Making the Most of Medicare

Transcription

1 A Step-by-Step Guide to Getting More from Your Benefits Making the Most of Medicare

2 Making the Most of Medicare Few things are more important than your health. That s why it s nice to know that Medicare can help pay for your health care needs. Medicare covers more services and offers more coverage options than ever before. But with so many choices, finding the right Medicare plan can seem downright complicated. Choices are a good thing. After all, everyone is different. Maybe you re enrolling in Medicare for the first time. Or maybe you want to change your current coverage plan. This booklet can help you weed through the choices. Follow each step. You ll have a better sense of what you need and how to use Medicare coverage to your benefit.

3 Step 1 Understand How Medicare Works To build your Medicare plan, you need to understand the basics. What Are the Basics? Medicare is a federal health insurance program for adults ages 65 and older who are eligible. It s also available to people younger than age 65 with kidney failure or certain disabilities. There are four parts. Each one helps pay for different health care costs. The parts are named after alphabet letters. The letters can help you remember the insurance each part provides: Part A acts as hospital insurance. Part B brings medical insurance. Part C is available through private health plans and combines hospital, medical and sometimes prescription drug coverage. Part D deals with prescription drug coverage. You can qualify for Medicare in many ways. First, you need to know if you want to enroll in Original Medicare (Part A and Part B). What Does Original Medicare Offer? Part A and Part B complement each other. Part B helps pay for some services that Part A doesn t cover. Part A (hospital insurance) helps pay for: Your inpatient care in hospitals. For example, Part A will help cover the cost of a shared hospital room, meals and nursing. It also can assist with costs associated with hospice, home health and skilled nursing facility care if you meet certain requirements. Making the Most of Medicare 1

4 Part B (medical insurance) helps pay for: Services that are considered important for the diagnosis or treatment of a medical condition. These include: Doctor visits Procedures that didn t require an overnight hospital stay Some preventive care services, such as flu shots What it costs: If you or your spouse paid Medicare taxes while working, you may not have to pay a premium (or monthly fee) for Part A services. If you don t qualify for premium-free Part A, you can purchase it. To learn if you qualify for Part A at no additional cost, contact Medicare. Most people pay a monthly premium for Part B. It is typically taken out of your Social Security check. Some people pay more or less for their premiums based on their income. For Original Medicare (Part A and Part B), you also may pay: A deductible, a set amount you pay every year before Medicare coverage begins The entire cost of services not covered by Medicare Co-insurance, or a portion of what the Medicare-approved service costs. In most cases, you pay 20 percent. Why Choose Coverage Beyond Original Medicare? Original Medicare only helps pay for certain medical costs. For additional coverage, you can opt for Medicare Part C or enroll in Part D. You also may select a Medicare supplemental insurance policy. Some parts of the U.S. may offer other Medicare options, such as a medical savings plan.

5 Part C (Medicare Advantage plan): Medicare Part C provides an alternative coverage option called a Medicare Advantage plan. Private companies approved by Medicare provide the plans. To qualify for a Medicare Advantage plan, you must: Live in the plan service area Be entitled to Medicare Part A Be enrolled in Medicare Part B In most cases, you cannot have end-stage renal disease. What Part C helps pay for: Medicare Advantage plans provide your Medicare Part A and Part B benefits. They also help pay for health care services not covered by Original Medicare. For example, some Medicare Advantage plans may offer: Routine eye and dental care Hearing aids and eyewear Wellness programs Discount programs for services and products, such as acupuncture and vitamins There are many different Medicare Advantage plans. Some may include Medicare Part D prescription drug coverage. (See Page 4 for more on Part D.) Here s an overview of common Medicare Advantage plans: Health Maintenance Organizations (HMOs) If you enroll in an HMO, you choose a primary care physician who is responsible for managing your medical needs. Should you need care from a specialist or other provider, the primary care physician can authorize these services. Care that is provided, arranged or authorized by the HMO plan and the primary care physician within the HMO network will be covered. Preferred Provider Organizations (PPOs) PPOs allow members to visit any doctor they wish. But members often pay more to see doctors who don t belong to their preferred provider network. No referrals to specialists are necessary, in most cases. Point of Service (POS) plans POS plans are HMOs that allow you to get some out-of-network services at in-network costs. Private-Fee-for-Service (PFFS) plans A PFFS plan will cover services from providers who accept Medicare and the plan s payment terms. But doctors can refuse to accept the plan and its terms. Doctors also don t have to agree to treat patients from the plan. The government requires PFFS plans to have provider networks. Making the Most of Medicare 3

6 Medicare alone or with a supplemental insurance policy. Or, in certain circumstances, they are in a PFFS plan or another Medicare Advantage plan that does not include Part D. Special Needs Plans (SNPs) SNPs are available for people who meet certain qualifications. These include people with a chronic illness, older adults with limited income and those who live in a nursing home. What it costs: Medicare Advantage plans typically require you to pay a premium. You must continue to pay your Part B premium. These plans sometimes have lower deductibles and co-insurance for Medicare-approved services. It s a good idea to call these plans before enrolling in them to determine what services cost. Part D prescription drug coverage: Medicare Part D helps cover your costs for prescription drugs. Medicare Part D plans are run by private companies approved by Medicare. To receive this benefit, you must enroll in a private plan. There are two ways to enroll in Medicare Part D: 1. You can enroll in a Medicare Advantage plan that offers Part D coverage. 2. You can join a stand-alone Medicare prescription drug plan (PDP). This is an option for people who want drug coverage but still want Original What Part D helps pay for: Medicare drug plans cover commonly used brandname and generic drugs. They typically don t cover over-the-counter medicines. Drugs that are covered can vary. And some plans offer more drugs than others. What it costs: Higher-income beneficiaries must pay a monthly income-related premium for Part D benefits. In addition to the Part D premium charged by the government, you may also have a monthly premium charged by the plan. Additional costs may include an annual deductible and co-insurance or copayments. If you have limited financial resources, you may qualify for extra help with Part D plan premiums, co-insurance and copayments. Certain organizations, such as the Social Security Administration, offer financial assistance. To learn more, see Page 16. Also, most Medicare drug plans have a coverage gap. After you and the plan spend a certain amount on prescriptions, coverage stops. You are responsible for paying any future prescription costs until you reach a predetermined amount. Now, if you reach the coverage gap for your Medicare prescription drug plan, you may qualify for savings on brand-name and generic drugs. 4 Making the Most of Medicare

7 You can build the Medicare plan that s right for you. You can pull together different types of Medicare coverage into one package. Or you can opt for an all-in-one Medicare Advantage plan that combines the different parts. Part A Hospital Insurance + Part B Medical Insurance Part C Medicare Advantage Plan (Includes Medicare Part A, Part B and often Part D) + Part D Prescription Drug Coverage Making the Most of Medicare 5

8 Step 2 Understand Your Needs Clearly identify your needs and preferences before you select a plan. Even if you re not enrolling for the first time, your circumstances may have changed since the last Medicare plan election period. The questionnaire on the following pages can help. Your answers can provide a foundation for choosing the type of coverage that s right for you. 6 Making the Most of Medicare

9 Questionnaire page one Ask yourself: Yes No If No, you can: Do I qualify for Medicare Part A? Most people automatically qualify at age 65 and pay no premium. Some exceptions apply. For details, contact Medicare at MEDICARE ( ) (TTY: ), 24 hours a day, seven days a week. Should I sign up for Part B now? Enroll when you re eligible in order to avoid extra costs. If you wait, you will pay 10 percent more for each year that you qualified and didn t enroll. There are some exceptions. One exception is that you recently had group health insurance through a current or former employer. Can I afford to pay the health care costs Original Medicare doesn t cover? You will pay: Part A and Part B deductibles before coverage begins A monthly premium for Part B 20 percent of the amount Medicare approves for the medical services it covers 100 percent of the cost for services not covered by Medicare Do I have special needs? Consider a Medicare Advantage Special Needs Plan if you: Have a qualified disabling illness Live in a facility such as a nursing home Think about buying Part A coverage if you are age 65 or older or are disabled and have returned to work. To receive Part A benefits, you may have to enroll in Part B and pay its monthly premium. To enroll in a Medicare Advantage plan, you need to be enrolled in Part B. If you had group health insurance, you can enroll in the Special Enrollment Period. (See Page 13 for enrollment dates.) Consider other plan types, such as a Medicare Advantage plan. You can compare plan costs and coverage online at The worksheet on Page 10 can help you determine what you can afford to pay each month for health care. Assistance programs are available for those who are eligible for financial help. (See Page 16.) Choose either Original Medicare or a different Medicare Advantage plan. If you have group retiree benefits, check with your employer or union to determine how it works with Medicare. Making the Most of Medicare 7

10 Questionnaire page two Ask yourself: Yes No If No, you can: Do I want prescription drug coverage? You can get Medicare Part D prescription drug coverage by enrolling in a stand-alone Medicare prescription drug plan. Most Medicare Advantage plans also offer the coverage. Does the plan cover my prescription drugs and include my pharmacy in its network? Remember: Medicare drug plans vary in what they cover and cost. Some plans do cover certain drugs during the coverage gap. Do I want coverage for hearing aids, routine eye exams and dental services, and extra preventive care not covered by Medicare? Medicare Advantage plans often offer these additional benefits. You may pay extra for them. Is my current doctor in a Medicare Advantage plan network? If your doctor is in a Medicare Advantage HMO or PPO network, consider joining it. You can save money. Even if you don t take medicine now or don t think you need coverage, you still may want to consider enrolling in Part D through a private plan. It will protect you from unforeseen expenses. Also, you may have to pay a penalty if you join later. To find a plan that provides prescription drug coverage, visit You can search each company s formulary, benefits, costs and pharmacy network. Consider Original Medicare. Consider Original Medicare or a Medicare Advantage PPO that lets you see doctors outside their network. Or ask if your doctor accepts a Medicare Advantage PFFS plan s payment terms. 8 Making the Most of Medicare

11 Questionnaire page three Ask yourself: Yes No If No, you can: Do I want a primary care physician who will coordinate my specialty care? Opt for a Medicare Advantage HMO plan. Your PCP and your specialists will work together on your plan of care. Most services require a referral from your PCP. Am I willing to pay more so that I can receive care from any provider? You ll pay more out of your pocket for plans such as Medicare Advantage PPOs or Original Medicare. But they help cover services from most providers. Do I live out of state part of the year? Snowbirds, adults who spend the winter in warm climates, need a plan that covers routine preventive services anywhere in the U.S., such as a Medicare Advantage PPO or PFFS plan. Some Medicare Advantage HMOs also offer out-of-state travel benefits for snowbirds. Do I need coverage for traveling abroad? Select a Medicare Advantage plan that covers emergency care in foreign countries. Opt for Original Medicare or a Medicare Advantage PFFS or PPO plan. If doctors and hospitals you like are in a network and cost is an issue, a Medicare Advantage HMO plan is a good choice. You must stay in the network to receive most benefits. A Medicare Advantage PFFS or PPO plan are alternative options. Join a Medicare Advantage HMO plan if you stay in your service area and can easily access network providers or if the HMO meets your coverage needs when you re traveling. In an emergency, you are covered anywhere in the U.S. Consider a less costly policy that covers only basic benefits. Making the Most of Medicare 9

12 Monthly Budget Worksheet This worksheet can help you estimate how much money you can afford to spend on health care each month. Monthly Income Source 1 $ Source 2 $ Other income $ A. Total Monthly Income $ Fixed Expenses Mortgage/rent $ Loan(s)/debt $ Property taxes $ Homeowner s/renter s insurance $ Life insurance premiums $ Auto insurance premiums $ Cable TV $ Internet service provider $ Other $ B. Total Monthly Fixed Expenses $ Variable Expenses Groceries $ Electricity $ Natural gas/heating oil $ Water and sewer $ Telephone (home/cell) $ Auto (gas/maintenance) $ Clothing $ Personal grooming $ Entertainment/travel $ Gifts/donations $ Miscellaneous $ C. Total Monthly Variable Expenses $ D. Total Monthly Expenses (line B + line C) $ Summary Income (line A) $ Minus total expenses (line D) $ E. Amount Available Monthly for Health Care Expenses (Medicare premiums, plan premiums, copayments and deductibles) $ 10 Making the Most of Medicare

13 Step 3 Enroll in a Plan As you plan your Medicare coverage, be sure to understand the enrollment rules for the plans you re considering. Here are the answers to some frequently asked questions. Q. When can I enroll in Medicare? A. If you will be eligible for Social Security, you will be automatically enrolled in Original Medicare Parts A and B. Your coverage will begin the first day of the month you turn age 65. If you aren t getting Social Security, contact Social Security three months before you turn age 65 to sign up for Medicare. Q. Do I have to enroll in Medicare Part B and pay the monthly premium to enroll in a Medicare Advantage plan? A. Yes. In most cases, if you enroll in a Medicare Advantage plan, you must continue to pay your Part B premium. Q. When can I enroll in a Medicare Advantage plan? A. You can join one when you first become eligible for Medicare. You re eligible three months before you turn age 65 until three months after. If you re already enrolled in Original Medicare, you can join a Medicare Advantage plan Making the Most of Medicare 11

14 during the fall Open Enrollment Period. (See the chart on Page 13 for time frames.) Q. Can I change Medicare Advantage plans if the one I enrolled in isn t quite right for me? A. Yes, you can switch once a year during the Open Enrollment Period. The enrollment dates and rules are the same as those for joining a Medicare Advantage plan for the first time. (See the previous question.) To change, just join a new Medicare Advantage plan. You will be automatically disenrolled from the old plan when your new coverage begins. You also can switch from a Medicare Advantage plan to Original Medicare during the Annual Disenrollment Period. (See the chart on Page 13 for time frames.) During the Annual Disenrollment Period, you can disenroll from your Medicare Advantage plan and choose Original Medicare. You can also enroll in a separate Medicare prescription drug plan if you switch to Original Medicare during this time. Q. What if I need to join or change Medicare Advantage plans outside the designated times? A. You can only do so in special circumstances. These include if you: Move out of your existing plan s service area Live in an institution such as a nursing home Qualify for extra help, such as if you receive both Medicare and Medicaid, get Supplemental Security Income or apply for and receive financial assistance Q. Can I enroll in both a Medicare Advantage plan and a supplemental policy? A. No. If you have a Medicare Advantage plan, you don t need (and can t buy) a supplemental policy. Q. Can I enroll in both a Medicare Advantage plan and a stand-alone prescription drug plan (PDP) for drug coverage? A. In most cases, no. If your Medicare Advantage plan offers drug coverage, you usually have to use that plan s drug coverage. In most cases, if your plan offers drug coverage and you enroll in a stand-alone PDP anyway, you will be disenrolled from the Medicare Advantage plan and returned to Original Medicare. Important Dates to Remember Are You Turning 65? Three months before you turn 65, call Social Security at (TTY: ), 7 a.m. to 7 p.m. Monday through Friday, to determine your Medicare eligibility. If you already get Social Security benefits, you may be automatically enrolled. (Continued on next page) 12 Making the Most of Medicare

15 When to Sign Up You can first sign up for Medicare and additional coverage during the Initial Enrollment Period shown below. 3 months to 1 month before turning 65 Sign up early to avoid a delay in coverage. The month you turn 65 and up to 3 months after turning 65 If you wait until the last four months of your Initial Enrollment Period to sign up, your coverage start date will be delayed. Source: Centers for Medicare & Medicaid Services If you don t sign up for Medicare Part A and Part B at this time, you can apply during the General Enrollment Period, which occurs January through March each year. But you may have to pay a higher premium for late enrollment. You may qualify for the Special Enrollment Period in certain circumstances. Call the plan for details. Are You Already Enrolled? Each year you can choose whether to keep or change your Medicare coverage. Here are some time frames to remember. For exact dates, visit Time frame October 15 through December 7 January 1 January 1 through February 14 Event Fall Open Enrollment Period During this time, you can: Join a Medicare Advantage medical plan or Part D prescription drug plan Switch a Medicare Advantage medical plan or Part D prescription drug plan Change from a plan that includes Medicare Part D prescription drug coverage to one that does not Disenroll from a Medicare Advantage plan If you joined a new plan, new coverage begins. Annual Disenrollment Period During this time, you can disenroll from your Medicare Advantage plan and choose an Original Medicare plan instead. If you switch to Original Medicare during this time, you can also enroll in a separate Medicare prescription drug plan. After the Annual Disenrollment Period ends, only people who are enrolling in Medicare for the first time or have special circumstances can join or change Medicare plans. Call the plan for details. Note: If benefits are available to you through an employer group plan, contact the benefits administrator for enrollment information. Making the Most of Medicare 13

16 Step 4 Maximize Your Benefits Even if you re watching your pennies, you shouldn t sacrifice your health. Here are some tips to help you minimize costs and maximize your benefits. To Save Money on Health Care Don t pay for duplicate coverage. If you get group benefits from a current or former employer or union, ask the administrator how they compare and coordinate with Medicare before selecting an option. Compare your group plan s costs and benefits against Original Medicare and a Medigap policy or a Medicare Advantage plan. Make sure your provider accepts Medicare before receiving services under Original Medicare. Otherwise you may pay up to 15 percent more than the Medicare-approved amount. If you have a Medicare PFFS plan, also ask if the provider accepts the plan s specific payment terms. Stay in the network if you have a Medicare Advantage HMO or PPO. These plans may negotiate lower rates with providers in their networks. Take advantage of them! Schedule your physical. You are entitled to a free physical exam within the first year under any Medicare 14 Making the Most of Medicare

17 plan that includes Part B. Beginning in 2011, annual physicals are covered. Get covered immunizations and preventive health screenings. Prevention is half the battle to staying healthy. Get flu shots, mammograms or prostate cancer tests and other covered screenings to catch problems early, when they re most treatable. Most preventive services are now covered. Check with your plan. Take advantage of benefits for special conditions. People with diabetes, for example, may be eligible for two free fasting plasma glucose screenings annually. The Part B deductible and co-insurance do not apply. To learn what s covered, visit Use discount programs. From chiropractic services to vitamins to weight-loss programs and more, discount programs can save you a bundle. Find out if your plan offers them. Keep abreast of changes in coverage. Make sure to read information you receive from Medicare and your health plan coverage provider. To Save Money on Drugs Stay within the pharmacy network. This will help you pay less for your covered prescription drugs. Go generic. Ask your doctor to prescribe generic alternatives. They meet FDA requirements, are safe and effective and cost less. Some Medicare drug plans cover generics during the gap period. Substitute preferred for nonpreferred brands. Sometimes a generic isn t available. Your doctor may prescribe a drug that s on your plan s nonpreferred brand list. If your doctor does, ask if there s a less expensive option from the preferred list that works just as well. Shop around. Prices vary by pharmacy. Explore mail-order pharmacies; some may offer lower pricing. Plus, your plan may offer a lower copayment for a threemonth mail-order supply. Use a discount drug card. If your plan offers a discount drug card, use it to pay for prescriptions not covered. Some pharmacies may offer discount cards, too. If there s a fee, consider the cost versus the benefit. Ask your doctor for samples. Physicians sometimes can give out samples from pharmaceutical companies. Check pharmaceutical assistance programs. Some major drug manufacturers offer assistance programs. Visit Medicare s Pharmaceutical Assistance Program website at index.asp to determine if programs are offered for the drugs you take. Making the Most of Medicare 15

18 Get Help You may qualify for help with paying your health care coverage and prescription drugs. The following organizations offer financial assistance. Contact them directly for qualifications and further details. Helpful Resources Social Security Administration Social Security helps pay premiums, deductibles and prescription copayments for people with limited income and assets. Apply online at TTY: a.m. to 7 p.m. Monday through Friday Michigan State-Specific Resources Eldercare Locator links those who need assistance with state and local area agencies on aging and community-based organizations that serve older adults and their caregivers. To learn more, call toll-free , TTY 711, 9 a.m. to 8 p.m. ET Monday through Friday. For more information, visit MMAP is a free counseling service that aims to educate, counsel and empower Medicare beneficiaries and their caregivers so they can make informed health benefit decisions. To speak with an MMAP counselor, call , TTY 711, 8 a.m. to 5 p.m. ET Monday through Friday. Visit MMAP online at The Blue Cross Blue Shield of Michigan and Blue Care Network website is While website addresses for other organizations are provided throughout this publication, BCBSM and BCN do not control these sites and are not responsible for their content. 16 Making the Most of Medicare

19 Simple Ways to Get Moving Physical activity is good for both body and spirit. Research also suggests being active may help you live longer. Exercise doesn t have to be hard. A brisk walk counts as moderate activity. To boost the health benefits of walking, consider these ideas: Ask a friend along. You can motivate each other to stick to your walking routine. If you don t feel like walking, tell yourself you re going out for just five minutes. Once outside, you ll probably walk longer. Swing your arms to increase your heart rate and burn more calories. Strength training can help build your muscle and bones. Try these chair exercises. Repeat each 10 times. Shoulder shrugs. Shrug your shoulders up toward your ears, then lower 1 them back down. Leg extensions. Lift one leg off the floor and straighten it so your leg is 2 parallel to the seat of your chair. Hold for two seconds, then lower your foot and repeat with the other leg. Seat lifts. Sit in a chair with sturdy arms. Place both hands on the chair 3 arms and slowly lift your bottom off the chair. Hold this position for two seconds and slowly lower yourself back to the chair.

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21 Important Phone Numbers Centers for Medicare & Medicaid Services MEDICARE ( ) (TTY users call ) Available 24 hours a day, seven days a week. Blue Cross Blue Shield of Michigan and Blue Care Network Medicare Advantage Plans (TTY users call 711) February 15 through September 30 8 a.m. to 9 p.m. ET, Monday through Friday October 1 to February 14 8 a.m. to 9 p.m. ET, seven days a week Call for information about our Medicare plans or for help finding an agent who can advise you about your plan choices. My Primary Care Doctor My Pharmacist

22 Our Interactive Health Connection If you re trying to live a healthier life, don t do it alone. Visit where you can read blogs, join our social network, chat in discussion groups and more. This publication is sent to you courtesy of Blue Cross Blue Shield of Michigan and Blue Care Network. Medicare Plus Blue PPO SM and BCN Advantage HMO-POS SM and BCN Advantage HMO SM are health plans with Medicare contracts. Prescription Blue PDP SM is a prescription drug plan with a Medicare contract. CB11730 SEP 12 Y0074_O_13MakingMostMdcare FVNR 0912 PR Gold Award Merit Award