Welcome to Medicare
Medicare 101
XXXX, Regional Manager
Seniors’ Health Insurance Information
Program (SHIIP)
Understanding
Medicare
• The Primary/Secondary relationship
of coverage.
• How various Medicare Insurance
products work together.
• Enrolling in and changing
coverage is only allowed during
certain periods.
What is Medicare?
• Federally sponsored Individual
Health Plan providing coverage for
Medically Necessary procedures and
services.
• Medicare coverage requires copays,
coinsurance and deductible
payments that are the responsibility
of the beneficiary (or other
Secondary Insurance).
Who is Eligible for Medicare?
• Anyone age 65 or older who has participated in
Social Security, Railroad Retirement System or
employees of Federal, State, or Local
Governments or whose spouse has participated.
• Individuals under age 65 that have been awarded
Social Security or Railroad Retirement Disability
after 24 months.
• Those disabled due to ALS (Lou Gehrig's
Disease).
• Individuals with End Stage Renal Disease
(ESRD).
What does Original
Medicare Cost?
Part A is premium free to most beneficiaries
based on having contributed 40 quarters into
the Medicare system. For those with less than
30 quarters, Part A has a premium.
Part B premium based on income. If you are
single and your income is over $85,000 or if
married and your income is over $170,000, you
will pay more for your monthly premium.
Otherwise the Part B premium is $104.90 per
month.
What does Original Medicare Cover?
Medicare Part A
• Inpatient Hospital
Coverage
• Skilled Nursing Care in a
facility (requires a
minimum 3 day prior
hospitalization)
• Home Health Care
• Hospice
• Blood
Medicare Part B
• Following services are
generally covered at
80%:
– Physician Services
– Outpatient Surgery and
Services
– Home Health Care
– Durable Medical
Equipment
– Blood
Medicare benefits are administered by the Centers for Medicare and Medicaid
Services (CMS) 1-800-633-4227
What Is NOT Covered by
Original Medicare?
•
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Prescription Medications
Routine Dental Care
Routine Vision Care & Eyeglasses
Hearing Aids
Foreign Travel
Cosmetic Procedures & Treatments
Long Term Care
How Does One Enroll in
Medicare?
Automatic Enrollment
• Individuals collecting Social Security Retirement Benefits
prior to age 65.
• Individuals entitled to Social Security Disability Benefits.
• Beneficiary will receive Medicare Card in the mail
indicating automatic enrollment in Part A and B.
– Beneficiary has option to decline Part B coverage by
returning card to Social Security.
• Coverage will begin 1st day of birth month unless
birthday is the 1st of month in which case coverage
begins first day of preceding month.
How Does One Enroll in
Medicare? (cont’d)
Initial Enrollment Period
Individuals turning age 65 and NOT collecting Social Security
Retirement have an initial 7 month period to enroll in Medicare. This
includes the 3 months prior to 65th Birthday, the month of 65th Birthday,
and the three months following the 65th Birthday.
• Medicare benefits take effect the first of the month of your 65th Birthday if
enrollment takes place in advance of the month of birth.
• Medicare benefits take effect the month following enrollment if done
during month of birth.
• Medicare benefits are delayed by two months if enrollment is done first
month after birthday month.
• Medicare benefits are delayed by three months if enrollment is done in
the second or third months after birth month.
How Does One Enroll in
Medicare? (cont’d)
General Enrollment Period
For those that do not enroll during their Initial Enrollment
Period there is another opportunity to enroll each year
during what is called the General Enrollment Period.
The General Enrollment Period is between January 1 and
March 31 of each year. Enrollments during this period
will have coverage beginning July 1.
Failure to enroll in Medicare when originally eligible results
in a 10% premium penalty for one’s lifetime for each 12
month period not enrolled (waived when Part B delayed
because of Primary EGHP coverage)
How Does One Enroll in
Medicare? (cont’d)
Special Enrollment
• If you or your spouse are “actively” working, then you
may be able to delay enrolling into Medicare Part B.
• If your employer plan is paying first, you would enroll into
Part A, and could delay enrolling into Part B. You would
pick up Part B after you stop working/retire without a
penalty.
– It is important to note that when you stop actively working, it is
necessary to enroll in Medicare Part B. It is not automatic
enrollment.
Where Do I Enroll?
Medicare enrollment is handled by the
Social Security Administration.
Contact Your Local Social Security Office
or Call
1-800-772-1213
Appointments can be made for local offices
through the above toll-free number.
Enrollment may also be completed online at
www.socialsecurity.gov.
Providers
Acceptance
and Choices
Assignment –
Medicare assigns a
reimbursement rate
for each service
based on a coding
system entered by
providers when filing
claims.
• Claims are paid based on the
providers decision to participate in
Medicare and whether they accept
assignment.
– Providers may or may not accept
Assignment.
• If provider accepts Medicare but
NOT assignment – Allowed to
charge 15% above Medicare
assigned charges – Applies to
Doctor charges only.
• It is possible that a provider does not
accept Medicare.
• NOTE: Hospitals and other
providers such as Ambulance
providers have to accept Medicare
Assignment.
The Decisions
• Do I need Part B of Medicare
immediately?
• Do I already have an Employer
Group Health Plan (EGHP) from a
previous employer?
• Do I want to exchange my benefits
under Original Medicare for a private
plan?
• Do I need a Medicare Prescription
Drug Plan?
• Do I need a Medicare Supplement
(Medigap) plan?
Do I Need Medicare Part B?
• Medicare is designed to be one’s PRIMARY
health insurance coverage.
• In most cases, any other coverage will pay
SECONDARY to Medicare.
• If you do not accept Medicare when eligible,
typically your Secondary Insurance/EGHP will
pay as if Medicare was primary. You (the
beneficiary) will be responsible for the
payments Medicare would have made had it
been in place.
• Failure to enroll in Medicare when originally
eligible results in a 10 percent premium penalty
for one’s lifetime for each 12 month period not
enrolled (this is waived when Part B is delayed
because of Primary EGHP coverage when you
or your spouse are actively working).
When is Medicare Secondary?
• Medicare may be secondary coverage when a
beneficiary is covered by an Employer Group
Health Plan based on current active employment
of the beneficiary or his/her spouse.
• Primary/Secondary relationship is based on age
of beneficiary and number of employees with the
Employer providing the Active Employee
coverage.
Medicare Secondary
• For beneficiary age 65 or above, and
covered by a group health plan because
beneficiary or spouse is still actively
working, Medicare IS secondary when
Employer has MORE THAN 20
employees.
• For beneficiary under age 65, and
covered by a group health plan because
beneficiary or spouse is still actively
working, Medicare IS secondary when
Employer has MORE THAN 100
employees.
Medicare Secondary
What To Consider?
• Typically Medicare pays very little as Secondary
insurance.
• Part A is premium free for most so having the
coverage has no cost to the beneficiary.
• Part B has a monthly premium which may
exceed the potential benefit.
• Medicare allows the delay of Part B Coverage
and has a Special Enrollment period for those
who make this choice. (Discussed earlier during
“How to Enroll”.)
Should a Beneficiary Continue
Employer Group Health Plan as
Primary?
• What is cost of the coverage?
• What additional benefits does the
coverage include?
• Are there dependents? Status of
those dependents?
• If cancelled, will plan allow future reinstatement?
Medicare is Primary
What Are Coverage Options?
You are not working and Medicare is your
primary coverage:
– Original Medicare only
– Original Medicare plus secondary
coverage such as an EGPH, TRICARE,
VA
– Medicare Advantage plan
– Medicare Supplement/Medigap plan
Medicare is Primary
Secondary Coverage Options?
• Medicaid – Low income individuals
• TRICARE for Life – Military Retirees and
dependents
• Federal and State plans for retirees and
dependents
• Employer Group Health Plans – Indemnity Style
plans
• Medicare Supplement (Medigap) Policy
Medicare Supplement
(Medigap) Plans
• Standardized Insurance plans sold by
private insurance companies designed
to cover “gaps” in Medicare coverage
(deductibles, copayments, and coinsurance, etc.).
• Plans are designated by letter codes
(A, B, C, D, F, G, K, L, M, N).
• All plans cover a basic group of
benefits, with plans each covering a
different group of “gaps”.
• Coverage is same from company to
company, but premiums do vary.
Medicare Supplement
(Medigap) Plans (cont’d)
• Pros:
– Match up with
Medicare benefits.
– Guaranteed
renewable as long
as premiums paid.
– Does not restrict
provider access.
– In most cases,
automatic
crossover of
claims.
– If claim paid by
Medicare, will be
paid by Medigap
plan.
• Cons:
– Cost: Premiums
vary by company
and may increase
over time.
– If you do not enroll
during your initial
open enrollment
period, may be
subject to
underwriting.
Medicare Supplement
(Medigap) Open Enrollment
• Those new to Medicare have an Open
Enrollment period for Medicare Supplement
plans which requires companies to accept
applicant at standard rates regardless of health.
• The Open Enrollment period is based on the
Part B effective date and is valid for 6 months
following enrollment.
Medicare Supplement
Guarantee Issue Rights
• If losing coverage under an Employer Group
Health Plan (EGHP) that is secondary to
Medicare, you will have a guarantee issue for
plans A, B, C, F, K or L. (If disabled and under
65, plans A, C or F.) You must apply within 63
days of the previous plan’s termination.
• Loss of coverage by Medicare Supplement or
Medicare Advantage plans that is outside the
control of the beneficiary also generates
Guarantee Issue rights.
Employer Group Plans for
Medicare Eligible
• Employer Plans come in many forms and can only
be understood on an individual basis.
• Some employers offer a variety of coverage options
to their retired employees.
• Plans may be Indemnity Style plans and work with
Medicare A and B in a manner similar to Medicare
Supplement plans.
• Some plans offer cash payments allowing
beneficiary to purchase their own coverage.
• Employer sponsored Medicare Advantage plans are
now being offered by some employers for their
retirees thus making the Medicare Advantage plan
their Primary Coverage instead of Original Medicare.
Why Consider a Medicare
Advantage (Part C) Plan?
• Structured and sometimes lower copayment levels for some services
(physician, hospital, E.R, etc.).
• Additional benefits not included in
Original Medicare such as Limited
Dental, Vision, Hearing.
• Plan may include Medicare
Prescription Drug coverage.
• Plans may have lower premiums than
a Medicare Supplement.
Medicare Advantage
(Part C) Limitations
• Plans may limit access to providers
(Physicians, hospitals, Skilled nursing
facilities, Home Health Agencies, DME
providers, Labs, etc.).
• Some copayments may be higher than
under Original Medicare.
• Limited service areas (however, if an
emergency you can go anywhere for
care).
• All plans may not be available in your
county of residence.
What about Medicare
Prescription Drug Coverage?
• Any one covered by Medicare (Part A and/or
Part B) is eligible to join a Medicare Prescription
Drug Plan (Part D).
• Plans are sold by private Insurance companies
and require payment of monthly premiums.
• Each plan covers a group of prescription
medications (Formulary list) and typically have
co-payments for prescriptions and possibly a
deductible.
• Plans and formulary lists may change from year
to year.
Do I Need Medicare Prescription
Drug Coverage?
• Do you have prescription drug coverage from
some other source such as an EGHP, TRICARE,
VA that is CREDITABLE? If yes, then in most
cases, you would not need a Part D plan.
• If you do not enroll in a Part D drug plan when
first eligible, you will be penalized 1% per month
in premium for each month you do not have
creditable coverage past original eligibility date.
– Penalty based on the national base premium and is
collected for life unless you have other creditable
coverage, or qualify for Low Income Subsidy or
Medicaid.
Choosing a Medicare Prescription
Drug Plan (Part D)
• Plan should be chosen based on analysis of prescription
medications, pharmacy used, monthly premium cost and
copayments through a comparison tool located on the
Medicare.gov web site. This comparison tool will assist in
determining best plan options based on your current
prescription drugs.
• Initial enrollment is allowed during the same initial
enrollment period as Medicare A/B.
• Annual election opportunity and change in plan is
allowed each year between October 15 and December
7, with coverage effective January 1 (Annual Election
Period).
Low Income Subsidy
(Extra Help) with
Medicare Prescription Drug Plans
• Those with limited incomes and assets may be
eligible for Extra Help with Medicare Prescription
Drug plan costs.
• If qualified will reduce or eliminate monthly
premiums and the coverage gap/donut hole and
provide reduced drug copayments and coinsurance.
• Extra Help (also known as Low Income Subsidy)
applications are processed by the Social Security
Administration.
• Medicaid beneficiaries automatically qualify for the
Extra Help program.
• If you qualify, you may be able to obtain a premium
free Part D plan and pay as little as $2.65 for your
generics and $6.60 for name brand drugs.
Qualifying for Extra Help (Low
Income Subsidy)
with Part D
• An individual can have a monthly income
of up to $1,471.25 to qualify and a married
couple can have a monthly income of up to
$1,991.25 to qualify.
• Assets can be up to $13,640 for an
individual and up to $27,250 for a married
couple. Assets do not include your home,
but do include checking, savings, IRA’s
and money market accounts.
What is a Medicare
Summary Notice? (MSN)
 This notice is like an Explanation of Benefits (EOB) for the
Medicare beneficiary.
 CMS will mail the Medicare Summary Notice quarterly. It
is possible to sign up with Medicare to view your MSNs
online through www.MyMedicare.gov.
 Take the time to review your notice. There is information
on the back of the form if you want to file an appeal.
 You are the “first line of defense” when it comes to catching
errors and possibly fraud.
 You also need to review the notices that you receive from
your providers/doctors and the notices from your
secondary insurance.
Where Can I Get help?
• Seniors Health Insurance Information
Program (SHIIP) 1-855-408-1212 or
www.ncshiip.com
• Senior Medicare Patrol (SMP) (Fraud
& Abuse) 1-855-408-1212
• Social Security 1-800-772-1213 or
www.socialsecurity.gov
• Medicare 1-800-633-4227 or
www.medicare.gov
• Employer health benefits
administrator
• Medicaid – Local County Social
Services
REV 03/2015