2004 REACH National Medicare Training Program

1. 2004 REACH National Medicare Training Program Speaker Name Group Name Date

2. All About Medicare in 2004Module 1

3. Session Topics • Medicare overview • Original Medicare Plan • Medicare Part A • Medicare Part B • Medicare Advantage plans • Formerly Medicare + Choice plans • Medicare Savings Programs • Key concepts MMA

4. Session Topics • Medicare overview • Original Medicare Plan • Medicare Part A • Medicare Part B • Medicare Advantage plans • Medicare Savings Plans • Key concepts

5. Overview CMS(Centers for Medicare & Medicaid Services) • Federal agency within HHS • Administers Medicare, Medicaid, SCHIP • Spends over $360 billion a year • Establishes policies for paying health care providers • Conducts research • Assesses quality

6. Overview Medicare • A health insurance program for • People 65 years of age and older • Some people with disabilities • People with ESRD • Administered by CMS • Enrollment handled by SSA or RRB • Prescription drug coverage

7. Overview Prescription Drug Coverage MMA • Medicare-approved drug discount card • Prescription drug benefit in 2006 • Medicare Advantage program

8. Overview Applying for Medicare • Apply 3 months before age 65 • Need not be retired • Automatically enrolled if receiving Social Security or Railroad Retirement Benefits

9. Overview Medicare Health Plan Choices • Original Medicare Plan • Medicare Advantage plans • Medicare Managed Care plans • Some have POS option • Medicare Preferred Provide Organization plans • Medicare Private Fee-for-Service plans • Medicare Specialty plans

10. Overview Some Interesting Statistics • 2002 • Medicare paid 247 billion dollars • 2003 • Over 41 million persons in Medicare • 2030 • Projected 70.5 million persons over 65 • Almost double in only 30 years

11. Session Topics • Medicare overview • Original Medicare Plan • Medicare Part A • Medicare Part B • Medicare Advantage plans • Medicare Savings Programs • Key concepts

12. Medicare has two parts Part A Hospital Insurance Part B Medical Insurance Original Medicare Medicare

13. Original Medicare Paying for Medicare Part A • Most people receive Part A premium free • People with < 10 years of Medicare-covered employment will pay a Part A premium • For information, call SSA • 1-800-772-1213 • 1-800-325-0778 for TTY users

14. Original Medicare Enrolling in Medicare Part B • Initial Enrollment Period • 7 months beginning 3 months before age 65 • General Enrollment Period • 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 • You carry this increase for the rest of your life • Limited exceptions

15. Original Medicare Enrolling in Medicare Part B • Special Enrollment Period • Sign up within 8 months of the end of employer or union group health plan coverage • No increased premium • For questions, or to enroll, call SSA or RRB

16. Original Medicare Paying for Medicare Part B • You pay • Monthly Medicare Part B premium • $66.60 in 2004 • $100 per year deductible • 20% coinsurance for most services • Some co-payments • Some programs may help

17. Original Medicare Paying the Part B Premium • Taken out of your monthly payment • Social Security • Railroad Retirement • Office of Personnel Management (OPM) • For information about premiums • Call SSA, RRB or OPM • May be billed every 3 months • Medicare Easy Pay

18. Original Medicare The Original Medicare Plan • Go to any provider that accepts Medicare • Part A is premium free for most people • You pay Medicare Part B premium • You pay deductibles • You pay coinsurance

19. Original Medicare Your Medicare Card(front) Jane Doe

20. Original Medicare Your Medicare Card(back)

21. Original Medicare Medicare Claims Contractors • Medicare Carrier • Durable Medical Equipment Regional Carrier • Fiscal Intermediary • Regional Home Health Intermediary

22. Original Medicare Other Insurance • Employee coverage • Retiree coverage • Medigap insurance (Medicare Supplement Insurance)

23. Original Medicare Medigap • Fills in gaps in the Original Medicare plan • Must follow federal and state laws • Ten standardized Medigap plans (A-J) in most states • Not Massachusetts, Minnesota, or Wisconsin • May get little benefit from Medigap if in Medicare Advantage plan • Will be changes in 2006 MMA

24. Original Medicare Buying Medigap • Company must sell you a Medigap policy • Within 6 months of when you turn 65 and are enrolled in Part B • If you lose certain kinds of health coverage through no fault of your own • If you leave your Medicare Advantage plan • Under certain circumstances

25. Original Medicare Your Medigap Rights • Insurance company cannot • Deny you coverage • Place conditions on your policy • Charge you more because of health problems • Different rules for those < 65 • You may buy a policy any time the company will sell you one

26. Introducing Ben… Hi! I’m Ben E. Ficiary. You can call me Ben. But, I don’t like the nickname Benny.

27. What does Ben know…. Which government agency is directly responsible for administering the Medicare program? • Social Security Administration • Department of Health & Human Services • Centers for Medicare & Medicaid Services • Centersfor Disease Control

28. Ben says… C. Centers for Medicare & Medicaid Services

29. Session Topics • Medicare overview • Original Medicare Plan • Medicare Part A • Medicare Part B • Medicare Advantage plans • Medicare Savings Programs • Key concepts

30. Part A Medicare Part A Helps Pay for • Hospital stays • Skilled nursing facility (SNF) care • Home health care • Hospice care • Blood • For information, call 1-800-MEDICARE

31. Part A 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

32. Part A A Benefit Period • Medicare’s measure of hospital and SNF services • Begins day admitted to hospital • Ends when you have not received care in a hospital or SNF for 60 days in a row • You pay deductible for each benefit period • No limit to the number of benefit periods

33. Part A Paying for Hospital Stays • For each benefit period in 2004 you pay • A total of $876 for a hospital stay of 1-60 days • $219 per day for days 61-90 • $438 per day for days 91-150 • Part of your 60 Lifetime Reserve Days • All costs for each day beyond 150 days

34. Part A Skilled Nursing Facility Care • Covered in full for the first 20 days • After a minimum 3-day qualifying hospital stay • You pay $109.50 per day for days 21-100 • You pay all costs after 100 days • Does NOT include custodial care

35. Part A Skilled Nursing Facility Care • Must meet all of the following conditions • Requires daily skilled services • Inpatient in a hospital at least 3 consecutive days • Admitted to SNF within 30 days after leaving hospital • Care in SNF is for a condition treated in the hospital • MUST be a Medicare participating SNF

36. Part A 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

37. Part A 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 • HHA must be approved by Medicare

38. Part A Home Health Care • Covered services • Part-time skilled nursing care • Therapy • Occupational • Physical • Speech-language • Some home health aide services • Durable medical equipment

39. Part A Paying for Home Health Care • You pay • Nothing for covered home health care services • 20% of the Medicare-approved amount for covered durable medical equipment

40. Part A Hospice • Special care • People who are terminally ill • Families • If you probably have less than 6 months to live • Certification required for each “period of care” • Two 90-day periods • Unlimited 60-day periods • Hospice must be Medicare-approved

41. Part A 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

42. Part A Paying for Hospice Care • You pay • Copayment up to $5 for outpatient prescription drugs • 5% for inpatient respite care • Amount you pay for respite care can change each year

43. What does Ben know…. The benefit period for a hospital or SNF stay ends the day the beneficiary • Has not received services in a hospital or SNF for 60 days in a row • Is discharged from the hospital or skilled nursing facility • Is released from his or her doctor’s care related to the hospital or skilled nursingfacility stay

44. Ben says… A.Has not received hospital or SNF services for 60 days in a row

45. Ben looks at a case study… Bert was hospitalized for congestive heart failure on April 12, 2004, and was discharged on April 26. He was readmitted to the hospital on May 5, 2004, for an unrelated condition. Is he in a new benefit period? Why or why not?

46. Session Topics • Medicare overview • Original Medicare Plan • Medicare Part A • Medicare Part B • Medicare Advantage plans • Medicare Savings Programs • Key concepts

47. Part B 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

48. Part B Covered Preventive Services • Bone mass measurement • Colorectal cancer screening • Diabetes services and some supplies • Glaucoma testing • Screening mammogram • Pap test/pelvic exam/clinical breast exam • Prostate cancer screening • Vaccination (shots)

49. Part B New Covered Preventive Services MMA • Beginning January 2005 • “Welcome to Medicare” physical • Cardiovascular screening blood tests • Diabetes screening tests

50. Part B Part B Also Helps Pay for • Clinical laboratory services • Home health care • Durable medical equipment (DME) • Outpatient hospital services • Blood • Ambulance service • If other transportation would endanger your health