Cabrillo College
Retiree Benefits and Medicare
Frequently Asked Questions
Table of Contents
What is Medicare? …………………………………………………………………….............. 3
What are the different parts of Medicare? ………………………………………............... 4
What does Medicare help cover – Part A? …………………………..……………………. 5
What does Medicare help cover – Part B? …………………………...……..….…………. 6
What does Medicare not cover? ……………………………………………………………. 7
Original Medicare enrollment period ……………………………………………………… 8
Medicare Part C (Medicare Advantage) …………………………….……………………. 9
Medicare Part D (Prescription drug coverage) ……………………..………………...… 10
Medicare Supplement plans (Medigap) …………………………………………………. 14
Medicare and group health plans ……………………………………….………………… 15
Do working seniors still need Medicare? ……………………………….……….............. 16
Make a financial comparison …………………………………………....…….…............. 17
Cabrillo College Plan-Specific Options …………………………………………………... 18
Cabrillo College Specific Q&A ……………………………………………………………... 24
page 2
Medicare
What is Medicare?
•
Fee-for-service health insurance
•
Medicare helps cover your
expenses on certain services
•
You can use any doctor/hospital
(provider) that accepts Medicare
Who is eligible?
•
People ages 65 or older
•
People under ages 65 with certain
disabilities
•
People of any age with end-stage
renal disease (ESRD)
page 3
Filling in the gaps
Making coverage complete
There are two main ways to get your Medicare coverage: through Original Medicare, which
can be supplemented by a Medicare Supplement plan, or with a Medicare Advantage Plan.
Medicare Advantage Plan
Original Medicare
Part A
Part B
Hospital
insurance
Medical
Insurance
Part D
Prescription drug
coverage
(like an HMO or PPO plan)
Combines Part A, Part B, and usually
Part D
Decide if you need to
add drug coverage.
Part D
Decide if you need to add supplemental coverage.
Medigap
(Medicare
Supplement
insurance policy)
page 4
Prescription drug coverage
(Most Medicare Advantage Plans
cover prescription drugs. Part D
drug coverage can only be added
to Medicare Advantage Plans that
do not have prescription drug
coverage.)
Medicare Part A
Hospital coverage
Helps cover:
1. Inpatient hospital care in hospitals
• Hospital deductible: $1,216.00
• Copayment for days 61-90: $304/day
• Copayment for days 91-150: $608/day
• After day 150: NO COVERAGE!
2. Skilled nursing facility stays
• You pay nothing for the first 20 days each
benefit period.
• Days 21-100: - $152/day
3. Hospice care
4. Home health services
• Part-time or intermittent care.
• You pay nothing for covered home
healthcare services.
page 5
Part A premium no cost
for beneficiaries who
meet certain criteria
(who work for 40
quarters or 10 years)
Medicare Part B
Fast facts
Medical coverage
Helps cover:
1.
Doctor and other healthcare providers’
visits
2.
Outpatient hospital care
3.
Durable medical equipment
4.
Home health care
5.
Many preventive services offered
6.
No cost for most preventive services
2014 beneficiary cost-sharing
amounts for Part B $104.90
standard monthly premium
•
$147.00 annual deductible.
•
Medicare pays 80% of approved charges
•
You pay 20% of approved charges
•
Physicians can’t charge more than 15%
on top of approved charges
•
You might be eligible to defer Part B
without incurring penalties if you have
group health coverage through an
employer or union.
•
Part B is available to all Medicare
beneficiaries. If you do not sign up when
you are eligible, you may have to pay a
late enrollment penalty for as long as you
have Medicare.
•
Monthly premiums are deducted directly
from the beneficiary’s Social Security
check, or billed quarterly.
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Medicare Parts A and B do not cover:
•
Most prescription drugs
•
Routine vision, foot, or dental care
•
Routine hearing exams and hearing aids
•
Acupuncture
•
Custodial care at home or in a nursing home
•
Health care outside of the U.S.
•
Part A and Part B deductibles and
coinsurance
•
Hospital care after 150 days
Medicare does not have a out-of-pocket
maximum .
page 7
Original Medicare
Enrollment periods
1. Initial Enrollment Period
•
•
•
When you first become eligible for Medicare.
Begins 3 months before the month of your 65th birthday.
Ends 3 months after the month of your 65th birthday.
2. Special Enrollment Period
•
•
Anytime you’re still covered by the group health plan.
During the 8-month period that begins the month after the
employment ends or the coverage ends, whichever happens first.
3. General Enrollment Period
•
•
•
January 1 through March 31 of each year.
Part B coverage starts on July 1 of the year you sign up.
Part B premium penalty of 10% for each 12-month period you could
have had Part B but did not. Penalty is waived if you were covered by
a group health plan and enroll during a Special Enrollment Period.
page 8
Medicare Part C
Medicare Advantage Plans
Fast facts
•
You must have both Medicare Parts A and B
•
Offered by private health plans
•
Designed to cover the gaps of Original Medicare
•
Copays are varied
•
Medicare Advantage Prescription Drug Plans include prescription drug
coverage
•
Must use the plan’s network doctors and facilities
•
In most cases, referrals are necessary
•
Some plans include routine vision, hearing and dental benefits, and
gym membership
page 9
Medicare Part D
Prescription drug coverage
Medicare Part D covers
prescription drugs only
What types of Part D plans
are offered?
A beneficiary can add Part D
to:
1. Prescription Drug Plan (PDP)
A PDP plan is sold as a standalone
plan by Medicare-approved
companies. It can complement a
Medicare Supplement (Medigap)
plan.
1. Original Medicare
2. Medicare Supplement
plans
3. Medicare Advantage
Plans without
2. Medicare Advantage
Prescription Drug Plan (MA-PD)
Prescription drug coverage is
offered as part of an MA-PD plan.
prescription drug
coverage
page 10
Medicare Part D
Fast facts
1. Part D is not offered by Medicare.
A beneficiary needs to pick a private health plan,
which is then subsidized by the government.
2. Don’t go 63 days or more in a row without a
Medicare drug plan or other creditable coverage.
3. Tell your plan about any drug coverage you had if
they ask about it.
4. Coverage in Part D is optional .
However, if beneficiaries don’t enroll when first
eligible, they could be subject to a late enrollment
penalty (higher monthly plan premiums) unless they
are enrolled in a plan with drug coverage that is
creditable.
page 11
Medicare Part D
2014 Costs for Covered Drugs
Plan premiums may vary
Phase 1
Annual
deductible
This is the amount you must pay before your drug plan begins
to pay its share of your covered drugs. Some drug plans don’t
have a deductible.
Phase 2
Initial coverage
You pay a copayment, and your plan pays its share for each
covered drug until your combined amount (plus the
deductible) reaches $2,850.
Phase 3
Coverage gap
You pay 47.5% of covered brand-name drug costs and 72% of
covered generic drug costs until your out-of-pocket costs
reach $4,550. Some plans will offer coverage of some drugs
through the gap.
Phase 4
Catastrophic
coverage
Once you’ve spent $4,550 for the year, you will pay only a
small copayment or coinsurance for each covered drug until
the end of the year.
page 12
Medicare Part D
Enrollment periods
1. Initial Enrollment Period
Initial Enrollment Period (3 months
before 65 birthday, month of
birthday and 3 months after)
Newly eligible for Medicare
2. Annual Election Period
Open Enrollment Period(Oct. 15 –
December 7)
3. Special Election Period
Special Enrollment Period (you move,
lose insurance coverage, qualify for
Extra Help).
4. Extra Help paying for prescription
drugs (for those who qualify)
page 13
Medicare Supplement plans
(Medigap)
Fast facts
•
Medicare Supplement plans are also known as Medigap plans.
•
You must have both Medicare Parts A and B.
•
Offered by private health plans.
•
10 standardized plans with varying benefits, plus a high-deductible option for
Plan F.
•
Designed to cover the gaps of Original Medicare including some deductibles
and coinsurance of Medicare-allowed amounts for covered healthcare
expenses.
•
Freedom to choose any doctor, specialist, and hospital in the U.S. that accepts
Medicare.
•
Must pay monthly plan premiums in addition to Medicare Part B premium
•
Medicare Supplement does not cover long-term care, pharmacy, dental,
routine vision, hearing aid, and private-duty nurse.
•
Guaranteed renewable.
page 14
Medicare and group health plans
•Generally, employers with 20 or more employees must offer current employees or
spouses 65 and older the same health benefits that they offer younger employees.
•If you have Medicare and you’re offered coverage under a group health plan, you
can choose to accept or reject the plan.
•If you or your spouse are still working and you have health coverage through that
employer or union, contact your employer or union benefits administrator to find out
how your coverage works with Medicare. It may be to your advantage to delay
Part B enrollment.
•When you have health coverage based on current employment, you can sign up for
Part B at any time, without penalty.
•Once the employment ends, you have 8 months to sign up for Part B without a penalty.
•This period will run whether or not you choose COBRA. If you choose COBRA, don’t wait
for COBRA to end to enroll in Part B – if you don’t enroll in Part B during the 8 months, you
may have to pay a penalty, and you won’t be able to enroll until the next General
Enrollment Period.
page 15
Do working seniors still need Medicare?
Questions you may want to ask when you speak to your benefits administrator
Employee is turning 65
Am I just
covering myself?
No
Yes
Younger spouse/
adult child
Is employer plan
cheaper than $104.90?
Both stay on employer plan
or just cover the younger
spouse
Retiree 65+ defer Part B or
elect an individual plan for
yourself
No
Yes
Get Part B
Stay on employer plan
Look into Medicare Individual
options
page 16
Defer Part B
Make a financial comparison
Group plan
Monthly payroll
deductions
Non-group plan
$
Part B Premium +
Medicare Part D
$
$
Plan cost for
Medicare option
$
Max out-of-pocket
$
Max out-of-pocket
$
Plan deductible
$
Plan deductible
$
Hospital deductible
$
Hospital deductible
$
Doctor visits
$
Doctor visits
$
Specialist visits
$
Specialist visits
$
Prescription cost
$
Prescription cost
$
X-rays and lab work
$
X-rays and lab work
$
Vision coverage
$
Vision coverage
$
Dental coverage
$
Dental coverage
$
Gym membership
$
Gym membership
$
page 17
Cabrillo College – Specific Plan Options
2014/2015 HMO Plan Options – These plan design options are also
provided for Active employees.
Option
1
HMO $10-0
This plan offers:
• No deductible
• $1000 ind/$2000 family out-ofpocket maximum
• $10 office visit
• Generic/Brand Rx $5/$10 through
Navitus/COSTCO (mail order)
$671
Single w/Medicare A & B
$975
Single w/out Medicare
$1342
2-person w/Medicare A & B
$1890
2-person w/out Medicare A & B
$459
Single w/Medicare A & B
$771
Single w/out Medicare
$918
2-person w/Medicare A & B
$1512
2-person w/out Medicare A & B
• Medicare is Primary
• Must select Blue Shield HMO
provider
Option
2
HMO $25500
This plan offers:
• No deductible
• $2000 ind/$4000 family out-ofpocket maximum
• $25 office visit
• Generic/Brand Rx $9/$35 through
Navitus/COSTCO (mail order)
• Medicare is Primary
• Must select Blue Shield HMO
provider
page 18
Cabrillo College – Specific Plan Options
2014/2015 HMO Plan Options – These plan design options are also
provided for Active employees.
Option
3
HMO $3020%
This plan offers:
$457
Single w/Medicare A & B
• No deductible
$724
Single w/out Medicare
$914
2-person w/Medicare A & B
$1417
2-person w/out Medicare A & B
• $1500 per member out-of-pocket
maximum
• $30 office visit
• Generic/Brand Rx $9/$35 through
Navitus/COSTCO (mail order)
• Medicare is Primary
• Must select Blue Shield HMO
provider
page 19
Cabrillo College – Specific Plan Options
2014/2015 PPO Plan Options – These plan design options are also
provided for Active employees.
Option
4
PPO 80-E
This plan offers:
$520
Single w/Medicare A & B
• $300 ind/$600 family deductible
$956
Single w/out Medicare
$1040
2-person w/Medicare A & B
$1778
2-person w/out Medicare A & B
This plan offers:
$474
Single w/Medicare A & B
• $750 ind/$1500 family deductible
$848
Single w/out Medicare
$948
2-person w/Medicare A & B
$1578
2-person w/out Medicare A & B
• $1000 ind/$3000 family out-of pocket
maximum
• $20 office visit
• Generic/Brand Rx $7/$25 through
Navitus/COSTCO (mail order)
• Medicare is Primary
• May see any Blue Shield PPO Provider (CA &
Non-CA)
Option
5
PPO 80-J
• $3000 ind/$6000 family out-of pocket
maximum
• $30 office visit
• Generic/Brand Rx $9/$35 through
Navitus/COSTCO (mail order)
• Medicare is Primary
• May see any Blue Shield PPO Provider (CA &
Non-CA)
page 20
Cabrillo College – Specific Plan Options
2014/2015 PPO Plan Options – These plan design options are also
provided for Active employees.
Option
6
PPO HDHP B
This plan offers:
$483
Single w/Medicare A & B
(Deductible
must be met
before plan
pays any
cost
sharing)
• $2,500 ind/$5,000 family deductible
$681
Single w/out Medicare
$966
2-person w/Medicare A & B
$1281
2-person w/out Medicare A & B
• $5,000 ind/$10,000 family out-of pocket
maximum
• 10% office visit (after deductible)
• Generic/Brand Rx $7/$25 (after deductible)
• Medicare is Primary
• May see any Blue Shield PPO Provider (CA &
Non-CA)
• Rx is through Blue Shield
page 21
Cabrillo College – Specific Plan Options
2014/2015 Individual Retiree Medical Plan Options – These plan
options are only available for Retirees over 65.
Option 7
Companion
Care
This plan is a Medicare Supplement Plan that pays the difference
of what Medicare does not pay such as deductibles, in-patient
per day costs, Skilled Nursing, etc. Note that this plan only pays on
Medicare allowable expenses.
$370 per person
$740 (2-person)
• Must be enrolled in Medicare Part A & B
• May see ANY Medicare provider
• Anthem Blue Cross is the claims processor not network
• Members are enrolled in Part D
• The Rx plan on CompanionCare included an enhanced Rx drug
plan with no coverage gaps ($9/$35 copays through any
pharmacy that takes Navitus retail or COSTCO mail order) CMS
approved formulary
• The $0 generic copay & diabetic supplies for generic at
COSTCO is not applicable to this plan
Option 8
Blue Shield
Medicare
Advantage
This plan assigns the Medicare benefits to Blue Shield. Copays
apply, most benefits covered at 100%
$406 per person
• Must be enrolled in Medicare Part A & B
$812 (2-person)
• Must select Blue Shield HMO Medicare provider in approved zip
code/service area
• Not all HMO Primary Care Physicians (PCP) are available in this
plan
• Physicians Medical Group of Santa Cruz provider network only
• Member are enrolled on Part-D and provided Blue Shield CMS
approved formulary
page 22
(NorCal Region)
Cabrillo College – Specific Plan Options
2014/2015 Individual Retiree Medical Plan Options – These plan
options are only available for Retirees over 65.
Option 9
Kaiser
This plan assigns the Medicare benefits to Kaiser. Copays apply,
most benefits have $10 copay
$329 per person
• Must be enrolled in Medicare Part A & B
$658 (2-person)
• Must select Kaiser provider in approved service area/zip code
• Rx Included w/Kaiser facility
page 23
Cabrillo College – Specific Q&A’s
Q: What is the benefit period for Medicare benefits?
A: January 1 – December 31
Q: Is the Medicare Advantage plan an HMO or a PPO?
A: For Cabrillo College, the plan is an HMO
Q: Is CompanionCare different than a PPO?
A: Yes. On this plan, you may visit any provider that accepts Medicare. The provider
will bill Medicare first. The balance of the claim is sent to Anthem Blue Cross for
processing. It’s important to note that the Rx formulary will be slightly different than the
traditional “Active” plans.
Q: What happens to my Rx benefits if I move out of state?
A: Please refer to pages 18-23 of this document. Most retail Rx plans are through
Navitus. COSTCO walk-in pharmacies may not be available but you may still participate
in the mail order program.
page 24
Cabrillo College – Specific Q&A’s
Q: What if I am enrolled in the traditional “Active” plan and I want to switch to one of
the Individual Retiree plans?
A: You may enroll in an Individual Retiree Medical plan at any time. You do not have
to wait for an open enrollment period. However, you must submit a completed
enrollment form to your District's Benefit representative 45-days prior to the effective
date. The effective date of coverage will be the first of the month following the 45-day
notice. Once you are enrolled, you may NOT go back to the group "Active" plan (e.g.
PPO or HMO).
Q: If I enrolled in the CompanionCare and my doctor does not accept Medicare,
what will happen.
A: There is a great possibility that you may be billed for the balance for whatever
Medicare does not pay. CompanionCare requires that you receive services from a
participating Medicare provider.
Q: I am 65 but my spouse is younger. Can I split us up on different plans?
A: Yes. You may enroll in an individual plan while your spouse remains on a District
“Active” plan with “under age 65” rates.
Q: May I receive Homeopathic care?
A: Generally the Individual Retiree Plans will not cover Homeopathic care. However,
please consult your benefits booklet or contact the customer service department for
specific benefits.
page 25
Cabrillo College – Specific Q&A’s
Q: Does Medicare provide subsidy assistance for low income households?
A: Medicare does have a program called LTS – Low income Subsidy
Q: Do I qualify for low income subsidy?
A: You may contact CMS (Center for Medicare/Medicaid Services) at
http://www.cms.gov/ or 1-800-MEDICARE (800-633-4227)
page 26