Transcript Medicare Part A Payment Plan Beneficiary Pays

Medicare
Unit 7
Medicare Part A Payment Plan
Beneficiary Pays (2009)
Hospital Stays
SNF
1-60 days
$1068
1-20 days
61-90 days
$267/day
91-150 days
$534/day
21-100 days $133.50 per
day max
151+ days
all costs
101+ days
Monthly premium $244
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nothing
all costs
Annual deductible $1,068
Medicare Part A Payment Plan
Beneficiary Pays
Home Health Care
Nothing for approved
home health care
services
20% of approved
durable medical
equipment
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Hospice
Co-payment of $5 for
prescription drugs
5% of Medicareapproved amount for
respite care
Medicare Part B
Beneficiary Pays
Medical & Other
$135 deductible
$96.40 per mo. premium
Home Health Care
Nothing for Medicareapproved services
20% of Medicare approved
physician cost
20% outpatient physical,
occupational, & speechlanguage therapy
50% outpatient mental
health care
20% of Medicare-approved
durable medical
equipment
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Premium higher for singles
with incomes of $85,000
+ & incomes of $170,00 +
Medicare Part B
Beneficiary Pays
Clinical Lab Services
Nothing for Medicareapproved services
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Outpatient Hospital
Services
20% of billed amount
after deductible
Other Part B Coverage
 Insurance Company incentive - $12 billion in
subsidies to private insurers that offer health
plans to Medicare beneficiaries.
 Beginning 2010 Medicare will face
competition among private insurance plans.
 Medicare savings accounts – tax shelters for
individuals with deductibles above $1,000 for
singles & $2,000 for couples.
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Prescription Drug Benefit (2009)
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Premium - $450/yr
Deductible - $250
Coverage – 75% of drug costs up to $250; 25% $259 - $2,250
Gap – no coverage between $2,250 – $5,100
After $5,100 Medicare pays drug costs
Low-income subsidies – premium, deductible, & coverage gap
waived for those at 135% FPL & lower ($22,588 for couples) &
have less than $6,000 liquid assets
 Company incentive – tax-free subsidies to employers who
maintain to insurance companies
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Medicare Advantage + Choice
Plans Beneficiary Pays
Part A
Same payments
Part B
$58.70/mo. premium + additional
Choice Plan’s premium (?)
Choice Plan’s co-payments for
services
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“Accepting Assignment”
Payment to Physician
Medicare pays
Physicians
accepting
assignment
Physicians not
accepting
assignment
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Beneficiary pays
80% of approved 20% of cocharge
payment
80% of approved 20% co-payment
charge
+ 15% of
additional cost
Example of Accepting Assignment
Physician
accepting
$100 per visit
Physician not
accepting
$120 per visit
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Medicare pays
Beneficiary pays
$80
$20
$80
$20 + $3
(15% of $20)
Medicaid
 Monthly income of $1,737 for single
 Spend down to $2,000 liquid assets for
institutionalized spouse
• Entire SSI goes to pay for institutionalization
 Community spouse can have between $95,100 in
assets
• Maximum monthly income $1,737
•
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Window – 3 yrs from date of institutionalization or
5 yrs for transfers to trust
Main Problems in Providing Care
for Elderly

Limited coverage under Medicare
−homebound status
−skilled nursing
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1.4% or $13/mo increase in SSI – 1/3 of this will
go for increase in Medicare premiums
Private insurance option at cost to elderly
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Cost of home health care services expensive
Cost of long-term care expensive
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Problems with managed care plans
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