Medicare

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General Overview

Medicare is a federal program enacted in 1965 and administered by the The Centers for Medicare and Medicaid Services (CMS). The Medicare Modernization Act of 2003 made significant improvements to Medicare, including the addition of a prescription drug benefit. Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).

Traditional Medicare involves two parts: Part A, which covers hospital charges, normally costs you nothing, and Part B, which covers doctor’s bills and other medical care, involves a monthly premium. Medicare beneficiaries have a choice between traditional Medicare (Parts A and B) and a Medicare HMO.

Effective January 1, 2006, a new voluntary prescription drug benefit, Part D, was offered and involves a monthly premium.

Questions and Answers About Medicare

  1. Who is eligible for Medicare?

    Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant)
  2. How do I enroll in Medicare?

    The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their web site at www.socialsecurity.gov.
  3. Are my spouse and dependent children eligible to get Medicare coverage?

    Medicare is not offered as a family or dependent benefit. This means all people must qualify on an individual basis.
  4. How do I file a claim (bill) with the SAG-Producers Health Plan after Medicare processes my claim?

    If the provider is in the SAG-Producers Health Plan network, they should file the claim for you. Simply show them both your Medicare and SAG-Producers Health Plan ID cards when services are rendered. If the provider does not file secondary with the SAG-Producers Health Plan, submit a copy of the bill and the Medicare Summary Notice, showing what Medicare approved and paid, to the SAG-Producers Health Plan.

Medicare Parts A and B

Medicare has two parts, which help pay for different kinds of health care costs.

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care, if you meet certain conditions. Most people do not have to pay a monthly premium for Part A because they or their spouse paid Medicare taxes while working.

Medicare Part B (Medical Insurance) helps cover your medically necessary doctors' services, outpatient hospital care and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. A monthly premium is required for Part B.

If you and/or your spouse are not enrolled in Medicare Part A or B at age 65, Health Plan benefits may be reduced. When you lose “active” coverage under the SAG-Producers Health Plan and become eligible for either the Senior Performers Plan, the Self-Pay Program or Earned Inactive coverage, Medicare will become your primary payor and the SAG-Producers Health Plan your secondary payor. The Plan rules provide that if you are not enrolled in Medicare when Medicare is primary and the SAG-Producers Health Plan is secondary, the Health Plan benefits will be reduced by 80%. You are responsible for the remainder of the charges. See the Coordination of Benefits with Medicare section of the SAG-Producers Health Plan Summary Plan Description for additional information on how benefits are coordinated. For detailed information on when you should enroll in Medicare Parts A and B, see our Medicare Parts A, B & D Notice and Medicare’s Medicare and You handbook.

Questions and Answers About Medicare Parts A and B

  1. What types of services are covered under Medicare Parts A and B?

    Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals and skilled nursing facilities (not custodial or long-term care). Medicare Part B (Medical Insurance) helps cover medically necessary doctor’s services and outpatient care.
  2. I don't want to enroll in Medicare because I already have such great coverage under the SAG-Producers Health Plan and I can't afford the Medicare Part B premiums. Do I have to enroll in Medicare Parts A and B?

    Yes. You are required to enroll in Medicare Parts A and B when Medicare is your primary coverage and the SAG-Producers Health Plan is secondary. If you fail to enroll in Medicare, the Plan's benefits are reduced by 80%. See the Medicare Parts A, B & D Notice for more information.
  3. Does Medicare cover dental services?

    Medicare does not cover either routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. In rare cases, Medicare Part B will pay for certain dental services. In addition, Medicare Part A will pay for certain dental services that you get when you are in the hospital. Depending on your eligibility type, you may have dental coverage through the SAG-Producers Health Plan.
  4. Does Medicare cover hearing aids or eyeglasses?

    Medicare does not cover hearing aids or eyeglasses, but you may have coverage through the SAG-Producers Health Plan for those items.

 

Medicare Part D – Prescription Drug Plans

Medicare Prescription Drug Plans (PDPs) are available for Medicare eligible retirees starting January 1, 2006. Private insurance carriers create and administer the PDPs and charge individuals a monthly premium for the coverage.

Medicare PDPs vary in what prescription drugs are covered, how much you have to pay, and which pharmacies you can use. All PDPs have to provide at least a standard level of coverage, which Medicare establishes. However, some plans offer more coverage and additional drugs for a higher monthly premium. If you enroll in a Medicare PDP, it is important for you to choose one that meets your prescription drug needs.

If you are in the SAG-Producers Health Plan you already have prescription drug coverage through Express Scripts that is comparable to Medicare coverage so you do not need to enroll in a Medicare PDP. You can be in either the SAG-Producers Health Plan or a Medicare PDP, but not both. If you decide to join a Medicare PDP, then the Health Plan will not provide you with any prescription drug coverage.

You may hear that there is a penalty if you do not sign up for Medicare prescription drug coverage right away. However, if you are covered by the SAG-Producers Health Plan, you will not be subject to the penalty as long as you stay in the Health Plan. Our Notice of Creditable Coverage explains this further. If you join a Medicare PDP sometime in the future, you can use this notice to avoid the higher premium.

Special Provisions for People with Limited Resources
The Medicare Modernization Act includes special provisions for people with limited income and resources. These special provisions allow you, if you qualify, to receive Medicare Prescription Drug benefits with no premium, a lower or no deductible, and small or no co-payments. Therefore, if you qualify under this provision, you would pay less for prescription drugs with a Medicare PDP than through the SAG-Producers Health Plan prescription drug coverage. Many people who qualify for this provision may receive a mailing from Medicare or be automatically enrolled in a Medicare PDP. If you do not receive a mailing, but think that you may qualify, you can contact the Social Security Administration (SSA) at (800) 772-1213. If you determine that you may qualify for the assistance, you should complete the Application for Help with Medicare Prescription Drug Plan Costs.

Self-Pay Program and Medicare HMO Participants
If you are currently on our Self-Pay Program (COBRA) primarily for the prescription drug coverage, you should compare our Self-Pay premium and prescription drug benefits to the cost of a Medicare PDP and benefits. Remember, if you enroll in a Medicare PDP and decide to stop paying our Self-Pay premium, you will have no hospital, medical or prescription drug coverage through the SAG-Producers Health Plan.

If you are enrolled in a Medicare HMO, that plan may have automatically enrolled you in their Medicare PDP. The HMO may not allow you to drop just the prescription drug coverage without dropping hospital and medical coverage as well. You should compare the benefits and costs of the Medicare HMO with the SAG-Producers Health Plan to determine which is best for you

Questions and Answers About Medicare Part D

  1. What are Medicare prescription drug plans?

    Beginning January 1, 2006, Medicare prescription drug plans (PDPs) are available to people with Medicare. Insurance companies and other private companies work with Medicare to offer these drug plans.
  2. What if I have prescription drug coverage through the SAG-Producers Health Plan?

    If you have prescription drug coverage through the SAG-Producers Health Plan, you will get a Notice of Creditable Coverage from us that tells you that you already have prescription drug coverage that is more generous than the Medicare coverage; therefore you do not need to enroll in a Medicare PDP.
  3. Is there a penalty if I do not enroll in a Medicare Prescription Drug Plan?

    You may hear that there is a penalty if you do not sign up for Medicare Prescription Drug Coverage right away. However, if you are covered by the SAG-Producers Health Plan, you will not need to pay the penalty, as long as you stay in the Health Plan.

Senior Performers Health Plan

The Senior Performers Health Plan primarily provides coverage for eligible pensioners who are age 65 or older and their eligible dependents. (Disability pensioners whose disability was the result of an injury incurred while working under a Screen Actors Guild contract are eligible for Senior Performers health coverage at any age.) You are eligible for Senior Performers Plan I coverage if you are receiving a pension based on at least 20 Pension Credits. Effective 1/1/2013, there will be a $50 monthly premium for Senior Performers coverage for participants with no spouse or with a spouse or same-sex domestic partner age 65 and over. There is a $100 monthly premium for Senior Performers coverage for participants with a spouse or same-sex domestic partner under age 65.

Pensioners who have at least 15, but less than 20 Pension Credits can obtain coverage under Senior Performers Plan I by paying a premium equal to 25% of the actual cost of the coverage. The actual premium will be determined at the time your coverage starts and will be adjusted from time to time by the Trustees based on the experience of the Plan.

Senior Performers Health Plan coverage is secondary to Medicare; therefore you must be enrolled in Medicare Parts A and B. Your spouse must also be enrolled in Medicare Parts A and B if he or she is age 65 or older, or is eligible for Medicare due to disability. The Plan rules provide that if you are not enrolled in Medicare when Medicare is primary and the SAG-Producers Health Plan is secondary, the Health Plan benefits will be reduced by 80%. You are responsible for the remainder of the charges.

Your Senior Performers eligibility may be replaced with Earned coverage if you meet the minimum earnings requirement for Earned Eligibility based on sessional earnings or the minimum Days of Employment requirement. You will receive Plan I coverage, but will only be required to pay the $50 or $100 Senior Performers Plan premium if that is what you had been paying. If you were paying 25% of the cost of coverage, you will pay the Earned quarterly premium. Refer to Coordination of Benefits with Medicare below for additional information.


Medicare Web Site

Detailed information regarding Medicare can be found on their Web site: www.medicare.gov and in their publication Medicare and You.

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