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Medicare 101 - 2019 Update

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Learn about what's new for Medicare in 2019 from American HealthCare Group, licensed independent Medicare brokers. Invite us to speak at your place of work and educate your retiring employees, free of charge!

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Medicare 101 - 2019 Update

  1. 1. MEDICARE 101 NOVEMBER 2019 UPDATE ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  2. 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. ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  3. 3. HEALTH INSURANCE MARKET  Individual Plans  Group Plans  Medicare  Medicaid  Workers Comp  Auto  Personal Liability ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  4. 4. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  5. 5. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  6. 6. 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) ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  7. 7. NEW FOR MEDICARE  Open Enrollment Period: January 1 – March 31  Network changes in 2019  New narrow network plans ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  8. 8. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  9. 9. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  10. 10. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  11. 11. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  12. 12. MEDICARE PREVENTIVE SCHEDULE  Initial physical exam  Cardiovascular screening  Cancer tests  Shots – vaccines  Bone mass measurements ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228  Diabetes screening  Glaucoma test  Tobacco cessation  Medical Nutrition Therapy
  13. 13. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  14. 14. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  15. 15. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  16. 16. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  17. 17. 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. ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  18. 18. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  19. 19. MEDICARE SUPPLEMENT PLANS (MEDIGAP) ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807
  20. 20. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  21. 21. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  22. 22. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  23. 23. 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). ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  24. 24. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  25. 25. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  26. 26. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  27. 27. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228
  28. 28. 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 ERIN HART - EHART@AMERICAN-HEALTHCARE.NET - 412-563-7807 733 WASHINGTON ROAD, PITTSBURGH, PA 15228

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