Transcript Document

Understanding Medicare
Module 1
11-29-06
1
Lessons
1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C)
and other Medicare plans
4. Medicare prescription drug coverage
(Part D)
5. Programs for people with limited
income and resources
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Medicare Basics
Module 1: Lesson 1
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Medicare Basics
Lesson 1 Topics
Medicare overview
Enrollment
Part A
Part B
Medicare plan choices
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Medicare
 Health insurance for people
 Age 65 and older
 Under age 65 with certain disabilities
 Any age with End-Stage Renal Disease (ESRD)
 Administered by
 Centers for Medicare & Medicaid Services (CMS)
 Enroll through
 Social Security Administration (SSA) or
 Railroad Retirement Board (RRB)
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Applying for Medicare
Apply 3 months before age 65
 Need not be retired
Automatically enrolled if receive Social
Security or Railroad Retirement benefits
 If don’t already receive benefits, apply
3 months before age 65
• Call SSA at 1-800-772-1213
– TTY users call 1-800-325-0778
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Medicare
Medicare has
 Part A – Hospital coverage
 Part B – Medical coverage
 Part C – Medicare Advantage Plans (like
HMOs and PPOs)
 Part D – Prescription drug coverage
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Paying for Medicare Part A
 Most people receive Part A premium free
 People with less than 10 years of Medicarecovered employment
 Can pay a premium to get Part A
 For information, call SSA
 1-800-772-1213
 TTY users call 1-800-325-0778
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Enrolling in Medicare Part B
 Initial Enrollment Period (IEP)
 7 months beginning 3 months before age 65
 General Enrollment Period (GEP)
 January 1 through March 31 each year
 Coverage effective July 1
 Premium increases 10% for each 12-month
period you were eligible but did not enroll
• Pay this penalty as long as you have Part B
• Limited exceptions
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Enrolling in Medicare Part B
Special Enrollment Period
 Sign up within 8 months of the end of
employer or union health plan coverage
 No increased premium
For questions or to enroll
 Call SSA or RRB
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Paying for Medicare Part B
Monthly Medicare Part B premium
 2006
• Most people pay $88.50
 2007
• Most people pay $93.50
• Some with higher incomes pay more
Some programs may help
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Paying the Part B Premium
 Taken out of your monthly payment
 Social Security
 Railroad Retirement
 Federal Government retirement
 For information about premiums
 Call SSA or RRB
• Office of Personnel Management if a retired Federal
employee
 May be billed every 3 months
 Medicare Easy Pay
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Part A Helps Pay for
Hospital inpatient care
Skilled nursing facility (SNF) care
Home health care
Hospice care
Blood
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Hospital Stays
 Covered services
 Semi-private room
 Meals
 General nursing
 Other hospital services and supplies
 Includes care in critical access hospitals
 190 days in a lifetime for inpatient mental
health care
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Skilled Nursing Facility Care
Must meet all of the following conditions
 Require daily skilled services
 Hospital inpatient at least 3 consecutive
days
 Admitted to SNF within 30 days after
leaving hospital
 Care is for a condition treated in the
hospital
 MUST be Medicare participating SNF
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Skilled Nursing Facility Coverage
 Semi-private room
 Meals
 Skilled nursing care
 Physical, occupational, and speechlanguage therapy
 Medical social services
 Medications, medical supplies/equipment
 Ambulance transportation
 Dietary counseling
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Home Health Care
Covered services
 Part-time skilled nursing care
 Therapy
• Occupational
• Physical
• Speech-language
 Some home health aide services
 Durable medical equipment
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Home Health Care
 For as long as you are eligible
 Limited hours per day
 Limited days per week
 Four conditions



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Doctor must make a plan for your care at home
Must need specific skilled services
Must be homebound
Home health agency must be Medicare-approved
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Hospice
 Special care for terminally ill
 And family
 If you likely have less than 6 months to live
 Certification required for each “period of care”
 Two 90-day periods
 Unlimited 60-day periods
 Hospice provider must be Medicare-approved
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Covered Hospice Services
 Medical equipment and supplies
 Drugs for symptom control and pain relief
 Respite care in a Medicare-certified facility
 Up to 5 days each time
 No limit to number of times
 Home health aide and homemaker services
 Social worker services
 Dietary counseling
 Grief counseling
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Part B Helps Pay for
 Doctors’ services
 Outpatient medical and surgical services and
supplies
 Diagnostic tests
 Outpatient therapy
 Outpatient mental health services
 Some preventive health care services
 Other medical services
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Covered Preventive Services
 “Welcome to Medicare”
physical exam
 Bone mass
measurement
 Cardiovascular
screenings
 Colorectal cancer
screenings
 Diabetes screenings
 Glaucoma tests
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 Mammograms (screening)
 Pap test/pelvic exam/
clinical breast exam
 Prostate cancer screening
 Flu shots
 Pneumococcal shots
 Hepatitis B shots
 Smoking cessation
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Part B Also Helps Pay for
 Clinical laboratory tests
 Home health services
 Durable medical equipment
 Outpatient hospital services
 Blood
 Ambulance service
 If other transportation would endanger your health
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Medicare Plan Choices
Original Medicare Plan
Medicare Advantage Plans
Other Medicare plans
Medicare drug plans
 Medicare Prescription Drug Plans
 Medicare Advantage Plans and other Medicare
plans with prescription drug coverage
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Original Medicare Plan
Module 1: Lesson 2
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Original Medicare Plan
Lesson 2 Topics
What it is and how it works
Your costs in Original Medicare Plan
Assignment
Medigap (Medicare Supplement
Insurance)
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Original Medicare Plan
 Red, white, and blue Medicare card
 Part A and/or Part B
 Go to any provider that accepts Medicare
 You pay
 Part B premium
• Part A free for most people
 Deductibles
 Coinsurance or copayments
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Medicare Card (front)
Jane Doe
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Medicare Card (back)
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Medicare Claims Contractors
 Fiscal Intermediary (FI)
 Regional Home Health Intermediary (RHHI)
 Medicare Carrier
 Durable Medical Equipment Regional
Carrier (DMERC)
 Medicare Administrative Contractors (MAC)
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Original Medicare Plan—Part A
Charges based on “benefit period”
 Inpatient hospital care and SNF services
 Begins day admitted to hospital
 Ends when no care received in a hospital or
SNF for 60 days in a row
 You pay deductible for each benefit period
 No limit to number of benefit periods
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Paying for Hospital Stays
Each benefit period in 2006 you pay
 Inpatient hospital stay of 1 – 60 days
• $952 total
 Days 61 – 90
• $238 per day
 Days 91 – 150
• $476 per day
• 60 Lifetime Reserve Days
 All costs for each day beyond 150 days
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Paying for Hospital Stays
Each benefit period in 2007 you pay
 Inpatient hospital stay of 1 – 60 days
• $992 total
 Days 61 – 90
• $248 per day
 Days 91 – 150
• $496 per day
• 60 Lifetime Reserve Days
 All costs for each day beyond 150 days
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Skilled Nursing Facility Care
 Each benefit period in 2006 you pay
 Days 1 – 20
• $0
 Days 21 – 100
• $119 per day in 2006
• $124 in 2007
 All costs after 100 days
 Must meet requirements for Medicarecovered stay
 Does NOT include custodial care
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Paying for Home Health Care
In the Original Medicare Plan you pay
 Nothing for covered home health care
services
 20% of the Medicare-approved amount for
covered durable medical equipment
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Paying for Hospice Care
In the Original Medicare Plan you pay
 Up to $5 for prescription drugs
 5% for inpatient respite care
• Amount can change each year
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Paying for Part B
 In the Original Medicare Plan you pay
 Monthly Part B premium
• $88.50 in 2006
• $93.50 in 2007
 Yearly deductible
• $124 in 2006
• $131 in 2007
 20% coinsurance for most services
 Some copayments
 Some programs may help
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Assignment
 Agreement between you, doctor, and Medicare
 Applies to Original Medicare Part B claims
 Providers who accept assignment
 Can’t try to collect more than Medicare deductible
and coinsurance amounts
 Providers who don’t accept assignment
 May charge more than Medicare-approved amount
• Limit of 15% more for most services
– Doesn’t apply to supplies
 May ask you to pay entire charge at time of service
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Assignment
 In some cases, providers must accept
assignment
 Some examples
• Medicare Part B-covered prescription drugs
• Ambulance providers
 Doctors/providers generally have to file claim
 May have to file own claim for Part B-covered
drugs or supplies
• If supplier or pharmacy not enrolled in Medicare
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Private Contracts
Agreement between you and doctor
 Original Medicare Plan will not pay
 Medigap will not pay
 Other Medicare plans will not pay
 You will pay charges
 No claim should be submitted
 Cannot be asked to sign in an emergency
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Therapy Limits
 $1,740 cap
 Effective January 1, 2006
 Combined physical therapy and speech-language
pathology services
 Separate cap for occupational therapy
 Exceptions allowed
 If medically necessary
 Certain diagnoses get automatic exception
 Some situations justify automatic exception
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What Is Medigap?
 Health insurance policies
•
•
•
•
•
Sold by private insurance companies
Follow Federal and state laws that protect you
Must say “Medicare Supplement Insurance”
Cover “gaps” in Original Medicare Plan
12 standardized policies, plans A – L
• Except in Massachusetts, Minnesota, Wisconsin
• Costs may vary
• By plan
• By company
• Where you live
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How Medigap Works
Only works with Original Medicare
 Don’t need Medigap policy in
• Medicare Advantage Plan
• Other Medicare plans
Can go to any doctor, hospital, or
provider that accepts Medicare
 Except with a Medigap SELECT policy
You pay a monthly premium
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Medicare Advantage Plans
and Other Medicare Plans
Module 1: Lesson 3
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Medicare Advantage Plans
Lesson 3 Topics
What are Medicare Advantage Plans
and other Medicare plans
Who can join
How plans work
Joining and switching plans
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What Are Medicare Advantage
Plans?
 Health plan options approved by Medicare
 Run by private companies
 Part of the Medicare program
 Sometimes called “Part C”
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Medicare Advantage Plans
 Medicare Health Maintenance
Organization (HMO)
 Medicare Preferred Provider
Organization (PPO)
 Medicare Private Fee-for-Service (PFFS)
 Medicare Special Needs Plans (SNPs)
 Medicare Medical Savings Account (MSA)
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Other Medicare Plans
Medicare Cost Plans
Demonstrations/Pilot Programs
Programs of All-inclusive Care for the
Elderly (PACE)
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Who Can Join?
Eligibility requirements
 Live in plan’s service area
 Have Medicare Part A
 Have Medicare Part B
 Not have ESRD at time of enrollment
• Some exceptions
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How Do Medicare Advantage
Plans Work?
 Generally get all Medicare-covered services
through the plan
 Can include prescription drug coverage
 May have to see certain doctors or go to
certain hospitals to get care
 Benefits and cost-sharing may be different
from those in Original Medicare Plan
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Out-of-Pocket Costs
 Generally must still pay Part B premium
 Some plans may pay all or part
 May pay additional monthly premium
 Pay other out-of-pocket costs
 Different from Original Medicare Plan
 Vary from plan to plan
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In a Medicare Advantage Plan
 Still in Medicare program
 Still have Medicare rights and protections
 Still get all regular Medicare-covered services
 May get extra benefits
 Such as vision, hearing, or dental care
 May be able to get prescription drug
coverage
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Medicare HMO Plans
Copayment amounts set by plan
Generally must get care and services
from plan’s network
 Use doctors and hospitals that join the plan
 May have to pay in full for care outside
plan’s network
• Covered if emergency or urgently needed care
• Point-of-Service option allows visits to “out-ofnetwork” providers
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Medicare HMO Plans (cont’d)
May need to choose primary care doctor
 Usually need a referral to see a specialist
 Doctors can join or leave
May get Medicare drug coverage
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Medicare PPO Plans
Can see any doctor or provider that
accepts Medicare
 Don’t need referral to see specialist
 Don’t need referral to see out-of-network
provider
 Copayment amounts set by plan
• Will usually pay more for out-of-network care
May get Medicare drug coverage
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Medicare PFFS Plans
 Can see any Medicare-approved doctor or
hospital that accepts the plan
 Can get services outside service area
 Don’t need referral to see a specialist
 Plan sets copayment amounts
 Can get emergency care anywhere
 Without prior approval
 If offered, can get Medicare prescription drug
coverage
 If not offered, can join a Medicare Prescription
Drug Plan
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Medicare Special Needs Plans
(SNPs)
 May limit membership to people
 In certain institutions (like a nursing home)
 Eligible for both Medicare and Medicaid
 With certain chronic or disabling conditions
 Designed to provide
 Special expertise of providers
 Focused care management
 Available in limited areas
 Must provide prescription drug coverage
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Medicare MSA Plans
 Will be offered beginning in 2007
 Similar to Health Savings Account plans
 Have two parts
1. Medicare Advantage Plan with high deductible
•
Pays covered costs after you meet annual deductible
– Deductible varies by plan
2. Medical Savings Account
•
Medicare deposits money the person may use
– To pay health care costs
 MSA demonstration available in some areas
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Medicare Cost Plans
 Available in limited areas
 Similar to Medicare HMO Plans
 Except out-of-network services covered under
Original Medicare Plan
 Can join any time plan accepts new members
 Can leave at any time
 Prescription drug coverage may be offered
 If not offered, can join a Medicare Prescription
Drug Plan
 Plans may differ for some rules
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Medicare Demonstrations/
Pilot Programs
 Special projects
 Test improvements in Medicare coverage,
payment, and quality of care
 Eligibility usually limited
 Specific group of people
 Specific area of country
 Examples
 Medicare Advantage Plan for ESRD patients
 New Medicare preventive services
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Medicare PACE Plans
 Programs of All-inclusive Care for the Elderly
 Combine medical, social, and long-term care
services for frail elderly people
 Include prescription drug coverage
 Might be better choice than nursing home
 Only available in states that offer it under
Medicaid
 Qualifications vary from state to state
 Contact state Medical Assistance office to see if
you qualify
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When Can You Join?
 You can join a Medicare Advantage Plan
or other Medicare plan
 When first eligible for Medicare
• Initial Enrollment Period
 Specific enrollment periods
• Annual Coordinated Election Period
• Medicare Advantage Open Enrollment Period
• Special Enrollment Periods
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When Can You Switch?
Annual Coordinated Election Period
Medicare Advantage Open Enrollment
Period
Special circumstances
 Move out of the plan’s service area and
can’t stay in the plan
 Plan leaves Medicare program
 Other special situations
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Annual Coordinated Election
Period
November 15 – December 31
 Can choose new plan
 New plan starts January 1 (in most cases)
 Plan must accept new members
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Medicare Advantage
Open Enrollment Period
 January 1 – March 31, 2007
 Same period each year
 Change effective first day of following month
 Cannot be used to start or stop Medicare
drug coverage
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Medicare Advantage Plan
Open Enrollment Period Limits
If coverage is
Can use OEP to
get
Cannot use OEP to
get
Medicare Advantage Plan
with prescription drug
coverage (MA-PD)
MA-PD or
Original Medicare and
PDP
MA-only or
Original Medicare only
(Exception: PFFS and PDP)
Medicare Advantage Plan
with no prescription drug
coverage (MA-only)
MA-only or
Original Medicare only
MAPD or
Original Medicare and PDP
Original Medicare Plan and a
prescription drug plan (PDP)
MA-PD
MA-only or
A different PDP to use with
Original Medicare
Original Medicare Plan only
MA-only
MA-PD or
Original Medicare and PDP
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Medicare Prescription Drug
Coverage
Module 1: Lesson 4
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Lesson 4 Topics
Overview
Eligibility and enrollment
Extra help
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Prescription Drug Coverage
Coverage began January 1, 2006
Available for all people with Medicare
Provided through
 Medicare Prescription Drug Plans
 Medicare Advantage Plans and other
Medicare plans
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Prescription Drug Costs
Costs vary by plan
Most people will pay
 Monthly premium
 Deductible
 Copayments or coinsurance
 Very little after $3,850 out-of-pocket in 2007
Extra help available for people with
limited income and resources
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Eligibility and Enrollment
You must
 Have Medicare Part A, Part B, or both
 Live in plan’s service area
 Enroll in a Medicare prescription drug plan
to get coverage
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Enrollment Periods
Initial Enrollment Period (IEP)
 7 months beginning 3 months before the
first month of Medicare eligibility
Can change plans
 Annual Coordinated Election Period
• November 15 – December 31 each year
 Some special enrollment periods available
Some people are enrolled automatically
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Late Enrollment Penalty
People who wait to enroll after their IEP
 Pay additional 1% of base beneficiary
premium
• For every month eligible and not enrolled
• For as long as they have Medicare drug
coverage
 Except those with other creditable drug
coverage
• Coverage at least as good as Medicare
prescription drug coverage
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Special Enrollment Periods
 For people who
 Permanently move out of plan’s service area
 Lose creditable prescription drug coverage
 Enter, reside in, or leave a long-term care facility
• Like a nursing home
 Have Medicaid or are in a Medicare Savings
Program
• Have a continuous special enrollment period
 Have other exceptional circumstances
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Extra Help
 Help with drug plan costs for people with
limited income and resources
 Eligibility determined by SSA or state
 Income and resources are counted
 Some groups are automatically eligible
 People with Medicare and
• Medicaid
• Supplemental Security Income only
• Medicare Savings Programs
 Everyone else must apply
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Income and Resource Limits
 Income
 Below 150% Federal poverty level
2006
amounts
• $1,225 per month for an individual* or
• $1,650 per month for a married couple*
• Based on family size
 Resources
2006
amounts
 Up to $11,500 (individual)
 Up to $23,000 (married couple)
• Includes $1,500/person funeral or burial expenses
• Counts savings and stocks
• Does not count home you live in
*Higher amounts for Alaska and Hawaii
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How to Apply for Extra Help
Multiple ways to apply
 Paper application
 www.socialsecurity.gov
 State Medical Assistance office
 Local organization
You or someone on your behalf can
apply
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Drug Plan Costs for People with
Extra Help
 Those below Federal poverty level save over
95% on average
 People with lowest income and resources
 Pay no premiums or deductibles
 Have small or no copayments
 Those with slightly higher income and
resources
 Have a reduced deductible
 Pay a little more out of pocket
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Programs for People with
Limited Income and Resources
Module 1: Lesson 5
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Lesson 5 Topics
Medicaid
Medicare Savings Programs (MSP)
Help for people living in U.S. territories
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Medicaid
 Federal-state health insurance program
 People with limited income and resources
 Certain people with disabilities
 If eligible, most health care costs covered
 Eligibility determined by state
 Application processes and benefits vary
 Office names vary
 Social Services
 Public Assistance
 Human Services
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Medicare Savings Programs
Help from Medicaid paying Medicare
premiums
 For people with limited income and
resources
 May also pay Medicare deductibles and
coinsurance
 Programs include
• Qualified Medicare Beneficiary (QMB)
• Specified Low-income Medicare Beneficiary
(SLMB)
• Qualifying Individual (QI)
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Programs in U.S. Territories
 Help people pay their Medicare costs
 U.S. territories





Puerto Rico
Virgin Islands
Guam
Northern Mariana Islands
American Samoa
 Programs vary
 Contact state Medical Assistance office
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If you think you might qualify…
1. Review guidelines
2. Collect your personal documents
3. Get more information
 Call your state Medical Assistance office
 Call your SHIP
 Call your local Area Agency on Aging
4. Complete application with state
Medical Assistance office
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Module 1 Lessons
1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C)
and other Medicare plans
4. Medicare prescription drug coverage
(Part D)
5. Programs for people with limited
income and resources
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For More Information
1-800-MEDICARE (1-800-633-4227)
 TTY users should call 1-877-486-2048
Medicare & You handbook
Other Medicare publications
www.medicare.gov
www.cms.hhs.gov
Your local State Health Insurance
Assistance Program (SHIP)
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Thanks for your attention!
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