Medicare Module 1
What are eligibility requirements for Part A & B? (3)
1. Age 65 2. If under 65, must be disabled (getting SS or Railroad Retirement Board (RRB) benefits for 24 months and people with Amyotrophic Lateral Sclerosis (ALS), often referred to as Gehrig's Disease or have end-stage renal disease (ESRD) 3. Be a US citizen (if an alien, must be a lawful citizen for 5 continuous years
What is the penalty for people who are not eligible for Part A and who don't buy Part A when they are first eligible?
A late penalty up to 10% unless they enroll during a special enrollment period. (They will have to pay the higher premium twice the number of years they could have had Part A but didn't sign up)
Medicare Parts A entitlement and Part B enrollment
A person is entitled to Part A if he or she is eligible for premium-free Part A of if the person has enrolled in Part A and continues to pay premium (or have the premium paid on his/her behalf) For a person to remain enrolled in Part B, the person must continue to pay the Part B premium (or have the premium paid on his/her behalf)
Not covered by Medicare Part A and B
Acupuncture, Routine dental care/dentures, cosmetic surgery, custodial care, health care while traveling outside the US-exceptions apply, hearing aids, orthopedic shoes (limited exceptions), hearing aids, outpatient prescription drugs (covered under Part D), routine foot care, routine eye care and eyeglasses, some screening tests and labs, Vaccines (those not covered under B are covered under Part D), Syringes and insulin unless used with an insulin pump
Other Part B Items and services
Ambulance services Chiropractic services-for limited situations Clinical research studies-some costs of certain care in approved studies Diabetic supplies Eyeglasses after cataract surgery-limits Kidney dialysis Mental health care OT and PT limits apply Telegraph services, in rural areas Transplant physician services and drugs
What are some helpful method of payments you could use to assist with Part B premiums?
Can be deducted from SS checks, RRB checks, Office of Personnel Managaement (civil service annuity) checks Employers may pay monthly Part B premiums on behalf of retirees
Part B Benefits- preventive services and screening, continued
Colorectal cancer screening- five different tests, vary in frequency Depression Screening- every 12 months Diabetes screenings- up to two per year for those with risk factors Diabetes self-management training- for persons with diabetes Prostate cancer screening- every 12 mos. for men over age 50 Smoking and tobacco-use cessation counseling- for any illness related to tobacco use Shots for flu, pneumococcal infections, and Hepatitis B
What is Medicare?
Federal health insurance program- Administerd by the Center for Medicare &Medicaid Services (CMS) for aged or disabled people
Most people are entitled to Part A without paying a premium. What are the requirements?
For people age 65 or older to be entitled to premium-free Part A, the person or their spouse must have worked and paid Medicare taxes for at least 10 years OR all people eligible for Medicare due to a disability, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS) are eligible
Part A covers what?
Hospital benefits, which also includes coverage for skilled nursing facilities, rehab facilities, and hospice
Premiums for Part B
In 2020, the standard monthly premium is $144.60. Most people pay the standard monthly premium. However, some people pay more based on income.
Medicare Part A- Original Medicare Cost Sharing for Inpatient Hospital Care
In 2020: $1,408 deductible for each benefit period Day 1-60: $0 coinsurance for each benefit period Day 61-90: $352 coinsurance per day of each benefit period Day 91 and beyond: $704 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over a beneficiary's lifetime) Beyond lifetime reserve days: all costs
Medicare Part B- Original Medicare Cost Sharing
In 2020: A deductible each year ($198 in 2020). The deductible does not apply to certain Part B covered preventive services After the deductible , is satisfied, beneficiaries typically pay 20% of the Medicare-approved cost for Part B covered services
Medicare Part A- Original Medicare Cost Sharing for skilled nursing and rehab care
In 2020: Days 1-20: $0 for each benefit period Days 21-100: $176 coinsurance per day of each benefit period Days 101 and beyond: all costs
Benefits of Plan A
Inpatient hospital care (acute care hospitals, critical access hospitals, inpatient rehab, long-term care hospitals) Skilled nursing and rehab care, only after a three-day hospital stay (Medicare Advantage plans may waive the 3-day requirement) Blood, hospice care, home health care, inpatient psychiatric care (up to 190 lifetime days) Does not cover custodial or long-term care
Original Medicare and Part D Prescription drug coverage
May be received as a stand-alone drug plan Unless you are dually eligible for Medicare and Medicaid, Medicare beneficiaries must actively select a Part D plan Annual Election Period for Part D is October 15 to December Cost- beneficiaries who enroll in Part D typically pay a monthly premium, annual deductible, and per-prescription cost-sharing
Help for people with limited income/resources-apply to State Medicaid Office
Medicaid: help with health care cost Medicare savings program: help paying for the Medicare Part A and B premiums and in some cases, deductibles and coinsurance. The Qualified Medicare Beneficiary program is one type of Medicare Savings Program. Part D- income subsidy (also known as "Extra Help": help to pay for drug coverage. The State Medicare office will check eligibility for this and other programs such as the Medicare Saving Program. People interested can only call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov.prescriptionhelp. People not eligible for Part D low-income subsidy but are of limited means may qualify for help in paying cost through a State's Pharmaceutical Assistance Program
Medicare Part B Benefits
Medically necessary physician and other health care professional services Outpatient hospital Clinical lab and diagnostic tests, therapies, mental health care Medical equipment Medications and supplies provided incident to a physician's service
Part C covers what?
Medicare Advantage plans, which must cover part A & B benfits
Part E covers what? (lesser known)
Medicare cost plans (only offered in a limited number of states) Medicare supplemental insurance (Medigap Plans)
Medicare Part A Premiums
Most people get this coverage without paying a premium (said person or their spouse paid Medicare taxes while working for at least 10 years, aka 40 quarters) For people who don't qualify, as of 2020: -$458, for individuals or their spouses who paid Medicare taxes for less than 30 quarters -$252 for people or their spouse who paid Medicare taxes for 30-39 quarters
Part B Benefits- preventive services and screening
One-time "welcome to Medicare" physical Annual wellness visit after 12 months enrolled in Part B and annually thereafter Immunizations- pneumococcal, hepatitis B, annual flu shot (shingles shots are covered under Part D, not Part B) Bone mass measurements- every 24 months for certain conditions or meets certain criteria
What are the different ways beneficiaries can choose to receive their Medicare coverage?
Original Medicare (Part A & B), can also be combined with a Medicare Supplement Plan and/or a Medicare Prescription Drug Plan Medicare Advantage Plans (Medicare Part C, without Part D) Medicare Prescription Drug Plans (Medicare Part D) Medicare Cost Plans
Other ways to get Medicare- Eligibility Overview (Part C, D, Cost Plans)
Part C: people must be entitled to Part A and enrolled in Part B and reside in MA plan's service area Part D: be entitled to Part A and/or enrolled in Part B and reside in the Part D plan's service area Cost Plans: people must be entitled to Part A and/or enrolled in Part B (if they are not entitled to Part A, they will not have coverage of Part A benefits under the cost plan); and reside in the Part D plan's service area
Some people are automatically enrolled in Parts A & B, who are these people?
People who are already getting benefits from SS or Railroad Retirement Board (RRB) (automatically enrolled starting the first day of the month they turn 65, if their birthday is on the first day of the month, it starts the first day of the month before). CAN REFUSE PART B People with disabilities who are under age 65 are enrolled the month after they have received SS or RRB disability benefits for 24 months. CAN REFUSE PART B People with ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig's disease) get Part A & B automatically the month their SS disability begin
For those who don't meet the automatic enrollment requirements, they have to sign up. What does this person look like?
People who are close to 65 but are not getting benefits from SS RRB (people who are typically not eligible for premium-free Part A) may sign up for Parts A & B during their initial enrollment period, which begins 3 months before their 65th birthday, includes the month they turn 65 and ends 3 months after People with end-stage renal disease (ESRD) may sign up for Medicare at any time. However, the date on which their Medicare coverage begins is usually on the forth month after dialysis treatments begin but may be earlier if certain conditions are met
Enrollment in Parts A & B after initial enrollment period
People who do not enroll in Part B (or Part A if they have to buy it) when they are first eligible, can enroll during a General Enrollment Period each year from Jan 1-Mar 31 (coverage begins on July 1 of the year they enroll) People who have group health plan coverage based on their current employment or employment of a spouse may enroll in Part A (if they have to buy it) and/or Part B anytime while covered under the group health plan or during a Special Enrollment Period that occurs during the 8-month period immediately following the last month of the group coverage
What is the exception regarding Plan B premium late enrollment penalty?
People who have group health plan coverage based on current employment or the employment of a spouse anytime while covered under the group health plan or during the special enrollment period that occurs during the 8-month period immediately following the last month of the group coverage
Part D covers what?
Prescription drug coverage
People with low incomes can use what to assist them with premiums?
Qualified Medicare Beneficiary (QMB) program, which pays for their Medicare Part A and B premiums and other Medicare costs
Part B covers what?
Supplementary Medical Insurance Benefits, which includes a broad range of outpatient services such as physician care
Help for people with limited income/resources. (Where to lead them)
Tell them to call or visit their Medicare office, and ask for information on Medicare Savings Programs. Visit Medicare.gov/contacts or call 1-800-633-4227 or contact the State Health Insurance Assistance Program (SHIP)
What is the penalty for people who don't enroll in Part B when first eligible?
The premium will be increased by 10% for each full 12-month period the beneficiary could have had Part B but did not enroll, known as the "late enrollment penalty"
True or false People who meet the age or disability criteria are eligible for Medicare regardless of income
True
