Welcome to the MEDICARE TRAINING

1
Welcome to the MEDICARE TRAINING
A Continuing Education Course presented
by UNICARE Life and Health Insurance
Company Course 36387CA020
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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.

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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.

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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

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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

6

History of Medicare

• 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

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What is Medicare and Who is Entitled?

• 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 50of
  the nations elderly population had any health
  insurance.
• Today, only about 1 of the elderly are uninsured.

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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

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What is Medicare and Who is Entitled?

• 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)

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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

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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

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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 DRGs

13
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

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Who Pays For Medicare?

• 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.

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Who Pays For Medicare?

• 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.

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Who Pays For Medicare?

• 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.

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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.

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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.

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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.

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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.

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Medicare Enrollment

• Initial Enrollment Period
• Seven 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.

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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 spouses 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.

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Medicare Enrollment

• Extenuating Circumstances
• You can delay Part B enrollment if
• you are over 65 and have group health insurance
  through you or your spouses current employment,
  or...
• you are disabled and have group health insurance
  through you or your spouses current employment.

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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 Medicares next
  general enrollment period.

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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.

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Health Insurance Claim Number

• 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

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MEDICARE BENEFITS
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Medicare consists of two parts

• Hospital Insurance protection - PART A
• Medical Insurance protection - PART B

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MEDICARE BENEFITSPART A
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Medicare PART A provides institutional care,
including

• PART A
• Medicare helps pay for
• care in a hospital
• skilled nursing facility
• home health care
• hospice care

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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.

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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.

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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.

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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

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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.

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Part A Skilled Nursing Facility

• 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

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Part A Skilled Nursing Facility

• 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.

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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

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Part A Home Health Care

• 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.

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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.

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Part A Home Health Services Cover

• 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

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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.

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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.

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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

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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.

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Part AHospice Care

• 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.

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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)

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MEDICARE BENEFITS PART B
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Part B Benefits

• 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.

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Part B Covered Services

• Doctors services
• Outpatient hospital services
• Ambulance services
• Durable medical equipment
• Lab, X-ray and radiation therapy
• Other health-related services

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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.

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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)

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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.

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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.

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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.

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Part B Medicare Assignment

• 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.

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Part B Medicare Assignment

• 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

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Lets ReviewThe Gaps In Medicare
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Gaps In Hospital Part A

• 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

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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

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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

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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

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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

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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

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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

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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

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Standardization andMedicare Supplement
Medigap Policies
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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

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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.

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Standardization
Medicare Select is a type of standardized plan

• 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

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Standardization

• Every company selling Medicare
  Supplements must offer Plan A.
• Companys may then offer any of the remaining
  plans (B through J)

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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

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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

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Standard Plan B

• Includes Basic Plan A Benefits
• Pays Medicare Part A Inpatient Hospital
  Deductible (812 per 60 day benefit period)

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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

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Standard Plan D

• Includes Basic Plan A Benefits
• 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

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Standard Plan E

• Includes Basic Plan A Benefits
• 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

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Standard Plan F

• Includes Basic Plan A Benefits
• 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)

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Standard Plan G

• Includes Basic Plan A Benefits
• 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)

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Standard Plan H

• Includes Basic Plan A Benefits
• 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

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Standard Plan I

• Includes Basic Plan A Benefits
• 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)

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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

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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.

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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.

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Medicare Open Enrollment

• 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

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Medicare Open Enrollment

• 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.

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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

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Balance Budget Act of 1997You 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.

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Balance Budget Act of 1997You 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 plans service area, or your plans
  contract with Medicare ended.

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Balance Budget Act of 1997You 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.

91
Balance Budget Act of 1997

• 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.

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Balance Budget Act of 1997

• 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.

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Balance Budget Act of 1997

• 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)

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Balance Budget Act of 1997

• 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)

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Thank you for attending today's seminar on
Medicare!