News Alert

MEDICARE 2009 FACT SHEET

NEW 2010 MEDICARE PART D PRESCRIPTION DRUG PLAN

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Volunteers Needed

The Senior Health Insurance Assistance Program (SHIP) Needs volunteers to help people with Medicare learn about the many available benefits:

ü Medicare & Medigap

ü Prescription Drug Plans

ü Claims and Appeals

ü Medical Assistance

We are recruiting volunteers to assist people with Medicare, do community outreach, provide educational programs, provide individual counseling and give general program support !!

FOR MORE INFORMATION ON ASSISTING THOSE IN NEED

CALL(301) 590-2819

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Senior Health Insurance Assistance Program (SHIP)

(301) 590 – 2819 www.medicarehelp.org

What is the SHIP Program?

The Senior Health Insurance Assistance Program (SHIP) funded by the Maryland Department on Aging with a grant from the Center for Medicare and Medicaid Services (CMS) and Montgomery County , provides freeinformation, educational programs, individual assistance and counseling about Medicare, supplements to Medicare (Medigap Plans), Medicare Advantage Plans (Managed Care Plans), Prescription Drug Programs, Income saving programs (QMB/SLMB), Maryland Health Insurance Plans, Federal Health Insurance Plans, Employer Health Insurance Plans, and Long Term Care Insurance. The SHIP program provides advocacy on Medicare Fraud and Abuse and billing issues.

Who does the SHIP Program Serve?

There are more than 110,000 people with Medicare in Montgomery County, including those who are aged 65 and older, and those who are disabled. Our outreach is to this population, their family members and caregivers, as well as to our aging network partners. One third of our senior citizens over the age of 65 live alone and need special assistance and advocacy with health insurance programs and options.

How does the SHIP Program serve Montgomery County?

The SHIP Program provides educational programs, seminars, and trainings to community groups, church groups, clubs, neighborhood associations, and our aging network partners. SHIP updates and supplies printed information, comparison charts and tables outlining health insurance options and maintains a web site (www.medicarehlep.org) in several languages, as a 24 hour answering machine and tries to respond to messages in a timely manner. Trained volunteers meet on an individual basis with seniors, the disabled, their family members and caregivers on a walk-in or scheduled basis in county libraries, senior centers, senior communities, and HOC buildings to provide objective information, help solve individual insurance problems, assist with Medicaid and Medicare forms, insurance claims, and act as advocates in making appeals.

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MEDICARE 2009 FACT SHEET

PART A MEDICARE BENEFITS

1. INPATIENT HOSPITAL CARE

Benefits are paid on the basis of “benefit periods”. A benefit period begins the first day you are hospitalized and ends when you have been out of a hospital or skilled nursing facility for 60 consecutive days. If you enter a hospital again after 60 days, a new benefit period begins.

In 2009, a Medicare beneficiary is responsible for a deductible of $1,068 for the first day of each benefit period, after which Medicare pays for up to 60 days of full hospital care. For days 61-90, the beneficiary is responsible for $267 per day (co-payment). In addition, a beneficiary has 60 lifetime reserve days, and would be responsible for a co-payment of $534 per day for days 91-150. There is no Medicare coverage for days 150 - 365.

2. SKILLED NURSING FACILITY (SNF) CARE

After a hospital stay of at least 3 consecutive days, Medicare covers 100 days of skilled nursing or rehabilitative care in a SNF, provided the SNF is approved by Medicare and your treatment is connected with the illness that caused you to be hospitalized. You must need skilled nursing care or skilled rehabilitative care on a daily basis. Days 1-20 are paid in full by Medicare. The beneficiary is responsible for a $133.50 per day co-pay for days 21-100 in a skilled nursing facility. NO CUSTODIAL OR INTERMEDIATE NURSING HOME CARE IS PROVIDED.

3. HOSPICE CARE

Medicare pays for a maximum of 210 days of care for terminally ill patients in a Medicare approved hospice program, through two 90-day periods and one 30-day period. There are no deductibles or co-payments, except for covered prescription drugs and inpatient respite care. Individuals must choose hospice care.

4. HOME HEALTH CARE

Medicare provides for full payment of intermittent part-time skilled care from registered nurses, therapists, and home health aides from a Medicare approved home health agency. Intermittent part-time care is generally defined as daily care for 5 days a week up to 2 or 3 weeks. In exceptional cases, longer care may be provided. In order to be eligible, a beneficiary must meet all the following criteria:

(1) Be under the care of a doctor

(2) Need care for a specific illness

(3) Be homebound

(4) Need skilled services

(5) Need services on a part-time or occasional basis

(6) Agency providing the care must be Medicare approved

If you require skilled services (nursing, physical therapy, or speech therapy), you may also receive occupational therapy, social work services, and home health aide services if your physician determines you need them. Prior hospitalization is not required to receive home health services under Medicare.

PART B MEDICARE BENEFITS

A Medicare beneficiary pays a $135 annual deductible and a 20%

co- payment for Medicare-approved charges and services. Medicare pays 80% of the Medicare-approved charge. A beneficiary is responsible for all costs above Medicare-approved charges (“excess charge”). Physicians who do not accept assignment of a Medicare claim are limited as to the amount they can charge Medicare beneficiaries for covered services.

The Limiting Charge is 115% of the fee schedule amount for non-participating physicians. NOTE: Medicare-covered services, such as mental health services, physical and occupational therapy, and certain services rendered by special practitioners have special payment rules. Note: if you income is above $85,000 (single) or $170,000 (married couple filing a joint tax return), then your Medicare Part B premium may be higher than $96.40 per month.

2. DRUGS AND BIOLOGICALS

Medicare pays the full-approved charge for flu shots and pneumococcal vaccine and its administration. Neither the annual Part B deductible nor the 20%

co-payment apply to these services. Medicare may cover certain oral anti-cancer, asthma, and ophthalmologic drugs subject to the Part B premium and 20% co-payment rules. Medicare helps pay for Hepatitis B vaccine and its administration, furnished to beneficiaries considered to be at high or intermediate risk of contracting the disease. Medicare also pays for immunosuppressive drugs post transplant if the transplant was Medicare-approved (certain time guidelines do exist). Medicare Part D prescription drug plans are authorized to cover the shingles vaccine (Zostavax). The vaccine may be dispensed and administered at an in-network pharmacy, and the pharmacist will collect a copayment from the beneficiary. If the vaccine is provided by a physician, the physician will bill the beneficiary for the vaccine and the administration. The beneficiary will have to submit a paper claim to the Part D plan for reimbursement for both the vaccine and its administration.

MEDICARE PART D (Prescription Drug Program)

New Medicare prescription drug coverage is available to everyone with Medicare. The drug plans are offered by insurance companies and other private companies approved by Medicare. Drug plans will vary in monthly premiums, list of covered drugs, deductibles and co-pays, and pharmacies accepting the plan. It is important to review the list of drugs you take and review the plans every year. You may change plans during the open enrollment November 15 – December 31 every year.

Qualifying for extra help to pay for your prescriptions:

The Low Income Subsidy (LIS) from the Federal Government

You may automatically qualify for extra help with Medicare Part D expenses if:

You are enrolled in both Medicare and Medicaid or

You are enrolled in a Medicare Savings Program that helps pay your medical bill or pays for your Medicare premiums (OMB, SLMB), or

You receive Supplemental Security Income (SSI)

If you do not automatically qualify for help with Medicare Part D expenses but you have limited income and assets, you may still be eligible for some extra help.

If your income for (2009) is no more than $15,600 a year ($1,300 per month) for individuals and $21,000 a year ($1750 per month)

for couples and you have limited assets of no more than

$11, 990 (individuals) and $23,790 (couples), you may qualify for help.

Assets include savings, stocks, bonds but not your home or car. Income

levels maybe higher if some of the income is earned income.

If you qualify, you will get help paying for your drug plan’s monthly premium, deductible and for some of the cost of your prescriptions. The type of extra help will be based on income and assets. You may apply for the Low Income Subsidy (LIS) by calling Social Security at

1 800 772 1213 or SHIP 301 590 2819.

The Senior Prescription Drug Program from the State of Maryland (SPDAP). If your income or assets are too high to qualify for the Low Income Subsidy (LIS), or if you qualify for only partial extra help, you may be eligible for the Senior Prescription Drug Assistance Program (SPDAP) from the State of Maryland . This program pays up to $25.00 per month for Medicare Part D Plan premium, and may pay up to $1200 toward the cost of drugs for people in the “GAP” or “Donut Hole “. Assistance in the “GAP” or Donut Hole applies only to select participating plans. SPDAP but does not help with the cost of copays or deductibles. To be eligible for the $25 Senior Prescription Drug Program premium assistance, the income should be below 31,200 per year ($2600 per month) for a single person, and $41,070, ($3422.50 per month) for a couple. Income is the only considerations for this program, the amount of assets do not count in determining eligibility.

3. PREVENTIVE HEALTH BENEFITS

Mammograms:

A beneficiary 40 years of age or older is entitled to one screening mammogram every year. Medicare will pay 80% of the approved charge; you pay 20% and the Medicare Part B deductible will not apply. Beneficiaries must receive their mammography at a Medicare-approved mammography site.

Pap smear screening:

Medicare pays for one Pap smear screening and related medically necessary physician services, including a physician’s interpretation of the results of the tests every 2 years or more frequently for women at high risk of developing cervical or vaginal cancers. Medicare will pay 80% of the approved amount; you pay 20% and the Medicare Part B deductible will not apply.

Colon cancer screening:

These tests help find precancerous growths so they can be removed and prevent cancer. If you are age 50 or older, or are at high risk for colorectal cancer, one or more of the following tests is covered: Fecal Occult Blood Test, Flexible Sigmoidoscopy, Screening Colonoscopy, and/or Barium Enema. How often Medicare pays for these tests depends on the test you and your doctor decide is best and your level of risk for this cancer.

Diabetic services and supplies:

Medicare Part B will cover the cost of blood glucose monitors, test strips and lancets for people with diabetes (both insulin and non-insulin dependent) depending on the physicians specific orders. Medicare will provide coverage for educational and training services furnished to an individual with diabetes by a qualified provider at the direction of the beneficiary’s physician. The providers must accept Medicare beneficiaries.

Bone mass measurement:

For an individual at risk, Medicare will cover 80% of the cost of bone mass measurement tests. You pay 20% after the annual Part B deductible.

Prostate cancer screening:

Medicare will cover prostate cancer screening, digital rectal exams and prostate specific antigen tests every 12 months for men age 50 and older, Medicare will pay 80% of the approved amount for the exam, you pay 20%. There is no co-insurance or deductible for the PSA test.

Glaucoma screening:

Medicare will cover glaucoma screening, once every 12 months for an individual who is at risk for glaucoma, including people with diabetes or a family history of glaucoma, and African-Americans who are 50 or older.

Welcome to Medicare:

Medicare will provide a one time “Welcome to Medicare” Physical Exam, a preventive physical exam performed within the first six months that you have Part B. The exam will include a thorough review of your health, education and counseling about the preventive services you need, like certain screenings and shots, and referrals for other care. This service has a 20% co-payment after you meet the yearly Part B deductible ($135 for 2009). Medicare Part B covers abdominal aortic screening, a one time screening ultrasound for people at risk (for smokers). Cardiovascular screenings is a Part B service covered every 5 years to test your cholesterol, lipid, and triglyceride levels. Smoking cessation counseling includes 2 cessation attempts within a 12 month period if you are diagnosed with a smoking related illness or are taking medicine that may be affected by tobacco.

SOME COMMON SERVICES NOT COVERED BY MEDICARE

· Long term custodial care (nursing home)

· Private hospital room (unless determined to be medically necessary), telephone and television

· Private duty nursing

· First 3 pints of blood, if you cannot replace them in some manner

· Routine physical care, other than the “Welcome to Medicare” one time physical exam

· Dental care and dentures

· Routine hearing exams and hearing aids

· Routine eye exams and eyeglasses, except cataract lenses (routine eye exams for individuals with medical conditions which affect sight may be covered)

· Out of hospital prescription drugs and all over-the-counter drugs

· Routine podiatry care (care for persons with certain medical conditions, such as diabetes or vascular heart disease, may be covered)

· Inpatient psychiatric care, after 190 days (lifetime limit)

· Acupuncture, and most chiropractic services

· Cosmetic surgery, unless after injury or to improve the function of a malformed body part

· Full-time home care, homemaker services, home-delivered meals

· Christian Science practitioners and Naturopath’s services

· Orthopedic shoes, unless part of a leg brace and included in orthopedist’s charges or vascular or nerve defects due to diabetes

· Ambulance services unless medically necessary

· Services provided outside the United States (except for certain hospital and physician services in Canada or Mexico , under certain conditions)

MEDICARE MONTHLY PART A PREMIUM

Most individuals are entitled to “premium-free” Part A based on their or their spouse’s work history. Other individuals may be eligible to purchase Part A benefits at $443 per month, if they have fewer than 30 quarters of Social Security coverage, or $244 per month if they have 30 – 39 quarters of Social Security coverage.

MEDICARE MONTHLY PART B PREMIUM

The regular Part B premium will be $96.40 per month in 2009, if your countable income is below $85,000 for an individual or $170,000 for a couple. Higher premiums will be charged for incomes above these levels.

IMPORTANT RELATED SUBJECTS

1.QUALIFIED MEDICARE BENEFICIARY PROGRAM (QMB or “Quimby”)

This program will pay the premiums, deductibles and co-insurance payments of the Medicare Program for older and disabled individuals who are financially eligible. The current QMB eligibility guidelines are: $867 a month income and $4,000 in assets for an individual; and $1167 month income and $6,000 in assets for a couple. QMB-eligible beneficiaries must go to medical care providers who participate in the Medical Assistance Program. In addition to the income and assets stated, an individual or couple may have a house, car, and a burial plan (with a value not to exceed $1500), and still be eligible for the QMB Program. Applications are made for the QMB Program through the local Departments of Social Services, using the special application for QMB/SLMB.

2. SPECIFIED LOW INCOME MEDICARE BENEFICIARY PROGRAM (SLMB or “Slimby”)

This program will pay the Medicare Part B premium ($96.40) per month in 2008) for people whose income is slightly more than the QMB criteria. The current SLMB eligibility guidelines are: $1,040-1,170 income or less and $4,000 in assets for an individual, and $1,400- 1,575 income or less and $6,000 in assets for a couple. As with the QMB Program, an individual or couple may hold certain assets (house, car, burial fund, etc.) which may be exempt from consideration. Applications are made for the SLMB Program through the local Departments of Social Services.

3. PROTECTION FROM SPOUSAL IMPOVERISHMENT PROGRAM

This amendment applies to couples when one spouse begins a continuous period of residence in a nursing home and subsequently applies for Medicaid. All non-exempt assets (savings and checking accounts, stocks, bonds, etc.) owned by either spouse, jointly or separately, are pooled as of the date of institutionalization. The “community spouse” may keep $20,880 or ½ of the assets, whichever is greater, but not more than $104,400 (The home and car do not count as assets.) The couple’s remaining assets are used to pay for nursing home care or other eligible expenses until the institutionalized spouse’s assets reach the Medicaid eligibility level of $2,500. The “community spouse’s” income will be evaluated to determine how much, if any, of the

institutionalized spouse’s monthly income can be allowed for the community spouse’s monthly maintenance allowance. This maintenance allowance will supplement the community spouse’s own income up to $1,712/month. If shelter

expenses alone exceed $514/month (30% of $1,712), an additional amount, equal to the excess will be allowed. The maximum total allowance cannot exceed $2,610/month. The institutionalized spouse also is allotted

an allowance of $66/month. A family allowance may be made if there is a dependent child, parent, brother or sister of either spouse residing with the community spouse, in the amount of 1/3 of the community spouse’s maintenance allowance less any income of the dependent individual, for each dependent family member. Local Departments of Social Services are responsible for evaluating a couple’s income and assets and determining eligibility.

4. TRANSFER OF ASSETS

Transfers made after August 10, 1993 have the potential to impose an unlimited penalty period delaying Medical Assistance eligibility for a nursing home patient. Such transfers will be subject to a “look-back” period of up to 60 months. For every $4,300 disposed of you may be disqualified for one month of medical assistance coverage of your nursing home care. Advice and information on this subject should be obtained from the State Health Department’s Medical Assistance Division of Eligibility Service. Individuals should also obtain competent financial/legal advice before transferring or disposing of assets.

5.Social Security (SSA) Extra Help

People with Medicare with limited income and assets may qualify for Extra Help paying for Medicare prescription drug coverage costs. If they qualify they will get help paying for their plan’s monthly premium, yearly deductible, and prescription copayments. The amount of Extra Help people qualify for is based on the persons’ income and assets. If a person has a yearly income below $15,600; ($21,000 for a married couple living together), he or she may qualify for Extra Help. The income and resource amounts are for 2008 eligibility and may increase each year. The resource limits include $1,500 per person for burial expenses. Assets include savings and stocks, but not a person’s home or care. Extra Help is also called the Low Income Subsidy (or LIS)

FOR MORE INFORMATION OR TO SCHEDULE AN INDIVIDUAL APPOINTMENT CALL

SHIP at 301-590-2819

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