11/10/2015. Get More from Medicare. Medicare Administrators Centers for Medicare & Medicaid Services (CMS)

Transcription

1 Get More from Debra E. Schroeder, M.S. Extension Educator Nebraska Extension November, 2015 What Is? is health insurance for people: Age 65 or older Under age 65 with certain disabilities Any person with End-Stage Renal Disease (permanent kidney failure requiring dialysis or kidney transplant) pays 80% of the cost of covered services; you pay the remaining 20% Jane Doe A FEMALE HOSPITAL (PART A) MEDICAL (PART B) Administrators Centers for & Medicaid Services (CMS) Issues regulations, determines covered services, determines fee schedules Social Security Administration (SSA) Eligibility and enrollment Railroad retirees served by Railroad Retirement Board, not SSA Eligibility and enrollment Components of Part A Hospital Supplement Part B Medical Part D Drugs OR Part C Advantage Plan How do I apply for? If you already get Social Security, you are automatically enrolled in A and B If you receive Social Security before age 65, starts month you turn 65 If your birthday is on first of month, Part A and B start first of prior month If you receive SSDI (Social Security Disability Income), starts your 25 th month on SSDI If you have ALS (aka Lou Gehrig s disease), starts same month as SSDI Enroll in Part A and B If you are not already receiving Social Security, you must sign up for Sign up with Social Security Your area office xxx-xxxx Phone SSA at Online at If you work for railroad, contact Railroad Retirement Board at If you have ESRD call Social Security at

2 Social Security & Can get without taking SS benefits Apply on-line Pay monthly premiums 2

3 Initial Enrollment Period 7 months 65 th Birthday 3 months before birthday 3 months after birthday General Enrollment Period Did 65 General Enrollment Period (3 months) Enroll here & Effective date is 1 st day of birthday month Enroll herecoverage next month Enroll here and coverage will begin 3 months after enrollment January 1 March 31 April 1 June 30 July 1 Enroll here & effective date July 1 of same year No coverage No coverage 10% penalty for each year enrollment is delayed starts with premium penalty Delaying Part A or B You can delay Part A or B without penalty if you/spouse work beyond age 65 and you have creditable coverage Creditable coverage is equal to or better than and tied to current employment Only your employer or health plan can tell if your coverage is creditable You have 8 months to get coverage without a penalty You may pay a penalty if you delay and do not have creditable coverage from employer Delaying Part A Hospital Little benefit in delaying Part A enrollment if you have creditable coverage through work 99% of people with pay $0 premium 1% did not pay into and will pay Part A premium (up to $407/mo.) by delaying Part A is secondary payer after employer group health plan If you have a Health Savings Account, special rules apply (Can t contribute once Part A starts) Delayed Enrollment REMINDER If you delay enrollment and have creditable coverage from your/spouse s current employment You will not pay late enrollment penalties If you delay enrollment and do not have creditable coverage You may pay late enrollment penalties Check on this before you turn 65 This is your Special Enrollment Period Your Card Name claim number, usually Social Security number plus a suffix letter Railroad retiree s card will have prefix letters Hospital Part A effective coverage date Medical Part B effective coverage date 3

4 Part A Hospital Supplement Components of Part B Medical Part D Drugs OR Part C Advantage Plan Original Any hospital, doctor or specialist who accepts assignment of payment Agrees to receive only the amount approves for their services (Parts A & B) You will be charged the deductible or coinsurance amount unless you have other insurance pay 80%, You or other insurance pays 20% The Parts of Original Part A Hospital Part B Medical Private includes Part C and D. Benefits come from private insurance companies that contract with CMS (Centers for & Medicaid Services). Supplements cannot be purchased when you have an Advantage plan. Original includes Part A and B. Benefits come from federal government. Part D and a Supplement can be added to Original. Private Part C Advantage Part D Prescription Drugs Part A - Hospital Coverage Inpatient hospital stays Skilled nursing facility (SNF) care After 3 nights as an Inpatient in hospital & Dr. orders Home health care Hospice care Part A - Benefits Period Inpatient hospital and skilled nursing care Begins first day of stay Ends after 60 consecutive days out of hospital and/or skilled nursing care There can be more than one benefit per year Part A - Costs 2015 Premiums per month: 40+ quarters (10 years) - $0 (Free) quarters - $224 Less that 30 quarters - $ Part A deductible for each benefit period $1,260 covers first 60 days each benefit period th day in hospital you pay $315/day th day - $630/day - Life time reserve 150+ days you or supplemental insurance pays full cost Skilled nursing: pays for days 1-20 Days $157.50/day 4

5 Part B - Medical Coverage Doctor s services Outpatient hospital care Physical, occupational & speech therapists Durable medical equipment, diabetic testing supplies Ambulance Emergency room Part B Monthly Premiums Individual Tax Return Joint Tax Return 2015 Premium $85,000 or less $170,000 or less $ $85,001 - $107,000 $170,001 - $214,000 $146.90* $107,001 - $160,000 $214,001 - $320,000 $209.80* $160,001 - $214,000 $320,001 -$428,000 $272.70* Above $214,000 Above $428,000 $335.70* * Includes Income Related Monthly Adjustment Amount (IRMAA) for higher income earners. Part B Costs Annual Deductible: $147 20% of -approved amount for most medical services and for outpatient mental health Excess Charges (difference between what doctor charges and what pays) Generally limited to 15% above approved amount 100% of non-covered Items Routine dental, vision, hearing Penalty 10% for each full 12 month period, if didn t sign up on time lasts a lifetime Part B Diabetic Testing Supplies Changes in diabetic testing supplies effective July 2013 If shipped or delivered to home, must come from contract supplier Can be picked up from any pharmacy contracted with Cost is same either way Find suppliers on Help Paying Part B Costs Savings Programs can help pay Part B premium and copays if you meet qualifications 2015 income and asset qualifications Individuals Income < $16,140 Assets < $7,280* Married Couple living together Income < $21,756 Assets < $10,930* Apply at ACCESSNebraska or *Assets do not include your home or car Supplement Insurance (often called Medigap) Sold by private insurance companies Fills gap in Original coverage Policies must follow federal & state laws 10 standardized policies (A, B, C, D, F, G, K, L, M, N) Plan F can have a high deductible for a lower premium No family policies, only individual, Ask about Household discount Doesn t cover long-term care, hearing aids, vision or dental care, eyeglasses, or private nursing In Nebraska, not required to sell policies under age 65 5

6 More on Supplement Insurance Must have both Parts A & B Must still pay monthly premium for Part B, & possibly Part A Best time to buy - the month you turn 65 and the five months following, called Guarantee Issue Period : Can t refuse you any policy it sells Make you wait for coverage to start Charge more for health problems Once you are 65 and your Part B starts, your 6-month open enrollment begins; cannot be changed More on Supplement If you delay Part B enrollment because you have group health coverage from current employment, your 6-month open enrollment starts whenever you sign up for Part B May have a waiting period for a pre-existing condition if you have a lapse in coverage between employer and (this did NOT change with the Affordable Care Act) If you delay enrolling in Med Supp beyond 6-month open enrollment, you may be denied Supplement based on your health history Ten Standard Supplement Plans 2015 Basic Benefits A B C D F G K L M N Part A Hospital-Coinsurance (Days 61-90) X X X X X X X X X X Lifetime Reserve Days (Days ) X X X X X X X X X X 365 More Hospital Days-100% X X X X X X X X X X Parts A & B - Blood X X X X X X 50% 75% X X Part B Co-insurance X X X X X X 50% 75% X Co-Pay $20 office $50 ER Part A Hospice Co-insurance X X X X X X 50% 75% X X Additional Benefits Skilled Nursing Facility X X X X 50% 75% X X Coinsurance (Days ) Part A Deductible X X X X X 50% 75% 50% X Part B Deductible X X Part B Excess Charges X X Foreign Travel Emergency X X X X X X 2014 Out-Of-Pocket Limit $4940 $2470 Standardized Plans An F is an F is an F Every Plan F has the exact same benefits vs. The only differences are: Premiums and rate increases Company rating and customer service Agent availability Plan F also available with $2,180 deductible 2015 Choosing Medigap Policy guide pdf 2013 Example Attained Age 6

7 * 11/10/2015 How To Lose Medigap coverage Don t pay your premiums Weren t truthful on your application Insurance company becomes insolvent 63 days to enroll in A, B, C, F, K or L in another company and Affordable Care Act (ACA) & ACA If you have You do not need new insurance You do not need different insurance Can t be used an supplemental insurance ACA does make some changes Adds many preventive and screening services available without cost Reduces drug costs by shrinking the Donut Hole and ACA ACA adds free preventive & screening services Abdominal aortic Nutrition therapy aneurysm Obesity Alcohol misuse Prostate cancer Bone density STI infections Cardiovascular Shots Cervical & vaginal Flu cancer Hepatitis B Colorectal cancer Pneumococcal Depression Tobacco cessation Diabetes Welcome to visit Glaucoma Yearly Wellness visit HIV Mammograms Part D - Prescription Drug Coverage Part A and B do not cover most prescription drugs Buy Part D Drug Plan from -approved private insurance companies Nebraska has 26 statewide Part D Plans in 2016 Part D Drug Plans cover Prescription drugs only Brand names and generics No over-the-counter drugs When to Enroll in Part D Initial Enrollment Period Need to be enrolled in either Parts A &/or B - 3 months before 65 th birthday, month of birthday or 3 months following Coverage begins month following enrollment Special Enrollment Period Up to 63 days after creditable coverage ends No penalty for enrolling during SEP Annual Coordinated Election Period ( Open Enrollment ) October 15 December 7 Review or change Plan annually If you delay enrolling, you may pay a penalty Delaying Part D Enrollment No penalty for delaying Part D if you enroll within 2 months of the last day of your creditable coverage Part D late enrollment penalty Applies if no creditable coverage for > 63 days 1% penalty of national base premium for each month eligible, but not enrolled, in Part D or without creditable coverage Penalty paid each month you have Part D 7

8 Part D Costs for 2016 Beneficiary costs Deductibles range from $20 to $360 8 plans $0 deductible Premiums range from $18.40 to $ If your income is above $85,000 (single) or $170,000 (married), you pay a higher premium Co-pays and co-insurance per medication Enroll in cheapest plan, if taking no medications Part D Costs (cont.) Penalty for life, if enrollment is delayed You do not need a Part D plan if: You have creditable drug coverage (as good as or better than s coverage) through a retiree health plan VA drug benefits TRICARE drug benefits More on Part D Drug Costs You pay different drug copays in four stages Stage 1 $360 Deductible Stage 2 Initial coverage = 25% avg Stage 3 Coverage Gap or Donut Hole in 2016 When total drug cost reaches $3,310 you enter Donut Hole You pay 45% for brand name drugs, 58% for generic drugs Stage 4 Catastrophic coverage = 5% When your cost reaches $4,850 you enter Catastrophic coverage for remainder of year Basic Standard Coverage 2016 Total Drug Costs You Pay Plan Pays Your Total per Year* Deductible $0-$ % ($360) $0 $360 Coinsurance $3260-$ % 75% $1097 Coverage Gap $3310- $ Catastrophic Over $ % Brand 58% Generic 5% Brand 35% Generic 50% Brand Discount (Manufacturer pays) $4850 in the Gap Total $5947 5% 95% $2.95 Generic $ % of additional costs $7.40 Brand * Plus cost of premium Part D Covered Services Each Plan has formulary (list of drugs covered) Different Drug Plans have different formularies Plans must include more than one drug in each classification If a specific drug is not on a formulary, a similar drug may be Choosing Part D Plan Choose your Drug Plan carefully Everyone is different Different drugs, pharmacy, budget Plan that works for spouse or friend may not work for you Plan that works for you this year may not work for you next year Always compare plans at Use website yourself Compare Drug Plans every Oct 15 - Dec 7 Call for assistance 8

9 Need Help Paying for Prescription Drugs & Premiums? Low Income Subsidy (LIS) Apply to Social Security any time On-line or pen & paper 2015 income guidelines $17,655 annual income (single) or $1, monthly $23,895 annual income (couple) or $1, monthly 2015 assets/resources guidelines $13,640 (single) $27,250 (couple) Includes savings, CD, real estate, stocks/bonds, etc. Receive letter of acceptance or denial Reduced cost for premium & drugs Advantage Plans (MA)/ Part C Health Plans Approved by, but sold by private insurance companies must meet state and federal requirements Part A: Hospital Part B: Medical Part D: Prescriptions Supplemental plus other coverage, ie., Dental, Vision, etc. Advantage (MA) Or Health plans (Part C) Low premiums Original money goes to insurance company to pay costs Must be accepted by doctors, specialists and hospitals (this is not Original ) Plans available locally, but may not be contracted by doctors, specialists and hospitals! You need to check with each one! Examples HMO (Health Maintenance Org.), PPO (Preferred Provider Org.), PFFS (Private Fee-for-Service) Some include Prescription Drug coverage Part C Advantage Plans Advantage Plans operate differently You must Continue to pay Part B premium Live in MA Plan service area Use network providers (or pay higher/all costs) Plan must Take all beneficiaries (except ESRD) Have no waiting period for pre-existing conditions Cap your annual out-of-pocket costs Include all -covered services Have contract with Part C Premiums and Costs 16 Advantage Plans in Nebraska in 2016 MA Plans in your area will be limited Premiums Range from $0 - $188 per month In addition to Part B premium Advantage Plan Co-pays Co-pay for every service used Counties with No MA Plan in 2016 Antelope Garden Pierce Brown Grant Red Willow Chase Greeley Richardson Cherry Harlan Rock Clay Hitchcock Saline Custer Holt Sioux Deuel Howard Thayer Dundy Kimball Valley Fillmore Nemaha Webster Franklin Pawnee York Frontier Phelps 9

10 Twelve Month Trial Rights Allows people to try MA Plan with no risks Can leave the MA plan any time during first 12 months Must leave MA plan within the first 12 months to get supplement back guaranteed issue (GI) Only have 63 days after leaving MA to get supplemental back Must be first time ever to have MA Plan GI will apply to those who have NOT had a Medigap policy first 63 day rule applies to get a Medigap policy Disabled & Auto enrolled - Parts A & B beginning 25 th month of entitlement to Social Security benefits Can decline Part B or Part D if has group health coverage from employer or spouse s employer Must have both Parts A & B in order to get a Supplemental Policy Not required to be sold in Nebraska Very expensive -- limited plans and companies Available at age 65 open enrollment Insurance companies can t refuse to sell due to disability or other health problems or charge higher premium than others at 65 for ESRD End-Stage Renal Disease (ESRD) automatic upon diagnosis ESRD under age 65 might not be able to buy policy Too expensive Not required to be sold by insurance company s in Nebraska Available at age 65 open enrollment Insurance companies can t refuse to sell due to disability or other health problems or charge higher premium than others at 65 & COBRA (Consolidated Omnibus Budget Reconciliation Act) Continuation of group insurance for a limited time You buy at full price plus 2% admin fee Timing 18-month extension of group insurance coverage for self, spouse and covered dependents Begin with COBRA, then eligible for, COBRA ends Talk to benefits administrator for more information My.gov Online information with all your claims and benefits Eliminating monthly statement of claim information Welcome to letter Use number and password for Mymedicare.gov 10

11 Nebraska Senior Health Insurance Information Program (SHIIP) Trained counselors & Medicaid eligibility & benefits Medigap (Supplemental Insurance) plans prescription drug plans Advantage plans Long-term insurance Free, unbiased answers Educational materials Coordinated within the Nebraska Dept. of Insurance State-wide Toll-free number Resources MEDICARE or Social Security Scottsbluff Lincoln Norfolk North Platte Omaha Grand Island Sioux City, IA NE Dept. of Insurance Local Help Local help for Prescription Drug enrollment and information Northeast Area Agency on Aging 119 W Norfolk Ave, Norfolk, NE or Components of Part A Hospital Part B Medical Supplement Part D Drugs OR Part C Advantage Plan 11