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Understanding Medicare

Understanding Medicare

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Understanding Medicare

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  1. Understanding Medicare Module 1

  2. Lessons • Medicare Basics • Original Medicare Plan • Medicare Advantage Plans (Part C) and other Medicare plans • Medicare prescription drug coverage (Part D) • Programs for people with limited income and resources

  3. Medicare Basics Module 1: Lesson 1

  4. Medicare BasicsLesson 1 Topics • Medicare overview • Enrollment • Part A • Part B • Medicare plan choices

  5. Medicare • Health insurance for people • Age 65 and older • Under age 65 with certain disabilities • Any age with End-Stage Renal Disease (ESRD) • Administered by • Centers for Medicare & Medicaid Services (CMS) • Enroll through • Social Security Administration (SSA) or • Railroad Retirement Board (RRB)

  6. Applying for Medicare • Apply 3 months before age 65 • Need not be retired • Automatically enrolled if receive Social Security or Railroad Retirement benefits • If don’t already receive benefits, apply 3 months before age 65 • Call SSA at 1-800-772-1213 • TTY users call 1-800-325-0778

  7. Medicare • Medicare has • Part A – Hospital coverage • Part B – Medical coverage • Part C – Medicare Advantage Plans (like HMOs and PPOs) • Part D – Prescription drug coverage

  8. Paying for Medicare Part A • Most people receive Part A premium free • People with less than 10 years of Medicare-covered employment • Can pay a premium to get Part A • For information, call SSA • 1-800-772-1213 • TTY users call 1-800-325-0778

  9. Enrolling in Medicare Part B • Initial Enrollment Period (IEP) • 7 months beginning 3 months before age 65 • General Enrollment Period (GEP) • January 1 through March 31 each year • Coverage effective July 1 • Premium increases 10% for each 12-month period you were eligible but did not enroll • Pay this penalty as long as you have Part B • Limited exceptions

  10. Enrolling in Medicare Part B • Special Enrollment Period • Sign up within 8 months of the end of employer or union health plan coverage • No increased premium • For questions or to enroll • Call SSA or RRB

  11. Paying for Medicare Part B • Monthly Medicare Part B premium • 2006 • Most people pay $88.50 • 2007 • Most people pay $93.50 • Some with higher incomes pay more • Some programs may help

  12. Paying the Part B Premium • Taken out of your monthly payment • Social Security • Railroad Retirement • Federal Government retirement • For information about premiums • Call SSA or RRB • Office of Personnel Management if a retired Federal employee • May be billed every 3 months • Medicare Easy Pay

  13. Part A Helps Pay for • Hospital inpatient care • Skilled nursing facility (SNF) care • Home health care • Hospice care • Blood

  14. Hospital Stays • Covered services • Semi-private room • Meals • General nursing • Other hospital services and supplies • Includes care in critical access hospitals • 190 days in a lifetime for inpatient mental health care

  15. Skilled Nursing Facility Care • Must meet all of the following conditions • Require daily skilled services • Hospital inpatient at least 3 consecutive days • Admitted to SNF within 30 days after leaving hospital • Care is for a condition treated in the hospital • MUST be Medicare participating SNF

  16. Skilled Nursing Facility Coverage • Semi-private room • Meals • Skilled nursing care • Physical, occupational, and speech-language therapy • Medical social services • Medications, medical supplies/equipment • Ambulance transportation • Dietary counseling

  17. Home Health Care • Covered services • Part-time skilled nursing care • Therapy • Occupational • Physical • Speech-language • Some home health aide services • Durable medical equipment

  18. Home Health Care • For as long as you are eligible • Limited hours per day • Limited days per week • Four conditions • Doctor must make a plan for your care at home • Must need specific skilled services • Must be homebound • Home health agency must be Medicare-approved

  19. Hospice • Special care for terminally ill • And family • If you likely have less than 6 months to live • Certification required for each “period of care” • Two 90-day periods • Unlimited 60-day periods • Hospice provider must be Medicare-approved

  20. Covered Hospice Services • Medical equipment and supplies • Drugs for symptom control and pain relief • Respite care in a Medicare-certified facility • Up to 5 days each time • No limit to number of times • Home health aide and homemaker services • Social worker services • Dietary counseling • Grief counseling

  21. Part B Helps Pay for • Doctors’ services • Outpatient medical and surgical services and supplies • Diagnostic tests • Outpatient therapy • Outpatient mental health services • Some preventive health care services • Other medical services

  22. “Welcome to Medicare” physical exam Bone mass measurement Cardiovascular screenings Colorectal cancer screenings Diabetes screenings Glaucoma tests Mammograms (screening) Pap test/pelvic exam/ clinical breast exam Prostate cancer screening Flu shots Pneumococcal shots Hepatitis B shots Smoking cessation Covered Preventive Services

  23. Part B Also Helps Pay for • Clinical laboratory tests • Home health services • Durable medical equipment • Outpatient hospital services • Blood • Ambulance service • If other transportation would endanger your health

  24. Medicare Plan Choices • Original Medicare Plan • Medicare Advantage Plans • Other Medicare plans • Medicare drug plans • Medicare Prescription Drug Plans • Medicare Advantage Plans and other Medicare plans with prescription drug coverage

  25. Original Medicare Plan Module 1: Lesson 2

  26. Original Medicare PlanLesson 2 Topics • What it is and how it works • Your costs in Original Medicare Plan • Assignment • Medigap (Medicare Supplement Insurance)

  27. Original Medicare Plan • Red, white, and blue Medicare card • Part A and/or Part B • Go to any provider that accepts Medicare • You pay • Part B premium • Part A free for most people • Deductibles • Coinsurance or copayments

  28. Medicare Card (front) Jane Doe

  29. Medicare Card (back)

  30. Medicare Claims Contractors • Fiscal Intermediary (FI) • Regional Home Health Intermediary (RHHI) • Medicare Carrier • Durable Medical Equipment Regional Carrier (DMERC) • Medicare Administrative Contractors (MAC)

  31. Original Medicare Plan—Part A • Charges based on “benefit period” • Inpatient hospital care and SNF services • Begins day admitted to hospital • Ends when no care received in a hospital or SNF for 60 days in a row • You pay deductible for each benefit period • No limit to number of benefit periods

  32. Paying for Hospital Stays • Each benefit period in 2006 you pay • Inpatient hospital stay of 1 – 60 days • $952 total • Days 61 – 90 • $238 per day • Days 91 – 150 • $476 per day • 60 Lifetime Reserve Days • All costs for each day beyond 150 days

  33. Paying for Hospital Stays • Each benefit period in 2007 you pay • Inpatient hospital stay of 1 – 60 days • $992 total • Days 61 – 90 • $248 per day • Days 91 – 150 • $496 per day • 60 Lifetime Reserve Days • All costs for each day beyond 150 days

  34. Skilled Nursing Facility Care • Each benefit period in 2006 you pay • Days 1 – 20 • $0 • Days 21 – 100 • $119 per day in 2006 • $124 in 2007 • All costs after 100 days • Must meet requirements for Medicare-covered stay • Does NOT include custodial care

  35. Paying for Home Health Care • In the Original Medicare Plan you pay • Nothing for covered home health care services • 20% of the Medicare-approved amount for covered durable medical equipment

  36. Paying for Hospice Care • In the Original Medicare Plan you pay • Up to $5 for prescription drugs • 5% for inpatient respite care • Amount can change each year

  37. Paying for Part B • In the Original Medicare Plan you pay • Monthly Part B premium • $88.50 in 2006 • $93.50 in 2007 • Yearly deductible • $124 in 2006 • $131 in 2007 • 20% coinsurance for most services • Some copayments • Some programs may help

  38. Assignment • Agreement between you, doctor, and Medicare • Applies to Original Medicare Part B claims • Providers who accept assignment • Can’t try to collect more than Medicare deductible and coinsurance amounts • Providers who don’t accept assignment • May charge more than Medicare-approved amount • Limit of 15% more for most services • Doesn’t apply to supplies • May ask you to pay entire charge at time of service

  39. Assignment • In some cases, providers must accept assignment • Some examples • Medicare Part B-covered prescription drugs • Ambulance providers • Doctors/providers generally have to file claim • May have to file own claim for Part B-covered drugs or supplies • If supplier or pharmacy not enrolled in Medicare

  40. Private Contracts • Agreement between you and doctor • Original Medicare Plan will not pay • Medigap will not pay • Other Medicare plans will not pay • You will pay charges • No claim should be submitted • Cannot be asked to sign in an emergency

  41. Therapy Limits • $1,740 cap • Effective January 1, 2006 • Combined physical therapy and speech-language pathology services • Separate cap for occupational therapy • Exceptions allowed • If medically necessary • Certain diagnoses get automatic exception • Some situations justify automatic exception

  42. What Is Medigap? • Health insurance policies • Sold by private insurance companies • Follow Federal and state laws that protect you • Must say “Medicare Supplement Insurance” • Cover “gaps” in Original Medicare Plan • 12 standardized policies, plans A – L • Except in Massachusetts, Minnesota, Wisconsin • Costs may vary • By plan • By company • Where you live

  43. How Medigap Works • Only works with Original Medicare • Don’t need Medigap policy in • Medicare Advantage Plan • Other Medicare plans • Can go to any doctor, hospital, or provider that accepts Medicare • Except with a Medigap SELECT policy • You pay a monthly premium

  44. Medicare Advantage Plans and Other Medicare Plans Module 1: Lesson 3

  45. Medicare Advantage PlansLesson 3 Topics • What are Medicare Advantage Plans and other Medicare plans • Who can join • How plans work • Joining and switching plans

  46. What Are Medicare Advantage Plans? • Health plan options approved by Medicare • Run by private companies • Part of the Medicare program • Sometimes called “Part C”

  47. Medicare Advantage Plans • Medicare Health Maintenance Organization (HMO) • Medicare Preferred Provider Organization (PPO) • Medicare Private Fee-for-Service (PFFS) • Medicare Special Needs Plans (SNPs) • Medicare Medical Savings Account (MSA)

  48. Other Medicare Plans • Medicare Cost Plans • Demonstrations/Pilot Programs • Programs of All-inclusive Care for the Elderly (PACE)

  49. Who Can Join? • Eligibility requirements • Live in plan’s service area • Have Medicare Part A • Have Medicare Part B • Not have ESRD at time of enrollment • Some exceptions

  50. How Do Medicare Advantage Plans Work? • Generally get all Medicare-covered services through the plan • Can include prescription drug coverage • May have to see certain doctors or go to certain hospitals to get care • Benefits and cost-sharing may be different from those in Original Medicare Plan