Oregon Medical Insurance > Medicare Plan Information > Medicare 101

Medicare 101

Eligibility for Social Security does not determine when one is eligible for Medicare
Eligibility for Medicare is determined by:

• Age - 65+ years old
• Disability for 24 consecutive months

Medicare starts the first of the month of:

• Your 65th birthday or The month prior to your 65th birthday if you birthday is on the first of the month (If you are collecting social security and you don't receive your Medicare card three months prior to your 65 birthday, you may want to contact SSN to check on the status)

How To Enroll In Medicare at Age 65

Turning 65 and receiving Social Security

• Automatic enrollment by Social Security
• If you don't want Medicare you will need to send back paperwork to Social Security

Turning 65 and not receiving Social Security

• Enrollment is not automatic - Visit or call your local Social Security office

If You are Waiving Medicare Due to Group Coverage - Things to Consider

Part A

Take your Part A regardless of you or your spouse's employment status:

• It's free
• May help offset inpatient charges

Part B

In order to avoid the Part B late enrollment penalty one should address the following question before waiving their Part B:

• Question - Do you have active employer group health coverage either through yourself or your spouse?
  • If no, you would want to enroll in Part B in order to avoid the Part B late enrollment penalty
  • If yes, you have access to active group coverage, you would want to address the next question
• Question - Is the employer a large or small group based on Medicare?
  Small: Employer has under 20 employees
  • Medicare is primary and group plan is secondary
    • If covered by a small employer you should strongly consider enrolling in Medicare since Medicare is considered prime and the group plan, per Medicare COB rules, is secondary. Most plans will assume the secondary position regardless of whether or not you have taken Part B, meaning they typically will only cover 20% of Part B services.
    • If you do not sign up for Part B when you are first eligible, you may pay a late enrollment penalty for as long as you have Medicare. The penalty is 10% per month attached to future Part B premiums.
  Large: Employer has 20 or more employees
  • Group plan is primary and Medicare is secondary
    • If covered by a group health plan you will be eligible for a special enrollment period (SEP) to apply for Part B when you lose your active group coverage, and you will not be subject to the 10 percent penalty assuming you apply during the SEP
    • Waive the benefits of the group plan versus Medicare to see what is in your or your spouse's favor. In most situations it is best to waive your Part B due to the premium associated with Part B.

Medicare Part A

• In Patient Services - Hospitalization, skilled nursing facility & hospice care
• No monthly premium - Funded through your payroll taxes while working

Medicare Part B

• Out Patient Services - Doctor and specialist visits, lab services, x-ray, emergency room, & ambulance
• There is a monthly premium - $99.90 per month in 2012
• Monthly premium may be higher based on income - $85,001 filing single or $170,001 filing jointly

Medicare Part D

Enrollment

• Not done through the Social Security Department (exception - those receiving financial assistance)
• One enrolls through a Medicare Advantage with a Part D plan or a Stand Alone Prescription drug plan
• Cost for the Part D plan varies between the companies

Voluntary Program

• You are not required to take a Part D plan
  • By not enrolling when first eligible for Medicare, it does not preclude you from enrolling at another point in time (Exceptions: Creditable coverage through an employer group plan, TRICARE or the Department of Veterans Affairs).
  • If you do not enroll into a Part D plan when you are eligible you may be subject to a 1% penalty per month for every month you are not enrolled in a Part D plan (Lifetime Penalty) The penalty is calculated off of the national base beneficiary premium amount, which can change yearly (2011 - $32.34)

Part D penalty will not apply if you have a creditable prescription drug plan (a drug plan that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. VA benefits are considered creditable.)

Medical plan types

Original Medicare (Parts A & B)

• Inpatient (Part A) for 2012
  • 1-60 days $1,156
  • 61-90 days $289 per day
  • 91-150 days $578 per day
• Outpatient (Part B) for 2012
  • Calendar deductible $140
  • 20% to possible 35% coinsurance for most services

Medicare Supplement or Medigap Plans

• Secondary to Medicare
• Helps cover the "gaps" that Original Medicare will not cover like coinsurance and deductibles
• Plans A through N
• Plan benefits are standardized, but premium can vary between carriers
• Age may affect your premium Doctor access is determined by Original Medicare
• You can choose any stand alone Part D plan
• If you move, the plan may allow you to continue in the plan.
• Must have both Medicare Parts A & B
• Best time to buy a supplement plan is during the 6-month period that begins on the first day of the month in which you are both age 65 or older and enrolled in Part B
• Other than a few exceptions, outside the first 6 month window the carrier may be able to underwrite you if you try to enroll for coverage.

Medicare Advantage (MA) - (Part C) PPO, HMO and PFFS

• Your Medicare benefits are handled by the Company and plan you select
• Covers all the same benefits as Original Medicare, as well as other services not typically covered by Medicare (preventive services, case management, vision, etc..)
• Plans receive funding from Medicare
• MA Plans must have a contract with the Centers for Medicare and Medicaid Services (CMS)

ICEP (aging into Medicare)

• 7 month window
• Effective date determined by receipt of application

Annual Election Period (AEP)

• October 15th - Dec 7st
• Plan change opportunity
• Add or drop a Part D coverage
• Option to drop Medicare Advantage and go back to Original Medicare
• Change goes into effective January 1st

After January 1, Medicare Advantage members will be locked into their Advantage plan for 2012 unless they decide to dis-enroll from their Advantage plan and go back to Medicare. From January 1st to February 15th, seniors enrolled in Medicare Advantage plans will be allowed to sign up for a stand-alone Part D plan if they drop out of their Advantage plan.

Special Election Period (SEP)

• Loss of coverage
• Moved to new area or state

IMPORTANT MEDICARE CONTACTS

Social Security Department

• To enroll or waive Medicare
• To discuss income assistance programs
  1-800-772-1213 / TTY 1-800-325-0778
  Online at: http://www.ssa.gov

Medicare

• Publications and Questions about Medicare
  1-800-Medicare (1-800-633-4227)
  Online at: http://www.medicare.gov

Senior Health Insurance Benefits Assistance Program (SHIBA)

• Gives you access to a volunteer who can help answer questions
  1-800-772-4134 / TTY 1-800-735-2900
  Online at: http://www.oregonshiba.org

CDA Insurance LLC

• For assistance with Medicare Supplements, Medicare Advantage plans and Part D
  1-541-484-2330 / 1-800-884-2343
  Online at: http://www.hior.net