MEDICARE BENEFITS AND UPDATES FOR 2012 Senior Health

MEDICARE BENEFITS AND UPDATES FOR 2012 Senior Health Insurance Program 800 -548 -9034

WHAT IS SHIP? Senior Health Insurance Program Established in 1988 Free Medicare Counseling Program Sponsored by the State of Illinois Department of Insurance Does not sell or solicit insurance Dedicated to educating people with Medicare SHIP trains volunteer counselors throughout Illinois Provide one-on-one counseling With Medicare Beneficiaries, family members and caregivers Through community based sites

MEDICARE Medicare has four parts Part A – Hospital Insurance Part B – Medical Insurance Part C – Medicare Advantage HMO, PPO, PFFS, SNP, and MSA Part Original Medicare Also know as Managed care D – Prescription Drug Coverage Medicare Supplement Insurance Not to be confused with secondary insurance

PART A – COVERED SERVICES Inpatient Skilled Home Hospital Care Nursing Facility Care Health Care Hospice Care

PART A COSTS FOR INPATIENT HOSPITAL STAYS For each benefit period in 2012 Days 1 -60 Days 61 -90 Days 91 -150 All days after 150 You Pay $1, 156 deductible $289 per day $578 per day (60 lifetime reserve days) All Costs 5

PART A COSTS FOR SKILLED NURSING FACILITY CARE For each benefit period in 2012 You Pay Days 1 -20 $0 Days 21 -100 $144. 50 per day All days after 100 All Costs

PART B – COVERED SERVICES Medical Home Expenses Health Care Outpatient Durable Hospital Services Medical Equipment (DME)

2012 PART B AMOUNTS 06/22/2011 Part B Annual Deductible - $140 Part B Monthly Premium DRAFT Medicare Current Topics If your income is $85 K or less and you You pay this in paid this in 2011 2012 $96. 40, $110. 50, $115. 40 $99. 90 8

INCOME-RELATED PART B PREMIUM Part B premium income thresholds at 2010 levels through 2019 In 2012 You Pay* File Individual Tax Return File Joint Tax Return $85, 001–$107, 000 $107, 001–$160, 000 $160, 001–$214, 000 above $214, 000 $170, 001–$214, 000 $214, 001–$320, 000 $320, 001–$428, 000 above $428, 000 *Higher if you have a late enrollment penalty $139. 90 $199. 80 $259. 70 $319. 709 DRAFT Medicare Current Topics If your Yearly Income in 2010 was 06/22/2011 Frozen

MEDICARE PART C Medicare Advantage (MA) Provided Offered through HMO, PPO, PFFS, MSA an SNP Must offer all services covered under Medicare Part A and Part B through private insurance companies May be able to offer extra services May No include Drug Coverage need to have a Supplement plan Must live in plans service area Must follow plans guidelines for coverage

MEDICARE PART D Began in 2006 Offered by private companies contracted with Medicare to provide prescription drug coverage Available to anyone enrolled in Medicare Part A and/or Part B Coverage offered Stand-alone Prescription Drug Plan (PDP) As part of a Medicare Advantage Plan (MA-PD)

MORE AFFORDABLE PRESCRIPTION DRUGS Discounts for 2012 50% discount on brand-name drugs and 14% discount on generic-drugs during the donut hole. Elimination of the Donut Hole by 2020 Your cost-share should be approximately 25% during the plan year.

COST SHARING FOR BRAND-NAME DRUGS IN THE MEDICARE PART D COVERAGE GAP, 20102020

COST SHARING FOR GENERIC DRUGS IN THE MEDICARE PART D COVERAGE GAP, 2010 -2020

NEW SPECIAL PART D CO-PAY STRUCTURE NEW FOR 2012 For dual eligibles receiving Home and Community Based Waiver Services (HCBS) $0 co-pay for prescriptions Similar to co-pay structure for duals in a nursing home Must keep dual eligible status

HOME AND COMMUNITY BASED WAIVER SERVICES There are 9 HCBS programs in Illinois: Http: //www. hfs. illinois. gov/hcbswaivers/ Includes DRS Home Services Program Includes Department on Aging Community Care Program

HOME AND COMMUNITY BASED WAIVER SERVICES CONTINUED HCBS “status” works like Medicaid dual eligible status If you have HCBS enrollment in any month of the year, you get $0 Part D co-pays for the rest of the year If you have HCBS enrollment in July or later, you get $0 co-pays for the following year Must keep the dual eligible status Most people will have the waiver program and be a dual eligible as waiver programs now count toward meeting spend-down

ENROLLMENT PERIODS Annual Open Enrollment Period Oct. 15 th – Dec. 7 th, Join, switch, or drop 2011 Plan effective Jan. 1, 2012 Dual eligibles have continuous enrollment options throughout the year Special Enrollment Period Special circumstance that allows you to enroll outside the normal time frame

ANNUAL ENROLLMENT PERIOD EXTENDED Elections may be made through December 10 AEP extended to advocates such as SHIP, MIPPA grantees, ADRCs, and the Aging Network During enrollment use code AEP 2012

MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP) Begins Jan. 1 and end Feb. 14 each year May disenroll from Medicare Advantage Plan (MA Plan) or from MA-Prescription Drug Plan (MA-PD) May NOT enroll into another MA plan during MADP May return to Original Medicare May choose a Part D plan regardless if moving from a MA-only or a MA-PD New plan choice effective the first day of the following month

INITIAL ENROLLMENT PERIOD Seven-month period when a beneficiary is entitled to enroll into Medicare Part A, B, D and/or C Starts 3 months prior to eligibility month (3) Includes the month of eligibility (1) End 3 months after the eligibility month (3) Referred to as the 3 – 1 – 3 rule

SPECIAL ENROLLMENT PERIOD (SEP) FOR THOSE LOSING ‘CURRENT’ EGHP SEP begins when beneficiary’s primary status in an Employer Group Health Plan ends Eight month period beginning with the first month employment is no longer ‘Current’ Coverage in EGHP could be from a spouse Enroll in Medicare Part B at this time to avoid late enrollment penalty Avoid part D penalty by enrolling in a part D plan no later than 63 days after employment ends

MEDICARE GENERAL ENROLLMENT PERIOD Begins Jan. 1 and ends March 31 of every year May enroll into parts A and/or B Coverage effective date is July 1 of same year For those who must pay premiums for Medicare Part A This could include those who declined Part B and now wish to enroll Penalties for late enrollment usually apply

MEDICARE PREVENTIVE SERVICES Implemented January 1, 2011 Elimination You of Part B Deductible and Coinsurance pay nothing for most preventive services When a doctor or health care provider accepts assignment Example: Bone Mass Measurement In 2010 you pay 20% after Part B deductible In 2011 you pay no deductible or copay

PREVENTIVE SERVICE – COST The amount you pay varies and depends on whether you get your Medicare benefits through Original Medicare (fee-for-service); or Medicare Some Advantage Plan (HMO, PPO, etc) services are completely free

MEDICARE PREVENTIVE SERVICES…. . CONT. Physical Exams “Welcome A one-time exam available to new Medicare beneficiaries within first 12 months of Medicare Part B enrollment Annual to Medicare” physical exam “Wellness” Exam Available to beneficiaries who’ve been enrolled into Medicare Part B for more than 12 months

Medicare-covered Preventive Services Abdominal Aortic Aneurysm (AAA) Screening Bone Mass Measurements A one-time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your one-time "Welcome to Medicare" physical exam. Before January 1, 2011, you pay 20% of the Medicare-approved amount. Starting January 1, 2011, you pay nothing for the screening if the doctor accepts assignment. Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment Cardiovascular Screening Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the tests, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit. Flu Shots Helps prevent influenza or flu virus. Generally covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor or other health care provider accepts assignment for giving the shot. Note: Medicare Part B also covers administration of the H 1 N 1 flu shot. You pay nothing if your doctor accepts assignment for giving the shot. Glaucoma Test Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you also pay the hospital a copayment

Medicare-covered Preventive Services Hepatitis B Shots HIV Screening Breast Cancer Screening (Mammograms) This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. Starting January 1, 2011, you pay nothing for the shot if the doctor accepts assignment. Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. You pay nothing for the test, but you generally have to pay the doctor 20% of the Medicare approved amount for the doctor’s visit. Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35– 39. January 1, 2011, you pay nothing for the test if the doctor accepts assignment. Medicare Nutrition Medical Therapy Service Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. Before January 1, 2011, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Starting January 1, 2011, you pay nothing for the test if the doctor accepts assignment Pap Test & Pelvic Exams (includes clinical breast exams) Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. Starting January 1, 2011, you pay nothing for Pap test specimen collection, and pelvic and breast exams if the doctor accepts assignment.

Medicare-covered Preventive Services Pneumococcal Shot Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot. Prostate Cancer Screening Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50 (coverage for this test begins the day after your 50 th birthday). You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor's visit. You pay nothing for the PSA test. In a hospital outpatient setting, you also pay the hospital a copayment. Smoking Cessation Includes up to 8 face-to-face visits in a 12 -month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment. Note: Medicare coverage of smoking cessation counseling is now considered a covered preventive service if you haven’t been diagnosed with an illness caused or complicated by tobacco use. Starting January 1, 2011, you pay nothing for the counseling sessions. Diabetes Screening These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Test may also cover if you have two or more of the following ; Are you age 65 or older, or are you overweight, or have a family history of diabetes (parents, siblings), or have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds. Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.

Medicare-covered Preventive Services Colorectal cancer is usually found in people age 50 or older, and the risk of getting it increases with age. Medicare covers colorectal screening tests to help find pre-cancerous polyps (growths in the colon) so they can be removed before they turn into cancer. Treatment works best when colorectal cancer is found early. One or more of the following tests may be covered. Fecal Occult Blood Test — Once every 12 months if 50 or older. You pay nothing for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit. Colon Cancer Screening (Colorectal) Flexible Sigmoidoscopy — Generally, once every 48 months if 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment. Colonoscopy — Generally, you can get this procedure once every 120 months, or 48 months after a previous flexible sigmoidoscopy. If your doctor says you’re at high risk, you can get it every 24 months. There’s no minimum age required for you to get a colonoscopy. Starting January 1, 2011, you’ll pay nothing for the procedure if your doctor accepts assignments. Barium Enema — Once every 48 months if 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare approved amount for the doctor’s services. In a hospital outpatient setting, you also pay the hospital a copayment.

ACA MEDICARE PRESCRIPTION DRUG COVERAGE PREMIUM Higher income individuals pay a higher Part D premium same thresholds used to compute income-related adjustments to the Part B premium As reported on your IRS tax return from 2 years ago Must pay if you have Part D coverage DRAFT Medicare Current Topics Uses 06/22/2011 31

ACA INCOME-RELATED ADJUSTMENT TO PART D PREMIUM File Joint Tax Return In 2012 You Pay DRAFT Medicare Current Topics File Individual Tax Return 06/22/2011 If your Yearly Income in 2010 was $85, 000 or below $170, 000 or below Base Premium (BP) $85, 000. 01 – $107, 000 $170, 000. 01 – $214, 000 BP + $11. 60 $107, 000. 01 – $160, 000 $214, 000. 01 – $320, 000 BP + $29. 90 $160, 000. 01 – $214, 000 $320, 000. 01 – $428, 000 BP + $48. 10 $214, 000. 01 or higher $428, 000. 01 or higher BP + $66. 40 32

USE MEDICARE. GOV FOR RESOURCES Top 7 Services on Medicare. gov Find out what Medicare costs in 2012 Find health and drug plan, compare and enroll! Apply on-line for Medicare now Find out if Medicare covers your tests, items, services Get Extra Help with prescription drug costs Find out how Medicare works with your other insurance Get a new Medicare card Link to My. Medicare. gov

RESOURCE AND PUBLICATION SHIP Medicare & You 2012 handbook 1 -800 -633 -4227 www. medicare. gov www. mymedicare. gov TTY 1 -877 -486 -2048 Social Security Administration Medicare Supplement Premium Comparison Guide 800 -548 -9034 www. insurance. illinois. gov “Extra Help” application 800 -772 -1213 www. ssa. gov Dept on Aging - (Illinois Cares Rx) 800 -252 -8966 www. cbrx. il. gov