ROADMAP TO
MEDICARE 2015
Presented by HICAP
Health Insurance Counseling & Advocacy Program
HICAP is funded in part by a grant from California Department of
Aging and Centers for Medicare & Medicaid Services Silver Tsunami Non Profit Serving
Seniors 41 Years 87% of every dollar
goes directly to
programs & services. Promoting the
independence, health
and dignity of adults
through compassion,
education and
advocacy. CORE PROGRAMS
Impact Programs Advocacy and Protection • HICAP • Ombudsman
• FAST Education and Outreach • Education
• Answers Guide
• SmileMakers Socialization • ReConnect
• Friendly Visitor History of Medicare
July 1965, President Johnson
• Medicare Title XVIII of the Social Security Act to provide health insurance to people age 65 and
older, regardless of income or medical history.
• Many seniors had no health insurance. • Unavailable or unaffordable because older adults paid 3 x’s for health insurance as younger
people.
• In 1966, Medicare facilitated racial integration of waiting rooms, hospital floors, and physician
practices by making payments to health care
providers conditional on desegregation. What is Medicare?
Government health insurance for the following:
• People over 65 or older
• People under 65 with certain disabilities
• People of any age with End-Stage Renal Disease
• No income eligibility requirements
• 50M enrollees What is Medicare?
Established in 1965
Administered by the Centers for Medicare & Medicaid
Services (CMS)
• Enrollment by:
• Social Security (SSA) or
• Railroad Retirement Board (RRB)
• Must be U.S. citizen or Resident Visa in U.S. for 5 consecutive years The Four Parts of Medicare Part A
Hospital
Insurance Part B
Medical
Insurance Part C
Medicare
Advantage
Plans (like
HMOs/PPO
s) Includes
Part A, Part B
and
sometimes
Part D
coverage Part D
Medicare
Prescriptio
n Drug
Coverage What Does Medicare Cover?
Medicare Part A (Hospital Insurance)
• In patient hospital • Inpatient skilled nursing facility
• Home health care
• Hospice care What Does Medicare Cover?
Medicare Part B (Medical Insurance)
• Doctor services • Durable medical equipment
• Home health care
• X-rays, lab services
• Outpatient services
• Preventive services What Does Medicare Cover?
Medicare Part C (Medicare Advantage)
• Combines Part A hospital insurance and Part B medical insurance providing all benefits through their providers
at their facilities.
• Some Medicare Advantage programs also include
Medicare Part D (Medicare Prescription Drug
Coverage) and extra services not covered by Medicare What Does Medicare Cover?
• Medicare Part D (Medicare Prescription Drug Coverage)
• Prescription drugs What Medicare Does Not Cover
• Routine dental care
• Routine vision care
• Routine hearing care or hearing aids
• Routine foot care
• Custodial care at home or in nursing home Medicare Enrollment
• Initial Enrollment Period (IEP)
• Part A & B
• Seven months to enroll
• Three months before age 65, month of, and 3 months following
• Automatic for those receiving
• Social Security benefits
• Railroad Retirement Board benefits • Premium penalty for late enrollment
• 10% for as long as the person has Part B
• Enroll on line
• • www.socialsecurity.gov and click on “Apply for Benefits”. Enroll by phone or in person
•
1-800-772-1213
•
Appointment with SSA Medicare Enrollment
If you or spouse is working and covered by
employee or union benefits
• Contact benefits administrator – confirm how your coverage works with Medicare
• Enroll in Part A and delay Part B enrollment
without penalty When Medicare Part A & B
Becomes Effective
If you enroll in this month of
your initial enrollment period
(IEP):
One to three months before
you reach age 65 Part A & B coverage starts: The month you reach age 65 One month after the month you
reach age 65 One month after you reach
age 65 Two months after the month of
enrollment Two or three months after
you reach age 65 Three months after the month
of enrollment The month you reach age 65 Medicare Enrollment
If you didn’t sign up when first eligible
• General Enrollment Period (GEP)
•
•
• Part A & B
January 1 through March 31
Coverage begins July 1 • Penalties apply Medicare Enrollment
If you didn’t sign up for Part B when first eligible
because your covered under group health plan
based on current employment (your own, a
spouses) you can sign up
• Special Enrollment Period (SEP)
• 8 month period that begins employment ends or coverage ends • Penalties do not apply
• Learn more at; Medicare.gov/publications “Enrolling in Medicare
Part A & B” Medicare Card
• Keep it and accept Medicare Part A and Part B
• Return it to refuse Part B
• Follow instructions on back of card Front Jane Doe Back Medicare Choices
1. Original Medicare 80/20 2. Medicare Supplement Plans (Medigap) 3. Medicare Prescription Drug Plans 4. Medicare Advantage Plans (MA) 5. Retiree and Other Coverage (PDP) Decide how
you wish to
take your
Medicare Original Medicare Premiums,
Coinsurance & Deductibles
• Medicare Part A (Hospital Insurance)
• $0 monthly premium with
• 40 Social Security quarters
• Up to $407/month with fewer than 40 quarters
• $1,260 deductible for hospital stays up to 60 days
• Medicare Part B (Medical Insurance)
• $104.90 monthly premium
• $147.00 annual deductible
• 20% coinsurance for most part B services Original Medicare Premiums,
Coinsurance & Deductibles
Medicare Part D (Prescription Drug Plans)
• $33.00/mth premium (Est)
• Introduced January 1, 2006
• Provided through • Medicare Prescription Drug Plans (PDP)
• Medicare Advantage Plans
• Some employers and unions
• 31 PDP’s in Southern California 2014
• 5 Benchmark Plans
• Caution
• Not required for those in a Medicare Advantage plan Part B Medicare Income Based
Premiums 2015
Beneficiaries who file an
individual tax return with
income: Beneficiaries who file a joint
tax return with income: Total Monthly Premium
Amount: Less than or
equal to $85,000 Less than or
equal to $170,000 $104.90 $85,001 - $107,000 $170,001 - $214,000 $146.90 $107,001 - $160,000 $214,001 - $320,000 $209.80 $160,001 - $214,000 $320,001 - $428,000 $272.70 Above $214,000 Above $428,000 $335.70 *Sliding scale based on MAGI (Modified Adjusted Gross Income) is
your adjusted gross income and tax-exempt interest income. IRMAA Adjustment Form Medicare Premiums
Original Medicare Medicare Advantage • Part A – Premium Free • Part A – Premium Free • Part B – $104.90 & Up • Part B – $104.90 & Up • GAP Premium – Est. $150 • Plan Premium - $0 & Up Part D – Est. $33 • Part D - Included Supplementing Original Medicare
Supplemental insurance (Medigap) covers Original
Medicare's copayments and deductibles
Medicare approved services only
• During IEP:
• Guaranteed issue – no pre-existing conditions
• 6 months to buy Medigap policy at the lowest price for your age
• No underwriting required
• Go to any doctor or specialist Supplementing Original Medicare
Guaranteed renewable – cannot be canceled due
to health conditions
• Can be canceled due to non-payment of premium
• 10 standardized Medigap plans
• Premiums vary by company, plan, location
• Benefits the same regardless of company selling the plan
• A,B,C,D,F,G,K,L,M and N
• E,H,I and J eliminated in 2010 • California birthday rule
• Cannot move up in coverage • Continue to pay Medicare premiums Decision: Do I need a Medigap policy?
Consider
• It only works with Original Medicare
• Do you have other supplemental coverage?
• If so, you might not need Medigap
• Can you afford Medicare deductibles and copayments?
• What does the monthly Medigap premium cost? Changing Medigap Plans
This rule requires you must: 1) Live in California
2) Have an active
Medigap plan
3 ) Switch to a plan
with same or lesser
benefits
4) Be within 30 days
of your birthday 30 Days of
Birthday MA Landscape for Orange County
2015
• 37 Medicare Advantage Plans
• 33 MA-PD premiums = $0-$176.00/mth
• 3 PPO’s premiums = $108.00-$139:00/mth
• *Aetna Medicare Choice
• *Aetna Medicare Select Plus
• *Anthem Medicare Preferred Standard • 1 MA Only without PDP premium = $0 • Continue to pay Medicare Premiums
• 21 Special Needs Plans (SNP) • Regional breakdown Medicare Advantage Plans
• 46% Orange County
• 27% Nationally • MOOP
*New Medicare Part C (Medicare Advantage)
Run by private companies
• Medicare pays a set amount to plan for your care
• Use plan network only
• All Part A and Part B covered services
• Most plans include Part D (Rx Drug) coverage
• Some Extra Benefits
• Vision, hearing, dental services
• You are still in the Medicare program
• You still have all Medicare rights and protections
• You still get all regular Medicare-covered services Medicare Part C (Medicare Advantage)
Initial 12 month trial period
• Return to Original Medicare and still qualify for a supplemental insurance plan (MediGap) with Guaranteed issue
• After 12 months if you return to Original Medicare you no longer
get a Guaranteed issue • Annual Disenrollment January 1 – February 14
• Can leave MA plan and switch to Original Medicare • Special Enrollment
• 5 Star Plans – Anytime
• Following Certain “Trigger Events” Part D *IRMAA for Higher Income Part
D Enrollees – 2015
Income bracket
(single) Income bracket
(file jointly) IRMAA ≤$85,000 ≤$170,000 n/a >$85,000 but
≤$107,000 >$170,000 but
≤$214,000 +$12.30 >$107,000 but
≤$160,000 >$214,000 but
≤$320,000 +$31.80 >$160,000 but
≤$214,000 >$320,000 but
≤$428,000 +$51.30 >$214,000 >$428,000 +$70.80 *Sliding scale based on MAGI (Modified Adjusted Gross Income) is
your adjusted gross income and tax-exempt interest income. IRMAA Adjustment Form Medicare Part D (Prescription Drug Plans)
PDP
• Optional
• Consider joining even if you don’t take prescription drugs
• If you don’t join when first eligible and you don’t have:
• Creditable prescription drug coverage
• Extra help
• Subject to a late enrollment penalty *Lifetime Premium Penalty for Late Enrollment
= 1% of Avg. Nat’l Monthly Premium x Mos. Late + Part D Plan Premium Medicare Part D (Prescription Drug Plan)
PDP
Enroll when first eligible for Medicare
• Not automatically enrolled if on Social Security
• Join, switch or drop Prescription Drug Plan (PDP)
• Annual Enrollment Period October 15 – December 7
• New Policy takes effect January 1
• HICAP offers over 60 enrollment clinics
• Special Enrollment Involuntary Loss/Reduction of Coverage
• 5 Star Plans Anytime (Medicare Advantage Only) Medicare Part D (Prescription Drug Plan)
Costs vary by plan
• Premium
$33.00 (Est)
• Deductible
$320 (Year)
• Enter the initial coverage phase
•
• You pay copayment or coinsurance
Your plan pays it’s share for covered drugs • Once you and your PDP have spent $2,960
• You enter the gap or donut hole
• 100% of the cost Gap in Coverage (Prescription Drug Plan)
Discounts 2015
Brand 55% discount
• You pay 45% Generic 35% discount
• You pay 65% Total out of pocket spend is
$4,700 leave the gap, donut hole
Includes copayment, coinsurance
deductible.
Catastrophic coverage
On Extra help MSP gap, donut hole doesn’t
apply In the
Donut Hole
Discounts
Apply Retiree Plans
Benefits and costs vary widely
Retiree plans differ from employer group health
plans (EGHPs)
Can change each year
• Generally three types of retiree plans:
• Fee for service
• Non Medicare Managed Care plans
• Medicare Advantage plans Retiree Plans
Meet with benefits administration
• Prescription drug coverage is often included
• Once on Medicare it is your primary coverage
• Your retiree benefits pay after Medicare pays
• Coordinate with Medicare – retiree plans aren’t Medigap plans
• Some plans cover what Medicare does not
• Vision, dental, hearing
California Health Advocates
• www.cahealthadvocates.org
Medicare topics
• Other health Insurance Affordable Care Act People With
Medicare Medicare benefits aren’t changing Marketplace does not affect your Medicare coverage Medicare is not part of the Marketplace Additional benefits Free Annual Wellness Visit
• Prevention Plan
• More Help with Prescription Drugs
• Coverage Gap closed 2020 Affordable Care Act People With Medicare
• Free Annual Wellness Visit
• Prevention Plan
• More Help with Prescription Drugs
• Coverage Gap closed 2020
• Medicare Advantage Plans
• MOOP maximum • Other
• Efficiencies
• Coordination of benefits
• Fraud Medicare Fraud and Abuse
Intentional Deception or Misrepresentation Resulting in
Unauthorized Benefit
• Don’t Become a Victim
•
•
•
• Review Medicare Summary Notices (MSNs)
Check with Providers on Billing Discrepancies
Don’t Give Out Your Medicare number
Medicare will never call you….. • Report
• HICAP at 1-800-434-0222 Help for People with Limited Income and
Resources
• Medicaid/Medi-Cal
• Medicare Savings Programs • Extra Help Apply at HICAP 1 (714) 560.0424
www.socialsecurity.gov, or state Medical Assistance office HICAP Benefit Enrollment
Centers
Community based on site facilities
HICAP counselors assist with the application process
Centers designed to help low income seniors enroll
• Benefits
•
•
•
•
•
• Medicare Part D Extra help
Medicare Savings Programs
Cal/Fresh Food Stamps
Medi-Cal for those on Medicare
Utilities Assistance Program
Other Applicant
• Single
• Married Monthly Income Limit
$1,580
$2,133 Help with open enrollment
Open Enrollment 2015
• Oct 15 to Dec 7
• Join, switch or drop plans 35 Senior Centers 2014
• Assisted 832 seniors
• Saved over $1.4M www.coaoc.org For More Information
• Council on Aging-Orange County Health Insurance Counseling and Advocacy Program (HICAP)
1-714-560-0424
www.coaoc.org
• Medicare 1-800-MEDICARE
www.medicare.gov
www.healthcare.gov
• Social Security Admin. 1-800-772-1213
www.ssa.gov
• Covered California 1-800-300-1506
www.coveredca.com
• Veterans or TRICARE for life
Veterans Services Office to Check Eligibility
1 (714) 567-7450
www.veterans.ocgov.com We Understand We Care We Help
Contact Information
1971 E. 4th Street, Suite 200
Santa Ana, CA
www.coaoc.org 714-479-0107

Attachments:

• 1505195520-2015 Road Map To Medicare0106153.pdf