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Understanding Medicare. Module 1. 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. Medicare Basics. Module 1: Lesson 1.

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Understanding Medicare


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    Presentation Transcript
    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