New Mexico Aging and Long Term Services Department

1. New Mexico Aging and Long Term Services Department

2. New Mexico Aging and Long Term Services Department • * State Health Insurance Assistance Program • * NM Aging and Disability Resource Center • * Senior Medicare Patrol • * Medicare A, B, D, C • * Medigap • * Low income assistance

3. * Federal partnership • * Counseling • * Education • * Outreach • * Free and Unbiased • * People on Medicare • * Family members • * Caregivers New Mexico State Health Insurance Assistance Program (SHIP)

4. We are here to help The ADRC connects people with resources to maximize personal choice and independence It is the single point of entry for older adults, people with disabilities, their families and the general public to access: * State and Federal benefits *Centennial Care *Community Resources * Community based services New Mexico Aging and Disability Resource Center(ADRC) 1-800-432-2080

5. Services 1. Benefits Counseling – guidance and problem solving for Medicare/Medicaid issues 2. Prescription Drug Assistance Programs 3. Community Services – home health care, caregiver support, adult day programs, legal services, healthcare fraud New Mexico Aging and Disability Resource Center(ADRC) 1-800-432-2080

6. PROTECTDETECTREPORT 1. Protect yourself against Medicare fraud and abuse 2. Keep your RedWhite and Blue Medicare card SAFE Senior Medicare Patrol (SMP)

7. PROTECTDETECTREPORT 3. Review your Medical Summary Notice (MSN) - detect possible errors and make sure you’re billed for the right services 4.Reportpossible fraud to the ADRC 1-800-432-2080 Senior Medicare Patrol (SMP)

8. Examples of Fraud and Abuse * Billing for services and supplies that were not provided * Submitting duplicate claims * Obtaining your Medicare number for “free” services * Improper coding to get a higher payment * Claims for services or supplies that are not medically necessary - excessive x-rays or lab tests Senior Medicare Patrol (SMP)

9. Who is committing this crime? *Physicians/Practitioners *Physician’s employees *Medical equipment suppliers *Billing agencies *Beneficiaries Senior Medicare Patrol (SMP)

10. Protect yourself Do: * Use a journal to keep track of appointments and services * Ask questions – you have a right to know everything about your medical care * Count your pills before leaving the pharmacy Don’t: * Let anyone persuade you to see a doctor for care you don’t need * Accept medical supplies from door-to-door salespeople, Medicare does not make house calls or phone calls Senior Medicare Patrol (SMP)

11. Medicare Enrollment *Is automatic if you already receive a Social Security check *Enroll online or at the SSA office -3 months before you turn 65 - the month you turn 65 - 3 months after you turn 65

12. Medicare

13. Medicare Enrollment *Initial Enrollment Period - 7 months *General Enrollment Period - Jan. 1 through Mar. 31 Coverage begins July 1 * Special Enrollment Period – moving, employer coverage ends, entering or leaving a long term care facility

14. Medicare Part D: Prescription Drugs Part C: Advantage Plan Part A: Hospital Insurance Part B: Medical Insurance

15. Medicare 1. Decide how you want coverage Original Medicare OR Medicare Advantage Part A Part B PartD Part C = A + B + D

16. Medicare 3. Decide if you need supplemental coverage Original Medicare OR Medicare Advantage If you join a Medicare Advantage Plan, you do not need and cannot be sold a Medigap policy Medigap (pays 20%)

17. Part A Hospital Insurance - what it covers 1. Inpatient Hospital stay 2. Inpatient skilled nursing facility 3. Blood 4. Home health care 5. Hospice care

18. Part A Hospital Insurance - what it covers 1. Inpatient Hospital stay - Covers everything administered during your stay in the hospital * once you’ve been admitted: semi-private roommeals general nursing equipment medication supplies

19. Part A Hospital Insurance - what it covers 2. Skilled Nursing Facility- Covers skilled nursing and rehabilitative services and supplies that are medically necessary Hospital stay condition 3 day stay as inpatient Admit within 30 days Ambulance (limited)

20. Part A Hospital Insurance - what it covers 3. Home health care - Covers medically necessary part- time or intermittent skilled nursing care, physical therapy or speech pathology Homebound Approved agency Review every 60 days DME 20%

21. Part A Hospital Insurance - what it covers 4. Hospice Care - Covers medical needs when certified as terminally ill Recertify 6 months Medication for pain Respite care Medical equipment Grief counseling Approved agency

22. Part A Hospital Insurance - what it covers 5. Blood – if you need blood while admitted as inpatient * Free from blood bank * If hospital has to pay You pay for first 3 units You or someone else can donate to replace

23. Part A Cost 1. Deductible = $1340.00 per benefit period (2018) (begins the day you are admitted in a hospital, ends after 60 days) 2. Monthly premium = $0 *If you worked and paid Medicare Taxes for at least 10 years * Call Social Security to determine your monthly premium if you worked less than 10 years

24. Part A Cost 3. Co-pays/co-insurance = a. Hospital stay – first 60 days = $0 days 61-90 = $355.00 per day (2018) b. Skilled Nursing – first 20 days = $0 days 21-100 = $167.50 per day (2018) c. Home healthcare - $0 d. Hospice Care - $0

25. Part B Medical Insurance – what it covers 1. Doctor visits 2. Outpatient surgery and supplies 3. Labs – X-rays, MRI, CT scan, EKG 4. Durable Medical equipment 5. Preventive services

26. Part B Preventive services – what it covers • * Abdominal aortic • aneurysm • * Advanced Care • Planning • * Alcohol misuse • * Bone mass • * Cardiovascular • * Colorectal • * Depression • * Diabetes • * Flu shot • * Glaucoma • * Hepatitis B shot • * Hepatitis C • * HIV • * Lung caner • * Mammogram • * Medical • nutritional therapy • * Obesity • * Pap test and pelvic • exam • * Pneumococcal shot • * Sexually • transmitted • infections • * Tobacco cessation • * Welcome to • Medicare • * Yearly Wellness • visit

27. Part B Cost 1. Deductible = $183.00 (2018) 2. Monthly premium = $134.00 (2018) *You might be eligible to get help paying for the premium with a Medicare Savings Program. 3. Co-pays/co-insurance = 20%

28. Part B Cost * Penalty for late enrollment = premium goes up 10% for each 12 month period; for the life of coverage Example: $134.00 x 10% = 13.40 x 2 years = $26.80 +134.00 = 160.80 total Part B premium after 2 year penalty!

29. Part B Opt out *If covered by an employer plan or spouse *Retiree plans - Review guidelines with benefits administrator *Creditable coverage

30. Medigap Policy AKA Supplemental Insurance *A Medigap policy can be bought to cover your out of pocket expenses with Original Medicare *Some policies will pay for your deductibles, co-payments or coinsurance *Plans are identified by letters *Sold by private insurance companies

31. Part D Eligibility 1. Must have Medicare part A and/or B 2. Must live in the service area 3. Join when your first eligible for Medicare Prescription Drug Insurance - What it covers 1. Lower co-pays for medication 2. Choices of generic or brand name drugs

32. Part D Cost 1. Deductible = up to $405.00 (2018) 2. Monthly Premiums = vary by plan. The national average is $35.02 /month (2018) 3. Co-payments/co-insurance = depend on your prescriptions

33. Part D Cost * Penalty for late enrollment = 1% of the national base premium multiplied by each month you’re not enrolled; for the life of coverage Example: $35.02 x 1% = .35 x 24 months = $8.40 + 35.02 = 43.42 total Part D premium with 2 year penalty!

34. Part C AKA Medicare Advantage Plans Includes Medicare A, B and usually D Eligibility 1. You must have Medicare Part A and B to join a Medicare Advantage Plan 2. You must live in the plan’s service area 3. Cannot have End Stage Renal Disease

35. Part C Cost 1. Annual deductible = each plan is different 2. Monthly premium = Part B premium ($134.00 for 2018) + the monthly premium charged by the health plan 3. Co-pays and co-insurance = depends on the plan you choose *Call your plan for details about the cost on different services*

36. Low Income Programs Social Security Administration (SSA) 1. Extra Help/Low Income Subsidy (LIS) pays Part D deductible, premium and co-pays

37. Is means tested on income and resources. Depending on the percentage of FPL determines the ‘amount’ of extra help a beneficiary will receive. Income guidelines range from 135% to 150% of FPL for any individual or couple: 135% = 100% extra help 140% = 75% extra help 145% = 50% extra help 150% = 25% extra help EXTRA HELP Income Guidelines

38. 100% FPL individual = 1011.67 /month (12140.00 annually) • 100% FPL couple = 1371.67/month (16460.00 annually) • 135% FPL individual = 1365.75 month (16389.00 annually) • 135% FPL Couple = 1851.75/month (22221.00 annually) • 150% FPL Individual = 1517.50/month (18210.00 annually) • 150% FPL Couple = 2057.50/month (24690.00 annually) EXTRA HELP 2018 Income Numbers 48 Contiguous States and DC

39. FULL Extra Help (PART D Premiums, deductibles, copays) • Individual 2018 Resource Limit: 7560.00 • Couple 2018 Resource Limit: 11340.00 • PARTIAL Extra Help (100% premium, but less help with deductibles/copays) • Individual 2018 Resource Limit 12600.00 • Couple Resource Limit 25150.00 EXTRA HELP Individual Resource Limits

40. State of New Mexico Medical Assistance Division 1. QMB - pays Medicare Part A deductible and premium pays Medicare Part B deductible and premium pays co-pay amounts 2. SLMB - pays Medicare Part B premium only 3. QI-1 - pays Medicare Part B premium only Medicare Savings Programs

41. Qualified Medicare Beneficiary (QMB) * Pays Medicare Part B deductible, premium and co-pays *Automatic help with Rx. QMB INCOME LIMIT = 100% FPL 2018 Numbers: Income : Individual = $1011.67 Couple = $1371.67 Resources: Individual = $8780.00 Couple = $13930.00 Qualified Medicare Beneficiary (QMB)

42. 2. Specified Low Income Medicare Beneficiary (SLIMB) * pays Medicare Part B premium * automatic help with Rx INCOME LIMITS SLIMB = greater than 100% FPL up to 120% FPL 2018 NUMBERS: Income: Individual = $1214.00 Couple =$1646.00 Resources: Individual = $8780.00 Couple = $13930.00 Specified Low Income Medicare Beneficiary (SLIMB)

43. Qualified Individual (QI1) * pays Medicare Part B premium * automatic help with Rx Income limit QI1 between 120% and 135% FPL 2018 Numbers: Income: Individual =$1365.75 Couple = $1851.75 Resources: Individual = $8780.00 Couple = $13930.00 Qualified Individual (QI1)

44. Recap • * State Health Insurance Assistance Program • * NM Aging and Disability Resource Center • * Senior Medicare Patrol • * Medicare A, B, D, C • * Medigap • * Low income assistance

45. Questions? Call the ADRC for confidential one-on-one counseling 1-800-432-2080