MEDICARE BENEFITS
AND UPDATES FOR 2012
Senior Health Insurance Program
800-548-9034
WHAT IS SHIP?
 Senior
Health Insurance Program
 Established in 1988
 Free Medicare Counseling Program
 Sponsored by the State of Illinois

Illinois Department of Insurance
 Does
not sell or solicit insurance
 Dedicated to educating people with Medicare
 SHIP trains volunteer counselors throughout
Illinois

Provide one-on-one counseling


With Medicare Beneficiaries, family members and
caregivers
Through community based sites
MEDICARE

Medicare has four parts

Part A – Hospital Insurance

Part B – Medical Insurance

Part C – Medicare Advantage

HMO, PPO, PFFS, SNP, and MSA



Original Medicare
Also know as Managed care
Part D – Prescription Drug Coverage
Medicare Supplement Insurance

Not to be confused with secondary insurance
PART A – COVERED SERVICES
Inpatient
Skilled
Home
Hospital Care
Nursing Facility Care
Health Care
Hospice
Care
PART A COSTS FOR INPATIENT HOSPITAL STAYS
For each
benefit period
You Pay
in 2012
Days 1-60
$1,156 deductible
Days 61-90
$289 per day
Days 91-150
$578 per day (60 lifetime
reserve days)
All days after
All Costs
5
150
PART A COSTS
FOR
SKILLED NURSING FACILITY
For each benefit
period in 2012
CARE
You Pay
Days 1-20
$0
Days 21-100
$144.50 per
day
All days after 100
All Costs
PART B – COVERED SERVICES
Medical
Home
Expenses
Health Care
Outpatient
Durable
Hospital Services
Medical Equipment (DME)
2012 PART B AMOUNTS
06/22/2011
Part B Annual Deductible - $140
 Part B Monthly Premium

You pay this
in 2012
$96.40, $110.50, $115.40
$99.90
DRAFT Medicare Current Topics
If your income is $85K or less
and you paid this in 2011
8
INCOME-RELATED PART B PREMIUM

Part B premium income thresholds
Frozen at 2010 levels through 2019
File Individual Tax
Return
File Joint Tax
Return
$85,001–$107,000
$107,001–$160,000
$160,001–$214,000
above $214,000
$170,001–$214,000
$214,001–$320,000
$320,001–$428,000
above $428,000
*Higher if you have a late enrollment penalty
In 2012
You
Pay*
$139.90
$199.80
$259.70
$319.709
DRAFT Medicare Current Topics
If your Yearly Income in 2010 was
06/22/2011

MEDICARE PART C

Medicare Advantage (MA)

Provided through private insurance companies

Offered through


HMO, PPO, PFFS, MSA an SNP
Must offer all services covered under Medicare Part A and
Part B

May be able to offer extra services

May include Drug Coverage

No need to have a Supplement plan

Must live in plans service area

Must follow plans guidelines for coverage
MEDICARE PART D
 Began
in 2006
 Offered by private companies contracted with
Medicare to provide prescription drug coverage
 Available to anyone enrolled in Medicare

Part A and/or Part B
 Coverage


offered
Stand-alone Prescription Drug Plan (PDP)
As part of a Medicare Advantage Plan (MA-PD)
MORE

Discounts for 2012


AFFORDABLE PRESCRIPTION DRUGS
50% discount on brand-name drugs and 14% discount
on generic-drugs during the donut hole.
Elimination of the Donut Hole by 2020

Your cost-share should be approximately 25% during
the plan year.
COST SHARING FOR BRAND-NAME DRUGS IN THE
MEDICARE PART D COVERAGE GAP, 2010-2020
COST SHARING FOR GENERIC DRUGS IN THE
MEDICARE PART D COVERAGE GAP, 2010-2020
SPECIAL PART D CO-PAY STRUCTURE
NEW
NEW FOR 2012
 For dual eligibles receiving Home and
Community Based Waiver Services (HCBS)
 $0 co-pay for prescriptions
 Similar to co-pay structure for duals in a nursing
home
 Must keep dual eligible status

HOME AND COMMUNITY BASED
WAIVER SERVICES
There are 9 HCBS programs in Illinois:
 Http://www.hfs.illinois.gov/hcbswaivers/



Includes DRS Home Services Program
Includes Department on Aging Community Care
Program
HOME AND COMMUNITY BASED WAIVER
SERVICES CONTINUED
HCBS “status” works like Medicaid dual eligible
status
 If you have HCBS enrollment in any month of
the year, you get $0 Part D co-pays for the rest of
the year
 If you have HCBS enrollment in July or later,
you get $0 co-pays for the following year
 Must keep the dual eligible status
 Most people will have the waiver program and be
a dual eligible as waiver programs now count
toward meeting spend-down

ENROLLMENT PERIODS
 Annual

Open Enrollment Period
Oct. 15th – Dec. 7th, 2011

Join, switch, or drop
Plan effective Jan. 1, 2012
 Dual eligibles have continuous enrollment
options throughout the year

 Special

Enrollment Period
Special circumstance that allows you to enroll
outside the normal time frame
ANNUAL ENROLLMENT PERIOD EXTENDED



Elections may be made through December 10
AEP extended to advocates such as SHIP,
MIPPA grantees, ADRCs, and the Aging Network
During enrollment use code AEP2012
MEDICARE ADVANTAGE DISENROLLMENT
PERIOD (MADP)
Begins Jan. 1 and end Feb. 14 each year
 May disenroll from Medicare Advantage Plan
(MA Plan) or from MA-Prescription Drug Plan
(MA-PD)


May NOT enroll into another MA plan during MADP
May return to Original Medicare
 May choose a Part D plan regardless if moving
from a MA-only or a MA-PD
 New plan choice effective the first day of the
following month

INITIAL ENROLLMENT PERIOD
Seven-month period when a beneficiary is
entitled to enroll into Medicare Part A, B, D
and/or C
 Starts 3 months prior to eligibility month (3)
 Includes the month of eligibility (1)
 End 3 months after the eligibility month (3)
 Referred to as the 3 – 1 – 3 rule

SPECIAL ENROLLMENT PERIOD (SEP) FOR
THOSE LOSING ‘CURRENT’ EGHP

SEP begins when beneficiary’s primary status in
an Employer Group Health Plan ends
Eight month period beginning with the first month
employment is no longer ‘Current’
 Coverage in EGHP could be from a spouse

Enroll in Medicare Part B at this time to avoid
late enrollment penalty
 Avoid part D penalty by enrolling in a part D
plan no later than 63 days after employment
ends

MEDICARE GENERAL ENROLLMENT
PERIOD
Begins Jan. 1 and ends March 31 of every year
 May enroll into parts A and/or B
 Coverage effective date is July 1 of same year
 For those who must pay premiums for


Medicare Part A
This could include those who declined Part B and
now wish to enroll
 Penalties for late enrollment usually apply

MEDICARE PREVENTIVE SERVICES

Implemented January 1, 2011

Elimination of Part B Deductible and Coinsurance

You pay nothing for most preventive services

When a doctor or health care provider accepts assignment
Example: Bone Mass Measurement

In 2010 you pay 20% after Part B deductible

In 2011 you pay no deductible or copay
PREVENTIVE SERVICE – COST
 The
amount you pay varies and depends
on whether you get your Medicare
benefits through

Original Medicare (fee-for-service); or

Medicare Advantage Plan (HMO, PPO, etc)
 Some
services are completely free
MEDICARE PREVENTIVE SERVICES…..
 Physical

Exams
“Welcome to Medicare” physical exam

A one-time exam available to new Medicare
beneficiaries within first 12 months of Medicare Part
B enrollment
 Annual

CONT.
“Wellness” Exam
Available to beneficiaries who’ve been
enrolled into Medicare Part B for more than 12
months
Medicare-covered Preventive
Services
Abdominal Aortic
Aneurysm (AAA)
Screening
A one-time screening ultrasound for people at risk. Medicare only covers this
screening if you get a referral for it as a result of your one-time "Welcome to
Medicare" physical exam. Before January 1, 2011, you pay 20% of the Medicareapproved amount. Starting January 1, 2011, you pay nothing for the screening if
the doctor accepts assignment.
Bone Mass
Measurements
Helps to see if you are at risk for broken bones. This service is covered once every
24 months (more often if medically necessary) for people who have certain
medical conditions or meet certain criteria. Before January 1, 2011, you pay 20%
of the Medicare-approved amount, and the Part B deductible applies. Starting
January 1, 2011, you pay nothing for this test if the doctor accepts assignment
Cardiovascular
Screening
Flu Shots
Glaucoma Test
Helps detect conditions that may lead to a heart attack or stroke. This service is
covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No
cost for the tests, but you generally have to pay 20% of the Medicare-approved
amount for the doctor's visit.
Helps prevent influenza or flu virus. Generally covered once a flu season in the
fall or winter. You need a flu shot for the current virus each year. No cost to you
for the flu shot if the doctor or other health care provider accepts assignment for
giving the shot. Note: Medicare Part B also covers administration of the H1N1 flu
shot. You pay nothing if your doctor accepts assignment for giving the shot.
Helps find the eye disease glaucoma. Covered once every 12 months for people at
high risk for glaucoma. You are considered high risk for glaucoma if you have
diabetes, a family history of glaucoma, are African-American and age 50 or older,
or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the
state must do the tests. You pay 20% of the Medicare-approved amount, and the
Medicare-covered Preventive
Services
Hepatitis B Shots
This is covered for people at high or medium risk for Hepatitis B. Your risk for
Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD),
or a condition that increases your risk for infection. Other factors may increase
your risk for Hepatitis B, so check with your doctor. Starting January 1, 2011, you
pay nothing for the shot if the doctor accepts assignment.
HIV Screening
Medicare covers HIV screening for people with Medicare who are pregnant and
people at increased risk for the infection, including anyone who asks for the test.
Medicare covers this test once every 12 months or up to 3 times during a
pregnancy. You pay nothing for the test, but you generally have to pay the doctor
20% of the Medicare approved amount for the doctor’s visit.
Breast Cancer
Screening
(Mammograms)
Medicare covers screening mammograms once every 12 months for all women
with Medicare age 40 and older. Medicare covers one baseline mammogram for
women between ages 35–39. January 1, 2011, you pay nothing for the test if the
doctor accepts assignment.
Medicare
Nutrition Medical
Therapy Service
Medicare may cover medical nutrition therapy and certain related services if you
have diabetes or kidney disease, or you have had a kidney transplant in the last
36 months, and your doctor refers you for the service. Before January 1, 2011, you
pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Starting January 1, 2011, you pay nothing for the test if the doctor accepts
assignment
Pap Test & Pelvic
Exams
Medicare covers these screening tests once every 24 months, or once every 12
months for women at high risk, and for women of child-bearing age who have had
an exam that indicated cancer or other abnormalities in the past 3 years. No cost
Medicare-covered Preventive
Services
Pneumococcal Shot
Helps prevent pneumococcal infections (like certain types of pneumonia). Most
people only need this preventive shot once in their lifetime. Talk with your
doctor. No cost if the doctor or supplier accepts assignment for giving the shot.
Prostate Cancer
Screening
Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test
once every 12 months for all men with Medicare over age 50 (coverage for this
test begins the day after your 50th birthday). You pay 20% of the Medicareapproved amount, and the Part B deductible applies for the doctor's visit. You
pay nothing for the PSA test. In a hospital outpatient setting, you also pay the
hospital a copayment.
Smoking Cessation
Includes up to 8 face-to-face visits in a 12-month period if you are diagnosed with
an illness caused or complicated by tobacco use, or you take a medicine that is
affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part
B deductible applies. In a hospital outpatient setting, you also pay the hospital a
copayment.
Note: Medicare coverage of smoking cessation counseling is now considered a
covered preventive service if you haven’t been diagnosed with an illness caused
or complicated by tobacco use. Starting January 1, 2011, you pay nothing for the
counseling sessions.
Diabetes Screening
These screenings are covered if you have any of the following risk factors: high
blood pressure (hypertension), history of abnormal cholesterol and triglyceride
levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Test may
also cover if you have two or more of the following ; Are you age 65 or older, or
are you overweight, or have a family history of diabetes (parents, siblings), or
Medicare-covered Preventive
Services
Colorectal cancer is usually found in people age 50 or older, and the risk of getting
it increases with age. Medicare covers colorectal screening tests to help find precancerous polyps (growths in the colon) so they can be removed before they turn
into cancer. Treatment works best when colorectal cancer is found early.
One or more of the following tests may be covered.
Fecal Occult Blood Test — Once every 12 months if 50 or older. You pay nothing
for the test, but you generally have to pay 20% of the Medicare-approved amount
for the doctor’s visit.
Colon Cancer
Screening
(Colorectal)
Flexible Sigmoidoscopy — Generally, once every 48 months if 50 or older, or 120
months after a previous screening colonoscopy for those not at high risk. Starting
January 1, 2011, you pay nothing for this test if the doctor accepts assignment.
Colonoscopy — Generally, you can get this procedure once every 120 months, or
48 months after a previous flexible sigmoidoscopy. If your doctor says you’re at high
risk, you can get it every 24 months. There’s no minimum age required for you to
get a colonoscopy. Starting January 1, 2011, you’ll pay nothing for the procedure if
your doctor accepts assignments.
Barium Enema — Once every 48 months if 50 or older (high risk every 24 months)
when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare
approved amount for the doctor’s services. In a hospital outpatient setting, you also
pay the hospital a copayment.
ACA
MEDICARE PRESCRIPTION DRUG
COVERAGE PREMIUM
Higher income individuals pay a higher Part D
premium
Uses same thresholds used to compute incomerelated adjustments to the Part B premium


As reported on your IRS tax return from 2 years ago
Must pay if you have Part D coverage
DRAFT Medicare Current Topics

06/22/2011

31
ACA
INCOME-RELATED ADJUSTMENT TO PART D
PREMIUM
06/22/2011
File Joint Tax Return
DRAFT Medicare Current Topics
If your Yearly Income in 2010 was In 2012 You
Pay
File Individual Tax
Return
$85,000 or below
$170,000 or below
$85,000.01 – $107,000
$170,000.01 – $214,000
BP + $11.60
$107,000.01 – $160,000
$214,000.01 – $320,000
BP + $29.90
$160,000.01 – $214,000
$320,000.01 – $428,000
BP + $48.10
$214,000.01 or higher
$428,000.01 or higher
BP + $66.40
32
Base Premium (BP)
USE MEDICARE.GOV FOR RESOURCES

Top 7 Services on Medicare.gov








Find out what Medicare costs in 2012
Find health and drug plan, compare and enroll!
Apply on-line for Medicare now
Find out if Medicare covers your tests, items, services
Get Extra Help with prescription drug costs
Find out how Medicare works with your other
insurance
Get a new Medicare card
Link to MyMedicare.gov
RESOURCE AND PUBLICATION

SHIP




Medicare






Medicare & You 2012 handbook
1-800-633-4227
www.medicare.gov
www.mymedicare.gov
TTY 1-877-486-2048
Social Security Administration




Medicare Supplement Premium Comparison Guide
800-548-9034
www.insurance.illinois.gov
“Extra Help” application
800-772-1213
www.ssa.gov
Dept on Aging - (Illinois Cares Rx)


800-252-8966
www.cbrx.il.gov