Health Insurance, Health Care Reform

and Resources

in Chicago

Dancers’ Health Insurance Resource Center

A program of The Actors Fund with

support from The Doris Duke FoundationPresenter: Jim Brown, Director of Health Services, jbrown@actorsfund.org.

The Basics of Medicare

Artists Health Insurance Resource Center

www.ahirc.org

A program of The Actors Fund

www.actorsfund.org

Presenter: Elizabeth Tripp, Medicare Counselor etripp@actorsfund.org

What is Medicare?

Medicare is health insurance for people 65 and over, people under 65 with certain disabilities, and people of any age with End Stage Renal Disease (ESRD).

What Are the Different Parts of

Medicare?

• Part A (Hospital Insurance)

• Part B (Medical Insurance)Parts A and B are called “Original Medicare”

• Part D (Medicare prescription drug coverage)

• Medicare Advantage Plans – Sometimes referred to as Part C

What does Part A cover?

• Inpatient care in hospitals

• Skilled nursing facility care

• Hospice care

• Home health care

What are the costs associated

with Part A?

Part A is free for those who have worked 40 quarters or 10 years.

Hospital Stay• $1,184 deductible per benefit period [Note that a benefit period

begins the day you enter the hospital and ends 60 days after you are discharged, so it is possible to incur the Part A deductible several times in one year.]

• For the first 60 days in the hospital, in most cases all you pay is the deductible. Should you be hospitalized for more than 60 days, Medicare charges a day rate for each additional day in that benefit period that you are an inpatient.

What are the costs associated

with Part A?

Skilled Nursing Facility Stay• $0 for the first 20 days of each benefit period• $148 co-pay per day for days 21–100 of each benefit period• All costs for each day after day 100 of the benefit period

Hospice CareYou pay nothing for hospice care, except: • a copayment of up to $5 per prescription for outpatient prescription

drugs for pain and symptom management. • 5% of the Medicare-approved amount for inpatient respite care

What are the costs associated

with Part A?

Home health care• Home health care is medically necessary care for the homebound.

A doctor must certify that you need these services and order your care.

• If you have been in the hospital as an inpatient for three days, or have been in a skilled nursing facility after a hospital stay, Medicare Part A covers your first 100 days of home health care. Medicare Part B covers the additional days.

What does Part B cover?

• Services from doctors and other health care professionals

• Mental health care

• Some preventive services and early detection screenings

• Home health care (Note: as long as you are homebound and need skilled care, there is no prior hospital stay requirement for Part B coverage of home care).

• Durable medical equipment (such as walkers, wheelchairs, oxygen, etc.)

What else does Part B cover?

• Many diagnostic tests and lab services

• Ambulance services

• Limited chiropractic services

• Diabetes supplies and self-management training

• Physical and occupational therapy• and more…

What are the costs associated

with Part B?

• The Part B premium for individuals who make less than $85,000 per year ($170,000 for couples) is $104.90.

• Part B also has a $147 annual deductible.

• For most Part B services, Medicare pays 80%, and you pay 20%.

• Exceptions include laboratory services including certain blood tests, urinalysis, and some screening tests, and certain preventive services, which are 100% covered by Medicare. Medicare’s website has a list of services that are covered at no cost to you.

What does Original Medicare

not cover?

• Long-term care• Custodial care (non-skilled personal care, such as help with bathing,

dressing, eating, etc) • Routine dental care (including dentures) or vision care• Cosmetic surgery• Acupuncture• Hearing aids and exams for fitting them

When should I Enroll in

Medicare? • You can sign up during the 7 month period that begins 3 months

before the month you turn 65, includes the month you turn 65, and ends 3 months after you turn 65.

• People who are already collecting Social Security are automatically enrolled in Parts A&B, and will receive their Medicare card in the mail a few months before their birthday.

• If you are not collecting Social Security yet, you have to contact them to enroll.

• If you have been receiving disability benefits under social security, you will be automatically enrolled in Medicare Part A and Part B beginning the 25th month of your disability

I didn't enroll in Part B when I

was eligible. What do I do?

• If you do not enroll in Part B when you first become eligible, you will have to wait until the General Enrollment Period (January 1 – March 31 each year, with benefits beginning July 1)

• A late enrollment penalty will apply – 10% of the Part B premium (current penalty is $10.40/year) for every year you delayed enrollment, will be added to your monthly Part B premium.

• If you are still working and have employment-based insurance, you will get a special enrollment period when you retire.

How do I enroll?

Online: http://www.ssa.gov/pgm/medicare.htm

By phone: 1-800-772-1213

In person: Find a local office here: https://secure.ssa.gov/apps6z/FOLO/fo001.jsp

Can I stay on my union

coverage?

There are a few different circumstances involving union or other employment-based insurance. It is always advisable to contact your employer or union benefits administrator, as well as a Medicare counselor at The Actors Fund, to find out how your coverage works with Medicare, and explore your options.

• Active employment: If you qualify for insurance through your union based on active employment, you do not have to enroll in Medicare Part B when you turn 65. You can delay enrollment in Part B until you're ready for it, or until you retire. After your employment ends, you have the following 8 months to sign up for Part B without a penalty.

Can I stay on my union

coverage?

Self-pay: With most unions, you cannot delay enrollment in Medicare Part B after you turn 65 and self-pay for union insurance instead. If you are not sure about your earnings and status with your union insurance, call your union and ask them about your options.

COBRA: If you have COBRA when you turn 65, or are offered COBRA when your employment-based insurance ends and are already over 65, don’t wait until your COBRA ends to enroll in Part B. COBRA does not count as employment-based coverage. If you don’t enroll in Part B during the 8 months after your active employment ends, you'll have to wait until the General Enrollment period to enroll, and you may have to pay a penalty.

Can I stay on my union

coverage?

Retiree/pension plan: Some unions offer insurance plans that work with Medicare as supplemental coverage. Check with your union to see what you qualify for. Shop around and compare the cost and benefits of your union retiree plan with other plans - in some cases, union insurance is more expensive than supplemental plans. Consider your union’s vision and dental coverage benefits as part of your cost/benefit analysis, as Medicare does not cover those services.

What is Medicare Part D?

• Part D is prescription insurance. Unlike Parts A and B, Part D is only sold through private companies, so you have a choice of many private plans.

• The best plan for you depends entirely on your prescription needs.

• You will have to pay monthly premiums, deductibles and co-pays, so consider the cost of all factors when choosing a Part D plan.

What are the costs associated

with Medicare Part D?

• Premium – Average premium is $30. In New York, the least expensive premium is $18.50

• Deductible – Maximum is $325

• Co-pays – Vary depending on cost of the drug; may be cheaper at certain pharmacies

• The Medicare Plan Finder on www.medicare.gov is an excellent resource for finding the most affordable prescription drug plan available to you.

What are Medicare Advantage

Plans? • A Medicare Advantage plan is insurance offered by a private

insurance company that replaces Medicare Parts A, B, and D.

• If you join an Advantage Plan, you still have Medicare, but you’ll get your coverage from the Advantage Plan, not Original Medicare. Advantage Plans have different rules for how you get services, like whether you can go to an out-of-network provider. If you go to a provider that doesn’t belong to the plan, your services may not be covered or your costs may be higher.

• Advantage plans must cover all services that Original Medicare covers, and may offer extra coverage, like vision, hearing, dental, and/or health and wellness programs.

What are the costs associated

with Medicare Advantage

Plans?• When you belong to an Advantage plan, you still pay your Part B premium.

• Medicare Advantage Plans can charge different out‑of‑pocket costs (such as co-pays, premiums and deductibles).

• Again, the Medicare Plan Finder on www.medicare.gov is an excellent resource for finding the most suitable Advantage plan available to you.

When can I enroll in Part D and

Medicare Advantage plans?

• You have a 7 month period - from 3 months before your 65th birthday until 3 months after - to enroll in either a Part D plan or a Medicare Advantage plan.

• If you do not enroll during that time, you will have to wait until the Medicare Fall Open Enrollment Period: October 15 – December 7 each year (with benefits beginning January 1).

• You will have to pay a late enrollment penalty - 1% of the national average Part D premium (currently around 30¢) - for every month you delayed enrollment. This will be added to your monthly premium.

What are Medigap Plans?

• Medicare Supplemental Insurance, also known as Medigap because it fills the “gaps” in Medicare, covers costs associated with Original Medicare benefits (like copayments, coinsurance, and deductibles).

• There are 10 federally standardized plans to choose from, sold by private insurers.

• Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it.

What are the costs associated

with Medigap Plans?

• Cost is the only difference between Medigap policies with the same ‘letter’ (A-N) sold by different insurance companies.

• You have the right to buy a Medigap plan during the 6 month open enrollment period, which starts the month you turn 65 and enroll in Part B. After that, your right to buy a plan varies by state.

• Your state’s Department of Insurance or SHIIP (Senior Health Insurance Information Program) can help you compare the costs of Medigap plans and the insurance companies offering them, and can inform you of your right to buy a policy.

http://medicare.gov/supplement-other-insurance/compare-medigap/compare-

medigap.html

Medicare Process Summary Step 1:

Enroll in Medicare A & B

• If you are already collecting Social Security, you will receive your Medicare card in the mail approx 3 months before your birthday month. If you are not currently collecting Social Security, you can call Social Security at 1-800-772-1213 or visit your local office to enroll.

Medicare Process Summary Step 2:

Decide on Additional Coverage

• Once you’ve decided whether you want a Part D or Advantage plan, use the Health and Drug plan finder of on www.medicare.gov to find the most cost-effective Part D and Advantage plans available to you. You can view all the co-payments, deductibles and premiums that different plans charge, and compare the annual costs. For Advantage plans, make sure to look at the detailed lists of benefits so you are aware of all the co-pays for various services.

• In order to research Medigap plans, refer to the website on the previous slide and call your state’s SHIP department to compare prices of various plans. You can find your state SHIP by visiting www.hapnetwork.org/ship-locator. Remember that once you’ve decided on a lettered plan, no matter who you buy it from, the coverage is the same, so it’s important to compare costs.

Medicare Process Summary Step 3: If you

choose to enroll in a Part D or Advantage

Plan…• If you choose to enroll in a Part D or Advantage plan, you can do it online at www.medicare.gov, or you can call 1-800-MEDICARE. You can also call the insurance company you choose directly, but keep in mind that they may try to up-sell you or inform you of other plans they have available.

• No matter who you enroll with, write down your enrollment confirmation number, the date and time of your call, and the name of the person you spoke with.

• Your coverage begins the first day of the next month no matter what day of the month you sign up for it, so if you would like your coverage to begin in time for your birthday month, be sure to call the month before.  

Medicare Process Summary Step 4: If you

choose to enroll in a Medigap plan…

• If you decide to enroll in a Medigap plan, you must contact the insurance plan directly. Be sure you know the letter of the Supplemental plan you want. You may be referred to sales agent, or asked to fill out an application and mail it in.  Be certain to make copies, take names and ask for confirmation numbers!

Medicare Process Summary Step 5:

Initial Enrollment Periods

• Initial Enrollment Period for Parts A, B, and D, and Medicare Advantage Plans: 3 months before you turn 65, the month you turn 65, and 3 months after you turn 65 (7 months total)

• Open Enrollment Period for Medigap: starts when you turn 65 and goes for 6 months

Medicare Process Summary Step 6:

Follow up!

• Make sure you get all of your cards in the mail. Mark your calendar for 10 business days after you’ve enrolled, and if you haven’t gotten documentation of your enrollment, call whoever you enrolled with and have the details of your original enrollment handy.

Additional Resources

• This tutorial was designed to educate you on the basics of Medicare. For information on help with Medicare costs, see our tutorial Help with Medicare Costs

• For more detailed information on Medicare, visit: • www.medicare.gov• www.Medicareinteractive.org