Welcome to the MEDICARE TRAINING

1. Welcome to the MEDICARE TRAINING A Continuing Education Course presented by UNICARE Life and Health Insurance Company

2. Course Objective • To make Medicare coverage, guidelines and co-insurance issues easier to understand. • To educate you so that you can better assist and educate your clients.

3. Benefit to Attendees • You will experience a "user-friendly, easy-to-understand" approach to an otherwise complex subject. • You will better understand the senior citizen situation when seeking a quality Medicare Supplement.

4. Seminar Agenda • What is Medicare and Who is Entitled • Centers for Medicare and Medicaid Services (CMS) • Major Changes in Medicare • Who Pays for Medicare • Medicare Eligibility and Enrollment • Part A -Benefits and Purchasing • Part B - Benefits • Medicare Assignment and Payment • New Preventative Benefits

5. Seminar Agenda(continued) • Supplemental Insurance • Supplement Open Enrollment • Plans A-J • Standardization and Medicare Select • Remaining Gaps in Medicare • Balance Budget Act of 1997 • Guarantee Issue Provision • New Health Care Options

6. History of Medicare • Through out history there have been many significant events that led to the enactment of Medicare. • Medicare is the result of many attempts by union groups, congress and presidents to implement socialized medicine in the United States. • Most efforts to block socialized medicine came from medical groups and hospital organizations

7. What is Medicare and Who is Entitled? • Medicare is federal health program for the aged and disabled • It was established as part of the Social Security Act of 1965 • Medicare was introduced in 1966, when only 50%of the nation’s elderly population had any health insurance. • Today, only about 1% of the elderly are uninsured.

8. What is Medicare and Who is Entitled? • When first implemented in 1966 Medicare covered 19 million beneficiaries nation wide • Medicare originally covered only most people age 65 and older • In 1999 Medicare covered about 39 million enrollees at an annual cost of about 213 billion • The average calendar year cost was about $5500. per enrollee

9. What is Medicare and Who is Entitled? • Medicare expanded in 1973 to cover persons who were entitled to Social Security or Railroad Retirement disability for at least 24 months and persons with end-stage renal disease requiring continuing kidney dialysis or a kidney transplant. (End-stage renal disease now 6 months)

10. Health Care Financing Administration • In 1977, the Health Care Finance Administration was established under the Department of Health and Human Services to administer the Medicare program. • In 2001 (HCFA) name was changed to Centers for Medicare & Medicaid Services

11. Centers for Medicare & Medicaid Services • (CMS) is the federal agency within the Department of Health and Human Services that administers Medicare and regulates the Senior Risk (HMO) Industry • (CMS) responsibilities for Medicare include formulation of policy and guidelines, contract oversight and operations, maintenance and review of utilization records and the general financing of Medicare

12. Major Changes in Medicare • Part A • Prospective Payment/DRGs for Hospital Care • Medicare-Approved HMOs • Part B • Physicians Assignment • Medicare Catastrophic Coverage Act • Passed in 1988, Repealed 1989. • Home Health Care adopts DRG’s

13. Who Pays For Medicare? • Medicare Part A is financed through mandatory payroll deduction (FICA tax). • The FICA tax is 1.45% of earnings (paid by both the employee and employer), and 2.9% for self-employed persons. This tax is paid on all covered wages and self-employed income without a limit

14. Who Pays For Medicare? • Medicare beneficiaries also contribute in part by paying deductibles, coinsurance and premiums. • For those people who are eligible due to age or medical conditions, but have not paid into Social Security, Medicare PART A is available at a premium.

15. Who Pays For Medicare? • For most people, the monthly premium for Hospital PART A is $319, if they have paid FICA tax for 30 to 39 quarters the monthly premium is reduced to $175.

16. Who Pays For Medicare? • Medicare PART B is financed through • monthly premiums paid by beneficiaries these premiums cover about 25% of expenditures • monthly premium is $54.00 • contributions from the Federal Governments general fund.

17. Medicare Eligibility • To be eligible for Medicare, you: • or your spouse must have worked for at least ten years in Medicare covered employment. • must be 65 years of age and a citizen or permanent resident of the United States. • or a person younger than 65 with a disability or a chronic kidney disease.

18. Medicare Enrollment • Automatic Enrollment • If already getting Social Security benefits when you turn 65, you will automatically be enrolled in Medicare Parts A and B. • You will receive your card about three months before your 65th birthday.

19. Medicare Enrollment • Automatic Enrollment(continued) • If disabled, you will automatically get a Medicare card in the mail after receiving Social Security Benefits for 24 months.

20. Medicare Enrollment • Applying for Medicare • If not receiving Social Security benefits, you must apply by contacting any Social Security Administration office three months prior to your 65th birthday.

21. Medicare Enrollment • Initial Enrollment Period • Seven months, starting 3 months before the month in which you turn 65. If you do not enroll during this period, you must wait until the next general enrollment period. • General Enrollment Period • January 1st to March 31st each year • Your Medicare coverage will be effective the following July 1st.

22. Medicare Enrollment • Late Enrollment Consequences • If you wait 12 months or more to enroll and you do not have group health insurance as a result of your or your spouse’s current employment,Part B premiums increase 10%for each 12 months that you do not enroll. • If you have to pay a premium for Part A, • the cost increases is limited to10% no matter how late you enroll.

23. Medicare Enrollment • Extenuating Circumstances You can delay Part B enrollment if: • you are over 65 and have group health insurance through you or your spouse’s current employment, or... • you are disabled and have group health insurance through you or your spouse’s current employment.

24. Medicare Enrollment • Extenuating Circumstances (continued) You may enroll while you are covered by a group health plan or wait till your group coverage ends. • A special 8-month enrollment period begins the month your coverage ends. • If you do not enroll by the end of this period, you will have to wait until the Medicare’s next general enrollment period.

25. What Is a Medicare Card? • A Medicare Card is issued to every Medicare Beneficiary • Card shows name of beneficiary • Card shows Medicare claim number • Card also shows if the beneficiary has Hospital (Part A) and Medical (Part B) insurance, as well as the effective dates of coverage.

26. Health Insurance Claim Number • Claim number usually is the beneficiaries Social Security number followed by an ”A” • If beneficiary is receiving benefits through their spouse, the claim number would be the spouses Social Security number followed by a “B.” • If the beneficiary is receiving benefits through a deceased spouse the card would have the spouses Social Security number followed by a “D”

27. MEDICARE BENEFITS

28. Medicare consists of two parts: • Hospital Insurance protection - PART A • Medical Insurance protection - PART B

29. MEDICARE BENEFITSPART A

30. Medicare PART A provides institutional care, including: PART A: • Medicare helps pay for: • care in a hospital • skilled nursing facility • home health care • hospice care

31. Part A Benefits • Benefit Period • Coverage is measured in a ‘Benefit Period’ which begins the day you are admitted to a hospital and ends when you have been out of a hospital or skilled nursing facility for 60 consecutive days. • If you go back to the hospital after 60 days a new benefit period starts • There is no limit on the number of benefit periods you can have in a year.

32. Part A: Hospital Covered Services • Semi-private room and board • General nursing care • Operating and recovery room • Intensive care • Inpatient prescription drugs • Lab and X-Ray services • All other medical necessary services and supplies provided in the hospital.

33. Part A: Hospital Benefits • For each benefit period you pay: • Day 1 through 60 - Medicare pays all covered costs except a $812 in patient hospital deductible. Hospital deductible must be met each benefit period. • Day 61 through 90 - Medicare pays all covered costs except $203 per day coinsurance.

34. Part A: Hospital Benefits • Day 91 through 150 Lifetime Reserve Days. Medicare pays all covered costs except $406 per day. • The 60 lifetime reserve days never renew. • Beyond 151 days Medicare pays nothing

35. Part A: Skilled Nursing Facility • A skilled nursing facility is different from a nursing home. It is a special kind of facility that primarily furnishes skilled and rehabilitation services. • It may be a separate facility or a distinct part of another facility such as a hospital.

36. Part A: Skilled Nursing Facility • Qualifications • You require daily skilled care, which can only be provided on an inpatient basis • You must be hospitalized for at least 3 consecutive days • Be admitted for the same condition for which you were hospitalized • Be admitted within 30 days of your discharge from the hospital • Certified as medically necessary

37. Part A: Skilled Nursing Facility • Medicare will help pay for this care for up to 100 days per benefit period... • Day 1 through 20 - Medicare pays all covered costs. • Day 21 through 100 - Medicare pays all covered costs except $99 per day. • Day 101+ - you pay full cost.

38. Part A: Home Health Care • Medicare will pay the full cost of medically necessary home health care visits provided by a Medicare approved home health care agency • A home health agency is a public or private agency that provides skilled nursing care, physical therapy speech therapy and other therapeutic services

39. Part A: Home Health Care Qualifications • You must be hospitalize for at least 3 consecutive days. • Home health services must be initiated within 14 days of discharge from the hospital or skilled nursing home. • Finding of Medical Necessity and prescribed by physician.

40. Part A: Home Health Care • Qualifications • Patient is receiving intermittent skilled nursing care, physical therapy or speech therapy. • Patient is confined to their home. • Care is not primarily custodial.

41. Part A: Home Health Services Cover • Part-time or intermittent skilled nursing care • Part-time or intermittent home health aide services • Physical therapy, speech therapy, occupational therapy • Medicare Social Services • Durable medical equipment has a 20% coinsurance

42. Part A: Home Health Care Benefits • The first 100 home health visits are financed under Part A as post institutional home health services. • If home health not initiated within 14 days benefits are covered under Part B.

43. Part A: Home Health Care Benefits • If all 100 visits are exhausted under Part A then Part B finances home health care visits. • If you do not have a qualifying hospital stay then all home health care is financed by Part B without a visit limit.

44. Custodial Care • Medicare will NOT cover care in a skilled nursing facility or pay home health benefits if the care is primarily custodial - as defined by Medicare

45. Part A: Hospice Care • Medicare pays for hospice care if you are terminally ill with a life expectancy of 6 months or less and you choose to receive it, instead of the standard Medicare benefits for your illness. • If you choose hospice care and require treatment for an illness other than a terminal condition, standard Medicare benefits apply.

46. Part A:Hospice Care • 100% Medicare payments for: • Physicians services • Nursing care • Medical appliances and supplies • Physical, occupational and speech therapy • Dietary and social counseling • Home health aide and homemaker services • Unlimited benefit period.

47. Part A: Hospice Care • Nearly 100% Medicare payments for: • Prescription drugs for pain and symptom relief (5% but not to exceed $5 for each prescription) • Respite care for care givers (cost of about $5 per day)

48. MEDICARE BENEFITS PART B

49. Part B Benefits • Helps pay doctor bills and outpatient hospital care. • The monthly premium is $54.00, deducted from your Social Security, or Civil Service Retirement check. • If not receiving checks, they pay the premium directly to the Government usually on a quarterly basis.

50. Part B: Covered Services • Doctor’s services • Outpatient hospital services • Ambulance services • Durable medical equipment • Lab, X-ray and radiation therapy • Other health-related services