You are 65 or older, and you receive or are eligible to receive full benefits fr om Social Security or the Railroad Retirement Board
You are under 65 and have End-Stage Renal Disease
If you do not qualify for premium-free Part A, you may be able to buy it. Contact the Social Security Administration at 1-800-772-1213 for more information.
Part A - Deductibles and Copayments
- $1,132 per hospital benefit period for 2011 (A hospital benefit period begins the first day you receive inpatient hospital treatment and continues until you have been out of the hospital or skilled nursing facility for 60 days in a row.)
Hospital Stay Copayment
- Medicare pays in full (after the hospital deductible of $1,132 in 2011) for days 1-60
- Medicare pays all but $283 per day for days 61-90.
- Medicare pays all but $566 per day for days 91-150.
- You pay all costs for each day over 150 days
Skilled Nursing Facility Co-Payment
- You pay nothing for days 1-20
- You pay $141.50 per day for days 21-100
- You pay all costs for each day beyond 100 days
Usually, a Medicare Supplement policy will pay for Part A deductibles and Co-Payments.
Part B - Monthly Premium
The Part B premium for 2011 is $115.40 per month for most people. Individuals with income over $85,000 or couples with incomes greater than $170,000 will pay more. Everyone who has Part B pays a monthly premium.
The monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. Beneficiaries enrolled in Part B who do not receive a monthly retirement check are billed by Medicare every three months.
Part B - Deductibles and Copayments
- Medicare helps pay 80% of the Medicare-approved amount. You usually pay 20% of the Medicare-approved amount
- You pay all of the limiting charge when a provider does not accept the assignment.
Doctors and other providers who accept assignment agree to accept the Medicare-approved amount for a service. Providers who do not accept assignment may charge you a 15% surcharge. You would be responsible for paying the surcharge (or limiting charge) as well as any copayments.
Therefore, you should always ask a provider to accept the assignment.
For a list of providers in Indiana who accept assignment, contact 1-800-MEDICARE.
Some Medicare Supplement policies help pay Part B deductibles and Copayments.
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Should I take Medicare Part B?
You should take Medicare Part A when you are eligible. However, some people may not want to apply for Medicare Part B (Medical Insurance) when they become eligible.
You can delay enrollment in Medicare Part B without penalty if you fit one of the following categories.
- If you turn 65, continue to work, and are covered by an employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 20 or more employees must offer active workers who are 65 or older the same health benefits provided to younger employees.
- If you turn 65 and are covered under your working spouse's employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 20 or more employees must offer spouses of active workers the same health benefits regardless of age or health status.
- If you are under 65 and receive Medicare due to a disability, you continue to work, and are covered by an employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 100 or more employees must offer disabled workers, who are actively working, the same health benefits provided to other employees.
- If you are under 65 and receive Medicare due to a disability, and are covered under your working spouse's employer group health plan, you may want to delay enrolling in Medicare Part B. Note: Group health plans of employers with 100 or more employees must offer the disabled spouses of active workers, the same health benefits given to non-disabled spouses.
Employer group health plans may cover items normally not covered by Medicare Part B. If so, and you meet one of the categories above or below, then you may not need to enroll in Medicare Part B and pay the monthly premium.
If you are:
- an active worker
- a spouse of an active worker
- a disabled, active worker
- a disabled spouse of an active worker
and choose coverage under the employer group health plan, you can refuse Medicare Part B during the automatic or initial enrollment period. You wait to sign up for Medicare Part B during the special enrollment period, an eight month period that begins the month the group health coverage ends or the month employment ends, whichever comes first.
You will not be enrolling late, so you will not have any penalty.
If you choose coverage under the employer group health plan and are still working, Medicare will be the "secondary payer," which means the employer plan pays first.
If the employer group health plan does not pay all the patient's expenses, Medicare may pay the entire balance, a portion, or nothing. An employer group health plan must be primary or nothing.
They are NOT allowed to offer Medicare supplemental coverage to people who are actively employed--unless the company has under 20 employees, or if disabled, under 100 employees.
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What are my rights as a Medicare beneficiary?
As a Medicare beneficiary, you have certain guaranteed rights. These rights protect you when you get health care, they assure you access to needed health care services, and protect you against unethical practices.
You have these rights whether you are in Original Medicare or another Medicare health plan.
Your rights include, but are not limited to:
The Right to Receive Emergency Care
If you have severe pain, an injury, or a sudden illness that you believe may cause your health serious danger without immediate care, you have the right to receive emergency care. You never need prior approval for emergency care, and you may receive emergency care anywhere in the United States.
The Right to Appeal Decisions About Payments or Services for Medical Care
If you are enrolled in Original Medicare, you have the right to appeal denial of a payment for a service you have been provided. If you are enrolled in another Medicare health plan, you have the right to appeal the plan's denial for a service to be provided.
The Right to Information About All Treatment Options
You have the right to know about all your health care treatment options from your health care provider. Medicare forbids its health plans from making any rules that would stop a doctor from telling you everything you need to know about your health care. If you think your Medicare health plan may have kept a provider from telling you everything you need to know about your health care options, then you have the right to appeal.
The Right to Know How Your Medicare Health Plan Pays Its Doctors
You must request this information. If you request information on how a Medicare health plan pays its doctors, then the plan must give it to you in writing. You also have a right to know whether your doctor has a financial interest in a health care facility since it could affect the medical advice he or she gives you.
Your other rights include:
- The right to protection from discrimination in marketing and enrollment practices.
- The right to information about what is covered and how much you have to pay.
- The right to choose a women's health specialist.
- The right, if you have a complex or serious medical condition, to receive a treatment plan that includes direct access to specialists.
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PowerPoint Presentation - Medicare at a Glance
Medicare at a Glance
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What is Medicare Advantage?
Medicare Advantage expands health care options for Medicare beneficiaries. These options were created with the Balanced Budget Act of 1997 to reduce the growth in Medicare spending, make the Medicare trust fund last longer, and give beneficiaries more choices.
With Medicare Advantage (also called Medicare Part C), you can choose from new ways in which to receive your Medicare benefits.
It is important to remember that each of these options will have advantages and limitations, and no option will be right for everyone. Also, not all options will be available in all areas.
An Annual Open Enrollment Period is available every year from November 15 to December 31. During this period, you will be able to enroll in Medicare Advantage plan and coverage will start on January 1.
Please Note: If you do not actively choose and enroll in a new plan, you will stay in Original Medicare or the original Medicare managed care plan you currently have.
When learning about these new options, please keep in mind that you do not have to change if you are happy with how you currently receive Medicare benefits. You should not change to a new program until you have carefully analyzed it and determined how you would benefit from it.
View a list of current plans in Indiana.
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About Medicare Advantage Programs
Medicare Advantage Options
Original Medicare will always be available. If you want to continue receiving your benefits this way, then you do not have to do anything.
This is a managed care plan with a network of providers who contract with an insurance company. You choose a primary care physician who coordinates your care. You agree to follow the rules of the HMO and use the HMO's providers.
HMO with Point-of-Service (HMO w/pos)
This is similar to the Medicare Advantage HMO, except you can use providers outside of the network. However, you will pay higher deductibles and copayments when you go outside of the network.
Preferred Provider Organization (PPO)
This is another managed care plan. It is formed by a group of doctors, hospitals, and other providers who contract with an insurance company. You do not have to choose a primary care physician. You can go outside of the network, but you will pay higher deductibles and copayments when you do.
Provider Sponsored Organization (PSO)
This is a managed care plan with a network of providers. The providers administer the plan and take the financial risk. You choose a primary care physician and agree to use plan providers. Most services will be provided by the network.
Private Fee for Service Plans (PFFS)
This is an insurance plan, not a managed care plan. The plan, not Medicare, sets the fee schedule for providers, but providers can bill up to 15% more. You see any providers you choose, as long as the provider agrees to accept the payment schedule. Medical necessity is determined by the plan. The plan does not have to have a quality assurance program.
Religious Fraternal Benefit Society Plans
This is one of the managed care plan types (HMO, HMO w/pos, PPO, PSO) which is formed by a religious or fraternal organization. These plans may restrict enrollment to members of their organization.
Medical Savings Accounts (MSA)
This is a health insurance policy with a high deductible ($3,000) combined with a savings account ($2,000). Medicare pays the insurance policy premium and deposits moey into your MSA each month. You can use the money in your MSA to pay your medical costs (tax free). You have free choice of providers. The providers have no limit on what they charge.
Medicare Advantage Plans: Beneficiary Protections
- Guaranteed Issue: The plan must enroll you if you meet the requirements.
- Care must be available 24 hours per day, seven days a week.
- You must have access to specialists.
- Doctors must be allowed to inform you of all treatment options.
- The plan must have a grievance and appeal procedure.
- If a layperson would think that a symptom could be an emergency, then the plan must pay for the emergency treatment.
Medicare Advantage Managed Care Plans: Beneficiary Protections
- The plan cannot charge more than a $50 copayment for visits to the emergency room.
- You or your doctor can appeal a denial of service and the appeal must be handled in a "timely" way. The plan must make an initial determination within 14 days. Reconsideration of a decision must be made within 30 days. Decisions regarding urgent care must be made within 72 hours.
- The plan must have a process for identifying and evaluating persons with complex or serious medical conditions. A treatment plan must be developed within 90 days of your enrollment.
- If your treatment plan includes specialists, you must have direct access to those specialists. You do not need a referral from your primary care physician.
Medicare Advantage Plans: Common Elements
- All plans have a contract with the Centers for Medicare and Medicaid Services (Medicare).
- The plan must enroll anyone in the service area that has Part A and Part B, except for end-stage renal disease patients.
- Each plan must offer an annual enrollment period.
- You must pay your Medicare Part B premium.
- You pay any plan premium, deductibles, or copayments.
- All plans may provide additional benefits or services not covered by Medicare.
- There is usually less paperwork for you.
- The Centers for Medicare and Medicaid Services (Medicare) pays the plan a set amount for each month that a beneficiary is enrolled.
The Centers for Medicare and Medicaid Services monitors appeals and marketing plans. All plans, except for Private Fee-for-Service, must have a quality assurance program.
Who is eligible to enroll in a Medicare Advantage plan?
If you meet the following requirements, the Medicare Advantage plan must enroll you.
You may be under 65 and you cannot be denied coverage due to pre-existing conditions.
- You have Medicare Part A and Part B.
- You pay the Medicare Part B premium.
- You live in a county serviced by the plan.
- You pay the plan's monthly premium.
- You are not receiving Medicare due to end-stage kidney disease.
Another type of Medicare Managed Health Maintenance Organization is a Cost Contract HMO. These plans have different requirements for enrollment.
- You have Medicare Part A and Part B, or only Part B.
- You pay the Medicare Part B premium.
- You live in a county serviced by the plan.
- You pay the plan's monthly premium.
- You are not receiving Medicare due to end-stage kidney disease, and you are not in the Medicare Hospice program.
Learn more about Medicare Advantage HMOs and Cost Contract HMOs.
What are the benefits and limitations of Medicare Advantage plans?
Currently in Indiana, Medicare Advantage plans are widely available throughout the state.
View a list of plans for your area.
- Medicare Advantage plans cannot turn you down due to age, poor health, or pre-existing conditions during the Annual Open Enrollment Period from November 15 to December 31 of each year or when you first become eligible for Medicare. (Exceptions: You can be turned down if you have end-stage renal disease.)
- If you are under 65 with Medicare due to a disability, you may enroll in a Medicare Advantage plan and not be denied.
- Medicare Advantage plans must provide all Medicare covered services and are approved by Medicare.
- Medicare Advantage plans may provide some services that Medicare doesn't usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
- Medicare HMOs may provide some services that Medicare doesn't usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
- You usually have less out-of-pocket expenses, such as premiums, copayments for doctor services and prescription drugs. You do not need a Medicare supplement policy.
- You have no bills or claim forms to complete. Filing and organizing of claims is done by the Medicare Advantage plan.
- You have 24-hour access to services, including emergency or urgent care with providers outside of the network. This includes foreign travel not covered by Medicare.
- Medicare requires and monitors quality assurance for doctors and facilities.
- The Medicare Advantage plans must enable you to appeal denial of claims or services. If the service is still denied, then you have other appeal rights with Medicare.
- You must live within the service area of the Medicare Advantage plan. If you move outside of the service area, then you must join a different plan or get a Medicare supplement policy to go with your Original Medicare.
- You must follow the rules and use the providers in the plan, except for emergency or urgently needed care. (Exception: PPOs allow you to use providers outside of the network, and Medicare will still pay 80% of the approved amount. PFFSs do not have a network of providers, but your provider may not accept the plan.)
- Your current doctor or hospital may not be part of the Medicare Advantage network so you would have to choose a new doctor or hospital.
- You must get a referral from your Primary Care Physician to receive care from health care providers outside of the network, or the plan will not pay (unless you are in a PPO or PFFS).
- A provider could leave the plan, or the plan's contract with Medicare could be canceled. Then, you would have to find another Medicare Advantage plan or get a Medicare Supplement Policy to go with your Original Medicare.
- If your Primary Care Physician (PCP) leaves the plan, then you would have to choose another PCP.
- If you live outside of the plan area for 12 or more months in a row, the Medicare Advantage plan may ask you to disenroll and re-enroll when you return to the area. However, if a Medicare Advantage plan is available where you are living outside of Indiana, you could enroll in it for coverage while you were outside of your regular plan area, and then re-enroll in your Indiana plan when you return home.
- When you travel outside of the plan’s service area, you are only covered for emergency or urgent care. For routine health care services, you would need to return to your Primary Care Physician.
Medicare Advantage plans that include prescription coverage may require you to use particular medications to lower their costs and yours.
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Are there any protections if I enroll in a plan and do not like it?
In order to enable beneficiaries to try a Medicare Advantage plan, but still have the option of returning to Original Medicare, a number of protections are in place. These protections will enable beneficiaries, in certain situations, to try a plan, but then return to Original Medicare and a Medicare Supplement policy if they want to do so.
Under these protections, beneficiaries will have guarantee issue of a Medicare Supplement policy as long as they meet one of the following criteria. For eligible beneficiaries, companies which sell supplement policies will not be able to deny coverage, charge more, or exclude benefits. However, to receive these protections, beneficiaries must apply for a supplement policy within 63 days of disenrolling from the health plan, or within 63 days of the termination of the health plan.
A beneficiary would be eligible for the Medicare Supplement protections if they meet one of the following criteria.
You are enrolled in a Medicare Advantage plan (such as a Medicare HMO) and one of the following happens:
- The contract between Medicare and the plan ends.
- The plan service area no longer covers the county where you live.
- You move out of the plan service area.
- There are violations by the plan.
In this case, you would get a guaranteed issue of a Medicare Supplement Plan A, B, C, or F from any company (as long as you apply within 63 days of losing your other coverage).
You have a Medicare Supplement plan and you cancel it in order to enroll in a Medicare Advantage plan for the first time. Then you disenroll from the plan within 12 months and return to Original Medicare.
You are able to return to the same Medicare Supplement plan with the same company if it is still available. If it is not still available, you will get a Medicare Supplement plan A, B, C, or F from any company (as long as you apply within 63 days from disenrolling).
When you first take Medicare Part B, you enroll in a Medicare Advantage plan. Then you disenroll from the plan within 12 months and return to Original Medicare.
You are guaranteed to get any Medicare Supplement plan with any company (as long as you apply within 63 days from disenrolling).
You have an employer group health plan which supplements Medicare and your employer terminates the health plan, or stops providing supplemental coverage. (This does not apply if you voluntarily drop the employer group health plan.)
You are guaranteed to get a Medicare Supplement policy A, B, C, or F from any company.
Remember, to be eligible for any of these protections, you must apply within 63 days of losing, or disenrolling from your other health coverage.
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Are any Medicare Managed Care Plans available where I live?
Currently, you can choose from three types of Medicare Managed Care:
- Cost Contract HMO
- Medicare Advantage PPO
- Medicare Advantage PFFS
These plans are available in selected counties of Indiana and it is important to know the differences between them.
View a complete list of available plans for your county.
Cost Contract HMO
Medicare will reimburse the plan for covered services you receive. You choose a primary care provider within the HMO network. When you stay within the network, you pay nothing except the plan premium and any small copayment amounts preset by the HMO.
You may also choose to use services outside of the network. When you choose to use a service or provider outside the Cost Contract HMO network, Medicare would still pay their usual share of the approved amount. You would be responsible for the Medicare deductibles and copayments. The Cost Contract HMO would not pay these. Cost Contract HMOs may enroll you if you don't have Medicare Part A but have and pay for Medicare Part B. Cost Contract HMOs do not have to enroll you if you have end-stage kidney disease or are already enrolled in the Medicare hospice program.
Medicare Advantage PPO
This type of managed care plan maintains a list of preferred providers but lets you see doctors and hospitals outside the plan for an additional cost. If you choose to use a provider outside of the network, the plan will pay the same reimbursements as Original Medicare will unless you need emergency or urgent care.
You will be responsible for the Medicare deductibles and co-insurance. Usually with a preferred provider organization you are not required to have a primary care physician and do not need a referral to see a doctor outside the plan. You must have both Medicare Part A and B.
Medicare Advantage PFFS
If you enroll in a private fee-for-service, you can receive care from any Medicare doctor that agrees to the plan's terms, but you must live in the plan's service area to be eligible. Medicare pays the plan a set amount every month for each beneficiary enrolled in the plan. The plan pays providers on a fee-for-service basis. The plan charges enrollees a premium and cost-sharing amounts.
The PFFS plan offers the same benefits covered under Original Medicare and may provide extra benefits, but you have to pay more for any extra benefits. In most cases, beneficiaries enrolled in the private fee-for-service plan will pay less to see a doctor than under original fee-for-service.