Navigating Medicare 2018 - National Organization for Rare Disorders (NORD) www.rarediseases.org
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Navigating Medicare 2018
Created and Presented by Barbara Tucciarone
Operations Specialist, NORD
National Organization for Rare Disorders (NORD)
www.rarediseases.org
Property of NORD rarediseases.org
Welcome
The informa7on being presented here is for
informa7on purposes only.
It is strongly recommend that you seek advice
and guidance from appropriately trained and
creden7aled individuals and organiza7ons.
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Social Security and
Medicare
If you are currently receiving Social Security Benefits:
– You should automa7cally receive your Medicare card
for part A and part D which will show your start date
– These start dates determine when you will be allowed to
enroll in Medicare Advantage (MA), and Prescrip7on Drug
Plans (PDPs)
– If you are receiving Social Security Disability Insurance
• Medicare coverage will begin automa7cally on the 25th month
aOer your disability coverage began
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1. Between April 2018 and April 2019, The Centers for
Medicare and Medicaid Services (CMS) will be
mailing new Medicare cards.
2. Medicare is removing Social Security Numbers from
Medicare Cards and assigning unique numbers called
Medicare Beneficiary Iden7fiers (MBIs) to enrollees.
3. This change will help protect your iden7ty.
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Things to know about your new
Medicare Card
• You don’t need to take any ac7on to get your new Medicare card.
• The new card does not mean your Medicare coverage or benefits have changed.
• There is no charge for your new card.
• CMS is planning a transi7on period from April 1, 2018 to December 31, 2019.
• By January 1, 2020 you should already be using only your new MBI.
Watch out for scams!
• Medicare will never ask for your personal or private informa7on to issue your new card
with your new Medicare number.
• Scam ar7sts may try to get your new Medicare number by contac7ng you about your new
Medicare card.
• Scam ar7sts oOen claim to be from Medicare or Social Security
• DO NOT…
• Confirm your Medicare or Social Security Number
• Believe that there is a charge for the new card and that they need to verify your
informa7on
• Let them threaten to cancel your health benefits if you don’t share your
personal informa7on or Medicare Number
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Who is Eligible for Medicare?
• those who are U.S. ci7zens or are lawfully
present in the United States
• are age 65 and over
• individuals with certain medical disabili7es
• anyone of any age with end-stage renal
disease (permanent kidney failure that
requires a regular course of dialysis or a
kidney transplant) are eligible to receive
Medicare Benefits
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When to Enroll
When enrolling for the first 7me…
• Begin doing your research early - at least 12 weeks before your 65th birthday
– Keep in mind, It takes about 6 to 8 weeks for coverage to begin
– The Social Security Administra7on determines your start date for each part of Medicare.
• Medicare plans begin on the first of the month of your date of birth ie. BD 2/16/1952, coverage begins Feb. 1st,
2018
– This means begin your research now ( mid October of this year),, and you should choose your plans and
enroll some7me near December 15, 2017, and absolutely no later than January 1st 2018
• However, if your birthday is the 1st of the month, your Medicare Parts A, B and D dates should begin one
month BEFORE your 65th birthday. For example, if your birthday is August 1, your Medicare Parts A, B & D will
begin on July 1.
– Please take a moment and make note of your Medicare start dates, especially if you do not enroll in
all parts of Medicare when you turn 65.
• For example: If you are s7ll working aOer age 65 you may decide to delay your enrollment in Medicare Part B,
however, you can s7ll enroll in Medicare Parts A and D, and you have a 7 month window to enroll in a
Medicare Advantage or Prescrip7on Drug Plan
– This 7 month window consists of:
» The 3 months before your 65th birthday
» The month of your 65th birthday
» The three months aOer your 65th birthday
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When to Re-Enroll
If you are already enrolled in Medicare
• Open Enrollment and the ability to make changes to current
plans or shop for new plans is held annually.
October 15, 2017 to December 7, 2017
• Coverage begins January 1
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What can be done during Open
Enrollment
1. Anyone with Medicare Parts A and B can add or drop their Part D prescrip7on
drug plan
2. You can switch your exis7ng Part D prescrip7on plan to another prescrip7on
drug plan
3. Original Medicare Parts A & B enrollees can switch to a Medicare Advantage
Plan and vice-versa
4. Exis7ng Medicare Advantage plan enrollees can switch to a new Advantage
plan
5. If you are happy with your plan choices and they are available for 2018, you
don’t need to do anything.
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Special Enrollment
Eligibility
• If you had employer insurance (for health and prescrip?on drug coverage) through a current job or your
spouse’s job at the ?me you became eligible for Medicare:
1. You may be eligible for a Special Enrollment Period, which means…
1. you can enroll in Medicare without penalty at any 4me while:
– you have group health coverage, and for eight months aOer you lose your group health coverage,
– or you (or your spouse) stop working, whichever comes first.
2. If you are under 65, have Medicare due to disability, and have health insurance through
your domes7c partner’s current employer, you may also be en7tled to a Special Enrollment Period…
1. if there are at least 100 employees at your domes7c partner’s place of work.
• If the above does not apply then:
– You can apply for Medicare during the General Enrollment Period, between January 1 and March 31
of each year. Your coverage will start the following July and you will have to pay a Part B premium
penalty.
• For each 12-month period you delay enrollment in Medicare Part B, you will have to pay a 10 percent Part
B premium penalty (based on the standard Part B premium
• The penalty is then added to your actual premium amount. In most cases you will have to pay that penalty
every month for as long as you have Medicare.
• But if you are enrolled in Medicare because of a disability and pay premium penal7es, once you turn 65, you no
longer have to pay the premium penalty.
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Medicare is offered two ways:
•Provides coverage for out
Original • Tradi7onal Medicare program Supplemental of pocket costs such as
deduc7bles, copays and
administered directly through the Insurance coinsurance
Medicare federal government. •Many choices, Plans A – N
• Consist of Parts A, B & D (Medigap) •Purchased from a private
company
OR
Medicare • Medicare private health plans offered
through private insurance companies
• Only those enrolled in
Advantage • AKA Part C (instead of parts A & B)
• Most will include part D as well
No Supplement Original Medicare may
purchase supplement
plans
Part C
Property of NORDDetails of the “parts” of Medicare
Original Medicare is administered directly by the federal
government, and it consists of 2 parts:
• Part A - Hospital Insurance - covers most medically necessary
hospital, skilled nursing facility, home health, and hospice care. It is
free if you have worked and paid Social Security taxes for at least 40
calendar quarters or 10 years
– you will pay a monthly premium if you have worked and paid taxes for
less 7me
• Part B - Medical Insurance - covers most medically necessary
doctors' services, preventa7ve care, durable medical equipment,
hospital outpa7ent services, lab tests, x-rays, mental health care,
and some home health and ambulance services. You pay a monthly
premium for this coverage.
Property of NORDPart D plan (Prescrip?on Drug Plan)
If you have Original Medicare, choose a stand-alone Part D Prescrip?on
Drug Plan through a private insurance company
• Part D - Outpa7ent Prescrip7on Drug Insurance provides outpa7ent
prescrip7on drug coverage.
• Part D is provided only through private insurance companies that have
contracts with the government.
– All Medicare drug plans have different costs and a different list of drugs that
they cover. Make sure the plan you choose covers the drugs you need at a
cost you can afford.
• Enrollment is op7onal and only allowed during approved enrollment
periods (though recommended to avoid incurring future penal7es) .
• Whether or not you should sign up for a Medicare Part D plan depends on
your circumstances.
Property of NORDPart D Late Enrollment Penalty
• You may owe a late enrollment penalty if…
– You did not sign up for Medicare Prescrip7on Drug Plan (Part D) when you were first eligible to
do so or,
– If you went more than 63 days without drug coverage that was at least as good as Medicare
Part D coverage (this is known as creditable coverage).
• How much is the penalty?
– The average monthly 2018 Medicare Part D base premium used to calculate the late-
enrollment penalty will decrease to $35.02 (from $35.63 in 2017)
– The penalty is calculated by the Social Security Administra7on by mul7plying 1% of the
“na7onal base beneficiary premium” 7mes the number of full, uncovered months you didn’t
have Part D or creditable coverage (rounded to the nearest .10)
– This amount is added to your monthly Part D premium - permanently
• The na7onal base premium amount may increase each year, so your penalty amount could increase
each year.
– If you get “Extra Help”, you don’t pay the late enrollment penalty
Property of NORDMedicare Advantage Plans
• Part C - is the part of Medicare policy that allows private health insurance companies to
provide Medicare benefits.
• If you choose to, you may get your Medicare coverage through a Medicare Advantage Plan
INSTEAD of through Original Medicare (Parts A & B).
• There are many Advantage Plans to choose from, and you may pay a monthly premium for
this coverage, in addi7on to your Part B premium.
– It’s always a good idea to compare Medicare Advantage plans every year because some
subtle changes could impact individual recipients.
• Typically, Part D is also provided as part of Medicare Advantage benefits packages, but can be
purchased as a stand alone PDP as well.
• Call or visit the website of the plan you want to join to find out how to enroll.
Property of NORDMedicare’s consumer website has a place for you to start.
Click here to see special
enrollment circumstances and
5-star special enrollment
period
Property of NORDMedicare Coverage Choices
Property of NORDMedicare Plan Finder
• On the medicare.gov home page, click on Sign Up/
Change Plans, choose “find health & drug plans”
• Step 2 will ask for a list of the drugs you take
• Step 3 allows you to skip step 2
• Step 4 allows you to refine your plan results, but will
show you a list with the number of plans available
Property of NORDSupplemental Insurance
Supplemental Insurance – also known as Medigap
• Supplemental Insurance Plans can be bought from a private insurance company to fill in the
gaps in Parts A and B coverage by paying for your Medicare Deduc7bles, coinsurances and
copayments.
– Original Medicare first pays its share for your care, and then Medigap pays all or part of
the remaining costs.
– Medigaps may also cover some health care costs that Medicare doesn't cover at all, like
care received when traveling out of the country.
– If you have a Medicare Advantage plan instead of Part A and B, you cannot buy a
Medigap plan.
• Depending on where you live you may have up to 10 different Medigap plans to choose from
(A, B, C, D, F, G, K, L, M, N). (Plans in Wisconsin, Massachusess, and Minnesota have
different names).
• For addi7onal informa7on on Medigap policies in your state, you can contact your State
Department of Insurance.
Property of NORDMedigap Policy Search
Property of NORDMedigap Policy Search
Property of NORDContac7ng Medicare by phone
• Call 1-800-MEDICARE
– To speak with a representa7ve you will most likely be on hold for quite some 7me
• Keep in mind representa7ves are available 24 hours a day/7days a week.
• Call during off hours
– Informa7on about most recent claims without having to speak with a representa7ve
– Have your Medicare number available
• Listen to the status of your claims
• Obtain current deduc7ble status
• Informa7on regarding your current prescrip7on drug plan enrollment
• Order Medicare publica7ons
• Recorded answers to frequently asked ques7ons (24/7)
– Hearing and speech impaired (TTY) may call 1-877-486-2048
• Benefits Coordina7on & Recovery Center (BCRC)
– Report changes in your insurance informa7on
– Let Medicare know you have other insurance
• 1-855-798-2627
• TTY: 1-855-797-2627
Property of NORDMyMedicare.gov
• Go to Medicare.gov to sign up
– All of your informa7on at your finger7ps
Property of NORDThe Donut Hole - Review
What is the Donut Hole?
• Most Medicare Prescrip7on Drug Plans have a gap in coverage
known as the “donut hole”
• This refers to a temporary limit on what the drug plan will cover for
drugs
• If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount
aOer your plan's coverage has been applied to the price of the drug. The discount for brand-name
drugs will apply to the remaining amount that you owe.
• This gap does not effect everyone
– This gap begins aOer you and your drug plan have spent a certain amount
for covered drugs
• In 2018, once you and your plan pay the $3,750 on drugs covered by your plan, you have
entered the donut hole. (up from $3,700 in 2016)
• This amount may change each year
• Those with Medicare who get “Extra Help” with paying for Part D costs won’t enter the
donut hole
Property of NORDChanges in the Coverage Gap
Brand-name Prescrip7on Drugs
• You will pay no more than 35% of the plan’s cost (down 5% from 2017’s 40%)
• Some plans may offer higher savings
• Brand-name medica7ons are discounted by 65% (you pay 35%), but you will receive credit of 85% of the retail drug
price toward mee7ng the 2018 TrOOP threshold.
• The discount will be deducted from the price that your plan has set with the pharmacy for that drug
– The dispensing fees are NOT counted toward your out-of-pocket spending
Generic Drugs
• Medicare will pay 56% of the price for generic drugs (up 7% from 2017’s 49%)
• You will pay the remaining 44% (down 7% from 2017’s 51%)
• Only the amount you pay will count toward getng you out of the coverage gap, unlike the discount that is applied
to the gap for Brand-name drugs.
– This gap begins aOer you and your drug plan have spent a certain amount for covered drugs
• In 2018, once you and your plan pay the $3,750 on drugs covered by your plan, you will enter the
donut hole. ($3,700 for 2017)
• Again, those with Medicare who get “Extra Help” with paying for Part D costs won’t enter the donut
hole at all
Items that count towards the coverage gap:
• Your yearly deduc7ble, coinsurance, and copayments
• The discount on brand-name drugs in the coverage gap
• The por7on you pay in the coverage gap
Property of NORDCoverage Gap Expected Cost Changes
– Ini7al deduc7ble is increasing from $400 to $405 (+$5)
– Ini7al coverage limit will go from $3,700 to $3,750 (+$50) = Donut
Hole Entry Point
– Out-Of-Pocket Threshold will increase from $4,950 to $5,000 (+$50) =
Donut Hole Exit Point
– True out-of-pocket cost limit will increase from $8,071.16 to $8,417.60
(+346.44)
– Copay for generic drugs aOer TrOOP cost limit is $3.35 (+.05)
– Copay for brand drugs aOer TrOOP cost limit is $8.35 (+.10)
Property of NORDMedicare premiums are announced in October. Check the website or call to
get updated informa7on.
Medicare.gov, the official government website for Medicare, has not been
updated with 2018 cost informa7on as of the beginning of October.
Please verify All cost and plan informa7on as you do your research and plan
inves7ga7ons.
Property of NORD2018 Premium Surcharges
IRMAA - Higher-income beneficiaries pay higher premiums for Part B and
Medicare prescription drug coverage (Part D) (This affects less than 5% of people with
Medicare).
• The initial income threshold of $85,000 for individuals and $170,000 for married couples that triggers a
premium surcharge will remain the same in 2018. (Part B premium is $134/month, $109 for those
under hold harmless provision)
• So will the second income tier of $85,001 to $107,000 for individuals and $170,001 to $214,000 for
married couples. ($187.50)
• But tiers three and four will be compressed in 2018
• Meaning, based on 2016 incomes:
• individuals with incomes between $133,501 and $214,000 ($267.90 in 2017) and
• married couples with incomes between $267,001 and $428,000 will pay higher Medicare
premiums surcharges in 2018 than they would today at the same income level.
($348.30 in 2017)
Property of NORDHelp For Low-Income Medicare Beneficiaries
• If you get Medicare and have low-income and few resources, your state may pay your Medicare
premiums and, in some cases, other Medicare costs for which you are normally responsible such as
deduc7bles and coinsurance. This is called a Medicare Savings Program or MSP.
• Only your state can decide if you qualify for this assistance. To find out if you do, contact your state
or local welfare office or Medicaid agency.
• For addi7onal informa7on about the program, please go to the Medicare.gov "
Get help paying costs" page.
• Don’t forget to check other avenues such as veterans benefits, low-cost health centers and clinics,
and consider applying to pa7ent assistance programs
• 40 states will lower their Medicare Part D Low-income Subsidy(LIS) benchmark values in 2018. New
Jersey will see the largest benchmark decrease with the 2018 LIS subsidy being $35.97, compared
to $40.81 in 2017. Colorado will have the largest increase to $34.18, from $32.04 in 2017.
Note: The benchmark premium is the maximum monthly premium that will be paid by CMS for persons qualifying for LIS or the Medicare Part D “Extra
Help” program. If a person receiving the low-income subsidy enrolls in a Medicare Part D plan that has a premium higher than the subsidy amount listed
for their state, the beneficiary is responsible for paying the difference in premiums.
Property of NORD8 Things to Consider
1. Coverage
1. How well does the plan cover the services you need?
2. Other coverage
1. Do you have other types of health or prescrip7on drug coverage, if so, how does it work?
3. Costs
1. How much are the premiums, deduc7bles, out-of-pocket maximums?
2. Am I eligible for assistance?
4. Doctor and Hospital choices
1. Do your doctors accept coverage?
2. Are the doctors you want/need to see accep7ng new pa7ents?
3. Do my choices have to be in-network?
5. Prescrip?on Drugs
1. Do you already have creditable prescrip7on drug coverage?
2. Will you pay a penalty if you join a drug plan later?
3. What will your prescrip7on drug costs be under the different plans?
4. Are your drugs covered under the plan’s formulary?
6. Quality of Care – How have other people rated your health and drug plan’s care and services?
1. Go to Medicare.gov/Forms, Help, & Resources to find and compare doctors, hospitals and other providers
7. Convenience – Where are the doctors’ offices located, what are their hours, which pharmacies can I use?
8. Travel – Will the plan cover you if you travel to another state or outside of the U.S.?
Property of NORDv Informa7on can be found in many places, presented by
many sources.
v Use the mediums with which you are comfortable.
v Be sure to check more than one source to op7mize your
understanding and confirm validity. When in doubt, go
to an official Medicare government source.
v For example, if you search Medicare 101 on Youtube.com
you will find recorded presenta7ons that could be helpful
as a back up to informa7on in a wrisen format.
Property of NORDResources
• Alpha1.org – for informa7on specific to your own case
• Medicare Toll Free number 1-800-772-1213
• For the deaf or hard of hearing TTY number 1-800-325-0778
• Medicare.gov (to apply on-line, research and compare plans, download 2018 “Medicare & You” handbook
• CMS.gov (Center for Medicare and Medicaid Services)
• SSA.gov (to apply on-line)
• Find your State’s health Insurance Assistance program (SHIP)
– SHIP is a free health benefits counseling service for Medicare beneficiaries and their families or
caregivers.
• Q1medicare.com/partD-PartDCoverageGap Calculator2018.php
• SeniorsResourceGuide.com – to find local resources
• MedicareRights.org – good resource to help answer many common ques7ons
• MedicareSolu7ons.com
• MyMedicareAnswers.com
• EHealthMedicarePlans.com – for ar7cles about cost of plans and plan comparison costs by zip code
• Youtube.com, search Medicare
• If you are s7ll working, consider speaking with your companies benefits or human resources administrator
• Call your personal insurance representa7ve for informa7on or assistance
– Agents must be cer7fied to sell Medicare Advantage Plans
– Licensed Insurance Agents may sell Supplemental plans but no cer7fica7on is required
• Check your local library or Senior Ci7zen Center for help or informa7on
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