Medicare & Retiree Health Benefits Information from our resident expert, Erin Hagan Hart. Erin is an independent Medicare broker who can give you an unbiased review of your benefits needs and options. Call 412-563-7807 to invite Erin to speak to your group for free!

1. MEDICARE 101 & RETIREE HEALTH
BENEFITS
JULY19, 2016

2. INTRODUCTION
 Health Insurance is insurance against loss by
illness or bodily injury.
 Health Care is the treatment of illness or
injuries.
 Wellness is good physical & mental health
obtained by healthy diet, physical activity
and healthy lifestyle.

3. WELLNESS AS COST CONTAINMENT
• Don’t have a good diet83%
• Are over weight or obese65%
• Don’t get enough exercise to get the health benefits67%
• Of all causes of death are lifestyle related and
preventable
~70%

4. HEALTH INSURANCE MARKET
 Individual Plans
 Group Plans
 Medicare
 Medicaid
 Workers Comp
 Auto
 Personal Liability

5. HEALTH INSURANCE TERMS
 Premium – monthly cost of policy
 Copay – flat amount charged for health care service
 Coinsurance – percentage charged for health care service
 Deductible – initial payment due to health care provider before
insurance pays
 Out of pocket max – the most the member pays out of pocket –
does not include premium

6. HEALTH INSURANCE TERMS
 Network – the providers that have contracted with the
insurance company
 PPO – Preferred Provider Organization – a product that
has an out-of-network benefit
 HMO – Health Maintenance Organization – a product
that does not have an out-of-network benefit
 Emergency Coverage – most plans allow for emergency
coverage notwithstanding network

7. MEDICAL ASSISTANCE: MEDICAID
 Find out if you’re eligible: http://www.phlp.org/quickscreen-
questionnaire
 Single – on Medicare - $990 – dual eligible
 Single Monthly Income Limit: $1,354
 Household size of 4 Income Limit: $2,789
 Pregnant Women: $2,922
 Household size of 4 (Pregnant woman counts as 2): $4,447

8. MEDICARE BASICS
1965: Medicare (Part A & B)
1996: Medicare Advantage (Part C)
2006: Prescription Drug Program (Part D)
2010: Patient Protection and Affordable Care Act (PPACA)
Centers for Medicare & Medicaid Services (CMS)

9. RETIREE MESSAGING
 Educate on alternatives
 Medicare/Medigap
 Annual changes made to plans
 Part D
 Pace/Pacenet
 Voluntary Assessments

10. RETIREE FACTS
 Retiree benefits for all 65+
 25% in 2005
 16% in 2014
 Large employers offering retiree health coverage
 66% in 1988
 23% in 2015
Source: Kaiser Family Foundation

11. HOW TO APPLY
1. Apply via the telephone at Social Security Administration (SSA):
 SSA at 1-800-772-1213 (TTY 1-800-325-0778)
2. Paper forms can be requested at:
 SSA at 1-800-772-1213 (TTY 1-800-325-0778)
3. Online forms available at:
 http://www.ssa.gov/prescriptionhelp/
4. Additional information is available at:
 http://www.socialsecurity.gov/pubs/10525.html

12. MEDICARE COVERAGE DETAILS
Cost Sharing for 2016
 Part A: Generally Free (or up to $411/mo)
 $1,288 for a hospital stay 1 – 60 days
 $322/day for a hospital stay for days 61 – 90
 $644/day for a hospital stay for days 91 – 150
 All costs for 150+ days
 SNF - $161/day for days 21 – 100 for each benefit period – covered after 3 day
hospital stay
 Part B: $104.90/month or $121.80/month
 Hold Harmless Clause – 2016 rates
 $166 deductible, then 20%

13. MEDICARE PREVENTIVE SCHEDULE
 Initial physical exam
 Cardiovascular screening
 Cancer tests
 Shots – vaccines
 Bone mass measurements
 Diabetes screening
 Glaucoma test
 Tobacco cessation
 Medical Nutrition Therapy

14. MEDIGAP
 Private insurance coverage to cover “gaps”
 Covers certain cost sharing (deductibles, coinsurance, copayments)
 Open Enrollment during IEP – Initial Election Period
 Secondary to Medicare
 Utilize Medicare’s Network
 Does not include Prescription Drug Plan – Part D

15. MEDIGAP PLANS

16. PART D – PRESCRIPTION DRUG PLANS
 Prescription Drug Coverage
 Available from private insurers
 Uses a formulary & tiers
 2016 Coverage Gap: $3,310; $4,550 – 42% discount
on generic; 55% discount on brand name
 Counts toward the gap: deductible, coinsurance,
copays, discount on brand name drugs in the
coverage gap

17. PART C: MEDICARE ADVANTAGE
 Includes Part A, Part B and sometimes Part D in one plan
 From private insurers
 Medicare Advantage and Medicare Advantage Prescription
Drug plans
 Live in plan’s service area
 Entitled to Part A & enrolled in Part B
 Premiums range from $0 – over $300.
 Copays for services

18. PART C CONTINUED
 Services covered that original Medicare doesn’t cover
 Lower cost sharing
 Vision, Hearing, Dental
 Podiatrist & Chiropractic
 Gym Membership
 Types: HMO, PPO, SNP, POS

19. HOW TO CHOOSE?
 Check network providers
 Check formulary
 Annualize monthly premium
 Project services needed in the year (based on known
problems & family history)
 Calculate copays, coinsurance & deductibles for these
services
 Choose most affordable plan

20. PROGRAMS TO SAVE
 Medical Assistance - $990 or less; $7,280 in assets
 Low Income Subsidy/Extra Help - $1,485 or less; $13, 640 in assets
 Medicare Part D subsidy
 Medicare Savings Program - $1,337 or less; $8,180 in assets
 State pays Part B premium – even w/penalty

21. PACE/PACENET INFORMATION
Income Individual Married
Percentage of FPL 133% 120%
Yearly $14,500 $17,700
Monthly $1,208 $1,470
Income Individual Married
Yearly $23,500 $31,500
Monthly $1,958 $2,625
PACE PACENET
RX Benefit $6.00 & $9.00,
potentially lower based
on income level
$8.00 & $15.00
Premium Benefit Covers the
premium if RX plan
is a partner plan
No premium
benefit

22. IMPORTANT DATES
 Parts A & B
 Initial enrollment – 3 months before, the month of and 3 months after
65th birthday
 January 1 – March 31 for July 1 effective date for Parts A & B
 Medicare Advantage
 October 15 – December 7 in 2016 for January 1, 2017 effective date
 January 1 – February 14 – disenrollment
 Anytime throughout the year – Special Enrollment Periods

23. SPECIAL ENROLLMENT PERIODS
 Dual eligible
 Chronic Disease SNP
 Move out of service area: 60 days
 Institutionalized – nursing home
 Lose employer coverage – 8 month period
 Low Income Subsidy/Extra Help
 Medicare Savings Program
 Pace/Pacenet

24. CONTACT ERIN HART
DIRECTOR, HEALTH BENEFIT SERVICES
EMAIL: EHART@AMERICAN-HEALTHCARE.NET
CALL: (412)563-7807