Cabrillo College Retiree Benefits and Medicare Frequently Asked Questions

Transcription

1 Cabrillo College Retiree Benefits and Medicare Frequently Asked Questions

2 Table of Contents What is Medicare?... 3 What are the different parts of Medicare?... 4 What does Medicare help cover Part A?... 5 What does Medicare help cover Part B? What does Medicare not cover?. 7 Original Medicare enrollment period. 8 Medicare Part C (Medicare Advantage).. 9 Medicare Part D (Prescription drug coverage) Medicare Supplement plans (Medigap) Medicare and group health plans.. 15 Do working seniors still need Medicare>.. 16 Make a financial comparison Cabrillo College Plan-Specific Options. 18 Cabrillo College Specific Q&A. 24 page 2

3 Medicare What is Medicare? Fee-for-service health insurance Medicare helps cover your expenses on certain services You can use any doctor/hospital (provider) that accepts Medicare Who is eligible? People ages 65 or older People under ages 65 with certain disabilities People of any age with end-stage renal disease (ESRD) page 3

4 Filling in the gaps Making coverage complete There are two main ways to get your Medicare coverage: through Original Medicare, which can be supplemented by a Medicare Supplement plan, or with a Medicare Advantage Plan. Original Medicare Part A Hospital insurance Part B Medical Insurance Medicare Advantage Plan (like an HMO or PPO plan) Combines Part A, Part B, and usually Part D Part D Prescription drug coverage Decide if you need to add drug coverage. Decide if you need to add supplemental coverage. Medigap (Medicare Supplement insurance policy) Part D Prescription drug coverage (Most Medicare Advantage Plans cover prescription drugs. Part D drug coverage can only be added to Medicare Advantage Plans that do not have prescription drug coverage.) page 4

5 Medicare Part A Hospital coverage Helps cover: 1. Inpatient hospital care in hospitals Hospital deductible: $1, Copayment for days 61-90: $304/day Copayment for days : $608/day After day 150: NO COVERAGE! 2. Skilled nursing facility stays You pay nothing for the first 20 days each benefit period. Days : - $152/day 3. Hospice care 4. Home health services Part A premium - no cost for beneficiaries who meet certain criteria (who work for 40 quarters or 10 years) Part-time or intermittent care. You pay nothing for covered home healthcare services. page 5

6 Medicare Part B Medical coverage Helps cover: 1. Doctor and other healthcare providers visits 2. Outpatient hospital care 3. Durable medical equipment 4. Home health care 5. Many preventive services offered 6. No cost for most preventive services 2014 beneficiary cost-sharing amounts for Part B $ standard monthly premium Fast facts $ annual deductible. Medicare pays 80% of approved charges You pay 20% of approved charges Physicians can t charge more than 15% on top of approved charges You might be eligible to defer Part B without incurring penalties if you have group health coverage through an employer or union. Part B is available to all Medicare beneficiaries. If you do not sign up when you are eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Monthly premiums are deducted directly from the beneficiary s Social Security check, or billed quarterly. page 6

7 Medicare Parts A and B do not cover: Most prescription drugs Routine vision, foot, or dental care Routine hearing exams and hearing aids Acupuncture Custodial care at home or in a nursing home Health care outside of the U.S. Part A and Part B deductibles and coinsurance Hospital care after 150 days Medicare does not have a out-of-pocket maximum. page 7

8 Original Medicare Enrollment periods 1. Initial Enrollment Period When you first become eligible for Medicare. Begins 3 months before the month of your 65th birthday. Ends 3 months after the month of your 65th birthday. 2. Special Enrollment Period Anytime you re still covered by the group health plan. During the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first. 3. General Enrollment Period January 1 through March 31 of each year. Part B coverage starts on July 1 of the year you sign up. Part B premium penalty of 10% for each 12-month period you could have had Part B but did not. Penalty is waived if you were covered by a group health plan and enroll during a Special Enrollment Period. page 8

9 Medicare Part C Medicare Advantage Plans Fast facts You must have both Medicare Parts A and B Offered by private health plans Designed to cover the gaps of Original Medicare Copays are varied Medicare Advantage Prescription Drug Plans include prescription drug coverage Must use the plan s network doctors and facilities In most cases, referrals are necessary Some plans include routine vision, hearing and dental benefits, and gym membership page 9

10 Medicare Part D Prescription drug coverage Medicare Part D covers prescription drugs only A beneficiary can add Part D to: 1. Original Medicare 2. Medicare Supplement plans 3. Medicare Advantage Plans without prescription drug coverage What types of Part D plans are offered? 1. Prescription Drug Plan (PDP) A PDP plan is sold as a standalone plan by Medicare-approved companies. It can complement a Medicare Supplement (Medigap) plan. 2. Medicare Advantage Prescription Drug Plan (MA-PD) Prescription drug coverage is offered as part of an MA-PD plan. page 10

11 Medicare Part D Fast facts 1. Part D is not offered by Medicare. A beneficiary needs to pick a private health plan, which is then subsidized by the government. 2. Don t go 63 days or more in a row without a Medicare drug plan or other creditable coverage. 3. Tell your plan about any drug coverage you had if they ask about it. 4. Coverage in Part D is optional. However, if beneficiaries don t enroll when first eligible, they could be subject to a late enrollment penalty (higher monthly plan premiums) unless they are enrolled in a plan with drug coverage that is creditable. page 11

12 Medicare Part D 2014 Costs for Covered Drugs Plan premiums may vary Phase 1 Annual deductible This is the amount you must pay before your drug plan begins to pay its share of your covered drugs. Some drug plans don t have a deductible. Phase 2 Initial coverage You pay a copayment, and your plan pays its share for each covered drug until your combined amount (plus the deductible) reaches $2,850. Phase 3 Coverage gap You pay 47.5% of covered brand-name drug costs and 72% of covered generic drug costs until your out-of-pocket costs reach $4,550. Some plans will offer coverage of some drugs through the gap. Phase 4 Catastrophic coverage Once you ve spent $4,550 for the year, you will pay only a small copayment or coinsurance for each covered drug until the end of the year. page 12

13 Medicare Part D Enrollment periods 1. Initial Enrollment Period Initial Enrollment Period (3 months before 65 birthday, month of birthday and 3 months after) Newly eligible for Medicare 2. Annual Election Period Open Enrollment Period(Oct. 15 December 7) 3. Special Election Period Special Enrollment Period (you move, lose insurance coverage, qualify for Extra Help). 4. Extra Help paying for prescription drugs (for those who qualify) page 13

14 Medicare Supplement plans (Medigap) Fast facts Medicare Supplement plans are also known as Medigap plans. You must have both Medicare Parts A and B. Offered by private health plans. 10 standardized plans with varying benefits, plus a high-deductible option for Plan F. Designed to cover the gaps of Original Medicare including some deductibles and coinsurance of Medicare-allowed amounts for covered healthcare expenses. Freedom to choose any doctor, specialist, and hospital in the U.S. that accepts Medicare. Must pay monthly plan premiums in addition to Medicare Part B premium Medicare Supplement does not cover long-term care, pharmacy, dental, routine vision, hearing aid, and private-duty nurse. Guaranteed renewable. page 14

15 Medicare and group health plans Generally, employers with 20 or more employees must offer current employees or spouses 65 and older the same health benefits that they offer younger employees. If you have Medicare and you re offered coverage under a group health plan, you can choose to accept or reject the plan. If you or your spouse are still working and you have health coverage through that employer or union, contact your employer or union benefits administrator to find out how your coverage works with Medicare. It may be to your advantage to delay Part B enrollment. When you have health coverage based on current employment, you can sign up for Part B at any time, without penalty. Once the employment ends, you have 8 months to sign up for Part B without a penalty. This period will run whether or not you choose COBRA. If you choose COBRA, don t wait for COBRA to end to enroll in Part B if you don t enroll in Part B during the 8 months, you may have to pay a penalty, and you won t be able to enroll until the next General Enrollment Period. page 15

16 Do working seniors still need Medicare? Questions you may want to ask when you speak to your benefits administrator Employee is turning 65 Am I just covering myself? No Yes Younger spouse/ adult child Is employer plan cheaper than $104.90? Both stay on employer plan or just cover the younger spouse No Get Part B Yes Stay on employer plan Retiree 65+ defer Part B or elect an individual plan for yourself Look into Medicare Individual options page 16 Defer Part B

17 Make a financial comparison Monthly payroll deductions Group plan $ Part B Premium + Medicare Part D $ Plan cost for Medicare option Non-group plan Max out-of-pocket $ Max out-of-pocket $ Plan deductible $ Plan deductible $ Hospital deductible $ Hospital deductible $ Doctor visits $ Doctor visits $ Specialist visits $ Specialist visits $ Prescription cost $ Prescription cost $ X-rays and lab work $ X-rays and lab work $ Vision coverage $ Vision coverage $ Dental coverage $ Dental coverage $ Gym membership $ Gym membership $ $ $ page 17

18 Cabrillo College Specific Plan Options 2014/2015 HMO Plan Options These plan design options are also provided for Active employees. Option 1 HMO $10-0 This plan offers: No deductible $1000 ind/$2000 family out-ofpocket maximum $10 office visit $671 Single w/medicare A & B $975 Single w/out Medicare $ person w/medicare A & B Generic/Brand Rx $5/$10 through Navitus/COSTCO (mail order) $ person w/out Medicare A & B Medicare is Primary Must select Blue Shield HMO provider Option 2 HMO $ This plan offers: No deductible $2000 ind/$4000 family out-ofpocket maximum $459 Single w/medicare A & B $771 Single w/out Medicare $918 2-person w/medicare A & B $25 office visit Generic/Brand Rx $9/$35 through Navitus/COSTCO (mail order) $ person w/out Medicare A & B Medicare is Primary Must select Blue Shield HMO provider page 18

19 Cabrillo College Specific Plan Options 2014/2015 HMO Plan Options These plan design options are also provided for Active employees. Option 3 HMO $30-20% This plan offers: No deductible $1500 per member out-of-pocket maximum $30 office visit $457 Single w/medicare A & B $724 Single w/out Medicare $914 2-person w/medicare A & B $ person w/out Medicare A & B Generic/Brand Rx $9/$35 through Navitus/COSTCO (mail order) Medicare is Primary Must select Blue Shield HMO provider page 19

20 Cabrillo College Specific Plan Options 2014/2015 PPO Plan Options These plan design options are also provided for Active employees. Option 4 PPO 80-E This plan offers: $300 ind/$600 family deductible $1000 ind/$3000 family out-of pocket maximum $20 office visit $520 Single w/medicare A & B $956 Single w/out Medicare $ person w/medicare A & B $ person w/out Medicare A & B Generic/Brand Rx $7/$25 through Navitus/COSTCO (mail order) Medicare is Primary May see any Blue Shield PPO Provider (CA & Non-CA) Option 5 PPO 80-J This plan offers: $750 ind/$1500 family deductible $3000 ind/$6000 family out-of pocket maximum $30 office visit $474 Single w/medicare A & B $848 Single w/out Medicare $948 2-person w/medicare A & B $ person w/out Medicare A & B Generic/Brand Rx $9/$35 through Navitus/COSTCO (mail order) Medicare is Primary May see any Blue Shield PPO Provider (CA & Non-CA) page 20

21 Cabrillo College Specific Plan Options 2014/2015 PPO Plan Options These plan design options are also provided for Active employees. Option 6 PPO HDHP B (Deductible must be met before plan pays any cost sharing) This plan offers: $2,500 ind/$5,000 family deductible $5,000 ind/$10,000 family out-of pocket maximum 10% office visit (after deductible) Generic/Brand Rx $7/$25 (after deductible) Medicare is Primary $483 Single w/medicare A & B $681 Single w/out Medicare $966 2-person w/medicare A & B $ person w/out Medicare A & B May see any Blue Shield PPO Provider (CA & Non-CA) Rx is through Blue Shield page 21

22 Cabrillo College Specific Plan Options 2014/2015 Individual Retiree Medical Plan Options These plan options are only available for Retirees over 65. Option 7 Option 8 Companion Care Blue Shield Medicare Advantage This plan is a Medicare Supplement Plan that pays the difference of what Medicare does not pay such as deductibles, in-patient per day costs, Skilled Nursing, etc. Note that this plan only pays on Medicare allowable expenses. Must be enrolled in Medicare Part A & B May see ANY Medicare provider Anthem Blue Cross is the claims processor not network Members are enrolled in Part D The Rx plan on CompanionCare included an enhanced Rx drug plan with no coverage gaps ($9/$35 copays through any pharmacy that takes Navitus retail or COSTCO mail order) CMS approved formulary The $0 generic copay & diabetic supplies for generic at COSTCO is not applicable to this plan This plan assigns the Medicare benefits to Blue Shield. Copays apply, most benefits covered at 100% Must be enrolled in Medicare Part A & B Must select Blue Shield HMO Medicare provider in approved zip code/service area Not all HMO Primary Care Physicians (PCP) are available in this plan Physicians Medical Group of Santa Cruz provider network only Member are enrolled on Part-D and provided Blue Shield CMS approved formulary page 22 $370 per person $740 (2-person) $406 per person $812 (2-person) (NorCal Region)

23 Cabrillo College Specific Plan Options 2014/2015 Individual Retiree Medical Plan Options These plan options are only available for Retirees over 65. Option 9 Kaiser This plan assigns the Medicare benefits to Kaiser. Copays apply, most benefits have $10 copay Must be enrolled in Medicare Part A & B Must select Kaiser provider in approved service area/zip code Rx Included w/kaiser facility $329 per person $658 (2-person) page 23

24 Cabrillo College Specific Q&A s Q: What is the benefit period for Medicare benefits? A: January 1 December 31 Q: Is the Medicare Advantage plan an HMO or a PPO? A: For Cabrillo College, the plan is an HMO Q: Is CompanionCare different than a PPO? A: Yes. On this plan, you may visit any provider that accepts Medicare. The provider will bill Medicare first. The balance of the claim is sent to Anthem Blue Cross for processing. It s important to note that the Rx formulary will be slightly different than the traditional Active plans. Q: What happens to my Rx benefits if I move out of state? A: Please refer to pages of this document. Most retail Rx plans are through Navitus. COSTCO walk-in pharmacies may not be available but you may still participate in the mail order program. page 24

25 Cabrillo College Specific Q&A s Q: What if I am enrolled in the traditional Active plan and I want to switch to one of the Individual Retiree plans? A: You may enroll in an Individual Retiree Medical plan at any time. You do not have to wait for an open enrollment period. However, you must submit a completed enrollment form to your District's Benefit representative 45-days prior to the effective date. The effective date of coverage will be the first of the month following the 45-day notice. Once you are enrolled, you may NOT go back to the group "Active" plan (e.g. PPO or HMO). Q: If I enrolled in the CompanionCare and my doctor does not accept Medicare, what will happen. A: There is a great possibility that you may be billed for the balance for whatever Medicare does not pay. CompanionCare requires that you receive services from a participating Medicare provider. Q: I am 65 but my spouse is younger. Can I split us up on different plans? A: Yes. You may enroll in an individual plan while your spouse remains on a District Active plan with under age 65 rates. Q: May I receive Homeopathic care? A: Generally the Individual Retiree Plans will not cover Homeopathic care. However, please consult your benefits booklet or contact the customer service department for specific benefits. page 25

26 Cabrillo College Specific Q&A s Q: Does Medicare provide subsidy assistance for low income households? A: Medicare does have a program called LTS Low income Subsidy Q: Do I qualify for low income subsidy? A: You may contact CMS (Center for Medicare/Medicaid Services) at or MEDICARE ( ) page 26