medicare 101 · volunteers are trained and certified volunteers have access to staff support, cms,...
TRANSCRIPT
THE LINK BETWEEN YOU AND MEDICARE
This material has been created or produced by CLAIM with financial assistance, in whole or part, through a grant from the Administration for Community
Living. Funding is administered through the Missouri Department of Commerce and Insurance and service is provided by Primaris Foundation, a
non-profit organization.
Medicare 101
Who is CLAIM?
Community Leaders Assisting the Insured of Missouri
Missouri’s SHIPState Health Insurance Assistance Program
Nationwide network
Meets needs of the local Medicare population
Creation of SHIPs (1990)
Created by Congress as part of Medigap reform package
Provide Medicare education
Give feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS)
Funding
Missouri Department of Commerce and Insurance (DCI) received the first federal grant in 1993.
Primaris Foundation has been awarded the contract through the DCI since 1993.
How are clients’ needs met?Volunteers are trained and certified
Volunteers have access to staff support, CMS, and other professionals
Currently 300+ volunteers statewide and 180 community partners
Examples of Who We Serve
A 70-year-old widow
A 45-year-old disabled person
A daughter taking care of her mom and dad
A social worker helping a very sick client
A 64-year-old retiring in 3 months
Someone who recently lost benefits
A professional or caregiver who needs information
A person who needs help enrolling in Part D
How CLAIM Counselors Can Help
Enrollment and billing
Medicare Advantage Plans
Medigap and supplemental insurance
Medicare Prescription Drug Program
Long-term care insurance
Public benefits
Appeals and grievances
Suspected waste, fraud, and abuse
President Lyndon B. Johnson at the signing ceremony July 30, 1965, at the Truman Library in Independence, Missouri.
Qualifying for Medicare
Beneficiary reaches age 65 (“Age in”)Determined by age and credits
SSA determined beneficiary is disabled24 month waiting period after payments start
ESRD One month on home dialysis
Three months on facility dialysis
Enrollment
Have 40 credits?
Don’t have 40 credits or not
sure?
Automatic Enrollment
Apply for Benefits at the Local Social Security
Administration Office*
Enrollment ContinuedPart A
Required for automatic enrollees
Manual enrollees
Part BMay be declined without penalty in some circumstances
i.e. still employed
Late EnrollmentPenalties may apply
Enrollment PeriodsInitial enrollment period (3-1-3)
Automatic enrollment – receiving Social Security benefits
Manual enrollees – not yet drawing Social Security benefits, still working, or not enough credits
General enrollment period – January, February, or March every year
Effective July
Four Parts of Medicare
Part A Hospital
Insurance
Part B Medical
Insurance
Part C Medicare
Advantage Plans , like HMOs and
PPOs .Includes Part A
& B, usually Part D
coverage
Part D Prescription
Drug Coverage
Part A
Hospital Insurance
Medicare Part A
Coverage:Inpatient Hospital Care
Skilled Nursing Facility (SNF)
Home Health
Hospice
Blood
Paying for Part A
Premiums paid by Medicare taxes
Must have 40 creditsThose without 40 credits pay a pro-rated premium
Hospital must accept “Medicare Assignment” for services
Deductible for each benefit period
2020 = $1,408
Co-Pays may also apply
Benefit Periods
Measures use of inpatient hospital and skilled nursing facility (SNF) services
Begins the day you first receive inpatient hospital care
Ends when not in hospital/SNF 60 days in a row
Pay Part A deductible for each benefit period ($1,408 in 2020)
No limit to number of benefit periods
Part B
Medical Insurance
Medicare Part BCoverage:
Doctor’s office visits
Outpatient hospital services
Home health
Ambulance transportation
TherapyPhysical
Occupational
Speech
Clinical Lab Services
Durable Medical Equipment
Preventative Services
Paying for Part BMonthly premium
Current 2020 premium is $144.60
Premium paid by beneficiary is 25% of actual cost
Late enrollment penalties
Normally withheld from Social Security benefit
Annual Deductible:$ 198 for 2019
May increase annually
Co-pays and deductibles may apply
Part B Covered Preventive Services“Welcome to Medicare” visit
Annual “Wellness” visit
Abdominal aortic aneurysm screening
Alcohol misuse screening and counseling
Behavioral therapy for
cardiovascular disease
Bone mass measurement
Cardiovascular disease screenings
Colorectal cancer screenings
Depression screening
Diabetes screenings
Diabetes self-management training
Part B Covered Preventive ServicesGlaucoma tests
Hepatitis B shots
HIV screening
Immunizations
Mammograms (screening)
Obesity screening and counseling
Pap test/pelvic exam/clinical breast exam
Prostate cancer screening
Sexually transmitted infection screening (STIs) and high-intensity behavioral counseling to prevent STIs
Smoking cessation
Medicare Part C
Medicare Advantage Plans
Part C: Medicare Advantage PlansAlternative method of obtaining benefits
Administered by private insurance companies
Another way to receive Medicare Coverage
Must provide coverage found in Original Medicare
Can provide additional benefits Part D
Hearing
Vision
Dental
Medicare Advantage Plan Costs
Must still pay Part B premiumSome plans may pay all or part for you
Plan may have monthly premium
Deductibles, coinsurance, and copayments may apply
Different from Original Medicare
Varies from plan to plan
Plans have out of pocket maximums
Medicare Advantage (MA) Open Enrollment Period
MA OEP starting 2019
January 1- March 31 each year
Must be in an Advantage plan on 1/1 to use MA OEP
Can only be used once
During the MA-OEP
People in an MA Plan on January 1 can :
Switch MA plans
Leave MA to join Original Medicare • Coordinating Part D SEP
Can add or drop Part D when switching plans
Part D not guaranteed unless you were in an MA Plan on January 1
Can’t switch from one stand alone PDP to another standalone PDP
MA Eligibility Requirements
Live in plan’s service area
Enroll in Medicare Part A and Part B
Must not have ESRD at the time of enrollment
Some exceptions
Starting in 2021, people with ESRD can enroll
Must provide necessary information
May only belong to one plan at a time
How Medicare Advantage Plans WorkStill enrolled in Medicare with all rights and protections
Benefits and cost-sharing differ and are set by the plan and approved by Medicare
Co-payments for certain services and cost sharing for other services (20%)
Plans may require prior authorization for services.
Part D
Medicare Prescription Drug Plans
Medicare Part DAdministered through private insurance coverage in conjunction with Medicare
Must be enrolled in Part A and/orB
Two sources of coverageMedicare Prescription Drug Plans (PDPs)
Medicare Advantage Plans with (MA-PDs)
Paying for Part D for 2020Premiums
2020 = $13.20 up to $89.00
Penalties apply for late enrollment
Deductible – maximum $435
Cost-sharing and deductibles determined by:
the type of medication
terms of the plan selected
Gap – plan pays 75%
Enrollment Periods for Prescriptions
Initial Enrollment Period (IEP)
7 month period Starts 3 months before month of eligibility
Annual Enrollment Period Oct. 15 – Dec. 7
Annual Medicare Advantage Enrollment Period
Between Jan. 1–March 31, you can leave an MA plan for another or switch to Original Medicare with a Part D plan to add drug coverage. Coverage begins the first of the month after the plan gets the enrollment form.
Prescription Drug CostsCosts vary by plan
In 2020, most people will pay:A monthly premium
National average = $32.74
An annual deductible – no more than $435
Copayments or coinsurance may apply
Part D Late Enrollment PenaltyHigher premium for some who wait to
enroll
Additional 1% of base national average premium ($33.20 in 2020)
Every month eligible and not enrolled
For as long as they have Medicare drug coverage
No penalty with creditable drug coverage
Coverage at least as good as Medicare drug coverage
Access to Covered Drugs
Coverage and rules vary by plan
Plans manage access to drug coverage
Formularies (list of covered drugs)
Prior authorization (doctor contacts plan)
Step therapy (type of prior authorization)
Quantity limits (limits quantity for period of time)
Supplemental Insurance
Medigaps and Employer Plans
Purpose of Supplements
Gaps
• Medicare was not designed to pay all health care costs
• Medicare coverage has gaps
Medical Care Cost
• Costs of medical care outpaced coverage
Individual
• Percentage of income that people pay for health care continues to increase
• Medicare cost-sharing has increased since 1965
Medigap Policies
Medigap - Medicare Supplement Insurance policies
Private health insurance for individuals
Sold by private insurance companies
Supplement Original Medicare coverage
Follow Federal/State laws that protect you
Medigap Open Enrollment PeriodSign up for Part B
Once started, cannot be delayed or repeated
Medigap Policies
Costs vary by plan, company, and location
Medigap insurance companies can only sell a “standardized” Medigap policy• Identified in most states by letters
Does not work with Medicare Advantage
No networks except with a Medicare SELECT policy
Monthly premiums
Plans C & F are no longer offered to people who become Medicare eligible 1/1/2020 and after.
Employer Insurance
Part B coverage is optional if a person is:
EmployedCovered under active employer medical plan; or
Covered under a working spouse’s active medical plan
Secondary Payer Rule
Company must have 20 or more employees for someone 65 or older and,
100 employees for under 65 for the employer insurance to be primary; otherwise, it is secondary to Medicare
When Employer or Union Coverage Ends
Options:May be a chance to elect COBRA
May get a Special Enrollment PeriodSign up for Part B without a penalty
Can enroll in a Medigap, PDP, or Medicare Advantage Plan within certain time frames of coverage ending.
Stretching Your Health Care Dollars
Low Income Subsidy (LIS)
Extra Help through Social Security AdministrationMay qualify for zero premium for Part D Drug Plan
Reduced co-payments/co-insurance
Qualify for continuous open enrollment to change plans
Eligibility and level of help determined by income and resources
Application available through Social Security or CLAIM
Online at www.socialsecurity.gov
Medicare Savings Programs
Federal and State funding through MO HealthNet to assist with:
Medicare premiums
Deductibles and coinsurance (QMB only)
Auto enrolled in Part D Extra Help
Income and resources determines assistance-QMB
SLMB
Qualifying Individual
Enrollment - Missouri Family Support Division
MO HealthNet
MO HealthNet acts as a supplement to Medicare -
pays co-insurance & deductibles for Parts A & B
Eligibility for Low Income Subsidy for Part D (Extra
Help)
Income and Resource Guidelines
Programs Extra Help
from Social
Security
(Low-Income
Subsidy)
Qualifying
Individual- 1
(QI-1)
Specified Low-
Income
Medicare
Beneficiary
(SLMB)
Qualified
Medicare
Beneficiary
(QMB)
MO HealthNet
(Medicaid)
Monthly
Income
Single
$1,581
Couple
$2,134
Single
$1,426
Couple
$1,923
Single
$1,269
Couple
$1,711
Single
$1,061
Couple
$1,430
Single
$905
Couple
$1,218
Resources Single
$14,390
Couple
$28,720
Single
$7,730
Couple
$11,600
Single
$7,730
Couple
$11,600
Single
$7,730
Couple
$11,600
Single
$4,000*
Couple
$8,000*
Missouri SMP Program
Statewide volunteer program whose mission is to empower and assist Medicare beneficiaries, their
families, and caregivers to prevent, detect and report healthcare fraud, errors, and abuse through
outreach, counselling and education.
Program funded through Administration on Aging and administer by Care Connection.
1-800-515-6565
Missouri
myMedicare.gov
View claim status(excluding Part D claims)
Order a duplicate Medicare Summary Notice or replacement Medicare card
View eligibility, entitlement and preventive service info
View or modify your drug list & pharmacy info
View address of record with Medicare & Part B deductible status
Access online forms, publications & messages sent to you by CMS
Join Our Team!
Counselors
Leaders in Outreach
Administrative Support
Interest Specialists
Mentoring
AmeriCorps Members
Thank You!
