What is it, how to enroll, the 3 ways to complete your coverage

1. All About Medicare in
New York State
Jennifer Lavelli
Personal Insurance and Medicare Advisor
914-295-4502
TheMedicareAdvisor@gmail.com

2. Agenda
• What is Medicare, and How Do I Enroll?
• How Medicare Works with Private Insurance:
Three Ways to Complete Your Medicare Coverage
• Impacts of the Affordable Care Act, and
Resources to Help Reduce Your Costs
2

3. Agenda – Part 1
• What Medicare Is
• How and When to Enroll
3

4. Part 1: Key Takeaway
If you do not enroll in Medicare on time, you
will pay a monthly penalty
4

5. What Is Medicare?
• National health insurance program for
people 65+
• Administered by the Centers for Medicare and
Medicaid Services (CMS)
• Enrollment through the Social Security
Administration (SSA)
5

6. Who Is Eligible for Medicare?
• Everyone over 65
– All U.S. citizens
– Legal residents who have lived in the U.S.
continuously for at least 5 years
• Some people under 65 who receive Social
Security disability benefits
6

7. Usually→
Four Parts of Medicare
Part A
Hospital
Insurance
Federal/State
Part B
Medical
Insurance
Federal/State
Part C
Medicare
Advantage
Plan
Insurance
company
Part D
Prescription
Drug
Coverage
Insurance
company
7

8. Enrollment Periods
• Initial Enrollment: 3 months before, the month of, and 3
months after your 65th
birthday.
• Special Enrollment: For people who did not sign up for Parts
B and D during their initial enrollment period because they were
covered as a worker, or spouse of a current worker, by a large
(≥20 employees) group plan.
– Special enrollment period for Part B is anytime before coverage ends, or
for the 8-month period starting the month group coverage ends
– Special enrollment period for Part D is anytime before coverage ends, or
within 63 days after coverage ends
• General Enrollment: People that missed their Initial
Enrollment period can sign up between Jan 1 – Mar 3, though
coverage won’t start till July 1 8

9. Enrollment Periods (cont’d)
• Annual Election Period: From October 15 – December 7,
people who are already enrolled in a Medicare plan and want to
CHANGE their coverage can do so
• Medicare Advantage Unenrollment Period: People who
decided to try a Medicare Advantage plan can drop it and switch
back to Original Medicare (ONLY) from Jan-Mar of the
following year. These people MUST go back to Original
Medicare, though they can add a Medigap Policy and a Part D
9

10. Initial Enrollment: Medicare Parts A & B
• You must be enrolled for Parts A and B to avail yourself of any of the
three options to complete your Medicare coverage
• Enroll when you’re first eligible (age 65) to ensure you incur no penalties
or delays in coverage
• If you are receiving Social Security when you turn 65:
– Medicare Parts A and B are automatic
(can decline if don’t need Part B due to other coverage)
– Coverage starts 1st
of month turn 65
– Parts C and D are not automatic; must choose private insurer and
proactively enroll
• If you are not receiving Social Security when you turn 65:
– Must sign up through Social Security Administration during a
Medicare enrollment period
10

11. Initial Enrollment: Part D
• When you’re signed up for Parts A and B and know you’ll want
prescription drug coverage, either now or at any time in the
future
– Must sign up when first eligible (at 65) or face late
enrollment penalty (unless covered by another drug plan with
coverage at least as comprehensive as Medicare — called
“creditable” coverage)
– Obtain Part D by calling your preferred insurer, calling
Medicare, or working with an insurance advisor (like me!)
11

12. If You Don’t Enroll in
Medicare During Your Initial
Enrollment Period…
• You may pay late-enrollment penalties for Parts
B and D for the rest of your life
• Your health care expenses may not be covered
by insurance due to delayed coverage
12

13. Agenda Part 2: How to Complete
Your Medicare Coverage
• There are three ways to complete your Medicare
coverage
1. Original Medicare Parts A & B with a Part D
prescription drug plan
2. Addition of a Medical Supplement (aka Medigap Plan)
to Option #1 above to cover deductibles, co-pays, and
coinsurance for Parts A and B
3. Purchase a Part C plan from a private insurer
13

14. Part 2: Key Takeaways
Evaluate all three options before deciding - -
premiums and total out-of-pocket costs and
covered services will differ, sometimes
dramatically
If you do not get the right private insurance to
go with Medicare, your doctors and
prescriptions may not be covered
14

15. Part A
HOSPITAL
$0 premium
Part B
DOCTORS
$104.90 base
premium
Medical Supplements
Letters A Through N
Monthly Premiums vary by Plan and
Carrier
Part D
PRESCRIPTION DRUGS
Varying Monthly Premium
Copayments Vary by Tier
FIRST Way to Complete Your Medicare Coverage
Original Medicare (Parts A and B) and Part D =
Option 1
Part C
Medicare Advantage Plan
Hospital+Doctors+Part D
+Extras
$0 or Low
Monthly Premiums, though
Part B Premium continues
Pay Copayments Up to the
Maximum Out-of-Pocket
(MOOP)

16. What Original Medicare Parts A and B
Cover
• Hospital: 100% of first 60 days
• Medical services (doctor visits, outpatient services):
80% of Medicare-approved amount (varies)
• Some preventive services (flu shots, certain
screenings)
See “Medicare & You 2013” for complete list of covered services.
Call 800-663-4227 or go to www.medicare.gov.
16

17. What Original Medicare Parts A and B
Do Not Cover
• Long-term care
• Care delivered outside the U.S.
• Dental care
• Vision care
• Hearing aids
• Cosmetic surgery
• Acupuncture and other alternative care
• Amounts over Medicare-approved amount
17

18. 2013 Out-of-Pocket Costs for Original
Medicare Parts A and B
• Premiums for Part B paid to Medicare (usually
$104.90; people with incomes over $85,000 will pay
more)
• Deductibles ($1,184 for Part A; $147 for Part B)
• Copays and Coinsurance
• Services not covered by Medicare, or provider
charges over the Medicare-approved amount
18

19. PART D: Prescription Drug Plans
• EVERYONE must have creditable drug coverage
– If you’re not covered by another creditable plan, you MUST purchase Part D
when you’re eligible or face penalties later
• Part D is purchased from a private insurer as a standalone
supplement to Original Medicare Parts A and B
• Each drug plan has its own list of coverage drugs
(formulary)
– Brand name and generics are grouped into “tiers”, each with different
copays/coinsurance
• Premiums, co-pays, and coinsurance amounts for Part D
plans vary by insurer, by plan, and by geography
19

20. Part D coinsurance 2013
Medicare’s standard benefit design; individual plans vary and may pay more
Coverage Part D plan pays You pay
Annual deductible
(varies by plan)
$0 Applicable co-pay
Initial coverage period
(up to $2,970 including
deductible)
75% Varies by plan 25% Varies by plan
Coverage gap (donut
hole) Starts when costs
exceed $2,970; ends
when total out-of-pocket
cost reaches $4,750 )
Probably $0 47.5% of covered brand
name drugs plus
dispensing fee; 79% of
covered generic drugs;
100% of rest.
Catastrophic coverage
Starts when total out-of-
pocket cost reaches
$4,750
95% or the drug cost
minus the copay
Greater of 5% of the
drug costs or $2.60
copay for a generic drug
or $6.50 for a brand
name drug 20

21. The Second Way to Complete Your
Medicare Coverage: Add Coverage and
Reduce Out of Pocket Costs
Add a Medigap plan (aka a Medicare Supplement)
to Original Medicare Parts A, B, and D
21

22. Part A
HOSPITAL
$0 premium
Part B
DOCTORS
$104.90 base
premium
Medical Supplements
Letters A Through N
Monthly Premiums vary by Plan and
Carrier
Part D
PRESCRIPTION DRUGS
Varying Monthly Premium
Copayments Vary by Tier
SECOND Way to Complete Your Medicare
Coverage
Add a Medical Supplement to Original Medicare
(Parts A and B) and Part D = Option 2
Part C
Medicare Advantage Plan
Hospital+Doctors+Part D
+Extras
$0 or Low
Monthly Premiums, though
Part B Premium continues
Pay Copayments Up to the
Maximum Out-of-Pocket
(MOOP)

23. Medigap Policies
(Medicare Supplement Insurance)
• Private health insurance sold by private insurance
companies
• Supplements Original Medicare coverage Parts A
and B
• Follow federal/state laws that protect you
• Can be purchased anytime after enrolling in Part B,
though pre-existing conditions may be excluded for
a limited time
23

24. Medigap Policies
(Medicare Supplement Insurance)
• Insurance companies can only sell a “standardized”
Medigap policy
– Identified in most states by letters (NY = A through N)
• You pay a monthly premium that varies by plan by plan,
insurance company, and your location
• Go to any Medicare-approved doctor
24

25. Medigap Policies
Medigap 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 up
         
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      50% 75% 
Medicare Part B deductible  
Medicare Part B excess charges  
Foreign travel emergency (up to plan limits)      
Plan F has a high-deductible option
Out-of-pocket limit for Plan K = $4,660, for Plan L = $2,330
Source: Choosing a Medigap Policy, CMS and NAIC http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf 25

26. What a Medigap Policy May Cover in
Full or Part
• Deductibles and coinsurance amounts, such as:
– The $1,184 deductible for Part A
– Hospital costs after 60 days
– The 20% of doctor bills that Medicare doesn’t pay
– Amounts the doctor charges over the Medicare-approved amount
26

27. Part A
HOSPITAL
$0 premium
Part B
DOCTORS
$104.90 base
premium
Medical Supplements
Letters A Through N
Monthly Premiums vary by Plan and
Carrier
Part D
PRESCRIPTION DRUGS
Varying Monthly Premium
Copayments Vary by Tier
THIRD Way to Complete Your Medicare Coverage
A Private Insurance Company’s
Enhanced Medicare Program = Option 3
Part C
Medicare Advantage Plan
Hospital+Doctors+Part D
+Extras
$0 or Low
Monthly Premiums, though
Part B Premium continues
Pay Copayments Up to the
Maximum Out-of-Pocket
(MOOP)

28. Medicare Advantage Plans Replace your
Original Medicare Coverage
• Private insurance sold by private insurance companies
• Known as PART C - - deliver the same benefits (or more) as
Original Medicare Parts A and B
• Follow federal/state laws that protect you
• Medicare pays most of the premium for each member’s care
• May have to use network doctors or hospitals
• Most plans offer prescription drug coverage
• Many include extra benefits like vision, dental, hearing aids,
Silver Sneakers
• Benefits and cost-sharing differ from Original Medicare AND
between plans 28

29. Shop Carefully for Private Insurance
• Medicare supplement plans are standardized but
premiums vary considerably
➡Choose the policy that offers the coverage you need (A-N)
➡Choose a reputable company offering that policy at the
lowest price
➡Make sure your health care provider processes the billing for
the company you choose
• Drug plan benefits vary considerably
➡Choose the plan offering the coverage you need for the
medicines you take
• Medicare Advantage plans (Part C) also vary considerably
➡Choose the plan offering the coverage you need at a fair price
29

30. What to Consider When
Choosing Coverage
• Costs - - evaluate premiums, deductibles, and
total potential out of pocket
• Do they contract with your doctors, hospitals,
pharmacies?
• Insurance Provider ratings (for Medicare
Advantage and Part D plans)
30These are the Services I Provide!

31. Agenda Part 3: The Affordable
Care Act and Additional Resources
• How will the Affordable Care Act Impact
Medicare?
• Resources That May Help to Reduce Your
Costs
31

32. Part 3: Key Takeways
• The Affordable Care Act includes additional
benefits for Medicare recipients
• Don’t wonder - - call and ask about additional
resources!
32

33. The Affordable Care Act and
Medicare: No Cuts to Benefits
• Reduced spending growth extends Medicare solvency
until 2026
• More help with prescription drug costs
– 2013 you pay less than half (47.5% of what your plan charges
for brand name drugs. For generics, you pay 79%
– 2020 The donut hole will be slowly phased out and
completely eliminated
• Free annual wellness checkup and a range of
prevention services, including cancer and diabetes
screenings
• Bonuses to primary care doctors to improve access
33
National Council on Aging: Straight Talk for Seniors on Health Reform: www.NCOA.org

34. Popular Medicare Resources
• EXTRA HELP: A Medicare program to help people with limited income
pay prescription drug costs, such as premiums, deductibles and coinsurance.
• EPIC: The Elderly Pharmaceutical Insurance Coverage Program is a free
New York State program that helps more than 280,000 income-eligible
seniors aged 65 and older to supplement their out-of-pocket Medicare Part D
drug plan costs. Seniors can apply for EPIC at any time of the year and must
be enrolled or eligible to be enrolled in a Medicare Part D drug plan to
receive EPIC benefits and maintain coverage.
• Medicare Savings Programs: help from your state paying your Medicare
premiums. May also pay Medicare Part A (Hospital Insurance) and Medicare
Part B (Medical Insurance) deductibles, coinsurance, and copayments if you
meet certain conditions 34

35. Determine Your Eligibility for
Additional Benefits
• Go to medicare.gov or call 1-800-Medicare
• Go to BenefitsCenter.org
35

36. Thank you!
36