Medicare Benefit Review
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1 Medicare Benefit Review
2 What is Medicare? Medicare is Health Insurance For people 65 or older For people under 65 with certain disabilities For people at any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
3 Medicare Has Different Parts Medicare Part A Hospital Insurance Medicare Part B Medical Insurance Medicare Part C Medicare Advantage Plans Medicare Part D Prescription Drug Coverage
4 Medicare Part A (Hospital Insurance) Medicare Part A covers partially or totally: Inpatient care in hospitals (partially) Skilled nursing facility (partially) Hospice (totally) Home Health Care (totally)
5 Medicare Part B (Medical Insurance) Helps cover medically-necessary services Doctor s s services Outpatient care Some preventive services to help maintain health and to keep certain illnesses from getting worse
6 Medicare Part C Advantage Plans Another way to have Medicare benefits Combines Medicare Part A & B & sometimes Part D coverage Medicare Advantage Plans are managed by private insurance companies approved by Medicare The plans must cover medically-necessary services but may charge different co-payments, coinsurance or deductibles for these services
7 Medicare Part D Prescription Drugs Helps cover prescription drugs. May help lower prescription costs and help protect against higher costs in the future
8 Medicare s s Covered Services
9 Medicare s s Part A Covered Services Hospital Stays Covers a semi-private room, meals, general nursing, drugs as a part of inpatient treatment, procedures, surgery, other hospital services and supplies. Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime. Blood - starting with the 4 th pint (the first 3 pints aren t covered)
10 Medicare s s Part A Covered Services, cont. Skilled Nursing Facility (SNF) After a 3-day 3 minimum inpatient hospital stay for a related illness or injury Covers a semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies Care in a SNF requires skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in a SNF
11 Medicare s s Part A Covered Services, cont. Home Health Services (Reasonable and necessary part-time time or intermittent skilled care) Nursing (Skilled service) Physical Therapy (Skilled service) Speech Therapy (Skilled service) Occupational Therapy (If a skilled service is required) Medical Social Work (If a skilled service is required) Home Health Aide (If a skilled service is required) Durable Medical equipment (Wheelchairs, hospital beds, oxygen, walkers) w Medical Supplies
12 Medicare s s Part A Covered Services, cont. Hospice Care for people with a terminal illness who are expected to live 6 months or less if the disease runs its normal course Drugs Medical services Support services Some short-term term inpatient stays (for pain & symptom management) Inpatient respite (to provide the caregiver with rest) Bereavement services
13 Medicare's Part B Covered Services Covers medically-necessary services like doctor s s services, outpatient care and other medical services that Part A doesn t t cover. Part B has a premium each month. In 2008 the standard premium amount is $96.40 There is also a yearly deductible before Medicare starts to pay it s s share. In 2008 the deductible amount is $135
14 Medicare's Part B Covered Services, cont. Medicare B covers a great many services. Some examples follow: Ambulance services Ambulatory surgery Clinical laboratory services Disease screenings, colorectal cancer, diabetes, cardiovascular disease, glaucoma, mammogram Emergency room services Diabetes supplies Doctor services
15 Medicare's Part B Covered Services, cont. Ongoing durable medical equipment Immunizations flu, hepatitis B, pneumonia Foot exams and treatment Physical, Occupational, & Speech-Language Language therapy Prosthetic/Orthotic Items Second surgical opinions Surgical dressing services Tests X-Ray, MRIs, CT scans, EKGs Transplants
16 What is NOT covered by Medicare Parts A & B Acupuncture Cosmetic surgery Custodial care & long term care Dental care Routine eye care Routine foot care Tests that haven t t been ordered by the doctor Physical exams Additional items & services as identified in the Medicare handbook
17 Medicare Part C Medicare Advantage Plans are health plan options (like HMOs and PPOs) ) approved by Medicare and run by private companies. Medicare pays an amount for your care every month those private health plans. Medicare Advantage Plans must follow rules set by Medicare. Medicare Advantage Plans are not supplimental insurance.
18 Medicare Part C, cont. Medicare Advantage Plans provide all of the Medicare Part A & B benefits and must cover at least all of the medically-necessary services that the original Medicare plan provides. Medicare Advantage plans can charge different co- payments, coinsurance and deductibles. Medicare Advantage Plans may offer extra benefits such as vision, hearing, dental, and/or health and welfare programs. Most include prescription drug coverage (usually for an extra cost)
19 Medicare Part C, cont. Medicare Advantage Plans usually have provider networks. This means that the individual will probably have to see a doctor who belongs to the plan or go to a certain hospital to receive covered services. The individual may need a referral to see specialists. If the individual uses providers who are not in the network he may have to pay the full amount of the charges.
20 Medicare Part C, cont. Individuals considering a Medicare Advantage Plan should understand the plan and it s s limitations and should discuss options with a knowledgeable person (not just the person who represents the plan in question) An individual enrolled in a Medicare Advantage Plan is still in the Medicare program with Medicare rights and protections including the right to appeal An individual may opt out of the plan and go back to traditional Medicare coverage. Contact Medicare for the timeframe for changing plans.
21 Medicare Part D (Prescription Drugs Coverage) Medicare offers prescription drug coverage for everyone with Medicare. To get prescription drug coverage the individual must join a Medicare drug plan. Medicare drug plans are run by insurance companies and other private companies approved by Medicare. Each plan can vary in cost and drugs covered.
22 Medicare Part D There are two ways to get Medicare prescription drug coverage Join a Medicare Prescription Drug Plan Join a Medicare Advantage Plan Things to consider when comparing plans Coverage check to see if the plan covers the drugs taken by the individual Cost Check to see how much the prescription drugs cost in each plan Convenience Make sure the plan s s pharmacies include the ones the individual wants to use
23 Medicare Part D Costs vary depending on the drugs the individual uses, the plan chosen, and qualification for extra help to pay for Part D costs Payments made to a Medicare drug plan include: Monthly premium paid in addition to the Part B premium Yearly deductible Amount paid for prescriptions before the plan begins to pay Co-payment or coinsurance Amounts paid for prescriptions after the deductible. Medicare Part D Plans vary so the individual must compare plans prior to making a choice.
24 Getting Help to Compare Plans Visit on the web. Under Search Tools select Compare Medicare Prescription Drug Plans. Call MEDICARE ( ) TTY users should call Call the State Health Insurance Assistance Program (SHIP) (toll free in Illinois)
25 Medicare s s Quality Monitoring at To compare certified facilities visit: Compare Dialysis Facilities in Your Area Compare Home Health Facilities in Your Area Compare hospitals in Your Area Compare Nursing Homes in Your Area To compare Medicare Health Plans and Medigap (Medicare supplemental insurance) visit: Medicare Options Compare To compare Medicare drug coverage visit: Medicare Prescription Drug Plan Finder
26 Questions?
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that contracts with the Federal government.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.cs.ny.gov/employee-benefits or by calling 1-877-7-NYSHIP
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