I wanted to understand the Medicare program basics. This presentation really helped.

Transcription

1 Welcome to Medicare 101! I wanted to understand the Medicare program basics. This presentation really helped. What is Medicare? What benefits does Medicare cover? What benefits doesn t Medicare cover? What are my other coverage options? When can beneficiaries enroll? M_LG_PS_20130

2 What is Medicare? The nation s largest health insurance program. It provides high-quality health care to: People age 65 and older People under age 65 with certain disabilities All people with end-stage renal disease (ESRD) Administered by the Centers for Medicare & Medicaid Services (CMS) Has four parts: A and B managed by the federal government, referred to as Original Medicare C and D offered by private health insurance companies with an approved Medicare contract

3 What does Original Medicare cover? Part A Hospital insurance managed by the government to help cover: Inpatient hospital care Skilled nursing facility care Hospice care Some home health care Beneficiary may go to any provider that accepts Medicare Beneficiaries must pay (rates are per benefit period for 2013 and change annually): Days in hospital $1,184 deductible $296 copay per day $592 copay per lifetime reserve day % $0 copay $148 copay per day 100% Days in skilled nursing facility

4 What does Original Medicare cover? Part B Medical insurance managed by the government to help cover: Covered preventive services Covered in- and outpatient doctor services Outpatient surgery, hospital and emergency room visits Lab fees and X-rays Durable medical equipment, such as an oxygen tank or cane Beneficiaries may go to any provider that accepts Medicare Beneficiaries must pay (rates are for 2013 and change annually): $ (or more) monthly Part B premium (based on income) + $147 annual deductible 20% coinsurance for most services after deductible is met

5 What doesn t Original Medicare cover?* $1,184 Part A deductible $296 per day hospital copay, days $148 per day skilled nursing facility copay, days $147 annual Part B deductible 20% coinsurance for covered non-preventive doctor services Emergency medical coverage outside of the United States (except in limited circumstances) Annual hearing exams Allowances for eyewear and hearing aids Part D prescription drugs Out-of-pocket medical costs annual limit If beneficiaries only have Parts A and B coverage, they may have to pay more than $23,000 out of their own pockets each year for these services* * Rates are for 2013 and change annually; Part A deductible and inpatient copays are per benefit period.

6 Part C Medicare Advantage Plans Part D Medicare Prescription Drug Coverage Medigap Medicare Supplement Plans Medicare Coverage Options

7 Part C Medicare Advantage Plans Offered by private health insurance companies with an approved Medicare contract Beneficiaries must have Parts A and B to enroll, and continue to pay their Part B premium May require using providers in the plan network Combine Parts A (hospital) and B (medical) benefits and add in benefits and features not covered by Parts A and B, which may include: coverage for Parts A and B deductibles an annual limit on medical costs prescription drug coverage (with most plans) routine hearing exams eyewear and/or hearing-aid allowances worldwide emergency medical coverage Parts A and B Coverage Additional Medical Coverage Medicare Prescription Drug Coverage

8 Part C Medicare Advantage Plans Two main types of Medicare Advantage plans: Health Maintenance Organizations (HMO) Must use doctors and hospitals in the plan network to receive benefits By contracting with a network of doctors and hospitals, Medicare Advantage plans may provide more benefits for less money than Original Medicare Some plans require referrals to see specialists Some offer added benefits to those with government assistance Preferred Provider Organizations (PPO) Provide all the benefits of an HMO while offering the flexibility to use doctors and hospitals outside of the plan network, often at a higher copay or coinsurance

9 Part C Medicare Advantage Plans Beneficiaries generally must pay (rates are for 2013 and change annually): Monthly Premiums $ (or more) Part B premium + Part C plan premium (if applicable; varies by plan) Medical Coverage + Copays until Maximum-Out-of-Pocket (MOOP) limit is met (copays and MOOP vary by plan) + $0 for covered services (after MOOP is met) + Rx Coverage (not included in all plans; copays and coinsurance vary by plan; some plans may not have a deductible and may offer coverage during the gap) $325 deductible $ Initial Coverage Limit $3, Coverage Gap 5% Catastrophic

10 Part C Medicare Advantage Plans Beneficiaries will NOT have to pay (rates are for 2013 and change annually): $1,184 Part A deductible per benefit period $296 per day hospital copay, days $147 Part B annual deductible 20% coinsurance for covered non-preventive doctor services 100% for foreign emergency coverage, annual hearing exams, eyewear and/or hearing aids Additional monthly premium for Part D Medicare prescription drug coverage (when plan includes prescription drug coverage) A Medicare Advantage plan may cost less than enrolling in Parts A and B and a separate stand-alone Prescription Drug plan.

11 Part D Medicare Prescription Drug Coverage Offered by private health insurance companies with an approved Medicare contract Purchased in addition to Parts A and/or B benefits Helps cover prescription drug costs, generally through: Stand-Alone Medicare Prescription Drug Plans OR Medicare Advantage Plans with prescription drug coverage Extra Help is available for beneficiaries with limited income and resources Parts A and/or B Coverage No Additional Medical Coverage Medicare Prescription Drug Coverage

12 Part D Medicare Prescription Drug Coverage All four steps must be reached within the same calendar year before Catastrophic becomes active. Step 1 Step 2 Step 3 Step 4 Deductible Initial Coverage Period Coverage Gap Catastrophic Copay varies based on drug tier: Generic You 79% Plan 21% Cost sharing below applies after you reach $4,750 in True Out-of-Pocket expense. You $325 You $ OR = Plan $1, All Medicare Prescription Drug plans must be equal to or offer better coverage than the Standard Prescription plan. Your plan may differ than this plan and may not include a deductible or coverage gap phase. Brand You 47.50% Plan 2.5% Manufacturer Discount 50% You 5% Plan 15% Medicare 80%

13 Part D Medicare Prescription Drug Coverage Beneficiaries generally must pay (rates are for 2013 and change annually): Monthly Premium $ (or more) Part B premium + Part D plan (varies by plan) or C plan premium (if applicable; varies by plan) Medical Coverage (Original Medicare) + $1,184 deductible (Part A) $147 deductible (Part B) Part A inpatient copays ($296 per hospital day 61-90) ($148 per SNF day ) 20% coinsurance (Part B) + Rx Coverage (copays and coinsurance vary by plan; some plans may not have a deductible and may offer coverage during the gap) $325 deductible $ Initial Coverage Limit $ Coverage Gap 5% Catastrophic

14 Medigap Medicare Supplement Plans Health insurance policies sold by private insurance companies Supplement Parts A and B services and supplies to cover medical benefit gaps, such as Parts A and B deductibles and coinsurance 11 standardized plans ( ) Do not include Part D prescription drug coverage Parts A and B Coverage Additional Medical Coverage No Medicare Prescription Drug Coverage

15 Medigap Medicare Supplement Plans Beneficiaries generally must pay (rates are for 2013 and change annually): Monthly Premium $ (or more) Part B premium + Medigap plan premium (varies by plan) + Part D plan premium (optional) Medical Coverage (Medicare Parts A and/or B + additional benefits (see next slide)) + $1,184 deductible (Part A) $147 deductible (Part B) Part A inpatient copays ($296 per hospital day 61-90) ($148 per SNF day ) 20% coinsurance (Part B) Rx Coverage (NOT included) Beneficiaries can buy a stand-alone Medicare Prescription Drug plan for an additional premium (cost sharing varies by plan; some plans may not have a deductible and may offer coverage during the gap) $325 deductible $ Initial Coverage Limit $3, Coverage Gap 5% Catastrophic

16 Medigap Medicare Supplement Plans BASIC BENEFITS FOR 2013 A B C D F* G K L M N Part A (hospital) coinsurance: days 61 to 150 Hospital costs for 365 additional days after Medicare benefits end First three pints of blood each year 50% 75% Part B (medical) coinsurance or copayments for hospital outpatient services Hospice Care coinsurance/copayment 50% 75% 50% 75% Except for copayments of up to $20 for office visits and $50 for emergency room visits ADDITIONAL BENEFITS FOR 2013 A B C D F* G K L M N Skilled Nursing Facility (SNF) coinsurance: days 21 to % 75% Part A (hospital) deductible: $1,184 50% 75% 50% Part B annual deductible: $147 Part B Excess Charges: covers up to 115% percent of Medicare's approved charge Foreign Travel Emergency: $250 deductible, 80% of the cost of emergency care during the first 60 days of the trip, $50,000 lifetime limit Out-of-Pocket Limit: $4,800 $2,400 * A high-deductible Plan F is available for a lower monthly plan premium and an annual deductible of $2,110 in 2013.

17 Medicare Coverage Options Parts A and B Original Medicare Medical Part A Inpatient hospital care Skilled nursing care Home health/hospice care Usually no premium Part B Doctor services Outpatient care Preventive services Monthly premium Rx Part C Medicare Advantage Plans Part D Medicare Rx Coverage Part C Part D Part A benefits Part A benefits and/or Part B benefits Part B benefits May offer additional benefits Available as a standalone plan or as part of not covered under Original Medicare Medicare Advantage plan Must use plan s provider coverage network to receive highest level of benefits Medigap Medicare Supplement Plans Medigap Supplement Parts A and B benefits Help cover deductibles and coinsurance Cover visits to any provider that accepts Medicare Move with you as long as premiums are paid Does not include Part D prescription drug coverage Often include Part D prescription drug coverage Part D prescription drug coverage only Do not include Part D prescription drug coverage Costs Must pay deductibles, coinsurance, copays No annual limit on out-ofpocket medical costs Managed by the government Low or $0 monthly premium (plus Part B premium) No in-network deductibles Predictable copays Annual limit on out-of-pocket medical costs Offered by private insurance companies with an approved Medicare contract Monthly premium (plus Part B premium, if you have it) May pay deductible Copays, coinsurance Help limit out-of-pocket costs Offered by private insurance companies with an approved Medicare contract Monthly premium (plus Part B premium) May pay deductible Coinsurance Help limit out-of-pocket costs Buy Part D coverage separately State regulated Offered by private insurance companies

18 Election periods apply to enrollment in a Medicare Advantage or Medicare Prescription Drug plan. Medicare Supplement plans are open for enrollment year-round. Enrollment Periods

19 Part C and Part D Enrollment Periods Initial Election Period (IEP): 7 months surrounding 65 th birthday Can enroll in Medicare coverage of choice If don t enroll during IEP, could pay government penalty and may have to wait several months to enroll February March April May June July August 65th Birthday 3 months prior birthday month 3 months after Enroll now for benefits to begin in birth month Enroll now and benefits will begin the month after application is received

20 Part C and Part D Enrollment Periods Annual Election Period (AEP): October 15 through 7 Can enroll in Medicare coverage of choice New plan benefits start 1 October 15 November 7 1 New plan benefits start

21 Part C and Part D Enrollment Periods Medicare Advantage Disenrollment Period (MADP): 1 through February 14 During this time, beneficiaries can: Disenroll from Part C plan Return to Parts A/B (Original Medicare) Disenroll from Part C plan with Rx During this time, beneficiaries cannot: Return to Parts A/B (Original Medicare) Enroll in Stand-Alone Part D Plan (optional) Disenroll from Part C plan Enroll in new Part C plan Switch from Parts A/B (Original Medicare) Enroll in Part C plan

22 Part C, Part D and Medigap Enrollment Periods Special Election Period (SEP): Year round Begins when special exceptions to the IEP, AEP or MADP are met, such as: 1. Losing employer coverage 2. Moving to a different service area 3. Getting both Medicare and Medicaid 4. Being assigned to a Medicare Prescription Drug plan by the government 5. Losing eligibility for state medical assistance coverage 6. Qualifying for Medicare due to a disability Remember: Medicare Supplement plans are open for enrollment year-round. Beneficiaries may be able to enroll without underwriting regardless of age or health history if they apply due to certain events, such as losing employer coverage or first becoming eligible for Medicare.

23 To learn more about Medicare program basics, you can also visit: or call MEDICARE (TTY: ), 24 hours a day, 7 days a week or call (TTY: ), 7 a.m. to 7 p.m., Monday through Friday Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. This material is for informational purposes only and is not an offer or invitation to contract CON E (1/13) 2013 Aetna Inc.