19
Day 2 (&3) Chapter 3-MA (Part C) Topics to Highlight Review difference in plans Review enrollment periods Review SEP Stress counselors always need to look at client’s card Stress need for awareness of group vs. non-group Handouts/Case Studies Medicare Coverage Options (Excerpt from Medicare & You Handbook) Medicare Coverage Types (Excerpt from Medicare & You Handbook) List of Medicare Advantage Plans Case Study – Ty Juan On (Confusion over Medicare/MA) Case Study – Travis Tee (Part B) Case Study – Tyme Leeness (Medicare vs. MA plan) Case Study – Jan Itor (On MA plan – moving from out of state) Medicare Advantage Quiz Medical Insurance Explained for the HMO System (joke) Case Study – Ms. Heart (Medicare vs. MA plan) Case Study – Ms. Fran Chise (Pt. B delay while covered) Case Study – Mr. Will B. Gone (Wants MA – travels out of state) Case Study – Mr. Chad R. Boxx (MA – moved out of area) Case Study – Sal Lowe (Foreign Travel) Optional Handout – MRC’s Questions to Ask Before Joining a Medicare Private Health Plan Homework: Read Chapter Four – Medicare Part D

Day 2 (&3) Chapter 3-MA (Part C) - TypepadDay 2 (&3) Chapter 3-MA (Part C) Topics to Highlight Review difference in plans Review enrollment periods Review SEP Stress counselors always

  • Upload
    others

  • View
    3

  • Download
    0

Embed Size (px)

Citation preview

  • Day 2 (&3) Chapter 3-MA (Part C)

    Topics to Highlight

    □ Review difference in plans □ Review enrollment periods □ Review SEP □ Stress counselors always need to look at client’s card □ Stress need for awareness of group vs. non-group

    Handouts/Case Studies

    □ Medicare Coverage Options (Excerpt from Medicare & You Handbook)

    □ Medicare Coverage Types (Excerpt from Medicare & You Handbook)

    □ List of Medicare Advantage Plans

    □ Case Study – Ty Juan On (Confusion over Medicare/MA)

    □ Case Study – Travis Tee (Part B)

    □ Case Study – Tyme Leeness (Medicare vs. MA plan)

    □ Case Study – Jan Itor (On MA plan – moving from out of state)

    □ Medicare Advantage Quiz

    □ Medical Insurance Explained for the HMO System (joke) □ Case Study – Ms. Heart (Medicare vs. MA plan)

    □ Case Study – Ms. Fran Chise (Pt. B delay while covered)

    □ Case Study – Mr. Will B. Gone (Wants MA – travels out of state)

    □ Case Study – Mr. Chad R. Boxx (MA – moved out of area)

    □ Case Study – Sal Lowe (Foreign Travel)

    □ Optional Handout – MRC’s Questions to Ask Before Joining a Medicare Private Health Plan

    □ Homework: Read Chapter Four – Medicare Part D

  • 49Section 2—Your Medicare Choices

    Your Medicare Coverage Choices There are two main choices for how you get your Medicare coverage. Use these steps to help you decide.

    In addition to Original Medicare or a Medicare Advantage Plan, you may be able to join other types of Medicare health plans. See pages 70–71. You may be able to save money or have other choices if you have limited income and resources. See pages 86–92. You may also have other coverage, like employer or union, military, or Veterans’ benefits. See pages 82–83.

    Note: If you join a Medicare Advantage Plan, you don’t need a Medigap policy. If you already have a Medigap policy, you can’t use it to pay for out-of-pocket costs you have in the Medicare Advantage Plan. If you already have a Medicare Advantage Plan, you can’t be sold a Medigap policy. See pages 57–59.

    Decide if You Want Original Medicare or a Medicare Advantage Plan

    Original Medicare Includes Part A (Hospital Insurance)

    and/or Part B (Medical Insurance) Medicare provides this coverage directly. ■You have your choice of doctors, hospitals, ■and other providers that accept Medicare. Generally, you or your supplemental ■coverage pay deductibles and coinsurance. You usually pay a monthly ■ premium for Part B.

    See pages 51–56.

    Decide If You Want Prescription Drug Coverage (Part D)

    Decide If You Want Prescription Drug Coverage (Part D)

    Decide If You Want Supplemental Coverage

    Medicare Advantage Plan (like an HMO or PPO)

    Part C—Includes BOTH Part A (Hospital Insurance) and Part B (Medical Insurance)

    Private insurance companies approved by ■Medicare provide this coverage. In most plans, you need to use plan doctors, ■hospitals, and other providers, or you may pay more or all of the costs. You usually pay a monthly premium (in ■addition to your Part B premium) and a copayment or coinsurance for covered services. Costs, extra coverage, and rules vary by plan. ■

    See pages 60–69.

    If you want this coverage, you must join ■a Medicare Prescription Drug Plan. You usually pay a monthly premium. These plans are run by private companies ■approved by Medicare. See pages 72–83. ■

    If you want prescription drug coverage, and ■it’s offered by your plan, in most cases you must get it through your plan. In some types of plans that don’t offer ■drug coverage, you can join a Medicare Prescription Drug Plan.

    See pages 66–67.

    You may want to get coverage that fills ■gaps in Original Medicare coverage. You can choose to buy a Medigap (Medicare Supplement Insurance) policy from a private company. Costs vary by policy and company. ■Employers/unions may offer similar coverage. ■

    See pages 57–59.

    Step 2

    Step 3

    Step 2

  • 50 Section 2—Your Medicare Choices

    Things to Consider When Choosing or Changing Your Coverage

    Coverage Are the services you need covered?

    Your other coverage

    Do you have, or are you eligible for, other types of health or prescription drug coverage (like from a former or current employer or union)? If so, read the materials from your insurer or plan, or call them to find out how the coverage works with, or is affected by, Medicare. If you have coverage through a former or current employer or union or other source, talk to your benefits administrator, insurer, or plan before making any changes to your coverage. If you drop your coverage, you may not be able to get it back.

    Cost

    How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? What’s the yearly limit on what you pay out-of-pocket? Your costs vary and may be different if you don’t follow the coverage rules.

    Doctor and hospital choice

    Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need referrals?

    Prescription drugs

    Do you need to join a Medicare drug plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary? Are there any coverage rules that apply to your prescriptions?

    Quality of care

    Are you satisfied with your care? The quality of care and services given by plans and other health care providers can vary. Medicare has information to help you compare plans and providers. See page 119.

    Convenience

    Where are the doctors’ offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records or prescribe electronically? See page 120.

    Travel Will the plan cover you in another state or outside the U.S.?

  • 66

    How Do Medicare Advantage Plans Work? Health Maintenance Organization (HMO) Plan

    Preferred Provider Organization (PPO) Plan

    Can I get my health care from any doctor or hospital?

    No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.

    In most cases, yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

    Are prescription drugs covered?

    In most cases, yes. Ask the plan. If you want drug coverage, you must join an HMO Plan that offers prescription drug coverage.

    In most cases, yes. Ask the plan. If you want drug coverage, you must join a PPO Plan that offers it.

    Do I need to choose a primary care doctor?

    In most cases, yes. No.

    Do I have to get a referral to see a specialist?

    In most cases, yes. Certain services like yearly screening mammograms don’t require a referral.

    No.

    What else do I need to know about this type of plan?

    If your doctor leaves the plan, your plan will ■notify you. You can choose another doctor in the plan. If you get health care outside the plan’s network, ■you may have to pay the full cost. It’s important that you follow the plan’s rules, like ■getting prior approval for a certain service when needed.

    There are two types of PPOs: Regional PPOs and Local PPOs.

    Regional PPOs serve one of ■26 regions set by Medicare. Local PPOs serve the ■counties the PPO Plan chooses to include in its service area.

    Section 2—Your Medicare Choices Medicare Advantage Plans

    There may be several private companies that offer different types of Medicare Advantage Plans in your area. Each plan can vary. Read individual plan materials carefully to make sure you understand the plan’s rules. You may want to contact the plan to find out if the service you need is covered and how much it costs. Visit www.medicare.gov/find-a-plan, or call 1-800-MEDICARE (1-800-633-4227) to find plans in your area. TTY users should call 1-877-486-2048.

  • 67

    How Do Medicare Advantage Plans Work? (continued) Private Fee-for-Service (PFFS) Plan Special Needs Plan (SNP)

    In some cases, yes. You can go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and agrees to treat you. Not all providers will. If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members.

    You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis).

    Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan (Part D) to get coverage.

    Yes. All SNPs must provide Medicare prescription drug coverage (Part D).

    No. Generally, yes.

    No. In most cases, yes. Certain services like yearly screening mammograms don’t require a referral.

    PFFS Plans aren’t the same as Original Medicare ■or Medigap. The plan decides how much you pay for services. ■Some PFFS Plans contract with a network of ■providers who agree to always treat you even if you’ve never seen them before.If you join a PFFS Plan that has a network, you may ■pay more if you choose an out-of-network doctor, hospital, or other provider. Out-of-network doctors, hospitals, and other ■providers may decide not to treat you even if you’ve seen them before. For each service, make sure your doctors, hospitals, ■and other providers agree to treat you under the plan, and accept the plan’s payment terms. In an emergency, doctors, hospitals, and other ■providers must treat you.

    A plan must limit membership to the following ■groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, ESRD, or HIV/AIDS). Plans may further limit membership. Plans should coordinate the services and ■providers you need to help you stay healthy and follow your doctor’s orders. If you have Medicare and Medicaid, your plan ■should make sure that all plan doctors or other health care providers you use accept Medicaid.If you live in an institution, make sure plan ■providers serve people where you live.

    Section 2—Your Medicare Choices Medicare Advantage Plans

  • Day 2 – 2012 1

    Case Study —Ty Juan On Ty Juan On calls you at the SHINE office. He has just become eligible for Medicare and received his card. He wants to know if he would need a referral from a primary care physician to access medical services when using Part A or B. Also, he heard that he needs to buy additional insurance - something called a Medicare Advantage Medigap plan. How would you help him?

  • Day 2 – 2012 2

    Case Study —Travis Tee

    Mr. Tee calls you at the SHINE office. He is 66 and retiring soon but does not plan to take Part B as his company will keep him on full insurance coverage for one year. A friend suggested he call the SHINE office to get information about Medicare. What questions would you ask Mr. Tee? What information would you give him?

  • Day 2 – 2012 3

    Case Study— Mr. Tyme Leeness

    Mr. Leeness comes to the SHINE office to get information on Medicare and Medicare HMO plans. He will be retiring in 3 months and wants to know when he can join a plan. He tells you that he spends 5 months of the year in Florida and the other 7 months in Massachusetts. How would you assist him?

  • Day 2 – 2012 4

    Case Study - Jan Itor

    Ms. Jan Itor calls you at the SHINE office. Her parents are moving to Massachusetts from Florida. They are enrolled in a Medicare Advantage plan in Florida. She wants to start the process of getting them insurance coverage in Massachusetts, but she knows nothing about Medicare or where to begin. How would you help her?

  • Day 2 – 2012 5

    Medicare Advantage Quiz 1. Amanda is a 67 year old beneficiary enrolled in a Medicare Advantage plan. As a member of this plan Amanda has all the rights and protections guaranteed under Medicare.

    ___ True ____ False

    2. When can a Medicare beneficiary join a Medicare Advantage plan? 3. Gordon has ESRD (End Stage Renal Disease) and belongs to an HMO through his employer. Gordon will be 65 next month and will retire from his employment. Gordon has been on Medicare for the past 7 months and wants to purchase a Medicare Advantage plan once he retires. Check all that apply. ____Gordon can purchase a Medicare Advantage plan if the employer HMO

    offers a Medicare Advantage plan. ____Gordon cannot purchase a Medicare Advantage plan under any

    circumstances because he has ESRD. ____Gordon can purchase any Medicare Advantage plan and all plans have to

    accept him 4. Ms. King joined a Medicare Advantage plan 6 months ago when she first became eligible for Medicare. She wants to change to a new PCP (primary care physician) but learned he is not affiliated with her MA plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Annual Election Period to make a change. How would you assist her? 5. List the eligibility criteria to enroll in a Medicare Advantage plan.

  • Day 2 – 2012 6

    Medical Insurance Explained for the HMO Systems Q. What does HMO stand for? A. This is actually a variation of the phrase, “HEY MOE” Its roots go back to a concept by Moe of the Three Stooges, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes. Q. I just joined a HMO. How difficult will it be to choose the doctor I want? A. Just slightly more difficult than choosing your parents. Your insurer will provide you with a book listing all the doctors in the plan. These doctors basically fall into two categories - those who are no longer accepting new patients and those who will see you, but are no longer participating in the plan. But don’t worry; the remaining doctor who is still in the plan, and accepting new patients, has an office just a half-day’s drive away. Q. Do all diagnostic procedures require pre-certification? A. No — only those you need. Q. Can I get coverage for my pre-existing conditions? A. Certainly, as long as they don’t require any treatment. Q. What happens if I want to try alternative forms of medicine? A. You’ll need to find alternative forms of payment. Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the Generic Medication, but it gave me a stomach ache. What should I do? A. Poke yourself in the eye. Q. What if I’m away from home and I get sick? A. You really shouldn’t do that.

  • Day 2 – 2012 7

    Case Study - Ms. Heart Ms. Heart meets with you at the SHINE office. She has just retired from her job. She has Medicare A+B and wants to know what her options are for additional insurance over and above Medicare. She asks you to explain the differences between Medicare and a Medicare Advantage plan, and wants to know which is better. What would you tell her?

  • Day 2 – 2012 8

    Case Study - Ms. Fran Chise Ms. Fran Chise meets with you at the SHINE office. She is 66 and has been retired for the past year. She did not sign up for Medicare Part B as her husband continued to work and she has been covered under his employer insurance plan. Her husband is retiring next month but the company will continue to provide full insurance coverage to both of them for six months after he stops working. Ms. Chise called Social Security to see when she must pick up Part B. Social Security told her she must pick up Part B immediately in order to avoid a penalty. Since she is covered in full for six months, she wanted to delay the Part B. What information would you give her?

  • Day 2 – 2012 9

    Case Study — Mr. Will B. Gone Mr. Gone meets with you at the SHINE office to clarify questions about Medicare and other insurance. He will be turning 65 in a few months. He has a friend who belongs to a Medicare Advantage plan and is very pleased with the services he receives. Mr. Gone takes no medication and wants to enroll in the cheaper, non prescription plan. He doesn’t see why he should sign up for the prescription plan if he doesn’t take medication. Mr. Gone has already checked that his doctor participates, so he’s pretty well set on the plan. In discussing his upcoming retirement, Mr. Gone tells you of his plans to spend more time with family in Florida. What information would you give to Mr. Gone?

  • Day 2 – 2012 10

    Case Study — Mr. Chad R. Boxx Mr. Boxx comes to see you at the SHINE office. He recently moved from another part of the state to live closer to his daughter. The Medicare Advantage plan he had is not available in his new location. He wants to know what his options are. How would you help him?

  • Day 2 – 2012 11

    Case Study — - Mr. Sal Lowe Sal calls you to find out why a bill is not being paid by Medicare. He tells you that he became violently ill while traveling on a cruise ship to Greece and was treated by the ship’s doctor. He is surprised that the bill is not being paid since had a similar circumstance a few years earlier while on a cruise to Alaska. He explains that on the Alaska trip he had dinner on shore and became ill soon after returning to the ship. He was seen and treated by the ship’s doctor and the bill was paid. He doesn’t understand why Medicare is not covering this time. How would you help him?

    Day 2 What to Highlight and Handouts List.docBlank.doc1 Medicare Coverage Options Excerpt from Medicare and You.pdfMedicare Advantage Types Excerpt from Medicare and you.pdf4 Meicare Rights Center - Questions to Ask Before Joining a MA plan.pdf3 - Day 2 Case Studies and Quizes.doc