SMP Foundations Training Chapter 2 – Medicare Basics

1. SMP Foundations Training Chapter 2 – Medicare Basics Funded by the U.S. Administration on Aging Prepared in Cooperation with the National Consumer Protection Technical Resource Center May 2011

2. Objectives of SMP Foundations Training Chapter 1 Chapter 2 Chapter 3 Refer to H-6 and H-7 At the end of this training, participants will be able to • Describe the background and mission of the national SMP program; • Identify the three roles of the SMPs; • Identify components and benefits of Medicare programs; • Describe eligibility and enrollment requirements of Medicare, Medicaid, and other assistance programs; • Review sample MSNs against case files for accuracy; • Describe how Medicare programs are subject to fraud, waste, and abuse; and • Identify strategies to combat fraud, waste, error, and abuse.

3. Agenda • Welcome, Introductions, Objectives of Training • History of Medicare • Medicare Overview • Eligibility for Medicare • The A,B,C,Ds of Medicare • Medicare Supplement Insurance (Medigap) • Enrollment in Medicare • Reading the Medicare Summary Notice (MSN) • Help for People with Limited Income • Medicare Rights & Protections • Evaluation and Wrap-Up Refer to H-6

4. Medicare: Today and Tomorrow • Managed by • Centers for Medicare and Medicaid Services (CMS) • Extent of Medicare • In 2009, Medicare spent $509 billion for health care costs of more than 46 million beneficiaries. • In the next ten years, Medicare spending will almost double.

5. The Good News Since 1996, when the government increased its focus on Medicare fraud and abuse: • AoA’s SMP program has made a significant impact in efforts to fight fraud; • A large part of the solution to the problem of health care fraud and abuse is the use of volunteers!

6. The Bad News • Bottom Line: The Federal government and taxpayers lose billions of dollars each year as a result of Medicare and Medicaid fraud and abuse. Fraud, errors and abuse cost the Medicare program billions of dollars every year.

7. You Are Part of the Good News! • SMP Volunteers help play an important role in • Educating Medicare and Medicaid beneficiaries, and • Reducing and preventing health care fraud and abuse. And THAT’s why it’s important for SMP volunteers to understand Medicare Basics.

8. Medicare Overview

9. Medicare Program • Program created by Congress in 1965 • The federal health insurance program for • People 65 years and older • Some people under 65 years who have disabilities • People with end-stage renal disease (ESRD) • Some people with Lou Gehrig’s Disease (ALS) • Administered by the Centers for Medicare and Medicaid Services (CMS) • Not intended to pay 100% of medical bills

10. Eligibility for Medicare AND

11. Medicare Parts Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Part D Prescription Drugs Medicare Supplement Insurance MEDIGAP Not part of Medicare

12. Do You Know the Medicare Parts? Refer to H-8. Match the Medicare Part listed in the left-hand column to its appropriate description in the right-hand column by drawing a line from the Medicare part to its description. Refer to H-8

13. Jigsaw: Learning Medicare Parts Refer to H-9 • What better way to learn about the Medicare Parts than to teach it to someone else? • Refer to Handout H-9 and read the instructions • Person 1 – Read about Medicare Part A on pages16-17 • Person 2 – Read about Medicare Part B on pages 18-20 • Person 3 – Read about Medicare Part C on pages 21-22 • Person 4 – Read about Medicare Part D on pages 23-24 • Person 5 – Read about Medigap Insurance on pages 25-26 • When all the Experts have completed teaching, everyone in your group will have learned key points of the parts of Medicare and about Medigap plans.

14. Learning the Medicare Parts (Cont.) • Part A – Hospital Insurance: • Benefits • Costs • Non-covered services • Your rights in the hospital • Part B – Medical Insurance: • Benefits • Costs • Non-covered services • Assignment Note: “Assignment” is the term used to indicate that a doctor or supplier has agreed to accept the Medicare-approved amount as full payment. See example on Chapter 2, p. 20.

15. Learning the Parts of Medicare (Cont.) • Part C – Medicare Advantage: • Run by private insurance companies • Eligibility • Costs • 5 types of Medicare Advantage plans • Part D – Prescription Drugs: • Run by private insurance companies • Eligibility • Costs

16. Medicare Supplement Insurance (Medigap) Note: Medigap is not a Medicare program. Eligibility Key points Costs

17. Parts of Medicare: Test your Knowledge Refer to H-10 • Refer to H-10; Review the statements, which come directly from Chapter 2 of the Manual. • Test your knowledge by filling in the blanks. • Refer to Chapter 2 for help.

18. Medicare Enrollment Enrollment handled through Social Security Administration (SSA) or Railroad Retirement Board (RRB) • Automatic enrollment • Initial Enrollment • General Enrollment • Special Enrollment

19. 1. Automatic Enrollment • Notes: • Individuals not eligible for automatic enrollment will need to sign up for Parts A and B. • Automatic enrollment does not apply to C, D, or Medigap. These plans will begin only if the beneficiary initiates them.

20. 2. Initial Enrollment Advice for beneficiaries: Enroll 1-3 months before birthday month to ensure that coverage begins by the time individual reaches age 65. If automatic enrollment does not apply, the best time to enroll in all parts of Medicare is during initial enrollment, when individual first becomes eligible for Medicare. • Parts A-D: 7 months surrounding 65th birthday • Medigap: must be 65 AND have Part B • 10% Penalty for delayed enrollment in Part B • Penalties may apply for delayed Part D enrollment

21. 3. General Enrollment Can a beneficiary get out of their plan? See page 30 of the SMP Foundations Training Manual. Timeframes for enrolling and making changes to plans are different for each part of Medicare and for Medigap. Beneficiaries who miss the initial enrollment period can enroll during the general enrollment period for each of the Medicare plans, as outlined in the SMP Foundations Training Manual.

22. 4. Special Enrollment

23. How to Enroll • \ • The enrollment process differs for each part of Medicare • Beneficiaries are responsible for their own enrollment; however, SMPs may assist beneficiaries with general information and resources Note: See the SMP FoundationsTrainingManual page 32 for descriptions re: how to enroll and where to get more information on Medicare and enrollment.

24. Check Your Knowledge • See how much you know about Medicare Basics! • Turn to H-11 and read each statement. • Determine whether the statement is True or False. • For each false statement, write the corrected statement in the space provided. Refer to H-11

25. Medicare Statements and Claims Tracking • Medicare Summary Notices (MSNs) • Key tool to help beneficiaries track medical information • Helps beneficiaries and SMPs to catch errors and potential fraud and abuse • Not all Medicare programs send out MSNs • Sometimes statement has a different name, e.g., • Medicare Part D plans send an “Explanation of Benefits” (EOB). • Medicare Advantage plans (Part C) send statements that are not standardized like other Medicare programs.

26. Examining the Medicare Summary Notice (MSN) Refer to H-12 Examining the Medicare Summary Notice • Refer to pages 36-45 in Chapter 2 of the SMP Foundations Training Manual and refer to H-12 in the participant handouts; • Review the MSN on pages 36-37 as you answer the questions on H-12

27. www.MyMedicare.gov • A valuable, real-time tool to combat fraud and abuse • Allows registered users to track health care services received • Users can • View most recent MSNs • Check Part B deductible status • View eligibility information • Track available preventive services • Find Medicare health or prescription drug plans. • Encourage beneficiaries to sign up for the site, where they can keep track of their personal information www.MyMedicare.gov

28. Assistance for People with Limited Income and Resources

29. Assistance for People with Limited Income and Resources Frequently targeted by scam artists, resulting in millions of dollars lost to fraud and abuse! • Types of assistance programs available • Medicaid • Medicare Savings Programs • Program of All-Inclusive Care for the Elderly (PACE) • Programs that help with prescription drug costs • Supplemental Security Income (SSI)

30. 1. Medicaid • Joint federal/state program; helps pay medical costs for some individuals with limited income and resources • “Dual-eligibles”– Persons eligible for both Medicare and Medicaid; most health costs are covered • Programs may cover services not fully covered by Medicare, e.g., nursing home and home health care • State Medical Assistance (Medicaid) office responsible for determining eligibility and enrollment.

31. Refer to H-13

32. 2. Medicare Savings Programs • Helps pay Medicare Premiums and, in some cases, Medicare Part A and B deductibles and co-insurance. • Persons eligible for Medicare Savings Programs must have Medicare Part A and have limited resources set annually by Medicare • State Medical Assistance (Medicaid) office responsible for determining eligibility and enrollment.

33. 3. Program of All-Inclusive Care for the Elderly (PACE) • Combines medical, social, and long-term care services for frail elderly people who live in and get health care in the community; • Provides all medically necessary services and prescription drugs; may prove a better choice than care through a nursing home; • State Medical Assistance (Medicaid) office responsible for determining eligibility and enrollment. Note: Not all areas have PACE; Refer to SMP Foundations Training Manual p. 47-48 for details

34. 4. Programs That Help With Prescription Drug Costs • Assists limited-income beneficiaries with premiums, deductibles, and co-payments for prescription drug plans • The Medicare “Extra Help” program and the State Pharmacy Assistance Programs (SPAPs) provide help with prescription drug costs for those who qualify (SPAPs not available in all states)

35. 5. Supplemental Security Income (SSI) Benefits • Monthly amount paid by Social Security to individuals with limited income and resources who are disabled, blind, or age 65 or older. • Provide cash to meet basic needs for food, clothing, and shelter. • SSI benefits ≠ Social Security benefits

36. Assistance for People with Limited Income and Resources • Five common types of assistance programs • Medicaid • Medicare Savings Program • SSI • PACE • Programs that help with prescription drug costs Can you describe them? • On H-14, match the type of assistance program with its description

37. Refer to H-14

38. Resources for Beneficiaries • Who can help with Medicare questions? • SHIP • 1-800-MEDICARE • Social Security • Web sites • www.MyMedicare.gov -sign up for own personal account • www.Medicare.gov -Consumer Web site for information about Medicare • Materials • Medicare and You Handbook (www.Medicare.gov) • Personal Health Care Journal (PHCJ)—Provided by local SMP

39. Medicare Offers Certain Rights & Protections To Learn More Refer to the Medicare & You Handbook! • Rights if plans no longer participate • Appeals • What to do if a person disagrees with a coverage or payment decisions • Advanced Beneficiary Notice (ABNs) • Notice that Medicare may not pay for some services • Medicare’s use of personal information • Medicare Ombudsmen role and responsibilities • Identity Theft • Fraud • Discrimination

40. Self-Check—Chapter 2 Refer to H-15 • Turn to H-15 and take the self-check inventory to assess how much you’ve learned about Chapter 2 content. • Refer to the SMP Foundations Training Manual to help you find the answers.

41. Your Thorough Understanding of Medicare… will help you to prevent, detect, and report …Medicare fraud and abuse

42. Chapter 2 Wrap-up