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Norvax University Online Training: Medicare 101: Introduction to Medicare. Agenda. Medicare Eligibility & Enrollment Overview of Medicare Coverage Options Benefits & Cost of Original Medicare Medicaid Medicare Resources for More Information. What is Medicare?.
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Norvax University Online Training: Medicare 101: Introduction to Medicare
Agenda • Medicare Eligibility & Enrollment • Overview of Medicare Coverage Options • Benefits & Cost of Original Medicare • Medicaid • Medicare Resources for More Information
What is Medicare? • Medicare is a federal program which provides health insurance benefits for people who meet one of 3 categories: • 65 or Older • Those with End Stage Renal Disease (ESRD) • Those under 65 with certain disabilities • Administration • Centers for Medicare & Medicaid Services (CMS) • CMS is an agency within the Department of Health and Human Services (HHS)
What is Medicare? • The Social Security Act established both the Medicare and Medicaid programs in 1965. • Original Medicare is a “fee-for-service” system, where a Medicare beneficiary is charged a fee for each health care service/supply received. • Beneficiaries can see any provider that is approved by the Medicare program.
Four Parts of Medicare Part A Hospital Insurance Part B Medical Insurance Part D Medicare Prescription Drug Coverage Part C Medicare Advantage
Enrollment • Automatic for those receiving • Social Security benefits • Railroad Retirement Board benefits • Initial Enrollment Period Package • Mailed 3 months before • 25th month of disability benefits • Age 65
Enrolling in Medicare • Some people need to sign up • Those not automatically enrolled • Enroll through Social Security • Railroad Retirement Board for railroad retirees • Apply 3 months before age 65 • Do not have to be retired
Enrollment Periods • Initial Enrollment Period (IEP) • Begins 3 months prior to the month of turning age 65 and continues through the end of the third month after • General Enrollment Period (GEP) • Allows individuals who did not enroll in Part B during the IEP to enroll between January 1 – March 31 of each year for a July 1 effective date • Special Enrollment Period (SEP) • Allows individuals who delayed enrolling in Part B because they were receiving benefits through an employer as an active employee (or dependent of someone who is); SEP runs eight months from the time of retirement or loss of coverage
Medicare Card • Keep it and accept Medicare Parts A and B • Return it and refuse Part B • Follow instructions on back of card FRONT BACK
Overview of Medicare Options • The choice of options to be considered are: • Premium Cost • Cost Sharing • Network Providers • Prescription Drug Coverage • Value-Added Benefits
Medicare Part A (Hospital Insurance) Premium • Most people receive Part A premium free • If you paid FICA taxes for at least 10 years • If you paid FICA taxes less than 10 years • Can pay a premium to get Part A • 30 or more quarters - $248/month in 2012 • Less than 30 quarters - $451/month in 2012 • May receive penalty if not bought when first eligible
Medicare Part A Coverage • Inpatient Hospital Stays • Semi-private room, meals, general nursing, and other hospital services and supplies • Care in critical access hospitals and inpatient rehabilitation facilities • Inpatient mental health care in psychiatric hospital (lifetime 190-day limit) • Generally covers all drugs provided during an inpatient stay received as part of treatment • Skilled Nursing Facility Care • Semi-private room, meals, skilled nursing and rehabilitation services, and other services and supplies
Medicare Part A Coverage • Home Health Care Services • Can include part-time or intermittent skilled care • Physical therapy, speech-language pathology, continuing need for occupational therapy • Some home health aide services, medical social services, medical supplies • Hospice Care • For terminally ill and includes drugs, medical care, and support services froma Medicare-approved hospice • Blood • Received during inpatient care
Part A Cost Sharing • Inpatient Hospitalization • Deductible for 2012: $1,156 (first 60 days) • Day 61-90: $289/day • After 90 days using lifetime reserve days (60 days): $578/day • After lifetime reserve days are used: No Coverage • Skilled Nursing Facility • First 20 days: No cost sharing • Day 21-100: $144.50/day • After 100 days: No Coverage
Part A Cost Sharing • Home Health Care • $0 for Skilled HHC Services • 20% for Durable Medical Equipment (DME) • Hospice Care • 5% for inpatient respite care • Room and board, in some cases • $5 for prescription drugs • Blood • 100% first 3 pints • 20% for additional pints
Paying the Part B Premium • Deducted monthly from • Social Security • Railroad Retirement Benefit • Federal retirement payments • If not deducted • Billed every 3 months • Medicare Easy Pay to deduct from bank account • Contact SSA, RRB, or OPM about premiums
Part B Late Enrollment Penalty • Penalty for not signing up when first eligible • 10% more for each 12-month period • May have penalty as long as you have Part B • Sign up during a Special Enrollment Period (SEP) • Usually no penalty
Part B & Employer or Union Coverage • May affect your Part B enrollment rights • You may want to delay enrolling in Part B if: • You have employer or union coverage and • You or your spouse, or family member if you are disabled, is still working • See how your insurance works with Medicare • Contact your employer/union benefits administrator
When Employer/Union Coverage Ends • When your employment ends • You may get a chance to elect COBRA • You may get a Special Enrollment Period • Sign up for Part B without a 10% penalty
Paying for Part B Services • In Original Medicare you pay • Yearly deductible of $140 in 2012 • 20% coinsurance for most services • Some programs may help pay these costs
Medicare Part B Coverage • Doctors’ Services • Medically necessary services (includes outpatient and some doctor services you receive when an inpatient) or covered preventive services • Except for certain preventive services, you pay 20% of the Medicare-approved amount (if the doctor accepts assignment) and the Part B deductible applies • Outpatient Medical & Surgical Services and Supplies • For approved procedures (like X-rays, a cast, or stitches) • You pay 20% of the Medicare-approved amount for the doctor’s services (if the doctor accepts assignment) • You also pay a copayment for each service and the Part B deductible applies
Medicare Part B Coverage • Home Health Care Services • Medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, occupational therapy • Medically necessary part-time or intermittent home health aide services, medical social services, and medical supplies • Durable medical equipment and an osteoporosis drug are also covered • You pay nothing for covered services • Durable Medical Equipment • Items such as oxygen, equipment and supplies, wheelchairs, walkers, and hospital beds for you in the home. Some items must be rented. • You pay 20% of the Medicare-approved amount and Part B deductible applies
Medicare Part B Coverage • Other Services (including but not limited to) • Medically necessary medical services and supplies, such as: • Clinical laboratory services • Diabetes supplies • Kidney dialysis services and supplies • Mental health care • Limited outpatient prescription drugs • Diagnostic X-rays, MRIs, CT scans, and EKGs • Transplants • Costs vary
Part B Covered Preventive Services • One-time “Welcome to Medicare” physical exam • Annual wellness visit after 12 mos. enrolled in Part B • Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1 • Abdominal aortic aneurysm screening – one time, with referral • Bone mass measurement – every 24 months for certain conditions • Cardiovascular screening blood tests – every five years for all persons • Colorectal cancer screening – four different tests, vary in frequency • Diabetes screenings – up to two per year for those with risk factors • EKG screening – one time, with referral • Glaucoma testing – once per year for those at high risk • HIV screening • Mammogram – annual screening for most women • Pap test and pelvic exam – every 24 months • Prostate cancer screening – every 12 months for men over age 50 • Smoking cessation counseling
NOT Covered by Part A and Part B • Acupuncture • Dental care/dentures • Cosmetic surgery • Custodial care • Health care while traveling outside the U.S. • Hearing aids • Orthopedic shoes • Outpatient prescription drugs (covered under Part D) • Routine foot care • Routine eye care and eyeglasses • Vaccines, except as previous listed (covered under Part D)
What is Original Medicare? • Health care option run by the Federal government • Provides Part A and/or Part B coverage • See any doctor that accepts Medicare • Beneficiary pays: • Part B premium (Part A free for most people) • Deductibles, coinsurance or copayments • Can join a Part D plan to add drug coverage • Can join a Medigap plan to pick up the “gaps”
Assignment • Doctor, provider, or supplier accepts assignment • Signed an agreement with Medicare • Or is required by law • Accept the Medicare-approved amount • As full payment for covered services • Only charge Medicare deductible/coinsurance amount • Most accept assignment • They submit your claim to Medicare directly
Supplier and Assignment • Suppliers that don’t accept assignment • May charge you more • The limiting charge is 15% more • May have to pay entire charge at time of service • Providers sometimes must accept assignment • Medicare Part B-covered prescription drugs • Ambulance suppliers
Medicaid • Federal-state health insuranceprogram • For people with limited income and resources • Certain people with disabilities • Most costs covered for Medicare/Medicaid • Called “dual eligible” • Eligibility determined by state • Application process and benefits vary • Office names vary
Medicare Savings Programs • Help from Medicaid paying Medicare costs • For people with limited income and resources • Programs include • Qualified Medicare Beneficiary (QMB) • Specified Low-Income Medicare Beneficiary (SLMB) • Qualifying Individual (QI) • Qualified Disabled & Working Individuals (QDWI) • See state websites for moreinformation
Upcoming Webinar • Medicare Advantage • September 6th 12:00pm CST *Annual Election Period (AEP) is October 15th – December 7th