SHIBA Senior Health Insurance Benefits Assistance

Transcription

1 Your Medicare Health Plan Choices SHIBA Senior Health Insurance Benefits Assistance

2 In compliance with the Americans with Disabilities Act (ADA), this publication is available in alternative formats. Call (503) or (503) (V/TTY).

3 Table of Contents Introduction...1 What is Medicare?...1 Medicare Part A Benefits...2 Medicare Part B Benefits...3 What is Medigap?...3 What is Medicare Advantage?...4 HMO...4 PPO...5 PSO...5 PFFS...5 How to choose a health plan...5 How to pay what Medicare doesn t...7 What about prescription drugs?...7 Should I buy a Medigap or MA plan?...8 Enrollment & election deadlines...9 Medicare Part A...9 Medicare Part B...9 Medigap...10 Medicare Advantage...11 Your Medicare rights...11 Terms to know...12 Internet resources...14 Publications...14 This publication was produced by the State of Oregon with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services (CMS), the federal Medicare agency. If you have difficulty reading or understanding this information, please call SHIBA, (800) , for assistance or to request this publication in an alternative format.

4 Introduction People with Medicare have several opportunities to make health insurance choices. These choices include Medicare Advantage, Medigap insurance, and original Medicare with Part A and Part B. SHIBA (Senior Health Insurance Benefits Assistance) can help people understand what is important to consider when making these choices. What is Medicare? Medicare is a federal health insurance program for some United States residents. It pays for many health-care expenses, but it does not cover all healthcare expenses. Medicare has copayments or coinsurance, which means that Medicare pays for part of the services that it covers after the first portion of the charges have been paid by you or your insurance. People who may be eligible for Medicare are those who are 65 or older or are any age and have received Social Security disability payments for 24 months. Other people also may be eligible for Medicare. All questions about eligibility for Medicare should be directed to your local Social Security office. The health-care services that Medicare covers are divided into two types: Part A for hospital care and Part B for doctor visits. Some of every worker s wages automatically go into a Medicare fund. People who have worked and paid into Medicare for 10 years or more do not have to pay for Part A when they go on Medicare. The Medicare payroll deductions that they paid while working are considered to have paid for their Medicare Part A premiums. Residents 65 or older and 1

5 some people with disabilities who have not worked for 10 years but have lived legally in the U.S. for at least five consecutive years can purchase Medicare by paying monthly premiums. Everyone who is on Medicare Part B must pay Part B premiums. The amount of the premium is determined at the beginning of each year. In 2004, the Medicare Part B premium cost is $66.60 a month. The premium amount is taken out of Social Security, Railroad Board, or civil service retirement payments automatically. If a person on Medicare does not receive Social Security payments, he or she is billed for Medicare Part B premiums four times a year. There are Medicaid programs to help people pay their Medicare premiums, if they qualify. Medicare Part A Benefits Medicare Part A helps pay for medically necessary care if you are admitted to a hospital. Part A also pays for care in a skilled nursing facility after an approved hospital stay, and for home health care. For people who are terminally ill and their caregivers, there are many flexible services available under the hospicecare benefit. For people on original Medicare, Part A has a deductible that must be paid before Medicare begins to pay for hospital charges. 2

6 Medicare Part B Benefits Part B helps pay for doctor bills, outpatient hospital visits, home health services, certain ambulance services, and durable medical equipment. Part B also helps pay for X-rays, physical and occupational therapy, speech and language pathology services, mental health care, home health care, and some preventive services. For people on original Medicare, Part B has a deductible of $100 in 2004 ($110 in 2005) that must be paid before Medicare begins to help pay for most doctor bills and other services covered by Part B. After the Part B deductible is paid, Medicare pays 80 percent of most covered charges. What is Medigap? In 1990, Congress created 10 standard types of Medicare supplement plans to fill the gaps in original Medicare. These are called Medigap plans A through J. People who are on original Medicare can purchase a Medigap plan from one of many private insurance companies. The Medigap plan pays for some of the medical expenses that Medicare Parts A and B don t cover, such as coinsurance, additional days in the hospital, and deductibles. 3

7 What is Medicare Advantage? In 1997, Congress expanded the 30-year-old Medicare program by adding Medicare+Choice (M+C) plans, in which private companies contracted with Medicare to offer managed care and private fee-forservices insurance. The 2003 Medicare Modernization Act change the name to Medicare Advantage (MA) and improved its benefits to providers and beneficiaries. Medicare pays the MA plans to take care of all of the members health-care needs. Members of MA plans pay a monthly premium to the plan, and their Medicare Part B premium. Members pay copayments and sometimes deductibles; however, they do not pay doctor bills. People who have kidney failure (ESRD) usually are not eligible to enroll in MA plans. Following are descriptions of the types of MA plans available in Oregon: HMO A health maintenance organization (HMO), also called a managed-care organization (MCO), is a group of doctors, hospitals, and other health-care providers that provides all health-care services to its enrolled patients in a specific area. HMOs offer all Medicare-covered services and may add extras, such as expanded preventive measures, prescription drugs, hearing exams, and vision services. Most regions in Oregon are served by at least one HMO, but some rural areas have none. Enrollees must see providers who are part of the network and copayments are charged for most services. Some plans have no deductibles, and some charge deductibles for out-of-network providers. 4

8 PPO A preferred provider organization (PPO) is a variation of managed care. It works like an HMO except you may go to a doctor who is not in the network and the plan will still pay a portion of the cost. PSO Oregon s only provider-sponsored organization (PSO) is Clear Choice, which serves Central Oregon. Clear Choice is an HMO owned and operated by local health-care providers. PFFS Sterling Life Insurance Company offers a nationwide, single-payer, private fee-for-service (PFFS) plan that operates a lot like original Medicare in that its members can go to any health-care provider in the nation that will accept their insurance, including specialists. The difference is that, like all MA plans, Sterling handles the billings and Medicare paperwork for its members. See the SHIBA Consumer Guide to Oregon Medigap & Medicare Advantage Plans for Sterling Life availability. How to choose a health plan Start by listing the individual s health care needs. With a calculator, add up all healthcare expenses for one year, including premiums, deductibles, copayments, medications, and uncovered out-of-pocket expenses. Using detailed descriptions of plan benefits, do the same for a year s worth of expenses under several different health plans. Include MA 5

9 plans that are available in the area, plus original Medicare with and without a Medigap supplement. Choose Medigap plans that cover some of the individual s particular health care needs. Consider high- and low-deductible Medigap plans. Calculate and compare the annual and monthly costs of different plans. Also consider the following important questions: Will the doctors that you prefer accept patients on Medicare? Are the doctors that you prefer in a Medicare Advantage network? For original Medicare, do your doctors accept assignment meaning do they accept the Medicare-approved amount for their services as payment in full? If providers do not accept assignment, you may have to pay them more of your own money, unless you buy a Medigap plan that covers Part B excess charges. Do you need specialized or routine care? If you need specialized care, how long will it take you to get to your specialist? For MA, will you need to see a primary care physician first to get a referral? Will the plan allow you to designate a specialist as your primary care doctor? Is it convenient for you to get to doctors that you need to see often? 6

10 How to pay what Medicare doesn t Some ways to cover health-care costs, Medicare deductibles and copayments, prescriptions, and other charges: Personal funds (income, savings, and credit accounts) Medicaid, for people who meet low-income criteria Insurance through an employer (yours or your spouse s) Medicare supplement or Medigap insurance Medicare Advantage plan Veterans Administration (VA) hospitals (U.S. military veterans) Tricare (U.S. Department of Defense health insurance program) What about prescription drugs? Medicare has a limited drug benefit which generally only covers chemotherapy, immunosuppressives, and hospice-related drugs. Medicare s new prescription drug discount card will save percent on your total drug costs. The Medicare-approved card may cost $30. CMS offers a free card and $600 credit for low-income beneficiaries. Contact SHIBA for more information. The discount card and assistance program ends January 1, 2006, when the new Medicare Part D becomes available. Medicare plans H, I, and J offer some prescription drug coverage. For other options, contact SHIBA. 7

11 Should I buy a Medigap or MA plan? Medigap plans are for people covered by original Medicare who receive their health-care benefits through Medicare Part A and Part B. Some gaps in coverage between Parts A and B are paid by the Medigap plan. People who buy a Medigap plan receive benefitsummary notices from the private insurer that provides their Medigap plan. They also receive Medicaresummary notices from both the Medicare Part A and Part B carriers and statements from doctors and other health-care providers. Sometimes people have to call their doctor s offices, private insurers, or Medicare Parts A and B office to correct billing and payment errors. SHIBA can help with this. Medicare Advantage plans streamline the process of paying health-care providers: the patient pays a monthly premium to the plan, and the government pays a certain amount to cover all of the plan members health-care needs. Health-care providers are paid by the plan, which also sets up terms and conditions that plan members and providers agree to follow in order to have medical expenses covered. If the plan requires copayment, the patient pays that amount directly to the provider at the time of the visit. Other than that, there are no doctor bills. It is unlawful for an insurance agent to sell a Medigap plan to a person enrolled in MA because both types of plans cover some of the same things. 8

12 Enrollment & election deadlines Your choices in Medicare can be limited by enrollment and disenrollment deadlines: Medicare Part A Initial: From three months before you turn 65 to three months after. If you are already receiving Social Security or Railroad Retirement payments, enrollment is automatic. General: Automatic at age 65, unless a premium is charged; then January, February, and March each year; coverage begins July 1. Late penalty: None, unless a premium is charged; then add to the premium 10 percent for double the number of years delayed. Medicare Part B Initial: From three months before you turn 65 to three months after. General: January, February, and March each year; coverage begins July 1. Special: 1-8 months after you are no longer covered by your or your spouse s employer group health plan. You or your spouse must have been working when covered. Late penalty: Premium increases 10 percent each 12 months you wait. Penalty lasts indefinitely. 9

13 People receiving Social Security benefits due to disability are automatically enrolled in Medicare after they have received cash benefits (SSDI) for 24 months. People with amyotrophic lateral sclerosis (Lou Gehrig s disease) are automatically enrolled in Medicare when they first receive Social Security disability benefits. People who receive continuing dialysis for permanent kidney failure are eligible for Medicare the third month after treatment begins or, if they have had a kidney transplant, the month they were admitted to the hospital. They must be eligible for Social Security cash benefits on their own record or that of a spouse, and must enroll for Medicare through the Social Security Administration. Medigap Open: 1-6 months from the Part B effective date on your Medicare card. General: Anytime, at the plan s discretion. May charge you more or refuse to insure you due to your health conditions. Special/guaranteed issue: 63-day period for Plans A, B, C, and F from date previous plan ends if you lose coverage through no fault of your own. Late penalty: May cost more. If beyond open enrollment and guaranteed-issue periods, insurer may refuse to insure you due to health conditions. In Oregon, all people enrolled in Medicare Part B have an open enrollment for Medicare supplement/medigap insurance. See Medigap open enrollment above. 10

14 Medicare Advantage Initial: The three months before you turn 65. Annual: November 15-December 31 of each year; coverage begins January 1 of the following year. Special: From October 1-December 31 if the plan announces it is leaving Medicare, plus 63 days after leaving a discontinued plan or moving out of the plan s service area. Open: Continuous open enrollment until December 31, 2004, providing the plan is open for new enrollment. Late penalty: None. Plans may be closed if full. The Medicare Advantage initial-election period for people with disability begins three months before entitlement to Medicare Part A and B. People with kidney failure are not eligible for Medicare Advantage plans. Your employer group health plan (EGHP) will pay first and Medicare will pay second for a 30-month period. At the end of the 30-month period, Medicare will pay first, and your EGHP may pay second. For more information, see the federal publication, Medicare Coverage of Kidney Dialysis and Kidney Transplant Services on Medicare s Web site, or order by calling (800) , Medicare s toll-free hotline. Your Medicare rights As a Medicare beneficiary, you have certain guaranteed rights. These rights protect you when you get health care. You have these rights no matter what kind of Medicare health plan you have. Your Medicare rights includes: Protection from discrimination in marketing and enrollment practices. 11

15 Emergency care when needed. Information in a language that you can understand. Information about all treatment options available to you. Information about how Medicare pays doctors, what is covered, and how much you have to pay. Direct access to a specialist for those who have a serious or complex medical condition. A women s health specialist. If you think that any of your rights have been violated, please call SHIBA (Senior Health Insurance Benefits Assistance), (800) , to get help from a volunteer assistant near you. Terms to know Accept assignment: When a health-care provider charges only the Medicare-approved amount. CMS: Centers for Medicare & Medicaid Services, the federal Medicare agency. Carrier: A private company hired by CMS to process Medicare billings and payments. Coinsurance: A percentage of covered expenses that insurance does not pay. Copayment: A set amount that you pay for each covered medical service you get, such as a doctor s appointment. Deductible: A certain amount for covered expenses that must be paid before insurance will start to pay its benefits. Enrollment/election: A period during which you can choose or change insurance plans. 12

16 Fee-for-service: When an insurer pays a provider for services after receiving a bill. Managed care: Health insurance and health services combined into one. Medicaid: A state and federal health-assistance program for people with low incomes and limited resources. Medicare: A federal health-insurance program for certain U.S. residents. Medicare Advantage (MA): Health insurance options that fill the gaps in Medicare coverage and may offer additional benefits. Medicare Summary Notice (MSN): A form describing what Medicare paid and did not pay on a claim. Medicare Part A: Federal health insurance that helps pay for hospital and skilled nursing facility stays, and for home health and hospice care. Medicare Part B: Federal health insurance that helps pay for visits to the doctor, ambulance services, therapy services, outpatient hospital services, equipment and supplies, and home health care. Part B excess charges: The amount that a patient or Medigap insurer has to pay when a doctor does not accept assignment for services. Premium: A payment for insurance, usually paid monthly. Primary care physician (PCP): A doctor who provides most of the medical care a patient needs. Provider: A doctor, therapist, home-health agency, hospital, or anyone who provides and bills for health-care services. 13

17 SHIBA: Senior Health Insurance Benefits Assistance, a program of the Oregon Insurance Division and CMS that offers free help to people on Medicare. Every state and U.S. territory has a Medicareassistance program similar to SHIBA. Internet resources Publications Available free of charge from SHIBA and the Oregon Insurance Division. Go to our Web site, or call toll-free in Oregon (800) , or call (503) SHIBA Consumer Guide to Oregon Medigap & Medicare Advantage Plans Your Medicare Health Plan Choices Free Help with Medicare and Other Health Insurance Consumer Guide to Oregon Insurance Complaints Oregon Long-Term-Care Insurance: Companies and Consumer Tips Medicare and You Choosing a Medigap Policy Guide to Health Insurance for People with Medicare Consumer Guide to Health Insurance A Shopper s Guide to Long-Term Care Insurance NAIC 14

18 About the Oregon Insurance Division The mission of the Insurance Division is to administer the Insurance Code for the protection of the insurance-buying public while supporting a positive business climate. We ensure the financial soundness of insurers, the availability and affordability of insurance, and the fair treatment of consumers by: Licensing insurance companies and monitoring their solvency. Reviewing insurance products and premium rates for compliance. Licensing insurance agents and consultants. Resolving consumer complaints. Investigating and penalizing companies and agents for violations of insurance law. Monitoring the marketplace conduct of insurers and agents. Educating the public about insurance issues. Advocating reforms that protect the insurancebuying public.

19 SHIBA Senior Health Insurance Benefits Assistance Senior Health Insurance Benefits Assistance P.O. Box Salem, OR (3/04/COM)