Health Literacy Toolkit

INITIAL ENROLLMENT PERIOD For most people, the first time you can enroll for Medicare is during the three months prior to the month you turn 65, the month you turn 65, and three months after you turn 65. If you are younger than 65, disabled, and receive Social Security Disability Insurance (SSDI) benefits, Medicare starts on the 25th month after you start receiving SSDI benefits.

MAKING CHANGES Every year during the Annual Enrollment Period, you have the opportunity to make a change in the Medicare Part C and D plan(s) you have. The change can be made without penalty during the “Open Enrollment” Period, from October 15th through December 7th. Under certain situations, changes can be made in addition to the “Open Enrollment” period.

MEDICARE PART A This is also known as “Hospital”Insurance. This pays for inpatient hospital stays, skilled nursing facility (SNF) stays, skilled home health care, and hospice. For most people, if you are 65 years old and have worked 40 quarters and contributed taxes toward Medicare, Medicare Part A is free and you don’t have to pay a monthly premium. If you have not worked 40 quarters, you will have to pay a monthly premium. The monthly premium is dependent on the number of quarters you worked. There are exceptions to the age and work requirements, most frequently for those who may be disabled, are still employed, have a retiree health insurance plan, or may have worked for federal, state or local governments.

MEDICARE PART B This is also known as “Medical” Insurance. While coverage is optional, there is a 10% penalty for every year that you are eligible that you do not sign up. In addition to doctor visits, Part B helps pay for other services including:

• preventative care
•  durable medical equipment (DME)
• oxygen, diabetic supplies
•  ostomy supplies
• care provided in outpatient clinics (medical, therapists, and mental health)
• immunizations (such as flu, pneumonia, and Hepatitis B)
• ambulance when medically necessary

A one-time annual deductible for Part B services must be paid by the beneficiary (or the Medicare Supplement/MediGap plan) before eligible services are paid by Medicare. After the deductible is paid, then Medicare pays 80% of the Medicare approved charge. This means if the provider does not accept “Medicare Assignment,” the provider will bill you for the 20% and for the difference between the provider’s charge and the charge that Medicare has approved. If you have a Medicare Advantage Plan, co-pays will vary depending on the health insurance company and plan you chose.

ORIGINAL MEDICARE (OR FEE FOR SERVICE MEDICARE) When you have combined Medicare Part A and Medicare Part B and you do not have an Advantage HMO (health maintenance organization) or PPO (preferred provider organization) Plan administering your health insurance benefits.

MEDICARE PART C Medicare Part C is better known as a “Medicare Advantage Plan.” Medicare Part C is a combination of Medicare Parts A, B, and D. Private insurance companies offer this insurance and actively participate in the delivery of care through networks of approved providers. The majority of plans require a monthly premium, may require copays for many procedures, and may charge coinsurance for some services. You choose to have either a Medicare Advantage Plan or a Medicare Supplement/MediGap Plan; you cannot have both plans.

MEDICARE PART D Medicare Part D or prescription drug coverage is provided through “Stand Alone Prescription Drug Plans” by private insurance companies. If you have Original Medicare, prescription drug coverage is optional, with its own monthly premium (cost). However, there is a 1% per month penalty for every month that you are eligible for Part D that you do not sign up, unless you have creditable coverage. In addition to the monthly premium, there will be the yearly deductible, and then depending on the plan you choose, there will be either a copayment or coinsurance for each prescription medication. When you choose a prescription drug plan, it is important to look at the medications you take, to make sure the medications are covered by the drug plan. The shingles shot is covered under Medicare Part D. Talk with your health insurance plan about the cost to get your shingles shot. For some people who have a high out-of-pocket cost because of their medication(s), they may reach the “donut hole,” which is a gap in prescription drug coverage. That means the drug plan will not pay as much money after they have paid a certain amount of money for your prescription medications. If that happens, you will have to pay a higher share of the cost. Then, once the “donut hole” has been crossed, the drug plan begins to pay a higher percentage of the cost. If you are receiving Low Income Subsidy (LIS) or Extra Help which pays for Medicare Part D costs, you will not have to worry about the donut hole.

When you decide to get your health insurance through either a HMO (health maintenance organization) or PPO (preferred provider organization), those plans will include a prescription drug coverage benefit. The amount of coverage will depend on two things: (1) if you use the health insurance plan’s in-network pharmacy and (2) if your medication is on the health insurance plan’s drug formulary. A formulary is the list of medications that are covered by the prescription drug plan.

MEDICARE SUPPLEMENT OR MEDIGAP PLAN You can buy this plan if you have Original Medicare (Medicare Part A and Part B). This is an optional plan through a private health insurance company, with its own monthly premium (cost). The plan helps pay some of the costs like the copayments, coinsurance, and annual deductibles when Medicare Part A and Medicare Part B does not fully cover a service, treatment, or item. You may use any provider in the United States that accepts Medicare without a referral. Care does not have to be prior authorized.

MEDICARE SAVINGS PROGRAM (MSP) A program for low-income people. Depending on your monthly income and assets, you are eligible for one of three levels of financial help to pay for Medicare Part B premiums. Low-income individuals can receive assistance with Part A and B deductibles as well as copays and coinsurance. The three programs are: 1. Qualifying Medicare Beneficiary (QMB) 2. Specified Low-Income Medicare Beneficiary (SLIMB) 3. Qualifying Individual (QI). You apply for the MSP program through the county Department of Human Services (or the Medicaid agency).

LOW INCOME SUBSIDY (LIS) OR EXTRA HELP A program for low-income people to help pay for prescription medication monthly premiums, annual deductibles, copayments and coinsurance. You receive LIS or Extra Help automatically If you: 1. Receive Medicare and Medicaid 2. Receive Supplemental Security Income and Medicare 3. Receive financial assistance from one of the three Medicare Savings Programs If you are on Medicare, your income is significantly low, and you meet the asset requirements and you have not yet applied for MSP, then apply for Extra Help first through the Social Security Administration, www.ssa.gov. Then one week later, apply for MSP through the county Department of Human Services.

MEDICARE ASSIGNMENT When a doctor, provider, or durable medical equipment (DME) supplier agrees to accept the amount of money Medicare approves for a service and only bills you for 20% coinsurance.

SPECIAL ENROLLMENT PERIOD You may qualify for a special enrollment period if you delay coverage in Medicare Part B and D due to employment; you are low income; or you move to a skilled nursing facility. If you need to change your Medicare coverage, check with 1-800- Medicare to see if qualify for a Special Enrollment Period. NOTE: Every year the income eligibility requirements and monthly premiums change. The information in this toolkit is based on 2018 numbers.