MEDICARE BASICS WHAT TO KNOW AND WHAT TO EXPECT WITH MEDICARE

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1 MEDICARE BASICS WHAT TO KNOW AND WHAT TO EXPECT WITH MEDICARE

2 AGENDA What is original Medicare? The A, B, C, and D s of Medicare Enrollment periods Medicare Advantage star rating system Where you can find more information

3 ORIGINAL MEDICARE Part A and Part B from Original Medicare.

4 PART A: HOSPITAL INSURANCE What it Covers In-patient hospital care Hospice care Home health services In-patient skilled nursing How you qualify You already get retirement benefits from Social Security or the Railroad Retirement Board. You're eligible to get Social Security or Railroad benefits but haven't filed for them yet. For premium free Part A, you or your spouse must have worked for at least 40 quarters of coverage (varies is applying due to age or disability)

5 PART B: MEDICAL INSURANCE What It Covers Doctor s visits Outpatient care Durable Medical Equipment Preventative screenings If You Decide To Enroll You can sign up through the Social Security offices Pay a monthly premium Social Security check deduction Quarterly billing from Social Security

6 ORIGINAL MEDICARE ENROLLMENT PERIODS Initial Enrollment Period (IEP) General Enrollment Period (GEP) Special Election Period (SEP)

7 PART C: MEDICARE ADVANTAGE What Is It? Private insurance plans, approved by Medicare, to act as your Medicare provider. Combine Part A and Part B May or may not include Part D (prescription coverage) In most plans, you need to use plan doctors, hospitals, and other providers or you pay more or all of the costs. How to Qualify You have Medicare Part A and Part B You live in the service area of the plan, if applicable You don t have end-stage renal disease (exceptions apply) You enroll when the plan is accepting enrollment

8 PART C: MEDICARE ADVANTAGE Types of Plans Health Maintenance Organization (HMO) Point-of-Service (POS) Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) Special Needs Plans (SNP)

9 PART D: PRESCRIPTION DRUG COVERAGE What Is It? Outpatient prescription drug coverage Medicare approved formulary How Do I Get One? Join a Medicare Advantage or Medicare Cost plan that includes Part D in their coverage Acquire a separate Part D plan from a private insurance company, approved by Medicare Each plan can vary in cost and drugs covered

10 2015 STANDARD MEDICARE PART D Initial Coverage Stage $320 ENROLLEE DEDUCTIBLE Catastrophic Coverage Coverage Gap Stage Stage Coverage Gap Brand Discount 75% Plan Contribution 25% Enrollee Coinsurance When the total paid by you and the plan reaches $2,960 the Coverage Gap Stage begins. 45% Enrollee Brand Discount 80% Paid by Medicare Payment 15% Plan Contribution 50% Pharmaceutical 5% Manufacturer Enrollee Coinsurance Brand Discount This 5% Plan coverage Brand ensures Contribution that once you have paid a certain amount 65% Enrollee Generic Payment of your covered Part D drugs, you 35% only Plan pay Generic a small Contribution share of the cost for the rest of the calendar year. You stay in this stage until your True Out-of-Pocket (TrOOP) costs reach $4,700. Enrollees pay 45% of the costs for Brand Name Drugs (plus a portion of the dispensing fee). The balance of the cost is paid by the manufacturer and the health plan as indicated above. *CAN CHANGE ON AN ANNUAL BASIS ON JANUARY 1.

11 MEDICARE PART C & PART D ENROLLMENT PERIODS Initial Coverage Election Period (ICEP) Annual Election Period (AEP) Part D Initial Enrollment Period (IEP) Special Election Period (SEP) Disenrollment Period (MADP)

12 MEDICARE STAR QUALITY RATINGS Objective ratings on Medicare plans Rated on a scale 1-5 from over 50 measures, grouped into different categories Rated on an annual basis Allows a one time switch to a 5 Star plan during the year (SEP) Find these ratings at MEDICARE

13 MEDIGAP: MEDICARE SUPPLEMENT PROGRAM What Is It? An extension of Original Medicare to help cover some of the extra costs Copay s Coinsurance Deductibles Owned by private insurance companies How It Works When you receive care, the provider will bill Medicare using your Original Medicare coverage. Then the provider bills the Medigap insurance for the remainder The beneficiary is responsible for any outstanding charges incurred after both payments have been made

14 TYPES OF MEDIGAP PLANS

15 WHAT YOU NEED TO KNOW ABOUT MEDIGAP Medigap doesn t cover everything Generally don t cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing You must have Medicare Part A and Part B You cannot have a Medicare Advantage plan and a Medigap plan at the same time The Medigap policy only covers one person. Medigap policies sold after January 1, 2006 aren t allowed to include prescription drug coverage. Any standardized Medigap policy is guaranteed renewable even if you have health problems. Medigap plans are not contracted with Medicare Medigap plans do not have a network of providers Doesn t include Emergency Room or Ambulance

16 FOR MORE INFORMATION MEDICARE toll free at (TTY ), 24 hours a day, seven days a week medicare.gov socialsecurity.gov Statewide Health Insurance Benefits Advisors (SHIBA) Social Security toll free at (TTY ), Monday through Friday from 7 a.m. to 7 p.m. Medicare & You Handbook

17 THANK YOU!

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