Medicare

1. Medicare Joley L. steffens Joley L. Steffens, PLLC 5402 Glenside Drive, Suite D, Richmond, VA 23228 joley@richmondelderlaw.com 804-756-0200; 804-461-8283 President of

2. Medicare Part A- Hospital Insurance Part B- Medical Insurance Part C- Medicare Advantage Plans Part D- Prescription Drug Insurance Medicare Supplement/Medigap

3. Medicare • Eligibility • Individuals age 65 or older • Individuals under age 65 who have been receiving Social Security Disability benefits for a period of 24 months • Individuals of any age with End-Stage Renal Disease (ESRD)- permanent kidney failure requiring dialysis or a kidney transplant • Individuals of any age with ALS (Lou Gehrig’s Disease)

4. Enrollment in Medicare *Most individuals are not automatically enrolled in Medicare. • Automatic Enrollment in Part A & Part B if already receiving: • Social Security Retirement Benefits • Social Security Disability Benefits • Railroad Retirement Benefits • If not receiving benefits, can apply via Social Security Administration during Initial Enrollment Period which is: • 3 months before turning 65 • The month beneficiary turns 65 • Three months after turning 65

5. General Enrollment in Medicare Delayed Enrollment • May delay enrolling if: • Individual (or spouse) is actively employed, AND • Is covered under group health insurance policy based on active employment (does not include COBRA insurance policy) • If Employer Group Health Insurance ends, you get a eight-month Special Enrollment Period. (Eight (8) month period begins the month after the employment ends or the coverage ends, whichever happens first. COBRA coverage does not extend this period.)

6. Medicare Enrollment at or after age 65 • Special Enrollment Period • Anytime while still covered by group plan, or • During eight (8) month period that begins the month after the employment ends or the coverage ends, whichever happens first. • *COBRA does not extend enrollment period.

7. Delaying Enrollment in Medicare • If you do not enroll during the Initial or Delayed/Special Enrollment periods, then you can enroll during General Enrollment Period : • January 1st– March 31st of each year • Coverage begins July 1st • Penalty is assessed on Part B and Part D premiums

8. Medicare Enrollment Options Option 1 Option 2 Basic Medicare (Parts A and B) as primary coverage Medicare Part C (Medicare Advantage Plan) as primary coverage Usually includes Part D coverage Access to Part C still requires enrollment in Basic Medicare • Supplement • (Medigap) Part D Drug Plan

9. Medicare Costs- Part AHospital Insurance • Most individuals pay $0 premium (since worked 40+ quarters) • If individual worked 30-39 quarters, $248 monthly premium • If worked <30 quarters, $413 monthly premium. • Deductible • $1,316 per hospital stay • Copayments/Coinsurance • $329 copay for hospital stay days 61-90; $658 copay days 91-150; All costs after day 150 (includes 60 lifetime reserve days) • Skilled Nursing Facility $0 copay days 1-20, $164.50 copay for days 21-100; all costs after day 100

10. Medicare Part A- Coverage • Inpatient Care in Hospitals • Inpatient Care in a Skilled Nursing Facility(not custodial or long‑term care) • Hospice Care Services • Home Health Care Services

11. Medicare Part A Covered Services

12. Medicare Part A- Cost • Most individuals pay a $0 premium for Part A. • Individuals who are not eligible for premium-free Part A coverage can pay $413/month if: • Aged 65 and older, have or are enrolling in Part B, and qualify under the citizenship and residency requirement; OR • Under age 65, disabled, and premium-free Part A coverage ended because they returned to work. • (Coverage continues for up to 8.5 yrs after return to work.) • Late Enrollment Penalty • For those ineligible for premium-free Part A who don’t buy in when first eligible, monthly premium increases by 10%. Higher premium enforced for 2x the number of years the individual could have had Part A, but didn’t enroll.

13. Medicare Costs- Part BMedical Insurance • Most individuals pay $134 premium; existing enrollees pay less (~$109) • Higher earning individuals have surcharge • Deductible- $183 • Copayments/Coinsurance- normally 20%

14. Medicare Part B- Coverage • Outpatient care • Medically Necessary Services from doctors and other health care providers • Home health care • Durable medical equipment • Some preventive services

15. Medicare Part B Covered Services

16. Medicare Part B Covered Preventive Services “Welcome to Medicare” exam Yearly “Wellness” exam Abdominal aortic aneurysm screening* Bone mass measurement Cardiovascular disease screenings Colorectal cancer screenings Diabetes screenings Flu shots • Glaucoma tests • Hepatitis B shots • HIV Screening • Mammograms (screening) • Pap test/pelvic exam/clinical breast exam • Prostate cancer screening • Pneumococcal pneumonia shots • Smoking cessation

17. Noncovered Services Routine Eye Care and Corrective Lenses Routine dental care Dentures Cosmetic surgery Acupuncture Podiatry care Hearing aids and exams for fitting hearing aids Long-term care

18. Medicare Part B- Should you Enroll? • Consider what other coverage you have first: • Individuals with Employer or Union Coverage may be able to delay Part B without penalty. • Enrollment is mandatory for most individuals with Part A and TRICARE coverage. • Enrollment in Part B triggers the one-time Medigap Open Enrollment Period for individuals aged 65 and older.

19. Medicare Part D- Prescription Drug Plans • Monthly premiums • Vary by plan, as low as $0. • Higher income individuals have higher premiums. • Late enrollment penalty • Begins accruing after 63+ consecutive days without coverage • 1% for each month without creditable drug coverage • Actual drug plan costs will vary depending on: • Plan selected, prescriptions and plan’s formulary. • Use of network pharmacies. • Eligibility for Extra Help. • Gross income.

20. Medicare Part DPrescription Drug Plans • Surcharge for Higher Earners

21. Medicare Part DPrescription Drug Plans • Eligibility Criteria • Must have Part A • Live in the plan’s service area. • Enrollment Periods • Initial 7-month Enrollment period (beginning 3 months before birthday or disability) • Annual General Enrollment/Open EnrollmentOctober 15- December7- can join, switch, or drop a Medicare Prescription Drug Plan. New plan takes effect January 1. • Special Enrollment Periods • Move out of plan’s service area. • Have Medicaid/Qualify for Extra Help. • Lose other creditable prescription drug coverage. • Live in an institution (like a nursing home).

22. Medicare Part D- Prescription Drug Plans • Initial Enrollment • Begins 3 months before birthday, includes birthday month, end 3 months after birthday. Coverage begins birthday month or month following enrollment. • Disabled individuals can join during the 7-month period that begins 3 months before 25th month of disability and ends 3 months after 25th month. • General Enrollment/Open Enrollment • Between October 15 and December7 anyone can join, switch, or drop a Medicare Prescription Drug Plan. Coverage will begin on January 1.

23. Medicare Part D- Prescription Drug Plans • Special Enrollment Periods • In most cases, individuals must stay enrolled for the calendar year starting the date their coverage begins. However, individuals may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period in certain situations: • Move out of plan’s service area. • Have Medicaid. • Qualify for Extra Help. • Lose other creditable prescription drug coverage. • Live in an institution (like a nursing home). • 5-Star Special Enrollment Period • From December to November, individuals can switch to a Medicare Advantage Plan that has a 5 star overall plan rating.

24. Medicare Part D- Prescription Drug Plans • Formulary- list of prescription drugs covered by the plan. Plans have “tiers” that cost different amounts.

25. Medicare Part DPrescription Drug Plans • Coverage Gap(“Donut Hole”) • To enter the donut hole, participant and drug plan together must spend $3,700To get out of donut hole, participant alone must spend $4,950 in out of pocket costs for prescription drugs. (Includes deductibles and copays, but not monthly premiums.) • During donut hole, participants pay 40% of the plan’s cost for covered brand-name drugs and 51% for covered generic drugs. • Once out of the donut hole, catastrophic coverage kicks in, and only a small copay applies for the remainder of the year.

26. Medicare Part C- Medicare Advantage Plans Offered by private insurance companies Must cover same services as Medicare Provide Part A and Part B coverage, and usually Part D coverage Often covers more than Medicare, such as vision, hearing, dental, health, fitness and wellness plan Monthly premiums $0 and up

27. Medicare Part C- Medicare Advantage Plans • Types of Plans • Health Maintenance Organization (HMO) • Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) • Special Needs Plans (SNP) • HMO Point-of-Service (HMOPOS) • Medical Savings Account (MSA)

28. Medicare Costs- Part CMedicare Advantage Plans • Premiums- vary • Deductibles- vary • Copayments/Coinsurance- vary • Costs depend on: • Plan selected, prescriptions and plan’s formulary. • Use of network pharmacies and providers. • Eligibility for Extra Help. • Late enrollment penalty for Part D

29. Medicare Part C- Medicare Advantage Plans • Eligibility • Individuals must: • Have Part A and Part B. • Live in the plan’s service area. • Not have End-Stage Renal Disease (ESRD).

30. Medicare Part C- Medicare Advantage Plans • Initial Enrollment • Begins 3 months before birthday, includes birthday month, end 3 months after birthday. Coverage begins birthday month or month following enrollment. • Disabled individuals can join during the 7-month period that begins 3 months before 25th month of disability and ends 3 months after 25th month. • General Enrollment/Open Enrollment • Between October 15 and December7 anyone can join, switch, or drop a Medicare Advantage Plan. Coverage will begin on January 1.

31. Medicare Part C- Medicare Advantage Plans • Special Enrollment Periods • In most cases, individuals must stay enrolled for the calendar year starting the date their coverage begins. However, individuals may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period in certain situations: • Move out of plan’s service area. • Have Medicaid. • Qualify for Extra Help. • Live in an institution (like a nursing home). • 5-Star Special Enrollment Period • From December to November, individuals can switch to a Medicare Advantage Plan that has a 5 star overall plan rating.

32. Medicare Supplemental PlanMedigap Insurance • Cost Comparison • Individuals pay a monthly premium for their Medigap policy. • Different insurance companies may charge different premiums for the same exact policy. It is important to compare Medigap policies since the costs can vary and may go up as you get older.

33. Medicare Supplemental PlanMedigap Insurance • Eligibility Criteria • Must Be age 65 or older • Have Part A and Part B. • Live in the plan’s service area. • Coverage (depending on plan selected) • Medicare Part A & B Deductibles, Coinsurances, Additional Expenses • Cost Comparison • Monthly premiums vary. Different insurance companies charge different premiums for the same exact policy. It is important to compare Medigap policies since the costs can vary and may go up as you get older. • Enrollment • 6-Month Guaranteed Enrollment Period- begins on the first day of the month in which you’re 65 or older and enrolled in Part B.. • If you delay enrolling in Part B because you have group health coverage based on your (or your spouse’s) current employment, your Medigap Open Enrollment Period won’t start until you sign up for Part B.

34. Medicare Supplemental PlanMedigap Insurance Offered by private insurance companies Reduce copays for Medicare participants Individuals have a one-time 6-month Medigap Open Enrollment Period which starts the first month they were 65 andenrolled in Part B. This period gives individuals a guaranteed right to buy any Medigap policy sold in their state regardless of health status. Once this period starts, it can’t be delayed or replaced.

35. Medicare Supplemental PlanMedigap Insurance • Enrollment • The best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This 6-month period begins on the first day of the month in which you’re 65 or older and enrolled in Part B. After this enrollment period, your option to buy a Medigap policy may be limited and it may cost more. • If you delay enrolling in Part B because you have group health coverage based on your (or your spouse’s) current employment, your Medigap Open Enrollment Period won’t start until you sign up for Part B.

36. Medicare Supplemental PlanMedigap Insurance

37. Joley L. steffens Joley L. Steffens, PLLC 5402 Glenside Drive, Suite D, Richmond, VA 23228 joley@richmonDelderlaw.com 804-756-0200; 804-461-8283