Welcome to Medicare

1. Welcome to Medicare Medicare 101 XXXX, Regional Manager Seniors’ Health Insurance Information Program (SHIIP)

2. Understanding Medicare • The Primary/Secondary relationship • of coverage. • How various Medicare Insurance • products work together. • Enrolling in and changing • coverage is only allowed during • certain periods.

3. What is Medicare? • Federally sponsored Individual • Health Plan providing coverage for • Medically Necessary procedures and • services. • Medicare coverage requires copays, • coinsurance and deductible • payments that are the responsibility • of the beneficiary (or other • Secondary Insurance).

4. Anyone age 65 or older who has participated in Social Security, Railroad Retirement System or employees of Federal, State, or Local Governments or whose spouse has participated. Individuals under age 65 that have been awarded Social Security or Railroad Retirement Disability after 24 months. Those disabled due to ALS (Lou Gehrig's Disease). Individuals with End Stage Renal Disease (ESRD). Who is Eligible for Medicare?

5. What does Original Medicare Cost? Part Ais premium free to most beneficiaries based on having contributed 40 quarters into the Medicare system. For those with less than 30 quarters, Part A has a premium. Part Bpremium based on income. If you are single and your income is over $85,000 or if married and your income is over $170,000, you will pay more for your monthly premium. Otherwise the Part B premium is $104.90 per month.

6. What does Original Medicare Cover? Medicare Part A Medicare Part B Following services are generally covered at 80%: Physician Services Outpatient Surgery and Services Home Health Care Durable Medical Equipment Blood • Inpatient Hospital Coverage • Skilled Nursing Care in a facility (requires a minimum 3 day prior hospitalization) • Home Health Care • Hospice • Blood Medicare benefits are administered by the Centers for Medicare and Medicaid Services (CMS) 1-800-633-4227

7. What Is NOT Covered by Original Medicare? • Prescription Medications • Routine Dental Care • Routine Vision Care & Eyeglasses • Hearing Aids • Foreign Travel • Cosmetic Procedures & Treatments • Long Term Care

8. Automatic Enrollment Individuals collecting Social Security Retirement Benefits prior to age 65. Individuals entitled to Social Security Disability Benefits. Beneficiary will receive Medicare Card in the mail indicating automatic enrollment in Part A and B. Beneficiary has option to decline Part B coverage by returning card to Social Security. Coverage will begin 1st day of birth month unless birthday is the 1st of month in which case coverage begins first day of preceding month. How Does One Enroll in Medicare?

9. Initial Enrollment Period Individuals turning age 65 and NOT collecting Social Security Retirement have an initial 7 month period to enroll in Medicare. This includes the 3 months prior to 65th Birthday, the month of 65th Birthday, and the three months following the 65th Birthday. Medicare benefits take effect the first of the month of your 65th Birthday if enrollment takes place in advance of the month of birth. Medicare benefits take effect the month following enrollment if done during month of birth. Medicare benefits are delayed by two months if enrollment is done first month after birthday month. Medicare benefits are delayed by three months if enrollment is done in the second or third months after birth month. How Does One Enroll in Medicare? (cont’d)

10. General Enrollment Period For those that do not enroll during their Initial Enrollment Period there is another opportunity to enroll each year during what is called the General Enrollment Period. The General Enrollment Period is between January 1 and March 31 of each year. Enrollments during this period will have coverage beginning July 1. Failure to enroll in Medicare when originally eligible results in a 10% premium penalty for one’s lifetime for each 12 month period not enrolled (waived when Part B delayed because of Primary EGHP coverage) How Does One Enroll in Medicare? (cont’d)

11. Special Enrollment If you or your spouse are “actively” working, then you may be able to delay enrolling into Medicare Part B. If your employer plan is paying first, you would enroll into Part A, and could delay enrolling into Part B. You would pick up Part B after you stop working/retire without a penalty. It is important to note that when you stop actively working, it is necessary to enroll in Medicare Part B. It is not automatic enrollment. How Does One Enroll in Medicare? (cont’d)

12. Where Do I Enroll? Medicare enrollment is handled by the Social Security Administration. Contact Your Local Social Security Office or Call 1-800-772-1213 Appointments can be made for local offices through the above toll-free number. Enrollment may also be completed online at www.socialsecurity.gov.

13. Providers Acceptance and Choices • Claims are paid based on the providers decision to participate in Medicare and whether they accept assignment. • Providers may or may not accept Assignment. • If provider accepts Medicare but NOT assignment – Allowed to charge 15% above Medicare assigned charges – Applies to Doctor charges only. • It is possible that a provider does not accept Medicare. • NOTE: Hospitals and other providers such as Ambulance providers have to accept Medicare Assignment. Assignment – Medicare assigns a reimbursement rate for each service based on a coding system entered by providers when filing claims.

14. The Decisions • Do I need Part B of Medicare • immediately? • Do I already have an Employer • Group Health Plan (EGHP) from a • previous employer? • Do I want to exchange my benefits • under Original Medicare for a private • plan? • Do I need a Medicare Prescription • Drug Plan? • Do I need a Medicare Supplement • (Medigap) plan?

15. Do I Need Medicare Part B? • Medicare is designed to be one’s PRIMARY health insurance coverage. • In most cases, any other coverage will pay SECONDARY to Medicare. • If you do not accept Medicare when eligible, typically your Secondary Insurance/EGHP will pay as if Medicare was primary. You (the beneficiary) will be responsible for the payments Medicare would have made had it been in place. • Failure to enroll in Medicare when originally eligible results in a 10 percent premium penalty for one’s lifetime for each 12 month period not enrolled (this is waived when Part B is delayed because of Primary EGHP coverage when you or your spouse are actively working).

16. When is Medicare Secondary? • Medicare may be secondary coverage when a beneficiary is covered by an Employer Group Health Plan based on current active employment of the beneficiary or his/her spouse. • Primary/Secondary relationship is based on age of beneficiary and number of employees with the Employer providing the Active Employee coverage.

17. Medicare Secondary • For beneficiary age 65 or above, and covered by a group health plan because beneficiary or spouse is still actively working, Medicare IS secondary when Employer has MORE THAN 20 employees. • For beneficiary under age 65, and covered by a group health plan because beneficiary or spouse is still actively working, Medicare IS secondary when Employer has MORE THAN 100 employees.

18. Medicare Secondary What To Consider? • Typically Medicare pays very little as Secondary insurance. • Part A is premium free for most so having the coverage has no cost to the beneficiary. • Part B has a monthly premium which may exceed the potential benefit. • Medicare allows the delay of Part B Coverage and has a Special Enrollment period for those who make this choice. (Discussed earlier during “How to Enroll”.)

19. Should a Beneficiary Continue Employer Group Health Plan as Primary? • What is cost of the coverage? • What additional benefits does the coverage include? • Are there dependents? Status of those dependents? • If cancelled, will plan allow future re-instatement?

20. Medicare is PrimaryWhat Are Coverage Options? You are not working and Medicare is your primary coverage: • Original Medicare only • Original Medicare plus secondary coverage such as an EGPH, TRICARE, VA • Medicare Advantage plan • Medicare Supplement/Medigap plan

21. Medicare is PrimarySecondary Coverage Options? • Medicaid – Low income individuals • TRICARE for Life – Military Retirees and dependents • Federal and State plans for retirees and dependents • Employer Group Health Plans – Indemnity Style plans • Medicare Supplement (Medigap) Policy

22. Medicare Supplement (Medigap) Plans • Standardized Insurance plans sold by private insurance companies designed to cover “gaps” in Medicare coverage (deductibles, copayments, and co-insurance, etc.). • Plans are designated by letter codes (A, B, C, D, F, G, K, L, M, N). • All plans cover a basic group of benefits, with plans each covering a different group of “gaps”. • Coverage is same from company to company, but premiums do vary.

23. Medicare Supplement (Medigap) Plans (cont’d) • Pros: • Match up with Medicare benefits. • Guaranteed renewable as long as premiums paid. • Does not restrict provider access. • In most cases, automatic crossover of claims. • If claim paid by Medicare, will be paid by Medigap plan. • Cons: • Cost: Premiums vary by company and may increase over time. • If you do not enroll during your initial open enrollment period, may be subject to underwriting.

24. Medicare Supplement (Medigap) Open Enrollment • Those new to Medicare have an Open Enrollment period for Medicare Supplement plans which requires companies to accept applicant at standard rates regardless of health. • The Open Enrollment period is based on the Part B effective date and is valid for 6 months following enrollment.

25. Medicare SupplementGuarantee Issue Rights • If losing coverage under an Employer Group Health Plan (EGHP) that is secondary to Medicare, you will have a guarantee issue for plans A, B, C, F, K or L. (If disabled and under 65, plans A, C or F.) You must apply within 63 days of the previous plan’s termination. • Loss of coverage by Medicare Supplement or Medicare Advantage plans that is outside the control of the beneficiary also generates Guarantee Issue rights.

26. Employer Group Plans for Medicare Eligible • Employer Plans come in many forms and can only be understood on an individual basis. • Some employers offer a variety of coverage options to their retired employees. • Plans may be Indemnity Style plans and work with Medicare A and B in a manner similar to Medicare Supplement plans. • Some plans offer cash payments allowing beneficiary to purchase their own coverage. • Employer sponsored Medicare Advantage plans are now being offered by some employers for their retirees thus making the Medicare Advantage plan their Primary Coverage instead of Original Medicare.

27. Why Consider a Medicare Advantage (Part C) Plan? • Structured and sometimes lower co-payment levels for some services (physician, hospital, E.R, etc.). • Additional benefits not included in Original Medicare such as Limited Dental, Vision, Hearing. • Plan may include Medicare Prescription Drug coverage. • Plans may have lower premiums than a Medicare Supplement.

28. Medicare Advantage (Part C) Limitations • Plans may limit access to providers (Physicians, hospitals, Skilled nursing facilities, Home Health Agencies, DME providers, Labs, etc.). • Some copayments may be higher than under Original Medicare. • Limited service areas (however, if an emergency you can go anywhere for care). • All plans may not be available in your county of residence.

29. What about Medicare Prescription Drug Coverage? • Any one covered by Medicare (Part A and/or Part B) is eligible to join a Medicare Prescription Drug Plan (Part D). • Plans are sold by private Insurance companies and require payment of monthly premiums. • Each plan covers a group of prescription medications (Formulary list) and typically have co-payments for prescriptions and possibly a deductible. • Plans and formulary lists may change from year to year.

30. Do I Need Medicare Prescription Drug Coverage? • Do you have prescription drug coverage from some other source such as an EGHP, TRICARE, VA that is Creditable? If yes, then in most cases, you would not need a Part D plan. • If you do not enroll in a Part D drug plan when first eligible, you will be penalized 1% per month in premium for each month you do not have creditable coverage past original eligibility date. • Penalty based on the national base premium and is collected for life unless you have other creditable coverage, or qualify for Low Income Subsidy or Medicaid.

31. Choosing a Medicare Prescription Drug Plan (Part D) • Plan should be chosen based on analysis of prescription • medications, pharmacy used, monthly premium cost and • copayments through a comparison tool located on the • Medicare.gov web site. This comparison tool will assist in • determining best plan options based on your current • prescription drugs. • Initial enrollment is allowed during the same initial • enrollment period as Medicare A/B. • Annual election opportunity and change in plan is • allowed each year between October 15 and December • 7, with coverage effective January 1 (Annual Election • Period).

32. Low Income Subsidy (Extra Help) withMedicare Prescription Drug Plans • Those with limited incomes and assets may be eligible for Extra Help with Medicare Prescription Drug plan costs. • If qualified will reduce or eliminate monthly premiums and the coverage gap/donut hole and provide reduced drug copayments and co-insurance. • Extra Help (also known as Low Income Subsidy) applications are processed by the Social Security Administration. • Medicaid beneficiaries automatically qualify for the Extra Help program. • If you qualify, you may be able to obtain a premium free Part D plan and pay as little as $2.65 for your generics and $6.60 for name brand drugs.

33. Qualifying for Extra Help (Low Income Subsidy) with Part D • An individual can have a monthly income of up to $1,436.25 to qualify and a married couple can have a monthly income of up to $1,938.75 to qualify. • Assets can be up to $13,440 for an individual and up to $26,860 for a married couple. Assets do not include your home, but do include checking, savings, IRA’s and money market accounts.

34. What is a Medicare Summary Notice? (MSN) • This notice is like an Explanation of Benefits (EOB) for the Medicare beneficiary. • CMS will mail the Medicare Summary Notice quarterly. It is possible to sign up with Medicare to view your MSNs online through www.MyMedicare.gov. • Take the time to review your notice. There is information on the back of the form if you want to file an appeal. • You are the “first line of defense” when it comes to catching errors and possibly fraud. • You also need to review the notices that you receive from your providers/doctors and the notices from your secondary insurance.

35. Where Can I Get help? • Seniors Health Insurance Information Program (SHIIP) 1-800-443-9354 or www.ncshiip.com • Senior Medicare Patrol (SMP) (Fraud & Abuse) 1-877-996-2767 • Social Security 1-800-772-1213 or www.socialsecurity.gov • Medicare 1-800-633-4227 or www.medicare.gov • Employer health benefits administrator • Medicaid – Local County Social Services