Medicare Made Simple

Transcription

1 Medicare Made Simple

2 TABLE OF CONTENTS 2 A Coverage Overview: What is Medicare? 3 Original Medicare Parts A and B 5 Medicare Part C Medicare Advantage Plans 6 Medicare Part D Prescription Drug Coverage 8 How to Enroll 12 Finding the Right Coverage 14 The Right Coverage Is All About the Right Choices 15 We re Here For All of Your Medicare Needs and It s Easy to Reach Us b

3 WITH THE RIGHT INFORMATION, YOU CAN MAKE THE RIGHT MEDICARE DECISIONS Peace of mind starts with clear, reliable information. At EmblemHealth, we believe it should be simple for you to get all of the answers you need to feel comfortable and secure with your Medicare coverage decisions. It can be easy when you have the facts. We promise to help you find the coverage that best fits your needs and gives you the care you deserve. This guide helps make Medicare simple for you: simple to understand, simple to navigate and simple to use. You re well on your way to making the right choices! 1

4 GETTING STARTED A COVERAGE OVERVIEW: WHAT IS MEDICARE? Medicare is the largest health insurance program in the United States. It is run by the Centers for Medicare and Medicaid Services (CMS), a government agency. You re eligible for Medicare if you re 65 or older and: You are either a citizen or a permanent resident of the United States, and You or your spouse worked at least 10 years in Medicare-covered employment. You may be also be eligible if you are under 65 see the Medicare & You handbook at medicare.gov. There are many ways that you can receive Medicare through Original Medicare, with add-ons like Medicare Part D and/or Medicare Supplement Plans, or through a Medicare Advantage plan: Original Medicare Plan Medigap Policy Part D Drug Coverage Part A (Hospital Insurance): No premium for most + Part B (Medical Insurance): Optional at a standard monthly premium Medicare Supplement Insurance This optional policy can be purchased from private insurance companies to fill in gaps in Original Medicare coverage. OR Medicare Advantage Plans (Part C) This optional prescription drug coverage can be purchased from private insurance companies. A late penalty may apply if you delay your Part D enrollment. Medicare Advantage plans combine the coverage of Original Medicare, and often Part D, into a single plan and can be purchased from private insurance companies. We ll describe each of these parts in detail in the sections that follow. 2 Toll free: , 8 am to 8 pm, seven days a week

5 ORIGINAL MEDICARE The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). It is a fee-for-service health plan. For a better understanding of Original Medicare, let s take a look at the different parts of Medicare and what each one covers. Medicare Part A Hospital Insurance Medicare Part A covers many inpatient hospital services, and services at skilled nursing facilities, home health care and hospice care. Most people get Part A coverage from the Federal government automatically when they turn 65 if they have worked for a combined 10 years, or 40 nonconsecutive quarters, paying into Medicare. Part A doesn t charge any premiums for most people. You do pay a portion of the costs for services you get under Medicare Part A. You pay a deductible, and after meeting your deductible, you pay your share of the Medicare-approved amount (coinsurance). Medicare Part B Medical Insurance Medicare Part B provides basic coverage that helps you pay for medical services, like physician services, diagnostic tests, outpatient hospital services and other costs. It s a voluntary program with a standard monthly premium and an annual deductible. The standard Part B premium amount is $ (or higher depending on your income). If you choose not to enroll in Medicare Part B when you become eligible for Medicare, but enroll later, you ll pay a higher monthly Part B premium. How much do I pay for care I receive under Part B? After you meet your annual Part B deductible, Medicare Part B insurance pays up to 80 percent of Medicare-approved charges for most covered services. You pay the remaining costs typically 20 percent. Medicare Part B also covers many preventive health care services with no cost-sharing, like annual exams, screenings and certain vaccines. Helpful definitions for some common words that describe health insurance cost sharing: A deductible is an annual amount you pay toward covered health services before the health insurer starts paying. Once you meet your deductible, you will then pay any coinsurance or copayments owed for the care you receive, according to your plan. A copayment (also called a copay ) is a fixed amount you pay each time you use covered health benefits, like seeing a doctor or picking up medicine at the pharmacy. Coinsurance is a percentage of the cost you pay for covered health services after you have met your deductible. (TTY/TDD: 711) Online: emblemhealth.com/medicare 3

6 In some cases, your out-of-pocket costs may be more than 20 percent. This can happen because not all doctors accept assignment the Medicare-approved rate for services. If a doctor does not accept assignment, you must pay the balance of whatever Medicare does not cover. Medicare Part A and Part B do not cover everything there are many services that you will need to pay for in full. For more information about what Medicare covers and a list of exclusions, contact Medicare at , or see the Medicare & You handbook at medicare.gov. Medicare Supplement Plans Because Original Medicare does not pay for all medical costs, some Medicare members choose to purchase a Medicare Supplement plan (also known as Medigap coverage) from a private company. They can help pay some of the health care costs that Original Medicare doesn t cover, like copayments, coinsurance, and deductibles. Medicare Supplement plans do not include prescription drug coverage you will need a separate plan for medications (see Medicare Part D section on page 6). 4 Toll free: , 8 am to 8 pm, seven days a week

7 MEDICARE PART C MEDICARE ADVANTAGE PLANS Why choose a Medicare Advantage plan over Original Medicare? Original Medicare coverage is good, but it can be hard to coordinate multiple plans, ID cards, bills and networks. With a Medicare Advantage plan, you can get reliable coverage under one single plan from a private company. So there s less hassle. And in addition to all of the benefits of Original Medicare (Parts A and B), a Medicare Advantage plan usually includes extra benefits often at no additional premium cost beyond your Part B premium. For example: Acupuncture Dental care Eye exams related to prescribing glasses Fitness programs Hearing aids and exams for fitting Routine foot care Benefits offered and the amounts that you pay to get services will vary from plan to plan. Many Medicare Advantage plans also include Medicare Part D prescription drug coverage for the same monthly premium. What kinds of Medicare Advantage plans are available? Health Maintenance Organization (HMO) plans give you all the benefits of Original Medicare plus additional benefits. A Primary Care Physician (PCP) coordinates all of your care and arranges for any referrals that you need. HMO plans have a network of doctors, hospitals and other providers you need to use to get services. You are only covered for in-network benefits, but in an emergency, you can go to any doctor or hospital. Preferred Provider Organization (PPO) plans, like HMOs, give you all the benefits of Original Medicare plus additional benefits. In most cases, PPOs have network doctors, other health care providers and hospitals, but you can also use out of network providers for covered services, usually for a higher cost. Special Needs Plan (SNP) is a type of Medicare Advantage plan that can either be an HMO or PPO plan. A Special Needs Plan is only available to people who: Are eligible for both Medicare and Medicaid, Live in certain institutions (like a nursing home) or who require nursing care at home, or Have specific chronic or disabling conditions (like diabetes or chronic heart failure) You can join a Special Needs Plan at any time if you qualify for one. Who can join a Medicare Advantage plan? You can join a plan if you live in the plan s service area, are eligible for Medicare Part A and are enrolled in Medicare Part B. If you have a qualifying condition or circumstance, you may be able to join a Special Needs Plan. You must continue to pay your monthly Part B premium in addition to any premium the plan charges. (TTY/TDD: 711) Online: emblemhealth.com/medicare 5

8 MEDICARE PART D PRESCRIPTION DRUG COVERAGE What is Medicare Part D and how do I enroll? Medicare Part D is a prescription drug coverage plan available to all people who have either Medicare Part A or Medicare Part B. To enroll and receive benefits, all you need to do is join a plan that offers Medicare Part D insurance. Medicare Part D is a voluntary program, which means you don t have to buy it. If you don t get Part D coverage when you re initially eligible and later decide to sign up for it, you may be penalized with a monthly late enrollment penalty. Where do I get Medicare Part D? You can get Medicare Part D as part of a plan that also offers Medicare Part A and Part B (a Medicare Advantage Prescription Drug Plan, or MAPD) or through a plan that offers Medicare Part D alone (called a Prescription Drug Plan or PDP). Medicare Part D is not offered by Medicare itself. What drugs are covered under Medicare Part D? All Medicare Part D plans have a prescription drug formulary. A formulary is a list of covered drugs. Plan formularies will include both generic and brand name drugs, and will list them in different costsharing tiers. In general, the lower the tier is for a drug, the lower your cost for the drug will be. Companies that offer Medicare Part D may cover different medications or charge different amounts for them. So you ll need to choose a plan that offers you the best solution for your own needs. 6

9 How much will a Medicare Part D plan cost? To join, you simply pay a monthly premium to the plan you choose. Some Medicare Advantage plans include the Medicare Part D premium in their monthly plan premium. Depending on your plan s benefits, you may also pay a deductible and coinsurance costs. If you need help paying for your drug coverage, you may qualify for Extra Help. See page 11 for more details. What if I receive my prescription drug coverage through my Union? If you receive your prescription drug coverage through your retiree group or Union, your plan must send you a notice every year that tells you if your coverage is creditable (at least as good as Medicare s). If your plan is not creditable, you may be subject to a late enrollment penalty if you decide to join a Medicare Part D plan. Please check with your benefits administrator to make sure you understand your options. How much will I pay for covered drugs? The amount you pay for covered drugs depends on the drug s tier and what stage of the benefit you have reached. Below is a summary of the four stages of Medicare Part D coverage: Four Stages of Medicare Part D 2017 Total Out of Pocket Cost Limits You Pay Yearly Deductible Stage Up to $400 You pay 100% of covered drugs. Initial Coverage Stage Up to $3,700 Your plan will pay its share of covered drug costs and you pay your share. The costs that you pay are called copayments or coinsurance. Coverage Gap Stage (also known as the Donut Hole ) Up to $4,950 You pay for a higher share of your drug costs (typically 40%-50%) and your plan pays the rest. Catastrophic Coverage Stage Over $4,950 You pay only small share (typically 5%) of your drug costs and your plan pays the rest. 7

10 HOW TO ENROLL Now that you understand Medicare, you re ready to enroll. Use this as a quick guide to enrolling in Medicare and applying for help. Just Starting With Medicare? Enrolling at Age 65 If you re approaching age 65 and are ready to retire, you ll probably be enrolling in Medicare for the first time. You have a limited time to enroll called the Initial Coverage Election Period (ICEP). This period covers three months before the month of your 65th birthday to three months after. During those seven months, you may enroll in any Medicare plan you re eligible for. But if you miss that window, you ll have to wait for the next Annual Enrollment Period (AEP), which will begin October 15 and continue through December 7. To apply for Medicare Parts A and B, contact your local Social Security Administration office (see page 16). If either you or your spouse worked for the railroad, contact the Railroad Retirement Board. Enrolling at a Later Retirement Age If you re over 65 and still working, or are an active employee covered under your employer s plan who has 20 or more employees, you have eight months to enroll in Medicare Part B after your employment ends. You then have two months prior to the start of your Medicare Part B coverage to choose a new plan. This is called a Special Election Period. If you do not elect coverage during this window, you will not be eligible to enroll again until the next Annual Enrollment Period (AEP) between October 15 and December 7. If you continue to work after your 65th birthday, you should sign up for Medicare Part A. This may help pay some of the costs not covered by your employer s health care plan. QUICK CHECK ENROLLING AT AGE 65 Your Medicare enrollment window when turning 65: Write in your 65th birthday: Enrollment period begins: Write in three months before your 65th birthday: Enrollment period ends: Write in three months after your 65th birthday: QUICK CHECK ENROLLING AT A LATER RETIREMENT DATE Your special enrollment period when retiring: Write in the month you are retiring: Enrollment period begins: Write in the month after you retire: Enrollment period ends: Write in eight months after the start of your enrollment period: Note: If your company has less than 20 active employees and you are still an active employee, Medicare will be primary and you should enroll in a Medicare plan. 8 Toll free: , 8 am to 8 pm, seven days a week

11 Enrolled in an Insurance Plan on the NY State of Health Marketplace and Turning 65? If you re enrolled in a plan through the NY State of Health marketplace, you can keep your coverage active until your Medicare coverage starts. Then you can cancel your marketplace plan without penalty. Once you qualify for Medicare, you ll have a limited time period (known was an initial enrollment period) to sign up. For most people, the enrollment period starts three months before their 65th birthday and ends three months after their 65th birthday. If you don t sign up for Part B when you re first eligible, you may have to pay a late enrollment penalty. For more information, visit emblemhealth.com/medicare/moving. (TTY/TDD: 711) Online: emblemhealth.com/medicare 9

12 Already Enrolled in Medicare? Add or switch coverage when you have the most options available to you. If you re over 65 and would like to switch Medicare plans, or if you did not sign up during your Initial Enrollment Period (IEP), you may only change plans at certain points in the year. Medicare Enrollment Timeline OCT 1 OCT 14 OCT 15 DEC 7 JAN 1 FEB 14 FEB 15 SEPT 30 Pre-Enrollment Period Learn about what plans offer for the upcoming year. Annual Enrollment Period People with Medicare Advantage plans can make plan changes for January 1 coverage. Annual Disenrollment Enrollment Period You can choose to disenroll from a Medicare Advantage plan and return to Original Medicare. If you choose this option you can also choose a Standalone Part D plan. But you cannot choose another Medicare Advantage plan. Special Enrollment Period You can only make plan changes if you qualify for a special election. For example, if you qualify for a Special Needs Plan or move outside your plan s service area. For a full list of reasons that allow you to make a special election, see emblemhealth. com/medicare. If you have any questions, or have a unique situation that is not on this list, call EmblemHealth immediately. An EmblemHealth Medicare specialist can help you determine whether you qualify. 10

13 What if I need help paying for Medicare coverage? There are many programs available to help you pay for your Medicare coverage: Medicare Savings Programs If you have limited income and resources, you may be able to get help from your state to pay your Medicare costs. Some of the programs may help to pay your Medicare Part B premium, or some of your deductibles, coinsurance or copays. Medicaid Medicaid is a joint federal and state program that helps pay medical costs if you have limited income and resources and meet other requirements. Some people qualify for both Medicare and Medicaid and are called dual eligibles. If you qualify, most of your health care expenses will be covered. What is Extra Help? Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug plan costs, such as premiums, deductibles, and coinsurance. You can qualify for Extra Help if: You have full Medicaid coverage. You get help from your state Medicaid program paying your Part B premiums (in a Medicare Savings Program). You get Supplemental Security Income (SSI) benefits. If you qualify for Extra Help, the amount of your premium and cost at the pharmacy will be lower than what it would be if you did not get Extra Help from Medicare. In some cases, it may even eliminate your premium and deductible costs. You also have no coverage gap, you pay no late enrollment penalties, and you can switch plans at any time. If you have any questions about any of these programs or if you qualify, an EmblemHealth Medicare specialist can help you. 11

14 FINDING THE RIGHT COVERAGE Choose a plan that has your best interests in mind we can help. When choosing the type of Medicare Advantage plan that will best suit you, remember to look for: Reliability A stable health plan you can count on. Options A plan design and benefits that meet your needs. 12 Toll free: , 8 am to 8 pm, seven days a week

15 If you know your needs, it s easier to find the right plan. Consider these questions: Q. A. Q. A. Q. A. How much will you pay in monthly plan premiums? Are you responsible for plan deductibles, coinsurance or copayments? These are key questions. Generally, the higher your monthly premiums are, the lower your out of pocket expenses (like copayments and deductibles) will be. Consider how often you need to see your doctors, which type of payments would be a better value for you and compare plans. Remember, for any plan you join, you are still responsible for paying your Medicare Part B monthly premium. Does your doctor participate in the plan? If you have a primary care physician or a specialist you would like to see, making sure they participate in your plan s network is a good idea. Remember, hospital and provider networks can vary from plan to plan, even among plans offered by the same company. Are there benefits covered in addition to what Original Medicare covers? Be sure that you understand what the plan covers or does not include. Benefits like dental, vision, hearing aids and fitness programs are included in some plans at no extra charge. Determine how much you re paying out of pocket for these costs. You may save money with these benefits included. Q. A. Q. A. Q. A. Does the plan include Medicare prescription drug insurance, and is the cost included in the monthly plan premium? Some plans include prescription drug coverage. Consider totaling your prescription drug costs and reviewing plan formularies before selecting a plan. If you have high prescription drug costs, it may make sense to choose a plan that provides prescription drug coverage. Do you qualify for Extra Help or a Special Needs Plan? If you qualify for Extra Help, you can save on what you pay for prescription drug costs. You might also qualify for a Special Needs Plan, which can also save you money or affect when you can enroll in a plan. Do you want coordinated care? Some plans use your primary care physician to manage your health care. If you like the convenience of having your care in the hands of one doctor, a plan like this may fit your needs. (TTY/TDD: 711) Online: emblemhealth.com/medicare 13

16 THE RIGHT COVERAGE IS ALL ABOUT THE RIGHT CHOICES EmblemHealth VIP Medicare Plans EmblemHealth has designed a variety of great VIP Medicare Advantage plans expressly for the needs of New Yorkers. Based on more than 75 years of experience, we know that different people have different needs. We provide a range of affordable plans that provide coverage for all the benefits of Original Medicare and more, plus access to coordinated care through a quality network of New York providers and hospitals. All-in-One Plans Our VIP Medicare plans are Medicare Advantage HMO plans that give you all of the benefits of Medicare Parts A and B, PLUS Medicare Part D for little or no additional cost above your Medicare Part B premium. Benefits Beyond Medicare In addition to the convenience of getting all your medical and drug benefits through one plan, our VIP Medicare Advantage plans include additional benefits beyond Original Medicare like vision, hearing, comprehensive dental, hearing aids and fitness benefits. Our Special Needs Plan also offers acupuncture and an over-the-counter drug card. Coordinated Care With all of our VIP Medicare Advantage plans, you get to choose an in-network primary care physician (PCP) whose job it is to refer you to the specialists and facilities you need. This makes your care more efficient, and you don t have to worry about finding your own specialists. The goal of coordinated care is to make accessing your medical services as easy as possible, often under one roof. You can rest easy knowing your priorities are covered with EmblemHealth. 14 Toll free: , 8 am to 8 pm, seven days a week

17 WE RE HERE FOR ALL OF YOUR MEDICARE NEEDS AND IT S EASY TO REACH US Do you have questions or are you ready to take the next step? Our EmblemHealth Medicare experts are available to help you. IN PERSON Call now to schedule a one-on-one consultation with an EmblemHealth Medicare expert. PHONE Toll free , TTY/TDD: 711 seven days a week, from 8 am to 8 pm WEBSITE emblemhealth.com/medicare 24 hours a day, seven days a week. Our website makes it easy to find the right plan for you with... Easy-to-Use Plan Finder Prescription Drug Cost Calculator Quick Doctor Finder Pharmacy Finder (TTY/TDD: 711) Online: emblemhealth.com/medicare 15

18 Other Helpful Resources OTHER HELPFUL RESOURCES Elderly Pharmaceutical Insurance Coverage (EPIC) Program Call: TTY/TDD: Monday through Friday, 8:30 am to 5 pm Website: health.ny.gov/health_care/epic/index.htm Health Insurance Information Counseling and Assistance Program (HIICAP) (New York s SHIP) Representatives will assist you with Medicare bills, questions about Medigap, dealing with payment denials and appeals, Medicare rights and protection. Call: TDD/TTY: 711 Website: aging.ny.gov Medicare (CMS) Call: MEDICARE ( ) TTY/TDD: Calls to this number are free. 24 hours a day, seven days a week. Website: medicare.gov Social Security Administration Call: TTY/TDD: Monday through Friday, 7 am to 7 pm Website: ssa.gov FINAL CHECK Do I understand the basics? (pages 2-7): What type of coverage do I need? (pages 2-7, 13): What type of plan is best for me? (pages 2-7, 13) Do I qualify for a SNP? (page 5): When can I enroll? (pages 8-10): How do I apply for Extra Help? (pages 11): 16 Toll free: , 8 am to 8 pm, seven days a week

19 (TTY/TDD: 711) Online: emblemhealth.com/medicare 17

20 55 Water Street, New York, New York emblemhealth.com/medicare Toll free: am to 8 pm, seven days a week (TTY/TDD: 711) Online: emblemhealth.com/medicare HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. Plans vary by county. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Premium, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak other langauages, language assistance services, free of charge, are available to you. Call (TTY/TDD: 711). ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al (TTY/ TDD: 711). 注意 : 如果您講中文, 我們免費提供相關的語言協助服務 請致電 (TTY/TDD: 711). H3330_ Accepted 9/11/ /16