Molly Janczyk: Medicare questions for Gary Russell

Molly Janczyk to Gary Russell, February 12, 2007

Subject: STRS/Medicare: Definition: Indemnity:

To clarify, Gary.

Under Medicare ONLY, the recipient has to pay the first $992 of a hospital stay for the first 1-60 days; $248 a day for the next 61-90 days and $496 a day for the next 91-150 days.

But, under STRS, Medicare recipients pay ONLY their $500 deduc. and then 20% until they reach $1500 per recipient for their max put of pocket.

Please verify_________Yes_________No

This is good news if I understand it as written above as I approach 65 and learning about Medicare. We make out much better than I thought.

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Gary Russell to Molly Janczyk, February 12, 2007

Subject: RE: Indemnity: 2nd request

Molly,

Please see my answers below. When I refer to the Plus plan I'm speaking of the Aetna or Medical Mutual Plus plan under the STRS Ohio Health Care Program.

Gary

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(Molly to Gary)

Gary, I remain confused. Please answer in Basic Class 101 verbiage.

Molly: Indemnity: 'defined as in paid back after the insured pays first.' Then, you say, No, retirees do not pay first if they have signed for crossover (meaning having both Medicare and Med. Mut./Aetna, etc. ). Does this mean :

1. Insured retirees with both Med Mut or Aetna, etc. NEVER pay first and wait until Medicare pays, sends paperwork, then Med. Mut. or Aetna, etc. pays , and then sends an EOB (explanation of benefits) telling retirees what to pay.

Russell: YES!

2. How do retirees have both Part A and Part B with Medicare as Primary? Med Mut. explained to me that retirees with no Part A have STRS (OPERS) as the primary acting as Part A and Med Mut (Aetna, etc.) as secondary acting as Part B for overnight stays. ???????????????

Medicare is always primary if someone has Medicare coverage. Medicare consists of two parts, Part A is Medicare hospital coverage and Part B is Medicare medical coverage. If someone is eligible for Part A for free, then she is required to enroll in Part A and it is primary to hospital coverage under the STRS Ohio plan. If a member is not eligible for Part A for free, then she does not have to enroll in Part A and STRS Ohio provides comprehensive hospital coverage at no additional cost to the retiree. If there is no Part A coverage, then STRS Ohio pays first since it is the only plan.

3. What is the Medicare deductible?

Medicare Part A enrollees pay $992 for days 1-60 in the hospital. An enrollee is responsible for $248 per day for days 61-90 and $496 per day for days 91-150. For a skilled nursing facility, the cost is $0 for the first 20 days, then $124 per day for days 21-100 and 100% of the cost for each day after 100. Medicare Part B enrollees have a $131 deductible then typically the enrollee pays 20% of the cost. For additional information regarding Medicare, the booklet Medicare & You is available on the Medicare website.

4. Is this Medicare deductible over and above the $500 deduc. we pay now or the Basic deduc. we pay now?

The STRS Ohio plan is going to cover the Medicare allowable amount that Medicare didn't cover. For example, let's say that there is a claim for $2,131 in allowable charges. Medicare Part B won't cover the first $131 which leaves $2,000 of which Medicare pays $1,600 (80%). This means that $531 has not been paid. Under the Plus plan the enrollee would pay the first $500 to meet her deductible and then the Plus plan would cover 80% of the remaining $31 and the enrollee would pay 20% of the $31. The difference with the STRS Ohio plan is that there isn't a separate deduction for hospital and medical coverage. So if in the example above there were hospital charge, then Medicare is not going to cover the first $992 for a hospital stay, but under the STRS Ohio Plus plan, $500 of the $992 would satisfy the deductible and then the Plus plan would cover 80% of the remaining $492.

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From Gary Russell, February 12, 2007

Subject: RE: Indemnity: 2nd request

Molly,

Please see my answers following your questions. In regards to any questions you get from older retirees about claims, I can't stress enough that they just need to call our toll-free call center at 1-888-227-7877 and we can answer any questions or resolve issues for them. We need to have the dialogue with them so that we can probe for the information we need to have to resolve either a breakdown in service or clarify any misunderstanding.

I hope this helps,

Gary

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From Molly Janczyk, February 9, 2007

Subject: Indemnity: 2nd request

1. What does indemnity mean to the Medicare recipient under STRS?

Russell ans: It is defined as paid after the insured pays as in paid back after recipient pays bill first.

Molly: Surely retirees 65 and older are not required to pay up front and this not what happened to my mother under OPERS.

Russell ans.: Under the indemnity plan for Medicare covered individuals, the provider first files with Medicare and then if the member has signed up for automatic crossover, Medicare will forward the claim to Aetna or Medical Mutual. The retiree does not pay first.

2. So, does it mean after Medicare pays, STRS pays? Or a combination of the 2? See #1 above.

3. Isn't Part A: STRS primary with Medicare secondary Part B: Medicare primary with STRS secondary and then recipient pays 20% of what is left and allowed?

For both hospital (part A) and medical (part B) Medicare is primary to STRS Ohio. The retiree has to first meet the deductible for Medicare, then Medicare pays, Aetna/Medical Mutual will then begin coverage on what is left over after the Aetna/Medical Mutual deductible is paid.

4. Do we not receive paperwork from Med Mut or Aetna just like before 65?

Russell ans.: Yes, the retiree receives explanation of benefits (EOB)

5. After $500 deduc and out of pockets max of $1500 is reached, STRS pays 100% of Medicare recipients just like non Medicare, correct?

Russell ans.: Yes, the plan works the same way after Medicare pays.

I am getting questions from retirees (one of which I sent you) who say:

1. they don't receive paperwork telling them how much of their deduc and out of pockets have been met and

2. who do not seem to know that they are out of pocket max after which STRS pays 100%.

Russell: (ans. above): Yes they receive EOB (explanation of benefits)