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ARC - A Benefits Navigation Presentation
- 1. Navigating Your Benefits and Healthcare System
- 6. Medicare Basics Known as Original Medicare Medicare Part A Hospital Part B Medical Part D Prescription Part C Medicare Advantage Medicare Health Plans (PPO, HMO, PFFS, SNP)
- 8. Medicare Part A Overview
- 12. Medicare Part B Overview
- 16. Medicare Prescription Drug Coverage
- 22. www.medicare.gov Prescription Drug Plan Finder
- 23. Part C -Medicare Advantage Private Health Plans Pays plan to provide Part A and B coverage Pays company $$ per person enrolled Medicare Medicare Advantage Plan
- 30. What card do I use?
- 33. Financial Assistance for Medicare Health Costs
- 37. To Apply for the Extra Help Visit www.ssa.gov
- 38. Resources for Bridging the Coverage Gap http://www.medicare.gov/bridging-the-gap.asp
- 50. Mymedicare.gov Virtual Tour http://www.mymedicare.gov/WBTMain.asp
- 53. What is Long-Term Care? How is it paid for?
- 55. Long-Term Care Activities of Daily Living (ADL’s) Instrumental Activities of Daily Living (IADLs) Bathing Dressing Eating Using the Toilet Transferring Continence Grocery Shopping Laundry Preparing Meals Housework Managing Medication Transportation
- 57. Long Term Care Settings Informal Care Formal Care Unpaid Caregivers Family & Friends Caregiver Support Home Care Services Community-Based Services Residential Care
Hinweis der Redaktion
- Good __morning/afternoon. My name is _________________ and I am a RSVP or ARC volunteer. Through this program, we are informing people about important resources and benefits.
- We will cover the following topics today: Medicare Enrolling and Managing Medicare Resources to help pay for Medicare costs Resources to help with medication cost And Long Term Care I will also show you some online tools and resources to enroll in benefits, manage benefits, or just learn more about them.
- Everything that we cover today can be found in one place at www.agewiseconnection.com. So you only have to remember one website address.
- You qualify for Medicare if you meet the following: You are a US citizen or resident VISA holders who has lived in the US for five consecutive years and you are 65 years or older and eligible for Social Security or Railroad Retirement Benefits 65 or older and married to someone eligible for Social Security/Railroad retirement Have received Social Security Disability income for at least 24 months Have ESRD (kidney failure) or ALS (Amyotrophic Lateral Sclerosis)
- SSA advises people to apply for Medicare benefits 3 months before age 65. If you meet all the requirements, SSA will enroll you in Medicare starting the first day of the month you become age 65. You don ’ t have to be retired to enroll in Medicare. Except for people with certain disabilities or ESRD, Medicare benefits can begin no earlier than the month you turn 65.* If you are already receiving Social Security benefits, you will be automatically enrolled in Medicare without an additional application. You will receive a welcome to Medicare package, which includes your Medicare card and other information about 3 months before age 65 or your 25 th month of disability benefits. (Note: People with ALS — Amyotrophic Lateral Sclerosis, or Lou Gehrig ’ s disease — automatically get Part A the month their disability benefits begin.) If you are not already getting benefits, you should call SSA at 1-800-772-1213 3 months before your 65 th birthday, even if you plan to continue working. (TTY users should call 1-800-325-0778.) *(Note: If your birthday falls on the first day of a month, you are eligible for Medicare beginning the first day of the previous month.)
- Medicare has 3 main parts. Part A which is the hospital coverage Part B which is the medical coverage Part D which is the prescription coverage Then there is part C/Advantage plan or Medicare Health Plans. We will now cover each part in more detail.
- Part A and or Part B is known as original Medicare. Which original Medicare you can go to any provider you accepts Medicare. You are responsible for pay the Part B premium of $96.40, deductibles and co-insurance costs.
- Now we will go over Medicare Part A
- Medicare is awarded at age 65 or if a person has received disability payments for 24 months. There is no premium for those who have 40 quarters of Medicare-covered Employment (or from a spouse). Medicare-covered employment means they worked at a job where they paid into Medicare. Part A premium for others: $423/month for those with less than 40 quarters of Medicare covered employment
- Hospital Services: Covered services Semi-private room Meals General nursing Other hospital services and supplies 190 days in a lifetime for inpatient mental health These services are not covered by Medicare Part A inpatient hospital services. Blood Part A: Beneficiary responsible for first 3 pints Beneficiary responsible for 20% coinsurance for >3 pints during hospital/SNF stay Benefit Period -Begins day 1 in hospital -Ends when beneficiary has not received hospital or skilled care for 60 consecutive days -Beneficiary may have as many benefit periods as needed in a lifetime Lifetime Reserve Days -60 additional days that Medicare will pay if hospitalized for >90 days -Can be used only once during lifetime
- These are your part A cost responsibilities. $1,068 deductible Per Benefit Period $267 Per day for days 61-90 $534 Per day for 91-150 (Lifetime Reserve Days) All costs for each day beyond 150 days
- Now we will review Medicare part B.
- Part B covers the following services: Doctor Services Outpatient therapy Outpatient mental health services Some preventive health care services Clinical laboratory services Durable medical equipment (DME) Outpatient hospital services Blood Ambulance service
- Your initial enrollment period for Medicare Part B is the 3 months before you turn 65, the month you month your turn 65, and then 3 months following you turning 65. You can enroll before 65 if you have received 24 months of Social Security Disability benefits.
- These are your part B cost responsibilities. $96.40 monthly premium $135 per year deductible in 2009 20% co-insurance for most services
- Now lets go over Medicare Part D or prescription drug coverage.
- Medicare Part D is your prescription drug coverage. You must enroll in Part D within 90 days of Medicare eligibility or a penalty will be applied. The penalty is 1% of the national average premium times as many months you could have been enrolled. Penalty is waived if you have creditable drug coverage through another insurance provider perhaps through work or retiree/union health plan. You can receive Part D benefits through a stand alone drug plan or a Medicare Advantage Plan.
- Anyone who has Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), or both Part A and Part B, and who lives in the plan’s service area is eligible to join a Medicare Prescription Drug Plan. To get prescription drug coverage through a Medicare Advantage Plan, generally the person must have both Part A and Part B of Medicare. Each plan has its own service area, and people must live in a plan’s service area to enroll. People in the U.S. territories, including the U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of Puerto Rico, and the Commonwealth of Northern Marianas, can enroll. As we said earlier, people who live outside the U.S. and its territories or who are incarcerated are not eligible to enroll in a plan and therefore cannot get this coverage. It’s important to understand that Medicare prescription drug coverage is not automatic. A person must enroll in a Medicare drug plan to get Medicare prescription drug coverage. So while all people with Medicare can have this coverage, most must take action to get it. Later on in this module, we will discuss the auto and facilitated enrollment processes for people eligible for the extra help. A person can only be a member of one Medicare drug plan at a time.
- You can enroll in Medicare Part D during your initial Medicare Enrollment Period, during the Annual Coordinated Election Period for Part D which November 15 to December 31, or during Open enrollment for Medicare Advantage plans which is January 1 to March 31. During the Annual Coordinated Election Period you can enroll in a stand along prescription drug plan or a Medicare Advantage Plan with prescription coverage. During Open Enrollment for Medicare Advantage you can only enroll in a Medicare Advantage plan that offers drug coverage.
- The Part D “donut hole” or “gap” is the time frame in which your drug costs are 100% your responsibility. Getting into the gap: You pay copays or coinsurance for each prescription filled; the plan pays the remainder until drug costs (retail) reach $2,700 The gap: You pay 100% of drug costs until out of pocket for the calendar year equal $4,350 After the Gap (Catastrophic Coverage): Small coinsurance charged for each drug until end of year.
- www.medicare.gov offers a prescription drug plan finder tool where you can enter your medications and get a cost comparison of plans based on that information.
- Medicare Advantage plans are an option . You DO NOT have to enroll in one. You can choose to remain in Original Medicare Part A and Part B or you can choose to enroll in a Medicare Advantage plan. An advantage plan replaces your original Medicare of Part A and B.
- Medicare Advantage plans or Part C: Replaces the manner in which benefits for Original Medicare are provided Offered through private companies May offer extra benefits including Part D coverage Most require additional premium in additional to annual Medicare premium Coinsurance/Co-pays May offer some vision or basic dental benefits For enrollment, MUST: Have Medicare Part A and Part B Live in plan’s geographical service area
- Medicare Manage Care Plans (HMOs)- See doctors in plan’s network Medicare Preferred Provide Organization (PPOs)- See any doctor, but costs less to stay in network Private Fee-for-Service Plans-You can see any doctor that accepts the plan’s payment terms. Private company-not Medicare-negotiates prices *Beneficiary should always verify whether or not their physician accepts Medicare Advantage Plan
- Someone may choose an Advantage plan because: Generally includes Physical Exam annually May include some Dental, Vision or Hearing Coverage Often , fixed copay for doctor services Sometimes , lower hospitalization costs Often, a lower monthly premium than Medigap
- Choosing an Advantage plan may: Result in cost savings for medical care for some people Offer additional services not covered by Original Medicare Any Medicare beneficiary can enroll and receive benefits – no pre-existing condition exclusion or waiting period for coverage
- To be sure a Medicare Advantage plan is right for you, you need to clearly understand the plan and feel comfortable with the copayments you pay for the care you receive. A Medicare Advantage Plan is NOT a replacement for your Medigap policy. Before you enroll in a Medicare Advantage Plan, answer the following questions: 1. Are my doctors and hospitals covered by the plan? That is, do they accept the plan’s terms and conditions? 2. Do I need a referral to see a specialist? 3. Can I get care outside the plan's service area or network? If so, how? 4. What costs are involved in the plan (premium, deductible, copayments)? 5. Are my prescriptions covered by the plan? 6. What are copayment requirements for lab tests, diagnostic tests, x-rays, MRI scans, or CT scans?
- You can enroll in Medicare Advantage plan when you first become eligible for Medicare or during the open enrollment period. If the plan does have Part D coverage, you must find out what your prescriptions will cost in the plan you are considering.
- No longer ask the provider “Do you take Original Medicare?” Instead need to ask “Do you take ABC company’s Medicare Advantage plan”
- You can enroll by calling Medicare or the insurance company that is offering the plan you want to enroll in. You can also visit www.medicare.gov to enroll.
- Now we are going to look at some resources to help costs.
- Georgia Department of Community Health administers Medicaid in Georgia which includes the Medicare Savings Programs. To qualify for these programs you must be: Over age 65 or blind or Disabled Must be a citizen, or legal permanent resident (Read through the eligibility information in the chart)
- You can visit the Georgia Compass site to learn more. COMPASS is the Common Point of Access To Social Services in Georgia. This website is a quick and easy way for people who live in Georgia to find out if they might be able to get: assistance with paying Medicare Part B premium and co-insurance , Medicaid benefits, help with buying food, low or no-cost health care, home energy assistance, cash assistance, and more.
- There is also the Extra Help benefit for Medicare Part D. A person qualifies if their income is below $1354 a month for a single person or $1821 for a couple and your assets are below $12,510 for a single person or $25,010 for a couple. If you qualify for the Extra Help you would have no or low premium for Part D, you would no or a low deductible, and you would have a small copayment for each prescription. You would also have coverage through the Part D “gap” or “doughnut hole.”
- You can apply for the Extra Help benefit by visiting www.ssa.gov.
- Now lets go over some resources for “Bridging the gap” if you do not qualify for the Extra Help benefit. Visit www.medicare.gov to learn more about ways to bridge the gap.
- You may be able to access a prescription assistance program to obtain assistance with medications. The following are resources to help you find programs: Partnership for Prescription Assistance Needy Meds And RxAssist
- Benefits CheckUp is a service of the National Counsel on Aging. BenefitsCheckUp includes more than 1,700 public and private benefits programs from all 50 states and the District of Columbia. You can find benefits programs for all of these things. (Read a few from the list on the slide.)
- Now let’s talk about Medigap. Medigap is sold by private insurance companies to cover the “gaps” or costs that Medicare does not cover. *You must have Part A&B to enroll *Premiums may be less for SELECT policies There are 12 types of plans. Some plans may require use of certain providers.
- You can enroll in a Medigap plan anytime after enrolling in Medicare Part B. However, the Medigap open enrollment period is the 6 months following your enrollment in Part B. During the Open Enrollment period you can not be turned down for any reason or be charged more because of existing health conditions. If you switch from one policy to another No waiting period if you buy the same or lesser plan. If you purchase a higher plan there may be a waiting period for the new benefits. -6 months if you had no previous health care coverage for the pre-existing condition-Shortened by months of previous creditable coverage
- 01/23/08 A Medigap policy only works with Original Medicare. Medigap policies won’t work with Medicare Advantage Plans or other Medicare plans. In fact, it is illegal for anyone to sell you a Medigap policy if you: Are in a Medicare Advantage Plan (unless your enrollment is ending) Have Medicaid (unless Medicaid pays for your Medigap policy or only pays your Medicare Part B premium), or Already have a Medigap policy (unless you are canceling your old Medigap policy). If you have a Medigap policy and you join a Medicare Advantage Plan or other Medicare plan, you may want to drop your Medigap policy. Even though you are entitled to keep it, it can’t pay for benefits you get under your Medicare Advantage Plan or other Medicare plan and can’t pay any cost-sharing under these plans. If you are in Original Medicare and you have a Medigap policy, you can go to any doctor, hospital, or other health care provider that accepts Medicare. However, if you have the type of Medigap policy called Medicare SELECT, you must use specific hospitals and, in some cases, specific doctors to get your full insurance benefits.
- 01/23/08 So far we’ve talked about what Medigap is. Let’s review some key points. Medigap is insurance sold by private insurance companies. It is designed to fill the gaps in Original Medicare There are standardized Medigap insurance plans labeled A through L Costs vary by plan, by company, and by where you live Medigap can help cover costs that are not covered by Medicare. But we also need to understand what Medigap is NOT. A Medigap policy is different from: Medicare Advantage Plans Medicare Part B Medicare Prescription Drug Plans Medicaid An employer or union group health plan TRICARE, and Veterans’ benefits
- 01/23/08 To buy a Medigap policy, you generally must have Medicare Part A and Part B. If you are under age 65 and have a disability or End-Stage Renal Disease (ESRD), you may not be able to buy a Medigap policy until you reach age 65. We will cover Medigap policies for people under age 65 later in this presentation. You are guaranteed the right to buy a Medigap policy if you are: In your Medigap open enrollment period, or Covered under a Medigap protection The best time to buy a Medigap policy is during your Medigap open enrollment period. Under Federal law, your Medigap open enrollment period lasts for 6 months. It starts on the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B. Laws may be more generous in some states. In some situations, you have the right to buy a Medigap policy outside of your Medigap open enrollment period. These rights are called “Medigap protections.” They are also called guaranteed issue rights because the law says that insurance companies must sell (“issue”) you a Medigap policy even if you have health problems. We will discuss Medigap guaranteed issue protections later in this presentation. [Note to instructor: Omit last sentence if not presenting Lesson 2.]
- 01/23/08 You may want to buy a Medigap policy because Medicare does not pay for all of your health care. There are “gaps” or costs that you must pay in Original Medicare. If you are in Original Medicare, a Medigap policy may help you: Lower your out-of-pocket costs Get additional health insurance coverage
- The Medigap (Medicare Supplement Insurance) Policy Search tool gives information on different types of Medigap policies by area and the contact information on the companies that offer them.
- Once you are enrolled in Medicare, you can use www.mymedicare.gov to: View claim status (excluding Part D claims) Order a duplicate Medicare Summary Notice (MSN) or replacement Medicare card View eligibility, entitlement and preventive services information View enrollment information including prescription drug plans View or modify your drug list and pharmacy information View address of record with Medicare and Part B deductible status Access online forms, publications and messages sent to you by CMS
- You can go this page to get a tutorial on how to use the mymedicare.gov site.
- Medicareinteractive.org is a great site to learn more about Medicare.
- Now let’s talk about long term care.
- Most long term care is paid for privately out-of-pocket! About 2/3 of those over age 65 will need some LTC, for an average of 3 years. Nearly 1 in 4 people provide long-term care to friends and relatives. 75% Americans have made no preparations for their own or loved one’s LTC needs 21% have purchased Long Term Care Insurance
- Long-term care can be defined as the medical and non-medical support services needed by an individual with a prolonged illness or disability to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs). ADLS are personal care and mobility activities that are necessary for everyday living.
- Reality – less than 15% persons who need long term care need skilled care Goal of personal care is to provide help with activities that individuals are unable to perform on their own. Most people who need long term care need personal care. Supervisory care: a safe or controlled environment, and stand-by help with ADLs to ensure that individuals do not harm themselves or others. Supervisory care is often needed because of a severe cognitive impairment.
- Informal Care: These caregivers are usually family members or friends who may provide a variety of services to assist their relatives or neighbors, from paying bills and preparing meals to helping them bathe or dress. Formal care is provided by paid caregivers or community based programs. In many cases, individuals will use a combination of different services in order to meet their LTC needs. For example, individuals may receive both formal home health care services and informal care from a family member or they may attend an adult day care program in addition to receiving home health care services.
- What we need to consider - fact that although we may be living healthier, longer lives, living longer also creates the potential for us to need some type of long term care in our advanced age. By planning for long term care you will have more control, choice, and options.
- Medicare.gov offers a long term care planning tool. The primary goal of this tool is to help you understand: What long-term care services are available, how much you can expect to pay for long-term care, and what financing options are available to support your long-term care costs.
- Agewise Connection has a retirement section to help you think broadly about retirement and planning. It also provides resources to help you plan for your future.
- Everything we covered today can be found at www.agewiseconnection.com.
- Thank you so much for your participation today. Please complete the post presentation questionnaire.