Welcome to Medicare

1. Welcome to Medicare

2. Jon Langmead Centers for Medicare and Medicaid Services Office of External Affairs Philadelphia Regional Office jon.langmead@cms.hhs.gov 215-861-4174

3. Goals • Learn the basics of Medicare coverage • Discuss critical dates for Prescription Drug Plans and Medicare Advantage Plans • Learn about the Low Income Subsidy • Find out how you or the people you work with can get help with Medicare

4. What is CMS and Medicare?

5. Centers for Medicare and Medicaid Services • Federal Agency - Division of DHHS • www.medicare.gov (for consumers) • www.cms.hhs.gov (for providers) • Estimated 44.8 million enrollees • Over 1 million in Virginia • 2007 Federal Outlays for CMS were 21% of the Federal Budget ($573.3 billion)

6. What Is Medicare? • Health insurance for • People 65 years of age and older • People under age 65 with certain disabilities • People of all ages with End-Stage Renal Disease • Sign-up: Handled by SSA or RRB

7. Medicare Parts A - D Original Medicare

8. Medicare Partners CMS AOA FDA HRSA IHS NIH SAMHSA CDC BOI VDA SMP AOA Senior Connections

9. Where To Go For Help Federal Resources • 1-800-Medicare and Medicare.gov • Social Security (www.ssa.gov) State and Other Resources • Eldercare Locator • BOI • FQHCs • Health Assistance Partnership (www.hapnetwork.org) • Coordination of Benefits Contractor: 800-999-1118 • QIO • MyMedicareCommunity

10. Insurance Cards You May Encounter • Medicare Card (Red, White and Blue) • Medicare Supplement Insurance (Medigap) • Medicare HMO, PFFS, PPO • Medicare Part D Prescription Plan • Employer Retirement Plan • DMAS • TRICARE

11. Medicare Parts A and B

12. Applying for Medicare • Initial Enrollment Period • 8 month period around 65th birthday • Enrollment automatically occurs at 65 if beneficiary is receiving Social Security or Railroad Retirement benefits

13. Exercise 1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare. True False

14. Exercise 1. People are automatically enrolled into Medicare when they turn 65. True False

15. Medicare Part A • Most people don’t pay a monthly premium for Part A • People with less than 10 years of Medicare-covered work • Can still get Part A • Will pay a premium • For information about Part A eligibility • Call Social Security Administration • 1-800-772-1213 • TTY users call 1-800-325-0778

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

17. Benefit Periods • The way that Medicare measures your use of Part A services

18. Paying for Hospital Stays (Part A) • For inpatient stays in 2009 you pay • Days 1 – 60: $1,068 deductible and no co-payment • Days 61 – 90: $267 co-payment per day • Each Day After 90: $534 co-payment per day ( Up to 60 lifetime reserve days) • All costs for each day after Lifetime Reserve Days

19. Paying for Hospice Care (Part A) • For hospice care in 2009 you pay • $0 • A co-payment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management • 5% of Medicare-approved amount for inpatient respite care

20. Paying for Skilled Nursing Facility Stays (Part A) • For skilled nursing facility stays in 2009 you pay: • $0 for the first 20 days in each benefit period • $133.50 per day for days 21 – 100 each benefit period • All costs for each day after day 100 in benefit period

21. Paying for Home Health Care (Part A) • For home health care in 2009 you pay: • $0 • $20% of the approved amount for DME

22. Enrolling in Medicare Part B • You choose whether or not to enroll in Part B • 2009 Monthly premium: $96.40 • Initial Enrollment Period (IEP) • General Enrollment Period (GEP)

23. Part B Enrollment PeriodsExample Marie turned 65 on June 25, 2008. She will have group health coverage from her employer until she stops working on December 31, 2008. Part B enrollment opportunities … 23

24. Paying the Part B Premium Taken out of monthly payments Social Security Railroad retirement Federal government retirement For information about premiums Call SSA, RRB, or Office of Personnel Management If no monthly payments Billed every 3 months Medicare Easy Pay Introduction 24

25. Paying for Part B Services • In Original Medicare you pay • Yearly deductible ($135 in 2009) • 20% coinsurance for most services • 50% for most outpatient mental health • Some copayments • Some programs may help

26. Part B Coverage • 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

27. “Welcome to Medicare” physical exam Abdominal aortic aneurysm screening Bone mass measurement Cardiovascular disease 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

28. A/B Claims Processing • Medicare A/B Claims are handled by Medicare Administrative Contractors (MACs) • Viewing Beneficiary Claims • Quarterly Statements • MyMedicare.gov

29. Medigap • Health insurance policy • Sold by private insurance companies • Must say “Medicare Supplement Insurance” • Covers “gaps” in Original Medicare • Deductibles, coinsurance, copayments • Does not work with Medicare Advantage Plans • Up to 12 standardized plans A – L • Except in Massachusetts, Minnesota, Wisconsin • So you can compare easily

30. Benefits for Medicare Beneficiaries Beneficiaries with both Medicare A and B

31. Benefits for Medicare Beneficiaries Beneficiaries with Medicare A or B

32. Additional Key Points • Travel • Medigap and Original Medicare • Delaying Enrollment in B

33. Key Things to Remember • Part B IEP • Variety of ways to receive coverage

34. Exercise 1. The Centers for Medicaid & Medicaid Services is responsible for enrolling most people in Medicare. • True • False

35. Exercise 2. Most people receive Part A premium free. • True • False

36. Exercise 3. The Part B premium for most people is $96.40 in 2008. • True • False

37. Exercise To be entitled to Medicare, you must be at least 65 years of age and retired. True False

38. Exercise A beneficiary can have both a Part C Plan and still be covered by a Medigap plan or employer plan. True False

39. Exercise Some people can delay enrolling in Part B without paying a penalty. True False

40. Exercise A beneficiary can have both a Medigap plan and a Part D Prescription Drug Plan. True False

41. Medicare Advantage Plans Medicare Part C

42. How Medicare Advantage Plans Work • Usually get all Part A and B services through plan • May have to use the plan’s providers • May get extra benefits • Vision, hearing, dental services • Prescription drug coverage • Still in Medicare program • Get all Part A and Part B services • Have Medicare rights and protections

43. Medicare Advantage Plans • Health Maintenance Organization (HMO) Plans • Some have Point-of-Service option • Preferred Provider Organization (PPO) Plans • Private Fee-for-Service (PFFS) Plans • Special Needs Plans • Medicare Medical Savings Account (MSA) Plans • Since 2007

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

45. Eligibility for Medicare Advantage • Live in plan’s service area • Have Medicare Part A and Part B • Continue to pay Part B premium • May also pay monthly premium to plan • Don’t have ESRD at enrollment • Some exceptions

46. Enrolling in Medicare Advantage Plans • Generally done during the Initial, Annual, or Open Enrollment Periods • Apply directly with the plan, through a broker or agent, or through Medicare

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48. Medicare Prescription Drug Plans Medicare Part D

49. Medicare Prescription Drug Coverage • Coverage began January 1, 2006 • All people with Medicare can join a plan • Provided through • Medicare Prescription Drug Plans • Medicare Advantage and other Medicare plans • Some employers and unions

50. Specifics of Part D • Definition of Part D covered drugs • Available only by prescription • FDA approved drugs • Used for a medically accepted indication • Includes supplies associated with injection of insulin • Syringes, needles, alcohol swabs, gauze covered • Test strips and lancets not covered as available under Part B • Part D does not cover drugs already covered under Part A or B (even if the person does not have Part A or Part B)