Understandingyour

Medicareoptions.
Medicare Made Clear

TM

Get Answers Series

Y0066_121128_152105 CMS Accepted

learning about
Medicare choices.
Eligibility
Coverage options
When to enroll
Next steps and resources

learning about
Medicare choices.
Eligibility

Eligibility for Original Medicare (Parts A and B).

Youre eligible to join Original

Medicare (Parts a and B) if:
Youre65yearsold,oryoureunder
65andqualifyonthebasisofdisability
orotherspecialsituation
AND

YoureaU.S.citizenoralegalresident
whohaslivedintheU.S.foratleast
fiveconsecutiveyears

Some things to know about the

age 65 rule:
EvenifyourealreadycollectingSocial
Security,youmustwaituntilyoure65
Youmustbe65yourspousesage
doesntcount
EvenifyourenotcollectingSocial
Securityyet,youreeligibleatage65

understanding Medicare.
Medicare choices

Medicare Choices
Step 1
Enroll in Original Medicare when you become eligible.
Original Medicare
+

Covers doctor and

outpatient visits

Covers hospital
stays

Government-provided

Step 2
If you need more coverage, you have choices.
Option 1
Keep Original Medicare and add:
Medicare Supplement
INSURANCE
Covers some or all of the costs not covered
by PartsA & B
Offered by private companies

and/or

or

Option 2
Medicare Advantage
(Part C)
Combines
Parts A & B
Additional benefits

Medicare Part D
Most plans cover
prescription drugs
Covers prescription drugs
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Offered by private companies

Offered by private companies

understanding Medicare.
Original Medicare (Parts A and B)

What Original Medicare (Parts A and B) covers.

Part A
Hospital costs and skilled
nursing services after a
hospital stay, plus some
other skilled care:

Part B
Doctors office visits and other medical
services thatdo not require a hospital stay:
Physician services
Outpatient hospital services (minor surgeries)

Inpatient hospital care

Ambulance

Inpatient mental health care

Outpatient mental health

Home health care

Laboratory services

Hospice care

Durable medical equipment (wheelchairs,

oxygen, etc.)*

Some blood for transfusions

during inpatient care

Outpatient physical, occupational and

speech-language therapy
Some preventive care

Services and supplies must be medically necessary.

Original Medicare (Parts A and B).

What to keep in mind.
Part A

Part B

Costs:
Most people dont pay a monthly premium
You only pay your deductible the first $1,184 in
2013 for a hospital stay of less than 60days

Costs:
There is no maximum out-of-pocket
For coinsurance, in general, you pay 20% of the
Medicare-approved cost after your deductible
ismet
If you wait to join until after your initial enrollment
period, you may have to pay a higher premium

Enrollment:
Enrollment is easy. You cant be turned
down because of your medical history or
pre-existing condition
Coverage:
Long hospitalizations can be expensive. Stays
of more than 60 days require a daily copayment
Multiple stays may mean multiple deductibles
You can go to any qualified hospital in the U.S.
that accepts new Medicare patients. Hospital
care outside the U.S. isnt usually covered

Enrollment:
Enrollment is easy. Your medical history or
pre-existing condition doesnt matter
Coverage:
Part B works the same way throughout the U.S.
You can get care wherever you are. Generally,
care outside the U.S. is not covered
You can receive care from any participating
physician who accepts new Medicare patients
Preventive care is limited

Original Medicare (Parts A and B).

What it doesnt cover.
Medicare Part A deductibles and coinsurance premiums
Medicare Part B deductibles and coinsurance premiums
Medicare Part B excess charges (amount billed over what Medicare agrees to pay)
Medicare Part D prescription drug coverage

10

understanding Medicare.
Medicare supplement insurance plans

Medicare supplement insurance plans eligibility.

Youre eligible if you:
Are enrolled in Medicare Parts A and B at the time your Medicare supplement insurance
coverage will begin
Are a resident of the state in which you are applying forcoverage
Are age 65 or older (or under age 65 with certain disabilities in some states)

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Medicare supplement insurance plans.

 rivate health insurance designed to supplement Original
P
Medicare (Parts A and B). Also known as Medigap plans.
Plans are for people on Medicare Parts A and B who want help
paying for some of the health care costs not paid by Medicare,
like coinsurance, copayments and deductibles
Plans are named with letters of the alphabet (A, B, C, D, F, G,
K, L, M and N), and benefit levels vary by plan*
Typically, the more comprehensive the coverage, the higher the
monthly premium for the Medicare supplement plan
Medicare supplement plans are regulated according to federal
and state laws and are required to offer the same coverage

13

*Plans E, H, I and J are no longer available to buy, but if you already have one of those policies, you can keep it.
Contact your insurance company for more information.

Medicare supplement insurance plans.

What to keep in mind.
Costs:
Depending on the Medicare supplement plan, some or all of your outofpocket
costs for care under Original Medicare (Parts A and B) are covered
Premium prices with different insurance companies can vary sharply for the
same coverage. In some plans, premiums rise as your age increases
Enrollment:
You are guaranteed the right to buy a Medigap plan during your open enrollment period
In some states, if you apply after your open enrollment period, you can be denied
coverage based on your health
Coverage:
No network restrictions and no referrals required
Coverage may go with you when you move or travel anywhere in the U.S.
With some plans, you have foreign travel coverage for emergencyservices
Coverage is guaranteed to continue as long as you pay your premiumontime
14

understanding Medicare.
Medicare Advantage (Part C)

Medicare Advantage (Part C) eligibility.

Youre eligible if you:
Are enrolled in Medicare Parts A and B
Live in the plan service area
Do not have end-stage renal disease (ESRD) or
have had a successful kidney transplant

16

Medicare Advantage (Part C).

A single plan offered by private insurance companies that combines coverage for
Original Medicare (Parts A and B) and sometimes prescription drug coverage (Part D).
All the benefits of Part A, except hospice care
Hospital stays Skilled nursing Home health
All the benefits of Part B
Doctors visits Outpatient care Screenings and shots Lab tests
Prescription drug coverage
Included in many Medicare Advantage plans, but not all
Additional benefits
May be bundled with the plan

Tip: Additional benefits may include eye care, hearing, wellness services and nurse phoneline.
17

Medicare Advantage (Part C).

What to keep in mind.
Costs:
Plan premiums and terms can change from year to year
Enrollment:
Your eligibility for enrollment is not affected by your health or financial status (special rules
for end-stage renal disease, ESRD)
Coverage:
Convenience of a single plan
Many plans may include prescription drug coverage (Part D)
In most plans, you receive your coverage in a service area unless its an emergency
For some plans, youre required to see doctors and hospitals that are included in the
plansnetwork
Many plans may offer additional benefits not covered by Medicare (e.g., dental, vision,
hearing and preventive care)
18

Five types of Part C plans.

Coordinated Care Plans
Health Maintenance Organization (HMO) Plans
Preferred Provider Organization (PPO) Plans
Special Needs Plans (SNP)
Other Plans
Private Fee-For-Service (PFFS) Plans
Medical Savings Account (MSA) Plans

19

Types of Part C plans: HMO.

Whats an HMO plan?
HMO stands for Health Maintenance Organization
A Medicare Advantage plan with a network
of physicians, hospitals and other health
care professionals
Generally, you must get routine care from an
approved network of doctors and hospitals
Your primary care physician oversees your care
and may refer you to specialists, if applicable
Care received outside the network unless its
in an emergency is not covered
Many plans include prescription drug coverage
and additional benefits

20

In all types of Medicare plans, if you have an emergency or need urgent care, you can go to the nearest
doctor or hospital. Coverage varies by plan. Not all plans are available in every state or county.

Types of Part C plans: PPO.

Whats a PPO plan?
PPO stands for Preferred Provider Organization
Hospital costs, doctor and outpatient care in one plan
No referral needed to see a specialist
Have more freedom to choose your doctor or hospital
Can choose to use doctors and hospitals inside the network and
receive the maximum benefit
Can go outside the network, but usually at a higher cost
Many plans include prescription drug coverage and additionalbenefits

21

Types of Part C plans: Special needs.

Coordinated care plans:
Are designed for people with special and often complex health care needs

Residents of nursing homes

People eligible for both Medicare and Medicaid

People with certain chronic diseases such as diabetes or heart disease
Focus on helping members receive well-coordinated care

Holistic, proactive approach

Specialized care team

Enhanced education and communication

22

Types of Part C plans: Private Fee-For-Service.

Offered by private insurance companies
Many plans may offer prescription drug coverage
Many plans may offer additional benefits beyond Original Medicare
(Parts A and B)
No restrictions on which doctors or hospitals you can use
Keep in mind:
Doctors and hospitals must accept the payment terms and conditions of
the private insurance company.
Payment comes from the Private Fee-For-Service plan, not Medicare
Important to make sure your doctor or hospital will accept payment from
a specific plan each time before receiving services

23

understanding Medicare.
Prescription drug plans (Part D)

Prescription drug plans (Part D).

Plans offered through private insurance companies
that help with the cost of prescription drugs.
Helps with prescription drug costs
Works differently from Medicare Part A and Part B. You can
only get Medicare Part D through a private insurance company
Must continue to pay Part B premium

25

Medicare Part D (prescription drug).

What to keep in mind.
Costs:
Helps with the cost of your prescription drugs
Total costs of a plan can vary significantly from plan to plan
Catastrophic coverage protects you from very high drug costs
Plan benefits including premium, deductible and copayments
can change each year
Enrollment:
You must enroll in a Part D plan. Coverage is not automatic
If you do not sign up for a Part D plan when you become eligible, you
may have to pay a late-enrollment penalty unless you qualify for an exception
Coverage:
Each plan has a list of drugs that it covers
Make sure your drugs are covered before you enroll in a plan
The list of drugs can potentially change each year
26

Part D: How a formulary (drug list) works.

Formulary:
List of drugs that the insuranceplan covers.

Formulary

Medicare provides guidelines about the

types of drugs to be covered but not the
specific drugs

.......... Tier 5 ($$$$$)

.......... Tier 4 ($$$$)

Each plan has its own formulary

.......... Tier 3 ($$$)

Medicare has excluded some types of drugs,

but some plans may include them as part of
an enhanced formulary
Medications not on a plans formulary, or
covered drug list, may not be covered or
may cost more

.......... Tier 2 ($$)

.......... Tier 1 ($)
Plans build their specific
formularies by selecting
drugs from these groups.

Tip: Many drug plans have a tiered formulary. That means the plan divides drugs into
groups called tiers. Generally, the lower the tier, the lower your copay.
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Tiered Formulary

Many plans utilize tiered

formularies to group
covered drugs according
to cost.

Partunderstanding
D: How costdrug
sharing
works.
payment
stages.
understanding drug payment stages.

PartDcoveragegap:whatyouneedtoknow.
annual deduCtiBle
Not all plans have a deductible.
You pay your deductible before
initial coverage begins.
initial COverage Stage
During this stage you pay a flat
fee (copay) or a percentage of a
drugs total cost (coinsurance)
for each prescription you fill.
The plan pays the rest until
your total drug costs (paid by
you and the plan) reach $2,970.

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initial
Upto$2,970

COverage gaP Stage

During this stage you pay 47.5%
of the total cost for brand name
drugs and 79% of the total cost
for generic drugs. Once your outof-pocket costs reach $4,750,
you move to catastrophic
coverage.

gap
Upto$4,750

CataStrOPHiC
COverage Stage
In this stage you pay only a
small copay or coinsurance
amount for each filled
prescription. The plan and
Medicare pay the rest until
the end of the calendar year.

Catastrophic
Throughendofyear

[Payment stage amounts may differ for select plans. For more information see the plans Summary
of Benefits.]

understanding Medicare.
When to enroll

Enrollment windows and timing.

When can I first enroll?

What if Im late?

Medicare Part A

Any time after you are 64 years and

nine months old or otherwise become
eligible for Medicare. Enrollment will be
automatic if you are already receiving
Social Security benefits; otherwise,
youll have to enroll at your local Social
Security office.

Generally, there are no penalties for signing

up late. You may pay a penalty on your
premium for signing up late if you are one of
the people who pay a monthly premium for
Part A because neither you nor your spouse
contributed enough to Social Security.

Medicare Part B

Seven-month window
Generally, for most, you can first
enroll three months before your 65th
birthday month, during your birthday
month, and up tothree months after
your birthday month.

Medicare Part C
(Medicare
Advantage)

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Seven-month window
Generally, for most, you can first
enroll three months before your 65th
birthday month, during your birthday
month, and up tothree months after
your birthday month.

Your eligibility month

Initial enrollment period
If you enroll after the initial enrollment period,
premiums will be higher unless you qualify for
an exception. Contact Medicare to learn more
about these exceptions.
Your eligibility month
Initial enrollment period
If you miss the enrollment window,
you must wait to join a plan between
October 15 and December 7, unless you
qualify foranexception.

Enrollment windows and timing.

When can I first enroll?
Medicare Part D

Seven-month window

What if Im late?
Your eligibility month

Generally, for most, you can first enroll

three months before your 65th birthday
Initial enrollment period
month, during your birthday month, and up
If you miss the enrollment window,
tothree months after your birthday month.
you must wait to join a plan between
October 15 and December 7, unless
you qualify for an exception. If you enroll
later, premiums could be higher.
Medicare
supplement
(Medigap)
insurance

31

Six-month window for guaranteed right

Month you qualify

When you turn 65 AND enroll in Medicare

Part B, you have a guaranteed right to
Open enrollment period
buy a Medigap policy for six months. You
If you miss the window, you can apply
cannot be refused if you sign up during
later at any time. But you may be
the open enrollment period.
charged a higher rate or be rejected
if you have a health history that makes
you appear to be at a higher risk.

Medicare enrollment periods.

Current Year

Upcoming Year
OEP

Open Enrollment Period

October 15 December 7

Special Election Period (SEP)

Enrollment periods allow you to enroll in or switch Medicare plans

The Medicare Open Enrollment Period (OEP) is between October 15 and
December 7
Some individuals may also qualify for a Special Election Period (SEP) depending
on their circumstances

32

Where can you go for extra help?

Extra help is available for people with low incomes and
few assets to help pay the costs of Medicare

Medicare Savings Program

Prescription Drug Assistance Programs

Low Income Subsidy (Federal)

State programs

Patient assistance programs

Medicaid

For singles,
helpmaystart
when incomeis
around $16,755*

For couples,
help may start
when combined
incomeis around
$22,695*

Your local Social Security Office or state Medicaid

office is a good place for more information

33

*2012 numbers.
Note: Income eligibility changes from
year to year.

understanding Medicare.
Next steps and resources

Next steps.

1Review enrollment periods: Understand when you qualify for coverage.

2Research: Compare plans and find the coverage thats the best option for you.
questions: Ask yourself important questions about your medical needs, such as:
3Ask
Do you take prescription drugs regularly? How frequently do you need care?
answers: Locate free resources to answer all of your Medicare questions. Visit
4Get
MedicareMadeClear.com, Medicare.gov or the Social Security Administrations website.
financial help: See if you qualify for financial assistance programs. Contact your
5Find
local Social Security or state Medicaid office.
Once you know what plan type is right for you, go online to Medicare.govs plan
6Enroll:
finder to see plans available in your area.
review: Mark your calendar and make any changes to your plan during the
7Yearly
Medicare Open Enrollment Period (OEP) (October 15 December 7).

35

Interested in learning more?

CheckoutMedicareMadeClear.comtowatchvideos,signupforournewsletter,take
quizzes,findtoolsandgetanswerstoyourMedicarequestions.
Stayinformed:

Twitter

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Newsletter

Additionalinformationresources:
VisitMedicare.gov
Call1-800-MEDICARE(1-800-633-4227),TTY1-877-486-2048,
24hoursaday,7daysaweek
CallyourStateHealthInsuranceAssistanceProgram(SHIP)
toseeifyouqualifyforanyfinancialassistance
Questions?

Call1-877-619-5582,TTY 711
8a.m.8p.m.localtime,7daysaweek

MedicareMadeClear.com
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Questions?

37

Copyright 2013 United HealthCare Services, Inc. All rights reserved. No portion of this work may be reproduced or used
without express written permission of United HealthCare Services, Inc., regardless of commercial or non-commercial nature
ofthe use.
The family of UnitedHealthcare Medicare Solutions plans are insured or covered by UnitedHealthcare Insurance Company
orone of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
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