The A, B, C’s … and D of Medicare

1. The A, B, C’s … and D of Medicare Presented by The Health Insurance Counseling and Advocacy Program HICAPServices of Northern California

2. Overview • Medicare Parts A and B • Ways to Supplement Medicare • Part C: Medicare Advantage Plans • Part D: Prescription Drug Program • Other Healthcare • Low Income Assistance Programs

3. … and how HICAP can help. HICAP helps Medicare beneficiaries • Understand Medicare • Compare Supplemental Insurance Plans • Review HMO benefits • Choose a Prescription Drug Plan • Prepare appeals and challenge denials • Learn about government assistance programs • Explore Long Term Care options • Clarify rights as a health care consumer

4. Health Insurance Counseling and Advocacy Program (HICAP) • HICAP offers objective information to help beneficiaries make their own decisions about health care coverage. • HICAP services are free to all Medicare beneficiaries.

5. What is Medicare? • Federal government insurance program • Provides insurance for people 65 and older, and people with disabilities • No income eligibility requirements

6. You are eligible for Medicare if... • You are a U.S. citizen; or • You have your resident visa and have lived in the U.S. for 5 consecutive years; • and • You are 65 and older; or • You have been getting Social Security disability income (SSDI) for at least 24 months; or • You have kidney failure (end stage renal disease); or • You have ALS (amyotrophic lateral sclerosis), also known as Lou Gehrig’s disease

7. Medicare Coverage • Part A - Hospital Insurance • Part B - Medical Insurance • Part C - Medicare Advantage • Part D - Prescription Drug Insurance

8. Medicare Part A Covers • Inpatient Hospital Care • Deductible $1100 • Skilled Nursing • Days 1 – 20 covered • Days 21-100 $137.50 /day • Home Health Care • Intermittent care prescribed by doctor • Hospice • Pain management program for terminally ill

9. Medicare Part B Covers • Physicians • Diagnostic Tests • Rehabilitation Services • Durable Medical Equipment • Ambulance • Mental Health Visits • Outpatient physical, occupational, speech therapy Care must be medically necessary and reasonable

10. Preventive Benefits now under Part B • Yearly mammogram (screening) • Pap smears (including pelvic and breast exam) • Diabetes screening, glucose monitoring and Self Management Training • Colorectal /Prostate cancer screenings • Bone mass measurement • Flu and Pneumonia shots • Prostate cancer screening • Hepatitis B vaccine • Nutrition therapy for people w/ diabetes, ESRD • Annual glaucoma screening • Cardiovascular Screenings • Abdominal Aortic Aneurism Screening • Smoking Cessation (counseling to stop smoking)

11. Note - Medicare Does Not Cover: • Routine dental care • Routine vision care • Routine hearing care • Routine foot care • Personal care at home or in a nursing home

12. Medicare Part A - Hospital Insurance Premium free if eligible for Social Security Otherwise can purchase for up to $461/month Inpatient hospital deductible ($1100), and hospital and SNF co-insurance Medicare Part B - Medical Insurance $96.40 monthly premium If SSA Withholds Part B Premium and Income is 85,000 (single) or $170,000 (Joint Filers). All others $110.50 monthly Premium $155 annual deductible 20% of Medicare approved amount for Part B services (Medicare pays 80% of approved amount for Part B services) What Does Medicare Cost?

13. What Does Medicare Cost? Medicare Part D – Prescription Drug Benefit • Monthly premium ranges from $17.60 - $105.00 • Up to $310 deductible • 25% co-pay of drugs up to $2830 • After $2830 No coverage until after $4550 paid • 5% of drugs after $ 6153.75 • Offered through private insurance companies • In California, there are 47 plans • Lifetime premium penalties will apply if you delay enrollment

14. MEDICARE PART B INCOME-RELATED PREMIUM

15. Medicare Summary Notice • Instead of a bill, you will receive a Medicare Summary Notice. • Call 1-800-MEDICARE with questions

16. A Word About Medicare Fraud Intentional Deception or Misrepresentation Resulting in Unauthorized Benefit • Don’t Become a Victim • Medicare Fraud and Abuse is Real! • Review Medicare Summary Notices (MSNs) for Accuracy • Check with Your Trusted Providers Concerning Billing Discrepancies • Don’t Give Out Your Medicare, Social Security, or Credit Card Numbers Over the Phone • How to Report • Call HICAP for Assistance at 1-800-434-0222

17. Watch Your Step: Falls Prevention Tips • Regular exercise for feet and legs • Ensure necessities are within reach • Ensure the correct bed height • Position beds to allow persons to exit on their strong side • Ensure rooms and walkways are free of clutter • Assistive devices, such as walkers, are within reach • Ensure furniture is sturdy and wheels are locked • Assess a person’s risk of falling • Reduce the person’s risk by asking for help and guidance

18. Watch Your Step: Falls Prevention Tips • The risks of not preventing falls: • Injury and premature death due to hip fractures • Danger of suffering traumatic brain injuries • Can lead to severe loss of independence

19. Ways to Supplement Medicare • Medicare Fee for Service (Original Medicare) • Medigap Plans • Medicare HMOs (Advantage Plans) • Retirement Plans • Tri-Care for Life • VA Benefits • Medi-Cal

20. In the Fee-for-Service System...(Original Medicare) • FIRST, person receives treatment (from a doctor, lab, hospital, SNF, Home Health Agency). • THEN Medicare, Medigap and the person are billed. • Doctors • Hospitals • Home Health • SNF • etc... Billing and Payment Services

21. Medigap Policies and the Fee-for-Service System • 12 “standardized” policies (A-L) • Policies pay after Medicare pays • Policies fill Medicare “gaps” • co-insurance, deductibles • All companies must offer Plan A (the basic benefit package)

22. Medigap Policies: Variations contiued... • Companies may differ in: • Premiums • Health screening • Waiting periods • Claims processing • Sales and service

23. Medigap Open Enrollment for People 65 and Over • When you are 65 or older AND first go on Medicare Part B • six-month period starts when Part B begins • When your employer sponsored health plan ends • When your health care coverage ends because of a military base closure • When you move out of geographic area served by your Medigap plan

24. Part C:Medicare Advantage Plans - the Managed Care System • HMO: Kaiser, HealthNet, Secure Horizon … • PPO: MAs contract with a network of providers • Health care stays within the network . . . • PFFS • Private Fee For Service

25. Medicare HMOs • Monthly premiums apply • Co-payments for doctors’ visits, prescription drugs, and other services • Hospital, skilled nursing facility, and ambulance co-payments may apply • Claims processing reduced • No health screening required to qualify

26. Part D – the Prescription Drug Benefit • The Basics: • Open Enrollment: Annually Nov. 15 – Dec 31 • Available for all people with Medicare • Provided through: • Prescription Drug Plans (PDPs) offered by private/commercial companies as stand-alone plans • Medicare Advantage Plans (MA-PDs) • offered by private/commercial managed care health plans

27. How Part D Works this year: 2010 $310 Deductible $2830 Initial Coverage Limit (25% / 75%) Coverage Gap After enrollees incur over $4550 in out-of-pocket expenses, Catastrophic benefit kicks in, paying 95% of all costs over $4550 in out-of-pocket. Beneficiary has 5% Co-Insurance

28. Part D “Special Enrollment” • Medicare/Medi-Cal beneficiaries can change plans any time. • Others must meet a special condition: • Individual entering, residing in, or leaving a long-term care facility • Permanent move out of the plan service area • Involuntary loss, reduction, or non-notification of creditable coverage • Other exceptional circumstances

29. Other Healthcare Options:1) Retiree Health Benefits • Beneficiaries with employer group health coverage will have Medicare as the second payor • Part A is free (if worked 10+ years) • Part B is optional and you will have to pay the monthly premium

30. Other Healthcare Options:2) Tri-Care for Life • Health care coverage for those retired from Military Service and for spouse • Excellent health care coverage already 3) VA Benefits • Priority given to veterans with service-related disabilities

31. Medi-Cal (Medicaid) • Low income program for 65 and over, blind, or disabled • Pays for “medically necessary” health care, including physician visits, laboratory tests, prescription drugs, eyeglasses, and dental care • Pays Medicare Part B premiums ($96.40/2009) • SSI eligibility = Medi-Cal automatically Note: You must use a Medi-Cal contracted provider/facility in order for Medi-Cal to pay

32. Important Resources • Medicare Website:www.medicare.gov Comparison and quality of care information on Medicare HMOs and Medigap plans • Health Services Advisory Group www.hsag.com;800-841-1602 Medicare Quality of Care Issues and Complaints • Department of Managed Health Care: www.dmhc.ca.gov; 888-466-2219 Quality of care issues and complaints about HMOs • Department of Insurance:www.insurance.ca.gov 1-800-427-9357 Complaints regarding insurance

33. For an appointment with a HICAP Counselor in the 9-county Sacramento Region call (916) 376-8915 Statewide 1-800-434-0222