BIA Medicare 101 Presentation Long Form

MEDICARE MADE SIMPLEBIABoone Insurance Associates Education Guide: New10/20/2014

Copyright by BIA 1www.booneinsuranceassociates.com

Today’s Agenda

About BIA Introduction & History of MedicareMedicare Parts A, B, C, D Coverage GapsGeneral Medicare Plan Types

And More . . .

BIACopyright by BIA 10/20/2014

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About Boone Insurance Associates

Boone Insurance Associates provides health and life insurance products to clients all overOregon.

We work directly with the companies to resolve any of your claim, benefit, & premiumquestions.

Unlike a captive insurance producer who represents that insurance company alone, we areindependent of a specific insurance company and represent a variety of differentcompanies and products.

Boone Insurance Associates provides this educational program today to help inform you.There is no obligation for you to purchase services from us.

“Our pledge is to provide our clients with superior customer service and product knowledge inorder to guide them in making the most informed decisions."

BIA10/20/2014Copyright by BIA

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Basic Medicare Terminology

Deductible Copay / Coinsurance OOP – Out of Pocket Maximum LIS – Low Income Subsidy


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Introduction & History of Medicare

Medicare is a Federal Insurance Program Administered by CMS, a federal agency in the

Department of Health and Human Services.“Center for Medicare & Medicaid Services”

Consists of Hospital insurance, Medical insurance,Medicare Advantage plans, and Prescription Drugplans

In July 1965, Congress passed a bill to establishMedicare.


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Introduction & History of Medicare cont…

Balanced Budget Act of 1997 established Part C,known as Medicare + Choice (M + C) Program Plans also called Medicare Advantage

Medicare Modernization Act (MMA) was passed in2003 Implements new prescription drug benefit Implements new Medicare Advantage program (replacing

M+C)


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Who gets Medicare?

It is available to qualified individuals, including: People age 65 or older

People under age 65 who have been declareddisabled

People with End-Stage Renal Disease (ESRD), alsoknown as kidney failure.


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Medicare is comprised of:

Medicare Part A: Hospital coverage

Medicare Part B: Medical coverage: (OutpatientSurgery & Doctor Visits)

Medicare Part C: Medicare Advantage

(Offered by Insurance Carriers)

Medicare Part D: Medicare Prescription Drugcoverage (Offered by Insurance Carriers)


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Medicare Part A(Hospital Insurance)

What do I pay for Medicare Part A? It has no premium cost for individuals who have

worked at least 40 calendar quarters Is automatically provided to those who reach 65

years of age Includes a monthly premium for those who have

worked fewer than 40 calendar quarters. All taxpayers are contributing towards Medicare

via payroll FICA deductions.


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Medicare Part A(Hospital Insurance) Cont…

What does Part A cover? Hospital stays Home health services Hospice care Minimal care in a skilled nursing facility (SNF) Cover the first 20 days in full days after a 3 day hospital

stay, then cover days 21-100 at a daily rate. Then nocoverage after 100 days.

Does not include intermediate or custodial coverage.


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Medicare Part A(Hospital Insurance) Cont…

Part A Deductibles

[2013] Hospital stay per benefit period: Days 1-60 [$1184] per benefit period Days 61-90 [$296] per day Days 91-150 [$592] per day

[2013] Skilled Nursing Facility: Days 1-20 [$0] per day Days 21-100 [$148] per day


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What is a Medicare Benefit Period?

Begins the day you go into a hospital or skillednursing facility, ends when you have not receivedhospital or skilled nursing care for 60 days in arow

If you go into the hospital after one benefit periodhas ended, a new benefit period begins

There is no limit to the number of benefit periodsyou can have.


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Medicare Part B

What does Medicare Part B cover?

Physician Services

Laboratory, X-rays, MRI, CT Scans

Chemotherapy

Ambulance, Emergency Room Care

Outpatient Surgery

Preventive Care

Part B Medications


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Medicare Part B Cont…

What do I pay for Medicare Part B?

Part B premium is based on Part B medical costs and annual income level perindividual

[2013] Part B Premium Annual Income per Individual

$104.90 [$85,000 or less]

$146.00 [$85,001 to $107,000]$209.80 [$107,001 to $160,000]$272.70 [$160,000 to $214,000]$335.70 More than [$214,000]

Double amounts listed above for married couples filing jointly

Premiums are deducted from the Social Security benefits, or billed quarterly


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Medicare Part B Cont…

Deductibles & Coinsurance for Deductible: 2013 [$147] per year

Other Services: Patient pays [20%] of approved amount, after

deductible. {Medicare pays 80%} [50%] for most Outpatient mental healthcare

services. There is no OOP maximum, risk is unlimited


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Original Medicare Does Not Cover

Out-of-pocket maximum spending safety net Certain deductibles and coinsurances Routine physical (beyond one-time initial physical and

annual wellness visit) Dental (except if medically necessary) Vision (except if medically necessary) Access to complementary (alternative) care benefits Gym Memberships or professional health coaches


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Covering Medical & Prescription Gaps

Three main options availableMedicare Part C (Medicare Advantage Plans)

Traditional Medicare Supplement Plans (Medigap)Medicare Part D Prescription Drug Plans (PDP)

Employer-Sponsored Retiree Plans


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Covering Medical & Prescription Gaps


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Original MedicareParts A & B

PDPPart D RX

MedicareSupplement(Medigap) Medicare

Advantage(Part C)

EmployerRetirement Plan

Medicare Part C (Medicare Advantage)

Expands Medicare choices with a variety ofoptions.

A few examples: Preferred Provider Organization (PPO) Health Maintenance Organization (HMO) Point of Service (POS) Private Fee For Service (PFFS)


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Medicare Part C (Medicare Advantage) Coverage

Who is eligible?

Must be enrolled in Medicare Part A & B?

Permanent resident in plan service area?

Cannot have End Stage Renal Disease (ESRD)?


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They are health plan options that are part of theMedicare program

Medicare pays the plan a set amount everymonth for your care

MA plans must offer all benefits of OriginalMedicare and coverage can include Part Dprescription drug coverage

You may have to use a network of providers thatparticipate with the plan


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In most plans, there are generally extra benefitsand out-of pocket costs that are lower that withOriginal Medicare.

Plans cover everything Medicare covers, at aminimum.

Plans typically have copay and coinsurance thatare paid when client goes in for services.

Plans may cover extra benefits such as routinevision exams, preventive dental, alternative care,gym membership, etc.


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Choose from options with or without integratedPart D prescription drug coverage.No drugs included: Medicare Advantage (MA) only Prescription drugs included: Medicare Advantage

with drugs (MA-PD)


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Medicare Part C (Medicare Advantage)Preferred Provider Organization (PPO)

Defined network of providersAllows flexibility to use providers who are not part

of the networkNo referral needed to see any doctor However, out-of-pocket costs increase significantly

when out-of-network providers are used


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Medicare Part C (Medicare Advantage)Preferred Provider Organization (PPO) Cont…

Greatest saving for use of network providersbecause the plan pays a larger share of thecostNo referrals are required. Prior authorizations

may be required for some services. (CostSharing with the co-pays and/or deductibles.Cost is reflected in the lower monthlypremium.)


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Medicare Part C (Medicare Advantage)Health Maintenance Organization (HMO)

Defined network of providersPrimary Care Physician (PCP) manages all

of your careYou must have a referral from your PCP to

see a SpecialistYou must use network providers for all

scheduled careOut-of-pocket costs may be significantly

lower with an HMO plan


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Medicare Part C (Medicare Advantage)Health Maintenance Organization (HMO) Cont…

Health maintenance organizations (HMO) offer a providernetwork, and members are covered for most of their Planservices in-network only. Urgent and emergency care iscovered inside and outside the HMO network, however.

With most HMOs, a primary care physician (PCP) acts asa health care coordinator (gatekeeper) to provide or torefer for all the patient care. Referrals are usuallyrequired to see a specialist.

You may change your PCP any time (usually not morethan twice a year.)


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Medicare Part C (Medicare Advantage)Point Of Service (POS)

A Point of Service (POS) plan usually offers HMO-stylebenefits in-network. It also provides the ability to choosewhether to get some selected services in-network or out-of-network.

Otherwise, POS plans are very similar to HMOs.


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Medicare Part C (Medicare Advantage)Private Fee For Service (PFFS)

No plan network Plan works similar to Original Medicare except the

insurance company pays for your services, not Medicare Freedom to use any provider that accepts Medicare and,

agrees to the plan’s payment terms You should check with your providers to make certain

that they are willing to accept the PFFS plan’s terms


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Medicare Part C (Medicare Advantage)Private Fee For Service (PFFS)

Out-of-pocket costs may be lower than with OriginalMedicare coverage

Private Fee For Service (PFFS) plans usually offer benefitsintended to compete with Medicare Supplements.

Members can go to any Medicare provider who acceptsthem as patient, and agrees to the plan’s terms andconditions of payment.

Before joining, people should contact their health careprovider to assure will accept PFFS.


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Traditional Medicare Supplements (Medigap Plans)

Private companies sell Medicare Supplement plans(also known as MediGap plans). After initial enrollment eligibility, may require health

statement underwriting. (exception is Bday Rule)

Nationally standardized plan designs (Plans A-N). Prescription drugs are not included in plans sold after

1/1/2006.

Medicare pays for Medicare-eligible benefits. ThenMediGap pays plan’s portion. MediGap also pays some benefits not covered by

Medicare. Benefits vary between plans A-N.


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Standardized plans offered by various insurancecompanies. Companies can offer between 1 to 10plans, plans lettered A-N most people get plan F.

Open Enrollment is for all people going onMedicare within the first six months of the effectivedate. After that, one is subject to medicalunderwriting.

You may see any Medicare provider in the UnitedStates. You do not have a Primary Care physicianand can see any specialist.


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All of your care is subject to what Medicareallows. It must be medically necessary. Thedoctor codes it, when the claim is submitted toMedicare. If Medicare pays on the claim, thenthe secondary insurance pays on it as well.

If the claim is denied – the secondary insurancecannot pay it.


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Employer Sponsored Retiree Plans

Employers may continue to offer coverage toretirees Retirees are usually provided with information at

retirement, if available. Check with employee benefits department.

Costs and coverage options may vary. Plan may include Part D creditable drug coverage, or

not. Important to know.


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Employer Sponsored Retiree PlansCont…To Note: If you currently have health coverage from an

employer or union, joining a Medicare Advantageplan or a stand-alone prescription drug plan couldaffect your employer or union health benefits. Ifyou have health coverage from an employer orunion, joining a Medicare Advantage or stand-alone prescription drug plan may change how yourcurrent coverage works. Read the communicationsyour employer or union sends you. If you havequestions, visit their website, or contact the officelisted in their communications.


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Medicare Part D RX Coverage

Private companies must be approved by The Centersfor Medicaid and Medicare Services (CMS) to offerPart D prescription drug coverage. Two ways to getRX coverage. (MAPD) People with a Medicare Advantage plan (such as

PPO or HMO) coverage may obtain Part D drugsintegrated with their health plan

(PDP) People with other insurance, such as OriginalMedicare, Medicare Supplements, and others, may obtain astand-alone prescription drug plan in addition to theirhealth coverage.


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Medicare Part D prescription drug plans(PDP)

Medicare Part D prescription drug plans (PDP) Stand-alone drug coverage(PDP) may be paired with

health plans such as: MediGap (Medicare Supplement) Only Original Medicare Private Fee for Service (not most MAPD plans) Some (not all) other private health coverage that doesn’t

include Part D creditable coverage


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Medicare Part D prescription drug plans (PDP) or(MAPD)

2014 Deductible $310 for RX. Initial coverage $2850 Doughnut Hole or Coverage Gap: Most Medicare drug

plans have a coverage gap (also called the “donut hole”).This means that after you and your drug plan has spent$285, you have to pay 72% for generics and 47.5% forbrand name prescriptions up to a yearly limit.

Catastrophic Coverage: Once paid $4550 then pays 95% Medicare print out is simply an estimate of the plans

available to you. Donut Hole or Coverage Gap Closing: In 2020 will be same

as initial coverage Limit.


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Medicare Part D prescription drug plans (PDP) or(MAPD)

Medicare offers an imaginary basic plan and then gives itto private health insurance companies.

Basic Plan has three elements. Deductible, Initial Coverage, and Catastrophic coverage. Doughnut hole. The plan has to be equal to, or greater than the basic

Medicare plan. Look at what you are taking, and run it thru the Medicare

web-site for analysis for the best plan for your needs.Plans change every year.


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Medicare Part D prescription drugplans (PDP)

Penalty. One must enroll when they first enroll inMedicare, or be charged a 1% penalty on premium forevery month they have not been enrolled. The penalty isbased on the “basic” plan offered by Medicare cost, andthen added to your premium with the plan you select.

Group Retirement RX or Veterans Benefits RX is excludedfrom penalty


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GENERAL ENROLLMENT PERIODSEnrollment Timeline examples

(IEP) Initial Enrollment in Medicare. Three monthsbefore and three months after the initial effectivedate.

Example: Birthday is May 15. Medicare is effective May1st. You may enroll in March or April for a May 1steffective date. Any day after May 1st, you will have aJune 1st, July 1st or August 1st effective date.

(AEP) Oct 15 – Dec 7: Switch plans. Add or deletePart D drug coverage for Jan 1.

(ADP) Jan 1 – Feb 14: Dis-enroll from a MedicareAdvantage and return to original Medicare

(SEP) Feb 14 – Dec 31: Medicare beneficiaries maystill qualify for additional enrollment periods(examples: change residence, loss of groupcoverage, and more) Special Election Period.


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Enrolling in a Medicare Plan

When entitled to Medicare and enrolling

Make sure to talk to social security 90 days priorto 65th b-day regardless if still working

Do your homework first. Apply for plan between30 and 60 days out from requested effective date.

Choose the plan that best fits your needs.

Work with your agent to complete the enrollmentform, or enroll online.


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Enrolling in a Medicare Plan

When entitled to Medicare and enrolling Cont…

Submit it during the appropriate enrollmentperiod.

You may not combine an MA-only PPO or HMOwith a stand-alone PDP. Choose one or the other.

If you did not have creditable coverage in [2006],your monthly plan premium may be slightlyhigher when you enroll in Part D coverage plan(MAPD, PDP).


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Help with RX Costs ? (LIS)

People with Medicare may be able to get extra help topay for prescription drug premiums and costs. To seeif you qualify for getting extra help, call. The SocialSecurity Administration at 1-800-772-1213. Your resources must be limited to $13,070 for an individual

or $26,120 for a married couple living together. Resourcesinclude such things as bank accounts, stocks, and bonds. Wedo not count your home, car, and any life insurance policy asresources.

Your annual income must be limited to $16,755 for anindividual or $22,695 for a married couple living together.


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Help with RX Costs? (LIS)

Apply for low-income subsidy (LIS) if you think youmay be eligible. Form available from Social Securityor Medicare.

Other assistance programs may be available. Oregon Prescription Drug Plan

The state of Oregon offers a prescription drug program toOregon residents who do not have prescription drugcoverage, or who are in a coverage gap.

For more information: Visit www.OPDP.org or call 1-800-913-4146


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Recap…how do I choose?

There are three basic factors to weigh when choosinga plan: Cost – Compare the out-of-pocket costs. (MAPD vs

Medicare Supplement)

Providers – Will the plan allow me to see the providers Ineed or want to see( HMO vs PPO)?

Benefits – Does the plan offer you the coverage andbenefits you need? (RX, OOP)


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BIA Medicare 101 Presentation Long Form

Health & Medicine

Transcript of BIA Medicare 101 Presentation Long Form