Erin Hart from American Healthcare Group, Inc. talks about the current details for Medicare coverage and plan options for Retiree health benefits.

1. MEDICARE 101 & RETIREE HEALTH
BENEFITS
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. HEALTH INSURANCE MARKET
 Individual Plans
 Group Plans
 Medicare
 Medicaid
 Workers Comp
 Auto
 Personal Liability

4. 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

5. 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

6. 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

7. 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)

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

9. 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

10. 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

11. 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%

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

13. 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

14. MEDIGAP PLANS

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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