Transcript Medicare Basic Webinar Part 1 2005

Medicare Basics
2005
Part 1
Presented by
The National Association of Health
Underwriters
Education Foundation
Medicare Program Basics
 Medicare is a health insurance program for:
– People age 65 or older
– People under age 65 with certain disabilities,
– People of all ages with end-stage renal disease (permanent kidney
failure requiring dialysis or a kidney transplant)
 Medicare has two basic parts:
– Part A Hospital Insurance
• (Most people don’t pay a premium for Part A), and
– Part B Medical Insurance – usually out of the hospital
• (Most people pay a monthly premium for Part B - $78.20 in
2005)
• The cost of Part B may go up 10% for each full 12-month
period that you could have had Part B but didn’t enroll and
your Part B coverage as a late enrollee will start on July 1 of
the year you enroll. This additional cost is permanent.
Medicare Basics
 People who are already getting benefits from Social
Security or the Railroad Retirement Board are
automatically enrolled in Part A starting the first day of the
month they turn age 65.
 If a person under age 65 qualifies for Social Security or
Railroad Retirement Board disability payments, they will
be automatically enrolled in Medicare after they have
received those payments for 24 months.
 Even though some people are now scheduled to initially
become eligible to receive Social Security benefits after
age 65, they will still be eligible for Medicare at age 65.
Medicare Part A
 Part A covers inpatient care in hospitals.
 For each episode of care in a hospital you pay
$912 for a stay of up to 60 days, $228 per day for
days 61-90 of a hospital stay and $456 per day for
days 91-150 of a hospital stay. You are
responsible for charges beyond 150 days for a
hospital stay.
 Part A also covers certain types of skilled nursing
care but not custodial long term care. You pay
nothing for the first 20 days and $114 per day for
days 21-100. You are responsible for all costs
beyond 100 days.
Hospital and Skilled Nursing
Facility Care
 Hospitals stays must be for medically necessary care.
 Part A covers a semiprivate room, and most other hospital
charges, but not a private room or private duty nursing,
television, or telephone.
 Critical access hospitals are also covered as well as mental
health facilities.
 Inpatient mental health care in a psychiatric facility is
limited to 190 days in a lifetime.
 Skilled nursing for rehabilitative services is covered after a
related three-day inpatient hospital stay.
Home Health Care and Blood
 Home health care is limited to medically necessary
part-time skilled nursing care and home health
aide services as well as physical therapy,
occupational therapy, and speech-language
therapy which are ordered by your doctor.
 Also covered are medical social services, durable
medical equipment (such as wheelchairs, hospital
beds, oxygen, and walkers, medical supplies, etc).
You pay 20% of the Medicare approved amount
for these services.
 You pay for the first three pints of blood.
Hospice care
 Hospice care is care for people with a terminal illness,
including drugs for pain relief and other services from a
Medicare-approved hospice, including some services that
would not otherwise be covered by Medicare.
 Hospice care is usually given at home, however, Medicare
covers some short-term hospital and inpatient hospice care
for respite purposes.
 You pay up to $5 for outpatient prescription drugs that are
part of a Hospice Program and 5% of the Medicare
approved amount for hospice inpatient respite are.
Medicare Part B
 Covers doctors’ services and outpatient care
 You pay a $110 (2005) deductible each year before
Medicare starts to pay its share and 20% coinsurance on
the balance of most Medicare approved charges for your
medical expenses covered by Part B.
 If your income is low, you may qualify for help from your
state to pay both your Medicare Part B premium and the
annual deductible.
 Enrolling in Part B is automatic unless you notify
Medicare that you don’t want to enroll.
 Premiums for Part B are usually deducted from your Social
Security, Railroad retirement, or Office of Personnel
Management retirement check.
Medicare Part B
Special Enrollment Period
 If you waited to enroll in Part B because you or your
spouse were working and had group health plan coverage
as an active employee, you are eligible for a special
enrollment period for Part B.
 This time period can be any time you or your spouse are
still covered as an active employee by an employer or
union group health plan or during the eight months
following the month that the employer or union group
health plan coverage ends, or when the employment ends,
whichever is first.
 Most people who sign up for Medicare during a special
enrollment period don’t pay an extra premium.
Part B Premiums
 Currently the federal government pays 75% of all
Part B premiums.
 All beneficiaries under $80,000 (single) $160,000
(couple) will continue to get the 75% government
subsidy and pay 25% of the cost of Part B
premiums, as they do now.
 Beneficiaries with incomes above these levels will
pay a greater share of Part B premiums on a
sliding scale.
Part B and COBRA Coverage
 Coverage under COBRA is not considered
coverage as an active employee.
 If you elect COBRA when you leave your
employer’s plan, you should also consider electing
Part B if you haven’t already done so since your
special enrollment period will end eight months
after you lose coverage as an active employee.
Signing up for Part B
 You may also find that your employer plan will
require you to sign up for Part B even before your
coverage as an active employee ends in order to
receive full benefits under the plan.
 Signing up for Part B triggers a six-month
Medigap open enrollment period.
 For this reason it is very important to consider all
of your options before deciding on the best time to
sign up for Part B.
What Part B Covers - Preventive
 Preventive Services
– Bone Mass Measurements every 24 months for
qualified individuals
• you pay 20% for this service after your Part B deductible
– Cardiovascular Screening blood tests
• This service is covered at 100% of Medicare approved charges
with no deductible, once every five years
– Pap Test and Pelvic Examination
• Once every 24 months for all women with Medicare and every
12 months for those at high risk
– You pay 20% of the Medicare approved amount with no
deductible for the pelvic exam and nothing for the pap test.
What Part B Covers - Preventive
– Colorectal cancer screening
• Fecal Occult Blood Test every 12 months
– Medicare pays 100% with no deductible
• Flexible sigmoidoscopy once every 48 months
– you pay 25% after the deductible - must be outpatient
• Screening Colonoscopy every 24 months if you are at high risk
for colon cancer or every 10 years if not at high risk (but not
within 48 months of a screening sigmoidoscopy)
– you pay 25% after the deductible - must be outpatient
• Barium enema every 24 months if you are at high risk for
colon cancer or every 48 months if you are not high risk.
– you pay 20% after the Part B deductible
• You must be age 50 or older for these tests, except there is no
minimum age for a colonoscopy
What Part B Covers - Preventive
– Glaucoma Testing
• Once every 12 months for people who have diabetes or have a
family history of glaucoma or who are African Americans age
50 and older
– You pay 20% of the Medicare approved amount after the Part B
deductible
– Diabetes Services
• Diabetes screening tests including fasting plasma glucose test
for certain people who are at risk for diabetes
– Medicare pays 100% for these services with no deductible
• Diabetes self-management training for certain people who are
at risk for complications from diabetes
– You pay 20% after the Part B deductible
What Part B Covers - Preventive
– Screening Mammogram
• Every 12 months for all women with Medicare age 40 and older and
one baseline between ages 35 and 39
– You pay 20% of the Medicare approved amount with no
deductible
– Prostate Cancer Screening
• Digital Rectal and PSA Test every 12 months for all men age 50 and
over on Medicare
– You pay 20% after the Part B deductible, except for the PSA test which
is paid by Medicare at 100% with no deductible
– Shots
• Flu shot each fall or winter
– Medicare pays 100% with no deductible
• Pneumococcal Shot – one per beneficiary
– Medicare pays 100% with no deductible
• Hepatitis B shots for people at medium to high risk for Hepatitis B
– You pay 20% after the Part B deductible
What Part B Covers - Preventive
– New Welcome to Medicare Physical Exam
• One time only within the first six months you have Part B.
Includes height, weight, blood pressure, an EKG, education,
and counseling
– You pay 20% of the Medicare approved charge after the Part B
deductible
What isn’t covered by Medicare
Part A and B
 Acupuncture
 Your deductible and
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coinsurance
Dental care/dentures
Cosmetic surgery
Custodial care
Health care while
traveling outside the US
Hearing Aids/Exams
Orthopedic shoes
 Outpatient prescription
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drugs
Routine foot care
Routine eye care and
eyeglasses
Routine exams
Screening tests and labs
except as previously listed
Vaccinations except as
previously listed
Syringes and insulin
unless used with an insulin
pump
Other Part B Services
 Unless otherwise indicated, you pay 20% of the
Medicare approved amount for these Part B
services after the Part B deductible
– Ambulance services when medically necessary to
nearest hospital or skilled nursing facility that provides
the services you need when transportation in another
vehicle would endanger your health.
– Chiropractic Services
– Clinical Trials (routine costs, not the experimental drug
or device)
– Diabetic supplies
• Glucose testing monitors, blood glucose test strips, lancet
devices and lancets, glucose control solutions, and therapeutic
shoes. Syringes and insulin aren’t covered under Part B.
Other Part B Services
– Durable Medical Equipment
– Emergency Room Services
– One pair of eyeglasses with standard frames that
include an intraocular lens after cataract surgery.
– Foot exams if you have diabetes related nerve damage
– Kidney dialysis, services and supplies
– Medical nutrition therapy services for people who have
diabetes or kidney disease
Other Part B Services
– Mental Health Care (outpatient) and partial hospitalization services
for people who need intensive coordinated outpatient care to avoid
inpatient treatment.
• You pay 50% after the Part B deductible
– Services provided by clinical social workers, physician assistants,
and nurse practitioners
– Second surgical options
– Surgical Dressings
– Telemedicine services in some rural areas.
– Tests like X-rays, MRIs, CT scans, EKGs, if medically necessary
– Prosthetic/Orthotic Items
• Arm, leg, and neck braces, artificial eyes, artificial limbs, breast
prostheses after mastectomy, prosthetic devices need to replace an
internal body part or function (including ostomy supplies)
Other Part B services
 Transplant Services
– Heart, lung, kidney, pancreas, intestine, and liver
transplants under certain conditions and in Medicarecertified facilities only, and bone marrow and cornea
transplants (under certain conditions.) Oral
immunosuppressive drugs if the transplant was paid for
by Medicare, or paid by an employer group health plan
that was required to pay before Medicare. You must
have been entitled to Part A at the time of the transplant
and entitled to Part B at the time you get
immunosuppressive drugs, and the transplant must have
been performed in a Medicare-certified facility.
• Some of these services will be covered under Part A and some
under Part B
Using Doctors Who Don’t
Accept Medicare
 Most doctors accept Medicare assignment
 This means they agree to Medicare’s rate
 Some doctors accept Medicare but don’t accept
Medicare assignment
 They must still bill Medicare but are allowed to
charge up to 15% above Medicare’s allowable rate
 You are responsible for the difference between
what Medicare pays these doctors and their total
allowable charge.
Does your doctor accept
Medicare?
 Some doctors don’t accept Medicare payments.
 If you want care from one of these doctors, you
may be asked to sign a private contract to
guarantee payment for their services.
 You can’t be asked to sign a private contract in an
emergency situation.
 If you do sign a private contract you will have to
pay whatever this doctor or provider charges for
the services. Medicare will not pay any of the
charges.
 If you have a Medigap policy, that policy will also
not pay anything for the services
New Benefits
Prescription Drug Discount Card
 A prescription drug discount card to provide
temporary assistance with the cost of drugs has
been available since 2004 and will last through
2005.
 Beneficiaries can compare prescription drug
discount cards available in their areas by going to
www.Medicare.gov and clicking on “Prescription
Drug and Other Assistance Programs.”
 1-800-Medicare also can provide this information.
What discounts are available?
 The companies offering the prescription drug
discount cards have negotiated discounts to allow
enrollees to pay a lower retail price.
 Savings are estimated to be 10-25%
 Only drugs included on the company’s discount
list will be discounted, but most drugs are
included.
 Different drugs may be discounted at different
rates, depending on what was negotiated, and the
discounted prices may change over the course of
the year.
Who can get a discount card with the
Medicare-approved seal?
 Anyone on Medicare who doesn’t have
drug benefits through Medicaid can
participate in the Medicare approved
discount card.
 If a person lives part-time in more than one
state, they should select a card that is
offered in all of the states where they live.
 Companies may charge an enrollment fee
each year of no more than $30.
Where will beneficiaries get their
prescriptions?
 Many pharmacies are participating in the program, and a
beneficiary is likely to be able to use their existing
pharmacy.
 To get the discount, a person must use the pharmacies
participating in the drug card program they select
 Companies may also have a mail-order benefit that allows
enrollees to get some of their medications by mail.
 This may be convenient for many people who regularly
take some medications and it may result in a better price
for the drug.
Is other financial assistance available to
help with the cost of prescription drugs?
 A Medicare beneficiary may still be able to get up to $300
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for 2005 to help pay for their prescriptions
They must have Medicare and have income of less than
$12,569 for single people or $16,862 if they are married
Assets are not counted for purposes of the $600 benefit
The assistance is not available if they have prescription
drug coverage from any of the following
– Medicaid
– TRICARE
– FEHBP
– An employer group health plan or a retiree plan
They are still eligible for the assistance if they have a
Medigap policy or a Medicare Managed Care plan.
How does a person use the
assistance?
 The amount they are eligible for will be applied to
the person’s drug discount card
 Each time the card is used, the pharmacy will
deduct the amount spent from the total they are
eligible for
 A statement will be included with the prescription
letting the person know how their balance is, and
they can also call the company’s toll-free number
to find out the balance on their card.
 When the assistance runs out, the card can still be
used to get discounts on prescriptions
New Prescription Drug Benefit
 Medicare will begin a new prescription drug benefit in 2006
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called Part D.
Coverage is voluntary – no senior will be forced to buy
coverage they don’t want or need.
The cost for this benefit will be an average of $35 per month.
This is in addition to your part B premium.
After a $250 deductible, Medicare will pay 75% of the next
$2,000 of your prescription drug expenses.
After $2,250 in expenses, your prescription drug benefit card
can be used to obtain discounted prices.
If your own share of prescription drug expenses is as high as
$3,600 in a year, Medicare catastrophic coverage will begin.
You will then pay no more than 5% of the discounted cost of
your covered drugs for the rest of the calendar year.
If you qualify for low income assistance, you may pay nothing
out of your own pocket for catastrophic coverage.
New Prescription Drug Benefit
 Seniors now paying the full retail cost for prescription
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drugs will on average be able to cut their drug costs
roughly in half.
Plan sponsors will use proven drug management
techniques like formularies and step therapy used by most
health plans today to keep costs affordable
Formularies must include drugs in each therapeutic
category and class. It cannot limit a category or class to
just one drug.
Pharmacists will be required to tell a beneficiary when a
more affordable generic drug is available to treat their
condition.
The law also calls for a medication therapy management
program for beneficiaries with multiple chronic conditions
to improve their outcomes.
Low Income Beneficiaries
 Those who are eligible for both Medicare and Medicaid will
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now receive their drug coverage through the Medicare
Prescription Drug Plan rather than Medicaid.
Medicare Beneficiaries with limited savings and incomes below
135% of FPL will pay no monthly premium for their drug
coverage, no deductible, and only $2 for generic and preferred
drugs and $5 for other drugs, with no coverage limit.
Beneficiaries who are eligible for both Medicare and Medicaid
and those with incomes below the federal poverty level will
have copays of only $1 for generic and preferred drugs and $3
for other drugs, with no coverage limit.
Nursing home residents who are eligible for both Medicare and
Medicaid will have no co-pay.
Other seniors with limited savings and incomes below 150% of
FPL will pay reduced monthly premiums on a sliding scale, a
$50 deductible, and 15% cost-sharing with no coverage limit.