Medicare & the Medicare Modernization Act of 2003

1. Medicare & the Medicare Modernization Act of 2003 Norma Lanier, State Outreach Coordinator First Coast Service Options, Inc. July 12, 2005

2. Today’s Discussion • Review of Medicare basics • Medicare changes in 2005 and 2006 • Preventive benefits covered by Part B • Prescription Drug Benefit • Medicare rights and protections • Alzheimer’s and Medicare • Program Evaluation

3. First, the Basic Facts

4. Medicare • A health insurance program for • People 65 years of age and older • Some people with disabilities • People with ESRD • Administered by CMS nationally • Administered by private contractors locally

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

6. Original Medicare The Original Medicare Plan • You may 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

7. Medicare Part A Benefits • Hospital stays • Skilled nursing facility (SNF) care • Home health care • Hospice care • Blood

8. 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

9. Part A Paying for Hospital Stays • For each benefit period in 2005 you pay • $912 deductible for a hospital stay of 1-60 days • $228 per day for days 61-90 • $456 per day for days 91-150 • Part of your 60 Lifetime Reserve Days • All costs for each day beyond 150 days

10. Part A Skilled Nursing Facility Care • Covered in full for the first 20 days • After a minimum 3-day qualifying hospital stay • You pay $114 per day for days 21-100 • You pay all costs after 100 days • Does NOT include custodial care

11. 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

12. 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

13. 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

14. 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

15. Part A Hospice • Special care • People who are terminally ill • Families • If a person has 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

16. 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

17. Part B Benefits • 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

18. 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 year you were eligible but did not enroll • You carry this increase for the rest of your life

19. 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 the Social Security Administration or Railroad Retirement Benefit

20. 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)

21. Medigap • Fills in gaps in the Original Medicare plan • Must follow federal and state laws • Standardized Plans A-J in most states • Except Minnesota, Massachusetts, Wisconsin • Don’t need Medigap if in Medicare Advantage • See Guide to Health Insurance for People with Medicare

22. Let’s talk about more changes in Medicare…

23. What We Heard • People with Medicare want • More choices • Better benefits • Health care delivery options • Improved access to care • Especially in rural areas

24. 2004 Drug discount card Medicare Advantage 2006 Prescription drug plans Two new Medigap policies Medicare Modernization Actof 2003 (MMA) 2005 • New preventive services • Part B deductible $110-based on expenditures in future

25. New Covered Preventive Services MMA Beginning January 2005 • “Welcome to Medicare” physical • Initial physical exam • Referral for screening and other preventive services • Cardiovascular screening blood tests • Screening blood tests for cholesterol and other lipids or triglyceride levels • Diabetes screening tests • Fasting plasma glucose test • Other tests appropriate for persons at high risk

26. Medicare Prescription Drug Plans • Available January 2006 • Offered through private prescription drug plans (PDPs) • Can be offered by Medicare Advantage plans

27. Eligibility and Enrollment • Must be entitled to Part A and/or enrolled in Part B • Enrollment is voluntary • Increased premiums for people who wait • 1 percent of the base premium for each month you don’t enroll • After May 15, 2006 • Exception for those covered under other comparable insurance

28. Why Join a Plan? • Medical practice relies on new drug therapies to treat chronic conditions • Out-of-pocket spending on drugs has increased • Most people need or will need prescription drugs to stay healthy • Medicare insurance coverage for prescription drugs will protect from high out-of-pocket costs • For most people, joining when first eligible means paying the lowest monthly premiums

29. Enrolling in a Plan People with Medicare can: • Enroll directly with the plan • Have a personal representative enroll them • Ask others to help them enroll

30. When to Enroll • Join between November 15, 2005, and December 31, 2006 • Coverage will begin on January 1, 2006 • Join between January 1, 2006, and May 15, 2006 • Coverage will begin the first day of the month after the month joined

31. Medicare Prescription Drug Coverage • Coverage begins January 1, 2006 • Available for all people with Medicare • Provided through: • Private prescription drug plans • Medicare health plans • Some employers and unions for retirees

32. What it Costs…How it Works • Pay a premium of about $37 each month • In addition to Part B premium • Enhanced benefit may cost more • Pay a yearly deductible up to $250 • Pay part of the cost of covered prescription drugs

33. How it Works in 2006

34. Lower-Income Assistance • People with limited resources: • Get extra help with their Medicare drug plan cost • Lowest incomes: • Pay no premiums or deductibles • Pay small or no copayments • People with slightly higher incomes: • Pay reduced deductible • Pay a little bit more out of pocket.

35. To Get Help Paying the Cost of Prescription Drug Plans • Person with Medicare must: • Reside in the United States • Meet the income and resource requirements of the subsidy program • Be enrolled in Medicare

36. To Get This Help • Person does not have to do anything • If currently receiving benefits from both Medicaid and Medicare or • Receiving Supplemental Security Income benefits and Medicare • Information will come in the mail from Medicare • Explaining eligibility for this coverage, and • What he/she should do this fall to enroll in a Medicare plan that offers prescription drug coverage

37. To Get This Help • Person with Medicare must have • Annual income less than $14,355 (single) • Annual income less than $19,245 (married) AND • Limited resources • Application will come from Social Security Administration (SSA) • Mail completed application to SSA • For additional information, contact the SSA at 1-800-772-1213

38. MMA Medicare Advantage Plans Another Way to Get Your Medicare Benefits

39. Medicare Advantage Plans • New name for Medicare+Choice plans • Medicare managed care plans • Preferred Provider Organization plans (PPOs) • Private-Fee-for-Service plans • Available in some states • Medicare Specialty Plans

40. If you join a Medicare Advantage Plan… • You still have rights and protections • You are still in the Medicare program • You still get all your regular Medicare-covered services • You may be able to get extra benefits • Coverage for extra days in the hospital

41. Overview Medicare Patients’ Rights • Right to • Information about all treatment choices • Participate in treatment decisions • Get easy-to-understand information • Know what costs are paid by Medicare • Know how much you have to pay

42. Overview Other Medicare Rights • Right to • Receive emergency room services • Have your personal and health information kept private • Right to non-discrimination: You cannot be treated unfairly because of race, color, national origin. disability, age, sex, religion

43. Overview Other Medicare Rights • Right to • Know what to do if you have to file an appeal or a grievance (complaint) • An appeal is when • Medicare does not pay • Medicare does not pay enough • You are not given a service • A grievance is about quality of care issues

44. Medicare and Alzheimer’s Medicare beneficiaries diagnosed with Alzheimer’s disease have the same rights and coverage than any other person with Medicare. • Part A covers inpatient mental health services, including room, meals, nursing care and other related services • Part B covers outpatient mental health services, including visits with health professionals such as doctors, clinical psychologists, clinical social workers, and clinical nurse specialists • Part B also covers laboratory services and partial hospitalization

45. For More InformationNational Sources • Visit www.medicare.gov • Call 1-800-MEDICARE (1-800-633-4227) • TTY 1-877-486-2048

46. Please complete the Program Evaluation Form Evaluation Form Thank You!