2015 don t delay. apply for Medicare as soon as you become eligible. MedicAre: You ve earned it. Make the most of it. You can enroll in Medicare the three months before, during and the three months after your 65th birthday month or during a Special enrollment Period, if you qualify. After you enroll, you ll have an opportunity to switch Medicare Advantage and Prescription drug plans once a year during the Open enrollment Period without penalty and throughout the year for Medicare Supplement plans. A simple guide providing useful information on Medicare, health and wellness, and more. Section 1 Medicare. Plain and SiMPle. Section 2 not a Medicare expert? no ProbleM. 879120 09/14 879120 09/14 INT_15_21680
Section 1 Medicare. Plain and SiMPle. Your health is as individual and unique as you are. That s why we created this handy guide. In it, you ll find answers to all your Medicare questions from understanding the differences between the plans themselves to knowing what to ask yourself when shopping for a plan, when to enroll and where to go for extra financial help. It s all here so you can easily find the Medicare plan that best fits your unique health care and pharmacy needs. do you qualify for Medicare? Generally, you re eligible if:* You or your spouse worked for at least 10 years in Medicare-covered employment You re 65 years or older If you re under 65, you can get Part A without having to pay premiums if you have: Received Social Security or Railroad Retirement Board disability benefits for 24 months End-stage renal disease and meet certain requirements * Other eligibility limitations may apply depending on certain situations. For more information, visit medicare.gov. 1
the a, b, c, ds of Medicare Part a: Hospital insurance original Medicare (Medicare pays 80% and you pay 20%) Hospital stays Skilled nursing facility Hospice care Some home health care Once you turn 65, you ll need to sign up for Medicare Part A (there are a few exceptions). There is no cost to you (outside of your deductible) because you or your spouse paid Medicare taxes while working. Part c: Medicare advantage Plans Combine Part A and Part B in one plan Often include Part D (prescription drug coverage) These plans are part of the government s Medicare program, but are offered and managed through private insurers and may offer plan extras not found with Original Medicare. You must be enrolled in Medicare Parts A and B to join. Medicare Supplement insurance A Medicare Supplement Insurance policy is private health insurance that helps pay the 20% of health care costs that Original Medicare doesn t cover. Helps pay some costs (copays, coinsurance and deductibles) that Original Medicare doesn t cover Part b: Medical insurance To learn more about Medicare, visit medicare.gov. Medical services Outpatient care Medical items Covered preventive services Medicare pays: 80% of approved charges. Beneficiary pays: 20% of approved charges. Part B is optional because you have to pay a monthly premium and satisfy a deductible before Medicare will pay benefits. Part d: Prescription drug coverage Help lower prescription drug costs and may protect against higher future costs Some Medicare Advantage plans offer built-in prescription drug coverage Part D plans are part of the government s Medicare program, but they re offered and managed through approved private insurers. Only works with Original Medicare Medicare Supplement Insurance cannot be used with Medicare Advantage plans, but can be used with Prescription Drug plans Medicare Part d: Prescription drug Plans Medicare Part D is designed to help lower prescription drug costs and can be purchased through private insurance companies. There are three coverage phases, and your costs change in each phase: Phase i: Deductible and Initial Coverage If a plan has a deductible you must pay those initial costs. After that, you will only pay a copay or coinsurance for your drugs until you reach the Initial Coverage limit. Phase ii: Coverage Gap This is commonly referred to as the donut hole. Here you will pay a discounted amount that is 45% for brand and 65% for generic drugs. Once your combined drug costs reach the upper level of the Coverage Gap, you will reach the Catastrophic Coverage phase. Phase iii: Catastrophic Coverage Once you have Catastrophic Coverage, you will pay a small amount for medications, typically as low as 5% of the cost of the drug. 2015 by 2020 Brand-name medications you ll pay 45% Generic medications you ll pay 65% You ll pay only 45% of the cost of your brand-name drugs (improved from paying 50% in 2012), while the amount you ll pay for generic medications will also be reduced to 65% of the cost of these drugs. Brand-name medications you ll pay 25 % Generic medications you ll pay 25 % You ll pay only 25% for brand-name and generic drugs. Why generic drugs make cents. When it comes to your health, only the best will do. Generic drugs are safe and effective alternatives to brand-name drugs. In fact, they have the same active ingredients, dosage and quality as their brand-name counterparts. But, there is one big difference between the two: cost. Typically, generics are less expensive than brand-name drugs; sometimes, much less. According to the U.S. Federal Drug Administration (FDA), generics can be 30% to 80% less expensive than their brand-name versions. The FDA approves new generic drugs each month. For details, go to fda.gov and search for new generic drug approvals. And talk with your doctor to see if there are generic alternatives to the brand-name drugs you currently take. Source: www.gphaonline.org/ about/generic-medicines $ 2 3
Medicare advantage Medicare Supplement Medicare Part c: Medicare advantage Plans With Part C, you will pay a monthly plan premium, which varies based on the type of plan, coverage and company you choose. Remember, it covers Parts A and B, but may also cover extra benefits such as dental, vision, and Part D prescription drugs. Medicare Advantage plans can simplify Medicare and are similar to the insurance plans you ve always used: You carry one insurance card, which you give to doctors before receiving care. The doctor charges your insurance for your medical care and you may pay a deductible, copay, or coinsurance depending on your plan. For many plans, you choose your doctors and hospitals from a network. You have a single point of contact for all your medical care. When you enroll in a Medicare Advantage plan, you keep all of your Medicare benefits. You have all the rights and protections of Original Medicare and, in some plans, you also have extra benefits like prescription drug coverage, dental coverage, eyewear allowance, and more at no extra cost. Medicare Supplement insurance plans help cover costs original Medicare doesn t cover These standardized plans help you pay the 20% of medical and hospital costs that Original Medicare doesn t cover. Medicare Supplement Insurance plans are the same regardless of the insurance company. You can use any doctors and hospitals that accept Medicare, with no referrals required.* You will have the freedom to travel and know you re covered, since these plans provide nationwide coverage. You won t need to worry about deductibles, copays or coinsurance your monthly plan premium is all you ll pay. When s the best time to buy a Medicare Supplement plan? The best time to buy a Medicare Supplement Insurance policy is during your Medicare Supplement Open Enrollment Period, which lasts six months and begins on the first day of your 65th birthday month. During that time, you have the right to buy any Medicare Supplement plan offered in your state. And, regardless of your health, insurance companies can t: Refuse to sell you any Medicare Supplement plan it offers Charge you more than they would charge someone without health problems You can count on: Medicare advantage plans may also include extra benefits, like: and remember, you ll still have: Once you have your Medicare Supplement Insurance policy, it can t be canceled regardless of your health or age. As long as you pay your premiums when due, your coverage is guaranteed renewable** for life. * In some cases, a referral is required. ** Policy cannot be canceled as long as you pay your premium when due. The company reserves the right to adjust premiums on a class basis. Low, or even $0 monthly plan premiums Low copays Low or no deductibles Prescription drug coverage Dental coverage + Fitness membership An eyewear allowance + And much more All of your Original Medicare benefits, plus more The same rights and protections as Original Medicare More value with lower out-of-pocket costs 4 5
What coverage is right for you Medicare advantage or Medicare Supplement? See chart below to find out which plan option best fits your individual needs. doctors Can go to any doctors and hospitals who accept Medicare (with no referrals) Must go to doctors and hospitals in a network (out-of-network available for emergencies) TrAVeL Nationwide coverage Local in-network coverage (out-of-network available for emergencies) PLAN costs Monthly plan premiums vary (depending on plan, age, state, health, insurance company) No deductibles, copays or co-insurance (monthly premium is all you ll pay) No or low monthly plan premiums (vary by plan) No or low deductibles, copays or coinsurance (vary by plan) coverage Standardized plans to help pay the 20% of medical and hospital costs Original Medicare doesn t cover Customized plans that cover your hospital and medical benefits and may include additional benefits such as dental, vision, hearing, fitness memberships, etc. (plans vary) Prescription drug coverage often included Coordinates and manages care by partnering with doctors dedicated to keeping you healthy changing PLANS Change to these plans any time during the year Change plans during annual Open Enrollment Period only (few special exceptions) YOur HeALTH Must complete a medical questionnaire (unless you re turning age 65 or your employer coverage ends) Plans are guaranteed renewable (insurance companies can t cancel your policy due to health problems as long as you pay your premiums) MEDICARE ADVANTAGE MEDICARE SUPPLEMENT Medicare and staying well Welcome to Medicare preventive visit Once you enroll in Medicare Part B, you re eligible for a free introductory Welcome to Medicare preventive visit. This appointment includes a medical and social history review, routine measurements, vision testing and a plan to help inform you on which screenings, shots and other preventive services you may need. This visit is only available to new Medicare Part B participants and is covered one time (within the first 12 months of signing up for Medicare Part B). You don t need to have this visit to be covered for your annual Wellness visits. Free annual wellness visit and prevention plan If you ve had Medicare Part B for longer than 12 months, you can get a free annual Wellness visit to develop or update your personalized prevention plan to help you stay healthy. This appointment includes a medical and family history review, provider and prescription update, routine measurements, cancer and diabetes screenings and more. This visit is covered once every 12 months (11 full months must have passed since the last visit). Who s eligible? Anyone enrolled in Original Medicare is eligible for the one-time Welcome to Medicare visit and the annual Wellness visits. What s the cost? If you re currently enrolled in Original Medicare, you pay nothing for these visits if your doctor or other qualified health care provider accepts assignment.* However, if your doctor or health care provider performs additional tests or services during the same visit that aren t covered under these preventive benefits, you may have to pay coinsurance and your Part B deductible may apply. * Assignment is an agreement by your doctor, health provider, or supplier to be paid directly by Medicare, or accept the amount Medicare approves for the service and not bill you for any more than the Medicare deductibles and coinsurance. For an additional resource to learn more about Medicare, visit ncoa.org, the National council on Aging website. Located in Washington, d.c., this nonprofit service and advocacy agency has a focused mission to improve the lives of all older Americans. 6 7
Section 2 not a Medicare expert? not a ProbleM. When you become eligible for Medicare, you receive lots of information, but not much guidance. But don t let not knowing every detail stop you from learning more about the Medicare choices you have and making informed decisions about your future care. Know yourself. Know your options. When comparing the different plans available, be sure to consider what s important to you. There s a lot to think about, so ask yourself the following questions. The answers may help point you in the right direction: How s your health? Are you in good health or do you have chronic conditions? Do you take prescription drugs regularly and if so, which ones? Are they brand name or generic? How much are you spending for them? How does health care fit into your budget? Will you qualify for financial help? How much are you able to spend each year on premiums or copays? What s your level of patience for paperwork? What doctors do you visit? How often do you see them? Would you be willing to see a new doctor, if necessary? Do you travel? Inside the U.S. or internationally? How much did you spend on medical care last year? This can help provide an estimate for what next year s costs might be. explore your options It s never too early to start shopping for your plan. If you have coverage through your employer, talk with your benefits or human resources manager about your options. There are many other resources available including the Medicare website medicare.gov, the annual Medicare & You handbook, your State Health Insurance Assistance Program (SHIP), the Social Security Administration and more. Know where to go for financial help When it comes to choosing the right plan, help is available. But did you know you can also get financial help, if you qualify? Extra financial assistance to help cover the costs of Medicare is available for individuals with lower incomes. If you think you might qualify, apply as soon as possible. It can take several months to process your application. You ll want to find out quickly if you re eligible, and how much help you could receive. Original Medicare (Parts A and B) or Medicare Advantage Plan (Part C) financial help Medicare may help pay Original Medicare (Parts A and B) or Medicare Advantage Plans (Part C): Premiums Deductibles Coinsurance Copays Part D Prescription Drug Plan Extra Financial Help If you qualify, Medicare Extra Help could pay up to 75% or more of your drug costs including prescription drug: Premiums Deductibles to find out how to apply for financial help, call: Coinsurance Copays 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users call 1-877-486-2048. The Social Security office at 1-800-772-1213, 7 am to 7 pm, weekdays. TTY users call 1-800-325-0778. Your state Medicaid office. 8 9
choosing the right plan for you Medicare offers many choices. You ll need to Meet John* Meet Anne* Meet rita* compare your needs to what s available. The following three scenarios offer examples of the types of plans available and the reasons why they may be a good fit. Remember, costs may vary. John just turned 65 and retired. He s in good shape, but takes a daily prescription drug to keep his high blood pressure under control. John takes good care of himself and is careful to live within his budget. John s wish list Access to a full range of health care services, including preventive care Coverage that provides a safety net in case of a serious illness Access to specialists if he needs them; he s comfortable with sticking to choices in a plan s network Access to prescription drug coverage, in case he needs to take more drugs later John s choice Medicare Advantage Plan To qualify for this plan, John must also have Medicare Part A and Part B Features One ID card that covers hospital stays, doctor visits, medications, urgent care clinics and emergency room visits Less paperwork Potential extras, such as a free fitness program Built-in prescription drug benefit Network of local doctors and hospitals Anne is turning 65 in three months and has started researching Medicare plans. Since she spends a lot of time out of state visiting children and grandchildren, she needs a plan that can travel with her. Anne is fairly healthy, although she takes a drug to keep her bones strong and another drug to keep her cholesterol down. anne s wish list Access to doctors and hospitals when she s out of state visiting her children Peace of mind knowing that she ll have significant help paying for her drug costs if they re large anne s choice Medicare Part A and Part B (Original Medicare) Stand-alone Medicare Part D Prescription Drug Plan Medicare Supplement Plan through a private insurance company Features Access to doctors and hospitals throughout the United States Medicare Part D coverage for the drugs she takes Help with her Part A and Part B costs through her Medicare Supplement plan Rita will be 65 next month. She s been working part-time since her husband passed away several years ago, but her income is limited. Rita has heart disease and takes a bloodthinning medicine every day. She does not feel she can afford the premiums for a Medicare Supplement Insurance policy. rita s wish list Health care at an affordable price Access to her trusted doctors Coverage for her prescription drugs rita s choice Medicare Part A and Part B (Original Medicare) Stand-alone Medicare Part D Prescription Drug Plan Features Access to the doctors and hospitals she uses now The possibility of help with her Part D Prescription Drug Plan premiums and cost-sharing if she qualifies for low-income assistance * John, Anne and Rita are hypothetical people used for illustrative purposes only. No need for a Medicare Supplement plan 10 11
enrollment Medicare advantage and Prescription drug Plans NOTES There are three types of enrollment periods: 1. initial: When you turn 65 For those new to Medicare, there is a seven-month window in which to enroll in Original Medicare and then choose your Medicare options. This enrollment period includes the three months before, during and the three months after your 65th birthday month. 2. Special: Year-round For those who qualify to enroll throughout the year due to special circumstances such as: moving into or out of a plan service area, losing employer insurance coverage, gaining or losing Medicaid financial assistance eligibility, qualifying for Extra Help, current plan termination, qualifying for a Special Needs Plan or while on Medicare disability. 3. annual: october 15 december 7 every year All Medicare beneficiaries can enroll, switch or drop Medicare Advantage and Prescription Drug coverage during this time each year. Medicare Supplement insurance Plans unlike Medicare Advantage and Prescription drug Plans, there isn t a designated annual enrollment period for Medicare Supplement Plans. You can apply for a Medicare Supplement policy any time throughout the year. MEDICARE SUPPLEMENT INSURANCE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC APPLY ANY time throughout the YeAr! 12 13