Welcome to Kaiser Permanente Presenting Medicare 101 and Kaiser - - PowerPoint PPT Presentation

Welcome to Kaiser Permanente

Presenting Medicare 101 and Kaiser Permanente Senior Advantage

City of San Diego Nancy Voltero Retiree Consultant

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Basics of Medicare

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What is Medicare?

• Medicare is a federally funded health insurance program

for eligible beneficiaries.

• Medicare was established in 1965.
• Medicare is administered by the Centers for Medicare &

Medicaid Services (CMS).

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Who is eligible?

Medicare beneficiaries include:

• Individuals 65 or older if they or their spouses are eligible for Social

Security.

• Individuals under 65 who are disabled.

– Must be eligible for Social Security disability – Requires 2-year waiting period

• Individuals with end-stage renal (kidney) disease (ESRD).

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Medicare Part A

• Inpatient insurance

– Hospital, skilled nursing facility, hospice, home health care

• Eligibility

– First day of the month that you turn 65 – 2 years after becoming disabled – After end-stage renal dialysis begins

• Cost

– No premium if you or your spouse has worked 40 quarters of Medicare-covered employment.

• If you worked fewer than 40 quarters, there is a monthly premium

up to $441 which is set by a Medicare formula.

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Medicare Part B

• Outpatient insurance

– Physician services, outpatient surgery, lab, radiology, durable medical equipment (DME), dialysis.

• Enrollment

– Optional: You are responsible for enrolling with Social Security Administration. – You can enroll over a 7-month period, which starts 3 months before your 65th birthday.

• Late enrollment penalty may apply if you do not enroll in this 7-

month window.

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Medicare Part B

Cost

• Monthly premium is usually deducted from your Social Security

check.

• Premium goes up 10 percent for each 12-month period that you

decline coverage.

– Known as late enrollment penalty.* – Not imposed if you continue to work for—and receive your health coverage from—an employer group or trust fund plan of 20 or more eligibles.

• In 2015, Part B premium will range from $104.90 to $335.70,

depending on income.

* This amount is not a one-time penalty, but continues throughout enrollment.

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2015 Monthly Premiums for Medicare Part B

You Pay I f Your Yearly I ncom e is* Single Married Couple $ 1 0 4 .9 0 $ 8 5 ,0 0 0 or less $ 1 7 0 ,0 0 0 or less $ 1 4 6 .9 0 $ 8 5 ,0 0 1 -$ 1 0 7 ,0 0 0 $ 1 7 0 ,0 0 1 -$ 2 1 4 ,0 0 0 $ 2 0 9 .8 0 $ 1 0 7 ,0 0 1 -$ 1 6 0 ,0 0 0 $ 2 1 4 ,0 0 1 -$ 3 2 0 ,0 0 0 $ 2 7 2 .7 0 $ 1 6 0 ,0 0 1 -$ 2 1 4 ,0 0 0 $ 3 2 0 ,0 0 1 -$ 4 2 8 ,0 0 0 $ 3 3 5 .7 0 Above $ 2 1 4 ,0 0 0 Above $ 4 2 8 ,0 0 0 You Pay I f You Are Married but You File a Separate Tax Return From Your Spouse and Your Yearly I ncom e 2 0 1 1 w as $ 1 0 4 .9 0 Under $ 8 5 ,0 0 0 or less $ 2 7 2 .7 0 $ 8 5 ,0 0 1 -$ 1 2 9 ,0 0 0 $ 3 3 5 .7 0 Above $ 1 2 9 ,0 0 0 * Modified adjusted gross income as reported on your 2011 IRS tax return. If you have questions about your Part B premium, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

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How to Enroll in Medicare Part B

• Fill out an Application for Enrollment in Medicare Part B.

Mail it to the nearest Social Security office, or

• Submit it in person to any Social Security office.
• Call Social Security to apply for Medicare
• Enroll on line at www.socialsecurity.gov

Note: Completing the application form and submitting it does not automatically enroll you in Medicare Part B. Social Security must first determine if you are eligible to enroll.

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Medicare Plan Options

Plan options for how you receive Medicare coverage:

• Option 1: Original Medicare Plan through the Centers for

Medicare & Medicaid Services (CMS).

• Option 2: Medicare Advantage Plans (Part C) such as:

– A Health Maintenance Organization (HMO) – Preferred Provider Organization (PPO) – Private Fee-for-Service (PFFS) – Medical Savings Account Plans (MSA)

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• Medicare Modernization Act (MMA) created Medicare

prescription drug coverage (Part D), effective January 1, 2006.

–Provides outpatient prescription drug coverage.

• Enrollment options for Part D

– Private insurer plan, such as Kaiser Permanente. – Prescription Drug Plan (PDP): A plan type that offers prescription drugs only.

Note: Unlike Parts A and B, Part D is enrolled directly with the plan. Part D is not available through Medicare or Social Security.

Medicare Part D

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Enrolling in Part D

• You are eligible for initial enrollment during the 7-month period,

which starts 3 months before your 65th birthday.

• Late enrollment penalty (LEP)

– As with Part B, you must obtain Part D or creditable Part D coverage as soon as you are eligible or you will be charged a penalty. – LEP is 1 percent of that year’s Part D base premium per month that enrollment is deferred.

Medicare Part D

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Medicare’s extra help program: Low Income Subsidy (LIS)

• For Medicare beneficiaries with limited income and resources.
• Provides extra help with Part D premiums and outpatient drug

copayments.

– Degree of help depends on income and resources.

• Additional facts about extra help:

– Apply at Social Security or state Medicaid office. – Administered by the member’s plan, for CMS. – Beneficiaries must be enrolled in a Part D plan to receive assistance.

Medicare Part D

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Medicare Part D

You pay If your yearly income is* Single Married couple $12.30 $85,001–107,000 $170,001–214,000 $31.80 $107,001–160,000 $214,001–320,000 $51.30 $160,001–214,000 $320,001–428,000 $70.80 Above $214,000 Above $428,000

• The Part D higher-income premium is in addition to the annual Part B

premium adjustment.

• The Part D premium is determined according to formulas set by

federal law, not by the health plan.

* Modified adjusted gross income as reported on your 2011 IRS tax return. If you have questions about your Part D premium, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

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Kaiser Permanente Senior Advantage (HMO)

All of the following information regarding Medicare and Kaiser Permanente Senior Advantage applies

• nly to employer group Members who have or are

eligible for Medicare.

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Kaiser Permanente region Star rating California Colorado Georgia Hawaii Mid-Atlantic States (MD, VA, D.C.) Northwest (OR, WA) Ohio

Plan performance star ratings are assessed each year and may change from one year to the next. Kaiser Permanente is a health plan with a Medicare contract. Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2015. Kaiser Permanente contract #s H0524, H0630, H1170, H1230, H2150, H9003, and H6360.

2015 Medicare ratings

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• The Kaiser Permanente Senior Advantage (HMO) plan is a

Medicare Advantage plan for people with Medicare.

• Senior Advantage provides services covered by Medicare (including

Medicare Part D prescription drug coverage).

• As a Senior Advantage member, you get your Medicare benefits

through Kaiser Permanente.

• The Medicare program pays Kaiser Permanente to manage health

care for people with Medicare (our Senior Advantage members).

Senior Advantage

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• If you have questions on the Employer Group Senior Advantage Plan,

contact your HR Benefits Department.

• Kaiser Permanente Senior Advantage Member Services 1-800-464-

4000 (TTY 1-800-777-1370), Monday through Friday, 7 a.m. to 7 p.m., Saturday and Sunday 7 a.m. to 3 p.m.

• Social Security: 1-800-772-1213 (TTY 1-800-325-0778), Monday

through Friday, 7 a.m. to 7 p.m.

• Medicare: 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048,

24 hours a day, seven days a week.

Contact Information

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Kaiser Permanente is a health plan with a Medicare contract. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1 of each year, and at other times in accord with your group’s contract with us. The benefit information provided is a brief summary, not a comprehensive description of

• benefits. For more information, contact the plan. Limitations, copayments, and

restrictions may apply. You must reside in the Kaiser Permanente Senior Advantage/Medicare Plus service area in which you enroll.