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Medicare & the Medicare Modernization Act of 2003
Norma Lanier, State Outreach Coordinator
First Coast Service Options, Inc.
July 12, 2005
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Today’s Discussion
• Review of Medicare basics
• Medicare changes in 2005 and 2006
• Preventive benefits covered by Part B
• Prescription Drug Benefit
• Medicare rights and protections
• Alzheimer’s and Medicare
• Program Evaluation
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First, the Basic Facts
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Medicare
• A health insurance program for– People 65 years of age and older– Some people with disabilities– People with ESRD
• Administered by CMS nationally
• Administered by private contractors locally
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Original Medicare
Medicare has two parts
Part AHospital Insurance
Part BMedical Insurance
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The Original Medicare Plan
• You may go to any provider that accepts Medicare
• Part A is premium free for most people
• You pay Medicare Part B premium
• You pay deductibles
• You pay coinsurance
Original Medicare
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Medicare Part A Benefits
• Hospital stays
• Skilled nursing facility (SNF) care
• Home health care
• Hospice care
• Blood
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A Benefit Period
• Medicare’s measure of hospital and SNF services
• Begins day admitted to hospital
• Ends when you have not received care in a hospital or SNF for 60 days in a row
• You pay deductible for each benefit period
• No limit to the number of benefit periods
Part A
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Paying for Hospital Stays
• For each benefit period in 2005 you pay– $912 deductible for a hospital stay of 1-60 days– $228 per day for days 61-90– $456 per day for days 91-150
• Part of your 60 Lifetime Reserve Days
– All costs for each day beyond 150 days
Part A
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Skilled Nursing Facility Care
• Covered in full for the first 20 days– After a minimum 3-day qualifying hospital stay
• You pay $114 per day for days 21-100
• You pay all costs after 100 days
• Does NOT include custodial care
Part A
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Skilled Nursing Facility Care
• Must meet all of the following conditions– Requires daily skilled services– Inpatient in a hospital at least 3 consecutive days – Admitted to SNF within 30 days after leaving
hospital– Care in SNF is for a condition treated in the
hospital– MUST be a Medicare participating SNF
Part A
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Skilled Nursing Facility Coverage
• Semi-private room• Meals• Skilled nursing care• Physical, occupational and speech-language
therapy• Medical social services• Medications, medical supplies/equipment• Ambulance transportation• Dietary counseling
Part A
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Home Health Care
• Covered services– Part-time skilled nursing care– Therapy
• Occupational
• Physical
• Speech-language
– Some home health aide services– Durable medical equipment
Part A
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Paying for Home Health Care
• You pay– Nothing for covered home health care services– 20% of the Medicare-approved amount for
covered durable medical equipment
Part A
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Hospice
• Special care – People who are terminally ill
– Families
• If a person has less than 6 months to live• Certification required for each “period of care”
– Two 90-day periods
– Unlimited 60-day periods
• Hospice must be Medicare-approved
Part A
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Covered Hospice Services
• Medical equipment and supplies• Drugs for symptom control and pain relief• Respite care in a Medicare-certified facility
– Up to 5 days each time– No limit to number of times
• Home health aide and homemaker services• Social worker services• Dietary counseling• Grief counseling
Part A
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Part B Benefits
• Doctors’ services• Outpatient medical and surgical services and
supplies• Diagnostic tests• Outpatient therapy• Outpatient mental health services• Some preventive health care services• Other medical services
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Enrolling in Medicare Part B
• Initial Enrollment Period– 7 months beginning 3 months before age 65
• General Enrollment Period– January 1 through March 31 each year– Coverage effective July 1– Premium increases 10% for each year you were
eligible but did not enroll• You carry this increase for the rest of your life
Original Medicare
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Enrolling in Medicare Part B
• Special Enrollment Period– Sign up within 8 months of the end of employer
or union group health plan coverage– No increased premium
• For questions, or to enroll, call the Social Security Administration or Railroad Retirement Benefit
Original Medicare
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Covered Preventive Services
• Bone mass measurement• Colorectal cancer screening• Diabetes services and some supplies• Glaucoma testing• Screening mammogram• Pap test/pelvic exam/clinical breast exam• Prostate cancer screening• Vaccination (shots)
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Medigap
• Fills in gaps in the Original Medicare plan
• Must follow federal and state laws
• Standardized Plans A-J in most states– Except Minnesota, Massachusetts, Wisconsin
• Don’t need Medigap if in Medicare Advantage
• See Guide to Health Insurance for People with Medicare
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Let’s talk about more changes in Medicare…
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What We Heard
• People with Medicare want– More choices– Better benefits– Health care delivery options – Improved access to care
• Especially in rural areas
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Medicare Modernization Act of 2003 (MMA)
2004• Drug
discount card
• Medicare Advantage
2006• Prescription
drug plans
• Two new Medigap policies
2005• New
preventive services
• Part B deductible $110-based on expenditures in future
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New Covered Preventive ServicesBeginning January 2005
• “Welcome to Medicare” physical– Initial physical exam – Referral for screening and other preventive services
• Cardiovascular screening blood tests– Screening blood tests for cholesterol and other lipids or
triglyceride levels
• Diabetes screening tests– Fasting plasma glucose test– Other tests appropriate for persons at high risk
MMA
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Medicare Prescription Drug Plans
• Available January 2006
• Offered through private prescription drug plans (PDPs)
• Can be offered by Medicare Advantage plans
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Eligibility and Enrollment
• Must be entitled to Part A and/or enrolled in Part B
• Enrollment is voluntary• Increased premiums for people who wait
– 1 percent of the base premium for each month you don’t enroll
• After May 15, 2006
– Exception for those covered under other comparable insurance
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Why Join a Plan?• Medical practice relies on new drug therapies to
treat chronic conditions• Out-of-pocket spending on drugs has increased • Most people need or will need prescription drugs to
stay healthy• Medicare insurance coverage for prescription drugs
will protect from high out-of-pocket costs• For most people, joining when first eligible means
paying the lowest monthly premiums
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Enrolling in a Plan
People with Medicare can:
• Enroll directly with the plan
• Have a personal representative enroll them
• Ask others to help them enroll
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When to Enroll
• Join between November 15, 2005, and December 31, 2006– Coverage will begin on January 1, 2006
• Join between January 1, 2006, and May 15, 2006– Coverage will begin the first day of the month
after the month joined
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Medicare Prescription Drug Coverage
• Coverage begins January 1, 2006
• Available for all people with Medicare
• Provided through: – Private prescription drug plans– Medicare health plans– Some employers and unions for retirees
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What it Costs…How it Works• Pay a premium of about $37 each month
– In addition to Part B premium
– Enhanced benefit may cost more
• Pay a yearly deductible up to $250
• Pay part of the cost of covered prescription drugs
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How it Works in 2006
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Lower-Income Assistance
• People with limited resources:– Get extra help with their Medicare drug plan cost
• Lowest incomes:– Pay no premiums or deductibles
– Pay small or no copayments
• People with slightly higher incomes:– Pay reduced deductible
– Pay a little bit more out of pocket.
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To Get Help Paying the Cost of Prescription Drug Plans
• Person with Medicare must:– Reside in the United States– Meet the income and resource requirements
of the subsidy program– Be enrolled in Medicare
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To Get This Help
• Person does not have to do anything– If currently receiving benefits from both Medicaid
and Medicare or
– Receiving Supplemental Security Income benefits and Medicare
• Information will come in the mail from Medicare– Explaining eligibility for this coverage, and– What he/she should do this fall to enroll in a
Medicare plan that offers prescription drug coverage
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To Get This Help• Person with Medicare must have
– Annual income less than $14,355 (single)– Annual income less than $19,245 (married)
AND– Limited resources
• Application will come from Social Security Administration (SSA)
• Mail completed application to SSA
• For additional information, contact the SSA at 1-800-772-1213
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Medicare Advantage Plans
Another Way to Get Your Medicare Benefits
MMA
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Medicare Advantage Plans
• New name for Medicare+Choice plans
• Medicare managed care plans
• Preferred Provider Organization plans (PPOs)
• Private-Fee-for-Service plans– Available in some states
• Medicare Specialty Plans
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If you join a Medicare Advantage Plan…
• You still have rights and protections
• You are still in the Medicare program
• You still get all your regular Medicare-covered services
• You may be able to get extra benefits– Coverage for extra days in the hospital
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Medicare Patients’ Rights
• Right to– Information about all treatment choices– Participate in treatment decisions– Get easy-to-understand information – Know what costs are paid by Medicare – Know how much you have to pay
Overview
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Other Medicare Rights
• Right to– Receive emergency room services– Have your personal and health information kept
private – Right to non-discrimination: You cannot be
treated unfairly because of race, color, national origin. disability, age, sex, religion
Overview
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Other Medicare Rights
• Right to– Know what to do if you have to file an appeal
or a grievance (complaint)– An appeal is when
• Medicare does not pay
• Medicare does not pay enough
• You are not given a service
– A grievance is about quality of care issues
Overview
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Medicare and Alzheimer’sMedicare beneficiaries diagnosed with Alzheimer’s disease have the same rights and coverage than any other person with Medicare.
• Part A covers inpatient mental health services, including room, meals, nursing care and other related services
• Part B covers outpatient mental health services, including visits with health professionals such as doctors, clinical psychologists, clinical social workers, and clinical nurse specialists
• Part B also covers laboratory services and partial hospitalization
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For More InformationNational Sources
• Visit www.medicare.gov
• Call 1-800-MEDICARE (1-800-633-4227)– TTY 1-877-486-2048
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Please complete the Program Evaluation
Form
Thank You!
EvaluationForm