Medicare Education by Ray McPherson
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Original Medicare vs Medicare Advantage
![Inpatient Hospital Ins.
Outpatient Medical Ins.
Part A
Part B
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
A
B
Part A
Part B
Most often
included
Part DRx – Prescription Drugs
[Stand Alone Plans]
Part D
Medi-Gaps
Medicare ADVANTAGE
Original Medicare
Federal Gov’t
2 Ways
To Get Medicare
10 Letter Plans in Washington
Use only by permission from Senior Insurance Services of NCW, LLC. VRM
Part C](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Medicare Education by Ray McPherson
- 2. Inpatient Hospital Ins. Outpatient Medical Ins. Part A Part B Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B Part A Part B Most often included Part DRx – Prescription Drugs [Stand Alone Plans] Part D Medi-Gaps Medicare ADVANTAGE Original Medicare Federal Gov’t 2 Ways To Get Medicare 10 Letter Plans in Washington Use only by permission from Senior Insurance Services of NCW, LLC. VRM Part C
- 4. Inpatient Hospital Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Part A [Hospital, Hospice, Homecare, Skilled Nursing, etc.] Original Medicare Federal Gov’t 2 Ways To Get Medicare Use only by permission from Senior Insurance Services of NCW, LLC. VRM Medicare ADVANTAGE Part C
- 5. Outpatient Medical Ins. Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% [Doctor, Outpatient Surgery, Ambulance, etc.] Part B Use only by permission from Senior Insurance Services of NCW, LLC. VRM Inpatient Hospital Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Part A [Hospital, Hospice, Homecare, Skilled Nursing, etc.] Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 6. Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B Inpatient Hospital Ins. Outpatient Medical Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% [Doctor, Outpatient Surgery, Ambulance, etc.] Part A Part B [Hospital, Hospice, Homecare, Skilled Nursing, etc.] [Monthly Changeable] [Network: Any provider that accepts Medicare]Medi-Gaps 10 Letter Plans in Washington Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 7. Use only by permission from Senior Insurance Services of NCW, LLC. VRM
- 8. NF 100% $179-$188 100% K 50% $57 $4940 MOOP $128 Pt. B $147 Doc/$20 - ER/$50 Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B Inpatient Hospital Ins. Outpatient Medical Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% [Doctor, Outpatient Surgery, Ambulance, etc.] Part A Part B [Hospital, Hospice, Homecare, Skilled Nursing, etc.] G $158 Pt. B $147 [Monthly Changeable] [Network: Any provider that accepts Medicare]Medi-Gaps Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 9. Use only by permission from Senior Insurance Services of NCW, LLC. VRM Rx – Prescription Drugs [Stand Alone Plans] Part D 1% Penalty Avg. $33.13/ mo. Formulary – Rx List Tiers 1 -5 Inpatient Hospital Ins. Outpatient Medical Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% NF 100% $188/mo. 100% K 50% $57-mo. $4940 MOOP $128/mo. Pt. B $147 Doc/$20 - ER/$50 [Doctor, Outpatient Surgery, Ambulance, etc.] Part A Part B A B [Hospital, Hospice, Homecare, Skilled Nursing, etc.] G $158/mo. Pt. B $147 [Monthly Changeable] [Network: Any provider that accepts Medicare]Medi-Gaps Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 10. Use only by permission from Senior Insurance Services of NCW, LLC. VRM Rx – Prescription Drugs [Stand Alone Plans] Part D 1% Penalty Avg. $33.13/ mo. 1. Formulary - a list of prescription drugs covered by a Plan. 2. Tier level determines what your copay will be for a given drug. Higher tier = higher cost 3. 90-Day Supply 4. Step Therapy – Some drugs require you to try another drug first. 5. Exceptions 6. Network Pharmacies – unless emergency 7. Low Income Subsidy
- 11. Stage 1. Yearly Deductible You Pay 100% $0 to $320 Stage 3. Coverage Gap – “Donut Hole” Brand-name Stage 2. Initial Benefit Period Copays Insurance Pays Balance You Pay Copays Manufacturer Provides 50% discount Insurance Pays 5% You Pay 45% Of Drug Value You Pay 65% Of Drug Value Insurance Pays 35% Of Drug Value Generic Stage 4. Catastrophic Coverage You pay Greater of | 5% or $2.65 generic / $6.60 Brand Medicare Pays 80% Of Drug Value Insurance Pays 15% of Drug Value TrOOP When YOU have paid $4700 (including Mfg. 50% disc.) then… In 2015, when in Stage 3 Coverage Gap, 95 percent of the full price of a brand name and 65 percent of the full price of a generic goes toward True Out of Pocket expense (TrOOP). Once this amount reaches $4700, then Stage 4 – Catastrophic coverage is reached. (Monthly Premiums are in addition to cost shown below.)Part D – Standard Benefit, what you pay for drugs. When You + Insurance Pays = $2960
- 12. Inpatient Hospital Ins. Outpatient Medical Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% NF 100% $188/mo. 100% K 50% $57-mo. $4940 MOOP $128/mo. Pt. B $147 Doc/$20 - ER/$50 [Doctor, Outpatient Surgery, Ambulance, etc.] Part A Part B $104.90/mo. Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B [Hospital, Hospice, Homecare, Skilled Nursing, etc.] G $158/mo. Pt. B $147 Part A Part B Most often included Part DRx – Prescription Drugs [Stand Alone Plans] Part D 1% Penalty Avg. $33.13/ mo. Formulary – Rx List Tiers 1 -5 [Monthly Changeable] [Network: Any provider that accepts Medicare]Medi-Gaps Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 13. Inpatient Hospital Ins. Outpatient Medical Ins. Prem: $104.90/mo. HMO – Get your care in Network You choose your doctor Low to No Monthly Premiums Copays more predictable PCP copays Specialist copays Outpatient Surgery Worldwide Emergency Care Additional Benefits - Dental - Vision - Health Club 1. Review maximum cost exposure Accumulation of copays 2. Review Recurring Costs Doctor Visits Lab Visits Physical Therapy RX Costs Monthly Premium 3. Trial Right Formulary – Rx List Tiers 1 -5 Part A Part B $104.90/mo. Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B Part A Part B Most often included Part DRx – Prescription Drugs [Stand Alone Plans] Part D Medi-Gaps ELIGIBILITY Part A & B ESRD 6 months in service area Election Periods AEP: Oct 15 – Dec 7 MADP: Jan 1 – Feb 14 SEP: common examples Leave employer coverage Moving out of area LIS Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C
- 14. Inpatient Hospital Ins. Outpatient Medical Ins. Ded. $1260/Stay (Benefit Period Day 1-60) Prem: $104.90/mo. Ded: $147/yr. Co-Ins. You – 20% & Medicare – 80% NF 100% HMO – Get your care in Network You choose your doctor Low to No Monthly Premiums Copays more predictable PCP copays Specialist copays Outpatient Surgery Worldwide Emergency Care Additional Benefits - Dental - Vision - Health Club 1. Review maximum cost exposure Accumulation of copays 2. Review Recurring Costs Doctor Visits Lab Visits Physical Therapy RX Costs Monthly Premium 3. Trial Right Formulary – Rx List Tiers 1 -5 $188/mo. 100% K 50% $57-mo. $4940 MOOP $128/mo. Pt. B $147 Doc/$20 - ER/$50 [Doctor, Outpatient Surgery, Ambulance, etc.] Part A Part B $104.90/mo. Use only by permission from Senior Insurance Services of NCW, LLC. VRM A B [Hospital, Hospice, Homecare, Skilled Nursing, etc.] G $158/mo. Pt. B $147 Part A Part B Most often included Part DRx – Prescription Drugs [Stand Alone Plans] Part D 1% Penalty Avg. $33.13/ mo. Formulary – Rx List Tiers 1 -5 [Monthly Changeable] [Network: Any provider that accepts Medicare]Medi-Gaps Original Medicare Federal Gov’t 2 Ways To Get Medicare Medicare ADVANTAGE Part C