AHIP Training Roadmap
Training Roadmap: Part 1
• After reviewing “Part 1: Medicare Program Basics” you will be able to explain:
o The different ways to get Medicare;
o Entitlement to Original Medicare;
o Medicare premiums;
o Eligibility for Medicare Advantage and prescription drug plans;
o Help for beneficiaries with limited income;
o Original Medicare benefits;
o Combining original Medicare and Part D; and
o Medigap coverage.
Medicare Program Basics
• Medicare is a health benefits program for U.S. citizens or permanent residents:
o Age 65 or older
o Under age 65 with certain disabilities
▪ Includes citizens determined to be disabled with Amyotrophic Lateral Sclerosis (ALS), often referred to as
Lou Gehrig’s Disease; or to be disabled based on exposure to environmental health hazards are entitled
to Medicare the month they are deemed to be disabled.
o For all ages with end-stage renal disease (ESRD)
• History – Medicare was signed into law in 1965. A brief history of Medicare is available at http://www.cms.gov/History/
• Medicare is administered by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health
and Human Services
Medicare Law -- Title XVIII of the Social Security Act (Parts A, B, C, D)
• Medicare law is Title XVIII of the Social Security Act: "Health Insurance for the Aged and Disabled"
o Part A – Hospital
o Part B – Medical
o Part C – Medicare health plans, which must cover Part A and Part B benefits
o Part D – Prescription drug
coverage Different Ways to Get
Medicare
• Original Fee-for-Service (FFS) Medicare (has two Parts – Part A and Part B)
o Part A – Hospital, skilled nursing facility, hospice, and home health services
o Part B – Professional services such as those provided by a doctor or non-physician professional, outpatient care,
and other medical services
Different Ways to Get Medicare, cont’d.
• Part C - Medicare Health Plans (Medicare Advantage plans must include Part A and Part B)
o Health Maintenance Organizations (HMOs) (some also include Part D)
o Preferred Provider Organizations (PPOs) (some also include Part D)
o Private Fee-for-Service Plans (PFFS) (some also include Part D)
o Special Needs Plans (SNPs) (always include Part D)
o Medical Savings Account Plans (MSAs) (do not include Part D)
o Cost and PACE Plans (not Part C MA plans - different plan types, may include Part D)
o Employer or Union Group Plans
Different Ways to Get Medicare,
cont’d.
• Part D – Prescription Drug Coverage
o Stand-alone Prescription Drug Plan (PDP) or
o Coverage in a health plan
Part C Medicare Health Plans
• All Medicare Advantage (MA) plans must:
o Cover all Part A and Part B benefits;
o Provide plan cost-sharing actuarially equivalent to cost sharing under Medicare Parts A and B, but may be different for
specific services; and
o Include an annual maximum out-of-pocket (MOOP) limit on total enrollee cost sharing (deductibles, coinsurance,
, and copayments) for Part A and Part B services.
• Extra Benefits – Medicare health plans also may cover extra benefits not covered by Original Medicare, such as:
o Lower Cost Sharing [Note: Some plans reduce the Part B premium.]
, o Vision Services
o Hearing Services
o Dental Services
o Routine foot care services
o Chiropractic Services
Medigap (Medicare Supplement
Insurance)
• Medigap insurance:
o Is sold by private insurance companies to fill "gaps" in Original Medicare coverage;
o Works only with Original Medicare;
o Covers all of a portion of Part A and Part B cost sharing (coinsurance, copayments, or deductibles) for beneficiaries in
Original Medicare.
▪ Does not cover Medicare Benefits, but works in tandem with Original Medicare coverage.
• Some Medigap policies cover benefits not covered by Part A or Part B of Original Medicare, such as extra days of coverage for
inpatient hospital care of foreign travel emergency care.
Entitlement to Original Medicare, Premiums, & Eligibility
Medicare Entitlement - Part A
• Most individuals automatically get Part A coverage without having to pay a monthly premium. This is because they or a spouse paid
Medicare taxes while working.
• These individuals receive Part A coverage without paying a Part A premium.
• For those individuals who do not automatically qualify for Part A coverage, the Part A premium in 2013 is $243 or $441 a month
depending on an individual's duration of Medicare-covered employment.
• Individuals with disabilities who are under age 65 are automatically enrolled in Part A after they have received Social Security or
Railroad Retirement disability benefits for 24 months.
Medicare Entitlement - Part B
• At Age 65
o Most individuals who file an application for Social Security or Railroad Retirement benefits 3 months before they
turn age 65 or later are automatically enrolled in Part B unless they refuse Part B coverage.
• Individuals with disabilities who are under age 65 are automatically enrolled in Part B the earlier of:
o the month they turn 65 if they have received Social Security or Railroad Retirement benefits for at least 4 months
before they turn age 65, without having to fill out any additional application for those benefits. They also are given an
opportunity to refuse Part B coverage.
o the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. They
also are given an opportunity to refuse Part B coverage. [Note: Exception for ALS disease or environmental
exposure.]
Medicare Premiums for Part B
• Beneficiaries enrolled in Part B must pay a monthly premium.
o The standard monthly premium for Part B is $104.90 in 2013.
o Individuals with income over $85,000, or filing jointly with incomes over $170,000, pay more, up to $335.70 a month in
2013 based on the income related monthly adjustment (IRMA).
• Part B premiums may be deducted from Social Security checks or Railroad Retirement checks.
o The Office of Personnel Management may offer premium deduction in the
future. Medicare Premiums for Part B, cont'd.
• Individuals who do not enroll in Part B when first eligible (e.g., at age 65) can enroll during a General Enrollment Period, January 1
– March 31.
o Part B coverage begins on July 1 of the year they enroll.
o The Part B premium is increased 10% for each full 12-month period the beneficiary could have had Part B but, did
not enroll.
• Exception: Individuals who have group health plan coverage based on their own current employment or the employment of a
spouse are not subject to the premium increase and may enroll in Part B anytime while covered under the group health plan or
during a special enrollment period that occurs during the 8-month period immediately following the last month of the group
coverage
Medicare Eligibility - Part C/Part D
• Part C Medicare Advantage Health Plan
o Individuals who are entitled to benefits under Part A and enrolled under Part B are eligible to enroll in a Medicare
Advantage plan.
• Part D Prescription Drug Benefits
, o Individuals who are entitled to benefits under Part A and/or enrolled under Part B are eligible for Part D prescription
drug benefits.
• Help for Individuals with Limited Income
•
Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office
• Beneficiaries with limited income and resources should be encouraged to apply to their State Medicaid office to
determine eligibility for various programs.
• Beneficiaries may qualify for help from the State to pay the Medicare Part A (if any) and Part B premium, the Part A and Part B
deductibles and cost sharing, and/or some Part D prescription drug costs.
• Tell them to call 1-800-Medicare (1-800-633-4227) and just say "Medicaid" for the State Medicaid telephone
number. Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office, cont'd.
• Beneficiaries may qualify for help through these programs:
o Medicaid: help with health care costs. Apply to State Medicaid office.
o Medicare Savings Program: help paying Medicare Part A and/or Part B premiums and, in some cases, deductibles and
coinsurance/copayments. Apply to State Medicaid office or Social Security Administration (SSA) at 1-800-772-1213
or apply online at http://www.socialsecurity.gov/prescriptionhelp.
o Part D low-income subsidy: help paying for prescription drug coverage. Apply to State Medicaid office and the State will
check for eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D
help only also may contact the SSA.
o Supplemental Security Income (SSI) benefits: help with cash for basic needs. Apply to State Medicaid office or SSA.
Original Medicare Benefits
Medicare Part A Benefits
• Part A helps cover inpatient care in hospitals that is medically necessary. In 2013, for each benefit period (as defined by Medicare)
in a year, beneficiaries pay:
o $1,184 deductible and no coinsurance for a stay of up to 60 days
o $296 per day for days 61-90 of a hospital stay
o $592 per "lifetime reserve day" after day 90 each benefit period (up to 60 days over your lifetime)
o All costs for each inpatient day beyond 150
days Medicare Part A Benefits, cont'd.
o Part A also helps cover:
▪ Blood
▪ Hospice care
▪ Home health care
▪ Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period
(as defined by Medicare). In 2013, beneficiaries pay $148 coinsurance for days 21-100 each benefit
period.
▪ Inpatient psychiatric care (up to 190 lifetime days)
o Part A does not cover custodial or long-term care.
• Cost-sharing may differ for enrollees of Medicare health
plans. Medicare Part B Benefits
• Generally cover medically necessary physician and other health care professional services, outpatient hospital, clinical lab and
diagnostic tests, therapies, mental health care, medical equipment, and medications and supplies provided incident to a physician
service.
• Beneficiaries pay a deductible each year ($147 in 2013), and after the deductible is satisfied, 20% coinsurance on most Part
B covered services.
• Cost-sharing may differ for enrollees of Medicare health plans.
Medicare Part B Benefits - Preventative Services and Screenings (1 of 3)
• Beneficiaries will have no cost-sharing for most preventative services.
• Preventative Services Include:
o One-time "Welcome to Medicare" physical exam
o Annual wellness visit after 12 mos. enrolled in Part B
o Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1
o Abdominal aortic aneurysm screening – one time, with referral>
o Alcohol misuse screening - every 12 months for certain individuals
Training Roadmap: Part 1
• After reviewing “Part 1: Medicare Program Basics” you will be able to explain:
o The different ways to get Medicare;
o Entitlement to Original Medicare;
o Medicare premiums;
o Eligibility for Medicare Advantage and prescription drug plans;
o Help for beneficiaries with limited income;
o Original Medicare benefits;
o Combining original Medicare and Part D; and
o Medigap coverage.
Medicare Program Basics
• Medicare is a health benefits program for U.S. citizens or permanent residents:
o Age 65 or older
o Under age 65 with certain disabilities
▪ Includes citizens determined to be disabled with Amyotrophic Lateral Sclerosis (ALS), often referred to as
Lou Gehrig’s Disease; or to be disabled based on exposure to environmental health hazards are entitled
to Medicare the month they are deemed to be disabled.
o For all ages with end-stage renal disease (ESRD)
• History – Medicare was signed into law in 1965. A brief history of Medicare is available at http://www.cms.gov/History/
• Medicare is administered by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health
and Human Services
Medicare Law -- Title XVIII of the Social Security Act (Parts A, B, C, D)
• Medicare law is Title XVIII of the Social Security Act: "Health Insurance for the Aged and Disabled"
o Part A – Hospital
o Part B – Medical
o Part C – Medicare health plans, which must cover Part A and Part B benefits
o Part D – Prescription drug
coverage Different Ways to Get
Medicare
• Original Fee-for-Service (FFS) Medicare (has two Parts – Part A and Part B)
o Part A – Hospital, skilled nursing facility, hospice, and home health services
o Part B – Professional services such as those provided by a doctor or non-physician professional, outpatient care,
and other medical services
Different Ways to Get Medicare, cont’d.
• Part C - Medicare Health Plans (Medicare Advantage plans must include Part A and Part B)
o Health Maintenance Organizations (HMOs) (some also include Part D)
o Preferred Provider Organizations (PPOs) (some also include Part D)
o Private Fee-for-Service Plans (PFFS) (some also include Part D)
o Special Needs Plans (SNPs) (always include Part D)
o Medical Savings Account Plans (MSAs) (do not include Part D)
o Cost and PACE Plans (not Part C MA plans - different plan types, may include Part D)
o Employer or Union Group Plans
Different Ways to Get Medicare,
cont’d.
• Part D – Prescription Drug Coverage
o Stand-alone Prescription Drug Plan (PDP) or
o Coverage in a health plan
Part C Medicare Health Plans
• All Medicare Advantage (MA) plans must:
o Cover all Part A and Part B benefits;
o Provide plan cost-sharing actuarially equivalent to cost sharing under Medicare Parts A and B, but may be different for
specific services; and
o Include an annual maximum out-of-pocket (MOOP) limit on total enrollee cost sharing (deductibles, coinsurance,
, and copayments) for Part A and Part B services.
• Extra Benefits – Medicare health plans also may cover extra benefits not covered by Original Medicare, such as:
o Lower Cost Sharing [Note: Some plans reduce the Part B premium.]
, o Vision Services
o Hearing Services
o Dental Services
o Routine foot care services
o Chiropractic Services
Medigap (Medicare Supplement
Insurance)
• Medigap insurance:
o Is sold by private insurance companies to fill "gaps" in Original Medicare coverage;
o Works only with Original Medicare;
o Covers all of a portion of Part A and Part B cost sharing (coinsurance, copayments, or deductibles) for beneficiaries in
Original Medicare.
▪ Does not cover Medicare Benefits, but works in tandem with Original Medicare coverage.
• Some Medigap policies cover benefits not covered by Part A or Part B of Original Medicare, such as extra days of coverage for
inpatient hospital care of foreign travel emergency care.
Entitlement to Original Medicare, Premiums, & Eligibility
Medicare Entitlement - Part A
• Most individuals automatically get Part A coverage without having to pay a monthly premium. This is because they or a spouse paid
Medicare taxes while working.
• These individuals receive Part A coverage without paying a Part A premium.
• For those individuals who do not automatically qualify for Part A coverage, the Part A premium in 2013 is $243 or $441 a month
depending on an individual's duration of Medicare-covered employment.
• Individuals with disabilities who are under age 65 are automatically enrolled in Part A after they have received Social Security or
Railroad Retirement disability benefits for 24 months.
Medicare Entitlement - Part B
• At Age 65
o Most individuals who file an application for Social Security or Railroad Retirement benefits 3 months before they
turn age 65 or later are automatically enrolled in Part B unless they refuse Part B coverage.
• Individuals with disabilities who are under age 65 are automatically enrolled in Part B the earlier of:
o the month they turn 65 if they have received Social Security or Railroad Retirement benefits for at least 4 months
before they turn age 65, without having to fill out any additional application for those benefits. They also are given an
opportunity to refuse Part B coverage.
o the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. They
also are given an opportunity to refuse Part B coverage. [Note: Exception for ALS disease or environmental
exposure.]
Medicare Premiums for Part B
• Beneficiaries enrolled in Part B must pay a monthly premium.
o The standard monthly premium for Part B is $104.90 in 2013.
o Individuals with income over $85,000, or filing jointly with incomes over $170,000, pay more, up to $335.70 a month in
2013 based on the income related monthly adjustment (IRMA).
• Part B premiums may be deducted from Social Security checks or Railroad Retirement checks.
o The Office of Personnel Management may offer premium deduction in the
future. Medicare Premiums for Part B, cont'd.
• Individuals who do not enroll in Part B when first eligible (e.g., at age 65) can enroll during a General Enrollment Period, January 1
– March 31.
o Part B coverage begins on July 1 of the year they enroll.
o The Part B premium is increased 10% for each full 12-month period the beneficiary could have had Part B but, did
not enroll.
• Exception: Individuals who have group health plan coverage based on their own current employment or the employment of a
spouse are not subject to the premium increase and may enroll in Part B anytime while covered under the group health plan or
during a special enrollment period that occurs during the 8-month period immediately following the last month of the group
coverage
Medicare Eligibility - Part C/Part D
• Part C Medicare Advantage Health Plan
o Individuals who are entitled to benefits under Part A and enrolled under Part B are eligible to enroll in a Medicare
Advantage plan.
• Part D Prescription Drug Benefits
, o Individuals who are entitled to benefits under Part A and/or enrolled under Part B are eligible for Part D prescription
drug benefits.
• Help for Individuals with Limited Income
•
Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office
• Beneficiaries with limited income and resources should be encouraged to apply to their State Medicaid office to
determine eligibility for various programs.
• Beneficiaries may qualify for help from the State to pay the Medicare Part A (if any) and Part B premium, the Part A and Part B
deductibles and cost sharing, and/or some Part D prescription drug costs.
• Tell them to call 1-800-Medicare (1-800-633-4227) and just say "Medicaid" for the State Medicaid telephone
number. Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office, cont'd.
• Beneficiaries may qualify for help through these programs:
o Medicaid: help with health care costs. Apply to State Medicaid office.
o Medicare Savings Program: help paying Medicare Part A and/or Part B premiums and, in some cases, deductibles and
coinsurance/copayments. Apply to State Medicaid office or Social Security Administration (SSA) at 1-800-772-1213
or apply online at http://www.socialsecurity.gov/prescriptionhelp.
o Part D low-income subsidy: help paying for prescription drug coverage. Apply to State Medicaid office and the State will
check for eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D
help only also may contact the SSA.
o Supplemental Security Income (SSI) benefits: help with cash for basic needs. Apply to State Medicaid office or SSA.
Original Medicare Benefits
Medicare Part A Benefits
• Part A helps cover inpatient care in hospitals that is medically necessary. In 2013, for each benefit period (as defined by Medicare)
in a year, beneficiaries pay:
o $1,184 deductible and no coinsurance for a stay of up to 60 days
o $296 per day for days 61-90 of a hospital stay
o $592 per "lifetime reserve day" after day 90 each benefit period (up to 60 days over your lifetime)
o All costs for each inpatient day beyond 150
days Medicare Part A Benefits, cont'd.
o Part A also helps cover:
▪ Blood
▪ Hospice care
▪ Home health care
▪ Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period
(as defined by Medicare). In 2013, beneficiaries pay $148 coinsurance for days 21-100 each benefit
period.
▪ Inpatient psychiatric care (up to 190 lifetime days)
o Part A does not cover custodial or long-term care.
• Cost-sharing may differ for enrollees of Medicare health
plans. Medicare Part B Benefits
• Generally cover medically necessary physician and other health care professional services, outpatient hospital, clinical lab and
diagnostic tests, therapies, mental health care, medical equipment, and medications and supplies provided incident to a physician
service.
• Beneficiaries pay a deductible each year ($147 in 2013), and after the deductible is satisfied, 20% coinsurance on most Part
B covered services.
• Cost-sharing may differ for enrollees of Medicare health plans.
Medicare Part B Benefits - Preventative Services and Screenings (1 of 3)
• Beneficiaries will have no cost-sharing for most preventative services.
• Preventative Services Include:
o One-time "Welcome to Medicare" physical exam
o Annual wellness visit after 12 mos. enrolled in Part B
o Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1
o Abdominal aortic aneurysm screening – one time, with referral>
o Alcohol misuse screening - every 12 months for certain individuals
