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Medicare
Basics
Who Qualifies for Medicare?
Citizen or U.S. resident and –
• Age 65 and older, or
• Under age 65 and disabled*, or
• Living with end-stage renal
disease (ESRD)
*Permanently disabled for 24 months or longer.
Medicare Election Periods
• Initial Enrollment Period (IEP):
3 months before, the month of, and 3 months after your 65th birth month
• Annual Enrollment Period (AEP):
October 15–December 7
• Medicare Advantage Disenrollment Period (MADP):
January 1–February 14
• Special Election Period (SEP):
Example: Loss of employer coverage or moving to new service area
Late Enrollment Penalties
• Part B Penalty:
If you don’t enroll in Part B when you are first eligible, you may have to pay
a penalty to get it later. The penalty is an additional 10% of the Part B
premium for every 12-month period that you delay enrollment. In most
cases, you will have to pay the penalty every month for as long as you have
Part B.
• Part D Penalty:
If you sign up for Medicare Part D after your Initial Enrollment Period, you
may be required to pay an additional 1% of the average monthly premium
each month, for as long as you are enrolled in a Part D plan.
Know Your A, B, Cs and D
Part A & Part B
Original Medicare
Know Your A, B, Cs and D
Part A - Hospital Insurance
• Part A covers:
 Inpatient hospital care
• Part A is free for most people
 Skilled Nursing Facilities (SNFs)
• There is a $1,260 Part A deductible
per benefit period
 Home health care
• After 60 days in the hospital, you pay:
 Hospice care
• Part A does not cover:
 Physician services or diagnostic
tests in the hospital
 Personal care items
 Private rooms
 Custodial care
 $315 per day copay for 61-90 days
 $630 per day copay for 91-150 days
 After day 150, you pay all hospital costs
Know Your A, B, Cs and D
Part B - Medical Insurance
• Part B is optional coverage
• There is a $104.90 standard per month premium
• There is a $147 annual deductible
• Original Medicare covers 80% of most Part B costs,
leaving you to pay the other 20% for services, like:
 Most physician services
 Home health care
 Outpatient therapies
 Durable medical equipment
• Delaying retirement at age 65?
 You can decline Part B
 No penalty if you enroll within 8 months
of retirement and have a creditable drug
coverage plan
Know Your A, B, Cs and D
Part C - Medicare Advantage Plans
• Medicare Advantage Plans are
offered by private companies
• Cover some of the costs not covered
by Medicare
• Often include extras like fitness and
wellness programs
• Many also offer Part D prescription
drug coverage
• Types of Medicare Advantage Plans:
 Health Maintenance Organization (HMO)
HMOs typically require you to access care from network
providers and hospitals, except for an emergency
 HMO with Point of Service (HMO-POS)
Like an HMO, you select a primary care provider from the
plan’s network, but you have the ability to see doctors
outside the network, usually at a higher cost
 Preferred Provider Organization (PPO)
PPO plans allow you to access care from in and
out of network providers, usually for a higher cost
 Special Needs Plans (SNP)
SNPs are for people with chronic illnesses, older adults
with limited incomes, and those living in nursing homes.
Know Your A, B, Cs and D
Part D - Prescription Drug Coverage
• Voluntary program
• Run by private companies
• You pay a monthly premium
• You pay a portion of the drug cost
• Plan designs must be equal to or better than
standard Medicare benefit designed by CMS
• Coverage varies from plan to plan
*VA and Part D benefits not coordinated
• Part D Coverage Options:
 Medicare Part D Plans
• Stand-alone Prescription Drug Plans (PDP)
• Medicare Advantage Prescription Drug Plans (MAPD)
 Employer Group Plans
• Plans must be creditable to avoid Part D penalties
 Military Plan Coverage
• Provides creditable coverage
• You may have both the VA and Part D coverage*
How Medicare Part D Phases
Work Annually
4
1
3
2
YOU pay $2.65/Generic
and $6.60/Brand or 5%
5%
COPAY
4 Catastrophic
YOU 5%
PLAN 95%
$4,700
3 Coverage Gap
YOU 45%
YOU 65%
BRAND
GENERIC
2 Initial Coverage
YOU 25%
PLAN 75%
1 Deductible
YOU 100%
PLAN 0%
$2,960
$320
This is an example of how Medicare Part D works and is not intended to portray a specific plan. In some instances, these costs
will be approximate amounts.
Part D Extra Help
• Low Income Subsidy (LIS) is
available from the government if
you meet certain requirements.
• Those that qualify may get help
paying monthly premiums,
copays, coinsurance, and
deductibles.*
• Do you qualify? You don’t know
unless you apply.
*Premiums, copayments, coinsurance, and deductibles may differ depending upon the level of help for which beneficiaries may qualify.
Your Medicare
Coverage Options
Your Medicare Coverage Options
START with
Original Medicare
Part A
(hospital insurance)
DECIDE if you want more coverage
Option 1
Option 2
Medicare Part D
Prescription Drug Plan
Medicare Advantage Plan
•
•
+
Part B
and / or
(medical insurance)
Medicare Supplement
Insurance Plan
•
Combines Parts A&B
Many cover prescription
drugs and may include
extra benefits
Your monthly plan premium
could be as low as $0*
Premera
Blue Cross
Medicare
Advantage
Medicare Advantage Eligibility
You Must:
•Have Medicare Parts A & B
•Continue to pay Part B premium
•Not have ESRD in most cases
•Live in plan service area
•Have a valid election period
Premera is proud to present our
2015 Medicare Advantage Products
Premera
Blue Cross
Medicare
Advantage
(HMO)
Premera
Blue Cross
Medicare
Advantage Plus
(HMO)
Premera
Blue Cross
Medicare
Advantage
(HMO-POS)
Premera
Blue Cross
Medicare
Advantage Plus
(HMO-POS)
Any Questions?
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for being here today!
Important Plan Information
Premera Blue Cross is an HMO and HMO-POS plan with a Medicare contract.
Enrollment in Premera Blue Cross depends on contract renewal.
You must continue to pay your Medicare Part B premium. The benefit information
provided is a brief summary, not a complete description of benefits. For more
information, contact the plan.
Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy
networks, provider networks, premium, and/or copayments/coinsurance may change on
January 1 of each year. You may also refer to the Summary of Benefits or Evidence of
Coverage (EOC) for more information.
Premera Blue Cross is too new to be rated with a Medicare Star rating.
Premera Blue Cross is an Independent Licensee of the Blue Cross and Blue Shield
Association.
H7245_PBC0357_Approved
030426 (02-2015)