2. Who are we?...
RLee Insurance Solutions
Providing the right information to help make the right decisions
“Having worked in the senior market for years I was continually frustrated with the way
seniors were treated by both agents and their companies. There was always the
assumption that they were incapable of making the decision that would be best for
them on their own and they were often pressured into products that may not have
been in truly their best interest. I have always found seniors to be more than capable
of making the right decision when given all the facts. I believe if I provide the right
information making the right decisions just becomes a matter of “common sense”
Robin Lee
President
3. In the Beginning…
At the bill-signing ceremony President Johnson
enrolled President Truman as the first Medicare
beneficiary and presented him with the first Medicare
card. This is President Truman's application for the
optional Part B medical care coverage, which
President Johnson signed as a witness.
Back then:
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President Johnson signing the
Medicare program into law, July 30,
1965. Shown with the President (on
the right in the photo) are (left to
right) Mrs. Johnson; former
President Harry Truman; VicePresident Hubert Humphrey; and
Mrs. Truman.
The average person retiring was male and his average life expectancy was only 68 years!
Part B cost just $3.00 a month!
19 million people signed up that first year.
4. Today…
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People are living much longer, and life expectancy
keeps going up!
Today there are 47 million people on Medicare
By 2030 that number will rise to 79 million!
5. RLee Insurance Solutions
What are my cost?...
Part A cost:
For 2013, for those that don’t get Part A at no cost they pay $441.00/month
Part B cost:
If your yearly income in 2011 was
You pay in
2013
File individual return
File a joint return
$85,000 or less
$170,000 or less
$104.90
Above $85,00 up to $107,000
Above $170,00 up to $214,000
$146.00
Above $107,000 up to $160,000
Above $214,000 up to $320,000
$209.80
Above 160,00 up to $214,000
Above $320,000 up to $428,000
$272.70
Above $214,000
Above $428,000
$335.70
6. RLee Insurance Solutions
When you are
Hospitalized for:
Medicare Covers:
1-60 days
Most confinement cost after
the required Medicare
Deductible.
61-90 days
All eligible expenses, after
the patient pays a per-day
copayment.
91-150 days
All eligible expenses, after
patient Pays a per-day
copayment (Theses Are
Lifetime Reserve Days which
may never be used again).
151 or more days
At least 3 days and enter
A Medicare approved
SKILLED NURSING
FACILITY within 30 days
After hospital discharge
NOTHING
All eligible expenses, for the
first20 days; then all eligible
expenses for 21-100, after
patient pays a per-day
copayment.
You pay:
(per benefit period)
$1,184 Deductible
$296 A DAY COPAYMENT
as much as $8,880
$592 A DAY COPAYMENT
as much as $35,520
YOU PAY ALL COST
After 20 days
$148.00 A
DAY COPAYMENT as much as
$11,840
7. RLee Insurance Solutions
When you are
Hospitalized for:
Medicare Covers:
1-60 days
Most confinement cost after
the required Medicare
Deductible.
61-90 days
All eligible expenses, after
the patient pays a per-day
copayment.
91-150 days
All eligible expenses, after
patient Pays a per-day
copayment (Theses Are
Lifetime Reserve Days which
may never be used again).
151 or more days
At least 3 days and enter
A Medicare approved
SKILLED NURSING
FACILITY within 30 days
After hospital discharge
NOTHING
All eligible expenses, for the
first20 days; then all eligible
expenses for 21-100, after
patient pays a per-day
copayment.
You pay:
(per benefit period)
$1,216 Deductible
$304 A DAY COPAYMENT
as much as $9,120
$608 A DAY COPAYMENT
as much as $36,480
YOU PAY ALL COST
After 20 days
$152.00 A
DAY COPAYMENT as much as
$12,160
8. RLee Insurance Solutions
On expenses
Incurred for:
Medicare Covers:
Medical Expenses
Physician’s services, inpatient, outpatient
medical/surgical services, physical/speech
therapy, diagnostic test and durable medical
equipment
Generally 80% of approved
Amount
(subject to Part B deductible)
You pay $147
Annual Deductible
PLUS:
Generally 20% of
Approved amount
Generally 100% of
Approved amount
Nothing for services
Home Health Care
Part-time or intermittent skilled care,
home health aide services, durable medical
supplies and other services.
(not subject to Part B deductible)
100% of the approved amount
(not subject Part B deductible)
80% of the approved amount for durable
medical equipment
(subject to part B deductible)
Nothing for services;
20% of approved amount for
Durable medical equipment
Outpatient Hospital Treatment
Services for the diagnosis or treatment
Of an illness or injury
Generally 80% or approved
Amount (subject to Part B deductible)
Blood
After first three pints of blood,
80% of approved amount
(subject to part B deductible)
Clinical Laboratory Services
Blood test for diagnostic services
Generally, 20% of billed amount
First three pints plus 20%
Of approved amount for additional pints
9. What are the gaps?...
RLee Insurance Solutions
They include…
Part A deductible
Part B deductible
Part B 20% including the first 3 pints of blood
Part B excess charge (15% of Medicare approved amount)
Foreign travel emergency care
Skilled nursing facility co-pay
Drug coverage
10. RLee Insurance Solutions
What is Part B excess?
Medicare assigns a price for any and all covered procedures. If the
doctor or hospital accepts this price they are accepting Medicare
“assignment” . If they choose to not accept assignment they can
charge 15% more than the Medicare approved amount only.
Example of Medicare Basics at Mayo
“Mayo Clinics don’t currently
accept assignment, here is an
example of how it could effect
your bill”.
Mayo Clinic Charge
$115.00
Medicare approved amount
$100.00
Medicare pays 80% of approved amount
$80.00
Secondary insurance pay 20% or approved amount $20.00
Total paid by Medicare and Secondary insurance
$100.00
Patient responsibility
$15.00
Heart Surgery
$150,000
Medicare Assignment
$100,000
Part B pays 80%
$80,000
Supplement pays 20%
$20,000
Part B Excess Charge 15%
$15,000
“How can Excess Charges effect a major
hospital stay”?
11. Why Will Excess
Charges be a Factor?...
The AMA explains that the
cost to run a medical practice
has risen every year
while reimbursements from
Medicare go down every year.
Where will it end?
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12. What Do Doctors
Think?...
RLee Insurance Solutions
AMA ONLINE SURVEY OF PHYSICIANS The Impact of Medicare
Physician Payment on Seniors Access’ To Care May 2010
Key Findings from a new AMA online survey of 9,000+ physicians who care for Medicare patients.
About one in five physicians overall (17%) are currently restricting the number of Medicare
patients in their practice. The top two reasons they gave*:
•
Medicare payment rates are too low (85%) • ongoing threat of future payment cuts makes Medicare an unreliable
payer (78%) primary care physicians**, nearly one-third (31 percent) currently restrict the
Looking at just
number of Medicare patients in their practice. The top two reasons they gave:
•
Medicare payment rates are too low (83%) • ongoing threat of future payment cuts makes Medicare an unreliable payer (82%)
In response to this year’s two short-term delays to the 21% Medicare physician payment cut, nearly two-thirds (60%) of physicians
looked into opting out of Medicare and treating patients through the private contracting option. Other actions included:
•
Delayed payments for supplies, rent and/or other expenses (39%)
•
Took out a loan or line of credit in order to continue paying bills (17%)
•
Held up paychecks or laid off/furloughed staff (17%)
•
Cancelled or postponed scheduled services to Medicare patients (14%)
•
Temporarily closed practice to new appointments with Medicare patients (13%)
Asked about temporary proposals under consideration by Congress, physicians say that the
short-term actions will impact patients’ access to care.
If Congress enacts a 4-7 month Medicare payment freeze with a 21% payment cut,
physicians say they will:
•
Restrict the number of Medicare patients they treat
(54%)
•
Stop taking new Medicare patients (50%)
•
Stop taking any Medicare patients (31%)
If Congress enacts a 3-5 year increase in Medicare payments with a 21% payment cut to
physicians in the future, physicians say they will:
•
•
•
Restrict the number of Medicare patients they treat
(48%)
Stop taking new Medicare patients (42%)
Stop taking any Medicare patients (26%)
*Physicians in this survey were
asked to check all answers that
apply. **Primary care is defined as
Family Practice, General Practice,
Internal Medicine, and
Obstetrics/Gynecology.
13. What about the very
near future?...
RLee Insurance Solutions
Physician Medicare Cuts Delayed Til 2014
Well, they did it again. The press is congratulating Congress on
the "success" of coming up with a New Year's Night deal on that
no one likes. For physicians, this deal contains a delay in the
27% cut in Medicare payments to physicians according to the
Sustainable Growth Rate (SGR). For full coverage of this story, I
encourage you to read articles from Medpage Today, Kaiser
Health News, and Modern Healthcare. (Photo credit: New York
Times)
The 26.5% cut in Medicare reimbursement mandated by the
sustainable growth rate (SGR) formula was averted in a literal
11th hour vote Tuesday in the House of Representatives. The
House vote to pass the "fiscal cliff" bill OK'd earlier by the
Senate delays the SGR cuts for a year. The bill cleared the House
by a vote of 257-167; senators had passed the same bill in an
89-8 vote just after 2:00 a.m. vote.
While Congress has put another Band-Aid on the SGR problem,
a long term solution is still needed, because when December
31, 2013 comes, we'll be going through this thing all over again,
and the potential cuts will probably be in the 30% range.
Medical organizations will again be out encouraging their
members to lobby congress for a long term Medicare payment
solution. How effective will they be? We'll see..
The bill cleared the House by a vote of 257167; senators had passed the same bill in an
89-8 vote just after 2:00 a.m. vote.
14. RLee Insurance Solutions
We can fill those gaps!...
With a Medicare supplement policy…
Plan A
Basic Benefits
Skilled nursing co-pay
Part A deductible
Part B deductible
Part B excess charges
Foreign Travel
Drug coverage
Plan F
Plan G
Plan N
Part D
Plan N has a $20
copayment per office visit and
a $50 copayment each ER
visit.
15. RLee Insurance Solutions
What are my cost?...
Part D cost:
If your yearly income in 2011 was
You pay in 2013
File individual return
File a joint return
$85,000 or less
$170,000 or less
Your plan
premium
Above $85,00 up to $107,000
Above $170,00 up to $214,000
$11.60 + your
plan premium
Above $107,000 up to $160,000
Above $214,000 up to $320,000
$29.90 + your
plan premium
Above 160,00 up to $214,000
Above $320,000 up to $428,000
$48.30 + your
plan premium
Above $214,000
Above $428,000
$66.60 + your
plan premium
16. RLee Insurance Solutions
2013 Part D coverage ...
2013 Basic Medicare Drug Coverage
2013 Basic Benefits
You Pay
Deductible
$325
100% of first $325
Initial Coverage Limit
$2645
25% of the next $2645 ($661.25)
Coverage Gap
$2970.00
100% of the drug cost
Annual – out- of- pocket amount
Catastrophic Coverage
Medicare and Plan
95%
$4750
5%
17. RLee Insurance Solutions
2014 Part D coverage ...
2014 Basic Medicare Drug Coverage
2014 Basic Benefits
You Pay
Deductible
$310
100% of first $310
Initial Coverage Limit
$2540
25% of the next $2540 ($635.00)
Coverage Gap
$2850.00
100% of the drug cost
Annual – out- of- pocket amount
Catastrophic Coverage
Medicare and Plan
95%
$4550
5%
18. New benefits in 2013...
“How will the new
healthcare law
benefit me?” …
RLee Insurance Solutions
19. RLee Insurance Solutions
What are your options?...
Medicare
Advantage Plans
Original
Medicare
Original
Medicare
Part A &B
Medicare
Supplement
Medicare
Part D
Part C
One or the other
Part D
20. What is part C or
Advantage Plans?…
RLee Insurance Solutions
What Are Advantage Plans?
•Medicare Advantage (MA) plans are health plan
options that are part of the Medicare program
•MA plans are not the same as Medicare
Supplement insurance
•Medicare pays the plan (the insurance company)
a set amount every month for your care
•MA plans must offer all benefits of Original
Medicare and can include Part D prescription
drug coverage
21. What is part C or
Advantage Plans?…
RLee Insurance Solutions
• Most plans offer health and drug
coverage, as well as extra benefits
• Most have lower out-of-pocket costs
than with Original Medicare
• You may have to use certain healthcare
providers
• You do not need a Medicare Supplement
22. What are your choices with
Advantage Plans?…
RLee Insurance Solutions
Choices in Medicare Advantage (MA) Plans
• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Private-Fee-For-Service (PFFS)
Plus, Part D Medicare Prescription Drug Coverage
• May be purchased as a stand-alone plan; or
• As part of a Medicare Advantage Prescription Drug plan (MAPD)
• All plans must meet minimum coverage level set by Medicare
•You should evaluate your prescription drug needs in relation to those
covered by the plan, and your cost for those drugs
23. Is an Advantage Plan
right for You?…
RLee Insurance Solutions
Things to consider before deciding on an Advantage
Plan
•What is the current state of your health?
•How often do you visit the doctor or hospital?
• Will the cost savings in monthly premium offset the co-pays?
• Where is the plan coverage area?
•Are the added benefits important to you?
•Can you return to “traditional Medicare” if you are not happy?
24. Things to consider...
… with your healthcare.
Does your current doctor accept assignment?
If so, will he be likely to continue to do so in the future?
How often do you visit the doctor?
How often do you visit the ER?
… with your agent.
Can I trust the agent?
Who do I call with my questions and concerns?
How well do they understand Medicare and my concerns?
Are they local?
… with the company.
Is my policy Guaranteed Renewable?
Will they pay my bills quickly?
Who will take care of all the paperwork?
What is the insurance company’s rating?
Is the plan accepted in my area?
RLee Insurance Solutions
26. Our Full line of
Services…
RLee Insurance Solutions
Making your healthcare decisions
A matter of “using common sense”
SERVICES AVAILABLE
Medicare Supplements
Medicare Advantage Plans
Part D Drug Cards
Life Insurance
Annuities
Long Term Care Insurance
Supplemental Health
Travel Insurance