Welcome to Kaiser Permanente Presenting Medicare 101 and Kaiser Permanente Senior Advantage City of San Diego Nancy Voltero Retiree Consultant
Basics of Medicare 2
What is Medicare? Medicare is a federally funded health insurance program for eligible beneficiaries. Medicare was established in 1965. Medicare is administered by the Centers for Medicare & Medicaid Services (CMS). 3
Who is eligible? Medicare beneficiaries include: Individuals 65 or older if they or their spouses are eligible for Social Security. Individuals under 65 who are disabled. Must be eligible for Social Security disability Requires 2-year waiting period Individuals with end-stage renal (kidney) disease (ESRD). 4
Medicare Part A Inpatient insurance Hospital, skilled nursing facility, hospice, home health care Eligibility First day of the month that you turn 65 2 years after becoming disabled After end-stage renal dialysis begins Cost No premium if you or your spouse has worked 40 quarters of Medicare-covered employment. If you worked fewer than 40 quarters, there is a monthly premium up to $441 which is set by a Medicare formula. 5
Medicare Part B Outpatient insurance Physician services, outpatient surgery, lab, radiology, durable medical equipment (DME), dialysis. Enrollment Optional: You are responsible for enrolling with Social Security Administration. You can enroll over a 7-month period, which starts 3 months before your 65th birthday. Late enrollment penalty may apply if you do not enroll in this 7- month window. 6
Medicare Part B Cost Monthly premium is usually deducted from your Social Security check. Premium goes up 10 percent for each 12-month period that you decline coverage. Known as late enrollment penalty.* Not imposed if you continue to work for and receive your health coverage from an employer group or trust fund plan of 20 or more eligibles. In 2015, Part B premium will range from $104.90 to $335.70, depending on income. * This amount is not a one-time penalty, but continues throughout enrollment. 7
2015 Monthly Premiums for Medicare Part B You Pay If Your Yearly Income is* Single Married Couple $104.90 $85,000 or less $170,000 or less $146.90 $85,001-$107,000 $170,001-$214,000 $209.80 $107,001-$160,000 $214,001-$320,000 $272.70 $160,001-$214,000 $320,001-$428,000 $335.70 Above $214,000 Above $428,000 You Pay If You Are Married but You File a Separate Tax Return From Your Spouse and Your Yearly Income 2011 was $104.90 Under $85,000 or less $272.70 $85,001-$129,000 $335.70 Above $129,000 * Modified adjusted gross income as reported on your 2011 IRS tax return. If you have questions about your Part B premium, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 8
How to Enroll in Medicare Part B Fill out an Application for Enrollment in Medicare Part B. Mail it to the nearest Social Security office, or Submit it in person to any Social Security office. Call Social Security to apply for Medicare Enroll on line at www.socialsecurity.gov Note: Completing the application form and submitting it does not automatically enroll you in Medicare Part B. Social Security must first determine if you are eligible to enroll. 9
Medicare Plan Options Plan options for how you receive Medicare coverage: Option 1: Original Medicare Plan through the Centers for Medicare & Medicaid Services (CMS). Option 2: Medicare Advantage Plans (Part C) such as: A Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) Medical Savings Account Plans (MSA) 10
Medicare Part D Medicare Modernization Act (MMA) created Medicare prescription drug coverage (Part D), effective January 1, 2006. Provides outpatient prescription drug coverage. Enrollment options for Part D Private insurer plan, such as Kaiser Permanente. Prescription Drug Plan (PDP): A plan type that offers prescription drugs only. Note: Unlike Parts A and B, Part D is enrolled directly with the plan. Part D is not available through Medicare or Social Security. 11
Medicare Part D Enrolling in Part D You are eligible for initial enrollment during the 7-month period, which starts 3 months before your 65th birthday. Late enrollment penalty (LEP) As with Part B, you must obtain Part D or creditable Part D coverage as soon as you are eligible or you will be charged a penalty. LEP is 1 percent of that year s Part D base premium per month that enrollment is deferred. 12
Medicare Part D Medicare s extra help program: Low Income Subsidy (LIS) For Medicare beneficiaries with limited income and resources. Provides extra help with Part D premiums and outpatient drug copayments. Degree of help depends on income and resources. Additional facts about extra help: Apply at Social Security or state Medicaid office. Administered by the member s plan, for CMS. Beneficiaries must be enrolled in a Part D plan to receive assistance. 13
Medicare Part D You pay If your yearly income is* Single Married couple $12.30 $85,001 107,000 $170,001 214,000 $31.80 $107,001 160,000 $214,001 320,000 $51.30 $160,001 214,000 $320,001 428,000 $70.80 Above $214,000 Above $428,000 The Part D higher-income premium is in addition to the annual Part B premium adjustment. The Part D premium is determined according to formulas set by federal law, not by the health plan. * Modified adjusted gross income as reported on your 2011 IRS tax return. If you have questions about your Part D premium, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 14
Kaiser Permanente Senior Advantage (HMO) All of the following information regarding Medicare and Kaiser Permanente Senior Advantage applies only to employer group Members who have or are eligible for Medicare. 15
2015 Medicare ratings Kaiser Permanente region California Colorado Georgia Hawaii Mid-Atlantic States (MD, VA, D.C.) Northwest (OR, WA) Ohio Star rating Plan performance star ratings are assessed each year and may change from one year to the next. Kaiser Permanente is a health plan with a Medicare contract. Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2015. Kaiser Permanente contract #s H0524, H0630, H1170, H1230, H2150, H9003, and H6360. 16
Senior Advantage The Kaiser Permanente Senior Advantage (HMO) plan is a Medicare Advantage plan for people with Medicare. Senior Advantage provides services covered by Medicare (including Medicare Part D prescription drug coverage). As a Senior Advantage member, you get your Medicare benefits through Kaiser Permanente. The Medicare program pays Kaiser Permanente to manage health care for people with Medicare (our Senior Advantage members). 17
Contact Information If you have questions on the Employer Group Senior Advantage Plan, contact your HR Benefits Department. Kaiser Permanente Senior Advantage Member Services 1-800-464-4000 (TTY 1-800-777-1370), Monday through Friday, 7 a.m. to 7 p.m., Saturday and Sunday 7 a.m. to 3 p.m. Social Security: 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, 7 a.m. to 7 p.m. Medicare: 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048, 24 hours a day, seven days a week. 18
Kaiser Permanente is a health plan with a Medicare contract. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each year, and at other times in accord with your group s contract with us. The benefit information provided is a brief summary, not a comprehensive description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. You must reside in the Kaiser Permanente Senior Advantage/Medicare Plus service area in which you enroll. 19