In this presentation we review Medicare, it's co-pays and deductibles along with eligibility requirements for seniors.

2. 1. When Medicare coverage begins
2. The four components of Original
Medicare
3. Coordination of Benefits
4. Special focus on Part D and
Immunosuppressants
Understanding Medicare 2

3. a. Age: The 1st of the month in which
you turn 65 *
b. Disability: The 25th month you
receive disability benefits *
c. ESRD: The 4th month of dialysis*
Understanding Medicare 3

4. DISABILITY
 Medicare begins 24
months after Social
Security benefits begin
• Exception ALS (Lou
Gehrig’s) – Medicare
begins the month
benefits begin
• Eligible for Medicare
based on age at 65
ESRD
Medicare begins:
• 1st day of 4th month of
dialysis
• Or 1st day of 1st month of
home dialysis
Medicare ends:
• 12 months after the month
dialysis stops or
• 36 months after the month
of the kidney transplant

5. Part A
Hospital
Insurance
Part B
Medical
Insurance
Part C
Medicare
Advantage
Plans
HMO/PPO
Includes Part
A, B, D
DDDDsometi
mes Part D
coverage
Part D
Medicare
Prescrip-
tion Drug
Coverage
Getting Started
5

6. For Each
Benefit Period
in 2017
You Pay
Part A Deductible $1,316
Days 0 - 60 $0
Days 61 - 90 $329 per day
Days 91 – 150
$658 per day
( 60 lifetime reserve days)
All days after 150 All Costs

7. Getting Started 7
For Each Benefit
Period in 2017
You Pay
Days 1-20 $0
Days 21-100 $164 per day
All days after 100 All Costs

8. ◦ Doctor’s visits
◦ Outpatient medical services
◦ Clinical lab tests
◦ Emergency Department Services
◦ Durable Medical Equipment
◦ Outpatient Chemotherapy
Understanding Medicare 8

9. ◦ Some home health services
◦ Kidney dialysis
◦ Mental health care
◦ Preventive services
◦ and more
◦ For a complete list of covered see
“Medicare and You”
Understanding Medicare 9

10. 11.14.15Getting Started 10
2017 You Pay
Monthly Premium
$134.00 (most people)
[$109.00]
Yearly Deductible
(once)
$183.00
Medicare Covered
Services
20%
(if provider accepts
“Assignment”)

11. Understanding Medicare 11

12.  YOUR period of Guaranteed Issue Rights
to purchase a Medigap:
 The first 6 months you are at least 65 AND
have Part B
 For 63 days after an Advantage plan or an
employer group health plan (including retiree
or COBRA coverage) that pays after Medicare
pays ends
Understanding Medicare 12

13.  Primary Payers
 Secondary Payers
 Payers of last resort
 ESRD 30-month Coordination
Period

14. Medicare is your only
insurance
Coordination of Benefits 14

15. If You … Medicare Pays ….
Or your spouse is actively working
and has an EGHP
Second …. Unless..
65 or older with EGHP coverage
through current employment (yours
or your spouse’s)
First if the employer has less than 20
employees
Under 65 with a disability and have
EGHP through current employment
(yours or family member’s)
First if the employer has less than
100 employees
Eligible for Medicare due to End-
Stage Renal Disease (ESRD) and you
have EGHP coverage
First when the 30-month
coordination period ends, or if you
had Medicare primary before the
ESRD

17. Coverage Starts Under the Following Circumstances
1st day of the 4th month You get a regular course of dialysis in a facility
1st day of the month of
the 1st month of dialysis
You participate in a home dialysis training program
during the first 3 months of the regular course of
dialysis – w/ expectation to complete
1st day of the month You get a kidney transplant
1st day of the month Admitted to a Medicare-approved facility for a
kidney transplant or procedures preliminary to a
kidney transplant if transplant takes place in the
same mo. or within the following 2 mos.
2 months before the
month of your
transplant if…
Your transplant is delayed more than 2 months
after you’re admitted to the hospital for the
transplant or for health care services you need for
the transplant

18.  If enrollment is based solely on ESRD
◦ Your GHP/employer coverage is the only payer
during first 3 months
 Medicare is the secondary payer during the
30-month coordination period
 Separate coordination period each time
enrolled based on ESRD
◦ No 3-month waiting period
◦ New 30-month coordination period if you have GHP
coverage
Medicare for People With End-Stage Renal Disease 18

19. Medicare Getting Started 19

20.  Part A generally pays for all drugs
during a covered inpatient stay
 Drugs used in hospice care for
symptom control and pain relief
20

21. • Most injectable and infusible drugs given as part
of a doctor’s service
• Drugs used at home with some durable medical
equipment (DME)
e.g. nebulizers and infusion pumps
• Certain oral anti-cancer
• Can cover immunosuppressive drugs under
certain conditions
21

22. If You … Immunosuppressive Drugs
Are entitled to Part A at time
of transplant and
 Medicare paid for your
transplant and the
transplant took place in a
Medicare-approved facility
or
 Medicare was secondary
payer but made no payment
Are covered by Part B
 Medicare pays 80%
 You pay 20%
Didn’t meet the transplant
conditions above
May be covered by Part D
(unless you would be covered
by Part B, but you haven't
enrolled in Part B)
22

23. Getting Started 23
2017 You Pay
Monthly Premium
Plan premium
(base price + income adj.)
Yearly Deductible
(once)
$0 - $360
For drugs on the
plan’s formulary
Coinsurance
(preferred network providers
are usually more affordable)

24. The Coverage Gap
Year What You Pay for Covered
Brand-Name Drugs in the
Coverage Gap
What You Pay for
Covered Generic Drugs
in the Coverage Gap
2017 45% 65%
2017 45% 58%
2017 40% 51%
2018 35% 44%
2019 30% 37%
2020 25% 25%
Medicare Prescription Drug Coverage 24

25. Things to Consider:
1. Plan formularies
2. Preferred v. standard pharmacies
3. Pre-Authorizations
4. Step Therapy
Understanding Medicare 25

26. 26
Open Enrollment
October 15 – December 7
Using immunosuppressants to
do a 2017 Part D search….

27. • Part A and Part B services
• Usually includes prescription coverage
• The plan may have a monthly premium
• May include benefits not usually covered:
• Dental, vision, hearing
Co-pays for appointments, services, hospital
stays, etc.
Costs may be higher out of network
Medicare Advantage and Other Medicare Health Plans 27

28. 1. www.medicare.gov
2. www.socialsecurity.gov
Understanding Medicare 28

29.  State Health Insurance Assistance
Program
 Free Local Help for People
with Medicare
Understanding Medicare 29