Welcome to Kaiser Permanente Presenting Medicare 101 and Kaiser Permanente Senior Advantage (HMO) Fresno Unified School District Yolanda Smith Retiree Consultant September 2014
Basics of Medicare
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). 3
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 of any age with end-stage renal (kidney) disease (ESRD). – Permanent kidney failure requiring dialysis – Requiring a kidney transplant 4
Medicare Part A • Hospital insurance – Inpatient care in hospital, skilled nursing facility care, hospice care, home health care • Eligibility – First day of the month that you turn 65 – 2 years after becoming disabled – After end-stage renal dialysis begins • Enrollment – If already receiving benefits from Social Security you will automatically receive Part A – If you are under 65 and disabled you will automatically receive Part A • 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 $426 which is set by a Medicare formula. 5
Medicare Part B • Medical insurance – Physician and other healthcare provider services, outpatient care, lab, radiology, durable medical equipment (DME), dialysis and some preventative care services. • Eligibility – First day of the month that you turn 65 – 2 years after becoming disabled – After end-stage renal dialysis begins • 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. (Known as the “Initial Enrollment Period”) • Late enrollment penalty may apply if you do not enroll in this 7-month window. • If you do not sign up for Part A and Part B when you are first eligible, you can sign up between Jan 1 to March 31 each year – known as the “General Enrollment Period” 6
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. (Special enrollment period- you have up to 8-months after the employment ends to enroll) • In 2014, Part B premium will range from $<104.90> to $<335.70>, depending on income. Individuals $85,000+/couples $170,000+ Determined by federal formulas *This amount is not a one-time penalty, but continues throughout enrollment. 7
How to Enroll in Medicare Parts A & B • For Medicare Part A – Individuals already receiving benefits from Social Security will be automatically enrolled starting the first day of the month turning 65. • For Medicare Part B – Optional: You are responsible for enrolling with Social Security Administration – You can enroll over a 7-month period, which starts 3-months before your 65 th birthday known as the “Initial Enrollment Period” 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. 8
Medicare Plan Options Plan options for how you receive Medicare coverage: • Option 1: Original Medicare Plan through the Centers for Medicare & Medicaid Services (CMS). – Enrolling in MediGap Plans supplements original Medicare, premiums are not covered. (note: Kaiser Permanente does not offer MediGap plans) • 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) 9
Medicare Part D • 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. – In 2014, Part D premiums will range from $11.60 to $66.60, depending on income Note: Unlike Parts A and B, Part D is enrolled directly with the plan. Part D is not available through Medicare or Social Security. 10
Medicare Part D 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. 11
Medicare Part D 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. 12
Kaiser Permanente Senior Advantage (HMO) All of the following information regarding Medicare and Kaiser Permanente Senior Advantage applies only to Fresno Unified School District Members who have or are eligible for Medicare. Fresno Unified School District requires that as a retiree of the District, you must enroll in both Medicare Part A & Part B. In addition, you must complete the Kaiser Senior Advantage Election Form and District enrollment form. 13
2014 Medicare ratings Kaiser Permanente region Star rating California Colorado Georgia Hawaii Mid-Atlantic States (MD, VA, D.C.) Northwest (OR, WA) Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2014. Kaiser Permanente contract #s H0524, H0630, H1170, 14 H1230, H2150 and H9003.
Senior Advantage • 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). 15
Fresno Unified School District Senior Advantage Summary of Benefits 07/01/14 – 06/30/15 Fresno Unified School District Services Fresno Unified School District Annual $1,500 per calendar year Out-of-Pocket Maximum $3,000 per calendar year Lifetime Maximum None Office Visits $15 per visit Lab/X-rays No charge Outpatient Surgery $50 per procedure Hospitalization Services $500 Admit Emergency Services $50 per visit Ambulance Services $100 per trip Prescription Drugs • Generic and Brand $10/$35 for up to a 100-day supply MOI Durable Medical Equipment 20% coinsurance Eyewear $150 allowance This is a benefit summary of Fresno Unified School District Kaiser Permanente Senior Advantage group plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the Kaiser Permanente Senior Advantage Evidence of Coverage. 18
Contact Information • If you have questions on the Fresno Unified School District Senior Advantage Group Plan, contact your HR Benefits Department. • Kaiser Permanente <Member Services>: 1-888-448-9400 (TTY 711 ) • 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. 19
Contract Disclaimer Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Benefits, formulary, pharmacy network, provider network, premiums, and/or co-payments/co-insurance may change on July 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 complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party. You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll. MOM 60168312 (12/2013) 20
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