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Medicare Madness:Navigating through open enrollment
Joani Shaver, DirectorBlount County Office on Aging
November, 2014
Health insurance for the following people:
◦Those 65 and older◦Those younger than 65 with certain disabilities
◦Those with End-Stage Renal Disease (permanent kidney failure)
What is Medicare?
•Most outpatient prescription drugs•Routine vision care•Long-term care•Routine dental care•Dentures•Hearing aids (exams and fittings)•Routine foot care
What's NOT covered by Original Medicare?
Medicare Part A (Hospital Insurance)◦ Inpatient care in hospitals◦ Skilled nursing facility, hospice, and home health
care
Medicare Part B (Medical Insurance)◦ Doctors’ services, hospital outpatient care and
home health care◦ Some preventive services
Different Parts of Medicare
Medicare Part D◦Prescription drug option run by Medicare-
approved private insurance companies◦Prescription drugs◦May help lower your prescription drug
costs and help protect against higher costs in the future
Different Parts of Medicare
Medicare Part C (Advantage Plan)◦Health plan managed by Medicare-
approved private insurance companies◦Includes all benefits and services
covered under Part A and Part B◦May include extra benefits and services
for an extra cost◦Usually includes Medicare prescription
drug coverage (Part D)
Different Parts of Medicare
TOTAL HEALTHCARE COVERAGE
ORIGINALMEDICARE
Premium remains $104.90 Part B deductible remains $147 Part A hospital inpatient
◦deductible raised to $1260 for each benefit period (was $1216)
◦Days 61-90: $315 per day coinsurance for each benefit period (was $304)
Changes to Medicare in 2015
Annual deductible rises from $310 to $320
Number of plan choices will drop – some are being eliminated
Average monthly premium will be $38.83
Doughnut hole is shrinking
Changes to Part D in 2015
First method
Original Medicare (Parts A & B) Prescription Drug Plan (Part D) Medicare Supplement or Medigap policy (identified by a letter)◦Supplements provide identical coverage,
but vary widely in price
How can I get my Medicare coverage?
Second Method
Medicare Advantage Plan (Part C)◦Includes Part A & B coverage
Prescription Drug Coverage (Part D)◦Some advantage plans include
prescription coverage
If you get retirement benefits from Social Security or the RRB, then you automatically get Parts A & B on 1st day of month you turn 65
If you get disability benefits from Social Security or certain disability from the RRB, then you automatically get Parts A & B on the 1st day of the 25th month after your benefits begin
Medicare Enrollment
If your disability is ALS (Lou Gehrig’s disease), then you automatically get Parts A & B on 1st day of month your disability benefits begin
If you’re still working and not getting Social Security, then you’ll need to talk with your HR department about your choices related to Medicare. You may want to delay enrollment, which you’ll do online through www.ssa.gov.
When you first turn 65, you have 3 months before and after your birthday month
Coverage begins based on your enrollment date
If you don’t sign up for Medicare when you’re first eligible, then you may pay penalty for Part B as long as you receive benefits
Initial Enrollment
Go from Original Medicare to Advantage Plan
Go from Advantage Plan to Original Medicare
Switch Medicare Advantage Plans Join Part D plan Switch Part D plans
What can I do during Open Enrollment from Oct 15 – Dec 7?
Medicare Supplement might make sense if you◦ Want flexibility in choosing your doctors◦ Visit doctors frequently◦ Travel extensively◦ Have a chronic medical condition◦ Don’t mind higher premiums to get lower out-of-
pocket costs (predictability)
11 different plans
What plan is right for me?
Medicare Advantage Plan might make sense if you◦ Are willing to change doctors, if necessary◦ Prefer all benefits from single plan & premium◦ Visit doctors infrequently & don’t mind paying per-
visit copayments and coinsurance◦ Don’t mind researching your options annually◦ Want lower premiums than supplements offer◦ Are informed about your choices and don’t mind
comparison shopping for plans◦ Want options beyond what Medicare provides
19 different plans
Remember all that?
Simple: buy thebest insurance thatyou can afford – after doing yourhomework!
Two ways to get Part D
◦ Purchase Medicare prescription drug policy
◦ Choose a Medicare Advantage Plan that offers prescription drug coverage
Even if you feel it’s not needed in your case, remember that you may pay a late enrollment penalty if you join a Part D plan later.
Medicare Part D
Monthly fee, varies by plan In addition to Part B cost of $104.90 Some Advantage Plans include Part D
coverage in the cost
Avoiding Part D Enrollment penalty◦ Join drug plan when first eligible◦ Don’t go 63 days or more without drug coverage
Penalty = 1% of full uncovered months (pg 105)
Part D Premium
Always be sure that your prescription drugs are in formulary of any plan you’re considering
Check what “tier” drugs are in – each tier has different cost
Do this every year during Open Enrollment!
Call the plan for info or check plan’s website
IMPORTANT!!
Begins when total drug costs reaches $2,960
Includes what you & plan have paid Plan no longer covers drugs for rest of year You pay discounted amounts
◦ 45% on brand name drugs◦ 65% on generic drugs
Once you’ve paid $4,700 out of pocket you pay 5% of cost for covered drugs or copay of $2.65/generic, $6.60 for brand name drugs
The Doughnut Hole
Drug plans may include preferred and non-preferred pharmacies in their network
You may pay less for drugs at preferred pharmacies
IMPORTANT!
Program to help people pay Medicare prescription drug costs
For single person, income less than $1,459 month and resources less than $13,440 per year
For married person living with spouse, income less than $1,966 month and resources less than $26,860 per year
EXTRA HELP
Apply through Social Security www.ssa.gov
Helps with monthly drug plan premium, annual deductible, coinsurance and copayments
Eliminates doughnut hole Switch plans at any time during year Same application used to get help from TN to pay your Medicare costs
EXTRA HELP
Benefit period: begins day you’re admitted to hospital or skilled nursing facility (SNF) and ends when you haven’t received any inpatient hospital care or SNF skilled care for 60 days in a row
Coinsurance: your share of cost for medical service or supply, expressed in percentage
Copayment: set amount you pay as your share of cost for medical service or supply
Glossary
Deductible: amount you pay for health care or prescriptions before Medicare or Advantage Plan or Drug Plan begins to pay
Extra Help: helps those with limited income pay health care costs
Formulary: list of drugs covered by prescription drug plan or other insurance plan
Medically necessary: services or supplies needed to prevent, diagnose or treat illness, injury, condition, disease or its symptoms
Medicare-approved amount: payment accepted by doctor or supplier from Medicare
Preferred Provider: doctor or supplier who is member of network for specific insurer’s HMO or PPO plan
Preventive services: health care to prevent illness or detect at early stage
Primary care doctor: person you see first for most health problems
Referral: written order from primary care doctor for you to see specialist or get some medical services. Required in most HMOs.
Signing up too early or too lateNot understanding difference between Medicare Supplement and Medicare Advantage
Guessing when picking planNot applying for extra helpNot re-evaluating coverage yearly
Five Biggest Mistakes Made When Enrolling in Medicare
www.medicare.govMedicare & You 2015www.mymedicarematters.orgSHIP (1-877-801-0044)www.aonhewittnavigators.comwww.benefitscheckup.org
Best Sources of Information
Joani Shaver, DirectorBlount County Office on AgingBlount County Community Action Agency3509 Tuckaleechee Pike, Maryville 37803(865) 983-8411 [email protected]
Contact Information