Medicare 101

1. Medicare 101 Missouri State Health Insurance Assistance Program SHIP 15-082-CLThis material has been created or produced by CLAIM with financial assistance, in whole or part, through a grant from the Administration for Community Living. Funding is administered through the Missouri Department of Insurance Financial Institutions and Professional Registration and service is provided by Primaris Foundation, a non-profit organization.

2. What is CLAIM? • Community Leaders Assisting the Insured of Missouri • Missouri’s SHIP • State Health Insurance Assistance Program • Nationwide network • Meets needs of the local Medicare population

3. Creation of SHIPs (1990) • Created by Congress as part of Medigap reform package • Provide Medicare education • Help understand Medicare • Make informed decisions about benefits • Resolve problems in paying for healthcare • Give feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS)

4. Funding • Missouri Department of Insurance Financial Institutions & Professional Registration (DIFP) received the first federal grant in 1993. • Primaris has been awarded the contract through the DIFP since 1993. • Primaris Foundation is a non-profit organization.

5. How are clients’ needs met? • Volunteers are trained and certified • Relate to the questions and needs of clients • Volunteers have access to staff support, CMS, and other professionals • Currently 300 volunteers statewide and 180 community partners

6. Examples of Who We Serve • A 70-year-old widow • A 45-year-old disabled person • A daughter taking care of her mom and dad • A social worker helping a very sick client • A 64-year-old retiring in 3 months • Someone who recently lost benefits • A professional or caregiver who needs information • A person who needs help enrolling in Part D

7. ServicesHow CLAIM Counselors Can Help • Enrollment and billing • Medicare Advantage Plans • Medigap and supplemental insurance • Medicare Prescription Drug Program • Long-term care insurance • Public benefits • Appeals and grievances • Suspected waste, fraud, and abuse

8. President Lyndon B. Johnson at the signing ceremony July 30, 1965, at the Truman Library in Independence, Missouri.

9. Qualifying for Medicare • Beneficiary reaches age 65 (“Age in”) • Determined by age and credits • SSA determined beneficiary is disabled • 24 month waiting period after payments start • ESRD • One month on home dialysis • Three months on facility dialysis

10. Enrollment Have 40 credits? Don’t have 40 credits or not sure? *Late enrollment penalty may apply. Automatic Enrollment Apply for Benefits at the Local Social Security Administration Office*

11. Optional Enrollment • Part A • Required for automatic enrollees • Manual enrollees • Part B • Optional for all enrollees • May be declined without penalty in some circumstances • i.e. still employed • Late Enrollment • Penalties may apply

12. Enrollment Periods • Initial enrollment period (3-1-3) • Automatic enrollment – receiving Social Security benefits • Manual enrollees – not yet drawing Social Security benefits, still working, or not enough credits • General enrollment period – January, February, or March every year • Effective July

13. Four Parts of Medicare What are the Four Parts of Medicare?

14. Part A Hospital Insurance

15. Medicare Part A • Coverage: • Inpatient Hospital Care • Skilled Nursing Facility (SNF) • Home Health • Hospice • Blood

16. Paying for Part A • Premiums paid by Medicare taxes • Must have 40 credits • Those without 40 credits pay pro-rated premium • Hospital must accept “Medicare Assignment” for services • Deductible for each benefit period • 2016 deductible is $1,288 • Co-Pays may also apply

17. Benefit Periods • Measures use of inpatient hospital and skilled nursing facility (SNF) services • Begins the day you first receive inpatient hospital care • Ends when not in hospital/SNF 60 days in a row • Pay Part A deductible for each benefit period • $1,288 in 2016 • No limit to number of benefit periods

18. Part B Medical Insurance

19. Medicare Part B • Coverage: • Doctor’s office visits • Outpatient hospital services • Home health • Ambulance transportation • Therapy • Physical • Occupational • Speech • Clinical Lab Services • Durable Medical Equipment • Preventative Services

20. Paying for Part B • Monthly premium • Current 2016 premium is $121.80 • Previous enrollees with SSA withdrawal pay $104.90 • Premium paid by beneficiary is 25% of actual cost • Late enrollment penalties • Normally withheld from Social Security benefit • Annual Deductible: • $ 166.00 for 2016 • May increase annually • Co-pays and deductibles may apply

21. Part B Covered Preventive Services • “Welcome to Medicare” visit • Annual “Wellness” visit • Abdominal aortic aneurysm screening • Alcohol misuse screening and counseling • Behavioral therapy for cardiovascular disease • Bone mass measurement • Cardiovascular disease screenings • Colorectal cancer screenings • Depression screening • Diabetes screenings • Diabetes self-management training

22. Part B Covered Preventive Services • Flu shots • Glaucoma tests • Hepatitis B shots • HIV screening • Mammograms (screening) • Obesity screening and counseling • Pap test/pelvic exam/clinical breast exam • Pneumococcal pneumonia shot • Prostate cancer screening • Sexually transmitted infection screening (STIs) and high-intensity behavioral counseling to prevent STIs • Smoking cessation

23. Supplemental Insurance Medigaps and Employer Plans

24. Purpose of Supplements

25. Medigap Policies • Medigap - Medicare Supplement Insurance policies • Private health insurance for individuals • Sold by private insurance companies • Supplement Original Medicare coverage • Follow Federal/State laws that protect you • Medigap Open Enrollment Period • Sign up for Part B • Once started, cannot be delayed or repeated

26. Medigap Policies • Costs vary by plan, company, and location • Medigap insurance companies can only sell a “standardized” Medigap policy • Identified in most states by letters • MA, MN, and WI standardize their plans differently • Does not work with Medicare Advantage • No networks except with a Medicare SELECT policy • Monthly premiums

27. Employer Insurance • Part B coverage is optional if a person is: • Employed • Covered under active employer medical plan; or • Covered under a working spouse’s active medical plan • Secondary Payer Rule • Company must have 20 or more employees for someone 65 or older and, • 100 employees for under 65 for the employer insurance to be primary; otherwise, it is secondary to Medicare

28. When Employer or Union Coverage Ends • Options: • May be a chance to elect COBRA • May get a Special Enrollment Period • Sign up for Part B without a penalty • Can enroll in a Medigap, PDP, or Medicare Advantage Plan within certain time frames of coverage ending.

29. Medicare Part C Medicare Advantage Plans

30. Part C: Medicare Advantage Plans • Alternative method of obtaining benefits • Administered by private insurance companies • Another way to receive Medicare Coverage • Must provide coverage found in Original Medicare • Can provide additional benefits • Part D • Hearing • Vision • Dental

31. Medicare Advantage Plan Costs • Must still pay Part B premium • Some plans may pay all or part for you • Plan may have monthly premium • Deductibles, coinsurance, and copayments may apply • Different from Original Medicare • Varies from plan to plan • Plans have out of pocket maximums

32. Medicare Advantage Eligibility Requirements • Live in plan’s service area • Enroll in Medicare Part A and Part B • Must not have ESRD at the time of enrollment • Some exceptions • Must provide necessary information • May only belong to one plan at a time

33. How Medicare Advantage Plans Work • Still enrolled in Medicare with all rights and protections • Benefits and cost-sharing differ and are set by the plan and approved by Medicare • Co-payments for certain services and cost sharing for other services (20%) • Plans may require prior authorization for services.

34. Part D Medicare Prescription Drug Plans

35. Medicare Part D • Administered through private insurance coverage in conjunction with Medicare • Must be enrolled in Part A and/or B • Two sources of coverage • Medicare Prescription Drug Plans (PDPs) • Medicare Advantage Plans with (MA-PDs)

36. Paying for Part D • Premiums • $15.70 and up • Penalties apply for late enrollment • Deductible • Cost-sharing and deductibles determined by: • the type of medication • terms of the plan selected • Gap

37. Enrollment Periods for Prescription Drug Programs

38. Prescription Drug Costs • Costs vary by plan • In 2016, most people will pay: • A monthly premium – average $34.10 • An annual deductible – no more than $360 • Copayments or coinsurance may apply

39. Part D Late Enrollment Penalty • Higher premium for some who wait to enroll • Additional 1% of base national average premium • Every month eligible and not enrolled • For as long as they have Medicare drug coverage • No penalty with creditable drug coverage • Coverage at least as good as Medicare drug coverage

40. Access to Covered Drugs • Coverage and rules vary by plan • Plans manage access to drug coverage • Formularies (list of covered drugs) • Prior authorization (doctor contacts plan) • Step therapy (type of prior authorization) • Quantity limits (limits quantity for period of time)

41. Stretching Your Health Care Dollars

42. Stretching Health Care Dollars Low Income Subsidy (LIS) • Extra Help through Social Security Administration • May qualify for zero premium for Part D Drug Plan • Reduced co-payments/co-insurance • Qualify for continuous open enrollment to change plans • Eligibility and level of help determined by income and resources • Application available through Social Security or CLAIM • Online at www.socialsecurity.gov

43. Stretching Health Care DollarsMedicare Savings Programs • Federal and State funding through MO HealthNet to assist with: • Medicare premiums • Deductibles and coinsurance (QMB only) • Auto enrolled in Part D Extra Help • Income and resources determines assistance- • QMB • SLMB • Qualifying Individual • Enrollment - Missouri Family Support Division

44. Missouri SMP Program Missouri Statewide volunteer program whose mission is to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect and report healthcare fraud, errors, and abuse through outreach, counselling and education. Program funded through Administration on Aging and administer by Care Connection. 1-800-748-7826

45. myMedicare.gov View claim status(excluding Part D claims) Order a duplicate Medicare Summary Notice or replacement Medicare card View eligibility, entitlement and preventive service info View or modify your drug list & pharmacy info View address of record with Medicare & Part B deductible status Access online forms, publications & messages sent to you by CMS

46. Join Our Team! Counselors, Leaders in Outreach, Administrative Support, Interest Specialists, Mentoring, and AmeriCorps Members

47. Thank You!

48. You may reach CLAIM at: 1-800-390-3330 www.missouriclaim.org 1-800-726-7390 www.difp.mo.gov