M EDICARE B ENEFITS AND UPDATES FOR 2012 Senior Health Insurance Program 800-548-9034.
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Transcript of M EDICARE B ENEFITS AND UPDATES FOR 2012 Senior Health Insurance Program 800-548-9034.
WHAT IS SHIP? Senior Health Insurance Program Established in 1988 Free Medicare Counseling Program Sponsored by the State of Illinois
Illinois Department of Insurance Does not sell or solicit insurance Dedicated to educating people with
Medicare SHIP trains volunteer counselors throughout
Illinois Provide one-on-one counseling
With Medicare Beneficiaries, family members and caregivers
Through community based sites
MEDICARE Medicare has four parts
Part A – Hospital Insurance
Part B – Medical Insurance
Part C – Medicare Advantage
HMO, PPO, PFFS, SNP, and MSA
Also know as Managed care
Part D – Prescription Drug Coverage
Medicare Supplement Insurance
Not to be confused with secondary insurance
Original Medicare
PART A – COVERED SERVICESInpatient Hospital Care
Skilled Nursing Facility Care
Home Health Care
Hospice Care
PART A COSTS FOR INPATIENT HOSPITAL STAYS
5
For each benefit period in 2012
You Pay
Days 1-60 $1,156 deductibleDays 61-90 $289 per dayDays 91-150 $578 per day (60
lifetime reserve days)All days after 150
All Costs
PART A COSTS FOR
SKILLED NURSING FACILITY CARE
For each benefit period in 2012
You Pay
Days 1-20 $0
Days 21-100 $144.50 per day
All days after 100 All Costs
PART B – COVERED SERVICES
Medical Expenses
Home Health Care
Outpatient Hospital Services
Durable Medical Equipment (DME)
2012 PART B AMOUNTS
Part B Annual Deductible - $140 Part B Monthly Premium
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If your income is $85K or less and you paid this in
2011
You pay this in 2012
$96.40, $110.50, $115.40 $99.90
INCOME-RELATED PART B PREMIUM Part B premium income thresholds
Frozen at 2010 levels through 2019 06
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If your Yearly Income in 2010 wasIn 2012
You Pay*
File Individual Tax Return
File Joint Tax Return
$85,001–$107,000 $170,001–$214,000
$139.90
$107,001–$160,000 $214,001–$320,000
$199.80
$160,001–$214,000 $320,001–$428,000
$259.70
above $214,000 above $428,000 $319.70
*Higher if you have a late enrollment penalty
MEDICARE PART C Medicare Advantage (MA)
Provided through private insurance companies Offered through
HMO, PPO, PFFS, MSA an SNP
Must offer all services covered under Medicare Part A and Part B May be able to offer extra services
May include Drug Coverage No need to have a Supplement plan Must live in plans service area Must follow plans guidelines for coverage
MEDICARE PART D
Began in 2006 Offered by private companies contracted
with Medicare to provide prescription drug coverage
Available to anyone enrolled in MedicarePart A and/or Part B
Coverage offeredStand-alone Prescription Drug Plan (PDP)As part of a Medicare Advantage Plan (MA-PD)
MORE AFFORDABLE PRESCRIPTION DRUGS
Discounts for 2012 50% discount on brand-name drugs and 14%
discount on generic-drugs during the donut hole.
Elimination of the Donut Hole by 2020 Your cost-share should be approximately 25%
during the plan year.
SPECIAL PART D CO-PAY STRUCTURE
NEW FOR 2012 For dual eligibles receiving Home and
Community Based Waiver Services (HCBS) $0 co-pay for prescriptions Similar to co-pay structure for duals in a
nursing home Must keep dual eligible status
NEW
HOME AND COMMUNITY BASED WAIVER SERVICES
There are 9 HCBS programs in Illinois: Http://www.hfs.illinois.gov/hcbswaivers/
Includes DRS Home Services Program
Includes Department on Aging Community Care Program
HOME AND COMMUNITY BASED WAIVER SERVICES CONTINUED
HCBS “status” works like Medicaid dual eligible status
If you have HCBS enrollment in any month of the year, you get $0 Part D co-pays for the rest of the year
If you have HCBS enrollment in July or later, you get $0 co-pays for the following year
Must keep the dual eligible status Most people will have the waiver program
and be a dual eligible as waiver programs now count toward meeting spend-down
ENROLLMENT PERIODS Annual Open Enrollment Period
Oct. 15th – Dec. 7th, 2011Join, switch, or drop
Plan effective Jan. 1, 2012Dual eligibles have continuous enrollment
options throughout the year
Special Enrollment PeriodSpecial circumstance that allows you to
enroll outside the normal time frame
ANNUAL ENROLLMENT PERIOD EXTENDED
Elections may be made through December 10
AEP extended to advocates such as SHIP, MIPPA grantees, ADRCs, and the Aging Network
During enrollment use code AEP2012
MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP)
Begins Jan. 1 and end Feb. 14 each year May disenroll from Medicare Advantage Plan
(MA Plan) or from MA-Prescription Drug Plan (MA-PD) May NOT enroll into another MA plan during
MADP May return to Original Medicare May choose a Part D plan regardless if
moving from a MA-only or a MA-PD New plan choice effective the first day of the
following month
INITIAL ENROLLMENT PERIOD
Seven-month period when a beneficiary is entitled to enroll into Medicare Part A, B, D and/or C
Starts 3 months prior to eligibility month (3) Includes the month of eligibility (1) End 3 months after the eligibility month (3) Referred to as the 3 – 1 – 3 rule
SPECIAL ENROLLMENT PERIOD (SEP) FOR THOSE LOSING ‘CURRENT’ EGHP
SEP begins when beneficiary’s primary status in an Employer Group Health Plan ends Eight month period beginning with the first
month employment is no longer ‘Current’ Coverage in EGHP could be from a spouse
Enroll in Medicare Part B at this time to avoid late enrollment penalty
Avoid part D penalty by enrolling in a part D plan no later than 63 days after employment ends
MEDICARE GENERAL ENROLLMENT PERIOD
Begins Jan. 1 and ends March 31 of every year
May enroll into parts A and/or B Coverage effective date is July 1 of same
year For those who must pay premiums for
Medicare Part A This could include those who declined Part B
and now wish to enroll Penalties for late enrollment usually apply
MEDICARE PREVENTIVE SERVICES Implemented January 1, 2011
Elimination of Part B Deductible and Coinsurance
You pay nothing for most preventive services
When a doctor or health care provider accepts assignment
Example: Bone Mass Measurement
In 2010 you pay 20% after Part B deductible
In 2011 you pay no deductible or copay
PREVENTIVE SERVICE – COSTThe amount you pay varies and
depends on whether you get your Medicare benefits through Original Medicare (fee-for-service); or
Medicare Advantage Plan (HMO, PPO, etc)
Some services are completely free
MEDICARE PREVENTIVE SERVICES…..CONT.
Physical Exams“Welcome to Medicare” physical exam
A one-time exam available to new Medicare beneficiaries within first 12 months of Medicare Part B enrollment
Annual “Wellness” Exam Available to beneficiaries who’ve been
enrolled into Medicare Part B for more than 12 months
Medicare-covered Preventive Services
Abdominal Aortic Aneurysm (AAA) Screening
A one-time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your one-time "Welcome to Medicare" physical exam. Before January 1, 2011, you pay 20% of the Medicare-approved amount. Starting January 1, 2011, you pay nothing for the screening if the doctor accepts assignment.
Bone Mass Measurements
Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment
Cardiovascular Screening
Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the tests, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
Flu Shots
Helps prevent influenza or flu virus. Generally covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor or other health care provider accepts assignment for giving the shot. Note: Medicare Part B also covers administration of the H1N1 flu shot. You pay nothing if your doctor accepts assignment for giving the shot.
Glaucoma Test
Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you also pay the hospital a copayment
Medicare-covered Preventive Services
Hepatitis B Shots
This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. Starting January 1, 2011, you pay nothing for the shot if the doctor accepts assignment.
HIV Screening
Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. You pay nothing for the test, but you generally have to pay the doctor 20% of the Medicare approved amount for the doctor’s visit.
Breast Cancer Screening (Mammograms)
Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39. January 1, 2011, you pay nothing for the test if the doctor accepts assignment.
Medicare Nutrition Medical Therapy Service
Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for the test if the doctor accepts assignment
Pap Test & Pelvic Exams (includes clinical breast exams)
Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. Starting January 1, 2011, you pay nothing for Pap test specimen collection, and pelvic and breast exams if the doctor accepts assignment.
Medicare-covered Preventive Services
Pneumococcal Shot
Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.
Prostate Cancer Screening
Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50 (coverage for this test begins the day after your 50th birthday). You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor's visit. You pay nothing for the PSA test. In a hospital outpatient setting, you also pay the hospital a copayment.
Smoking Cessation
Includes up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.
Note: Medicare coverage of smoking cessation counseling is now considered a covered preventive service if you haven’t been diagnosed with an illness caused or complicated by tobacco use. Starting January 1, 2011, you pay nothing for the counseling sessions.
Diabetes Screening
These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Test may also cover if you have two or more of the following ; Are you age 65 or older, or are you overweight, or have a family history of diabetes (parents, siblings), or have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds. Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
Medicare-covered Preventive Services
Colon Cancer Screening (Colorectal)
Colorectal cancer is usually found in people age 50 or older, and the risk of getting it increases with age. Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer. Treatment works best when colorectal cancer is found early.One or more of the following tests may be covered.
Fecal Occult Blood Test — Once every 12 months if 50 or older. You pay nothing for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.
Flexible Sigmoidoscopy — Generally, once every 48 months if 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment.
Colonoscopy — Generally, you can get this procedure once every 120 months, or 48 months after a previous flexible sigmoidoscopy. If your doctor says you’re at high risk, you can get it every 24 months. There’s no minimum age required for you to get a colonoscopy. Starting January 1, 2011, you’ll pay nothing for the procedure if your doctor accepts assignments.
Barium Enema — Once every 48 months if 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare approved amount for the doctor’s services. In a hospital outpatient setting, you also pay the hospital a copayment.
MEDICARE PRESCRIPTION DRUG COVERAGE PREMIUM
Higher income individuals pay a higher Part D premium Uses same thresholds used to compute income-
related adjustments to the Part B premium As reported on your IRS tax return from 2 years ago
Must pay if you have Part D coverage
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ACA
INCOME-RELATED ADJUSTMENT TO PART D PREMIUM
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If your Yearly Income in 2010 was
In 2012 You Pay
File Individual Tax Return
File Joint Tax Return
$85,000 or below $170,000 or below Base Premium (BP)
$85,000.01 – $107,000 $170,000.01 – $214,000
BP + $11.60
$107,000.01 – $160,000
$214,000.01 – $320,000
BP + $29.90
$160,000.01 – $214,000
$320,000.01 – $428,000
BP + $48.10
$214,000.01 or higher $428,000.01 or higher BP + $66.40
ACA
USE MEDICARE.GOV FOR RESOURCES
Top 7 Services on Medicare.gov Find out what Medicare costs in 2012 Find health and drug plan, compare and enroll! Apply on-line for Medicare now Find out if Medicare covers your tests, items,
services Get Extra Help with prescription drug costs Find out how Medicare works with your other
insurance Get a new Medicare card Link to MyMedicare.gov
RESOURCE AND PUBLICATION SHIP
Medicare Supplement Premium Comparison Guide 800-548-9034 www.insurance.illinois.gov
Medicare Medicare & You 2012 handbook 1-800-633-4227 www.medicare.gov www.mymedicare.gov TTY 1-877-486-2048
Social Security Administration “Extra Help” application 800-772-1213 www.ssa.gov
Dept on Aging - (Illinois Cares Rx) 800-252-8966 www.cbrx.il.gov