Medicare

1
Medicare the Medicare Modernization Act of 2003
Norma Lanier, State Outreach Coordinator First
Coast Service Options, Inc. July 12, 2005
2
Todays Discussion

• Review of Medicare basics
• Medicare changes in 2005 and 2006
• Preventive benefits covered by Part B
• Prescription Drug Benefit
• Medicare rights and protections
• Alzheimers and Medicare
• Program Evaluation

3
First, the Basic Facts
4
Medicare

• A health insurance program for
• People 65 years of age and older
• Some people with disabilities
• People with ESRD
• Administered by CMS nationally
• Administered by private contractors locally

5
Original Medicare
6
The Original Medicare Plan
Original Medicare

• You may go to any provider that accepts Medicare
• Part A is premium free for most people
• You pay Medicare Part B premium
• You pay deductibles
• You pay coinsurance

7
Medicare Part A Benefits

• Hospital stays
• Skilled nursing facility (SNF) care
• Home health care
• Hospice care
• Blood

8
A Benefit Period
Part A

• Medicares measure of hospital and SNF services
• Begins day admitted to hospital
• Ends when you have not received care in a
  hospital or SNF for 60 days in a row
• You pay deductible for each benefit period
• No limit to the number of benefit periods

9
Paying for Hospital Stays
Part A

• For each benefit period in 2005 you pay
• 912 deductible for a hospital stay of 1-60 days
• 228 per day for days 61-90
• 456 per day for days 91-150
• Part of your 60 Lifetime Reserve Days
• All costs for each day beyond 150 days

10
Skilled Nursing Facility Care
Part A

• Covered in full for the first 20 days
• After a minimum 3-day qualifying hospital stay
• You pay 114 per day for days 21-100
• You pay all costs after 100 days
• Does NOT include custodial care

11
Skilled Nursing Facility Care
Part A

• Must meet all of the following conditions
• Requires daily skilled services
• Inpatient in a hospital at least 3 consecutive
  days
• Admitted to SNF within 30 days after leaving
  hospital
• Care in SNF is for a condition treated in the
  hospital
• MUST be a Medicare participating SNF

12
Skilled Nursing Facility Coverage
Part A

• Semi-private room
• Meals
• Skilled nursing care
• Physical, occupational and speech-language
  therapy
• Medical social services
• Medications, medical supplies/equipment
• Ambulance transportation
• Dietary counseling

13
Home Health Care
Part A

• Covered services
• Part-time skilled nursing care
• Therapy
• Occupational
• Physical
• Speech-language
• Some home health aide services
• Durable medical equipment

14
Paying for Home Health Care
Part A

• You pay
• Nothing for covered home health care services
• 20 of the Medicare-approved amount for covered
  durable medical equipment

15
Hospice
Part A

• Special care
• People who are terminally ill
• Families
• If a person has less than 6 months to live
• Certification required for each period of care
• Two 90-day periods
• Unlimited 60-day periods
• Hospice must be Medicare-approved

16
Covered Hospice Services
Part A

• Medical equipment and supplies
• Drugs for symptom control and pain relief
• Respite care in a Medicare-certified facility
• Up to 5 days each time
• No limit to number of times
• Home health aide and homemaker services
• Social worker services
• Dietary counseling
• Grief counseling

17
Part B Benefits

• Doctors services
• Outpatient medical and surgical services and
  supplies
• Diagnostic tests
• Outpatient therapy
• Outpatient mental health services
• Some preventive health care services
• Other medical services

18
Enrolling in Medicare Part B
Original Medicare

• Initial Enrollment Period
• 7 months beginning 3 months before age 65
• General Enrollment Period
• January 1 through March 31 each year
• Coverage effective July 1
• Premium increases 10 for each year you were
  eligible but did not enroll
• You carry this increase for the rest of your life

19
Enrolling in Medicare Part B
Original Medicare

• Special Enrollment Period
• Sign up within 8 months of the end of employer or
  union group health plan coverage
• No increased premium
• For questions, or to enroll, call the Social
  Security Administration or Railroad Retirement
  Benefit

20
Covered Preventive Services

• Bone mass measurement
• Colorectal cancer screening
• Diabetes services and some supplies
• Glaucoma testing
• Screening mammogram
• Pap test/pelvic exam/clinical breast exam
• Prostate cancer screening
• Vaccination (shots)

21
Medigap

• Fills in gaps in the Original Medicare plan
• Must follow federal and state laws
• Standardized Plans A-J in most states
• Except Minnesota, Massachusetts, Wisconsin
• Dont need Medigap if in Medicare Advantage
• See Guide to Health Insurance for People with
  Medicare

22
Lets talk about more changes in Medicare
23
What We Heard

• People with Medicare want
• More choices
• Better benefits
• Health care delivery options
• Improved access to care
• Especially in rural areas

24
Medicare Modernization Act of 2003 (MMA)

• 2004
• Drug discount card
• Medicare Advantage

• 2006
• Prescription drug plans
• Two new Medigap policies

• 2005
• New preventive services
• Part B deductible 110-based on expenditures in
  future

25
New Covered Preventive Services

• Beginning January 2005
• Welcome to Medicare physical
• Initial physical exam
• Referral for screening and other preventive
  services
• Cardiovascular screening blood tests
• Screening blood tests for cholesterol and other
  lipids or triglyceride levels
• Diabetes screening tests
• Fasting plasma glucose test
• Other tests appropriate for persons at high risk

MMA
26
Medicare Prescription Drug Plans

• Available January 2006
• Offered through private prescription drug plans
  (PDPs)
• Can be offered by Medicare Advantage plans

27
Eligibility and Enrollment

• Must be entitled to Part A and/or enrolled in
  Part B
• Enrollment is voluntary
• Increased premiums for people who wait
• 1 percent of the base premium for each month you
  dont enroll
• After May 15, 2006
• Exception for those covered under other
  comparable insurance

28
Why Join a Plan?

• Medical practice relies on new drug therapies to
  treat chronic conditions
• Out-of-pocket spending on drugs has increased
• Most people need or will need prescription drugs
  to stay healthy
• Medicare insurance coverage for prescription
  drugs will protect from high out-of-pocket costs
• For most people, joining when first eligible
  means paying the lowest monthly premiums

29
Enrolling in a Plan

• People with Medicare can
• Enroll directly with the plan
• Have a personal representative enroll them
• Ask others to help them enroll

30
When to Enroll

• Join between November 15, 2005, and December 31,
  2006
• Coverage will begin on January 1, 2006
• Join between January 1, 2006, and May
  15, 2006
• Coverage will begin the first day of the month
  after the month joined

31
Medicare Prescription Drug Coverage

• Coverage begins January 1, 2006
• Available for all people with Medicare
• Provided through
• Private prescription drug plans
• Medicare health plans
• Some employers and unions for retirees

32
What it CostsHow it Works

• Pay a premium of about 37 each month
• In addition to Part B premium
• Enhanced benefit may cost more
• Pay a yearly deductible up to 250
• Pay part of the cost of covered prescription drugs

33
How it Works in 2006
34
Lower-Income Assistance

• People with limited resources
• Get extra help with their Medicare drug plan cost
• Lowest incomes
• Pay no premiums or deductibles
• Pay small or no copayments
• People with slightly higher incomes
• Pay reduced deductible
• Pay a little bit more out of pocket.

35
To Get Help Paying the Cost of Prescription Drug
Plans

• Person with Medicare must
• Reside in the United States
• Meet the income and resource requirements of the
  subsidy program
• Be enrolled in Medicare

36
To Get This Help

• Person does not have to do anything
• If currently receiving benefits from both
  Medicaid and Medicare
  or
• Receiving Supplemental Security Income benefits
  and Medicare
• Information will come in the mail from Medicare
• Explaining eligibility for this coverage, and
• What he/she should do this fall to enroll in a
  Medicare plan that offers prescription drug
  coverage

37
To Get This Help

• Person with Medicare must have
• Annual income less than 14,355 (single)
• Annual income less than 19,245 (married)
• AND
• Limited resources
• Application will come from Social Security
  Administration (SSA)
• Mail completed application to SSA
• For additional information, contact the SSA at
  1-800-772-1213

38
Medicare Advantage Plans
MMA

• Another Way to Get Your Medicare Benefits

39
Medicare Advantage Plans

• New name for MedicareChoice plans
• Medicare managed care plans
• Preferred Provider Organization plans (PPOs)
• Private-Fee-for-Service plans
• Available in some states
• Medicare Specialty Plans

40
If you join a Medicare Advantage Plan

• You still have rights and protections
• You are still in the Medicare program
• You still get all your regular Medicare-covered
  services
• You may be able to get extra benefits
• Coverage for extra days in the hospital

41
Medicare Patients Rights
Overview

• Right to
• Information about all treatment choices
• Participate in treatment decisions
• Get easy-to-understand information
• Know what costs are paid by Medicare
• Know how much you have to pay

42
Other Medicare Rights
Overview

• Right to
• Receive emergency room services
• Have your personal and health information kept
  private
• Right to non-discrimination You cannot be
  treated unfairly because of race, color, national
  origin. disability, age, sex, religion

43
Other Medicare Rights
Overview

• Right to
• Know what to do if you have to file an appeal or
  a grievance (complaint)
• An appeal is when
• Medicare does not pay
• Medicare does not pay enough
• You are not given a service
• A grievance is about quality of care issues

44
Medicare and Alzheimers

• Medicare beneficiaries diagnosed with Alzheimers
  disease have the same rights and coverage than
  any other person with Medicare.
• Part A covers inpatient mental health services,
  including room, meals, nursing care and other
  related services
• Part B covers outpatient mental health services,
  including visits with health professionals such
  as doctors, clinical psychologists, clinical
  social workers, and clinical nurse specialists
• Part B also covers laboratory services and
  partial hospitalization

45
For More InformationNational Sources

• Visit www.medicare.gov
• Call 1-800-MEDICARE (1-800-633-4227)
• TTY 1-877-486-2048

46
Please complete the Program Evaluation Form
Evaluation Form
Thank You!