3/22/2011
Making Sense of Medicare
Stephanie M. Turnbull
Manager, Member Benefits
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Highlights
Medicare Eligibility
Types of Medicare Coverage
Medicare Part A
Medicare Part B
Medicare Part C
Medicare Part D
Medicare Medigap Coverage
Applies to Part A and Part B Only
Medicare Low Income Subsidy (LIS)
Medicare Enrollment
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Eligibility
65 or older
Under 65 with certain disabilities
Any age with EndStage Renal Disease (ESRD)
Individual coverage
Specific enrollment deadlines
Red, White & Blue Card
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Medicare Part A "Inpatient Coverage"
Inpatient Coverage
Hospital
Hospice
Skilled Nursing Facility
No premiums if Medicare taxes were paid while
working
Patient payment responsibility varies depending on
the type of service received
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Medicare Part B "Outpatient Coverage"
Outpatient Coverage
Physician Services
Home Health
Durable Medical Equipment (DME)
Clinical Laboratory Services
Premium based on current income
2011 Deductible: $162
20% CoInsurance/Patient Responsibility
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Medigap "Medicare Supplement"
Medicare supplement insurance
Sold by private companies
Covers the "gaps" in Original Medicare Benefits Part A
and Part B such as copayments, coinsurance and
deductibles
Several policies labeled AN which vary in coverage
Does not apply to Medicare Part C or Part D
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Medicare Part C "Medicare Advantage"
Medicare Advantage Plan
Combines Medicare A, B and sometimes D into one plan
Offered by private insurance companies approved by
Medicare
Plan may include vision, hearing, dental and/or health and
wellness programs
Must pay Part B and Part C Premium
Out of Pocket may be reduced
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Medicare Part D "Prescription Drugs"
Medicare Prescription Drug Coverage
Insurance companies contract with Medicare to
manage prescription drug benefit
Patients must have Medicare Part A and/or Part B
Medicare Part C beneficiaries qualify
Medicare Part D Formulary
Coverage Gap or `Donut Hole'
Changes in copayment structure
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Medicare Part D "Prescription Drugs"
2010
2011
Deductible
$ 310
$310
Initial coverage
$2830
$2840
Limit
Coverage Gap
Member responsibility:100% of the
Member responsibility:50% on
coverage gap; $250 rebate for
brand name drugs, 93% on
reaching coverage gap
generic drugs. Full retail cost of
drug will apply to gap
Out of Pocket
$4550
$4550
Catastrophic
Generic: 5% or $2.50
Generic: 5% or $2.50
Coverage
Brand: 5% or $6.30
Brand: 5% or $6.30
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Brand Coverage Gap Discount Projection
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Medicare Coverage Gap Discount Program
Brand manufacturers must have a Signed Discount
Agreement with Center for Medicare and Medicaid
Services (CMS)
Brand drugs will be taken off the Medicare Part D
formulary if the manufacturer chooses not to
participate
Coverage Gap Discount applies to the portion of cost
that falls into the coverage gap
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Generic Coverage Gap Discount Projection
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Medicare Low Income Subsidy "LIS"
What is it?
Assistance with drug plan premiums, yearly deductible, co
insurance, and copayments
Medicare Part D coverage gap does not apply
Apply through Social Security Administration website or by
calling 8007721213
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Medicare LIS Eligibility
Single Person: Income less that $16,335 and resources
less than $12,640
Married Person: Income less than $22,065 and
resources less than $25,260
Resources Include Checking, Savings, Stocks, and
Bonds
Automatically Qualify if you meet one of the following
conditions
Full Medicaid Coverage
Assistance with Part B Premiums from State Medicaid Program
Supplemental Security Income (SSI) Benefit
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Important Enrollment Dates
Medicare A and B Enrollment
Dependant on date of birth and qualifying new diagnosis
Medicare D Open Enrollment
MidNovember ­End of December
New coverage and cost changes begin January 1
Medicare Part C Enrollees May Switch to Original
Medicare
January 1st ­February 15th of the current year
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Additional Information on Medicare
Medicare.gov
Basics of Medicare
My Eligibility
Part D Plan Finder
Online Enrollment
Medicare & You
1800MEDICARE (8006334227)
www.socialsecurity.gov
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Summary
Medicare Plan Types
A: Inpatient Coverage
B: Outpatient Coverage
C: Medicare Advantage
D: Prescription Drug Coverage
Medicare D 2011 Coverage Gap Discounts
Medicare Low Income Subsidy
Medicare Enrollment
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Additional Information
Health Care Reform Act
http://docs.house.gov/energycommerce/ppacacon.pdf
Manufacturers Signed Discount Agreement
http://www.cms.gov/PrescriptionDrugCovGenIn/05_Pharm
a.asp#TopOfPage
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Question & Answer
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References
"Medicare & You 2011." www.Medicare.gov. Centers for Medicare and Medicaid Services, Sept. 2010. Web. Feb. 2011.
<http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf>."Medicare Prescription Drug Coverage: How to Join a
Medicare Drug Plan." Medicare.gov. Centers for Medicare and Medicaid Services, Sept. 2010. Web. Feb. 2011.
<www.medicare.gov/publications/pubs/pdf/11111.pdf>.
"Closing the Coverage Gap ­Medicare Prescription Drugs Are Becoming More Affordable." www.Medicare.gov. Centers for
Medicare and Medicaid Services, Nov. 2010. Web. Feb. 2011. <www.medicare.gov/Publications/Pubs/pdf/11464.pdf>.
"Information Pharmacists Can Use On: Closing the Coverage Gap." www.CMS.gov. Centers for Medicare and Medicaid
Services, Nov. 2010. Web. Feb. 2011. <www4.cms.gov/partnerships/downloads/11522P.pdf>.
"Bridging the Coverage Gap in 2011." www.Medicare.gov. Centers for Medicare and Medicaid Services, Jan. 2011. Web. Feb.
2011. <www.medicare.gov/publications/pubs/pdf/11213.pdf>.
"ReDetermination of LowIncome Subsidy (LIS) Eligibility for 2011." www.CMS.gov. Centers for Medicare and Medicaid
Services, Oct. 2010. Web. Feb. 2011. <https://www.cms.gov/.../Downloads/LISundeemedplan1letter2011.pdf>.
Nothing contained in this power point is to be considered as the rendering of legal advice for specific cases. Readers/attendees are
responsible for obtaining such advice from their own legal counsel. The power point and any forms herein are intended for
educational and informational purposes only. Information contained in this power point is not a guarantee and official
determinations are made by the Centers for Medicare and Medicaid Services (CMS).
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