of health care they get A plan may recoup payments it made when Medicare should have been primary Page 15

16 Possible solutions Premium penalties and gaps in coverage are erased if Medicare eligibility changes For example, when a disabled beneficiary turns 65 and becomes eligible due to age Someone enrolls in a Medicare Savings Program (MSP) Must meet income requirements Someone qualifies for Equitable Relief Federal law lets people request relief from the Social Security Administration in the form of immediate or retroactive Medicare enrollment and/or elimination of Part B premium penalty Page 16

17 Medicare and the Small Business Health Options Program (SHOP) Page 17

18 The SHOP SHOP = Small Business Health Options Program Program within the Marketplace where small businesses and their employees can search for and purchase health coverage SHOPs will: Guarantee small businesses a choice of plans to offer employees Post health plan information on a state s website to allow comparisons between plans Page 18

19 Participation in the SHOP Companies can generally only participate in their state s SHOP if they have 50 or fewer employees Businesses must offer SHOP coverage to all full time employees (30+ hours) and 70 percent of employees must participate In 2016, all companies with 100 or fewer employees should be able to participate Sole Proprietors/Self-Employed Persons cannot participate in the SHOP Must buy QHPs through the Individual Marketplace Page 19

20 SHOP coverage and Medicare eligibility When people with SHOP coverage first qualify for Medicare, they need to decide whether to enroll in Medicare Parts B and/or D Decisions about Part B are based on how their SHOP plan coordinates with Medicare Decisions about Part D based on whether SHOP plan provides creditable coverage Page 20

21 Decisions about Part B Enrollment Page 21

22 Decisions about delaying Part B All people with SHOP coverage qualify for a Special Enrollment Period (SEP) to delay Part B without penalty After a current worker retires or loses their job, the worker and their spouse have up to 8 months to enroll in Part B without penalty However, many people with SHOP plans should enroll into Medicare Part B as soon as they are eligible This is because for these people, Medicare pays first and the SHOP plan pays second Before deciding about Part B, people must find out how their SHOP plan coordinates with Medicare Page 22

23 SHOP coverage and Medicare If Medicare pays first and the SHOP plan pays second, people should always enroll in Medicare Part B as soon as they are eligible If the SHOP plan pays first and Medicare pays second, people may consider delaying Part B People have coverage through the SHOP who don t enroll in Part B when they should may face these problems: Their existing coverage may not pay for care May have to pay the full cost of health care they get A plan may recoup payments it made when Medicare should have been primary Page 23

24 Fewer than 20 employees (65+) 65+ individuals with SHOP coverage from an employer with fewer than 20 employees need to take Part B when they qualify For 65+ individuals, Medicare is always primary to coverage from a current employer with fewer than 20 employees When Medicare pays first, a SHOP plan may provide little or no coverage if the person failed to enroll in Medicare Page 24

25 20 or more employees (65+) 65+ individuals with SHOP coverage from a company with 20 or more employees may consider delaying Part B For 65+ individuals, Medicare pays second to coverage from a current employer with 20 or more employees The SHOP plan must provide the same coverage as before people qualified for Medicare Before making decisions, individuals should talk to their employer to see how Medicare coordinates with the SHOP plan and confirm that information with Social Security Social Security Administration: Get answers in writing Page 25

26 The SHOP and Medicare due to a disability People under 65 who qualify for Medicare due to a disability should enroll into Medicare Part B when they first qualify All plans purchased through the SHOP pay second to Medicare for people who are under 65 but are eligible for Medicare due to a disability For under 65 people with disabilities, Medicare always pays before coverage from an employer with less than100 employees When Medicare pays first, a SHOP plan may provide little or no coverage if the person failed to enroll in Medicare Page 26

27 Decisions about Drug Coverage Page 27

28 Eligibility for Part D All people qualify for Medicare Part D once they are enrolled in Medicare Part A and/or B Part D plans provide outpatient prescription drug coverage for drugs purchased at a pharmacy or through mail order People may consider delaying Part D if the SHOP plan provides creditable coverage Page 28

29 Creditable coverage Creditable coverage is drug coverage that s at least as good as Medicare s basic drug benefit People with creditable coverage from a SHOP plan can delay Part D without penalty They must enroll in Part D within 63 days of losing creditable coverage to avoid penalties and gaps in coverage SHOP plans may or may not offer creditable coverage People should look for a yearly notice from their insurer that states whether not the SHOP coverage is creditable If they don t receive this notice, they should ask for proof of creditable coverage in writing from their employer Note: Even if people have creditable coverage, they may want to enroll in Part D if they qualify for Extra Help, a low income drug program, which could lower their Part D costs Page 29

30 Part D enrollment Someone should strongly consider enrolling in Part D if they don t have creditable drug coverage and: They have high drug costs Even if they don t have high drug costs, it s often best to enroll in Part D so they have it when they need it If someone waits to enroll, they ll likely face gaps in coverage and premium penalties Page 30

31 If someone doesn t enroll in Part D If someone has creditable coverage, they can enroll late without penalty as long as they aren t without creditable coverage for more than 63 days If they don t have creditable coverage, they can enroll later, but there may be consequences: They may have gaps in coverage because they ll usually need to wait for an enrollment period to sign up for Part D They may have to pay a premium penalty The penalty is 1% of the national average premium for every month they lacked creditable coverage for 63 days or more National average premium in 2014, is $32.42 Page 31

32 Conclusion Page 32

33 Summary If people have Medicare, they should keep it and should not consider QHPs If someone has an individual QHP, they should enroll in Medicare when they first qualify for it If an individual is enrolled in a SHOP plan They should take Medicare if they are under 65 and qualify for Medicare due to a disability They should take Medicare if they are over 65 and their SHOP plan comes from an employer with less than 20 employees They may be able delay Medicare if they are over 65 and their insurance comes from an employer with 20 or more employees Check with Social Security ( ). Get answers in writing. Page 33

34 Common consumer questions 1) Should people with Medicare switch to or add QHP coverage? 2) Should people with QHP coverage switch to or add Medicare coverage when they qualify? 3) Do employees with coverage through the SHOP exchanges need to enroll in Medicare Parts B and/or D? Page 34

35 Answers 1) Should people with Medicare switch to or add QHP coverage? No, people with Medicare should not add QHP coverage to their existing Medicare coverage 2) Should people with QHP coverage switch to or add Medicare coverage when they qualify? Yes, people with QHPs should switch to Medicare coverage when they become eligible 3) Do employees with coverage through the SHOP need to enroll in Medicare Parts B and/or D? It depends on the size of their employer and whether they receive creditable drug coverage through their SHOP plan Page 35

36 For more information and help Local State Health Insurance Assistance Program (SHIP) Find a SHIP phone number at Medicare 800-MEDICARE ( ) Medicare Rights Center Medicare Interactive (see next slide) Page 36

37 Medicare Interactive Medicare Interactive Web-based compendium developed by Medicare Rights to be used as a counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare? 1.1 million annual visits and growing Page 37

38 Dear Marci e-newsletter Timely, understandable answers to Medicare questions Links to deeper exploration of topics Additional resources and health tips Released every two weeks Sign up on our web site: MedicareRights.org/about-mrc/newsletter-signup.php Page 38

39 Medicare Rights University Web-based curriculum that empowers professionals to better help their own clients, patients, employees, retirees, and others navigate Medicare Beta tested with 30+ companies and nonprofits Four levels with four to five courses each Courses organized by knowledge level Free assessment Quizzes and downloadable course materials Builds on 25 years of Medicare Rights Center counseling expertise For details, visit MedicareRightsUniversity.org or contact Scarlet Watts: , Page 39

40 Medicare Rights University Page 40

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