Understanding Medicare and Coverage Expansion Options. Rick Seely Account Executive MDA Insurance

Transcription

1 Understanding Medicare and Coverage Expansion Options Rick Seely Account Executive MDA Insurance 1

2 Rick s Goals Today Help you determine if and when you should enroll in Medicare Parts A & B RECOMMEND Educate you regarding Medicare & answer your questions----clarify Ask you questions about your health status, RX use, work plans & coverage needs analyze Present solutions to effectively address those needs inform Serve as a resource if you choose to set a plan in motion------facilitate 2

3 Your Goals Amount of time? What do you want to accomplish? Other? 3

4 What is Medicare? Health insurance for people 65 and older, actively working or retired Under 65 with certain disabilities Any age with End-Stage Renal Disease (ESRD) It is Administered by Centers for Medicare & Medicaid Services (CMS) Enrollment is done by Social Security Administration (SSA) for most 4

5 Enrolling in Medicare Automatic for those receiving Social Security benefits Initial Enrollment Period Package Mailed by CMS 3 months before citizens turn 65 For all others Enroll Local SS office On-line at 5

6 Your Medicare Timeline 3 months before age 65 Your birthday month 3 months after your 65 th birthday 3 months to 1 month before you turn 65 The month you turn 65 and up to 3 months after Initial Enrollment Period, when you can first sign up for Original Medicare Sign up early to ensure coverage in the month you turn 65 Initial Enrollment Period continues Waiting could delay your Original Medicare start date 6

7 Election Periods Election Frequency Dates ICEP and IEP for Part D Once in a lifetime When a newly Medicare-eligible individual enrolls in BOTH Part A and Part B at first eligibility, the ICEP and the IEP for Part D occur together as one period. If enrollment in Part B is delayed, the ICEP and IEP for Part D become separate elections. In this instance, the ICEP changes to then occur as the 3 months preceding entitlement to BOTH parts A and B. General Enrollment Period (GEP) Each Year Jan. 1 st -March 31 st. Coverage becomes effective July 1 st. 7

8 Election Periods Election Frequency Dates Annual Election Period (AEP) Medicare Advantage Disenrollment Period Open Enrollment Period for Institutionalized Individuals (OEPI) Each Year Each Year Continuous Oct. 15 th - Dec. 7th Jan. 1 st Feb. 14 th If you switch to Original Medicare during this period, you ll have until Feb. 14 th to add a Part D plan. Continuous for an individual who moves into, resides in, or moves out of an institution and ends 2 months after the month the individual moves out of the institution. Special Election Period (SEP) When Certain Circumstances Apply Depends on specific circumstances (i.e., dual eligible, change in residence, plan termination) 8

9 The Four Parts of Medicare Part A Hospital Insurance (federal government) Part B Medical Insurance (federal government) Part C Medicare Advantage Plans (like HMOs and PPOs). Includes Part A & B and sometimes Part D coverage (private Medicare approved insurers) Part D Medicare Prescription Drug Coverage (private Medicare approved insurers) 9

10 Original Medicare Part A Hospital Insurance (in-patient) Hospital Skilled Nursing Facility Home health care Hospice care Part B Medical Insurance (out-patient) Doctor s visits & services (in hospital or in office) Outpatient hospital services Diagnostic tests Durable Medical Equipment Some preventive services Some mental health services 10

11 Medicare Part A Inpatient / Hospital Insurance You must be enrolled in Part A to obtain the coverage Most people receive Part A coverage premium-free because they paid FICA taxes for at least 40 quarters; otherwise you can pay a premium to get Part A Part A Benefit Period deductible -$1260-You pay that Services must be Medically Necessary to be covered Benefit schedule is based on the number of days you receive inpatient treatment/services in a facility

12 Medicare Part B Outpatient Medical Services Part B Annual Deductible - $147- You pay Medicare generally pays 80% of Medicare eligible charges You pay 20% balance You must enroll in Part B to obtain the coverage You pay a monthly premium for Part B once you enroll Y O U MEDICARE

13 Enrolling in Medicare-Part B ENROLL if: you DON T have coverage from active employment (yours or your spouses) you have group coverage but there are fewer than 20 employees at the company you have individual health coverage you are on COBRA If you are covered by a group health plan offered by a company that has 20 or more employees and you will remain eligible to participate Check with your employer to see how your coverage may change Depending on your situation you may want to delay Part B enrollment No federal penalty is assessed if you enroll while you have group coverage or within 8 months of losing your coverage 13

14 Enrolling in Medicare-Part B Contact social security 90 days prior to your 65 th birthday to enroll Delaying Part B enrollment may mean higher premiums (10% x each 12 month period delayed, permanently) & paying for your health care out-of-pocket Monthly premiums will be based on your Modified Adjusted Gross Income (MAGI) 2 years previous-irmaa 14

15 Monthly Medicare Part B Premium If your Yearly Income in 2013 was You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $ $85,001 $107,000 $170,001 $214,000 $ $107,001 $160,000 $214,001 $320,000 $ $160,001 $214,000 $320,001 $428,000 $ above $214,000 above $428,000 $

16 Not Covered by Medicare Dental care/dentures Hearing aids Routine eye care and eyeglasses Outpatient prescription drugs (covered under Part D) Health care while traveling outside the U.S. Routine foot care Acupuncture Cosmetic surgery 16

17 Not covered by Medicare Long term care/custodial services Medicare only pays for skilled nursing facility care if a medical professional says you need daily skilled care after you ve been in the hospital for at least three days. Length of stay determines coverage and co-pays. Does not pay if you need only custodial services (help with activities of daily living such as bathing, continence, dressing, eating, toileting & transferring). Does not cover homemaker services Does not cover home health aides to give you personal care unless you are getting skilled care in treatment of an illness or injury. 17

18 Current Gaps in Medicare=You Pay Part A Hospital deductible $1,260 per benefit period Part A Hospitalization (days 61-90) $350 per day Part A Hospitalization (days ) $630 per day Skilled Nursing Facility Care (days ) $ per day Skilled Nursing Facility Care (after 100 days) 100% The cost of the First 3 pints of blood if you need a transfusion Part B Annual Deductible $147 per year Most Outpatient Services & Medical Supplies 20% of the total amount Medicare approves Prescription Drug Costs Non-Covered Services 18

19 Decision Tree Or Original Medicare Part A Hospital Insurance Part B Medical Insurance Medicare Advantage Plan (like an HMO or PPO) Combines Part A, Part B and usually Part D Step 2:Need to add drug coverage? Part D Rx drug coverage Step 3: Need Supplemental coverage? Medigap (Medicare Supplemental Insurance) policy End Part D Prescription Drug Coverage (if not already included) End 19

20 Medicare Five-Star Rating System Medicare reviews plan performances & rates them annually with stars 5=excellent 1=poor Based on how well plans perform in various categories System applies to Medicare Advantage Plans Part D prescription drug plans System does not apply to Medicare Supplement/Medigap Plans These are usually rated on financial stability by AM Best 20

21 Part C Medicare Advantage Health plan options approved by Medicare o Alternative way to get Medicare coverage o Doesn t fill in the gaps of Original Medicare o Run by private companies You pay a monthly premium Usually requires you to use network doctors or hospitals o Like an HMO o Usually geographic-based network o Includes co-pays, coinsurance and deductibles 21

22 Medicare Advantage Plans Most bundle coverage Include Part D prescription drug plan Must accept Part D plan that is integrated into your plan May include coverage for dental, vision, hearing services May need a referral to see a specialist Can only join/leave plan during certain periods Doesn t work with Medigap policies You must have Part A and Part B to join 22

23 Part D Medicare Prescription Drug Coverage Helps cover some of the costs of prescription drugs Provided through Medicare Prescription Drug Plans Private companies Stand-alone plans Medicare Advantage Plans Private companies Usually included as part of the plan Other Medicare plans 23

24 How Medicare Part D Works You must have Part A and/or Part B You must live in the plan s service area You must complete an application & enroll to join You may have to pay a permanent federal penalty if you don t enroll in a plan during your IEP or SEP or you are without creditable coverage for more than 63 days (1% of national average Part D monthly premium x number of months you were eligible and not covered). 24

25 How Medicare Part D Works Plans have formularies Lists of covered drugs Each formulary must include range of drugs in each category Formularies vary by insurer You pay deductibles & copayments You pay a monthly premium to the insurance company May be impacted by your income-irmaa 25

26 Monthly Part D IRMAA Surcharge If your Yearly Income in 2013 was File Individual Tax Return File Joint Tax Return In addition to your monthly PDP premium you pay $85,000 or below $170,000 or below $85,001 $107,000 $170,001 $214,000 $12.30 $107,001 $160,000 $214,001 $320,000 $31.80 $160,001 $214,000 $320,001 $428,000 $51.30 above $214,000 above $428,000 $

27 Allowable Coverage Rules in a Part D Plan Prior Authorization- May require that you contact the plan for approval before the prescription can be filled. May have to prove that prescription is medically necessary. Quantity Limits- Limits on how much you can get at one time. Step Therapy- May require you to try one or more similar, lowercost drugs before the plan will cover the preferred prescription drug. 27

28 Enrolling in a Part D plan Consider Do you have creditable drug coverage, coverage as good as Medicare, through a group health plan, for example? Will that coverage end when you retire? What is the annual retail cost of all your prescription drugs? What do the premiums cost for Part D plans? 28

29 Medicare Part D Cost Sharing 15 5% paid by participant Catastrophic Coverage 15% paid by plan 80% paid by Medicare Initial Coverage Limit $2,960 25% paid by Participant Name Brands (50% Discount) 45% paid by Participants 5% paid by Plan Generics 65% paid by Participant 35% paid by Plan 75% paid by Plan Donut Holt $4,700 OOP Deductible $ % paid by Participants 29

30 $100 Retail Brand-Name Drug Yearly Deductible Initial Coverage Coverage Gap/ Donut Hole Catastrophic Coverage Mr. Smith pays $100 because his deductible has not yet been met. Once the $320 deductible is met Mr. Smith pays an average of $25 and the plan pays $75 according to the CMS Standard Plan. $100 is applied toward the run-up to the $2,960 limit for the initial stage. $345 ($320 + $25) applies toward OOP maximum for the year. The $100 brand-name drug is discounted 50% by the manufacturer in the donut hole so the cost is now $50. Mr. Smith pays 45% of the $50, or $22.50 for the drug. $50 + $22.50 are applied to his OOP maximum for a total of $ If it were a generic drug, he would pay $65, which would be applied to the OOP maximum. Mr. Smith would pay a maximum of 5% of the $100 drug cost in this stage, or $5. 30

31 Medigap Also referred to as Medicare Supplement Insurance Sold by private companies approved by Medicare Fills some or all of the gaps in Original Medicare Deductibles, coinsurance, copayments Standardized plans as mandated by Medicare All plans with the same letter offer the same coverage across all carriers Only the premiums are different All companies have to offer Plan A but don t have to offer the other plans You must have Medicare Part A & B to enroll in a Medigap plan You pay a monthly premium 31

32 Medigap You are not limited by a network of providers Statewide coverage National coverage You do not need a referral to see a specialist You can initially join during your Medigap Open Enrollment Period Begins first day of the month you turn 65 Lasts 6 months 32

33 = gaps in coverage *Plan F has a high-deductible option 33

34 Summary--- the coverage expansion options available to Medicare-eligible individuals are: Medicare Part D Prescription Drug Plans Medicare Advantage Plans Individual Medigap Plans 34

35 MDA exclusively offers an additional coverage expansion option: The MDA Retiree Health Plan For MDA members, their spouses and employees age 65+ who are either actively working or retired 35

36 Medicare and Gap Coverage Considerations Does your income impact your Part B and D monthly premiums? What are your individual health care needs? What is the annual retail cost of your prescription drugs? What other group coverage, if any, is available to you? If available how many employees? Do you regularly travel outside the State of Michigan? Do you travel outside of the U.S.? Do you prefer a closed provider network or the ability to receive services from the providers of your choice? How do the options impact your OOP$? 36

37 What is your preferred coverage strategy going forward? 37