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1. When Medicare coverage begins
2. The four components of Original
Medicare
3. Coordination of Benefits
4. Special focus ...
a. Age: The 1st of the month in which
you turn 65 *
b. Disability: The 25th month you
receive disability benefits *
c. ESR...
DISABILITY
 Medicare begins 24
months after Social
Security benefits begin
• Exception ALS (Lou
Gehrig’s) – Medicare
begi...
Part A
Hospital
Insurance
Part B
Medical
Insurance
Part C
Medicare
Advantage
Plans
HMO/PPO
Includes Part
A, B, D
DDDDsomet...
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
$6...
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 Cos...
◦ Doctor’s visits
◦ Outpatient medical services
◦ Clinical lab tests
◦ Emergency Department Services
◦ Durable Medical Equ...
◦ Some home health services
◦ Kidney dialysis
◦ Mental health care
◦ Preventive services
◦ and more
◦ For a complete list ...
11.14.15Getting Started 10
2017 You Pay
Monthly Premium
$134.00 (most people)
[$109.00]
Yearly Deductible
(once)
$183.00
M...
Understanding Medicare 11
 YOUR period of Guaranteed Issue Rights
to purchase a Medigap:
 The first 6 months you are at least 65 AND
have Part B
...
 Primary Payers
 Secondary Payers
 Payers of last resort
 ESRD 30-month Coordination
Period
Medicare is your only
insurance
Coordination of Benefits 14
If You … Medicare Pays ….
Or your spouse is actively working
and has an EGHP
Second …. Unless..
65 or older with EGHP cove...
Coverage Starts Under the Following Circumstances
1st day of the 4th month You get a regular course of dialysis in a facil...
 If enrollment is based solely on ESRD
◦ Your GHP/employer coverage is the only payer
during first 3 months
 Medicare is...
Medicare Getting Started 19
 Part A generally pays for all drugs
during a covered inpatient stay
 Drugs used in hospice care for
symptom control and...
• Most injectable and infusible drugs given as part
of a doctor’s service
• Drugs used at home with some durable medical
e...
If You … Immunosuppressive Drugs
Are entitled to Part A at time
of transplant and
 Medicare paid for your
transplant and ...
Getting Started 23
2017 You Pay
Monthly Premium
Plan premium
(base price + income adj.)
Yearly Deductible
(once)
$0 - $360...
The Coverage Gap
Year What You Pay for Covered
Brand-Name Drugs in the
Coverage Gap
What You Pay for
Covered Generic Drugs...
Things to Consider:
1. Plan formularies
2. Preferred v. standard pharmacies
3. Pre-Authorizations
4. Step Therapy
Understa...
26
Open Enrollment
October 15 – December 7
Using immunosuppressants to
do a 2017 Part D search….
• Part A and Part B services
• Usually includes prescription coverage
• The plan may have a monthly premium
• May include ...
1. www.medicare.gov
2. www.socialsecurity.gov
Understanding Medicare 28
 State Health Insurance Assistance
Program
 Free Local Help for People
with Medicare
Understanding Medicare 29
2016 Welcome to Medicare
2016 Welcome to Medicare
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2016 Welcome to Medicare

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

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2016 Welcome to Medicare

  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. ◦ Doctor’s visits ◦ Outpatient medical services ◦ Clinical lab tests ◦ Emergency Department Services ◦ Durable Medical Equipment ◦ Outpatient Chemotherapy Understanding Medicare 8
  8. 8. ◦ 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
  9. 9. 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”)
  10. 10. Understanding Medicare 11
  11. 11.  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
  12. 12.  Primary Payers  Secondary Payers  Payers of last resort  ESRD 30-month Coordination Period
  13. 13. Medicare is your only insurance Coordination of Benefits 14
  14. 14. 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
  15. 15. 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
  16. 16.  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
  17. 17. Medicare Getting Started 19
  18. 18.  Part A generally pays for all drugs during a covered inpatient stay  Drugs used in hospice care for symptom control and pain relief 20
  19. 19. • 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. Things to Consider: 1. Plan formularies 2. Preferred v. standard pharmacies 3. Pre-Authorizations 4. Step Therapy Understanding Medicare 25
  24. 24. 26 Open Enrollment October 15 – December 7 Using immunosuppressants to do a 2017 Part D search….
  25. 25. • 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
  26. 26. 1. www.medicare.gov 2. www.socialsecurity.gov Understanding Medicare 28
  27. 27.  State Health Insurance Assistance Program  Free Local Help for People with Medicare Understanding Medicare 29

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