History of Medicare

• Medicare was originally a program that provided medical care to families of military personnel, established by the Dependents’ Medical Care Act in 1956.
• President Dwight D. Eisenhower held the first White House Conference on Aging in January 1961, where a health care program for Social Security beneficiaries was proposed.

Efforts to Pass a Healthcare Bill

• Congress attempted to pass a healthcare bill for the elderly, but were unsuccessful.
• In 1963, a bill that included both Medicare and an increase in Social Security benefits passed the Senate.
• The bill was the first time either chamber had passed a bill embodying the principle of federal financial responsibility for health coverage.
• There was uncertainty over whether the bill would pass the House, but White House aide Henry Wilson tallied 180 votes as reasonably certain for Medicare.
• After the 1964 elections, pro-Medicare forces gained 44 votes in the House and 4 in the Senate.

Medicare Enactment and Expansion

• Under President Lyndon Johnson's leadership, Congress enacted Medicare under Title XVIII of the Social Security Act in July 1965.
• Medicare provided health insurance to individuals aged 65 and older, regardless of income or medical history.
• The Social Security Amendments of 1965 were signed into law by Johnson on July 30, 1965, at the Harry S. Truman Presidential Library in Independence, Missouri.
• Former President Harry S. Truman and his wife, former First Lady Bess Truman, were the first recipients of the program.
• Medicare made payments to healthcare providers conditional on desegregation, which spurred racial integration in healthcare facilities in 1966.
• The creation of Medicare led to approximately 60% of people over 65 having health insurance, compared to about 70% of the younger population.
• About 20% of the total, 75% of whom were eligible for all Medicaid benefits, became "dual eligible” for both Medicare and Medicaid.
• Medicare has been operating for almost 60 years and underwent numerous changes.
• Benefits for speech, physical, and chiropractic therapy were included in 1972.
• The program added the option of payments to health maintenance organizations (HMOs) in the 1970s.
• Hospice benefits became available to aid elderly people on a temporary basis in 1982 and made permanent in 1984.
• In 2001. Congress expanded Medicare to cover younger people with amyotrophic lateral sclerosis (ALS), or Lou Gehrig's disease.
• Eligibility was expanded to younger people with permanent disabilities receiving Social Security Disability Insurance (SSDI) payments and those with end-stage renal disease (ESRD).
• The association with HMOs was formalized and expanded in 1997 under President Bill Clinton, as Medicare Part C.
• In 2003, under President George W. Bush, Medicare Part D was passed to cover almost all self-administered prescription drugs, going into effect in 2006.

Medicare in 2022

• Medicare provided health insurance for 65.0 million individuals, including over 57 million people aged 65 and older and about 8 million younger people.
• Medicare Trustees spending topped $900 billion, with $423 billion from the U.S. Treasury and the remainder from the Part A Trust Fund and premiums.
• Households that retired in 2013 paid only 13 to 41 percent of the benefit dollars they are expected to receive.

Medicare Parts A, B, and C Coverage

• Medicare Part A, often referred to as hospital insurance, primarily covers the costs associated with inpatient care and specific types of medical services.
• It covers inpatient hospital stays, skilled nursing facility care after a qualifying hospital stay, hospice care, and home health care.
• Most people do not pay a premium for Part A if they or their spouse have paid Medicare taxes while working for at least 40 quarters.
• Part A generally has a deductible for each benefit period and may require coinsurance costs for each day of a hospital stay beyond a certain number of days.
• Individuals are generally eligible for Medicare Part A at age 65, as well as those under 65 who have been receiving Social Security Disability Insurance (SSDI) for 24 months.
• Individuals with End-Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) may also qualify for Part A.
• Medicare Part B covers doctor visits, outpatient hospital services, preventive services, diagnostic tests, durable medical equipment (DME), and mental health services.
• Most people pay a standard monthly premium for Part B.
• Part B has an annual deductible, and after the deductible is met, individuals typically pay 20% of the Medicare-approved amount for most services.
• Unlike Part A, Part B does not cover hospital stays, long-term care, or most custodial care.
• Many people with Part B also have supplemental insurance, such as Medigap or a Medicare Advantage Plan (Part C), to help cover additional costs.
• Medicare Part C, also known as Medicare Advantage, is an alternative way to receive Medicare benefits through private insurance companies approved by Medicare.
• Medicare Advantage plans combine coverage from both Medicare Part A and Part B.
• Many Medicare Advantage plans offer extra benefits not covered by Original Medicare, such as vision, dental, hearing care, and wellness programs.
• Most Medicare Advantage plans include Part D prescription drug coverage.

Types of Medicare Advantage Plans

• Health Maintenance Organization (HMO): Requires members to use a network of doctors and hospitals and may need a referral from a primary care doctor to see a specialist.
• Preferred Provider Organization (PPO): Offers more flexibility in choosing healthcare providers without needing referrals to see specialists, but with lower costs for using the plan's network.
• Private Fee-for-Service (PFFS): Allows individuals to go to any Medicare-approved provider that agrees to the plan's terms and conditions.
• Special Needs Plans (SNPs): Tailored for people with specific health conditions or needs, such as chronic diseases or dual eligibility for Medicare and Medicaid.
• HMO Point of Service (HMOPOS): A variation of HMO plans that offers some out-of-network coverage options.
• Medicare Advantage plans may have additional premiums, different deductibles and copayments, and out-of-pocket limits.
• Medicare Advantage plans have a maximum out-of-pocket limit to protect against high costs, covering 100% of covered services for the rest of the year once the limit is reached.

Medicare Enrollment Periods

• Initial Enrollment Period: When first becoming eligible for Medicare (around age 65), individuals can sign up for a Medicare Advantage plan.
• Open Enrollment Period: Each year, from October 15 to December 7, to switch to a different Medicare Advantage plan or return to Original Medicare.
• Medicare Advantage Open Enrollment Period: From January 1 to March 31, to switch from one Medicare Advantage plan to another or drop their Medicare Advantage plan and return to Original Medicare.
• Special Enrollment Periods: May apply if specific life events or changes occur, such as moving out of the plan's service area.
• When selecting a Medicare Advantage plan, compare coverage options, provider networks, costs, and extra benefits to find one that best meets individual needs.
• Reviewing the plan annually during Open Enrollment is essential to ensure it still meets changing health needs and plan benefits.

Medicare Part D

• Medicare Part D is the prescription drug coverage component of Medicare, available through private insurance companies approved by Medicare.
• Part D plans help cover the cost of both brand-name and generic prescription drugs.
• Each Part D plan has its own formulary, which is a list of covered drugs.
• Part D plans charge a monthly premium that varies by plan and can be influenced by income.
• The average premium for 2024 is approximately $33.

Medicare Prescription Payment Plan

• Starting in 2025, the drug law known as the Inflation Reduction Act will require all Medicare prescription drug plans to offer enrollees the option to pay out-of-pocket prescription drug costs in capped monthly installments.
• Medicare enrollment penalties affect premiums for those who do not sign up when first eligible or fail to maintain creditable coverage.

Part B Late Enrollment Penalty

• It applies if one does not sign up for Medicare Part B when first eligible and lacks other creditable coverage.
• The penalty is 10% of the standard Part B premium for each 12-month period of non-enrollment.
• This penalty is added to the Part B premium for as long as one has Part B.

Part A Late Enrollment Penalty

• Generally, Part A does not have a late enrollment penalty for those who have to buy it because they lack 40 quarters of Medicare-covered employment.
• However, if eligible for premium-free Part A and enrollment is delayed without other creditable coverage, challenges in accessing certain benefits may arise, but not a financial penalty.
• If having to buy Part A, the cost depends on how long enrollment was delayed.

Part D Late Enrollment Penalty

• This applies if one does not sign up for Medicare Part D when first eligible and lacks other creditable prescription drug coverage.
• The penalty is 1% of the national base premium for each month of non-enrollment, added to the Part D premium.
• The penalty is added to the Part D premium for as long as one has Part D.

Special Enrollment Periods (SEPs)

• Qualifying for a SEP allows enrollment in Medicare Part B or Part D without penalties.
• These are available for those experiencing qualifying events like losing creditable coverage, moving, or other significant life changes.

General Enrollment Period (GEP)

• Missing the Initial Enrollment Period and not qualifying for a SEP allows signing up during the GEP (January 1 to March 31 each year), but late enrollment penalties still apply.
• To avoid penalties, enroll in Medicare Parts A, B, and D when first becoming eligible.
• Maintaining other creditable coverage, such as employer insurance, also helps avoid late enrollment penalties.

Medicare Under Age 65 – Eligibility for Disability and Specific Conditions

• Social Security Disability Insurance (SSDI): those under 65 receiving SSDI for at least 24 months are eligible. The 24-month waiting period applies from the start of SSDI benefits.
• Initial Enrollment occurs automatically after the 24-month requirement, typically the month before the 25th month of SSDI benefits.
• End-Stage Renal Disease (ESRD): People under 65 with ESRD requiring regular dialysis or a kidney transplant are eligible. Eligibility begins on the first day of the fourth month of dialysis treatments.
• Amyotrophic Lateral Sclerosis (ALS): Individuals diagnosed with ALS (Lou Gehrig’s disease) are eligible as soon as they start receiving SSDI benefits, with no 24-month waiting period.

Medicare Coverage for Under 65

• Part A (Hospital Insurance): Includes inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
• Those who have worked enough qualifying quarters do not have to pay a premium; otherwise, a premium is required.
• Part B (Medical Insurance): Includes outpatient care, doctor visits, preventive services, and other healthcare services not covered by Part A.
• A monthly premium based on income is required. The standard premium for 2024 is $174.70.
• Part C (Medicare Advantage): Combines Part A and Part B coverage with additional benefits like vision, dental, and hearing coverage. Some plans include Part D (prescription drug coverage). Eligibility requires enrollment in Part A and Part B.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications. Plans vary in terms of drug formularies and costs. Enrollment is available through private insurance companies and needed for prescription drug coverage.

Enrollment and Costs

• Automatic Enrollment: Those receiving SSDI benefits are automatically enrolled in Medicare Parts A and B after the 24-month waiting period.
• Initial Enrollment: For ESRD and ALS, one can enroll as soon as they meet eligibility requirements.
• Costs include premiums for Part B (and potentially Part A), deductibles, copayments, and coinsurance. Part C and Part D plans have their own costs and coverage specifics.
• Traditional Medigap policies may not be available to those under 65, but some states offer limited options.
• Special Enrollment Periods: if having other health insurance coverage or experiencing specific life changes, one may qualify for Special Enrollment Periods to enroll in or switch Medicare plans.

Income-Related Monthly Adjustment Amount (IRMAA)

• The IRMAA is an additional charge applied to Medicare premiums for those with higher incomes, affecting enrollees in Medicare Part B and Part D.
• IRMAA is determined based on your modified adjusted gross income (MAGI) from two years prior.
• Thresholds and premiums change each year, so checking the latest information from the Social Security Administration or Medicare is important.

Medicare Part B IRMAA Premiums in 2025

• For individuals with incomes of $106,000 or less, or joint incomes of $212,000 or less, the monthly premium is $185 (no IRMAA).
• For incomes > $106,000 – $133,000 or joint incomes > $212,000 – $266,000, the monthly premium is $259.
• For incomes > $133,000 - $167,000 or joint incomes > $266,000 -$334,000, the monthly premium is $370.
• For incomes > $167,000 – $200,000 or joint incomes > $334,000 – $400,000, the monthly premium is $480.90.
• For incomes > $200,000 – $500,000 or joint incomes > $400,000 – $750,000, the monthly premium is $591.90.
• For incomes Greater than $500,000 or joint incomes Greater than $750,000, the monthly premium is $628.90.
• People with kidney transplants have lifetime access to Medicare Part B coverage of immunosuppressive drugs.

Medicare Part D IRMAA surcharges in 2025

• Irregular Medicare Part D, the IRMAA amounts are added to the regular premium for the enrollee's plan.
• Many Medicare Advantage plans include prescription drug benefits,
• Income levels triggering IRMAA surcharges for 2025 Part D coverage are based on 2023 tax returns.
• Individuals or couples with incomes of $106,000 or less, or joint incomes of $212,000 or less, pay their regular premium (no IRMAA).
• The income amounts increase incrementally to monthly premiums of $13.70, $35.30, $57, $78.60 and $85.80+ your premium.

IRMAA Appeals

• Can be appealed for significant life income changes
• Qualifying events include reitrement, job-loss and more

HSAs

• Can contribute only when enrolled in an HDHP
• Contributions are stopped when enrolling in Medicare
• Contributions are tax-deductible and withdrawals are tax-free
• Should time enrollment in Medicare carefully to continue contributions to an HSA.
• HSA funds can be used tax-free even after enrolling in Medicare.
• May face penalties for delay of enrolment beyond 65 if you are not covered by an HDHP
• No contributions are allowed after enrolling in Medicare
• Cannot use HSA funds to pay for Medicare premiums except Part B, Part D or Advantage,

Affordable Care Act (ACA) Key Features

• Passed in 2010
• Focused on affordability and accessibility in healthcare

Health Insurance Marketplaces (Exchanges)

• Online platforms where individuals and families can compare and purchase health insurance plans, often with the assistance of subsidies (or tax credits).
• Subsidies: For those with incomes between 100% and 400% of the federal poverty level (FPL), the ACA provides subsidies to make insurance more affordable. These are offered as premium tax credits, which reduce the cost of monthly premiums for health insurance plans.

Medicaid Expansion

• A government-run program that provides health coverage to low-income individuals.
• Medicaid eligibility was expanded to cover more low-income adults who previously did not qualify. The expansion was intended to help those with incomes up to 138% of the federal poverty level, though some states chose not to expand Medicaid, leaving gaps in coverage.
• State Decisions: Medicaid expansion was optional for states

Essential Health Benefits:

• Ambulatory patient services (outpatient care)
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services
• Laboratory services

ACA Insurance Reforms

• Preventive care is covered
• There is no lifetime or annual limits
• Young Adults Can Stay on Parents' Insurance

Employer Mandate

• The ACA requires that businesses with 50 or more full-time employees provide health insurance to their workers or face penalties.

ACA Insurance Regulations

• There are no ban on discriminatory practices
• Insurers can no longer charge higher premiums based on a person’s health status, gender, or occupation.
• Health insurance offer health insurance to anyone who applies.

Medicaid and Purpose

• Medicaid is designed to provide health coverage to low-income individuals and families who may not be able to afford health insurance on their own.
• Aims to improve access to healthcare services for vulnerable populations, including pregnant women, children, elderly adults, and people with disabilities.

Medicaid and Funding

• Medicaid jointly funded by Federal Gov and individual states
• Administered by individual states
• Eligibility and Admin may vary state to state

Medicaid - Benefits and Requirements

• Benefits vary by state but typically include a range of healthcare services, such as doctor visits, hospital care, prescription drugs, and preventive care.
• Individuals can apply for Medicaid through their state's Medicaid agency.
• May require small co-payments for certain services
• Helps millions gain entry to essential medical services

Social Security Disability Insurance (SSDI)

• Provides financial assistance to non- workers due to disabilities
• Disability must last for at least one year or result in death.
• The number of work credits required depends on age at said disability
• Severe Impairment: Medical condition must significantly limit ability to perform basic work-related activities
• SSDI applicants are initially denied benefits
• Must to seek assistance from legal professionals for aid
• Appeals process can involve multiple stages

To apply to SSDI

• Gather Documentation: Collect necessary documents to support application: medical records, doctor's reports and more
• Complete the Application: Apply for SSDI benefits online, over the phone, or by scheduling an appointment at local Social Security office.
• Submit Supporting Evidence: Submit all evidence to show that your condition affects your ability to work
• Keep in Touch: Stay in contact with the SSA throughout appeal process

Social Security

• Almost everyone who is employed or self-employed will receive Social Security benefits when they retire
• If worker's earnings exceed certain limits the benefit will be reduced
• The worker can keep working, and the Social Security benefit will not be reduced no matter how much is earned.
• There are benefits for :
• Spouses who are age 62 or older;
• Spouses who are younger than 62, if they are taking care of a child is your dependent
• Former spouses, if they are age 62 or older
• Children up to age 18

Tax related to Social Security

• Benefits may be taxed if it exceeds a certain limit

TRICARE for Life

• Medicare-wraparound coverage if eligible and have Medicare
• TFL Enrollment is not required
• Must pay Medicare Part B premiums
• Available worldwide

TRICARE for Life - how does it work

• Does not have enrollment card
• Requires medicare card and military ID as proof of coverage
• You may visit any authorized provider.
• Pays directly for covered services

Elder Law Definition

• Specialised area of legal practice that foucusses on the legal issues affecting older adults to help protect their well-being

Medicaid Planning

• Helps plan through the income test

Asset Protection Trusts

• Designed to shield assets from creditors or other claims,including potential Medicaid claims.

Long-Term Care Insurance

• Helps fill gaps by covering costs like custodial care
• Premiums are high but they can lead to avoiding liquidating assets for Long-term care

Using a Life Estate

• Retains right to live, but transfers ownership
• Helps against Medicaid purposes

Spousal Protection

• Spouse may be entitled to retain a certain amount of assets and income to ensure financial security while the other spouse qualifies for Medicaid
• Spousal Income Allowance helps prevent impoverishment

Gifting and Considerations

• Gifting assets to children or loved ones can help reduce countable assets for Medicaid purposes, but it must be done with caution due to Medicaid's look-back period
• Can trigger penalty on medacaid benefits

Life Estate Deed

• Tranfers home ownership if you are moving to a nursing home

Elder Abuse

• Vulnerable to elder abuse, help seniors by helpin protect legal safegaurds

Special Needs Trusts

• Designed to ensure beneficiaries can maintain government benefits
• Ensures Medicaid still aids
• Can't jeopardizing eligibility for these programs.

Guardianship and Conservatorship

• Decision-making for personal matters, including healthcare and living arrangements, while conservatorship pertains to managing financial affairs.

Maximizing Medicare Benefits

• Medicare Advantage Plans
• Medicare Supplement Insurance (Medigap):

Reviewing Estate Plans

• To aid minimize assets from tax and more

Long term Care facts

• 70% of adults aged 65 years and older will require long-term care at some point
• The average length of stay in long-term care is 3.2 years.
• About 14%, or $475.1 billion, was spent on long-term care facilities and services.
• Majority of long-term care residents are over the age of 85Women stay in long-term care facilities for an average of 3.7 years

Medical Conditions needing long-term care

• They are high blood pressure, depression. and arthritis

Types of medical Long-Term assistance

• In home and in home care help for those in need
• Assisted Living for those that allow independance
• Nursing Homes for those needing constant care.
• Memory Care:
• Daytime care during when family are at work

LTCI and Benefits

• Helps policy prices for long-term

LTCI Policies

• Provides trigger event
• Standalone policies that specifically cover -long-term care services.
• Life insurance policies that include long-term care
• Premiums can vary based on age, health, benefits selected, and the duration of coverage