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National Medicare Education Week: September 15–21Devoted to helping people:• Learn about Medicare• Get answers to questions• Feel confident making Medicare decisions

Navigating the MedicareMaze

NEWLOOK2018 the numbering system for medicare changed from social security numbers to 11 random digits and letters.Medicare always starts first day of any month eligible. One exception, if your birthday is the 1st of the month,Yours will begin in previous month. Medicare Begins Here with your card

NEWLOOKThis card represents Original MedicarePart A + HospitalPart B = Medical80%-20%Some times a person may not want to enrollin Medicare right away because they are ona group plan with a spouse. Social Securityis aware of this and provides a provision toopt out. If you are on Social Security you will have totake Part A and a card reflecting that will bemailed.

U.S. citizens and legal residents.Legal residents must live in theU.S. for at least 5 years in a row,including the 5 years just beforeapplying for Medicare.Who can get Medicare?

Who needs to enroll in Medicare?For some it is automatic Those turning 65 who are receiving a Social Security or Railroad Retirement Board Check.Medicare coverage will begin the first day of the month you turn 65. only exception; those born on the 1st of the Month will be covered the previous month. Example DOB 7/1/1956 will be eligible on June 1st.Medicare card will arrive approx 100 days prior to your birth month.

Some will need to Self-Enroll Those turning 65 who are NOT receiving a Social Security, on a Group Plan and loosing ACA subsidy. enrolling in Medicare you MUST create an SSA.gov account. You can enroll online: www.ssa.gov/MedicareOnly or Make anappointment with a local Social Security Office.Start to finish it will take approximately 4 weeks for Medicare card toarrive.BeforeWho needs to enroll in Medicare?

When to enroll in Medicare?Enrollment Period: IEP Initiala 7 month sign up period for those starting Medicare at 653 months before, month of and 3 months after turning 65We strongly encourage enrolling in advance so, you have your Medicare card the day you turn 65.You will avoid penalties and not have to go without insurance

Enrollment During an IEP - 7 monthsAprilMayJuneAugustSeptemberOctoberEnroll now coveragewill be delayedEnroll now coverage andcoverage will begin July 1Turning 65 JULY

Special Enrollment Period: SEP This is a special enrollment period for those who didn't enroll at 65 because they continued to be covered by their or their spouse's employer provided plan. 2 Step ProcessForm CMS L564 will be filled out by your/spouse's employer, going back toage 65, to verify continuous credible coverage and employment.Form CMS 40B you fill out very simple name address social security numberwill let Social Security know when you want to start Medicare benefits. Needsto be done 90 days prior to when you want coverage to begin to avoid lapsein coverage penalties.When to enroll in Medicare?

3 months before, month of and 3 months after turning 65IEP SEPUsed when starting Medicare DID NOT Start Medicare at 65Stayed on Employer Provided CoverageRetire and start Medicare at 65 & 4mos.+++a 7 month sign up period Besides AEP there are 2 ways an Individual can enroll in medicare

What doesMedicare cover?

Medicare Part A: Hospital InsuranceMedicare Part A covers hospital stays and inpatient care, including:Your hospital room and mealsCare in special units, such as intensive careDrugs and medical supplies used during an inpatient stayLab tests, X-rays and medical equipment as an inpatientOperating room and recovery room servicesSkilled nursing servicesSome blood transfusionsHospice care, including medicationsto manage symptoms and painPart-time, skilled care for the homeboundRehabilitation services after a qualified inpatient stay

Medicare Part A: Hospital InsuranceFast facts• Premium free if you or your spouse worked and paid taxes for 10 years or longer• Can’t be denied coverage• Coverage is nationwide, including any qualified hospital in the U.S.• Coverage and costs are per “benefit period”• Must be admitted as an inpatient (not on “observation status”)• Provides additional 60 “lifetime reserve” days

Medicare Part B: Medical InsuranceMedicare Part B covers doctor visits and outpatient care, including:An annual wellness visit and preventiveservices, like flu shotsDoctor visits, including when you are inthe hospitalClinical laboratory services, like blood andurine testsX-rays, MRIs, CT scans, EKGs and someother diagnostic testsSome health programs, like smokingcessation and obesity counselingDiabetes screenings, education andcertain suppliesMental health careDurable medical equipment for use athome, like wheelchairs and walkersAmbulatory surgery center servicesAmbulance and emergency room servicesPhysical therapy, occupational therapy andspeech-language pathology servicesSome skilled nursing care and health aideservices for the homebound

Medicare Part B: Medical InsuranceFast facts• Monthly premium, adjusted for income (give back program)• Can’t be denied coverage• Coverage is nationwide, including any provider who accepts Medicare• Premium penalty for late enrollment

Medicare Doesn’t Cover EverythingOriginal Medicare (Parts A & B) does not cover:• All of the cost of your care — you have out-of-pocket costs, with no limit• Prescription drugs• Routine dental, vision or hearing care• Eyeglasses, contacts or hearing aids• Long-term or custodial care (help bathing, eating, dressing)• Excess charges for services by doctors who don’t accept Medicare assignment• Care received outside the U.S., except for certain circumstances

How much does Medicare cover?

Types of costsPremiumDeductibleCopayCoinsuranceA fixed amount that you pay for coverage, usually monthlyA set amount that you pay for covered services before yourplan begins to payA fixed amount you pay at the time you receive a covered serviceAn amount you pay when the cost of a covered service is splitwith you by percentage, such as 80/20How much does Medicare cover?

PremiumDeductibleOther CostsNote$0 for most people can be up to $499$1556.00 per benefit period equal to 60 daysNO Out-of-Pocket limit$389 per day for days 61-90$778 per lifetime reserve day (60 days maximum)Beyond lifetime reserve days ALL COSTS$194.50 Skilled Nursing Facility co-insurance days 21-100 per benefit period TYPES OF COSTS

Matthew is admitted to the hospital in January and stays 5 days. He is readmitted in April and stays for 65 days.More than 60 days pass between Matthew being released and readmitted.Matthew’s Costs First Stay Medicare Part A deductible $1,556Days 1–5 $0Second StayMedicare Part A deductible $1,556 Days 1–60 $0Days 61–65(5 days at $389 per day) $1,945Mathews Total costs Per Benefit $5057

PremiumDeductibleOther CostsNote$174.70 for most people$240.00 for the yearNO Out-of-Pocket limit20% for each Medicare-covered service or item after deductible(and as long as your doctor or health care provider accepts theMedicare-approved amount as full payment.20% of the Medicare-approved amount for most doctor serviceswhile you’re a hospital inpatient.TYPES OF COSTS

Ellen has heard about doctors accepting Medicare assignment and that it hassomething to do with out-of-pocket costs. She asks what the difference in cost would be if the doctor acceptsassignment or not.Ellen’s Costs Usual and customary doctor’s fees Medicare-approved amount Reduced Medicare-approved amount Medicare pays 80% Ellen pays 20% coinsurance Ellen pays doctor’s excess charges $ 133AcceptsAssignmentRefuses AssignmentTotal Ellen pays $ 44 $ 300 $ 300$ 220 $ 220$ 176$ 209 $ 167$ 44 $ 42 $ 91The difference between Dr original fee and medicare reduced rate due to Dr. refusing

6 Medicare Coverage Combinations

Medicare Options

Plans may help pay:Part A and Part B deductiblesCopays, coinsurance and provider excesschargesCost for extra 365 days of hospital careafter lifetime reserve days usedCost of blood transfusions, first 3 pintsCost of foreign travel emergency, up toplan limitPlans do not help with:Prescription drugsRoutine dental, vision or hearing care*Eyeglasses, contacts or hearingaids*Extra days in a skilled nursingfacility after Part A benefitCustodial care (help) bathing,eating, dressing)Long-term careOptions: Medicare Supplement Insurance*Some plans may offer specialprograms to members to help withsome of these costs.

Options: Medicare Supplement = Medi-Gap PoliciesAll Plans Are "STANDARDIZED" by MedicareA B C D F G K L M NCovers all Gaps EXCEPT Part B Deductible & Excess Charges+ $20 Dr Copay & $50 Emergency room copay3 of the Most Common Original Medicare doesn't cover Long Term custodial care, Routine dental care, cosmetic surgery, Acupunture or Hearing AidsFG N IF Original Medicare doesn't cover pay neither will a supplement plan.Covers All Gaps 100% Coverage A&B gaps no longer available to anyone born after Jan 1, 1955Covers all Gaps EXCEPT Annual Part B Deductible

Medicare Supplement aka Medi-Gap Policies cont.Purchasing a PolicyDuring the very first six months of your Medicare Part B, you'll be given a once in alifetime opportunity to buy any Medigap policy sold in your state regardless of anyhealth conditions.During these 6 months insurance companies may not ask you any health questions,majing your acceptance GUARANTEED

• An alternative to Original Medicare (Parts A & B)• Plan members are still in the Medicare program• Benefits are administered by the plan• Plans offered by private insurance companiesOptions: Medicare Advantage

All the benefits of Part A (except hospice care, which is still coveredby Part A)All Medicare Advantage plans cover:All the benefits of Part BMost Medicare Advantage plans cover:Prescription drugsMedicare Advantage plans may offer additional benefits, such as:Dental exams, cleanings and X-raysEye exams, eyeglasses and corrective lensesHearing tests and hearing aidsWellness programs and fitness membershipsMedicare Advantage plans have an annual out-of-pocket maximum to help protect against high costs.Options: Medicare Advantage

Plan Types • Health Maintenance Organization plans (HMO)• Preferred Provider Organization plans (PPO)• Point of Service plans (POS)• Special Needs Plans (SNP)Coordinated care plansOther plan types• Private Fee-For-Service plans (PFFS)• Medical Savings Account plans (MSA)Options: Medicare Advantage

Medicare Advantage Fast facts • Must be enrolled in both Medicare Part A and Part B and live in plan service area• Can’t be denied coverage based on current financial or health status, including pre-existing conditions*• May be required to use provider and pharmacy networks• Coverage and costs vary by plan and may change each year• Annual limit on out-of-pocket costs for covered services• May charge a monthly plan premium• Must continue to pay Part B premium to Medicare* Special rules for people with end-stage renal disease.

Two ways to get coverage:Medicare Prescription Drug Coverage • Add a standalone Part D plan to Original Medicare• Choose a Medicare Advantage plan that includes prescription drug coveragePlans offered by private insurance companies Helps with the cost of prescription drugs

Medicare Prescription Drug Coverage Types of drugs most commonly prescribed for Medicarebeneficiaries as determined by federal standardsMedicare Part D plans cover:Specific brand name drugs and generic drugs included in theplan’s formulary, or list of drugsCommercially available vaccines not covered by Part B

Formulary: List of Covered DrugsDrugs are grouped into tiers based on costIn general, the lower the tier, the lower the costDeductibles may be charged by tierTiered formularyFormulary TiersTier 1 $Tier 2 $$Tier 3 $$$Tier 4 $$$$Tier 5 $$$$$

Part D Coverage StagesAnnual DeductibleInitialCoverage2025 ENDS(Donut Hole)CatastrophicCoverageUp to plandeductibleTo end of yearUp to planNo longerallowedAmount paid for prescriptions depends on stage• Dollar limits can change each year• Not all plans have a deductible• Many people never reach the coverage gap• Cycle starts over on January 1 each year

Initial Coverage Tier 1 Preferred Generic $ 0 - $ 3 Tier 2 Generic Drugs $ 0 - $ 10 Tier 3 Preferred Brand $ 20 - $ 45 Tier 4 Non Preferred Brand $ 35 - $ 95 Tier 5 Specialty 30% CoinsuranceRemain in Initial coverage until TOTAL Retail RX costs reach $2000 Part D Coverage StagesAnnual Deductible Begins: immediately amount is determined by Medicare $505Maximum. Amount varies depending on plan chosen. Co-pays applied

Must be enrolled in Part BMay be required to use pharmacy networkCoverage and costs vary by plan and may change each yearPart D premium penalty for late enrollmentMust continue to pay Part B premium to MedicareMedicare Prescription Drug Coverage Fast facts

SMARTpecificedically FitsffordableeliableimelyMedicare S.M.A.R.T. Planning

If you choose this option make sure you are getting someoneknowledgeable, more often than not they are not trainedadequately, placed on the phone too fast, captive therefor notshowing you ALL options available to you.2 Ways of Getting Assistance with Medicare &Plan Navigation Company Captive Agent, every call center advertised and 1. large corporation have employees.2. Independent broker. They have the right, because of the training and testing done, to write for all the companies, however NOT bound to any company. Bringing ALL the options to the table.

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