Navigating Your Benefits and Healthcare System

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What we will cover today:

• Medicare Overview• Enrolling in Medicare• Managing Your Medicare• Resources to Help pay Medicare Premiums

and Co-insurance• Resources to Help with Medication Costs• Long Term Care and Tools to Help You Plan for

Long Term Care

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www.agewiseconnection.com

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Qualifying for MedicareUS citizens or resident VISA holders who have lived in the US for five consecutive years and

• 65 years or older; eligible for Social Security or Railroad Retirement Benefits

• 65 or older; married to someone eligible for Social Security/Railroad retirement

• Have received Social Security Disability income for at least 24 months

• Have ESRD (kidney failure) or ALS (Amyotrophic Lateral Sclerosis)

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Applying for Medicare Initial Enrollment Period

Apply 3 months before age 65, the month of 65th birthday, or 3 months after month of 65th birthday*Need not be retired

Automatically enrolled if receiving Social Security or Railroad Retirement Benefits

Received Social Security Disability Benefits (SSDI) for 24 Months

Apply through the Social Security Administration (SSA)or Railroad Retirement Board (RRB)

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Medicare Basics

Medicare

Part AHospital

Part BMedical

Part DPrescription

Part C Medicare Advantage

Medicare Health Plans (PPO, HMO, PFFS,

SNP)

Known as Original Medicare

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The Original Medicare Plan

• Part A and/or Part B

• Go to any provider that accepts Medicare

• Pay Medicare Part B premium

• Pay deductibles

• Pay co-insurance

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Medicare Part AOverview

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Medicare Part A – Eligibility and Premiums

• Awarded at age 65 or if a person has received disability payments for 24 months

• $0 premium for those who have 40 quarters of Medicare-covered Employment (or from a spouse)

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Medicare Part A – Hospital Insurance – Helps Pay for

• Hospital stays

• Skilled nursing facility (SNF) care

• Home health care

• Hospice care

• Blood

Deductibles, Co-Payments For Part A (Hospitalization)

• $1,068 deductible Per Benefit Period

• $267 Per day for days 61-90

• $534 Per day for 91-150(Lifetime Reserve Days)

• All costs for each day beyond 150 days

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Medicare Part BOverview

Part B - MedicalOut-patient/Physician Insurance Helps Pay

for:• Doctor Services• Outpatient therapy • Outpatient mental health services• Some preventive health care services• Clinical laboratory services• Durable medical equipment (DME)• Outpatient hospital services • Blood • Ambulance service

– If other transportation would endanger health

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Enrolling in Medicare Part B

Initial Enrollment Period

• 7 months beginning 3 months before age 65

• Enrollment after 24 months of Social Security disability

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Paying for Medicare Part B – Outpatient Services

• $96.40 monthly premium

• $135 per year deductible in 2009

• 20% co-insurance for most services

Medicare Prescription Drug Coverage

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Medicare Part D: Prescription Drug

Coverage

• Medicare drug coverage• Must enroll in Part D within 90 days of Medicare

eligibility – else a penalty will apply– Penalty – 1% of the national average premium times as many

months you could have been enrolled– Penalty waived if you have “creditable” coverage by another

insurance – Part D enrollment needs to be within 63 days of loss of creditable coverage

• People to receive Part D benefits through stand alone PDP plan or Medicare Advantage Plan (MAPD)

Part D Eligibility Requirements

• Medicare Part A and/or Part B– Part A and Part B to join Medicare Advantage

plan with drug coverage

• Live in plan’s service area• Enroll in a plan

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Enrolling in Part D

Enrollment Periods for PDP • Initial Enrollment Period (7 mos. surrounding

Medicare effective date) • Annual Coordinated Election Period (AEP Nov. 15th-

Dec. 31st)-Can choose PDP or MA-PD• Special Enrollment Period (SEP)

Open enrollment period for MA-PD (OEP Jan. 1st-Mar. 31st)

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What is the Medicare prescription “donut hole” or “gap?”

• Getting into the gap:– You pay copays or coinsurance for each

prescription filled; the plan pays the remainder until drug costs (retail) reach $2,700

• The gap:– You pay 100% of drug costs until out of

pocket for the calendar year equal $4,350

• After the Gap (Catastrophic Coverage)– Small coinsurance charged for each drug until

end of year

*Note: excluded drugs do not help contribute towards out of pocket costs to be out of the gap

Choosing a Part D Plan• For assistance choosing a

Part D plan visit www.medicare.gov

• The following information is needed to compare plans:

-Name-Date of birth-Medicare card-Zip code-County-List of medications

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www.medicare.govPrescription Drug Plan Finder

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Part C -Medicare AdvantagePrivate Health Plans

Medicare

Medicare Advantage Plan

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Pays plan to provide Part A and B coverage

Pays company $$ per person enrolled

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Medicare Advantage (Part C)• Replaces the manner in which benefits for Original

Medicare are provided

• Offered through private companies

• May offer extra benefits including Part D coverage

• Most require additional premium in additional to annual Medicare premium

• Coinsurance/Co-pays

• May offer some vision or basic dental benefits

• For enrollment, MUST:– Have Medicare Part A and Part B

– Live in plan’s geographical service area

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What are Medicare Advantage Plan Options?

• Medicare Managed Care Plans (HMOs) – Health Maintenance Organizations

• Medicare Preferred Provider Organization (PPOs) – Preferred Provider Organizations

• Private Fee-for-Service Plans (PFFSs)

• Special Needs Plans (SNPs)

Why choose an Advantage Plan?• Generally includes Physical

Exam annually

• May include some Dental, Vision or Hearing Coverage

• Often, fixed copay for doctor services

• Sometimes, lower hospitalization costs

• Often, a lower monthly premium than Medigap

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What’s the Advantage?

• Can result in cost savings for medical care for some people

• Can offer additional services not covered by Original Medicare

• Any Medicare beneficiary can enroll and receive benefits – no pre-existing condition exclusion or waiting period for coverage

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Is Medicare Advantage right for you?• A Medicare Advantage Plan is NOT a replacement for

your Medigap policy.• Before you enroll in a Medicare Advantage Plan, answer

the following questions:– 1. Are my doctors and hospitals covered by the plan? That

is, do they accept the plan’s terms and conditions?– 2. Do I need a referral to see a specialist?– 3. Can I get care outside the plan's service area or

network? If so, how?– 4. What costs are involved in the plan (premium,

deductible, copayments)?– 5. Are my prescriptions covered by the plan?– 6. What are copayment requirements for lab tests,

diagnostic tests, x-rays, MRI scans, or CT scans?

Medicare Advantage Enrollment:General Periods

• When first eligible for Medicare

• Open Enrollment PeriodJanuary – March

• If plan has Part D coverage, additional period:November 15th - December 31st

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What card do I use?

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Medicare Advantage Enrollment

• You can use the Medicare Plan Comparison tool on Medicare.gov to find and compare plans

• You can enroll online

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Medicare Advantage Enrollment

To enroll, call: Medicare Private Insurance Company

Or, online: www.medicare.gov

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Financial Assistance for Medicare Health Costs

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Medicaid – Medicare Savings Programs (QMB, SLMB, and QI)

• Pays Medicare premiums and possibly additional coinsurances

• Savings Program eligibility varies state to state:• Georgia 2009 Eligibility

Coverage Single income limit

Single asset limit

Married Income limit

Married asset limit

QMB Part B premiums + coinsurances

$903 $4,000 $1,214 $6,000

SLMB Part B premiums $1,083 $4,000 $1,457 $6,000

QI1 Part B premiums $1,218 $4,000 $1,639 $6,000

Burial Allowance: $10,000 per person:

Georgia Compasshttps://compass.ga.gov/selfservice/

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Extra Help for Prescriptions/ Low Income Subsidy

• Who is eligible?Income < $0-1,354 Single

< $0-1,821 Married Assets (Resources)

$12,510 Single $25,010 Married

• What are the benefits?– No/low premiums for those with

limited incomes– No/low deductible– Small copayment or coinsurance for

each prescription

To Apply for the Extra Help Visitwww.ssa.gov

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Resources for Bridging the Coverage Gap

http://www.medicare.gov/bridging-the-gap.asp

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Resources for Bridging the Coverage Gap

• Needy Medswww.needymeds.org

• Partnership For Prescription Assistancewww.pparx.org

• RxAssistwww.rxassist.org

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Benefits CheckUpwww.benefitscheckup.org

Find Benefits Programs For:• Prescription drugs • Nutrition (SNAP/Food Stamps) • Energy assistance • Financial • Legal • Health care • Social Security • Housing • In-home services • Tax relief • Transportation • Educational assistance • Employment • Volunteer services

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What is Medigap ?• Sold by private insurance

companies

• Fills in the “GAPS” for Medicare

• 12 standardized plans (A through L)

• Must have Part A & B

• Medigap SELECT policies may require use of certain physicians and hospitals

Medicare Primary

Medigap/

Supplement Insurance

Secondary

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Enrolling in a MedigapOpen Enrollment Period

• 6 months following enrollment in Medicare Part B

• Cannot be turned down for any reason

• Cannot charge more because of health problem

• Cannot make beneficiary wait for all coverage to start– May wait for coverage of pre-existing

conditions – unless creditable coverage

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How Medigap Works

• Only works with Original Medicare– Won’t work with

• Medicare Advantage Plans • Other Medicare plans

• Can go to any doctor, hospital, or provider that accepts Medicare– Unless have Medigap SELECT policy

Medigap Is Not

• Medicare Advantage Plans• Medicare Part B• Medicare Prescription Drug

Plans• Medicaid• Employer or union plan• TRICARE• Veterans’ benefits

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Who Can Buy Medigap?• Must have Medicare Parts A

and B• May not be able to buy

Medigap under 65 – People with a disability– People with End-Stage Renal

Disease• Guaranteed right to buy a

Medigap policy– In your Medigap open

enrollment period– Covered under a Medigap

protection

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Why Buy Medigap?

• Original Medicare does not pay all costs

• Medigap policy may help

– Lower out-of-pocket costs

– Get more health insurance coverage

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Medigap Toolwww.medicare.gov

Provides:• Information on

different types of Medigap policies by area

• Contact information on the companies that offer them

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Once you are enrolled in Medicare, you can use www.mymedicare.gov to:

• View claim status (excluding Part D claims) • Order a duplicate Medicare Summary Notice (MSN) or replacement

Medicare card • View eligibility, entitlement and preventive services information • View enrollment information including prescription drug plans • View or modify your drug list and pharmacy information • View address of record with Medicare and Part B deductible status • Access online forms, publications and messages sent to you by CMS

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www.mymedicare.gov

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Mymedicare.gov Virtual Tourhttp://www.mymedicare.gov/WBTMain.asp

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www.medicareinteractive.org

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For More Information….

• Medicare 1-800-633-4227www.medicare.gov

• Social Security Administration 1-800-772-1213

www.ssa.gov

• Georgia Cares1-800-669-8387

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What is Long-Term Care?

How is it paid for?

Long-Term Care

About 2/3 of those over age 65 will need some LTC, for an average of 3 years

Nearly 1 in 4 people provide long-term care to friends and relatives

Long-Term Care

Activities of Daily Living (ADL’s)

Instrumental Activities of Daily Living (IADLs)

Bathing

Dressing

Eating

Using the Toilet

Transferring

Continence

Grocery Shopping

Laundry

Preparing Meals

Housework

Managing Medication

Transportation

Levels of Long Term Care

Skilled Care – medical or nursing care and therapies

Personal or Custodial Care – help with ADLs

Supervisory Care – monitoring, supervision and stand-by help with ADLs

Long Term Care Settings

Informal Care Formal Care

Unpaid Caregivers

Family & Friends

Caregiver Support

Home Care Services

Community-Based Services

Residential Care

Why Plan?

More control and choice

Better access to options

Preservation of assets and income

Fewer burdens on loved ones

www.medicare.gov/LTCPlanning

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www.agewiseconnection.com/retirement

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www.agewiseconnection.com/benefitsYou will find:• Resources to help you

navigate the Medicare system• Information on getting help

paying for prescriptions• Resources to help you plan for

Long Term Care• Resources to help you learn

more about health conditions• Tool to help navigate the

healthcare system – transition from one care setting to another

All in one place!61

Atlanta Regional CommissionArea Agency on Aging

www.agewiseconnection.com

404.463.3333

aginginfo@atlantaregional.com

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