MEDICARE & YOU

1. MEDICARE & YOU Fitting the Pieces Together Know us before you need us

2. INTRODUCTION Sue Brown and Leda Welke, Elder Benefit Specialists Aging and Disability Resource Center 721 Oxford Avenue, Room 1130 Eau Claire WI 54703 Email us: adrc@co.eau-claire.wi.us Call us:  715-839-4735, Toll free  1-888-338-4636   tty: use Relay (711) Web site: http://www.co.eau-claire.wi.us (click on ADRC link on home page) *If a page number follows a particular section in this Power Point, it is referring to corresponding information in the Medicare & You 2014 book

3. MEDICARE • The federal government healthcare coverage for people 65 and older, or, those (if under 65) found disabled by the Social Security Administration. Eligibility does NOT depend on income or assets. • Medicare year is from January thru December • If you are already receiving a Social Security benefit prior to age 65, you will receive a Medicare card by mail with your Part A & Part B start date. You MUST notify Social Security if you do NOT want Part B starting at that time. (P. 19) • If you are not receiving a Social Security benefit, YOU must contact Social Security before your 65th birthday. You can enroll on-line. (P. 20)

4. MEDICARE PART A-HOSPITAL/INPATIENT • Inpatient hospitalization, skilled nursing facility, inpatient psychiatric care (190 day), hospice, some home healthcare • Premium free if you have enough Social Security work quarters (10 years). If not, you will be assessed a premium (p. 26) • Deductible of $1,216.00 (2014) per benefit period (60 days) • Initial Enrollment period: 3 months before, the month of, and 3 months after turning 65 (P. 21)

5. MEDICARE PART B-MEDICAL/OUTPATIENT Doctor visits, Outpatient services, and services Part A does not cover Enrollment periods: (P. 21) • Initial – 3 months before, the month of, 3 months after turning 65 • Special enrollment period - when group coverage thru employment ends • General - Between January 1 and March 31 each year; coverage begins July 1

6. MEDICARE PART B • May have late enrollment penalty if you do not sign up when first eligible AND do not have other creditable coverage. • Monthly premium: $104.90 (2014) • Annual deductible : $147.00 (2014) • Pays approximately 80% of approved amount for almost all reasonable & necessary medical services

7. MEDICARE PART B Premiums higher for persons with income over $85,000/single $170,000/joint Premium deducted from Social Security benefit or, if not receiving a benefit yet, beneficiary will be billed quarterly Assistance available for premium payment if income/asset guidelines met (P. 108)

8. MEDICARE SUPPLEMENT INSURANCE • Medicare supplement aka Medigap (P. 67) • Private secondary health insurance designed to fill in the “gaps” after Original Medicare pays according to State and Federal laws example: deductibles, co-insurance, and co-payments • Costs vary depending on insurance company (average between $150 - $300/m) • Guaranteed renewable for life unless you commit fraud or you don’t pay the premiums

9. GUARANTEED ISSUE RIGHTS Insurance companies are required to accept your application for a Medicare supplement policy • Can’t deny you coverage • Must cover pre-existing conditions • Can’t charge you more for pre-existing, past or present health conditions GUARANTEED ISSUE RIGHTS: 6 month open enrollment when Part B first becomes effective, when you turn 65 OR 24 months after date of disability determination. (disabled persons receive a second open enrollment when they turn 65) GUARANTEED ISSUE RIGHTS: up to 63 days when loss of coverage is involuntary, includes employer/retiree groups, medical assistance, or Medicare Advantage

10. MEDICARE SUPPLEMENT COVERAGE Basic Benefits: • Covers the 20% gap in coverage after Medicare Part B pays • Covers co-payments for hospitalizations and skilled nursing care • Additional Inpatient Mental Health Care (175 days lifetime) • First 3 pints of blood • Additional 40 home health care visits

11. WISCONSIN MANDATED BENEFITS Applies ONLY to policies purchased in Wisconsin. These benefits are available even when Medicare does not cover these expenses. Coverage for usual and customary cost of non-Medicare covered chiropractic care Coverage for 30 days non-Medicare SKILLED nursing facility care with no prior hospitalization required (per benefit period) Coverage for the following when specific requirements are met: ● Home health care ● Surgery charges/anesthetics for dental care ● Kidney disease ● Breast reconstruction ● Diabetes treatment ● Colorectal cancer screening ● Chiropractic care ● Cancer clinical trials costs

12. OPTIONAL BENEFITS Part A deductible rider (covers the $1,216.00 deductible) Part B deductible rider ($147.00 annual deductible) Part B excess charges rider (covers the excess charges a provider can charge over the approved Medicare amount if provider doesn’t accept Medicare Assignment)

13. OPTIONAL BENEFITS • Additional Home Health Care (up to 365 visits per year) • Foreign travel emergency • New optional benefits (effective June, 2010) Part B 100% deductible with co-pays for office and ER visits Part A 50% deductible (no out-of-pocket maximum)

14. TYPES OF MEDICARE SUPPLEMENTS “Free Standing” Traditional Medicare Supplement Policies Medicare Select Policies (defined network of providers) Cost-Sharing Supplemental Policies (K & L – new for 2006) • K Plans –share in costs after Medicare at 50% rate • L Plans – share in costs after Medicare at 25% rate

15. MEDICARE ADVANTAGE PLANS What is an Advantage Plan? Private Medicare Replacement plans, replace original Medicare A&B (P. 72) Enrollments Periods (must have Parts A&B to enroll) Initial Enrollment: 3 months prior, the month of, 3 months after starting Medicare Open Enrollment : October 15 – December 7 Special Enrollment: i.e. relocation, trial period, loss of group. Disenrollment : January 1 – February 14

16. ADVANTAGE PLANS • Lock-in: You will be locked into your plan of choice for the calendar year (can only change during open enrollment stated above) • Trial Periods: May be allowed to disenroll back to Original Medicare during initial 12 months • No health care questions except for end stage renal disease

17. TYPES OF ADVANTAGE PLANS • Private Fee for Service (PFFS) • Preferred Provider (PPO) • Managed Care (HMO) (some plans have POS/point of service option) • Special Needs Plans (for persons with chronic diseases or for persons on Medical Assistance or for persons in institutional settings)

18. PREMIUMS/COSTS ADVANTAGE PLANS • Must continue to pay the Part B premium • Premiums vary by plan (range $0 - $320.00 per month for plans available in Eau Claire County for 2014) • Medicare pays the Advantage plan a set amount every month to cover Medicare services; you share in the cost with co-pays/co-insurance • Co-pays for every covered service with most Advantage plans • Maximum out of pocket limits may vary by plan

19. ADVANTAGE PLANS • Plans can change premiums/co-pays, coverage options on a yearly basis pending CMS approval • Plans send Annual Notice of Change each year in the fall (VERY IMPORTANT) • Providers may choose to “Balance Bill” up to 15% to beneficiaries enrolled in PFFS

20. MEDICARE COST PLANS • Medicare cost insurance is an arrangement between the Centers for Medicare & Medicaid and certain HMOs • Medicare cost insurance will pay full benefits if services are obtained through the plan providers selected by the plan • If services are obtained outside of the plan’s provider network, Medicare will still pay its share of the charges and you will be responsible for deductibles and copays • Can purchase a cost plan anytime, no specific enrollment periods

21. EMPLOYEE/RETIREE GROUP HEALTH COVERAGE • Includes coverage thru employer (p. 100) • Active employee health coverage, retiree coverage, COBRA Continuation Coverage, Federal Employer Health Benefits • Each plan has its own premiums/co-pays associated with the “approved contract” purchased by the employer • Contract may change at any time • May include “creditable drug coverage.” (ask before enrolling in Part D) • May provide Primary (if actively working and number of employees are ≥ 20 for 65 and up or ≥ 100 for disabled) OR Secondary coverage to Original Medicare

22. MILITARY COVERAGE Veteran’s Benefits (VA facilities only) (P. 101) • Prescription coverage is “creditable” • Does not coordinate with Medicare • Need to meet priority level of coverage for Veteran’s health care coverage • May want to purchase additional health care insurance

23. MILITARY COVERAGE • TRICARE for Life/Champ VA (P. 101) Prescription coverage is “creditable” Does coordinate with Medicare No additional health care insurance needed (acts as a Medicare supplement)

24. MEDICAL ASSISTANCE (MEDICAID) Benefits received are dependent on gross income and cash assets. Benefits range from full MA to help with paying Medicare Part B premiums. Apply at county Department of Human Services or the Aging and Disability Resource Center.

25. PRESCRIPTION COVERAGE OPTIONS • Medicare Part D Prescription Plan (P. 87) • Anyone on Medicare is eligible • Began 1/1/2006 Enrollments (can only make one selection per period) • Initial Enrollment Period: 3 months prior, month of, 3 months after turning 65 • Open Enrollment Period: October 15 thru December 7 • Special Enrollment Periods for specific circumstances

26. PART D PLAN COSTS Costs: • Premiums vary according to plan ($12.60 - $137/month) • Co-pays vary per drug, per plan, per pharmacy Standard plan: (P. 91) • Deductible: 0 - $310 (2014) • 25% of the first $2,850.00 in drug costs (initial coverage limit) • Pay 72% for generic meds and 47.5% for brand name meds in the coverage gap up to $4,550 • Pay 5% of costs thereafter (catastrophic)

27. COSTS (CONTINUED) May be assessed a penalty if not enrolled in a Part D drug plan OR have other creditable drug coverage (P. 94) • For 2014: penalty = # of months without creditable coverage x $0.32 Enrollees will receive an Annual Notice of Change each year in the fall. VERY IMPORTANT INFORMATION Low Income Subsidy “EXTRA HELP” (P. 103) • Assistance available for persons with low income/limited resources • Automatically eligible if on any Medicaid program • Apply through Social Security

28. MEDICARE. GOV HOME PAGE

29. SENIORCARE • Eligible if age 65 and over and Wisconsin resident • Recognized by Medicare as “creditable coverage” for drugs • Cost $30 (application fee) per person for 12 months coverage • Benefits received depends on income, four levels of coverage • Complete application on your own – no special enrollment period • Caution: Not able to know with certainty which medications are covered Does not cover medications with outpatient/observational stays at hospitals

30. OTHER CREDITABLE RX COVERAGE • Employer/Retiree Groups Prescription coverage (check with employer) • Military/Veteran’s Prescription coverage • Will NOT incur penalty with Part D if you have “creditable” RX coverage • NON-CREDITABLE PRESCRIPTION PROGRAMS • Discount Programs (Badger RX) • Canadian/Mexico mail-order • Pharmaceutical Patient Assistance Programs • NACO Prescription Discount Card Programs

31. MAKING YOUR COVERAGE DECISION • The decision to purchase insurance is a personal choice and should be based on your personal health care needs • There are many options to consider for best possible care • Keep in mind the potential out-of-pocket costs if insurance decisions are not made in a timely manner • Medigap counselors are available for your assistance to help you with possible options available to you – call 1-800-242-1060 for further questions

32. Prepared by: • Vicki Buchholz, Lead Medigap Insurance counselor • Sue Brown and Leda Welke, Elder Benefit Specialists