We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. Franklin D.

Transcription

1 Medicare Explained

2 We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. Franklin D. Roosevelt comments on signing The Social Security Act August 14, 1935

3 Medicare Part A INPATIENT Hospitalization *Skilled Nursing (not custodial or long-term care) *Home Health Care *Hospice Care Monthly Premium = Typically $0 *You must meet certain conditions to get these benefits

4 Year Benefit Period Began Medicare Beneficiaries Need Protection! Days 1-60 Inpatient Hospital Deductible Days Inpatient Hospital Coinsurance Days Lifetime Reserve Coinsurance Days Skilled Nursing Facility Coinsurance $40.00 $10.00 $20.00 $ $ $ $ $ $1, $ $ $ $1, $ $ $ $1, $ $ $ per benefit period Out of Pocket $1, Part A - Hospital Insurance DAYS OF CARE per day per day per day UP TO $9,660 UP TO $38,640 UP TO $12,880

5 Medicare Part B OUTPATIENT Services Office Visits E.R. Urgent Care Surgeons Radiology Labs Ambulance Monthly Premium = Typically $ or $121.80

6 Part B Medical Insurance Annual Deductible Covered Services Coinsurance Covered Services $ % of Approved Amount 2016 $ % of Approved Amount History of Medicare Assignment ,600,000 Claims Submitted 99.5% Accepted by Medicare Assignment On all Medicare-covered expenses, a doctor or other health care provider may agree to accept Medicare assignment. This means the patient will not be required to pay any of the expenses in excess of Medicare s approved charge. The patient pays only 20% of the approved charge not paid by Medicare. Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge for the covered services. In 2006, the most a physician can charge for services covered by Medicare is 115% of the fee schedule amount for non-participating physicians. 6

7 Medigap Plans (Medicare Supplements) Benefits A B C D F* G K L M N** Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used) Medicare Part B coinsurance or copayment 50% 75% Blood (first 3 pints) 50% 75% Part A Hospice care coinsurance or copayment 50% 75% Skilled nursing facility care coinsurance 50% 75% Medicare Part A deductible Medicare Part B deductible 50% 75% 50% Medicare Part B excess charges Foreign travel emergency (up to plan limits) *Plan F also offers a high-deductible plan in some states. If you choose this option, this means you must pay for Medicare-covered costs (coinsurance, copayments, deductibles) up to the deductible amount of $2180 in 2016 before your policy pays anything. Out-of-pocket limit in 2016 $4,960 $2,480 **Plan N pays 100% of Part B coinsurance, except for a copayment of up to $20 for some office visits and up to $50 copayment for emergency room visits that don t result in an inpatient admission.

8 Medicare Part D Lower Drug Costs Protect against Higher Costs Understand Penalty Compare Your Prescriptions

9 Medicare Advantage MEDICARE + MEDICARE + PART A PART B MEDICARE PART D Hospital Doctors Pharmacy ONE PLAN ~ ONE CARD

10 What Coverage is Best For You? Original Medicare Plan Part A (Hospital) Medicare provides this coverage. Part B is optional. You have your choice of doctors. Your costs may be higher than in Medicare Advantage Plans + Medigap Policy (Medicare Supplement Insurance) You can choose to buy this private coverage (or an employer/union may offer similar coverage) to fill in gaps in Part A and Part B coverage. Costs vary by policy and company. + Part B (Medical) Part D (Prescription Drug Coverage) You can choose this coverage. Private companies approved by Medicare run these plan. Plans cover different drugs. Medically necessary drugs must be covered. OR Medicare Advantage Plans like HMO s, PPO s and PFFS Called Part C this option combines your Part A (Hospital) and Part B (Medical) Private insurance companies approved by Medicare provide this coverage. Generally, you must see doctors in the plan. Your costs may be lower than in the Original Medicare Plan, and you may get extra benefits. + Part D (Prescription Drug Coverage) Most Part C plans cover prescription drugs. If they don t, you may be able to choose this coverage. Plans cover different drugs. Medically necessary drugs must be covered.

11 Next Steps Medicare Supplements Get Rate Quote and Complete Application Medicare Advantage and Part D Confirm Doctor s in Network, Rx in formulary and Complete Application Consider Ancillary Products

12 Items NOT covered by Medicare, Medicare Supplements, or Medicare Advantage Custodial Care (Nursing Facility, Assisted Living, Home Care, Adult Day Care) Dental/Vision/Hearing (Covered by select MA plans only) Hospital Co-Pays (On MA Plans Only) Final Expense Cancer, Heart Attack, Stroke (Out of Pocket exposure with MA Plans)

13 Today, more nursing home patients arrive from hospitals than they once did. And many nursing home officials believe that because hospitals themselves are under pressure to contain costs, they discharge patients quicker and sicker. Source: The New Math of Old Age US News and World Report, September, 2002

14 Short Term Care One of The Most Significant Changes in Medicare Since 1966 Occurred in DRG s 1983 Prospective Payment System Important Because: Hospitals are not keeping patients as long as they used to, and have to send them somewhere else to finish recovery.

15 Why choose Short Term Care? Chances of Nursing Home Stay Very Likely. * After age 65, Americans have more than a 70% chance of needing some form of long-term care. Source: * 76.3% are six months or less * 82.4% are twelve months or less Source: National Center for Health Statistics: National Nursing Home Survey: 2004 Overview Qualify for benefits if: * You cannot perform two or more of six ADL s * You have a cognitive impairment (such as Dementia or Alzheimer s disease)

16 Specific Tests for Medicare Payment in Extended Care Facility Medicare Part A Coverage Rehabilitation Potential Doctor: Daily Skilled Care 3 Days Prior Hospital Stay Medicare Approves Stay Show Improvement in Capability Extended Care Facility Necessary Same as Hospital Condition Medicare Approved Facility Enter Extended Care Facility Within 30 Days

17 Examples of Medically Necessary Care NOT covered by Medicare Broken ankle - outpatient surgery sent to SNF for Rehab for 30 days. Why wasn t this covered? Fell forward, breaking both arms and was sent to SNF to be cared for. Why wasn t this covered? Broken hip - kept in hospital Under Observation before going to Skilled Nursing Facility Why wasn t this covered? Treated in hospital for pneumonia for 3 days, then sent to SNF. (Did not show signs of improvement) Why wasn t this covered?

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19 Why choose Hospital Indemnity? Pays regardless of other coverage Daily Copay on MA Plans (Per Hospital Admittance) Benefits from 6-30 Days (Restores after discharged for 60 days) Affordable Pays if admitted for Inpatient or Under Observation Stays

20 Why have Cancer, Heart Attack or Stroke coverage? Expenses incurred besides treatment Restoration of Benefits (Not with every carrier) Out of Pocket costs with MA Plans Family Medical History Pays if admitted for Inpatient or Under Observation Stays Leading Causes of Death Centers for Disease Control and Prevention Data for 2010

21 Questions?

22 Thank You