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Medicare Basics

Medicare Basics. What is Medicare?. Health insurance for three groups of people 65 and older Under 65 with certain disabilities Any age with End-Stage Renal Disease (ESRD) Administration Centers for Medicare & Medicaid Services (CMS) Enrollment

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Medicare Basics

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  1. Medicare Basics

  2. What is Medicare? • Health insurance for three groups of people • 65 and older • Under 65 with certain disabilities • Any age with End-Stage Renal Disease (ESRD) • Administration • Centers for Medicare & Medicaid Services (CMS) • Enrollment • Social Security Administration (SSA) for most • Railroad Retirement Board (RRB) railroad retirees

  3. The Four Parts of Medicare

  4. OriginalMedicare • Has Part A – Hospital Insurance • Hospital • Skilled Nursing Facility • Home health care • Hospice care • Has Part B – Medical Insurance • Doctor’s visits • Outpatient hospital services • Clinical lab tests • Preventive services

  5. Enrolling in Medicare • Automatic for those receiving • Social Security benefits • Railroad Retirement Board benefits • Initial Enrollment Period Package • Mailed 3 months before • 25th month of disability benefits • Age 65

  6. DecisionShould a beneficiary keep/sign up for Part B? • Consider • Are they currently working and the employer is providing creditable coverage • If not, they may incur a Part B penalty for not enrolling • Do they have employer provided coverage or FEHBP that does not require Part B

  7. Options for Receiving Medicare Benefits • Original Medicare + Medigap policy • Original Medicare + a standalone PDP • Medicare Advantage Prescription Drug Plan • Medical-only Medicare Advantage plan + creditable coverage (i.e., Tricare, VA, IHS)

  8. When can someone enroll in a MA plan? • During 7 month initial enrollment period • Can join during annual fall open enrollment • October 15 – December 7 each year • Coverage begins January 1 • May be able to join during other special times • Such as after a permanent move • Becoming eligible for Medicaid

  9. How Medicare Advantage Works • Still in Medicare with all rights and protections • Still get Part A and Part B services • Plan may include prescription drug coverage • May include extra benefits like vision or dental

  10. DecisionDoes someone want to join a Medicare Advantage Plan? • Consider • Most offer comprehensive coverage • Including Part D drug coverage • May require use of a network • Must pay monthly premium to plan • Still must pay Part B premium • Can only join/leave plan during certain periods • Doesn’t work with Medigap policies • Must have Part A and Part B to join • Beneficiary cannot be enrolled in more than one MA or PDP plan at one time.

  11. Part D – Medicare Prescription Drug Coverage • Available for all people with Medicare • Provided through • Medicare Prescription Drug Plans • Medicare Advantage Plans • Must include range of drugs in each category • All Part D plan formularies have content requirements and must be CMS approved.

  12. Who Can Join Part D? • must have Medicare Part A and/ or Part B • must live in the plan’s service area • must enroll in a Medicare Part D plan • In most cases no automatic enrollment • Beneficiary must use an enrollment mechanism (phone, hard copy, website)

  13. DecisionShould someone enroll in a Part D plan? • Consider • Does the person have creditable drug coverage? • Coverage as good as Medicare’s • For example through an employer plan • Will that coverage end when at retirement? • May pay a penalty if Part D isn’t taken when first eligible • Unless they have creditable coverage

  14. Joining a Part D Plan • Can join during 7 month initial enrollment period • Can join during annual fall open enrollment • October 15 – December 7 • Coverage starts January 1 • Can join during other special times • Contact plan to join • Call • Visit website

  15. What help is there for people with limited income and resources? • Medicaid • Extra Help • Medicare Savings Programs • Qualified Medicare Beneficiary (QMB) state will pay your Part B premium and Medicare cost-sharing • Specified Low-income Medicare Beneficiary (SLMB) – state will pay your Part B premium.

  16. What is Extra Help? • Help paying prescription drug costs • Social Security makes determination • Some groups automatically qualify • People with Medicare and Medicaid • Supplemental Security Income (SSI) only • Medicare Savings Programs • The individual or someone on their behalf can apply through SSA

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