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Medicare 101 Module 1B
Medicare 101
Module 1B
4/9/2015 2
Medicare 101
Introduction to Medicare
Original Medicare Plan
Medicare Supplement Insurance (Medigap)
Medicare Advantage and other Medicare plans
Medicare prescription drug coverage
Medicaid and Medicare Savings Programs
http://www.medicare.gov/your-medicare-
costs/costs-at-a-glance/costs-at-glance.html
Medicare training material plus….
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What Is Medicare?
A health insurance program for
People 65 years of age and older
People under age 65 with certain disabilities
People with End-Stage Renal Disease (ESRD)
Administered by Centers for Medicare &
Medicaid Services (CMS) (July 1965)
Enrollment by Social Security Administration
(SSA) or Railroad Retirement Board (RRB)
Introduction
4/9/2015 4
Applying for Medicare
Apply 3 months before age 65
Don’t have to be retired
Contact the Social Security Administration
Enrollment automatic if receiving Social
Security or Railroad Retirement benefits
Introduction
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Medicare
Medicare Basics
Part A
Hospital Insurance
Part B
Medical Insurance
Prescription Drug
Coverage (Part D)
Introduction
4/9/2015 6
The Medicare Card
Jane Doe
Original Medicare
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Medicare Coverage Basics
Part A
Inpatient hospital care
Skilled nursing care
Home health care
Hospice care
Part B
Doctors’ services and outpatient care
Preventive services
Diagnostic tests
Some therapies
Durable medical equipment
Part D Outpatient prescription drugs
Introduction
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Medicare Part A
Most people receive Part A premium free
People with less than 10 years of Medicare (30-
39 quarters)- covered employment
Can still get Part A
• Will pay a premium of $248/$441/$407 per
month/2012/2013/2015
For information about Part A entitlement
Call SSA
• 1-800-772-1213
• TTY users call 1-800-325-0778
Introduction
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Enrolling in Medicare Part B
Pay monthly Part B premium
Base with higher amt based on income /beginning in 2007. $99.90 2012, down from $115 2011, $104.90 2013 amt same for 2015.
Initial Enrollment Period (IEP)
7 months starting 3 months before month of eligibility
General Enrollment Period (GEP)
January 1 through March 31 each year
Coverage effective July 1
Premium penalty
• 10% for each 12-month period eligible but not enrolled
• Paid for as long as the person has Part B
• Limited exceptions
Introduction
4/9/2015 10
Enrolling in Medicare Part B
Some people can delay enrolling in Part B
with no penalty
If covered under employer or union group
health plan
• Based on current employment
– Person or spouse
• Will get a Special Enrollment Period (SEP)
– Sign up within 8 months after coverage ends
Introduction
4/9/2015 11
Part B Enrollment Periods
Example
Marie turned 65 on June 25, 2007. She will have
group health coverage from her employer until
she stops working on December 31, 2007.
Part B enrollment opportunities …
Enrollment period Begins Ends
IEP 3/1/07 9/30/07
SEP (after losing
coverage)
10/1/07 8/31/08
(runs 8 mons
after)
GEP (each year) 1/1 3/31
Introduction
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Paying the Part B Premium
Taken out of monthly payments
Social Security
Railroad retirement
Federal government retirement
For information about premiums –call who
enrolled them
Call SSA, RRB, or Office of Personnel Management
If no monthly payments
Billed every 3 months if no retirement payment
Medicare Easy Pay/auto deduced bank acct
Introduction
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Medicare Choices
Original Medicare Plan
Medicare Advantage Plans
Other Medicare Plans
Medicare Prescription Drug Plans
Introduction
4/9/2015 14
Original Medicare Plan –
Medicare Costs Go to any health care provider that accepts Medicare - nationwide
People are responsible for
Part A
• $1156 deductible in 2012 /$1184 in 2013/$1260 in 2015 for hospital stays up to
60 days. If out of the hospital/Part A for 60 days = another inpt deductible is due.
– Additional costs after 60 days Coinsurance days 61-90 $289 per day./$296
2013/$315 2015.
– 91-150 Lifetime Reserve days $578 per day/$592 2013./$630 2015
– Pt pays 100% after 150 days without a 60 day break
• Different costs for other Part A services
Part B
• $140 annual deductible in 2012; $147 2013; $147 2015
• 20% coinsurance or copayment for most Part B services
• Outpt hospital APC program – frozen coinsurance amt per CPT
• Critical access hospitals – 20% of billed
Original Medicare
Skilled Nursing Facility
Requires 3 clinically appropriate midnights
as an inpt to have SNF coverage
100% coverage of skilled care up to 20
days
21-100 days, SNF per day out of pocket of
$144.50 2012/$148 2013/$157.50 2015
Very difficult to meet ‘skilled’ up to 100
days a year.
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Medigap
Health insurance policy
Sold by private insurance companies
Must say “Medicare Supplement Insurance”
Covers “gaps” in the Original Medicare Plan
• Deductibles, coinsurance, copayments
• Does not work with Medicare Advantage Plans
Up to 12 standardized plans A – L
• Except in Massachusetts, Minnesota, Wisconsin
• So people can compare easily
Medigap
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How Medigap Works
People can buy a Medigap policy
Within 6 months of enrolling in Part B
• Must be age 65 or older
If they lose certain kinds of health coverage
• Through no fault of their own
If they leave MA/Part C Plan under certain
circumstances
Whenever the company will sell them one
Monthly premium
Generally go to any doctor or specialist
Medigap
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Medicare Advantage
Plans/Part C – 5 different types
Health Maintenance Organization (HMO) Plans
Some have Point-of-Service option/costs more
Preferred Provider Organization (PPO) Plans
Regional PPOs new in 2006
Private Fee-for-Service (PFFS) Plans
Special Needs Plans (LTC, both M&M, chronic)
Medicare Medical Savings Account (MSA) Plans
New in 2007
Medicare Advantage and Other Medicare Plans
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Eligibility for MA /Part CPlans
Live in plan’s service area
Benefits are NOT Traditional Medicare- each
plan has it’s own benefit package
Entitled to Medicare Part A
Enrolled in Medicare Part B
Continue to pay Part B premium
May also pay monthly premium to plan
Don’t have ESRD at enrollment
Some exceptions
Medicare Advantage and Other Medicare Plans
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How MA Plans Work
Usually get all Part A and B services through plan
May have to use providers in plan’s network
Generally must still pay Part B premium• Some plans may pay all or part
May get extra benefits
Vision, hearing, dental services
Prescription drug coverage
Still in Medicare program
Get all Part A and Part B services
Have Medicare rights and protections
Medicare Advantage and Other Medicare Plans
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Medicare Prescription Drug Coverage
Coverage began January 1, 2006
Available to all people with Medicare A
and/or B
Must enroll, not automatic
Provided through
Medicare Prescription Drug Plans
Medicare Advantage and other Medicare plans
Some employers and unions
Medicare Drug Coverage
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Enrollment Periods
Initial Enrollment Period (IEP)
7 months
Starts 3 months before month of eligibility
Annual Coordinated Election Period (AEP)
November 15 through December 31 each year
Can join, drop, or switch coverage
• Effective January 1 of following year
Special Enrollment Period (SEP) – moved
out of plan’s service area, LTC, change in
credible coverage.
Medicare Drug Coverage
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Late Enrollment
People who wait to enroll may pay penalty
Additional 1% of national base premium for
every month eligible but not enrolled
Must pay the penalty as long as enrolled in a
Medicare drug plan
Unless they have other coverage at least
as good as Medicare drug coverage
“Creditable coverage” (EX: VA, TRICARE,
Retiree drug coverage, Fed Employees)
Medicare Drug Coverage
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Prescription Drug Plans
At a minimum, must offer standard benefit
Members may pay• Monthly premiums – based on income with the base of $31.17 per
month/2013- varies by plan/2015
• Annual deductible, no more than $320
• Copayments or coinsurance
• Coverage gap – Pt pays all/most of cost
• True out of pocket, $4550 – then Medicare 100%
May offer supplemental benefits
Plan information and costs available
www.medicare.gov
1-800-MEDICARE (1-800-633-4227)
Medicare Drug Coverage
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Extra Help With Drug Costs
People with lowest income and resources
Pay no premiums or deductibles
Have small or no copayments
Those with slightly higher income and resources
Pay no or a reduced premium
Have a reduced deductible
Pay a little more out of pocket
Medicare Drug Coverage
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Eligibility for Extra Help
Some people may automatically qualify
People with Medicare who
• Get full Medicaid benefits
• Get Supplemental Security Income (SSI)
• Get help from Medicaid paying Medicare premiums
Others must apply and qualify
Medicare Drug Coverage
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Medicaid
Joint Federal and state program
For some people with limited income and resources
If eligible, most health care costs covered
Eligibility determined by state
Application processes vary
Office names vary
Social Services
Public Assistance
Human Services
Medicaid and Medicare Savings Programs
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Other Savings Programs
Medicare Savings Programs
Help from Medicaid paying Medicare expenses
For people with limited income and resources
May also pay deductibles and coinsurance
State-specific programs (Ex: Pharmacy
assistance)
Income amts are updated annually with the
Federal poverty limits.
Medicaid and Medicare Savings Programs
Facilities and Eligibility
55% of denials are due to eligiblity –no
benefits, wrong insurance primary, wrong
subscriber #, wrong insurance, no
benefits.
Identifying the correct primary payer with
verified benefits is the key to rapid cash
turn around.
Learn about the Medicare uglies =
MSP/COB29
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What Does COB Mean?
Coordination of benefits – identifying
correct primary payer
Streamlining the payment process
Protecting the Medicare trust funds
• Slated to be bankrupt in 2024ish. (Issued 4-12)
• 4 workers to 1 beneficiary/now; changes to 2
workers to 1.5 beneficiaries
Supporting Part D plans in tracking TrOOP
• True out-of-pocket costs
Providing quality customer service
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Why Is COB Necessary?
Prior to 1980, Medicare was primary
Federal law changed
Medicare Secondary Payer (MSP)
• Certain employers’ insurance pays as primary
• Determination based on all available insurance
Medicare Modernization Act (MMA) 2003
• Requirements for plans providing drug coverage
• Improved oversight and communications
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What Is MSP?
Medicare Secondary Payer mandates
Certain insurance pays health care bills
before Medicare pays
Identify other insurance that may pay first
Medicare is primary
In the absence of other insurance
Includes prescription drug coverage
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Identifying the Appropriate Payer
Many possible coverage combinations
Medicare may be primary payer
Medicare may be secondary payer
Medicare may not make payment
Data sources include
Initial Enrollment Questionnaire (IEQ)
Providers, group health plans, employers
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Initial Enrollment
Questionnaire/IEQ
Improves how MSP information is gathered
Mailed to people
About 3 months before Medicare entitlement
Requests other health insurance information
Five different questionnaires
Information entered in Common Working
File/CWF
• Maintains record of person’s data
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COB Contractors-Coordination
of Benefits Coordinator Group Health Incorporated (GHI)
Assures claims are paid correctly “the first time,
every time”
Centralizes COB for MSP
NDCHealth (Per-Se) (May change /contract)
Acts as TrOOP facilitator
Centralizes COB for Medicare Part D
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COB Agreement Program
COB Agreement Program (COBA)
Contract between COB Contractor and other
health insurance organizations
• National standard contract
• Medigap plans, Part D plans, EGHPs, others
Consolidates Medicare crossover process
• Enrollee eligibility data
• Medicare paid claims data transmittals
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Other Possible Payers
primary to Medicare No-fault or liability insurance
Workers’ compensation
Federal Black Lung Program
COBRA continuation coverage
Employer/retiree group health plans
FEHBP
Military coverage (VA and TRICARE For Life)
Others
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Other Possible Drug Coverage
Medicaid programs
State Pharmacy
Assistance Programs
(SPAPs)
Patient Assistance
Programs (PAPs) and
charities
AIDS Drug Assistance
Programs (ADAPs)
Safety-net providers
Indian Health Service
coverage
Personal health savings
accounts
Part B drug coverage
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When Medicare is Primary
Medicare is the only insurance
Other source of coverage is
Medigap policy
Medicaid
Retiree benefits
Indian Health Service
Veterans benefits and TRICARE for Life
COBRA continuation coverage
• Except 30-month coordination period for people with End-Stage Renal Disease (ESRD)
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Medicare is Secondary
To employer group health plans (EGHP)
Working aged: EGHP with 20 or more employees
Disability: EGHP with 100 or more employees
ESRD/End Stage Renal Disease= EGHP of any
size
• 30-month coordination period
To non-EGHP involving
Workers’ Compensation (WC)
Black Lung Program
No-fault/liability insurance
41
Employer Group Health
Plans/EGHPOffered by many employers and unions
Current employees
Retirees
Spouse or family members
May be fee-for-service plan
May be managed care plan
Can choose to keep or reject
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EGHP…Working Aged
Age 65 or older AND
Working and covered by EGHP or
Covered by working spouse’s EGHP
Medicare is generally secondary payer
If employer has 20 or more employees
For self-employed, if covered by EGHP of
employer with 20 or more employees
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Large EGHP…Medicare Due to
Disability
Have Medicare based on disability AND
Working and covered by large EGHP (LGHP) or
Covered by LGHP of working spouse
• Or other family member
Medicare is secondary payer
If employer has 100 or more employees or
Self-employed, if covered by LGHP of employer
with 100 or more employees
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EGHP…ESRD
Have Medicare and ESRD AND
Covered by EGHP of any size
Coverage through self or family member
Need not be based on current employment
Medicare is secondary payer
During 30-month coordination period
Unless Medicare already primary to retiree plan
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EGHP…ESRD (continued)
EGHP primary payer for first 30 months
Medicare becomes primary after 30 months
Separate 30-month coordination periods
Each time eligible for Medicare based on ESRD
Applies only to people with ESRD
For details
www.cms.hhs.gov/ESRDGeneralInformation
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Retiree Health Plans
Medicare pays first
Retiree coverage pays second
Might offer additional benefits
• Prescription drug coverage
• Routine dental care
• May be a secondary plan, not
supplemental;
Refer to plan’s benefits booklet
• Employer/union may change benefits,
change premiums, or cancel
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Important Considerations for
People With Retiree Coverage
Most retiree plans offer “generous coverage”
for entire family
Employer/union must disclose how its plan works
with Medicare drug coverage
Talk to benefits administrator for more information
People who drop retiree drug coverage May lose other ‘creditable” coverage/has 63 days to find
comparable coverage with no penalty
May not be able to get it back
Family members may lose coverage
Impact of Part D & recession to Retiree packages
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People With Retiree Coverage
Who Qualify for Extra Help
Those with limited income and resources
Income at or below 150% of Federal poverty level
Pay very little for prescriptions in a Part D plan
CMS automatically enrolls people with
Medicare and full Medicaid benefits
Including those with retiree drug coverage
May have to choose between Medicare drug
coverage and retiree coverage
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To Assist People With Retiree
Coverage and Extra Help …
CMS encourages employers/unions to
Allow those disenrolling by mistake to re-enroll
Allow separate package for family members
Add supplemental coverage option
Help retirees who choose to opt out of
Medicare drug coverage
Coordinate with state Medicaid or other
assistance programs
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No-Fault Insurance
Pays regardless of who is at fault
Medicare is secondary payer
Medicare may make conditional primary payment
If claim not paid promptly
• Usually within 120 days
Person won’t have to use own money to pay bill
Must be repaid when claim is resolved
Remember – 1 year to submit claims.. Watch
closely any pending insurance disputes
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Liability Insurance
Protects against certain claims
Negligence, inappropriate action, or inaction
Medicare is secondary payer
Health care professionals must attempt to
collect before billing Medicare
Medicare may make conditional payment
If the liability insurer will not pay promptly
• Usually within 120 days
Medicare recovers conditional payment
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Workers’ Compensation
Medicare will not pay for health care
related to workers’ compensation claims
If workers’ compensation claim denied
Claim may be filed for Medicare payment
Medicare may make conditional payment
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Black Lung Program
Lung disease caused by coal mining
Services under this program
Considered workers’ compensation claims
Not covered by Medicare
Medicare primary for conditions not related to black lung
Information
Federal Black Lung Program
1-800-638-7072
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COBRA/Consolidated Omnibus
Budget Reconciliation Act of 1985
Employees and dependents can keep
health coverage after leaving EGHP
If private or state/local government
employer with 20 or more employees
Called “continuation coverage”
Continues for 18, 29, or 36 months
• Depending on the qualifying event
Person must pay entire premium
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COBRA and Medicare
Medicare is usually primary
Medicare is secondary during 30-month
coordination period for ESRD
State Health Insurance Assistance
Program (SHIP) counselors can help
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For More Information
1-800-MEDICARE (1-800-633-4227)
TTY users call 1-877-486-2048
www.medicare.gov
www.cms.hhs.gov
State Health Insurance Assistance
Program (SHIP)
Medicare & You handbook
Other publications
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Summary
Medicare coverage
Original Medicare Plan
Medicare Supplement Insurance (Medigap)
Medicare Advantage and other Medicare plans
Medicare prescription drug coverage
Medicaid and Medicare Savings Programs
This training module provided by the
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To view all available NMTP materials
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