Medicare 101 - 2019 Update

MEDICARE 101
NOVEMBER 2019 UPDATE
ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228

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.

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

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

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

MEDICARE BASICS
Medicare is a Federal health insurance program
Administered by: Centers for Medicare & Medicaid Services (CMS)
Eligibility and Enrollment handled by: Social Security Administration &
Railroad Retirement Board
1965: Medicare (Part A & B)
1996: Medicare Advantage (Part C)
2006: Prescription Drug Program (Part D)
2010: Patient Protection and Affordable Care Act (PPACA)

NEW FOR MEDICARE
 Open Enrollment Period: January 1 – March 31
 Network changes in 2019
 New narrow network plans

WHO IS ELIGIBLE?
 65 years or older US Citizen or permanent legal resident
 Under 65 year of age and receive disability payments for 24 months
(SSDI)
 People with End Stage Renal Disease (ESRD on dialysis) or Lou
Gehrig’s disease

MEDICARE PART A: HOSPITAL COVERAGE
Cost Sharing for 2019
 Part A: Generally Free (or up to $437/mo)
 $1,364 for a hospital stay 1 – 60 days; $341/day for a hospital stay for days 61
– 90; $682/day for a hospital stay for days 91 – 150; All costs for 150+ days
 Hospice
 Home Health Services
 Skilled Nursing Facility - $170.50/day for days 21 – 100 for each benefit period
– covered after 3-day hospital stay
 Blood

MEDICARE PART B: DOCTORS
Premium for 2019 is $135.50/month
 Medicare Part B Recipients $185 deductible, then 20% of all charges.
 Exception for higher earners
 You can pay your Part B premium out of your social security check

MEDICARE PART B: DOCTORS
Part B Covers:
 Doctors’ services – Welcome to Medicare Visit and Annual
 Outpatient care
 Durable medical equipment
 Mental health services
 Preventive services

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

PART C: MEDICARE ADVANTAGE
 From private insurers
 Still pay your Part B Premium
 Includes AT LEAST Part A, Part B and most of the time Part D in
one plan
 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 – not based on age
 Copays for services

PART C: MEDICARE ADVANTAGE
 You can pay your Part C premium out of your social security
check
 You will never be medically underwritten or asked any medical
questions – Except ESRD
 Services covered that original Medicare doesn’t cover:
 Lower cost sharing
 Vision, Hearing, Dental
 Podiatrist & Chiropractic
 Gym Membership
 Types: HMO, PPO, SNP, POS

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

PART D – PRESCRIPTION DRUG PLANS
 Prescription Drug Coverage
 Available from private insurers
 You must obtain a Part D plan when you become
eligible, or you will pay a penalty when you do sign up.
 Uses a formulary & tiers
 Coverage Gap
 What counts toward the gap? deductible, coinsurance,
copays.
 Discount on drugs in the coverage gap

SOME PEOPLE GET A & B AUTOMATICALLY
 If you are already collecting Social Security or Railroad Retirement
Benefits – you will be signed up automatically the first day of the month
you turn 65.
 If you’re under 65 and disabled, you’ll automatically get Part A & B after
you receive disability benefits for 24 months.
 If you have ALS (Lou Gehrig’s disease) you’ll get A & B automatically the
month your Social Security disability benefits begin.

MEDICARE SUPPLEMENT PLANS (MEDIGAP)
 No Managed Care/Medicare’s network
 Private insurance coverage to cover “gaps”
 Still pay your Part B Premium
 You will be medically underwritten outside of Open Enrollment (6 months
after joining Part B)
 Premiums are based on your age, zip code, tobacco use and/or gender
 Covers certain cost sharing (deductibles, coinsurance, copayments)
 Secondary to Medicare

MEDICARE SUPPLEMENT PLANS (MEDIGAP)
ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807

PROGRAMS TO SAVE
 Medical Assistance - $1,041 or less; $2,000 in assets
 PACE and PACEnet for Prescription Drug Plans
 Low Income Subsidy/Extra Help - $1,561 or less; $14,390 in assets
 Medicare Part D subsidy
 Medicare Savings Program - $1,406 or less; $7,730 in assets
 State pays Part B premium AND Part A premium – even w/penalty

PACE/PACENET INFORMATION: MUST BE 65+
INCOME INDIVIDUAL MARRIED
Percentage of FPL 133% 120%
Yearly $14,500 $17,700
Monthly $1,208 $1,470
INCOME INDIVIDUAL MARRIED
Yearly $27,500 $35,500
Monthly $2,291 $2,958
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

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 2019 for January 1, 2020 effective date
 January 1 – March 31: Open Enrollment Period
 Anytime throughout the year – Special Enrollment Periods

65 YEARS OF AGE AND STILL WORKING
 You can keep your employer plan and not be charged the Part B penalty.
***COBRA doesn’t count as employer coverage
 Sign up for Medicare Part A only - $0 hospital coverage, UNLESS
 You cannot have any parts of Medicare and still contribute to a Health
Savings Account (HSA).

SPECIAL ENROLLMENT PERIODS
 Dual eligible: once/quarter
 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

HOW TO APPLY
You must sign up for part B when you become eligible or you will pay a
penalty when you do.
(Unless you’re covered by employer coverage)
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

MEDICAL ASSISTANCE: MEDICAID
 Medicare/Medicaid: Dual eligible
 For individuals who receive Medicare, the income limit to enroll in Medical Assistance
is $1,060/month. Asset limit is less than $2,000.
 Medicaid is always payor of last resort, so Medicare is primary
 Primary coverage – Medicare or Medicare Advantage Dual SNP
 Coverage for Medicaid now through Community Health Choices – whole state will be
implemented 1/1/2020.
 Community Health Choices plans: Amerihealth, PA Health & Wellness & UPMC
 Find out if you’re eligible: http://www.phlp.org/quickscreen-questionnaire

MEDICAID BENEFITS
 Medicare/Medicaid: Dual eligible
 Medicaid is always payor of last resort, so Medicare is primary
 Coverage for Medicaid now through Community Health Choices – whole
state will be implemented 1/1/2020.
 Primary coverage – Medicare or Medicare Advantage Dual SNP

MEDICAID ENROLLMENT
 PA Department of Human Services
 Online: Compass website:
https://www.compass.state.pa.us/compass.web/Public/CMPHome
 Telephone: 866-550-4355
 In Person: County assistance office
 On Paper – download form

Medicare 101 - 2019 Update

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