presented by: warren coble certified senior advisor
TRANSCRIPT
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Presented by: Warren Coble
Certified Senior Advisor
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MedicareFederal programSocial SecurityEarned benefit from working
Medicaid State program Social Services Needs based
benefit depends on income and assets
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Over 300 Different plans available in NC in 2013
Like everything these days, … such a wide variety. Make personal choice decisions based on:
Coverage needs Cost you can afford Convenience of use
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The unknown parts: How sick are you going to get? How often will you use it? How will costs rise in the future? If we had a crystal ball, we’d know the
right decision to make every time. We don’t, so we have to make the best decision now based on the facts we have now.
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1. Age 65 2. Disability for 24 months 3. End-stage kidney failure 4. Lou Gehrig’s Disease
Have acquired sufficient work credits (40 quarters = 10 years)
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Receiving Social Security check? Enrolled automatically & premiums deducted
If not receiving Social Security, must apply up to 3 months ahead & premiums billed
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Individuals turning age 65 who are NOT
currently covered by Employer Group Health
Plan based on ACTIVE employment
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Retiree coverage offered by employer is voluntary on their part and is subject to change – Supreme Court ruling in 03/2008
COBRA does not count for Medicare enrollment period purposes
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Compare employer cost/coverage (premium/deductible/co-pay/oop max) to Medicare cost/coverage
If your cost/coverage are reasonable, better off with employer coverage while working
If high cost ($250 month+) or only partial coverage (high deductibles/co-pays) may be better with Medicare/Supp/Advantage
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Parts of Medicare A – Hospital C – Advantage B - Medical D - Rx
Standardized A & B 1966-2003 Medicare Modernization Act of 2003
Mandated “Choices” & RX coverage
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- Original - Medicare A & B usually go together, can add D
(Managed by federal government)
- Advantage - Medicare C alternative to A & B, may or may not include part D (Managed by private insurance companies)
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See SHIIP Combo Form
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A – Hospital Insurance *Inpatient hospital/nursing home/hospice*Usually no premium (earned by paying
Medicare tax while working)*$1184 deductible – per hospital stay
Up to 60 days of inpatient coverage(Deductible waived on re-admission
within 60 days)*Skilled nursing facility (short term only)
– Days 1-20 in full (Special Requirements)- Days 21-100 Medicare pays all but $148.00 day
*Hospice – Palliative care, including Rx *Home Health Care
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B – Medical Insurance Outpatient hospital/physician
care/medical equipment Standard premium $104.90 (2013)
(higher for higher incomes) $147 deductible per calendar year,
then 80% Medicare/20% recipient co-pay
Based on “approved” charges
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Not Covered By Medicare Or Supplement: Long term care Vision or dental care Hearing aids Eyeglasses Private duty nursing
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Stand alone with original Medicare
Included with an advantage plan
Stand alone with an advantage plan
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See COMBO form
D – Rx prescription drug coverage
Operated by private companies
Premium Deductible
5 Words: Co-Pay Gap Catastrophic
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1 – Premium $15.00 - $116.80
2 – Deductible $325.00You pay 100%
3 – Initial coverage limit $2970.00Includes deductible $325.00Co pay periodPart D pays 75% up to $1983.75You pay 25% of $2645.00 ($661.25)
4 - Coverage gap $3763.75 Discounts: 52.5% brand, 21% generic
$4750.00 (deductable + 25 out of pocket % + gap)
5 - Catastrophic 95/5%
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Annual preview period September 15–October 15Assistance available to choose
appropriate plans Open enrollment
October 15 - December 07 Changes effective January 1 each year
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Work with Original Medicare to fill in “gaps” Cannot buy but one at a time. Standardized/Regulated by N. C. Dept. of
Insurance Offered by individual companies Will not work with Part C/Advantage
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Depending on Plan type chosen, designed to pay out of pocket expenses (deductibles, co-insurance, and co-pays) not paid by Medicare
See Plans Chart (SHIIP Combo Form) Changed June 1, 2010
Gone - Plans E, H, I, J - New M, N42 Plan “F” companies in North Carolina
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Pricing method is important!!! No-age rated Issue-age-rated Attained-age-rated Price ranges from $122.50 - $253.60 for
Plan F (most common), 43 plan average is $155.19
Find out company history/stabilityDiscounts can confuse true cost
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Guaranteed renewable as long as premium is paid
Can never be cancelled due to health/excess use
Premiums will go up!!!! Changing plans re-sets the starting age,
often resulting in higher premiums
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Medigap Open Enrollment Period:
Starts 1st day of month you are both age 65 or older and enrolled in Medicare Part B. Continues for 6 months.
Can apply up to 6 months in advance to have timely coverage at 65
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During open enrollment, cannot be denied coverage, regardless of healthSome companies apply pre-existing condition limitations up to 6 monthsDeferring Medicare/Supplement to keep employer coverage will result in higher Supplement cost later
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SEE GOLD SHEET
Includes all benefits of regular Medicare Hospital and medical coverage Premiums/deductibles/co-pays vary by plan
May include extra benefitsVision, dental, hearing, gym
membership Not standardized Not regulated by N. C. Dept. of Insurance (CMS) Usually have a varied maximum out-of-pocket limit
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4 Basic plan types: 1. HMO – Health Maintenance
Organization (in network) 2. PPO – Preferred Provider
Organization (out of network) 3. SNP – Special Needs Plans 4. PFFS – Private Fee for Service
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Inpatient hospital◦ Per day co-pay
$140.00 - $290.00 per DAY Surgery usually included in in-patient costs Usually a limit on # of days you pay Plans vary on yearly maximum out of
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Skilled nursing facilityExtremely varied co-paysDays 1-100 - $0 - $137.50 per dayDepends on plan and typeNot accepted at all facilities
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Medical/doctor’s servicesVaried co-pays $10-$35 Primary care physician$10-$50 SpecialistVerify your doctor/hospital will accept
30% - 100 % Out of network ! Each plan is different!
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Prescription drug (Rx)
May or may not be included If not included, cannot buy stand-alone Usually standard drug plan
guidelines
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Original Medicare - $104.90 (IRMMA) Supplement – varied, $122.50 - $253.60
average for Plan F $155.19 month Part D Rx – varied, $15.00 - $116.80 -
average $35.00 per month Advantage – varied, from $0 to $169.80 per
month
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See Road To 65 Initial, General, Special Enrollment periods IEP – 3 months before, month of, 3 months
after 65 Eligibility date depends on when you sign up GEP – January – March each year, coverage
begins July 1 SEP – Any time while covered by employer group
health plan (cannot be during IEP) Up to 8 months after employer group terminates
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Check options 4-6 months ahead of age 65.
If keeping employer coverage, check again 2-3 months before leaving employment.
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If eligible, and you need Medicare, failure to enroll timely can result in delays in coverage and costly premium penalties. Although Cobra protects your Medigap/Supplement Enrollment period, it does not protect you for a Medicare Special Enrollment Period.
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Warren Coble & Associates
SHIIP – 1-800-443-9354
1-800-MEDICARE – 1-800-633-4227