Step Guide to MEDICARE

Transcription

1 3 Step Guide to MEDICARE I m new to Medicare I have Medicare

2 What s Inside W STEP 1 UNDERSTAND HOW MEDICARE WORKS 5 STEP GUIDE TO MEDICARE IF YOU'RE NEW TO MEDICARE you may be feeling overwhelmed by all of your options. This booklet is designed to help you understand your options. Our hope is that after reading it you'll feel more confident in selecting Medicare insurance plan that fits your personal needs and your budget. I s Four Things That Make Medicare Different 7 Medicare And Private Insurance Plan Options 14 How Does Medicare Part D Work? 18 7 Questions You Should Ask Before You Enroll 20 In A Medicare Part D Prescription Drug Plan How Does Medicare Advantage Work? 22 8 Questions You Should Ask Before You Enroll 24 In A Medicare Advantage Plan How Do Medicare Supplement Plans Work? 26 6 Questions You Should Ask Before You Enroll 30 In A Medicare Supplement Plan Medicare At A Glance 32 STEP 2 UNDERSTAND WHEN YOU CAN ENROLL 35 Medicare Enrollment Periods 38 State-By-State Medicare Supplement 50 Plan Enrollment Rules Medicare Enrollment FAQ 52 STEP 3 UNDERSTAND MEDICARE S COSTS 55 How Much Does Medicare Cost? 57 RESOURCES 58 Glossary Of Key Medicare Terms

3 Glossary of Key Medicare Terms Amyotrophic Lateral Sclerosis (ALS) Beneficiary Certificate Of Creditable Coverage Coinsurance Co-Payment Cost Sharing Creditable Coverage Deductible (Medicare) Drug List End State Renal Disease (ESRD) Excess Charges Extra Help Formulary Guaranteed Issue Rights Health Care Provider Hospital Outpatient Setting In-Network Initial Enrollment Period Inpatient Hospital Services Medicare Advantage Plan (Part C) Medicare Advantage HMO Plan Type: Health Maintenance Organization (HMO) Medicare Advantage PPO Plan Type: Preferred Provider Organization (PPO) Medicare Advantage HMO-POS Plan Type: Health Maintenance Organization Point-Of-Service (HMO-POS) Medicare Advantage PFFS Plan Type: Private Fee-For-Service (PFFS) Medicare Advantage SNP Plan Type: Special Needs Plan (SNP) Medicare Advantage MSA Plan Type: Medicare Savings Account (MSA) Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) Medicare Plan Medicare Supplement Policy Original Medicare Out-Of-Pocket Costs Out-Of-Network Pharmacy Network Premium Stand-Alone Medicare Prescription Drug Plan STEP 1 Understand How Medicare Works 4

4 FOUR WAYS Original Medicare Is Different From Employer-Based Health Insurance Original Medicare is different from the health insurance most Americans get from an employer in four key ways: Understand How Medicare Works How Does Original Medicare Work? Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) and Amyotrophic Lateral Sclerosis (also known as ALS or Lou Gehrig s disease). 1 Original Medicare Has Two Parts Part A (hospital insurance) Part B (medical insurance) 3 Original Medicare Typically Doesn t Cover Prescription Drugs Standalone Medicare Part D Plans Medicare Advantage Prescription Drug Plan 2 Original Medicare Does Not Limit Your Out-of-Pocket Medical Expenses Part A & Part B Costs Copayments Deductibles Coinsurance 4 Original Medicare Doesn t Have Standard Provider Networks Participating Doctors Non-Participating Doctors Doctors That Don t Accept Assignment 6 7 STEP 1 3 Step Guide to Medicare

5 1. Original Medicare Has Two Parts Medicare Part A and Part B were signed into law in 1965 to provide health insurance coverage for people 65 and older. Part A (hospital insurance) generally covers you when you re admitted to a hospital, skilled nursing or nursing home facility or when you receive hospice care or covered home health services. Part B (medical insurance) covers two types of services: The first is medically necessary care aimed at diagnosing or treating medical conditions in an outpatient setting (like a doctor s office or outpatient surgery center); and the second is care aimed at preventing or detecting illnesses at an early stage. 2. Original Medicare Does Not Limit Your Out-of-Pocket Medical Expenses Medicare s out-of-pocket medical expenses include any charges you have to pay yourself. With Medicare, these expenses may include copayments, deductibles, and coinsurance. Part A Benefits: Inpatient Hospital Care This has a deductible that can reset in as little as 30-days. Skilled Nursing Care Days 1-20 there is no cost-sharing; days you will have to pay a co-insurance amount per day which is subject to change annually. Long Term Care Hospitals If you are in an acute care hospital and are immediately transferred to a long-term care hospital or are admitted to a long-term care hospital within 60 days of being discharged from an acute care hospital, you will not pay an additional deductible. If you are discharged from an acute care hospital and admitted to a long-term care hospital more than 60 days from your discharge date, you will have to pay another in-patient hospital deductible. Home Health Care Services If you are homebound (unable to leave your home) and require Home Health Services from a nurse (to administer medications), Physical Therapist, Occupational and Speech pathology, you will not have to pay any additional cost-sharing. Most Durable Medical Equipment that is used in your home may be covered under Medicare Part B. Hospice Most hospice services are covered without any additional cost sharing. You may have to pay a copay for hospice related medications. You may be assessed a coinsurance amount for respite care. Part B Benefits: Medical insurance has an annual deductible as well as coinsurance. With Part B coinsurance you typically pay 20% of the cost of most services, after your deductible is met. A monthly premium is also required for Part B. 8 9 STEP 1 3 Step Guide to Medicare

6 3. Original Medicare Typically Doesn t Cover Prescription Drugs Medicare Part D became available in It makes prescription drug coverage available to people on Medicare. To get Medicare Part D coverage, you must enroll in a plan offered by a private insurance companies contracted with Medicare. Medicare Part D Private insurance companies approved by Medicare offer insurance plans that pay a portion of your prescription drug costs. Once enrolled, the government pays for much of your prescription drug costs. Medicare Part D Coverage Initial Coinsurance Coverage Gap Catastrophic Coverage You Pay $360 You Pay 25% You Pay 100% (at a discounted price) Substantially Reduced Co-pays Insurance Pays Nothing Insurance Pays 75% Insurance Pays 0% (on a basicpart D plan) Remaining Costs (After drug company discounts) STEP 1 3 Step Guide to Medicare

7 4. Original Medicare Doesn t Have Standard Provider Networks Doctor visits cost money even on Medicare. The amount you pay to see a doctor will depend on which type of doctor you visit. There are three kinds of doctors. Here s a very basic example of what you might pay for a doctor visit with each of these three types of doctors. The costs represented here are not actual costs, they re used for illustration purposes only: The amount the Doctor Charges for the Visit Medicarecovered amount for a Doctor Visit Medicare Pays You Pay Participating Doctors Participating doctors accept Medicare assignment, which means they ve signed an agreement with Medicare to accept the amount of money that Medicare pays for their services as payment in full. With a participating doctor, you usually pay 20% of the cost and Medicare pays 80%. $150 $100 $80 $20 Non-Participating Doctors Non-participating doctors have not signed an agreement with Medicare and therefore do not accept assignment for all of their services. A non-participating doctor may take a payment from Medicare for 80% of Medicare s approved cost. But, they can charge you 15% of the approved cost on top of the 20% amount that you would normally be expected to pay. $150 $100 $80 $35 Doctors That Do Not Accept Medicare Assignment If you choose to see a doctor that does not accept Medicare, you may be responsible for all the charges associated with your visit. $150 $100 $0 $ STEP 1 3 Step Guide to Medicare

8 Medicare and Private Insurance Plan Options There are three distinct types of private health insurance products offered by Medicare-approved insurance companies. They re designed to either go along with Original Medicare or replace it. Medicare Advantage plans Stand-Alone Part D Prescription Drug Plans Medicare Supplement Plans Also known as Medicare Part C these plans combine your Part A (hospital), Part B (medical) and usually Part D (prescription drug) coverage into a single health insurance plan. A Medicare Advantage plan must offer the same benefits as Original Medicare Part A and Part B. But, they must also limit your outof-pocket costs. And, many plans include extra benefits such as routine dental and vision coverage. Prescription drug coverage is available through the Medicare Part D program. Private insurance companies contract with Medicare to offer stand-alone Prescription Drug Plans. These plans pay part of your medication costs. This is an optional benefit, but Original Medicare Parts A and B offers only limited prescription drug coverage, and doesn t cover most medications taken at home. These plans are designed to work with original Medicare to help reduce some of your out-of-pocket costs that Part A and Part B do not cover. You can combine a Medicare Supplement plan with a Part D plan, but not with Medicare Advantage STEP 1 3 Step Guide to Medicare

9 Three common ways people choose to have Medicare coverage: Part A Hospital Insurance Part B Medical Insurance Part D Prescription Drug Coverage Dental Vision Limits on Out-of- Pocket Costs Original Medicare + Part D a a a x x x Medicare Advantage Prescription Drug Plan (Part C and Part D) a a a Sometimes Sometimes a Original Medicare + Part D + Medicare Supplement a a a x x a STEP 1 3 Step Guide to Medicare

10 How Does Medicare Part D Work? Original Medicare, Part A and Part B offers limited prescription drug coverage and does not cover most medications you take at home. To get prescription drug coverage you will need to enroll in Medicare Part D, either on its own or through a Medicare Advantage plan that includes prescription drug coverage. Once enrolled, the minimum Medicare Part D benefit must cover any Medicare-approved medications prescribed by your doctor as follows 1 : $360 Deductible You will pay the first $360 for prescription drugs $360 1 YOU PAY INSURANCE PAYS $0 1 $ % Coinsurance For every $1 in prescription drug costs you get, you pay $0.25 cents and the insurance company pays $0.75 cents. $2, $3,310 Coverage Gap Once your costs (deductibles and coinsurance) and the insurance company s costs combine to total $3,310, you pay 100% of the cost for your medications for a while. $1,560 1 $0 1 Total Combined Costs Total Spent to Reach Catastrophic Limit: In order to reach the catastrophic coverage limit, your personal drug costs would be $2, ($360 deductible + $ coinsurance + $1,560 in the coverage gap). Your insurance company s drug costs would be $2, Total: $2, Total: $2, $4,850 Catastrophic Coverage Once you and the insurer have paid a combined total of $4,850 on prescription drugs, you pay a substantially reduced rate for any additional prescription drug costs, so long as the drugs are covered by your plan. Catastrophic Limit: Once you reach the catastrophic limit, Medicare pays the majority of your co-pays.

11 7 1. Are my prescription drugs covered under this plan s formulary? 2. Do my prescription drugs require prior authorization, step therapy or include any quantity limitations? 3. Does my plan have a preferred pharmacy network? If so, is my pharmacy preferred? 4. What will be the monthly cost of this plan? QUESTIONS You Should Ask Before You Enroll in a Medicare Prescription Drug Plan 5. Will I hit the coverage gap (donut hole)? If so, when? 6. What is the late enrollment penalty? Should I sign up now or wait? 7. Do I qualify for Federal financial assistance such as extra help or low-income subsidies (LIS)? STEP 1 3 Step Guide to Medicare

12 How Does Medicare Advantage Work? How does Medicare Advantage differ from Original Medicare? Medicare Advantage plans (also called Medicare Part C) are offered by private insurance companies that contract with Medicare as an alternative way to get your Original Medicare (Part A and Part B, and usually Part D) in a single plan. Medicare Advantage plans may be available in HMOs, PPOs, POS, HMO-POS, PFFS, SNP and MSA style plans. Descriptions of each plan type can be viewed in the glossary. Many Medicare Advantage plans include Medicare prescription drug coverage (Part D). In addition to paying your Part B premium, you usually pay one monthly premium for the Medicare Advantage plan s medical and prescription drug coverage. Key Differences Limit on out-ofpocket medical expenses Prescription Drug Coverage Original Medicare No limit None Medicare Advantage Plans Limited to $6,700 or less Yes, in many cases Plan benefits can change from year to year, so you have the option to change your Medicare coverage every year during Medicare s Annual Election Period (AEP), also known as Open Enrollment for Medicare Advantage AND Medicare Prescription Drug coverage. The Annual Election Period runs from October 15 to December 7 each year. Defined provider networks Covers Routine Dental Care No No Yes Yes, on some plans Annual Election Period: Medicare s Annual Election Period October 15, to December 7 JAN FEB MAR Covers Routine Vision Covers Routine Hearing No No Yes, on some plans Yes, on some plans APR MAY JUN JUL AUG SEP Provides Fitness Benefits No Yes, on some plans OCT NOV DEC STEP 1 3 Step Guide to Medicare

13 8 1. Does my doctor accept this plan? 2. Are my current prescription drugs listed in this plan s formulary? 3. Does my current prescription drugs require prior authorization, step therapy or include any quantity limitations? 4. Does my plan have a preferred pharmacy network? If so, is my pharmacy preferred? 5. What will be the monthly cost of this plan? QUESTIONS You Should Ask Before You Enroll in a Medicare Advantage Prescription Drug Plan 6. Will I hit the coverage gap (donut hole)? If so, when? 7. Does this plan provide coverage for routine dental, vision or hearing? 8. What is this plan s maximum out-of-pocket limit? STEP 1 3 Step Guide to Medicare

14 How Do Medicare Supplement Plans Work? Medicare Supplement plans (also known as Medigap plans) are insurance plans offered by private insurance companies. They work like an extra layer of coverage that goes on top of your Medicare Part A and Medicare Part B coverage. Medicare Supplement plans can help pay some of the healthcare costs that Original Medicare does not pay, like deductibles, co-pays and coinsurance. Medicare Supplement plans are offered in a number of different plan types. This grid outlines what each plan type covers: Medicare Supplement Plan Types A B C D F 2 G K L M N Part A Cost-Sharing Part A Deductible 0% 100% 100% 100% 100% 100% 50% 75% 50% 100% Blood (First three pints) 100% 100% 100% 100% 100% 100% 50% 75% 100% 100% Part A skilled nursing facility coinsurance Part A hospice care coinsurance or copayments Part A coinsurance and hospital costs up to 365 days after Medicare benefits are exhausted 0% 0% 100% 100% 100% 100% 50% 75% 100% 100% 100% 100% 100% 100% 100% 100% 50% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Part B Cost-Sharing Part B Deductible 0% 0% 100% 0% 100% 0% 0% 0% 0% 0% Part B coinsurance or copayments 100% 100% 100% 100% 100% 100% 50% 75% 100% -- 4 Part B excess charges 0% 0% 0% 0% 100% 100% 0% 0% 0% 0% Miscellaneous Benefits Foreign Travel Emergencies 0% 0% 100% 100% 100% 100% 0% 0% 100% 100% Out-of-pocket limit 3 N/A N/A N/A N/A N/A N/A $5,120 $2,560 N/A N/A

15 Medicare Costs Table The Medicare Costs Table below provides a very simple example how a Medicare Supplement plan F (the most complete plan type) would work with your original Medicare. The details provided here are for illustration purposes only and should not be viewed as a portrayal of actual medical costs. Medical Expense What Original Medicare Pays What Medicare Supplement Plan F Pays on Your Behalf What You Pay Hospital Stay: $13,000 5 $11,712 $1,288 (Part A deductible) $0 Hospital Outpatient Care: $1,275 6 $ $166 (Part B deductible) $ (Part B coinsurance) $0 Total: $14,275 $12, $1, $ STEP 1 3 Step Guide to Medicare

16 6 QUESTIONS You Should Ask Before You Apply for a Medicare Supplement Plan 1. Does my doctor accept this plan? 2. Do I have a plan to get prescription drug coverage? (prescriptions are not covered by Medicare Supplements) 3. What will be the monthly cost of this plan? 4. Have I compared the monthly cost of this plan to others like it? Every Medicare Supplement Plan Type (e.g. Plan F, Plan C, etc.) must provide the same level of coverage. 5. Does this plan offer preventive care services? If so, how do I take advantage of them? 6. Do I need coverage for routine dental, vision or hearing care? STEP 1 3 Step Guide to Medicare

17 Medicare At A Glance THREE WAYS Most People Structure Their Medicare Coverage This table outlines the three ways most people structure their Medicare coverage. 1 2 Basic coverage starts with Medicare Part A and Medicare Part B, to which most people add a stand-alone Medicare Part D plan. Medicare Program Medicare Part A Medicare Part B Medicare Part D What is it? Hospital Insurance Medical Insurance Insurance Provider The Federal Government Medicare Advantage, which bundles up Part A, Part B and usually Part D into one plan. Prescription Drug Coverage Also called stand-alone drug coverage Private insurance companies offer competing plans 7 Medicare Program Medicare Advantage Prescription Drug (Medicare Part C and D) What is it? It provides an alternative way to receive the benefits covered by Medicare Part A and Part B and Part D in a single plan and limits your hospital and medical deductibles, coinsurance and copays to $6,700 or less. Insurance Provider Private insurance companies offer competing plans 7 3 Medicare Supplemental coverage, which is added to fill gaps in Part A and Part B. Medicare Program Medicare Part A Medicare Part B Medicare Supplement Plan F Medicare Part D What is it? Hospital Insurance Medical Insurance Insurance Provider The Federal Government Insurance that pays your deductibles, co-pays and coinsurance. Private insurance companies offer competing plans 7 Prescription Drug Coverage Also called stand-alone drug coverage Private insurance companies offer competing plans STEP 1 3 Step Guide to Medicare

18 STEP 2 Understand When You Can Enroll 34 I

19 WHEN YOU FIRST QUALIFY FOR MEDICARE Original Medicare is different from the health insurance most Americans get from an employer in four key ways: Understand When You Can Enroll You have turned 65 You have been awarded Social Security Disability Benefits and have been receiving benefits for 25 consecutive months This section outlines when you can enroll in: Medicare Part A; Medicare Part B; Medicare Supplement; a Stand-alone Medicare Prescription Drug Plan; Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan. You have been diagnosed with End Stage Renal Disease (ESRD) You have been diagnosed with Amyotrophic Lateral Sclerosis (also known as ALS or Lou Gehrig s disease) 36 STEP 2 3 Step Guide to Medicare 37

20 When you re newly eligible When can you enroll in Medicare for the first time? What You Can Do During Initial Enrollment Period 6 Initial Enrollment Period for Medicare Part D 9 Enroll in Original Medicare, Part A and Part B. Part A = Hospital Part B = Medical Enroll in a stand-alone Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan. When Qualifying by Age: Lasts seven months, starting three months before you turn 65, including the month of your 65th birthday, and ending three months later. Qualifying by Disability: Lasts seven months, starting three months before your 25th month of disability benefits, including the 25th month of benefits, and ending three months later. 8 Lasts seven months and usually takes place at the same time as your initial Enrollment Period for Medicare Part A and/or Part B. During the Initial Enrollment Period. What s the Initial Enrollment Period? The Initial Enrollment Period is a seven-month period that starts three months before the month you turn 65, the month you turn 65, and three months after the month you turn 65. For example, Mary Doe Jones turned 65 on April 27, She is first eligible for Medicare starting in April 2014 because she is turning 65. Her initial enrollment period for Medicare starts January 2014 and lasts until July 31, Initial Coverage Election Period W Enroll in Medicare Advantage plan or Medicare Advantage Prescription Drug plan. Medigap Open Enrollment Period Normally lasts seven months and takes place at the same time as your initial Enrollment Period for Medicare Part A and Part B, this period lasts for three months before you re enrolled in Part B. Example: 65-3 mo. JAN 65-2 mo. FEB mo. MAR APRIL mo. MAY mo. JUN mo. JUL 8 Enroll in Medicare Supplement (Medigap) plan with guaranteed rights to join any plan, regardless of any pre-existing conditions. (Note: Medigap only work with Original Medicare.) Lasts six months and starts automatically when you re 65 and enrolled in Medicare Part B. 39

21 What can you sign up for during your Initial Enrollment Period? Original Medicare, Part A and Part B If you re already getting Social Security benefits, you will be contacted a few months before you become eligible for Medicare and given the information you need. Most people will be enrolled in Medicare Parts A and B automatically. However, because you must pay a premium for Part B coverage, you have the option of turning it down. If you turn down or delay your enrollment in Part B, you may have to pay a 10 percent Part B premium penalty for each 12-month period for which you qualified but delayed enrollment. This penalty would begin once you enroll in Part B. If you aren t eligible for full Social Security or Railroad retirement benefits at age 65, you can still get your full Medicare benefits at age 65, but you must contact Social Security to sign up. People who are not automatically enrolled in Medicare Part A and/ or Part B can enroll during the Initial Enrollment Period. Most people will not have to pay an additional premium amount for Medicare Part A if they or their spouse worked 10 years and paid Medicare taxes. Example: In 2016 the standard Medicare Part B Premium amount is $ Mary Doe Jones first qualified to enroll in Medicare Part B on 4/1/2014. She delayed her enrollment. She enrolled in Medicare Part B during the General Enrollment Period (January March each year). Her coverage became effective 7/1/2016. The penalty will be assessed based on the Medicare Part B premium amount assessed upon enrollment. 10% of the standard Medicare Part B Premium in 2016 is $ Mary could have had Medicare Part B for 2 full 12-month periods. Therefore, the penalty that she may have to pay in addition to the Medicare Part B Premium amount is $24.36 for a total premium amount of $ You will have to pay this penalty for as long as you have Medicare Part B. People who did not work a minimum of 10 years, may still obtain Medicare Part A coverage but may have to pay a premium amount. That amount is determined by Social Security. 40 STEP 2 3 Step Guide to Medicare 41

22 Standalone Medicare Part D Prescription Drug Coverage You must be eligible for Medicare Part A and/or be enrolled in Part B. People can enroll in a Medicare Part D plan for the first time using the Initial Enrollment Period for Part D. The Initial Enrollment Period for Part D is a seven month period that starts three months before the month you turn 65, the month you turn 65, and three months after the month you turn 65. January Mary Doe Jones initial enrollment period for Medicare Part D is the same as her initial enrollment period for Part B which starts now. Example: Mary Doe Jones turned 65 on April 27, She is first eligible for Medicare starting in April 2014 because she is turning 65. Her initial enrollment period for Medicare Part D is the same as her Initial Enrollment Period for Part B which starts January 2014 and lasts until July 31, April She is eligible for Medicare starting in April 2014 because she is turning 65. If you don t enroll there is a Part D late enrollment penalty The late enrollment penalty is an amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without a Medicare Prescription Drug Plan (Part D), a Medicare Advantage Plan (Part C) (like an HMO or PPO), or another Medicare health plan that offers Medicare prescription drug coverage. A penalty of 1% may be added to your drug plan premium for each month. April July Mary Doe Jones turns 65 on April 27, Her enrollment period for Medicare Part D and B lasts until July 31, STEP 2 3 Step Guide to Medicare 43

23 Medicare Advantage You must have Medicare Part A and Medicare Part B to enroll in a Medicare Advantage plan. People can enroll in a Medicare Advantage Plan for the first time using the Initial Coverage Election Period. If you enroll in Medicare Part B when you are first eligible to do so, using the Initial Enrollment Period for Medicare Part B, the Initial Coverage Election Period will be the same as the Medicare Part B Initial Enrollment Period. Example: Mary Doe Jones Initial Enrollment Period for Medicare Part B is January 2014 through July 31, She went to Social Security and filled out an application on January 15, Her Medicare Part B was effective April 1, Her Initial Coverage Election Period for Medicare Advantage is also January 1 July 31, If she chooses a Medicare Advantage Plan in January 2014 and submits an enrollment request her Medicare Advantage plan would have also begun April 1, If an individual delayed their enrollment in Medicare Part B, their Initial Coverage Election Period is only the three months before Medicare Part B coverage begins. Example: John Doe Jones was first eligible to enroll in Medicare Part B September He delayed his enrollment, enrolling for the first time using the General Enrollment Period for 2016 (January March). His coverage for Medicare Part B was effective July 1, His initial coverage election period was April 2016 June If you delay enrollment, you may have to wait until the annual election period, which runs from Oct. 15 Dec. 7, each year. 44 STEP 2 3 Step Guide to Medicare 45

24 Medicare Supplement When can I apply for a Medicare Supplement plan? The best time to purchase is during your Medicare Supplement Open Enrollment Period. There are no cost penalties for late enrollment, but your eligibility for some supplement plans can be impacted if you delay enrollment. When is the Medicare Supplement Open Enrollment period? The Medicare Supplement Open Enrollment Period lasts for six months. It starts on the first day of the month in which you turn age 65 (or older) and enrolled in Medicare Part B. What happens if I miss my Medicare Supplement Open Enrollment period? Your eligibility may be impacted if you miss the Medicare Supplement Open Enrollment Period: Your application could be declined if you have a pre-existing medical condition. You may be charged more for coverage if you have a pre-existing medical condition. Some plans may require you to pay premiums TURN 65 APRIL mo. MAY mo. JUN mo. JUL mo. SEP mo. OCT but wait for a few months before they ll cover any expenses. 46 STEP 2 3 Step Guide to Medicare 47

25 Change your Medicare Advantage and Medicare Part D Prescription Drug coverage When can you change your Medicare Advantage and Medicare Part D Prescription Drug coverage? Annual Election Period: During Medicare s Annual Election Period unless you qualify for a Special Election Period (SEP). For a complete list of special election periods visit: Medicare/Eligibility-and-Enrollment/ MedicareMangCareEligEnrol/Downloads/CY-2015-MA-Enrollmentand-Disenrollment-Guidance.pdf Key Dates: Jan Feb Mar Apr May Jun When is Medicare s Annual Election Period? The Annual Election Period runs from October 15, to December 7 each year. Jul Aug Sep Oct Nov Dec 10/15 12/7 Only those with Qualifying Life Events can apply. Medicare s AEP October 15 through December 7 48 STEP 2 3 Step Guide to Medicare 49

26 State-By-State Medicare Supplement Plan Enrollment Rules When it comes to enrolling in a Medicare Supplement Plan (also sometimes called Medigap or MedSup ), the rules differ from state-to-state. You can always sign up during your initial enrollment period. But, if you miss the initial enrollment period, your options will differ depending on where you live. If you re over age 65, this map shows when you can enroll in a Medicare Supplement plan if you miss your initial enrollment period: NV UT CA CO AK OR WA ID AZ MT HI WY NM ND SD NE KS TX MN IA MO AR LA WI IL IN ALL STATES: You can typically add or switch Medicare Supplement plans if a plan you were enrolled in is terminated by the insurance company or regulator rules will vary from state-to-state. OK MS MI TN AL OH KY GA WV PA SC FL NC VT VA NY ME NH MA RI NJ CT DE MD DC In these states, you can apply for coverage at any time, at no cost, but your application may be declined if you have pre-existing medical conditions. In these states, you can apply for coverage at any time, at no cost, but your application may be declined if you have pre-existing medical conditions. You may also be able to add or change Medicare Supplement coverage, under certain circumstances, if you voluntarily leave coverage offered by an employer, union or government program rules vary from state-to-state. You can apply for coverage at any time, at no cost, but your application may be declined if you have preexisting medical conditions. You may also be able to add or change Medicare Supplement coverage, under certain circumstances, if you voluntarily leave an Employer Welfare benefit plan, if the plan is primary to Medicare. Limitations may apply and rules may vary from insurer to insurer. Guaranteed year-round, but limitations may apply. Once a year, you can apply for coverage and not have your application denied due to pre-existing medical conditions. The rest of the year you can apply for coverage, at no cost, but your application may be declined due to pre-existing conditions. In California and Oregon, your birthday determines when you can apply for guaranteed coverage. In Maine, coverage is guaranteed for Plan A but insurers get to set their own dates for when you can apply. Other limitations on the types of plans you can switch to may apply. You can switch Medicare Supplement plans at any time, but limitations may apply to the types of plans you can switch to. You can apply for coverage at any time, at no cost, but your application may be declined if you have pre-existing medical conditions. You can also switch Medicare Supplement plans within 30 days of your current plan s anniversary date, but certain limitations may apply.

27 Plan benefits can change from year to year, so you have the option to change your Medicare coverage every year during Medicare s Annual Election Period (AEP), also known as the Open Enrollment for Medicare Advantage AND Medicare prescription drug coverage which runs from October 15 to December 7 each year. What you can do during this time frame: Change from Original Medicare to a Medicare Advantage Plan. AEP QUESTIONS What can you do during the Annual Election Period (AEP)? Change from a Medicare Advantage Plan back to Original Medicare. Switch from one Medicare Advantage Plan to another Medicare Advantage Plan. Switch from a Medicare Advantage Plan that doesn t offer prescription drug coverage to a Medicare Advantage Plan that offers prescription drug coverage. Switch from a Medicare Advantage Plan that offers prescription drug coverage to a Medicare Advantage Plan that doesn t offer prescription drug coverage. Enroll in a stand-alone Medicare Prescription Drug Plan. Switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug plan. Drop your Medicare prescription drug coverage completely. 52 STEP 2 3 Step Guide to Medicare 53

28 STEP 3 Understand Medicare s Costs 54 Q

29 The chart below outlines the estimated average premiums you may pay on a monthly basis to cover the cost of Original Medicare and Medicare Part D, compared to the estimated average cost you might pay for Medicare Advantage or a combination of Original Medicare, Part D coverage and a Medicare Supplement plan: Estimated Average Costs Understand Medicare s Costs Original Medicare and Medicare Part D Original Medicare Plus Part D and Medicare Supplement Medicare Advantage with Rx Coverage Built-in Part A 9 $0 $0 $0 Standard Part B 10 $ $ $ How much does Medicare cost? As mentioned, you can choose different types of Medicare insurance plans. What you pay each month for coverage will depend on a number of factors, including where you live, and which combination of coverage you select. Part D 11 $ $ NA Medicare Ad-vantage (Part C) Medicare Supplement NA NA $ on average (As low as $0) NA $167 5 NA Combined Total Monthly Costs $ $ $ STEP 3 3 Step Guide to Medicare 57

30 Supporting Data in This Document 1 This information assumes all of your prescribed medications are approved by Medicare and covered by your prescription drug plan s formulary. Any prescribed medications that are not approved by Medicare or covered by your plan s formulary may not be covered by your plan and will not count toward your deductible, coinsurance, coverage gap or catastrophic limit. 2 Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount of $2,200 in 2017 before your Medigap plan pays anything. 3 After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year. 4 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don t result in inpatient admission. 5 Data according to the Healthcare Cost and Utilization Project for Costs-United-States-2012.pdf 6 Data according to the Agency for Healthcare Research and Quality (AHRQ) 7 Medicare Part D, Medicare Advantage and Medicare Supplement plans are only offered by private insurance companies. The Federal Government has established minimum coverage requirements for each type of plan. These minimums are outlined in more detail in this booklet. Monthly prices and additional benefits will vary from plan to plan as will deductibles and cost-sharing for Medicare Part D Prescription Drug and Medicare Advantage plans. Medicare Supplement plan F is the most popular but 10 different supplemental plan types are available in some areas. 8 Certain individuals may qualify for Medicare before 65 with no waiting period if they have amyotrophic lateral sclerosis (or Lou Gehrig s disease) or end-stage renal disease requiring dialysis or kidney transplant. 9 People that qualify for Social Security or Railroad Retirement benefits, will not have an additional premium, however people who do not qualify for Social Security or Railroad Retirement benefits may be assessed an additional Medicare Part A Premium. If you have to buy Part A, you ll pay up to $411 each month. 10 People with higher incomes may be assessed a higher Medicare Part B Premium amount. 11 Part D (prescription drug coverage): This was $41.46, per month on average in Part D monthly premiums can vary by plan (higher-income consumers may pay more) Data from an October 13, 2015 report from the Kaiser Family Foundation; Medicare Part D: A First Look at Plan Offerings in 2016 (link) 13 Data from a December 3, 2015 report from the Kaiser Family Foundation: Medicare Advantage 2016 Data Spotlight: Overview of Plan Changes (link) 58 RESOURCES 3 Step Guide to Medicare 59

31 Glossary Amyotrophic Lateral Sclerosis (ALS) Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Those in the later stages of the disease may become totally paralyzed. Beneficiary The name for a person who has health care insurance through the Medicare or Medicaid program. Certificate of Creditable Coverage A written certificate issued by a group health plan or health insurance provider (including an HMO) stating the period of time you were covered by your health plan. Possession of this certificate usually reduces how long a health care plan may exclude you from coverage for a preexisting health condition. Coinsurance The amount you may be required to pay for health care services after you meet your plan s deductibles. The coinsurance payment is a percentage of the cost of the service (like 20%). Co-Payment An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription drug. Cost Sharing An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or prescription drug. This amount can include copayments, coinsurance, and/or deductibles. Creditable Coverage Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period. Deductible (Medicare) The amount you must pay for health care before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B. These amounts can change every year. Drug List A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This list is also called a formulary. End Stage Renal Disease (ESRD) Kidney failure, also called end-stage renal disease (ESRD), is the last stage of chronic kidney disease. When your kidneys fail, it means they have stopped working well enough for you to survive without dialysis or a kidney transplant. Excess Charges If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge. Extra Help A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. Formulary A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list. Guaranteed Issue Rights (also called Medigap protections ) Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can t deny you a Medigap policy, or place conditions on a Medigap policy, like exclusions for pre-existing conditions, and can t charge you more for a Medigap policy because of a past or present health problem. Health Care Provider A person or organization that s licensed to provide health care services. Doctors, nurses, and hospitals are examples of health care providers. Hospital Outpatient Setting A part of a hospital where you get outpatient services, like an emergency department, surgery center, observation unit, or pain clinic. In-Network Doctors, hospitals, pharmacies, and other health care providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, 60 RESOURCES 3 Step Guide to Medicare 61

32 Glossary hospitals, pharmacies, and other health care providers. Initial Enrollment Period The first chance you have to enroll in Medicare. The Initial Enrollment Period (IEP) begins three months before you turn 65 and lasts for seven months. Inpatient Hospital Services Health care services provided in a hospital, including bed and board, diagnostic or therapeutic services, medical or surgical services, and nursing services. Medicare Advantage Plan (Part C) A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. Medicare Advantage HMO Plan Type: Health Maintenance Organization (HMO) HMOs require you to use doctors in the plan s network. You will have a primary care doctor and may need a referral to see a specialist. Medicare Advantage PPO Plan Type: Preferred Provider Organization (PPO) PPOs allow you to see out-ofnetwork providers, but you ll have lower costs if you use doctors in the plan s preferred network. Out-of-network or non-contracted providers are under no obligation to treat a PPO plan s members, except in emergency situations. For a decision about whether the PPO plan will cover an outof-network service, you or your provider should ask the PPO plan for a pre-service organization determination before you receive the service. Please call the PPO plan customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. You won t need a referral to see a specialist, and you are not required to have a primary care physician. Medicare Advantage HMO- POS Plan Type: Health Maintenance Organization Point-of-Service (HMO- POS) HMO-POS plans have features of HMO and PPO plans. You ll have a primary care doctor, like an HMO, but you ll also be allowed to pay more to see an out-of-network provider. HMO-POS plans may not require referrals if you need to see a specialist. Medicare Advantage PFFS Plan Type: Private Fee-for- Service (PFFS) Some Private Fee-for-Service plans don t have provider networks, and let you use any provider that will accept the plan s payment conditions. Providers contract with your Private Fee-for- Service plan and treat you on a case-by-case scenario, so you ll need to verify that the provider takes your plan on each visit. Other PFFS plans do have provider networks, and you may pay more if you see out-of-network doctors. You ll usually only pay the plan s cost-sharing requirements (which may vary among plans), but some providers can charge up to 15% above the Medicare-approved amount. Medicare Advantage SNP Plan Type: Special Needs Plan (SNP) Special Needs Plan membership is limited to people who meet certain eligibility criteria. There are three kinds of Medicare Special Needs Plans, each targeting a certain group, including people who have specific medical conditions, live in an institution, or receive Medicaid benefits. Every Special Needs Plan provides prescription drug benefits. Medicare Advantage MSA Plan Type: Medicare Savings Account (MSA) This is a high-deductible Medicare Advantage plan that includes a medical savings account. The Medicare Savings Account plan deposits money into a savings account that you can use to pay for health costs without being taxed. You spend this money on Medicare covered health-care costs that have been applied to your deductible. However, your plan won t pay for Medicare covered services until you 62 RESOURCES 3 Step Guide to Medicare 63

33 Glossary reach the deductible. Medicare Savings Account plans don t include prescription drug coverage. If you want to have prescription drug coverage, you may enroll in a standalone Prescription Drug Plan. Medicare Part a (Hospital Insurance) The part of Original Medicare that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Medicare Part B (Medical Insurance) The part of Original Medicare that covers certain doctors services, outpatient care, medical supplies, and preventive services. Medicare Plan A plan other than Original Medicare that that you can get your Medicare health or prescription drug coverage. This term includes all Medicare health plans and Medicare Prescription Drug Plans. Medicare Supplement Policy Medicare Supplement Insurance (Medigap) sold by private insurance companies to help pay some of the health care costs that Original Medicare doesn t cover, like copayments, coinsurance, and deductibles. Original Medicare Original Medicare is a fee-for-service health plan that has two parts: Part A (hospital insurance) and Part B (medical insurance). Out-Of-Pocket Costs Health or prescription drug costs you must pay your own because they are not covered by Medicare or other insurance. Out-Of-Network A benefit that may be provided by your Medicare Advantage plan. Generally, this benefit gives you the choice to get plan services from outside of the plan s network of health care providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit. Pharmacy Network Pharmacies that have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. Some Medicare plans will cover your prescriptions only if you get them filled at network pharmacies. Premium The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Pre-Service Organization Determination A request to provide or pay for items or services you think should be covered, provided, or continued. You, your representative, or your doctor can request an organization determination from your plan in advance to make sure that the services are covered. Prior Authorization Plans may require a prior authorization to make sure certain prescription drugs are used correctly and that only when medically necessary. This means before your plan will cover a certain drug, you must show the plan you meet certain criteria for you to have that particular drug. Quantity Limitations For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain period of time. For example, most people who are prescribed a heartburn medication take 1 capsule per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication. Respite Care Respite care is short-term assistance so your primary caregiver can rest. Medicare covers inpatient respite care for up to 5 days if you re getting covered hospice care services. Stand-alone Medicare Prescription Drug Plan (also called Medicare Part D) A type of Prescription Drug Plan that works alongside Original Medicare Part A and Part B coverage. Step Therapy Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that are also approved for use for your condition before you can move up a step to a more expensive drug. 64 RESOURCES 3 Step Guide to Medicare 65

34 Medicare Required Disclaimers Benefits, premiums and/or co-payments/co-insurance 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. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium. A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency. Dual Eligible SNP: This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, copays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for more details. Other Pharmacies and providers are available in the network. Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether your plan will cover an out-of-network service, we encourage you or your provider to ask the plan sponsor for a pre-service organization determination before you receive the service. Please call your plan sponsor s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 66 RESOURCES 3 Step Guide to Medicare 67

35 Y0040_MULTIPLAN_GHHJHM4EN Accepted 2017 ehealth, Inc. www.