Guide to Medicare
Letter from the Director Congratulations! You have arrived at an exciting milestone in your life as you begin to evaluate your medical insurance options, most specifically, Medicare coverage. We at Senior Promise and Franciscan Insurance Services are here to assist you every step of the way through this sometimes daunting task. This guide is a condensed version of the Medicare and You manual provided by Medicare. We hope that you are able to utilize this brief overview in your quest for answers to your many insurance questions. Please contact the Franciscan Insurance Services office at (317) 528-7770 in Indianapolis, or (317) 834-9548 in Mooresville from 8 a.m. to 4 p.m., Monday through Friday, to schedule a free appointment to meet one-on-one with a member of our licensed insurance staff. Best regards on your journey, Mindy King Franciscan Health Director, Senior Promise and Franciscan Insurance Services 1 1 Guide to Medicare
6 Medicare TABLE Part OF A & CONTENTS B 3 Medicare and You Eligibility 9 Medicare Supplemental Insurance (Medigap) Railroad Retirement Board 4 Enrollment Deadlines 10 Your IEP and Medicare Getting Extra Help 5 Annual Enrollment Period Special Enrollment Period Medicare 12 Medicare Savings Program 6 Medicare Advantage Disenrollment Period Medicare Part A & B 14 Hoosier Rx 7 Medicare Part C & D 8 The Doughnut Hole Guide to Medicare 2
MEDICARE AND YOU - AN INTRODUCTION Medicare is a federal program that provides health insurance coverage for those 65 and older, or individuals who qualify under special circumstances. Medicare was signed into law by President Lyndon B. Johnson in July of 1965. Since that time Medicare expanded its coverage to include individuals who were younger than age 65 and have certain disabilities, including end stage renal disease. In 2003, President George W. Bush signed in to law the Medicare Prescription Drug Plan, or Medicare Part D, which provides those on Medicare coverage for their prescription medications. Traditional Medicare does not cover all of your health care needs (such as dental and vision). There may be some out-of-pocket expenses occurred by the beneficiary of Medicare. We will look at this further as we explore the different elements of Medicare. ELIGIBILITY In order to qualify for Medicare, most individuals must be 65 years of age and have earned enough required quarters of coverage to be eligible. This means that either you or your spouse (or in some cases, your former spouse) must have worked and paid Social Security and Medicare payroll taxes for at least 10 years to be eligible. For more information about the St. Francis Insurance Services please contact us at (317) 528-7770 In some cases, individuals who are disabled may qualify for benefits prior to their 65th birthday, as long as the individual is a United States citizen or permanent resident. Approximately three months prior to your 65th birthday, an Initial Enrollment Questionnaire should be mailed to you if you are already receiving your Social Security benefits. If you do not receive this packet, contact your local Social Security office. Visit them online at www.ssa.gov or call them directly at 1-800-772-1213. Those individuals who are not receiving Social Security at age 65 must apply to the Medicare program through Social Security. Medicare will not reach out to you at age 65. You may contact them as previously noted. If you are a railroad worker and get Medicare from the Railroad Retirement Board, your Medicare benefits will generally work the same as for those who get Medicare through Social Security. There are just a few differences: RAILROAD RETIREMENT BOARD - RRB If you have retired from the railroad, your enrollment will be processed by the Railroad Retirement Board instead of by Social Security. If you are receiving railroad retirement benefits or railroad disability annuity checks when you become eligible for Medicare, the Railroad Retirement Board will automatically enroll you in Medicare Parts A and B. A few months before your Medicare eligibility begins, you will receive your Medicare card and a letter from the Railroad Retirement Board explaining that you have been enrolled in Medicare. If you qualify for railroad retirement benefits, but are not yet receiving them when you turn 65, you will need to contact your local Railroad Retirement Board field office to enroll in Medicare. 3 Guide to Medicare
If you are under 65 and have a disability, you will have to fulfill different eligibility requirements to qualify for Medicare. Whether you are eligible for Medicare and when you get it depends on how your disability is classified by the Railroad Retirement Board. Note: If you receive continuing dialysis for permanent kidney failure (end stage renal disease or ESRD), or you have had a kidney transplant, you should enroll in Medicare by contacting Social Security, even if you are a railroad worker. The Railroad Retirement Board will collect your Medicare Part A premiums (if you have them) and Part B premiums. If you receive railroad retirement benefits or railroad disability annuity checks, your Medicare premiums will be automatically deducted from your check each month. Your doctors and other health care providers will bill Medicare differently for services covered under Part B. Your providers must send Railroad Medicare Part B claims to the Part B carrier selected by the Railroad Retirement Board. To make sure that Medicare pays for your covered health services, always make sure your doctors and other health care providers know that you have Railroad Medicare, not Social Security Medicare. Your Medicare card will look different. Railroad Medicare Card Social Security Medicare Card Your card will say Railroad Retirement Board instead of showing the phone number to call Social Security. Your Medicare Claim Number will have a letter before your number, not after. Your card will have the Railroad Retirement Board address on the back. ENROLLMENT DEADLINES Initial Enrollment Period (IEP) Medicare enrollment is guided by election periods. For most, the election periods begin with what is called the Initial Enrollment Period (IEP). The IEP is characterized by a seven month window beginning three months before your 65th birthday, the month of your 65th birthday and three months after your 65th birthday. Enrollment deadlines may be different for those who are already receiving Social Security or Railroad Retirement Benefits, and those who are automatically enrolled into Original Medicare Parts A and B. Guide to Medicare 4
If you do not use your IEP to enroll in Medicare, you may face penalties in the future unless you have creditable coverage through another source. Be aware that not all forms of coverage are considered creditable; for instance COBRA may not be creditable coverage. It is important to verify during your IEP that your current coverage meets the criteria of creditability. Medicare requires individuals to carry coverage as good as, if not better than, Medicare Part B and Part D. When you do not enroll in these plans during your IEP, you may be charged higher premiums and a late enrollment penalty. You also may be limited to the time of year in which you can enroll in one of these programs. Annual Enrollment Period (AEP) The AEP has been designated as the 15th of October through the 7th of December each year. During this AEP, Medicare beneficiaries have the opportunity to choose to switch Medicare Part D prescription drug plans or Medicare Advantage Plans. Once you have passed this deadline, under normal circumstances, you will not be permitted to make changes to your Medicare Part D prescription drug plan or Medicare Advantage Plan until the following AEP. Special Enrollment Period (SEP) Some individuals are awarded what is known as a Special Enrollment Period which allows them to change their Medicare coverage other than times designated by the AEP of Oct. 15 through Dec. 7. Special Enrollment Periods can occur when certain events happen in your life - for example, if you have moved and your current plan is no longer available in your service area or if you lose your other insurance. Medicare Advantage Disenrollment Period (MADP) The Medicare Advantage Disenrollment Period (MADP) is Jan. 1 through Feb. 14 of each year. Changes you make during the Medicare Advantage Disenrollment Period go into effect the first day of the following month. During the MADP you can make changes only if you have a Medicare Advantage Plan. You can add or drop drug coverage when you are switching to Original Medicare. You cannot make any changes if you have original Medicare. Important: If you disenroll from your Medicare private health plan (Medicare Advantage), federal law does not give you the right to buy a Medigap Plan. The laws in your state may give you more rights and allow you to enroll in a Medigap plan. Medigap plans are supplemental policies that help pay for Original Medicare deductibles and coinsurances. 5 Guide to Medicare
If you have You can switch to... Medicare private health plan with drug coverage (Medicare Advantage Plan with prescription drug coverage MAPD). A Medicare Private Fee-For-Service (PFFS) plan that does not have prescription drug coverage and a standalone prescription drug plan (MA and PDP). Original Medicare or Original Medicare and a prescription drug plan. Original Medicare and a prescription drug plan or Original Medicare without a prescription drug plan. Original Medicare, but you must keep your current prescription drug plan. You cannot switch your plan during the MADP enrollment time. MEDICARE PART A, B, C AND D Medicare Part A Your hospital coverage When you apply for Medicare, you are automatically enrolled in Medicare Part A. For most people, Part A does not have a premium cost. Part A covers inpatient hospital stays, skilled nursing facility stays and some home health and hospice. If you are a citizen and/or a permanent resident and have not worked long enough to qualify for Part A, and do not qualify through a spouse, then you may be eligible to purchase coverage. Coverage is based on a benefit period for inpatient hopsital care and skilled nursing facility stays. A benefit period begins the day you are admitted as an inpatient to the hospital and ends when you have no care received in a hospital or skilled nursing facility for 60 days in a row. Medicare Part B Your medical coverage Medicare Part B helps to pay a portion of your doctor s office visits, some health care, medical equipment, outpatient procedures, rehabilitation therapy, laboratory tests, x-rays, mental health services, ambulance service and bloodwork. Part B also pays for overnight observation stays while in the hospital. Part B coverage is optional, and if you have coverage already through your employer, spouse or union you may want to think about opting out of coverage. Part Guide to Medicare 6
B requires a monthly premium, which is usually automatically deducted from your Social Security check. People with a higher income annually $85,000 for an individual and $170,000 for a couple pay higher premiums. You can sign up for Part B any time you have current employer insurance. (COBRA and retiree insurance do not count as current employer insurance.) Should you choose to opt out of Part B coverage, and are not covered under an employer, spouse or union plan, you may have to pay a higher premium once you are eligible to enroll. Your monthly Part B premium will go up 10 percent for each full 12-month period that you could have had Medicare Part B but did not take it. You will pay this higher premium as long as you have Medicare Part B. If Medicare Part B is not chosen during your IEP or within eight months after you lose employment, spouse or union coverage, then you must wait until the General Enrollment Period to apply for Part B which is Jan. 1 through March 31 of each year. Your Medicare Part B will then become effective July 1 of the same year. Medicare Part C Medicare Private Health Plans/Advantage Plans Medicare Part C plans are offered through private health insurance companies and approved by Medicare. These plans are referred to as Medicare Advantage Plans or Medicare Health Plans. By law, the Medicare Advantage Plans must pay for at least the same health coverage as traditional Medicare. Some plans offer even more benefits that are not covered under traditional Medicare, such as vision and dental. Most plans also include prescription drug coverage as well. Medicare Advantage Plans are generally divided in to health maintenance organizations (HMO), preferred provider organizations (PPO) and private fee for service plans (PFFS). In these plans, you choose a doctor as your primary care provider (PCP). Your choice of doctors, hospitals and other care providers is restricted to your PCP network. If you choose to see a doctor or provider that is out of your network, you will pay more, or possibly the entire cost of the visit. For availability of these plans in your area, visit www.medicare.gov. Medicare Part D Prescription Drug Plans There are two ways to receive your Medicare Part D Prescription Drug Plan coverage. You can either enroll in a stand-alone prescription drug plan through a private insurance company or you can receive your Part D benefits through a Medicare Advantage Plan. If you are enrolled in Prescription Part D plan you will have monthly premiums, sometimes a deductible and copayments for your drugs. Each of the plans varies in the cost of their premiums, price of the drugs and the list of drugs that they will cover. 7 Guide to Medicare
The Doughnut Hole or Coverage Gap Explained A disadvantage of Part D is the coverage gap known as the doughnut hole that s reached when the combined cost of your prescriptions in a given year, as paid by both you and your insurer, exceeds a certain amount. At that point, you essentially start paying for your medications as if you have no insurance. At the same time, you re also paying your Part D premiums. To ease the pain of falling into the doughnut hole, the new health care law provides that, since 2011, people with Medicare Part D have started to receive a 50 percent discount on most brand-name prescriptions and biologic drugs, and a seven percent discount on generic prescription drugs while they are in the coverage gap or doughnut hole. After your prescription drug costs reach a certain amount over the course of the year, you will qualify for lowcost catastrophic coverage. This takes you through to the end of the year, at which point the calculation starts all over again. The Part D doughnut hole coverage gap will gradually narrow until it disappears in 2020. Guide to Medicare 8
MEDICARE SUPPLEMENTAL INSURANCE (MEDIGAP) Supplements or Medigap policies are insurance policies that supplement or fill in the gaps where Medicare stops paying, such as for copays and deductibles. These plans are offered through private insurance companies and are available only to those who are enrolled in Medicare Parts A and B. If you have enrolled in a Medicare Advantage Plan (Part C), you are not eligible for a Medicare supplement. Even though there are some out-of-pocket expenses with a Medicare Advantage Plan, they tend to be less than outof-pocket costs with traditional Medicare A and B. As a general rule, people younger than 65 and on Medicare are not able to purchase supplement policies. Some exceptions do exist. See your state department of insurance for further details. There are 11 standard supplement policies available, indicated by (letter A through G and K through N). Each lettered plan offers a different set of coverage and benefits, each letter filling the gaps differently. It is important to note that all supplement plans with the same letter provide the same benefits. Only premiums and companies offering the plans may vary. Insurance agents are allowed to only sell one plan per customer under the law. It is illegal to sell you more than one Medigap or Medicare Supplement plan at a time. If your spouse is also covered under Medicare and would like one of these plans, they may purchase their own separate plan. Noncovered items: It is important to be aware that Medicare does not cover all medical charges. There are some things that traditional or fee-for-service Medicare does not cover, nor will they be covered by your supplement or Medigap plan. These services may includes: Custodial care, such as bathing, dressing, assistance with eating or toileting Routine vision care, eyeglasses, dental care or hearing aids Private-duty nursing Prescription drugs or any out-of-pocket expenses associated with your Part D plan Retiree health plans: Some retirees have a comprehensive retirement health plan through their former employers. Look at your current benefits carefully before deciding to enroll in a Medicare supplement or Medigap plan. If your retiree plan offers a more generous set of coverage than Medicare, you may want to stay with it rather than switch to a Medicare plan. Some retiree plans will not allow you to return to their plan once you have dropped your benefits. Make sure you understand all the stipulations of your plan before making changes. Medicare Select: Medicare Select is a type of supplement or Medigap policy that makes limitations on the providers you can see. These plans tend to be cheaper than traditional supplements since they only cover care at certain hospitals and 9 Guide to Medicare
providers. Check with your state department of insurance for Medicare Select plans available in your area at www.in.gov/idoi. Your Medigap Rights: You have the right to review your new Medigap policy for 30 days after you buy it, and you may cancel it during that time for a full refund. You also have the right to cancel a Medigap policy at any time for a partial refund. YOUR INITIAL ELECTION PERIOD (IEP) AND MEDICARE Supplement/Medigap: You have the right to enroll in a supplement or Medigap plan of your choosing without penalties during a six-month period that begins on the first day of the month in which you are 65 or older AND enrolled in Part B. In other words, your health history or current health status cannot be held against you during this time. After this window closes, insurance companies may be able to refuse you Medigap coverage. Generally, if you re on Medicare, have a disability and are under 65, you aren t eligible to enroll in a supplement or Medigap plan. Contact your state department of insurance assistance program for more information. NOTE: If you drop your Medigap policy for any reason, you might not be able to get it back. Before dropping a plan, be sure you fully understand the Medigap laws in your state. GETTING EXTRA HELP WITH MEDICARE COSTS First of all, what is the difference between Extra Help with Medicare Costs and Low-Income Subsidy (LIS)? The answer is, nothing. These are two different names for the same program. The Centers for Medicare and Medicaid Services (CMS) often refer to the program as LIS when communicating between insurance carriers and other business related entities. When communicating with you, the beneficiary, they tend to refer to the program as Extra Help. If you have limited resources and income you may be able to receive Extra Help to pay for the costs for your Medicare prescription Drug Plan. Often, people qualify for these benefits and don t even know it. If you qualify for Extra Help and enroll in a Medicare drug plan (Part D), you may get some of the following benefits: Help paying your Medicare Part D plan s monthly premium, yearly deductible and coinsurance and copayments. No coverage gap (or doughnut hole) Guide to Medicare 10
No late enrollment penalty Ability to change your drug plan once a month You automatically qualify for Extra Help if you have Medicare and meet one of these conditions: You have full Medicaid coverage You receive help from your State Medicaid program paying for your Part B premiums (in a Medicare Savings Program) You currently receive Supplemental Security Income (SSI) benefits. There is no need to enroll, you get it automatically. To qualify for Extra Help you must meet the following guidelines (in 2017): You must reside in one of the 50 United States or the District of Columbia. Your resources may not be more than $13,820 for an individual or $27,600 for a married couple living together. Resources include such things as bank accounts, stocks and bonds. They do not include your home, car or any life insurance policies. Your annual income may not be more than $18,090 for an individual or $24,360 for a married couple living together. If your income is higher than these limits, you still may qualify for Extra Help in certain circumstances. Some examples include: You support other family members who live with you You have earnings from work - You live in Alaska or Hawaii Applying for Extra Help Applying for Extra Help is relatively easy. There are several options available. Fill out an online application at socialsecurity.gov/extrahelp Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) Apply at your local Social Security office After receiving your completed application, Social Security will review it and then let you know by mail if you qualify to receive Extra Help. If you are not currently enrolled in a Medicare Prescription Drug Plan, you may apply for drug coverage once you receive Extra Help. If you do not apply for a Medicare prescription drug plan and are not currently enrolled in a drug plan, the Centers for Medicare and Medicaid Services (CMS) will apply for a drug plan for you. Keep in mind that the sooner you enroll in a plan, the sooner you can begin to enjoy the drug coverage benefits. Full Extra Help If you qualify for Full Extra Help, you do not pay a premium or deductible for your Medicare Part D plan as long as you choose a drug plan that offers basic coverage with a premium at or below the premium low-subsidy amount. You will only pay a small copay for your drugs. Copay amounts are dependent on your income and whether you have full Medicaid. 11 Guide to Medicare
Partial Extra Help If you qualify for Partial Extra Help, you will pay a premium amount based on a sliding-scale, dependent on your income. You will have to pay a portion of the annual deductible amount if required by your plan. Your co-pays will either be 15 percent of the cost of each drug or pay the plan s co-pay for non-extra Help members, whichever is lowest. Communications from CMS or Medicare about your Extra Help When Medicare or CMS communicates with you about your Extra Help they send these communications via mail on colored paper. The following colors indicate different types of communications: Gray paper When communicating information to you about losing your automatic eligibility for Extra Help, a letter will be sent in September on gray paper. This notice will explain to you why you no longer automatically qualify for the coverage. Another application for Extra Help will be enclosed along with a selfaddressed stamped envelope. It is highly recommended that you reapply for the coverage. Orange paper When communicating information to you about a change in your Extra Help co-payment level, a letter will be sent out in October on orange paper. Blue paper When communicating information to you about a change in your Prescription Part D plan for the upcoming year and you are receiving Extra Help, CMS will mail out a letter in November on blue paper. Medicare will reassign you if you meet three factors and have not changed plans on your own: 1. You qualify for the full (100 percent) premium subsidy 2. Your current Prescription Part D plan is raising its premiums above the determined low-income premium amount 3. Medicare has enrolled you in the current plan you are on Medicare will also reassign you if you qualify for Extra Help and your Medicare Part D plan is leaving the Medicare program. Medicare will mail this notice to you on blue paper in November. White paper If you chose your own Medicare Part D plan and your premium is increasing, Medicare will not reassign you to another plan. These notices will be mailed to you if you receive 100 percent Extra Help and your Medicare Part D prescription drug plan premium goes above the determined low-income premium subsidy amount. This notice will let you know the cost of your drug plan premium for the new year and your option to remain or join a new drug plan, including plans that have no monthly premium. Medicare Savings Programs When applying for Extra Help with Social Security, you can also apply for the Medicare Savings Program. These programs are administered through your state and can provide help with other Medicare costs. Social Security will send your information to your state unless you instruct them not to. You will have the option to opt-out of sharing your information on the application. Once your state receives the information from Social Security, they will contact you to apply for the Medicare Savings Program. Guide to Medicare 12
The Medicare Savings Program can help you pay for some of your Medicare costs if you have limited resources and income, including Medicare Part B, medical insurance premiums (see page 6). You may even qualify through the Medicare Savings Program to receive help paying for your Medicare A hospital insurance premiums, if any, and Part A and Part B deductibles and co-payments (see page 6). Medicare Savings Program in the State of Indiana In Indiana, if you are an eligible low-income beneficiary you will receive assistance through the Medicaid program to pay for your Medicare out-ofpocket expenses. You must meet specific requirements to receive these benefits. You may be eligible depending on your income and the value of your assets. Assets are things you own, such as checking and savings accounts, certificates of deposit, cash value or life insurance and stocks and bonds. Some things you own do not count toward your asset limit, such as your home and furnishings, car, burial plot and at least $1,500 in life insurance. The only way to be certain if you qualify is to apply for benefits. You may apply for benefits by visiting your Office of Family and Children or via online at in.gov/fssa. 4 Types of Medicare Savings Programs 1. Qualified Medicare Beneficiary (QMB) Program Program helps to pay for Part A premiums, Part B premiums, deductibles, coinsurance and copayments. 2. Specified Low Income Medicare Beneficiary (SLMB) Program Program helps to pay for Part B premiums only. 3. Qualifying Individual (QI) Program Program helps to pay for Part B premiums only. 4. Qualified disabled working individual (QDWI) Program Program helps to pay for Part A premium only. Hoosier Rx Hoosier RX is Indiana s State Pharmaceutical Assistance Program. This program will help pay your Prescription Part D premium (up to $70 per month). To be eligible you must be at least 65 years of age and a resident of Indiana. You must also have applied for Extra Help through Social Security and received either a Notice of Award for partial Extra Help to help pay for your prescription drug plan premium or a Notice of Denial because your resources are above the limit established by law. 13 Guide to Medicare
To apply you may call 1-866-267-4679 or download an application from the Indiana Government website at http://www.in.gov/fssa/ompp/2669.htm. ADDITIONAL RESOURCES 1) Make an appointment with a qualified insurance agent at St. Francis Insurance Services Indianapolis (317-528-7770) or Mooresville (317-834-9548). 2) Visit a local SHIIP office 3) www.medicare.gov www.ssa.gov www.socialsecurity.gov www.indianamedicaid.com www.in.gov Senior Guide Friendly to Medicare 2011 14 14
Rev 5/2017 8778 S. Madison Ave. 1201 Hadley Rd. Indianapolis, IN 46227 Mooresville, IN 46158 (317) 528-7770 (317) 834-9548