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Medicare & You

Medicare & You. Presented by: Warren Coble Certified Senior Advisor. Medicare or Medicaid?. Medicaid State program Social Services Needs based benefit depends on income and assets. Medicare Federal program Social Security Earned benefit from working. Choices, Choices, Choices.

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Medicare & You

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  1. Medicare & You Presented by: Warren Coble Certified Senior Advisor

  2. Medicare or Medicaid? • Medicaid • State program • Social Services • Needs based benefit depends on income and assets • Medicare • Federal program • Social Security • Earned benefit from working

  3. Choices, Choices, Choices • Over 300 Different plans available in NC in 2013 • Like everything these days, … such a wide variety. Make personal choice decisions based on: • Coverage needs • Cost you can afford • Convenience of use

  4. Choices, Choices, Choices, cont. • The unknown parts: • How sick are you going to get? • How often will you use it? • How will costs rise in the future? • If we had a crystal ball, we’d know the right decision to make every time. We don’t, so we have to make the best decision now based on the facts we have now.

  5. How Do I Qualify? • 1. Age 65 • 2. Disability for 24 months • 3. End-stage kidney failure • 4. Lou Gehrig’s Disease • Have acquired sufficient work credits (40 quarters = 10 years)

  6. How Do I Qualify, Cont. • Receiving Social Security check? Enrolled automatically & premiums deducted • If not receiving Social Security, must apply up to 3 months ahead & premiums billed

  7. Who Needs It? Individuals turning age 65 who are NOT currently covered by Employer Group Health Plan based on ACTIVE employment

  8. Who Needs It? Cont. • Retiree coverage offered by employer is voluntary on their part and is subject to change – Supreme Court ruling in 03/2008 • COBRA does not count for Medicare enrollment period purposes

  9. Who Needs It? Cont. • Compare employer cost/coverage (premium/deductible/co-pay/oop max) to Medicare cost/coverage • If your cost/coverage are reasonable, better off with employer coverage while working • If high cost ($250 month+) or only partial coverage (high deductibles/co-pays) may be better with Medicare/Supp/Advantage

  10. How Does It Work? • Parts of Medicare • A – Hospital C – Advantage • B - Medical D - Rx • Standardized A & B 1966-2003 • Medicare Modernization Act of 2003 Mandated “Choices” & RX coverage

  11. Medicare Plan ChoicesSee Gold Sheet - Advantage - Medicare C alternative to A & B, may or may not include part D (Managed by private insurance companies) - Original - Medicare A & B usually go together, can add D (Managed by federal government)

  12. Original Medicare See SHIIP Combo Form

  13. Original Medicare • A – Hospital Insurance *Inpatient hospital/nursing home/hospice *Usually no premium (earned by paying Medicare tax while working) *$1184 deductible – per hospital stay Up to 60 days of inpatient coverage (Deductible waived on re-admission within 60 days) *Skilled nursing facility (short term only) – Days 1-20 in full (Special Requirements) - Days 21-100 Medicare pays all but $148.00 day *Hospice – Palliative care, including Rx *Home Health Care

  14. Original Medicare cont. • B – Medical Insurance • Outpatient hospital/physician care/medical equipment • Standard premium $104.90 (2013) (higher for higher incomes) • $147 deductible per calendar year, then 80% Medicare/20% recipient co-pay • Based on “approved” charges

  15. Original Medicare cont. Not Covered By Medicare Or Supplement: • Long term care • Vision or dental care • Hearing aids • Eyeglasses • Private duty nursing

  16. Medicare Part D Plan Types • Stand alone with original Medicare • Included with an advantage plan • Stand alone with an advantage plan

  17. Medicare Part D Standard Plans • See COMBO form • D – Rx prescription drug coverage • Operated by private companies Premium Deductible • 5 Words: Co-Pay Gap Catastrophic

  18. Part D Basics , cont. • 1 – Premium $15.00 - $116.80 • 2 – Deductible $325.00 You pay 100% • 3 – Initial coverage limit $2970.00 Includes deductible $325.00 Co pay period Part D pays 75% up to $1983.75 You pay 25% of $2645.00 ($661.25) • 4 - Coverage gap $3763.75 Discounts: 52.5% brand, 21% generic $4750.00 (deductable + 25 out of pocket % + gap) • 5 - Catastrophic 95/5%

  19. Part D Basics , cont • Annual preview period September 15–October 15 Assistance available to choose appropriate plans • Open enrollment October 15 - December 07 • Changes effective January 1 each year

  20. Medicare Supplements • Work with Original Medicare to fill in “gaps” • Cannot buy but one at a time. • Standardized/Regulated by N. C. Dept. of Insurance • Offered by individual companies • Will not work with Part C/Advantage

  21. Medicare Supplementscont. • Depending on Plan type chosen, designed to pay out of pocket expenses (deductibles, co-insurance, and co-pays) not paid by Medicare • See Plans Chart (SHIIP Combo Form) • Changed June 1, 2010 Gone - Plans E, H, I, J - New M, N 42 Plan “F” companies in North Carolina

  22. Medicare Supplementscont. Pricing method is important!!! • No-age rated • Issue-age-rated • Attained-age-rated • Price ranges from $122.50 - $253.60 for Plan F (most common), 43 plan average is $155.19 Find out company history/stability Discounts can confuse true cost

  23. Medicare Supplementscont. • Guaranteed renewable as long as premium is paid • Can never be cancelled due to health/excess use • Premiums will go up!!!! • Changing plans re-sets the starting age, often resulting in higher premiums

  24. Medicare Supplementscont. Medigap Open Enrollment Period: • Starts 1st day of month you are both age 65 or older and enrolled in Medicare Part B. Continues for 6 months. • Can apply up to 6 months in advance to have timely coverage at 65

  25. Medicare Supplementscont. • During open enrollment, cannot be denied coverage, regardless of health • Some companies apply pre-existing condition limitations up to 6 months • Deferring Medicare/Supplement to keep employer coverage will result in higher Supplement cost later

  26. Advantage Medicare(Alternative To Original Medicare) SEE GOLD SHEET Includes all benefits of regular Medicare • Hospital and medical coverage • Premiums/deductibles/co-pays vary by plan • May include extra benefits Vision, dental, hearing, gym membership • Not standardized • Not regulated by N. C. Dept. of Insurance (CMS) • Usually have a varied maximum out-of-pocket limit

  27. Advantage Medicare, cont. • 4 Basic plan types: • 1. HMO – Health Maintenance Organization (in network) • 2. PPO – Preferred Provider Organization (out of network) • 3. SNP – Special Needs Plans • 4. PFFS – Private Fee for Service

  28. Advantage Medicare, cont. • Inpatient hospital • Per day co-pay • $140.00 - $290.00 per DAY • Surgery usually included in in-patient costs • Usually a limit on # of days you pay • Plans vary on yearly maximum out of pocket

  29. Advantage Medicare, cont. • Skilled nursing facility Extremely varied co-pays Days 1-100 - $0 - $137.50 per day Depends on plan and type Not accepted at all facilities

  30. Advantage Medicare, cont. • Medical/doctor’s services Varied co-pays $10-$35 Primary care physician $10-$50 Specialist Verify your doctor/hospital will accept 30% - 100 % Out of network ! Each plan is different!

  31. Advantage Medicare, cont. • Prescription drug (Rx) • May or may not be included • If not included, cannot buy stand-alone • Usually standard drug plan guidelines

  32. What Will It Cost Me? • Original Medicare - $104.90 (IRMMA) • Supplement – varied, $122.50 - $253.60 average for Plan F $155.19 month • Part D Rx – varied, $15.00 - $116.80 -average $35.00 per month • Advantage – varied, from $0 to $169.80 per month

  33. When Should I Do Something? • See Road To 65 • Initial, General, Special Enrollment periods • IEP – 3 months before, month of, 3 months after 65 • Eligibility date depends on when you sign up • GEP – January – March each year, coverage begins July 1 • SEP – Any time while covered by employer group health plan (cannot be during IEP) • Up to 8 months after employer group terminates

  34. When Should I Do Something? • Check options 4-6 months ahead of age 65. • If keeping employer coverage, check again 2-3 months before leaving employment.

  35. Why Should I Sign Up Now? • If eligible, and you need Medicare, failure to enroll timely can result in delays in coverage and costly premium penalties. • Although Cobra protects your Medigap/Supplement Enrollment period, it does not protect you for a Medicare Special Enrollment Period.

  36. Where Can I Get More Information? • Warren Coble & Associates • SHIIP – 1-800-443-9354 • 1-800-MEDICARE – 1-800-633-4227

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