Welcome to Medicare SHIP Tina Herrero-Backe 11.14.15

1. WelcometoMedicareSHIPTina Herrero-Backe11.14.15 Version 12

2. Topics • When Medicare coverage begins • The four components of Original Medicare • Coordination of Benefits • Special focus on Part D and Immunosuppressants Understanding Medicare

3. When can Medicare begin? • Age: The 1st of the month in which you turn 65 * • Disability: The 25th month you receive disability benefits * • ESRD: The 4th month of dialysis* Understanding Medicare

4. DISABILITY • Medicare begins 24 months after Social Security benefits begin • Exception ALS (Lou Gehrig’s) – Medicare begins the month benefits begin • Eligible for Medicare based on age at 65 ESRD Medicare begins: • 1st day of 4th month of dialysis • Or 1st day of 1st month of home dialysis Medicare ends: • 12 months after the month dialysis stops or • 36 months after the month of the kidney transplant

5. What Does Medicare Cover? Getting Started

6. Part A: Hospital Coverage

7. Part A: Skilled Nursing Facility Getting Started

8. Part B – Medical Insurance • Doctor’s visits • Outpatient medical services • Clinical lab tests • Emergency Department Services • Durable Medical Equipment • Outpatient Chemotherapy Understanding Medicare

9. Part B – Medical Insurance (cont’d) • Some home health services • Kidney dialysis • Mental health care • Preventive services • and more • For a complete list of covered services see pp. 43-66 in 2016 “Medicare and You” Understanding Medicare

10. Part B: Medical Coverage Getting Started

11. Understanding Medicare

12. Medigap Plans • YOUR period of Guaranteed Issue Rights to purchase a Medigap: • The first 6 months you are at least 65 AND have Part B • For 63 days after an Advantage plan or an employer group health plan (including retiree or COBRA coverage) that pays after Medicare pays ends Understanding Medicare

13. Coordination of Benefits • Primary Payers • Secondary Payers • Payers of last resort • ESRD 30-month Coordination Period

14. Medicare Is the Primary Payer If… • Medicare is your only insurance Coordination of Benefits

15. Medicare and Employer Plans

16. Medicareand ESRD

17. Medicare and ESRD

18. ESRD and the 30-Month Coordination Period • If enrollment is based solely on ESRD • Your GHP/employer coverage is the only payer during first 3 months • Medicare is the secondary payer during the 30-month coordination period • Separate coordination period each time enrolled based on ESRD • No 3-month waiting period • New 30-month coordination period if you have GHP coverage 18 Medicare for People With End-Stage Renal Disease 05/01/2015

19. Prescription Drug Coverage Medicare Getting Started

20. Part A: Prescription Drug Coverage • Part A generally pays for all drugs during a covered inpatient stay • Drugs used in hospice care for symptom control and pain relief

21. Part B: Prescription Drug Coverage • Most injectable and infusible drugs given as part of a doctor’s service • Drugs used at home with some durable medical equipment (DME) e.g. nebulizers and infusion pumps • Certain oral anti-cancer • Can cover immunosuppressive drugs under certain conditions

22. Immunosuppressive Drugs

23. Part D Prescription Drug Plans Getting Started

24. Initial Stage Understanding Medicare

25. The Coverage Gap Medicare Prescription Drug Coverage

26. Part D: Which is the best plan? Things to Consider: 1. Plan formularies 2. Preferred v. standard pharmacies 3. Pre-Authorizations 4. Step Therapy Understanding Medicare

27. Medicare’s Plan Finder Open Enrollment October 15 – December 7 Using immunosuppressants to do a 2016 Part D search…. Title

28. Part C: Advantage Plans • Part A and Part B services • Usually includes prescription coverage • The plan may have a monthly premium • May include benefits not usually covered: • Dental, vision, hearing Co-pays for appointments, services, hospital stays, etc. Costs may be higher out of network Medicare Advantage and Other Medicare Health Plans

29. Medicare Savings Programs SPDAP – Maryland Senior Prescription Drug Assistance Program Monthly income limits: $2942 /individual $3982/couple (no asset limit) Benefits: • $40/month towards Part D premium • One extra Part D switch per year Understanding Medicare

30. Healthcare Fraud and Abuse Step 1: Protect Yourself from Medicare Fraud and Abuse Step 2: Detect Medicare Fraud & Abuse Step 3: Report Suspected Medicare Fraud and Abuse SMP: Senior Medicare Patrol Understanding Medicare

31. Useful Websites 1. www.medicare.gov 2. www.insurance.maryland.gov • For Consumers • Medicare Related Information • Annual Premiums for Medicare Supplemental Policies Understanding Medicare

32. Contact Your Local SHIP • State Health Insurance Assistance Program • Free Local Help for People with Medicare Understanding Medicare