Welcome to the MEDICARE TRAINING

Welcome to the MEDICARE TRAINING

A Continuing Education Course presented by

UNICARELife and Health Insurance Company

Course Objective

To make Medicare coverage, guidelines and co-insurance issues easier to understand.

To educate you so that you can better assist and educate your clients.

Benefit to Attendees

You will experience a "user-friendly, easy-to-understand" approach to an otherwise complex subject.

You will better understand the senior citizen situation when seeking a quality Medicare Supplement.

Seminar Agenda

What is Medicare and Who is Entitled Centers for Medicare and Medicaid Services

(CMS) Major Changes in Medicare Who Pays for Medicare Medicare Eligibility and Enrollment Part A -Benefits and Purchasing Part B - Benefits

Medicare Assignment and Payment New Preventative Benefits

Seminar Agenda (continued)

Supplemental Insurance Supplement Open Enrollment Plans A-J Standardization and Medicare Select Remaining Gaps in Medicare Balance Budget Act of 1997

Guarantee Issue Provision New Health Care Options

Through out history there have been many significant events that led to the enactment of Medicare.

Medicare is the result of many attempts by union groups, congress and presidents to implement socialized medicine in the United States.

Most efforts to block socialized medicine came from medical groups and hospital organizations

History of Medicare

Medicare is federal health program for the aged and disabled

It was established as part of the Social Security Act of 1965

Medicare was introduced in 1966, when only 50%of the nation’s elderly population had any health insurance.

Today, only about 1% of the elderly are uninsured.

What is Medicare and Who is Entitled?

When first implemented in 1966 Medicare covered 19 million beneficiaries nation wide

Medicare originally covered only most people age 65 and older

In 1999 Medicare covered about 39 million enrollees at an annual cost of about 213 billion

The average calendar year cost was about $5500. per enrollee


Medicare expanded in 1973 to cover persons who were entitled to Social Security or Railroad Retirement disability for at least 24 months and persons with end-stage renal disease requiring continuing kidney dialysis or a kidney transplant. (End-stage renal disease now 6 months)


Health Care Financing Administration

In 1977, the Health Care Finance Administration was established under the Department of Health and Human Services to administer the Medicare program.

In 2001 (HCFA) name was changed to Centers for Medicare & Medicaid Services

Centers for Medicare & Medicaid Services

(CMS) is the federal agency within the Department of Health and Human Services that administers Medicare and regulates the Senior Risk (HMO) Industry

(CMS) responsibilities for Medicare include formulation of policy and guidelines, contract oversight and operations, maintenance and review of utilization records and the general financing of Medicare

Major Changes in Medicare Part A

Prospective Payment/DRGs for Hospital Care – Medicare-Approved HMOs

Part B– Physicians Assignment

Medicare Catastrophic Coverage Act Passed in 1988, Repealed 1989.

Home Health Care adopts DRG’s

Who Pays For Medicare?

Medicare Part A is financed through mandatory payroll deduction (FICA tax).

The FICA tax is 1.45% of earnings (paid by both the employee and employer), and 2.9% for self-employed persons. This tax is paid on all covered wages and self-employed income without a limit


Medicare beneficiaries also contribute in part by paying deductibles, coinsurance and premiums.

For those people who are eligible due to age or medical conditions, but have not paid into Social Security, Medicare PART A is available at a premium.


For most people, the monthly premium for Hospital PART A is $319, if they have paid FICA tax for 30 to 39 quarters the monthly premium is reduced to $175.


Medicare PART B is financed through monthly premiums paid by beneficiaries

these premiums cover about 25% of expenditures

monthly premium is $54.00 contributions from the Federal

Governments general fund.

Medicare Eligibility

To be eligible for Medicare, you: or your spouse must have worked for

at least ten years in Medicare covered employment.

must be 65 years of age and a citizen or permanent resident of the United States.

or a person younger than 65 with a disability or a chronic kidney disease.

Medicare Enrollment

Automatic Enrollment If already getting Social Security

benefits when you turn 65, you will automatically be enrolled in Medicare Parts A and B.

You will receive your card about three months before your 65th birthday.

Medicare Enrollment

Automatic Enrollment (continued) If disabled, you will automatically get a Medicare card in the mail after receiving Social Security Benefits for 24 months.

Medicare Enrollment

Applying for Medicare If not receiving Social Security

benefits, you must apply by contacting any Social Security Administration office three months prior to your 65th birthday.

Medicare Enrollment

Initial Enrollment PeriodSeven months, starting 3 months before

the month in which you turn 65. If you do not enroll during this period, you must wait until the next general enrollment period.

General Enrollment Period January 1st to March 31st each year Your Medicare coverage will be effective

the following July 1st.

Medicare Enrollment

Late Enrollment Consequences If you wait 12 months or more to enroll and

you do not have group health insurance as a result of your or your spouse’s current employment, Part B premiums increase 10% for each 12 months that you do not enroll.

If you have to pay a premium for Part A, the cost increases is limited to10%

no matter how late you enroll.

Extenuating CircumstancesYou can delay Part B enrollment if:you are over 65 and have group

health insurance through you or your spouse’s current employment, or...

you are disabled and have group health insurance through you or your spouse’s current employment.

Medicare Enrollment

Extenuating Circumstances (continued)You may enroll while you are covered by a group health plan or wait till your group coverage ends. A special 8-month enrollment period begins the

month your coverage ends. If you do not enroll by the end of this period, you

will have to wait until the Medicare’s next general enrollment period.

Medicare Enrollment

What Is a Medicare Card?

A Medicare Card is issued to every Medicare Beneficiary Card shows name of beneficiary Card shows Medicare claim

number Card also shows if the beneficiary

has Hospital (Part A) and Medical (Part B) insurance, as well as the effective dates of coverage.

Claim number usually is the beneficiaries Social Security number followed by an ”A”

If beneficiary is receiving benefits through their spouse, the claim number would be the spouses Social Security number followed by a “B.”

If the beneficiary is receiving benefits through a deceased spouse the card would have the spouses Social Security number followed by a “D”

Health Insurance Claim Number

MEDICARE BENEFITS

Medicare consists of two parts:

Hospital Insurance protection - PART A

Medical Insurance protection - PART B

MEDICARE BENEFITSPART A

Medicare PART A provides institutional care, including:

PART A: Medicare helps

pay for:care in a hospitalskilled nursing facility home health care hospice care

Part A Benefits

Benefit Period Coverage is measured in a ‘Benefit Period’

which begins the day you are admitted to a hospital and ends when you have been out of a hospital or skilled nursing facility for 60 consecutive days.

If you go back to the hospital after 60 days a new benefit period starts

There is no limit on the number of benefit periods you can have in a year.

Part A: Hospital Covered Services

– Semi-private room and board – General nursing care– Operating and recovery room– Intensive care– Inpatient prescription drugs– Lab and X-Ray services– All other medical necessary

services and supplies provided in the hospital.

Part A: Hospital Benefits For each benefit period you pay:

Day 1 through 60 - Medicare pays all covered costs except a $812 in patient hospital deductible. Hospital deductible must be met each benefit period.

Day 61 through 90 - Medicare pays all covered costs except $203 per day coinsurance.

Part A: Hospital Benefits

Day 91 through 150 Lifetime Reserve Days. Medicare pays all covered costs except $406 per day.

The 60 lifetime reserve days never renew.

Beyond 151 days Medicare pays nothing

Part A: Skilled Nursing Facility

A skilled nursing facility is different from a nursing home. It is a special kind of facility that primarily furnishes skilled and rehabilitation services.

It may be a separate facility or a distinct part of another facility such as a hospital.


Qualifications – You require daily skilled care, which can only

be provided on an inpatient basis– You must be hospitalized for at least 3

consecutive days– Be admitted for the same condition for which

you were hospitalized– Be admitted within 30 days of your discharge

from the hospital– Certified as medically necessary

Medicare will help pay for this care for up to 100 days per benefit period...– Day 1 through 20 - Medicare pays all

covered costs.– Day 21 through 100 - Medicare pays

all covered costs except $99 per day.– Day 101+ - you pay full cost.


Part A: Home Health Care Medicare will pay the full cost of

medically necessary home health care visits provided by a Medicare approved home health care agency

A home health agency is a public or private agency that provides skilled nursing care, physical therapy speech therapy and other therapeutic services

Qualifications

– You must be hospitalize for at least 3 consecutive days.

– Home health services must be initiated within 14 days of discharge from the hospital or skilled nursing home.

– Finding of Medical Necessity and prescribed by physician.

Part A: Home Health Care

Part A: Home Health Care

Qualifications

– Patient is receiving intermittent skilled nursing care, physical therapy or speech therapy.

– Patient is confined to their home.– Care is not primarily custodial.

– Part-time or intermittent skilled nursing care

– Part-time or intermittent home health aide services

– Physical therapy, speech therapy, occupational therapy

– Medicare Social Services– Durable medical equipment has a

20% coinsurance

Part A: Home Health Services Cover

Part A: Home Health Care Benefits

The first 100 home health visits are financed under Part A as post institutional home health services.

If home health not initiated within 14 days benefits are covered under Part B.

Part A: Home Health Care Benefits

If all 100 visits are exhausted under Part A then Part B finances home health care visits.

If you do not have a qualifying hospital stay then all home health care is financed by Part B without a visit limit.

Custodial Care

Medicare will NOT cover care in a skilled nursing facility or pay home health benefits if the care is primarily custodial - as defined by Medicare

Part A: Hospice Care

Medicare pays for hospice care if you are terminally ill with a life expectancy of 6 months or less and you choose to receive it, instead of the standard Medicare benefits for your illness.

If you choose hospice care and require treatment for an illness other than a terminal condition, standard Medicare benefits apply.

100% Medicare payments for: Physicians services Nursing care Medical appliances and supplies Physical, occupational and speech therapy Dietary and social counseling Home health aide and homemaker services Unlimited benefit period.

Part A:Hospice Care

Nearly 100% Medicare payments for:

Prescription drugs for pain and symptom relief (5% but not to exceed $5 for each prescription)

Respite care for care givers (cost of about $5 per day)

Part A: Hospice Care

MEDICARE BENEFITS PART B

– Helps pay doctor bills and outpatient hospital care.

– The monthly premium is $54.00, deducted from your Social Security, or Civil Service Retirement check.

– If not receiving checks, they pay the premium directly to the Government usually on a quarterly basis.

Part B Benefits

Part B: Covered Services

Doctor’s services Outpatient hospital services Ambulance services Durable medical equipment Lab, X-ray and radiation

therapy Other health-related services

Part B: Physician Services

Part B Deductible and Coinsurance you must pay the first $100 each year of

the charges approved by Medicare. After the deductible has been met,

Medicare will pay 80% of Medicare-approved charges.

Outpatient mental health services are covered at 50% of Medicare-approved charges.

New Preventive Benefits

New Medicare-covered benefits for 1998 edition: Yearly mammogram and pap smear,

including pelvic and breast exam, for which there is no Part B deductible (effective 1/1/98)

Diabetes glucose monitoring and diabetes education for which there is no Part B deductible (effective 7/1/98)

New Preventive Benefits

New Medicare-covered benefits for 1998 edition: Colon cancer screening (effective 1/1/98) Bone mass measurement (effective 7/1/98) Flu and pneumococcal pneumonia shots are

covered 100% if the physician accepts assignment.

Part B: Benefit Limits

Therapeutic shoes - once a year. Durable medical equipment - must be

prescribed by a doctor for use at home and be supplied by a Medicare-approved supplier.

Ambulance services - must meet Medicare requirements.

Part B: Medicare Assignment

Medicare has a fee schedule that lists the dollar amount that Medicare considers to be the reasonable charge for each of the services provided by a physician.

Physicians that accept assignment are physicians that accept these fee schedules as full payment.

If a physician accepts Medicare assignment as payment in full, Medicare pays 80% of allowable charges to doctor. Your co-payment will never be more

than 20% of charges.


If physician does not accept assignment they may charge up to an additional 15% above the Medicare approved amount

You owe doctor the 20% of the approved charges PLUS excess charges of up to15% of the original Medicare approved amount


Lets ReviewThe Gaps In Medicare

$812 hospital deductible for the first 60 days

$203 daily coinsurance for days 61 through 90

$406 daily coinsurance for days 91 through 150 (lifetime reserve days)

All cost after 150 in the hospital First 3 pints of blood

Gaps In Hospital Part A

Gaps In Hospital Part A

Private hospital room unless medically necessary

Private duty nursing Personal convenience items such as

telephone or television in your room. For care received outside the United

States even if an emergency

Gaps In Skilled Nursing

$101.50 daily coinsurance for days 21 through 100

All costs after 100 days All cost for care that is less than

that of skilled care. (intermediate and custodial care)

The first 3 pints of blood

Gaps In Skilled Nursing

All costs if you were not transferred to a skilled nursing facility in a timely manner after a qualifying hospital stay

Personal convenience items that you request, such as a television or telephone in your room

Private duty nursing

Gaps In Home Health Care

24-hour nursing care at home Self-administered drugs and

medications Meals delivered to home Homemaker services Blood transfusions 20% for durable medical equipment

Gaps In Medical Part B $100 annual deductible The 20% coinsurance The permissible excess charges above

Medicare approved amount (15%) 50% of the Medicare approved amounts

for most outpatient mental health treatment

Charges for most self-administered prescription drugs

Gaps In Medical Part B

Homemaker services that are primarily to assist you in meeting personal care or house keeping needs

Most dental care and dentures. Charges for acupuncture treatment All charges for routine eye examinations

and eyeglasses except prosthetic lenses after cataract surgery

Gaps In Medical Part B Hearing aids or routine hearing loss

examinations All charges for care outside the United

States (except limited in Mexico and Canada)

Charges for routine foot care except when a medical condition affecting the lower limbs (such as diabetes) requires care by a medical professional

The cost of the first 3 pints of blood

Standardization and

Medicare Supplement “Medigap” Policies

Standardization

In 1992 the National Association of Insurance Commissioners in conjunction with Health Care Financing Administration formulated 10 standard Medicare Supplements Plans that could be sold to the public.

These standardized plans must have a letter designation of A through J

Standardization

Benefits do not vary by company an A Plan is a A Plan, a C Plan is a C Plan, F is a F and so on. If they have the same letter designation the benefits are identical.

Plans were designed to make the purchasing of a Medigap policy easier for senior citizens to understand

Standardization is nationwide, Plans do not vary from state to state.

Standardization

The only difference between Medicare Select and Standard plans is the insurance company has specific hospitals and in some cases specific doctors in order to be eligible for full benefits.

Full benefits are paid in case of emergency

Generally has a lower premium in comparison to other Medigap policies

Medicare Select is a type of standardized plan

Standardization

Every company selling Medicare Supplements must offer Plan “A”.

Company’s may then offer any of the remaining plans (B through J)

Standard Plan A The Basic Benefits included in all plans:

Part A coinsurance $203 per day for the 61st through the 90th day of hospitalization

Part A coinsurance $406 per day for the 91st through 150th day (lifetime deserve days)

After Medicare hospital benefits are exhausted, covers 100% of hospital expenses for an extra 365 days

Standard Plan A The Basic Benefits included in all plans:

Coverage under parts A and B for the cost of the first 3 pints of blood.

Coverage for the coinsurance amount for Part B services (20% of approved amount for physicians services and 50% of approved amount for outpatient mental health services) after the $100 annual deductible is met

Standard Plan B

– Includes Basic Plan A Benefits Pays Medicare Part A Inpatient Hospital

Deductible ($812 per 60 day benefit period)

Standard Plan C

– Includes Basic Plan A Benefits

– Part A Deductible ($812) Coverage for Skilled Nursing Facility Coinsurance

amount ($101.50 per day for days 21 through 100 per benefit period)

– Coverage for the Medicare Part B $100 Deductible

Foreign Travel Emergency 80% coverage after a $250 deductible with a lifetime maximum of $50,000

Standard Plan D


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Foreign Travel Emergency Coverage for At Home Recovery. The at home

recovery benefit pays up to $1,600 per year for short-term, at home assistance with activities of daily living (like bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury or surgery

Standard Plan E


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Foreign Travel Emergency Coverage for Preventive Medical Care. The

preventive medical care benefit pays up to $120 per year for things like a physical examination, serum cholesterol screening, hearing tests, diabetes screening and thyroid function tests

Standard Plan F


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Part B Deductible ($100)– Foreign Travel Emergency Coverage for 100% of Medicare Part B Excess

Charges (maximum of 15% above approved amount)

Standard Plan G


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Foreign Travel Emergency– Coverage for At Home Recovery. ($1,600 per

year) Coverage for 80% of Medicare Part B Excess

Charges (maximum of 15% above approved amount)

Standard Plan H


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Foreign Travel Emergency Basic Drug Benefit after a $250 annual

deductible plan pays 50% of prescriptions with a maximum annual benefit of $1250

Standard Plan I


– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Foreign Travel Emergency– Coverage for At Home Recovery. ($1,600 per

year)– 100% of Medicare Part B Excess Charges– Basic Drug Benefit ($1250 Limit)

Standard Plan J

Includes Basic Plan A Benefits

– Part A Deductible($812)– Skilled Nursing Coinsurance ($101.50)– Part B Deductible ($100)– 100% of Medicare Part B Excess Charges– Foreign Travel Emergency

Standard Plan J

Includes Basic Plan A Benefits

– Coverage for At Home Recovery. ($1,600 per year)

– Preventive Care ($120) Extended Drug Benefit after a $250. annual

deductible plan pays 50% of prescriptions with a maximum annual benefit of $3000.

Medicare Open Enrollment

State and Federal laws guarantee that for a period of 6 months from the date you are enrolled in Medicare Part B and age 65 or older, you have a right to buy the Medigap policy of your choice regardless of any health problems you may have.


During this 6 month period you may purchase any Medigap sold by any insurer selling Medigap insurance in your state.

The company cannot deny coverage, place wavers or charge you additional premiums because of your health history


The company can, however, impose as much as 6 months waiting period for preexisting conditions

Preexisting conditions are generally health problems that you have seen a physician within the last 6 months before the policy effective date.

Balance Budget Act of 1997

Guaranteed issue Medicare supplement protection when other health insurance ends or is lost. Effective July 1, 1998

To qualify you must apply for a new policy within 63 days of loosing your other health coverage


You qualify if:

You were enrolled in an employer group health plan with benefits that supplemented your Medicare benefits and the plan stopped providing those benefits.


You qualify if:

You were enrolled in a Medicare Health Maintenance Organization or Medicare SELECT policy and your enrollment ended when you moved outside of the plan’s service area, or your plans contract with Medicare ended.


You qualify if:

You were enrolled in a Medigap policy and coverage stopped because of the insolvency of the company, because of other involuntary termination of coverage or the company violated or misrepresented a provision of your policy.


The guarantee applies to you if: You had a Medigap policy and dropped it

to enroll in a Medicare HMO or care SELECT policy for the first time. You then decided to disenroll from the Medicare HMO or Medicare SELECT policy within 12 months of first enrolling.


Under this guarantee, companies selling Medicare supplemental insurance must sell you one of 4 guaranteed issue Medigap policies, Medicare Supplement Plans A, B, C or F.

Medigap companies may not deny you coverage or charge you additional premium because of any health conditions.


Creates new health care options called Medicare + Choice Health Maintenance Organization (HMO) Health Maintenance Organizations with

Point of Service options (HMOs With POS)

Provider Sponsored Organizations (PSOs) Preferred Provider Organizations (PPOs)


Creates new health care options called Medicare + Choice Private Fee-for-Service Plan Medicare Medical Savings Account (MSA) Religious Fraternal Benefit Society Plans High Deductible Plans F and J

($1500 deductible)

Thank you for attending today's seminar on Medicare!

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