Medicare 101 Missouri State Health Insurance Assistance Program

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Medicare 101 Missouri State Health Insurance Assistance Program SHIP 15 -082 -CL This material

Medicare 101 Missouri State Health Insurance Assistance Program SHIP 15 -082 -CL This 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 Commerce and Insurance and service is provided by Primaris Foundation, a non-profit organization.

What is CLAIM? Community Leaders Assisting the Insured of Missouri’s SHIP State Health Insurance

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

Creation of SHIPs (1990) Created by Congress as part of Medigap reform package Provide

Creation of SHIPs (1990) Created by Congress as part of Medigap reform package Provide Medicare education Give feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS)

Funding Missouri Department of Commerce and Insurance (DCI) received the first federal grant in

Funding Missouri Department of Commerce and Insurance (DCI) received the first federal grant in 1993. Primaris Foundation has been awarded the contract through the DIFP since 1993.

How are clients’ needs met? Volunteers are trained and certified Volunteers have access to

How are clients’ needs met? Volunteers are trained and certified Volunteers have access to staff support, CMS, and other professionals Currently 300+ volunteers statewide and 180 community partners

Examples of Who We Serve A 70 -year-old widow A 45 -year-old disabled person

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

Services How CLAIM Counselors Can Help Enrollment and billing Medicare Advantage Plans Medigap and

Services How 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

President Lyndon B. Johnson at the signing ceremony July 30, 1965, at the Truman

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

Qualifying for Medicare Beneficiary reaches age 65 (“Age in”) Determined by age and credits

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

Enrollment Have 40 credits? Automatic Enrollment *Late enrollment penalty may apply. Don’t have 40

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

Optional Enrollment Part A Required for automatic enrollees Manual enrollees Part B Optional for

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

Enrollment Periods Initial enrollment period (3 -1 -3) Automatic enrollment – receiving Social Security

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

What. Four are the Four of Parts of Medicare? Parts Medicare Part A Hospital

What. Four are the Four of Parts of Medicare? Parts Medicare Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans , like HMOs and PPOs. Includes Part A & B, usually Part D coverage Part D Prescription Drug Coverage

Part A Hospital Insurance

Part A Hospital Insurance

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

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

Paying for Part A Premiums paid by Medicare taxes Must have 40 credits Those

Paying for Part A Premiums paid by Medicare taxes Must have 40 credits Those without 40 credits pay a pro-rated premium Hospital must accept “Medicare Assignment” for services Deductible for each benefit period 2019 = $1364 Co-Pays may also apply

Benefit Periods Measures use of inpatient hospital and skilled nursing facility (SNF) services Begins

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, 364 in 2019) No limit to number of benefit periods

Part B Medical Insurance

Part B Medical Insurance

Medicare Part B Coverage: Doctor’s office visits Outpatient hospital services Home health Ambulance transportation

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

Paying for Part B Monthly premium Current 2019 premium is $135. 50 Premium paid

Paying for Part B Monthly premium Current 2019 premium is $135. 50 Premium paid by beneficiary is 25% of actual cost Late enrollment penalties Normally withheld from Social Security benefit Annual Deductible: $ 185 for 2019 May increase annually Co-pays and deductibles may apply

Part B Covered Preventive Services “Welcome to Medicare” visit Annual “Wellness” visit Abdominal aortic

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

Part B Covered Preventive Services Glaucoma tests Hepatitis B shots HIV screening Immunizations Mammograms

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

Supplemental Insurance Medigaps and Employer Plans

Supplemental Insurance Medigaps and Employer Plans

Purpose of Supplements Gaps Medical Care Cost Individual • Medicare was not designed to

Purpose of Supplements Gaps Medical Care Cost Individual • Medicare was not designed to pay all health care costs • Medicare coverage has gaps • Costs of medical care outpaced coverage • Percentage of income that people pay for health care continues to increase • Medicare cost-sharing has increased since 1965

Medigap Policies Medigap - Medicare Supplement Insurance policies Private health insurance for individuals Sold

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

Medigap Policies Costs vary by plan, company, and location Medigap insurance companies can only

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

Employer Insurance Part B coverage is optional if a person is: Employed • Covered

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

When Employer or Union Coverage Ends Options: May be a chance to elect COBRA

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.

Medicare Part C Medicare Advantage Plans

Medicare Part C Medicare Advantage Plans

Part C: Medicare Advantage Plans Alternative method of obtaining benefits Administered by private insurance

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

Medicare Advantage Plan Costs Must still pay Part B premium Some plans may pay

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

Medicare Advantage (MA) Open Enrollment Period MA Disenrollment Period is no longer MA OEP

Medicare Advantage (MA) Open Enrollment Period MA Disenrollment Period is no longer MA OEP starting 2019 • January 1 - March 31 each year • Must be in an Advantage plan on 1/1 to use MA OEP • Can only be used once

During the Medicare Advantage (MA) Open Enrollment Period People in an MA Plan on

During the Medicare Advantage (MA) Open Enrollment Period People in an MA Plan on January 1 can : Switch MA plans Leave MA to join Original Medicare • Coordinating Part D SEP Can add or drop Part D when switching plans Part D not guaranteed unless you were in an MA Plan on January 1 Can’t switch from one stand alone PDP to another standalone PDP

Medicare Advantage Eligibility Requirements Live in plan’s service area Enroll in Medicare Part A

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

How Medicare Advantage Plans Work Still enrolled in Medicare with all rights and protections

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.

Part D Medicare Prescription Drug Plans

Part D Medicare Prescription Drug Plans

Medicare Part D Administered through private insurance coverage in conjunction with Medicare Must be

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)

Paying for Part D for 2019 Premiums 2019 = $20. 40 up to $152.

Paying for Part D for 2019 Premiums 2019 = $20. 40 up to $152. 60 Penalties apply for late enrollment Deductible – maximum $415 Cost-sharing and deductibles determined by: • the type of medication • terms of the plan selected Gap – 60% coverage

Enrollment Periods for Prescription Drug Programs Initial Enrollment Period (IEP) § 7 month period

Enrollment Periods for Prescription Drug Programs Initial Enrollment Period (IEP) § 7 month period § Starts 3 months before month of eligibility Annual Enrollment Period Oct. 15 – Dec. 7 Annual Medicare Advantage Enrollment Period § Between Jan. 1–March 31, you can leave an MA plan for another or switch to Original Medicare with a Part D plan to add drug coverage. Coverage begins the first of the month after the plan gets the enrollment form.

Prescription Drug Costs vary by plan In 2019, most people will pay: A monthly

Prescription Drug Costs vary by plan In 2019, most people will pay: A monthly premium National average = $33. 20 An annual deductible – no more than $415 Copayments or coinsurance may apply

Part D Late Enrollment Penalty Higher premium for some who wait to enroll Additional

Part D Late Enrollment Penalty Higher premium for some who wait to enroll Additional 1% of base national average premium ($33. 20 in 2019) • 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

Access to Covered Drugs Coverage and rules vary by plan Plans manage access to

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)

Stretching Your Health Care Dollars

Stretching Your Health Care Dollars

Stretching Health Care Dollars Low Income Subsidy (LIS) Extra Help through Social Security Administration

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

Stretching Health Care Dollars Medicare Savings Programs Federal and State funding through MO Health.

Stretching Health Care Dollars Medicare Savings Programs Federal and State funding through MO Health. Net 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

Missouri SMP Program Statewide volunteer program whose mission is to empower and assist Medicare

Missouri SMP Program 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

my. Medicare. gov View claim status(excluding Part D claims) Order a duplicate Medicare Summary

my. Medicare. 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

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

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

Thank You!

Thank You!

You may reach CLAIM at: 1 -800 -390 -3330 www. missouriclaim. org 1 -800

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