Medicare Advantage Medicare Supplement Plans

1. Medicare Advantage Medicare Supplement Plans

2. SCOPE OF APPOINTMENT

3. Independent Agent • I work for the best interest of my clients. • Each year I spend 4-6 weeks familiarizing myself with all the changes in Medicare and private insurance companies.

4. Unique Service • I represent 20 of the major health insurance carriers in California • Each of my clients are enrolled into an approved Medicare plan with the richest benefits that best suits their lifestyle and healthcare needs • Uncompromised Integrity • Unbiased information to help you select the right plan • ALL OF THIS at NO COST to you!

5. Medicare • Medicare is a health insurance program for: • People 65 years of age and older • People under age 65 with certain disabilities • People of all ages with End-Stage Renal Disease • Medicare is an entitlement • Part A premiums paid up with beneficiary or spouse working 40 quarters • Part B premiums $110.50 (or $96.40 if enrolled prior to 2009) per month.

6. Parts of Medicare Medicare PART A PART B PART C PART D

7. Medicare Basics: Part A Original Medicare – Part A • Hospital Stays • $1,100 Deductible for hospital stays days 1-60 • 61-90 days: $275/day coinsurance • 91-150 days: $550/day coinsurance • Skilled Nursing Facility Care • 1-20 days $0 per day • 21-100 days $137.50 per day • Days 100+ beneficiary pays 100% of costs

8. Medicare Basics: Part B Original Medicare – Part B • Doctors’ Services • Outpatient Hospital Care • Durable Medical Equipment • Some Medical Services (not covered by Part A) • For details, see "Medicare & You" at www.medicare.gov

9. Medicare Basics: Part B • $110.50 monthly Part B premium (varies per income) • $155 Annual Deductible* • Other deductibles, copayments, coinsurance (20% coinsurance for most services) • If you don't sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.

10. Medicare Basics: What Medicare DOESN’T Cover Original Medicare does NOTcover: • Deductibles • Coinsurance and co-pays • Most outpatient prescription drugs • Dental care • Hearing aids, hearing exams and screenings • Routine eye care and most glasses • Most health care outside the U.S.

11. How To Cover what Medicare Does Not: • Medicare Supplement or Advantage plans • One must: • Have Medicare parts A & B • Live in the plans service area • NOT have ESRD • Unless aging in or in CareMore service area

12. Medicare Supplement Plans • Health Insurance Plan sold by private insurance companies (policies) • Designed to fill in “gaps” of Original Medicare Part A and Part B • Companies must offer certain plans (A, C, F) but not all • Plans are standardized (6/2010) and regulated by states and Federal (CMS) • Plan premiums are in addition to Part B premiums • Do not include a Prescription Drug Plan (Part D)

13. Advantages of Med-Supp Plans • Choice of any Medicare contracted physician or hospital • Portable – Policy moves with the policyholder anywhere in the U.S. and its territories • Guaranteed renewable • May lower out-of-pocket costs • Covers co-pays and coinsurance

14. Where to go for Information • I represent 8 of the most competitive Medicare Supplements • Medicare and You Guide (2011) • 2011 Choosing a Medi-Gap Policy • Websites for Medicare and Social Security • www.medicare.gov • www.socialsecurity.gov • Medicare Beneficiaries also may want to check with their local State Health Insurance Assistance Program (SHIAP)

15. Prescription Drug Plans (Part D) • Medicare has minimum requirements • Plans can choose to increase benefits, but not fall below minimum requirements • Stand alone Prescription Drug Plans (PDP’s) have a monthly premium • Plans have different formularies, tiers, and co-pay amounts • One may have to pay a late enrollment penalty if not enrolled in a Part D plan when first eligible

16. Part D Terms Defined • Formulary: A list of prescription drugs, both generic and brand name that are available through your health plan. • Tier: Drugs on a formulary are usually grouped into tiers, and your co-payment is determined by the tier that your medication is on. • Co-Pay: Your share of the cost of a prescription. The remaining cost is paid by your health plan. • Mail-Order: Prescriptions ordered through mail-order may receive discounts, such as receiving a 3 month supply for the co-pay of 2 months

17. Medicare Minimum Part D Requirements • $310 Annual Deductible • Initial Coverage (IC) - 25% Co-insurance for next $2,530 of approved formulary prescription costs ($635.50) • Beneficiary pays 100% of all formulary drugs costs for next $3,607.50 (GAP). New 50% brand name donut hole discount applies. • When TROOP (TRue Out Of Pocket costs) reaches $4550, begin catastrophic coverage • Catastrophic Coverage - $2.50-6.30 copay or 5% co-insurance (whichever is greater) for formulary drug cost for remainder of calendar year TROOP DED $310.00 IC $635.50 GAP $3,607.50 $4,550.00

18. How Will the Donut Hole Discount Work?* • Part D plan members who reach the donut hole (after incurring $2,840 in drug costs in 2011) will immediately receive a 50% discount on Part D approved brand name drugs plus a $2-$5 dispensing fee. • “Applicable drugs” refer to brand name drugs provided by manufacturers who have signed an agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the discount program. Drugs sold by manufacturers who do not sign an agreement will not be covered under Part D and cannot be requested by exception. CMS expects that most, if not all, manufacturers will sign agreements. Beneficiaries with non-applicable drugs will automatically receive the 7% generic drug discount. What Costs Count Toward TrOOP — True Out-Of-Pocket Costs? For brand name drugs, the total cost of the drug will be counted toward one’s TrOOP, not just the 50% the beneficiary pays. For generics, however, only the amount the beneficiary pays, which in this case includes the dispensing fee, will count toward their TrOOP. This is because the 7% discount is provided through an additional subsidy from Medicare, rather than through rebates from the drug manufacturers. For example, Anne just entered the donut hole and her brand-name prescription drug costs $70, plus a $2 dispensing fee. She’ll pay $37 ($35 for 50% of the drug’s cost + $2 dispensing fee), but $70 will be counted toward her TrOOP. Anne also takes a generic drug which costs $10 plus a $2 dispensing fee. The 7% subsidy applies to both her drug cost and the dispensing fee, so she’ll pay a total of $11.16, all of which will count toward her TrOOP. *http://www.cahealthadvocates.org/news/drugs/2010/discount.html

19. Donut Hole Discount Exceptions* • The brand name and generic drug donut hole discounts do not apply to people with the low-income subsidy (LIS) and/or people in a retiree drug subsidy program. • As mentioned, the discount is only available if the drug's manufacturer has signed an agreement to participate in the discount program. Drugs sold by manufacturers who do not sign an agreement will not be covered under Part D and cannot be requested by exception. • The discount is only available if Medicare Part D is the primary payer. If there is secondary insurance, it will pay after the Part D discount has been applied. • In addition, if a beneficiary fills a prescription that crosses Part D stages of coverage, also referred to as a “straddle claim,” the discount will only apply to the portion of the prescription that falls under the donut hole. *http://www.cahealthadvocates.org/news/drugs/2010/discount.html

20. Extra Help You may qualify for Extra Help, also called the low-income subsidy (LIS), from Medicare to pay prescription drug costs if your yearly income and resources are below the following limits in 2010: • Single person—Income less than $16,245 and resources less than $12,510 • Married person living with a spouse and no other dependants—Income less than $21,855 and resources less than $25,010

21. Resources Defined • Resources include money in a checking or savings account, stocks, and bonds. • Resources DO NOT include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person), or life insurance policies. • If you qualify for Extra Help and join a Medicare drug plan, you will get the following: • Help paying your Medicare drug plan’s monthly premium, any yearly deductible, coinsurance, and copayments • No coverage gap • No late enrollment penalty

22. Medicare Advantage Plans (Part C) • Are offered by private companies approved by Medicare • Provide all Part A and Part B coverage and must cover, at least, all services of Original Medicare except hospice care • Hospice care is covered by Medicare • May offer extra coverage such as vision, hearing, dental, and/or health and wellness programs, and Part D. • Plan benefits are subject to yearly changes as approved by Medicare • Any Medicare Advantage premiums are in addition to Part B premiums

23. Medicare Advantage Plan Types • Health Maintenance Organization (HMO) Plans • Preferred Provider Organization (PPO) Plans • Private Fee-for-Service (PFFS) Plans • Special Needs Plans (SNP)

28. Medicare Advantage Election Periods • Annual Enrollment Period (AEP): November 15th through December 31st. (in 2011 changes to October 15th through December 7th) • Annual Dis-enrollment Period (ADP): January 1st through February 14th • Initial Election Period (IEP):7 month Election Period Begins 3 months before month of entitlement Ends last day of 3rd month after month of the earlier effective date of Part A/B entitlement (usually 65th birthday). • Lock-In: People with a Medicare Advantage plan are “locked-in,” meaning they can only switch Medicare plans during certain times of the year unless they qualify for a Special Election Period. • Special Election Period (SEP): A time when beneficiaries can change their benefits because of specific life changes. Examples are moving out of a plan service area, or becoming eligible for Medicaid/Medi-Cal.

29. Medicare Advantage Plans For all plans: • How to change your PCP (Primary Care Physician) • Enrollment and Dis-enrollment process • Appeals and Grievance process • Membership Card and Welcome Kit

30. Selecting Suitable Plans www.medicare.gov • Medications • Preferred Doctors • Specialists • Important Added Value Benefits