Medicare 103 Medicare Basics 1 Agenda 1 Medicare

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Medicare 103 Medicare Basics 1

Medicare 103 Medicare Basics 1

Agenda 1. Medicare Coverage Choices - Original Medicare + PDP + Med Supps -

Agenda 1. Medicare Coverage Choices - Original Medicare + PDP + Med Supps - Medicare Advantage Prescription Drug Plan (MAPD) 2. Medicare Advantage Types - MA, MAPD, MSA, PFFS, Demonstration Programs 3. Other Medicare Plans - Section 1876 (Cost Plans), PACE 4. Med Supps 5. What Medicare Part A and B Do Not Cover 6. What Medicare Part C Does Not Cover 7. What Medicare Part D Does Not Cover 8. Veteran’s, TRICARE, ESGP (Employer Sponsored Group Plans)

Medicare Coverage Choices - Original Medicare + PDP + Med Supps - MAPD

Medicare Coverage Choices - Original Medicare + PDP + Med Supps - MAPD

Medicare Coverage Choices • Original Medicare includes Medicare Part A (Hospital Insurance) and Part

Medicare Coverage Choices • Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). • If you want drug coverage, you can join a separate Part D plan. • To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also shop for and buy supplemental coverage. • Can use any doctor or hospital that takes Medicare, anywhere in the U. S. • You can also add: Supplemental coverage Some examples include coverage from: - a Medicare Supplement Insurance (Medigap) policy, - or coverage from a former employer or union.

Medicare Coverage Choices (continuation) • Original Medicare pays for much, but not all, of

Medicare Coverage Choices (continuation) • Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. • Medicare Supplement Insurance policies, sold by private companies, can help pay some of the remaining health care costs for covered services and supplies, like copayments, coinsurance, and deductibles. • Medicare Supplement Insurance policies are also called Medigap policies. • Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U. S.

Medicare Coverage Choices (continuation) • Medicare Advantage (also known as Part C). • Medicare

Medicare Coverage Choices (continuation) • Medicare Advantage (also known as Part C). • Medicare Advantage is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D (MAPD). • Plans may have lower out-of-pocket costs than Original Medicare. • In most cases, you’ll need to use doctors who are in the plan’s network. • Most plans offer extra benefits that Original Medicare doesn’t cover— like vision, hearing, dental, and more.

Medicare Coverage Choices (continuation)

Medicare Coverage Choices (continuation)

Medicare Advantage Plan Types • MAPD • MSA • PFFS • Demonstration Programs Other

Medicare Advantage Plan Types • MAPD • MSA • PFFS • Demonstration Programs Other Medicare Plans • Section 1876 (Cost Plans) • PACE

Medicare Advantage Plan Types (MA) • Usually a person cannot be enrolled in a

Medicare Advantage Plan Types (MA) • Usually a person cannot be enrolled in a Medicare Advantage plan that does not include drug coverage and then add a separate stand-alone Medicare Part D drug plan (PDP) – Two exceptions • you can join a Medicare Advantage PFFS plan that does not have drug coverage or • a Medicare Medical Savings Account (MSA) and add a standalone Medicare Part D prescription drug plan (PDP). • So, if you are enrolled in a Medicare Advantage HMO or Medicare Advantage PPO plan that does not include drug coverage and you enroll into a stand-alone Medicare Part D plan (PDP), you probably will be automatically disenrolled from your Medicare Advantage plan and returned you to original Medicare Part A and Medicare Part B – But you will still have your newly-selected stand-alone Medicare Part D drug plan.

Medicare Advantage Plan Types (MAPD) • Likewise, if you have a stand-alone Medicare Part

Medicare Advantage Plan Types (MAPD) • Likewise, if you have a stand-alone Medicare Part D plan (PDP) and try to join a Medicare Advantage HMO or PPO plan (with or without drug coverage), you will lose your stand-alone Medicare Part D coverage automatically - and have the Medicare Advantage plan instead. • A Medicare Advantage HMO or PPO without drug coverage may be an option for some people who already receive their prescription drug coverage from another source other than a stand-alone Medicare Part D plan (such as having VA drug coverage).

Medicare Advantage Plan Types (MSA) • Medicare MSA Plans combine a high-deductible insurance plan

Medicare Advantage Plan Types (MSA) • Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs. – High-deductible health plan: The first part is a special type of high-deductible Medicare Advantage Plan (Part C). The plan will only begin to cover your costs once you meet a high yearly Deductible, which varies by plan. – Medical Savings Account (MSA): The second part is a special type of savings account. The Medicare MSA Plan deposits money into your account. You can use money from this savings account to pay your health care costs before you meet the deductible • Medicare MSA plans cover the Medicare services that all Medicare Advantage Plans must cover. In addition, some Medicare MSA plans may cover extra Benefits for an extra cost, like: – Dental, Vision and Long-term care not covered by Medicare • If you join a Medicare MSA Plan and need drug coverage, you'll have to join a Medicare Prescription Drug Plan.

Medicare Advantage Plan Types (PFFS) • PFFS plans aren’t the same as Original Medicare

Medicare Advantage Plan Types (PFFS) • PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care. • You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will. • Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before. • Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before. • For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.

Medicare Advantage Plan Types (Demonstration Pilot Programs) • Demonstrations and Pilot programs, (also called

Medicare Advantage Plan Types (Demonstration Pilot Programs) • Demonstrations and Pilot programs, (also called “research studies”) are special projects that test improvements in Medicare coverage, payment, and quality of care. • They usually operate only for a limited time for a specific group of people and/or are offered only in specific areas. Dual Eligible Demonstration Programs Overview • According to the Centers for Medicare and Medicaid Services “dual eligible” beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. • A “dual eligible” demonstration program is also called an Integrated Care Delivery System (ICDS), which is a system of managed care plans selected to coordinate physical, behavioral, and long-term care services for individuals over the age of 18 who are eligible for both Medicaid and Medicare. “Demonstration” simply means that the program is in its pilot testing phase. MNS currently handles dual eligible demonstration programs for Texas (Star. Plus MMP) and Ohio (My. Care), with more programs coming in the future.

Medicare Advantage Plan Types (My. Care OH) • My. Care Ohio is a managed

Medicare Advantage Plan Types (My. Care OH) • My. Care Ohio is a managed care program designed for Ohioans over the age of 18 who are eligible to receive both Medicaid and Medicare benefits. This is called an Integrated Care Delivery System (ICDS) because it is a system of managed care plans selected to coordinate the physical health, behavioral health, and long-term care services of these beneficiaries. • While both Medicaid and Medicare programs provide individuals with access to critical services and care, there has always been a lack of coordination between these programs. My. Care Ohio Provides this coordination. Plus, My. Care Ohio plans may include additional services to their members. There is no additional cost to participate in this program.

My. Care Ohio (Dual Demonstration Program continuation) • Plan members may also be eligible

My. Care Ohio (Dual Demonstration Program continuation) • Plan members may also be eligible to receive added services that their current programs cannot offer (for example: extra dental visits), depending on which My. Care Ohio plan he/she chooses. Personal Care Services – Home Delivered Meals – Home Making Services – Adult Day Care – Emergency response system – Non emergency transportation up to 30 round trips/year for opt in members - Home Modification - Respite - Assisted Living - My. Care has specialized Long Term Services and Support providers that specialize in services for complex Nursing Facility and Waiver members

Other Medicare Plan Types (Section 1876 Cost Plans) • Medicare Cost Plans are a

Other Medicare Plan Types (Section 1876 Cost Plans) • Medicare Cost Plans are a type of Medicare health plan available in certain areas of the country. • You can join even if you only have Part B. • If you have Part A and Part B and go to a non-network provider, the services are covered under Original Medicare. You would pay the Part A and Part B Coinsurance and Deductible. • You can join anytime the plan is accepting new members. • You can leave anytime and return to Original Medicare. • You can either get your Medicare prescription drug coverage from the plan (if offered), or you can join a Medicare Prescription Drug Plan (Part D).

Other Medicare Plan Types (PACE) • Programs of All-Inclusive Care for the Elderly (PACE)

Other Medicare Plan Types (PACE) • Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their chronic health care needs in the community (frailest) instead of going to a nursing home or other care facility. • You have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. • PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need (physicians, nurses, therapists, health care aides). • If you join a PACE program, you'll get your Part D-covered drugs and all other necessary medication from the PACE program. You don't need to join a separate Medicare Prescription Drug Plan. If you do, you'll be disenrolled from your PACE health and prescription drug benefits.

Other Medicare Plan Types (PACE continuation) You can have either Medicare or Medicaid, or

Other Medicare Plan Types (PACE continuation) You can have either Medicare or Medicaid, or both, to join PACE is only available in some states that offer PACE under Medicaid. To qualify for PACE, you must: • Be 55 or older. • Live in the Service Area of a PACE organization. • Need a nursing home-level of care (as certified by your state). • Be able to live safely in the community with help from PACE. • PACE provides all the care and services covered by Medicare and Medicaid if authorized by your health care team. If your health care team decides you need care and services that Medicare and Medicaid doesn't cover, PACE may still cover them.

Other Medicare Plan Types (PACE continuation) The term “nursing home level of care” is

Other Medicare Plan Types (PACE continuation) The term “nursing home level of care” is not easily definable, as there is no formal federal definition. Instead, each state and the District of Columbia has the task of defining what this means in their own state. . 1. Physical Functional Ability One’s ability (or inability) to complete day to day activities, called activities of daily living (ADLs): bathing and personal hygiene, putting clothes on and taking them off, using the toilet, mobility / transferring (walking from one room to another, getting out of bed, and eating. 2. Health Issues / Medical Needs Needing assistance with injections, catheter care, and intravenous (put into a vein) medications. 3. Cognitive Impairment Cognitive (mental) functioning : Alzheimer’s disease or a related dementia, such as dementia from Parkinson’s disease or Lewy body dementia. 4. Behavioral Problems Behavioral issues: wandering from the home and becoming lost, impulsiveness, and aggressiveness (physical, sexual, verbal).

Other Medicare Plan Types (PACE continuation) What you pay for PACE depends on your

Other Medicare Plan Types (PACE continuation) What you pay for PACE depends on your financial situation: • If you have Medicaid, you won't pay a monthly Premium for the Longterm care portion of the PACE benefit. • If you don't qualify for Medicaid but you have Medicare, you'll be charged these: – A monthly premium to cover the long-term care portion of the PACE benefit – A premium for Medicare Part D drugs • There's no Deductible or Copayment for any drug, service, or care approved by your health care team. • If you don't have Medicare or Medicaid, you can pay for PACE privately.

Medicare Supplement Insurance (Med Supps) • Medigap is Medicare Supplement Insurance that helps fill

Medicare Supplement Insurance (Med Supps) • Medigap is Medicare Supplement Insurance that helps fill "gaps" in Original Medicare and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. • A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like: - Copayments - Coinsurance - Deductibles • Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U. S. If you have Original Medicare and you buy a Medigap policy, here's what happens: - Medicare will pay its share of the Medicare-approved amount for covered health care costs. - Then, your Medigap policy pays its share.

Medicare Supps - 8 things to know about Medigap policies 1. You must have

Medicare Supps - 8 things to know about Medigap policies 1. You must have Medicare Part A and Part B. 2. A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits. 3. You pay the private insurance company a monthly Premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare. 4. A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll each have to buy separate policies. 5. You can buy a Medigap policy from any insurance company that's licensed in your state to sell one.

Medicare Supps - 8 things to know about Medigap policies (continuation) 6. Any standardized

Medicare Supps - 8 things to know about Medigap policies (continuation) 6. Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium. 7. Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren't allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D). 8. It's illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare. Medigap policies don't cover everything Medigap policies generally don't cover Long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Medicare Supplement Insurance (Guaranteed Issue Rights) • When your 65 th birthday nears, it’s

Medicare Supplement Insurance (Guaranteed Issue Rights) • When your 65 th birthday nears, it’s time to consider your two choices in health care coverage: Enrolling in Medicare, with the addition of a Medicare supplement plan (also called Medigap), or enrolling in Medicare Advantage, which is Part A and B together with other options. • The period for a decision only lasts six months, starting from the first day of your birthday month. • During that six-month Medicare supplement plan open enrollment period right after your birthday, you can choose from any of the Medicare supplement plan policies offered in your state, regardless of your health condition.

Medicare Supps: Guaranteed Issue Rights (continuation) • Medicare supplement plan Guaranteed Issue Rights are

Medicare Supps: Guaranteed Issue Rights (continuation) • Medicare supplement plan Guaranteed Issue Rights are protections that give you the right to enroll in any Medicare supplement plan offered by any insurance company in your state, regardless of your health status. • If you qualify for one of the Rights, the insurance company must cover all of your pre-existing conditions (though you might have to wait up to six months). • It also cannot require medical underwriting for your coverage, cannot deny you coverage and cannot charge you more due to health reasons (unless the company specifically says it charges more for particular situations, which should alert you this policy is not a good choice for you . )

Medicare Supps; Medicare Advantage (MA) Trial Rights and Medigap

Medicare Supps; Medicare Advantage (MA) Trial Rights and Medigap

What Medicare Parts A and B Do Not Cover

What Medicare Parts A and B Do Not Cover

What Medicare Parts A and B Do Not Cover This is a list of

What Medicare Parts A and B Do Not Cover This is a list of some of the items and services that Original Medicare doesn't cover: • Long-term care (also called Custodial care; help with bathing, dressing, eating, etc. ) • Dental exams, most dental care or dentures • Routine eye exams, eyeglasses or contacts • Hearing aids, exams for fitting them, or related exams or services • Most care while traveling outside the United States • Most chiropractic services • Acupuncture or other alternative treatments • Cosmetic surgery • Comfort items such as a hospital phone, TV or private room • Routine foot care, orthopedic shoes (there are exceptions) • Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care) • Some screenings tests and labs 28

What Medicare Parts A and B Do Not Cover (continuation) This is a list

What Medicare Parts A and B Do Not Cover (continuation) This is a list of some of the items and services that Original Medicare doesn't cover: • Deductibles and Coinsurances – Medicare Part A pays for inpatient hospital care, skilled nursing facility care, hospice care, and home health care, and Part B covers doctors’ services and outpatient care, but the beneficiary is responsible for deductibles ($1, 408), coinsurance $352/$704/20% (DME), $176 (SNF)) and co-payments (Hospice drugs $5, Respite Care 5%). etc. ). • Part B typically covers 80% of medically necessary doctors’ services, outpatient care like lab tests and x-rays, durable medical equipment (DME), but the beneficiary will have to pay 20% coinsurance of the costs after a $198 deductible, and a monthly premium of $144. 60. • In general, Medicare doesn’t cover health care if you are traveling outside of the 50 states, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, American Samoa, and the Northern Mariana Islands (health care received while traveling in another country), except for very limited circumstances: 1. You are on a cruise ship within six hours of a U. S. port 2. if a foreign hospital is closer than the nearest U. S. hospital for a beneficiary injured in the U. S. or 3. if you receive emergency medical services in Canada while traveling between Alaska and the continental U. S and the nearest Canadian hospital is closer than the nearest U. S. hospital (you must be taking the most direct route and traveling “without unreasonable delay”. 29

What Medicare Parts A and B Do Not Cover (continuation) Observation vs. Admission: •

What Medicare Parts A and B Do Not Cover (continuation) Observation vs. Admission: • • • If the beneficiary ends up in the hospital, he/she needs to make sure whether he/she has been admitted or he/she is there for observation. It can make a big difference in what Medicare pays for, if their after-care involves skilled nursing. Say the beneficiary trips and falls and ends up in the hospital and he/she is there for a few days. After the beneficiary leaves, he/she might need rehab for the injury. Such skilled nursing care is covered through Medicare Part A if the beneficiary was admitted to the hospital for at least three days. However, if the hospital keeps the beneficiary for observation instead of admitting him/her, the rehab would not be covered. Observation is considered outpatient which means that the beneficiary will end up with a huge bill because he/she wasn't admitted as an inpatient. And in some cases, they won't admit the beneficiary even if he/she asks them to Medicare also generally does not cover Alternative Medicine like, Naturopathic medicine, acupuncture and massage therapy. Chiropractic Medicare covers manipulation of the spine if medically necessary to correct a subluxation (when one or more of the bones of your spine move out of position) when provided by a chiropractor or other qualified provider. You pay 20% of the Medicareapproved amount, and the Part B deductible applies. – Medicare doesn’t cover other services or tests ordered by a chiropractor, including X-rays, massage therapy. 30

What Medicare Parts A and B Do Not Cover (continuation) • • • Medicare

What Medicare Parts A and B Do Not Cover (continuation) • • • Medicare won’t cover cosmetic surgery, unless it is medically required because of an injury or to improve functionality of a deformed body part (elective cosmetic procedures are not covered). Medicare also generally won’t pay for housekeeping services, such as help with shopping, meals delivered to your home or 24 -hour assistance at home, unless the beneficiary is receiving hospice care. Medicare does not cover most routine foot care, like the cutting or removing of corns and calluses, nail maintenance nor does it pay for most orthopedic shoes or other foot supports (orthotics) or foot cleaning. Medicare does not pay for copies of X-rays or most non-emergency transportation including “ambulette” services. In general, Medicare doesn’t cover supplies, services, and drugs that are not “medically necessary” and reasonable: – • Medicare considers services needed for the diagnosis, care, and treatment of a patient’s condition to be medically necessary. These supplies and services cannot be primarily for the convenience of the provider or beneficiary. Medicare Concierge care is when a doctor or group of doctors, charges beneficiaries a membership fee. They charge this fee before they’ll see the beneficiary or accept the beneficiary into their practice. – – Medicare doesn't cover membership fees for concierge care. The beneficiary pays 100% of the membership fee for concierge care. The membership fee is governed by the contract or agreement the beneficiary signs with the doctor or doctor group. Doctors who provide concierge care must still follow all Medicare rules. 31

What Medicare Parts A and B Do Not Cover (continuation) Some additional screening tests

What Medicare Parts A and B Do Not Cover (continuation) Some additional screening tests and labs not covered by Medicare : 1. 2. 3. 4. 5. 6. Medicare does not cover routine blood tests ordered as part of a general physical examination or screening. If a medically reasonable diagnostic blood test is performed on an inpatient in a hospital or skilled nursing or rehabilitation facility, Medicare Part A covers it. Medicare does not cover screening for skin cancer in asymptomatic people. It does, however, cover a physician visit initiated by a concerned patient who has noticed, for example, a change in the color of a mole (clinically described as a pigmented nevus or, more generally, skin lesion), or a new skin growth. Predictive or pre-symptomatic genetic tests and services, in the absence of past or present illness in the beneficiary, are not covered under national Medicare rules. For example, Medicare does not cover genetic tests based on family history alone. Without symptoms, Medicare is not going to pay for a cardiac stress test. Medicare does not cover skin endpoint testing or neutralization testing. Medicare doesn’t cover therapy for subcutaneous, intracutaneous, or sublingual food allergies. 32

What Medicare Part C Does Not Cover

What Medicare Part C Does Not Cover

What Medicare Part C Does Not Cover Your out-of-pocket costs in a Medicare Advantage

What Medicare Part C Does Not Cover Your out-of-pocket costs in a Medicare Advantage Plan depend on : • • • • Whether the plan charges a monthly premium. You pay this in addition to the Part B premium. Whether the plan pays any of your monthly Medicare premiums. Some Medicare Advantage Plans will help pay all or part of your Part B premium. This benefit is sometimes called a “Medicare Part B premium reduction. ” Whether the plan has a yearly deductible or any additional deductibles for certain services. How much you pay for each visit or service (copayments or coinsurance). Medicare Advantage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care. The type of health care services you need and how often you get them. Whether you get services from a network provider or a provider that doesn’t contract with the plan. If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your services may not be covered, or your costs could be higher. 34

What Medicare Part C Does Not Cover (continuation) Your out-of-pocket costs in a Medicare

What Medicare Part C Does Not Cover (continuation) Your out-of-pocket costs in a Medicare Advantage Plan depend on : • Whether you go to a doctor or supplier who accepts assignment (if you’re in a Preferred Provider Organization, Private Fee-for-Service Plan, or Medical Savings Account Plan and you go out-of-network). • Whether the plan offers extra benefits (in addition to Original Medicare benefits) and if you need to pay extra to get them. • The plan’s yearly limit on your out-of-pocket costs for all Part A and Part B medical services. Once you reach this limit, you’ll pay nothing for Part A and Part B-covered services. • Whether you have Medicaid or get help from your state. 35

What Medicare Part D Does Not Cover

What Medicare Part D Does Not Cover

How Does Medicare Part D Work? There are 4 stages to a Part D

How Does Medicare Part D Work? There are 4 stages to a Part D drug plan: 1. Annual Deductible In 2020, the allowable Medicare Part D deductible is $435. Plans may charge the full Part D deductible, a partial deductible, or waive the deductible entirely. You will pay the network discounted price for your medications until your plan tallies that you have satisfied the deductible. After that, you enter Initial Coverage. 2. Initial Coverage During this stage of Part D drug coverage, you will pay a copay for your medications based on the drug formulary. Each drug plan will separate its medications into tiers. Each tiers has a copy amount that you will pay. For example, a plan might assign a $4 copay for a Tier 1 generic medication. Maybe a Tier 3 is a preferred brand name for a $45 copay, and so on. The insurance company tracks the spending by both you and the insurance company until you have together spent a total of $4, 020 in 2020. 3. The Coverage Gap After you’ve reached the initial coverage limit for the year, you enter the coverage gap. During the gap, you will pay only 25% of the retail cost of your medications. (This is so much better than in 2006 when many people had to pay 100% of their drugs in the gap. ) Your gap spending will continue until your total out of pocket drug costs have reached $6, 350 in 2020. 37

How Does Medicare Part D Work (continuation)? There are 4 stages to a Part

How Does Medicare Part D Work (continuation)? There are 4 stages to a Part D drug plan: Please note that to get into the gap, Medicare tracks the total costs of what you and the insurance company have spent, but to get OUT of the gap, they are counting only what you have paid in deductibles, copays and gap spending that year, plus manufacturer discounts. They do not count anything the federal government contributes. 4. Catastrophic Coverage After you’ve reached the end of the coverage gap, your plan will kick in to pay 95% of the costs of your formulary medications for the rest of the year. This feature in Part D drug plans helps you limit your potential spending if you have expensive medications. Medicare Tracks Your Part D Spending It’s important to note that Medicare itself tracks your True Out of Pocket Costs (Tr. OOP) for each year. This can protect you from paying certain costs twice. For example, say you have already satisfied the deductible on one plan. Then you later switch mid-year to a different Medicare Part D plan because you moved out of state. Your new plan will already see that you have paid the deductible for that year. The costs for coverage gap and catastrophic coverage work the same way. 38

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How Does Medicare Part D Work (continuation)? Whats is Tr. OOP: While in the

How Does Medicare Part D Work (continuation)? Whats is Tr. OOP: While in the donut hole, the costs that count toward your limit change slightly and for the better. The amount you pay counts toward the Tr. OOP limit, but the major difference between namebrand drugs and generic drugs is that for generic drugs, only the amount you pay counts toward your Tr. OOP. For name-brand drugs, the discount payment your plan makes also adds up toward your limit. So, if you’re paying 25 percent and your plan’s discount is 70 percent of the name brand drug, 95 percent of the drug’s price counts toward your Tr. OOP. Once you’ve reached your Tr. OOP limit, you’ll enter what’s called catastrophic coverage 40

What Medicare Part D Does Not Cover Drugs not covered under Medicare Part D:

What Medicare Part D Does Not Cover Drugs not covered under Medicare Part D: Since each Medicare Part D Prescription D plan decides which drugs not to cover on its formulary, the list here is not complete. However, plans usually do not cover: • • • Weight loss or weight gain drugs Drugs for cosmetic purposes or hair growth Fertility drugs Drugs for sexual or erectile dysfunction Over-the-counter drugs Medicare Part D also does not cover any drugs that are covered under Medicare Part A or Part B. 41

Veteran’s, TRICARE, ESGP (Employer Sponsored Group Plans)

Veteran’s, TRICARE, ESGP (Employer Sponsored Group Plans)

Creditable Prescription Drug Coverage The Medicare Modernization Act (MMA) requires entities (whose policies include

Creditable Prescription Drug Coverage The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage. Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage: • People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later. • Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or individual health insurance coverage. • Your plan must tell you each year if your drug coverage is creditable coverage. • If you go 63 days or more in a row without a Medicare drug plan or other creditable prescription drug coverage, you may have to pay a penalty if you join later. 43

Veteran’s Benefits This is health coverage for veterans and people who have served in

Veteran’s Benefits This is health coverage for veterans and people who have served in the U. S. military: You may be able to get prescription drug coverage through the U. S. Department of Veterans Affairs (VA) program. • • You may join a Medicare Prescription Drug Plan, but if you do, you can’t use both types of coverage for the same prescription at the same time. • VA care is limited to providers who accept VA treatment, and having Medicare coverage will expand your doctor network as well as provide supplemental coverage opportunities. • When it comes to drug coverage, there is less downside to putting off Medicare. VA coverage for prescriptions is typically less expensive than Medicare Part D drug plans, and you won’t be hit with late penalties if you lose VA coverage in the future, provided that you sign up with a Part D plan within two months of that coverage ending. 44

Veteran’s Benefits (continuation) This is health coverage for veterans and people who have served

Veteran’s Benefits (continuation) This is health coverage for veterans and people who have served in the U. S. military: • However, If you have both VA and Part D drug coverage, you have the flexibility of using one or the other. This would allow you to get prescriptions from non-VA doctors and fill them at local retail pharmacies (rather than relying solely on the VA's mail-order service) and to obtain medications the VA doesn’t cover. You can apply for lowcost drug coverage under Part D’s Extra Help program if your income is under a certain level. • The Medicare and VA systems are entirely separate, with no coordination of benefits between them. You would use your VA identity card at VA facilities and your Medicare card anywhere else. 45

TRICARE This is a health care plan for active-duty service members, military retirees, and

TRICARE This is a health care plan for active-duty service members, military retirees, and their families: • Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. • You generally must enroll in Part A and Part B when you’re first eligible to keep your TRICARE coverage. - However, if you’re an active-duty service member or an active duty family member, you don’t have to enroll in Part B to keep your TRICARE coverage. • If you have TRICARE, you don’t need to join a Medicare Prescription Drug Plan. However, if you do, your Medicare Prescription Drug Plan pays first, and TRICARE pays second • If you join a Medicare Advantage Plan with prescription drug coverage, your Medicare Advantage Plan and TRICARE may coordinate their benefits if your Medicare Advantage Plan network pharmacy is also a TRICARE network pharmacy • Otherwise, you can file your own claim to get paid back for your out-ofpocket expenses. 46

Employer Sponsored Group Plan (ESGP) Simply put, employer-sponsored plans are group health plans that

Employer Sponsored Group Plan (ESGP) Simply put, employer-sponsored plans are group health plans that employees can obtain through the businesses that they work for. This is health coverage from you, your spouse’s, or other family member’s current or former employer or union: • Before you make any changes, call your benefits administrator, or sign up for any other coverage. Signing up for other coverage could cause you to lose your employer or union health and drug coverage for you and your dependents. If you lose your employer or union coverage, you may not be able to get it back. • If you have prescription drug coverage based on your current or previous employment, your employer or union will notify you each year to let you know if your prescription drug coverage is creditable. • In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the Medicare Advantage Plan you join. Your employer or union may also offer a Medicare Advantage retiree health plan that they sponsor. 47

Comparing Medicare and Medicare Advantage Comparison Table 48

Comparing Medicare and Medicare Advantage Comparison Table 48

Comparing Medicare and Medicare Advantage Comparison Table 49

Comparing Medicare and Medicare Advantage Comparison Table 49

Comparing Medicare and Medicare Advantage Comparison Table 50

Comparing Medicare and Medicare Advantage Comparison Table 50

Comparing Medicare and Medicare Advantage Comparison Table 51

Comparing Medicare and Medicare Advantage Comparison Table 51

References • • • • • • Medicare & You 2020 https: //www. medicare.

References • • • • • • Medicare & You 2020 https: //www. medicare. gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/howdo-medicare-advantage-plans-work https: //www. medicare. gov/sign-up-change-plans/types-of-medicare-health-plans/private-fee-for-service-pffs-plans https: //q 1 medicare. com/q 1 group/Medicare. Advantage. Part. DQA/FAQ. php? faq=MA-and-MAPD---What-is-thedifference-between-a-Medicare-Advantage-MA-plan-and-a-Medicare-Advantage-MAPD-plan&faq_id=520&category_id=111 https: //q 1 medicare. com/q 1 group/Medicare. Advantage. Part. DQA/FAQ. php? faq=Can-I-enroll-in-an-HMO-Medicare. Advantage-plan-and-then-add-prescription-drug-coverage-through-a-stand-alone-Medicare-Part-D-plan&faq_id=627&category_id= https: //www. medicare. gov/sign-up-change-plans/types-of-medicare-health-plans/other-medicare-health-plans https: //q 1 medicare. com/q 1 group/Medicare. Advantage. Part. DQA/FAQ. php? faq=Can-I-enroll-in-an-HMO-Medicare. Advantage-plan-and-then-add-prescription-drug-coverage-through-a-stand-alone-Medicare-Part-D-plan&faq_id=627&category_id= https: //www. bing. com/search? q=medicare+limiting+charge+cms&src=IE-Search. Box&FORM=IENTSR https: //www. mnsnetwork. com/dualelgible https: //www. medicare. gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap https: //www. retirementliving. com/medicare-supplement-medigap-guaranteed-issue-rights https: //medicare. com/coverage/drugs-supplies-and-services-that-medicare-doesnt-cover/ https: //www. ehealthmedicare. com/medicare-part-d-articles/covered-drugs-medicare-part-d-drug-formulary/ https: //boomerbenefits. com/medicare-part-d-plans/what-is-part-d/ https: //living. medicareful. com/understanding-medicare-part-ds-true-out-of-pocket-limit https: //www. bing. com/search? q=what+does+troop+mean+medicare&src=IE-Search. Box&FORM=IENTSR https: //www. cms. gov/Medicare/Prescription-Drug. Coverage/Creditable. Coverage/index? redirect=/creditablecoverage/ http: //bestseniorinformation. com/veterans-benefits/ https: //www. medicareplanfinder. com/blog/medicare-for-veterans-with-va-benefits/ https: //www. aarp. org/health/medicare-qa-tool/does-medicare-work-with-veterans-coverage/ 2020 Choosing a Medigap Policy For Internal Use Only 52