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Getting Started with Medicare Beginning Medicare Training

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Page 1: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Getting Started with MedicareBeginning Medicare Training

Page 2: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

vvThis Medicare Counselor Training program was developed under a grant from UnitedHealthcare through a joint project with the National Association of Area Agencies on Aging (n4a). However, nothing in these educational materials shall imply an n4a endorsement of any kind regarding UnitedHealthcare or its products and services or those of any Medicare Advantage, Medicare Prescription Drug or Medicare Supplement insurance plan. As a matter of practice, n4a does not endorse any insurance products or services.

Page 3: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Learning Objectives

1. Define Medicare eligibility

2. Understand Medicare enrollment

3. Understand the differences between Medicare coverage options; Part A, B, C, D and Medicare Supplement

Page 4: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Top Medicare Questions

1. Who is eligible for Medicare?

2. What are the coverage options?

3. When can someone enroll?

4. Once covered by Medicare, how could an individual save money?

Page 5: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

QUESTION 1Who is eligible for Medicare?

Page 6: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

65 years oldU.S. citizen or resident(at least five consecutive years)

Qualified disability or special situation

For example, people of any age with end-stage renal disease (ESRD)

or amyotrophic lateral sclerosis (ALS)

Original Medicare &

ELIGIBILITY1

Page 7: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

ELIGIBILITY1

Original Medicare &

Page 8: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

QUESTION 2What are the coverage options?

Page 9: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Coverage

COVERAGE2

Coverage

Page 10: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Coverage Options

COVERAGE2

Original Medicare

&

Coverage

Page 11: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Hospital insuranceInpatient hospital care

Inpatient mental health care

Skilled nursing services

Hospice care

Some blood transfusions

Coverage

Page 12: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Fast factsCosts

No monthly premium (in most cases)

Deductible

EnrollmentCan’t be turned down because of medical history or a pre-existing condition

CoverageStays of more than 60 days require a daily co-payment

Multiple stays may mean multiple deductibles

Any qualified hospital in the U.S. that accepts new Medicare patients

Hospital care outside the U.S. isn’t usually covered

Coverage

Page 13: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Doctor and outpatient visitsPhysician services

Outpatient hospital services

Ambulance

Outpatient mental health

Laboratory services

Durable medical equipment (wheelchairs, oxygen, etc.)

Outpatient physical, occupational and speech-language therapy

Some preventive care

Coverage

True or False: Medicare Part A covers costs when you’re hospitalized, and Part B covers doctor visits and tests.

TF

Page 14: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Fast factsCosts

There is no maximum out-of-pocket

Co-insurance – generally 20% of the Medicare-approved cost

Part B has a monthly premium that is determined by income

Joining post-initial enrollment period may mean a higher premium

EnrollmentMedical history or pre-existing condition doesn’t matter

CoverageGenerally, care outside of the U.S. is not covered

Can receive care from any participating physician who accepts new Medicare patients

Some preventive health care is provided

Coverage

Page 15: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

What’s not coveredMedicare Part A and Part B deductibles, co-insurance and premiums

Medicare Part B excess charges (amount billed over what Medicare agrees to pay)

Prescription drug coverage

Additional benefits

Coverage

True or False: Original Medicare (Parts A and B) is premium free. Medicare Advantage (Part C) and Part D prescription drug plans are optional — you need to buy them.

TF

Page 16: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Medicare Advantage Plan

Coverage

Page 17: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Medicare Advantage planCombines Part A and Part B and, in many cases, includes prescription drug coverage

Offered by private insurance companies

Often includes additional benefits

Coverage

Page 18: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Eligibility for Part CMust be enrolled in Medicare Parts A and B

Must live in plan service area

Must not have end-stage renal disease (ESRD)*

*There are special rules for ESRD. People with ESRD may be able to join a Medicare Special Needs Plan (SNP) if one is available in their area.

COVERAGE2

Coverage

Page 19: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Fast factsCosts

Plan terms, premiums, covered services, co-pays, deductibles and other out-of-pocket limits can change from year to year

Must continue to pay Part B monthly premium

CoverageConvenience of one plan

Many plans include prescription drug coverage (Part D)

Must receive coverage in a service area — unless it’s an emergency (for some plans)

Required to see in-network doctors and hospitals (for some plans)

Many plans offer additional benefits not covered by Medicare

Coverage

Page 20: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Types of Part C plansCoordinated care plans

Health Maintenance Organization (HMO) plans

Preferred Provider Organization (PPO) plans

Special Needs Plans (SNP)

Health Maintenance Organization Point of Service (HMO-POS) plans

COVERAGE2

Coverage

Page 21: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Types of Part C plans (continued)Other plans

Private-Fee-For-Service (PFFS) plans

Medical Savings Account (MSA) plans

COVERAGE2

Coverage

Page 22: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Prescription Drug Plan

Coverage

Page 23: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Help with the cost of prescription drugsOnly offered through private insurance companies

Must continue to pay your Part A or Part B premium if you have one

Coverage

True or False: Original Medicare (Parts A and B) automatically includes prescription drug coverage (Medicare Part D).

TF

Page 24: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Fast factsCosts

Prescription drug coverage carries from plan to plan

Catastrophic coverage protects from very high drug costs

Benefits can change each year

CoverageEach plan has a list of drugs that it covers

Make sure prescribed drugs are covered before enrolling

The list of drugs can change each year

EnrollmentCoverage is not automatic

Penalties may apply for late enrollment

COVERAGE2

Coverage

Page 25: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Part D Formulary

Formulary Tiered Formulary

……Tier 5 ($$$$$)

……Tier 4 ($$$$)

……Tier 3 ($$$)

……Tier 2 ($$)

……Tier 1 ($)

Formulary: A list of drugs that the insurance plan coversMany drug plans have a tiered formulary. That means the plan divides drugs into groups called “tiers.” Generally, the lower the tier, the lower the co-pay.

Note: Not all plans have 5 tiers.

Coverage

Page 26: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Understanding drug coverage stagesIf a plan has a deductible, people pay the total cost of drugs until they reach the deductible amount set by their plan. Some plans may have a deductible for only specific drug tiers. If a plan has this type of deductible, people pay the total cost of their drugs on those tiers until they reach the deductible. Then they move to the initial coverage stage. If they don't have a deductible, their coverage begins in the initial coverage stage.

Note: On January 1 of each year, the coverage cycle starts over and the dollar limits can change. Amounts listed above reflect the 2015 plan year.

Initial Coverage

Coverage Gap(Donut Hole)

CatastrophicCoverage

Up to $2,960 Up to $4,700 Through the end of the year

Coverage

Page 27: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

ExampleHeavy prescription drug spending

Total annual savings with Medicare Part D plan: $6,134

Total annual drug cost without a Medicare Part D drug plan($950 per month x 12 months)

Annual premium for Part D drug plan($27.50 per month x 12 months)

Stage 1 – Initial coverage (Enrico’s share during this stage)

Stage 2 – Coverage gap (his additional cost-sharing up to the limit)

Stage 3 – Catastrophic coverage (his share during this stage)

Total Enrico pays out-of-pocket for the year

$11,400

$330

$720

$3,980

$236

$5,266

Coverage

Page 28: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Standardized MedicareSupplement insurance plan

Coverage

Page 29: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Medicare supplement insurance planHelps cover some of what Medicare Parts A and B don’t — such as co-insurance, co-payments and deductibles

Offered by private insurance companies

Plans are named A, B, C, D, F, G, K, L, M, N, and a high-deductible plan, F

Benefits vary by plan

Generally, the more comprehensive the coverage, the higher the premium

Note: Plans are different in MA, MN and WI.

COVERAGE2

Coverage

Page 30: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Medicare supplement insurance planEligibility

Generally must be enrolled in Medicare Parts A and BResident of the state in which someone is applying for coverageAge 65+ (or under age 65 with certain disabilities in some states)

People of any age with end-stage renal disease (ESRD)

COVERAGE2

Coverage

True or False: Original Medicare (Parts A and B), Medicare Advantage (Part C) plans and Medicare Part D prescription drug plans offer the same coverage nationwide. Medicare supplement insurance (Medigap) plans vary by state.

TF

Page 31: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Fast factsCosts

Helps with some of the out-of-pocket costs not paid by Medicare

Premiums vary based on the plan and insurance carrier

EnrollmentEveryone is guaranteed the right to buy a Medicare supplement insurance plan during the Open Enrollment Period

In some states and plans, enrollment after the Open Enrollment Period can be denied based on health

This period begins the first day of the month that someone is enrolled inMedicare Part B

COVERAGE2

Coverage

Page 32: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Fast factsCoverage

No network restrictions and virtually no referrals required

Coverage may go with someone during a move or travel anywhere in the U.S.

With some plans, someone has a foreign travel benefit for emergency medical services

Coverage is guaranteed to continue as long as someone pays his or her premium on time and has not made material misrepresentation on the application for insurance

COVERAGE2

Coverage

True or False: Where you live doesn’t matter. All Medicare choices are offered by the federal government, so coverage is the same nationwide.

TF

Page 33: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

COVERAGE2

Medicare ChoicesStep 1: Enroll in OriginalMedicare when youbecome eligible.

Step 2: If you need more coverage, you have choices.

OPTION 1

MEDICARE ADVANTAGE(PART C)

Combines Parts A & B

Additional Benefits

Most plans coverprescription drugs

Offered by private companies

MEDICARE SUPPLEMENTINSURANCE

Covers some or all of the costsnot covered by Parts A & B

Offered by private companies

MEDICARE PART D

Covers prescription drugs

Offered by private companies

OPTION 2or

ORIGINAL MEDICARE

Government-provided

Covers doctorand outpatient

visits

Covershospital

stays

+

Coverage

True or False: Medicare supplement insurance (Medigap) plans help pay for some of the things Original Medicare (Parts A and B) does not cover, such as out‐of‐pocket costs like deductibles and co‐pays. 

TF

Page 34: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

QUESTION 3When can someone enroll?

Page 35: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Enrollment

ENROLLMENT3

Parts A and BWhen can an individual first enroll?

The three months before their 65th birthday, the month of, and the three months after

Enrollment in Part A is automatic if someone is already receiving Social Security Benefits

What if an individual doesn’t enroll during this time?For Part A, usually no penalties (unless someone didn’t pay enough into Social Security)For Part B, premiums will be higher after the Initial Enrollment Period (unless someonequalifies for an exception)

YOUR ELIGIBILITY MONTH

THREE MONTHS BEFORE THREE MONTHS AFTER

Initial Enrollment Period

True or False: You can enroll in Medicare without penalty anytime after you turn 65.TF

Page 36: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

ExampleEnrolling after the Initial Enrollment Period

2014 standard Part B premium $104.90

3 years x 10% = 30% of $104.90 $31.47

$136.37Susan’s Part B monthly premium for 2014

Enrollment

ENROLLMENT3

Page 37: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Enrollment

ENROLLMENT3

Parts C and DWhen can an individual first enroll?

What if an individual is late?Wait until the Open Enrollment Period (OEP), Oct. 15 – Dec. 7.

THEIR ELIGIBILITY MONTH

THREE MONTHS BEFORE THREE MONTHS AFTER

Initial Enrollment Period

Page 38: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Enrollment

ENROLLMENT3

What if an individual works past age 65?

If working past age 65May enroll in Medicare Parts A and B

Recommend talking to their benefit administrator

Keep records of their health insurance coverage

Retiring after age 65When retiring, people are eligible for a Special Enrollment Period

Allows for 64 days after employer-sponsored coverage ends to enroll in a Medicare plan without penalty – best to sign up before retiring to avoid a lapse in coverage

Page 39: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Enrollment

ENROLLMENT3

Medicare supplement insurance plansWhen can an individual enroll?Open Enrollment Period lasts for 6 months and begins on the first day of the month in which the individual is both 65 or older and enrolled in Medicare Part B. Some states have additional open enrollment periods including those for people under 65.

What if an individual is late?They can apply later but may be charged a higher premium due to existing health problems, or rejected depending on their health history.

MONTH THEY QUALIFY

FIVE MONTHS AFTER

Open Enrollment Period

Page 40: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

QUESTION 4What are ways to save money?

Page 41: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Ways an Individual Could Save Money

SAVING MONEY4

What should an individual think about as they compare their options?Health status

Has their health changed?

FinanceHas their financial situation changed?

LocationHave they moved? (Could qualify for SEP) Will they be away from their hometown for a significant period of time in the next year?How frequently do they travel and where?

Coverage needsAre their doctors and hospital in-network? Are their prescriptions covered?Could they benefit from coverage for things like a gym membership, routine dental care, hearing aids, etc.?

The individual should review their situation and find the right insurance option based on their situation.

Page 42: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

SAVING MONEY4

Maximizing benefitsUtilize preventive services

Stay in network

Look for “extra” benefits compared with Original Medicare

Take advantage of preferred pharmacies or mail service pharmacies

Ways an Individual Could Save Money

Page 43: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

QUESTIONS?

Page 44: Beginning Medicare Training Prese… · Medicare supplement insurance plan Eligibility Generally must be enrolled in Medicare Parts A and B Resident of the state in which someone

Thank You

This Medicare Counselor Training program was developed under a grant from UnitedHealthcare through a joint project with the National Association of Area Agencies on Aging (n4a). However, nothing in these educational materials shall imply an n4a endorsement of any kind regarding UnitedHealthcare or its products and services or those of any Medicare Advantage, Medicare Prescription Drug or Medicare Supplement insurance plan. As a matter of practice, n4a does not endorse any insurance products or services.

Copyright ©2014 United Health Care Service, Inc. All rights reserved. No portion of this work may be reproduced or used without express written permission of United HealthCare Services, Inc., regardless of commercial or non commercial nature of the use.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

SPRJ18615Y0066_140828_163804 Accepted


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