Category Archives: Medicare Posts
If you are a Medicare beneficiary with a high income within the last couple of years, you may be penalized with a higher premium by Medicare. This penalty can affect your Part B premium and your prescription drug (Part D) premium.
The technical name for this penalty is the Income-Related Monthly Adjustment Amount, or IRMAA. There is a way to dispute and appeal your IRMAA. A Request for Reconsideration is a petition that you can file with Social Security if you feel your premium amount is unwarranted or based on inaccurate information (more on that below).
Once you retire, your income is likely to drop. Yet, the IRMAA can cause you to pay may more even though at retirement your income is lower. The Request for Reconsideration could help lower your premium.
How Your Part B and Part D Premium is Calculated
Your Modified Adjusted Gross Income (MAGI) is calculated by adding your adjusted gross income plus any tax-exempt income. This could include items such as dividends, interest, capital gains, wages, rental income, or non-taxable Social Security benefits.
In order to determine this amount, Social Security will use the information from your most recent federal tax return. So the amount that they are basing your premium on could be your MAGI from 18-24 months ago.
If Social Security determines that you are in a bracket that requires a higher premium, you will receive a letter from them informing you of what your premium will be. They will also include an explanation of your Medicare Part B premium penalty. If you disagree with their assessment, you can then file a Request for Reconsideration.
Situations That May Qualify You For a Lower Part B Premium
You can call the SSA to request the reconsideration. The number is 1-800-772-1213. Here are the situations that may cause your appeal to go through:
Tax return inaccurate or out of date:
- A beneficiary filed an amended tax return for the year SSA is using to make an IRMAA decision
- There was an error in the IRS data
- The IRS provided SSA with older data and the beneficiary wants to use newer information
- You had a major life-changing event that significantly reduced your income
Life-changing event that affects the beneficiary’s modified adjusted gross income:
- Death of spouse
- Divorce or annulment
- Work reduction
- Work stoppage
- Loss of income from income-producing property
- Loss or reduction of certain kinds of pension income
The most common of these is work reduction or work stoppage. If you were making $100,000 when you retired two years ago and your retirement income is now $40,000, you have a pretty good case for having your premium reduced.
How To Appeal
When following the steps below, be sure to keep a record of all your correspondence. This is your Medicare Part B premium penalty you are trying to lower, so it puts money back in your pocket if you are successful. So, make sure you keep a copy of everything. The IRMAA also can affect your Part D premiums, so if you are entitled to having it adjusted it is in your best interest to do so.
- Complete a request to SSA for Contact SSA to learn how to file this request. .
- If your reconsideration is successful, your premium amounts will be corrected. If your reconsideration is denied, you can appeal to the Administrative Law Judge (ALJ) within 60 days of the date on the reconsideration denial. Follow the directions on the denial to file an appeal with the ALJ. If you decide to appeal to the ALJ, you may want to contact a legal services organization or lawyer to help you with this or any further levels of appeal—but this is not required.
- You must submit any new evidence within 10 days of filing your appeal to the ALJ. Contact the ALJ to learn how to submit this. You can ask the ALJ for an extension if you are unable to submit new evidence within 10 days.
- If your ALJ appeal is successful, your premium amount will be corrected. If your appeal is denied, you can choose to appeal to the Medicare Appeals Council (MAC) within 60 days of the date on the ALJ denial.
- If your MAC appeal is successful, your Part B premium amount will be corrected. If the MAC denies your appeal, you can choose to appeal to the within 60 days of the date on the MAC denial.
Saving On Your Medicare Supplement Plan
The most popular plan that we sell is the Plan G. It is identical to the more popular Plan F except that with the Plan G you pay the annual Part B deductible which is $183 in 2017. Yet, in many cases, we find that the difference in premiums between Plan F and Plan G can be anywhere from $350 to $700 per year.
With either plan, Medicare is going to get that $183 deductible paid. With a Plan G, you can pay it directly to your Part B provider once per year. Under a Plan F, you are basically paying the deductible plus a convenience fee (in the form of a higher premium) for the insurance company to pay it for you. Most of our clients prefer to pay it themselves and pocket the premium difference. We have a short video that explains the difference between Plan F and Plan G and gives premium examples of how much you can save by choosing the Plan G over the Plan F.
If you want to see how much you can save by choosing the Plan G over the Plan F, call one of our licensed insurance agents at 1-888-228-6119, or use the form to the right to tell us how we can help.
This week we had a case with a gentleman who had diabetes and a history of mild neuropathy. On the applications for most Medicare supplement companies, they are not questioning the severity of the neuropathy or retinopathy. They simply want to know if you have been diagnosed with it or treated for it within a certain timeframe. The good news is that there are companies that will accept you with this condition, so you there is coverage under Medicare supplement for diabetes with neuropathy available.
When New To Medicare
If you are turning 65 or leaving an employer plan and enrolling in Medicare Part B for the first time, most of what we will discuss here to does not apply to you right now. When you first enroll in Part B, you have an Open Enrollment period that entitles you to choose any Medicare supplement plan that you want – no questions asked – for 6 months following your enrollment into Part B. So finding a Medicare supplement for diabetes with neuropathy is not an issue. While in Open Enrollment, you can with any company you choose for any plan available. There is no waiting period, no surcharges, and no pre-existing clause. You are covered from day one under the Medigap plan of your choosing if enrolling during Open Enrollment.
If New To a Medicare Advantage Plan
Medicare has a provision for those that enroll in a Medicare Advantage plan and want to leave it during the first 12 months. This is referred to as your Trial Right. Information available on the federal government’s Medicare.gov website says that if you joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare, you can purchase any Medigap plan available in your state from any company you choose.
They are required to sell you a Medicare supplement. They must cover all pre-existing conditions. Also, they cannot charge you more because of your health. You simply can call Medicare to disenroll from your Medicare Advantage plan and move back to original Medicare. They can also help you choose a Part D Prescription drug plan at the same time.
Call us and use our free comparison shopping service to find the best plan in your zip code if you are wanting to take advantage of this provision. Our number is 888-228-6119 and a licensed independent agent will be glad to assist you.
Guaranteed Issue For Losing Group Coverage
If you are losing employer coverage and are already covered by Medicare Part B, you have certain guaranteed-issue rights that allow you move onto a Medigap plan. Here is the information from the Medicare.gov website concerning that:
You have the right to buy Medigap Plan A, B, C, F, K, or L that’s sold by any insurance company in your state.
If you have COBRA coverage, you can either buy a Medigap policy right away or wait until the COBRA coverage ends.
You can/must apply for a Medigap policy no later than 63 calendar days after the latest of these 3 dates:
- Date the coverage ends
- Date on the notice you get telling you that coverage is ending (if you get one)
- Date on a claim denial, if this is the only way you know that your coverage ended
For Everyone Else
If you are outside of an Open Enrollment or Guaranteed Issue period, you will have to go through underwriting to enroll in a new Medicare supplement plan. There are some companies that will take you depending on the severity of your diabetes diagnosis.
With the gentleman I mentioned at the beginning of the article, he was taking Metformin to control blood sugar and Gabapentin for the pain in his feet from neuropathy. We had two companies in the state of Georgia that would accept that situation according to their application for coverage. Everest Reinsurance Company has one question on their application concerning diabetes. They want to know if within the past five years you have been prescribed or taken more than 100 units of insulin a day. Considering his other health history was good, other than taking a medication to control blood pressure, cholesterol, and a pain medication for an injury, he was eligible for coverage with them. However, every underwriting situation is different. So let us compare your health history against all the companies to see where you may qualify.
This gentleman would also qualify for Blue Cross Blue Shield of Georgia. We were looking at a Plan G Medicare supplement for him. The issue we had with BCBS was that their Plan G was just released last month. And considering that there is a $70 premium difference between their Plan F and Plan G, I am not comfortable putting people with them just yet. That is a very big premium difference considering the only thing Plan F covers that Plan G does not is the Part B deductible, which is $183 in 2017. Also, considering the rate increase history of BCBS in Georgia, I am not confident that their premium will stay that low for long. And if his health were to decline any at all, this client may be stuck in that plan and forced to pay whatever premium they increase to for those covered under Plan G.
The third option he had was to go with UnitedHealthcare. UHC will not ask any underwriting questions if you are within three years of enrolling in Part B for the first time – which was the case here. One issue that he saw with them was that they do not offer Plan G, which he wanted. The only other options he would consider were Plan F and Plan N, both of which UHC offers. Also, they require you to be a member of AARP to get their coverage, and he did not want to join AARP. But if he had been declined by the other companies, he had them as a last resort for getting a Medicare supplement for diabetes with neuropathy.
As I mentioned in the article, every underwriting situation is different. Let us check to see where we can get you placed. Our service is free. It costs you the same exact price whether you go directly to the company or use an independent agent, like Integrity Senior Solutions. If you go directly to the company, they will never tell you their competitor’s prices. They will not tell you of their upcoming rate increases. And if they decline you, they will also not tell you what other companies are an option for you. We can do all of those things and it costs nothing more for us to do it for you. We are licensed all across the country, so we can help you.
The advice on this website is informational. Please consult us before making a purchasing decision to determine what is best for your individual situation. You can contact Keith Murray at 888-228-6119 or using the form on the right side of the page.
Keith Murray is an independent agent and the owner and founder of Integrity Senior Solutions Inc. He has over 20 years of experience working with Seniors to meet their insurance and financial needs.
©2017 Integrity Senior Solutions Inc
For many years, it was easy to know when retirement, Social Security, and Medicare were going to be a reality in our lives. Age 65 was the defining marker. That one birthday used to mean that retirement (and hopefully a pension), better healthcare options through Medicare, and the beginning of Social Security benefits were available. That is no longer the case.
The Social Security Amendments of 1983 (H.R. 1900, Public Law 98-21) contained two provisions which may have an impact on when an individual decides to retire. For those born from 1943 through 1954, the age you can begin full SSI benefits in age 66. This means that turning 65 is no longer an automatic trigger for Medicare enrollment. Because of this change in retirement age, many seniors are unaware that they still need to enroll in Medicare at age 65, not 66. Not enrolling when you are first eligible could lead to lifelong penalties on your Medicare premium.
Seniors who are already receiving SSI payments when they turn 65 are not affected by enrollment issues. You will be automatically enrolled is you are receiving SSI benefits. If you postpone your Social Security benefits either because you are still working or want a higher payout by waiting to start, you will need to enroll yourself in Medicare at age 65.
Medicare Enrollment Period
If you are still covered by group coverage from a retiree plan, or your or your spouse’s plan, you might want to wait to enroll in Part B. However, you can sign up for free Part A (if you’re eligible) any time during or after your Initial Enrollment Period starts. Your coverage start date will depend on when you sign up. If you have to buy Part A and/or Part B, you can only sign up during a valid enrollment period. The General Enrollment Period (GEP) runs from January 1 through March 31 of each year. Coverage for enrollments during GEP will begin July 1 of that year.
If you are not covered by a group or retiree plan, you must enroll in Medicare during your Initial Enrollment Period (IEP). That period is a seven month period that begins three months before the month of your 65th birthday. It includes your birth month and ends three months after your birth month. You can enroll in Part A and Part B of Medicare at that time. Part A is free as long as you worked 40 quarter hours (or 10 years) during your lifetime. It covers hospital and most other inpatient services.
Part B requires a premium. It covers physician and outpatient services. For 2016, the Part B premium is $121.80. Part C is the Medicare replacement plan known as Medicare Advantage. Part D is the prescription drug plan, which you will also need to look into when you first enroll in Medicare. You can also get a Medicare supplement plan to cover the gaps in Medicare. These are also known as Medigap plans. If you are confused about the Parts and Plans of Medicare, be sure to check out our article and video that fully explains both by clicking here.
The Late Enrollment Penalty For Medicare Part B
If you do not enroll in Part B when first eligible, and you are not enrolled in a qualifying group or retiree plan, you will be penalized. For every year that you delay enrollment in Part B, you have a 10% surcharge added to your Part B premiums. The surcharge is permanent – you will pay it the rest of your life. So if you delay enrollment in Part B for two years, that would mean a 20% surcharge added to your Part B premium going forward.
As mentioned previously, you can delay Part B enrollment. You must be covered by an employer plan (yours or your spouse’s) or a retiree group plan. Once that coverage ends, you will be eligible for a Special Enrollment Period (SEP) to enroll in Part B. That SEP gives you up to eight months to sign up for Medicare without a penalty.
One important note about ending group coverage. If you opt for COBRA, you will not be exempted from needing to enroll in Part B. The 8-month SEP runs concurrently with COBRA. It is based on termination of group coverage, not termination of COBRA. So you need to enroll in Part B when your group coverage ends, not when COBRA ends. Otherwise, you will have the late enrollment surcharge applied to all future Part B premiums. That penalty applies ONLY to your Part B premium and does not affect Medicare supplement premiums.
To enroll in Medicare past age 65, you will need to call Medicare. Their number is 1-800-MEDICARE (1-800-633-4227). TIP: call them late at night or really early in the morning. Their service is available 24 hours a day. You can also visit the website at http://medicare.gov.
Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (H.R. 5772 and S. 3236)
As of the writing of this article, there is legislation in both houses of Congress to address this confusing enrollment process. In late August 2016, 73 state and national organizations that represent seniors, health insurers, unions, people with disabilities, and health care providers sent a letter to the lead sponsors of the legislation in both the House and Senate expressing their support for these bills.
“The basic rules underpinning the Part B enrollment system were developed more than 50 years ago, when Medicare was first established. Through bipartisan, low-cost reforms, the BENES Act shields people with Medicare from steep premium penalties, fills needless gaps in coverage and expands avenues for relief among those who mistakenly delay or decline Part B.” -From the coalition
The coalition also pointed out that over 750,000 Medicare beneficiaries were paying a lifetime penalty in 2014. These penalties were a result of not enrolling in Part B within the Initial Enrollment Period. The coalition also pointed out that the average penalty being paid was 30%.
In addition to this, Congressional leaders also received comments from eight past administrators of the Centers for Medicare & Medicaid Services (CMS) expressing their support. CMS is the agency that administers the Medicare program. These administrators were from both Republican and Democrat administrations. Their letter stated:
“The decoupling of eligibility ages for Medicare and full Social Security benefits, revisions to Medicare Secondary Payor law, and the growing number of Americans working past the age of 65 have, together, substantially complicated the decision-making process for eligible individuals and couples in deciding when and how to enroll in Medicare.”
Because of a shortened Congressional session and the fact that this is a Presidential election year, some believe the standalone bill has little chance of passage. However, once new Medicare premiums and Social Security benefits are announced for next year, this bill could attach itself to legislation addressing those issues. In 2015, Congress passed legislation addressing a very large Part B premium increase. If they were to do so again this year, this new bill could be lumped in with it. This would give it a much better chance of passage.
If you are still confused about enrollment periods and how this can affect you, please give us a call or write to us. The phone number is 888-228-6119. It is at the top of the page. You can use the request form on the right side of the page to send your questions, as well.
The advice on this website is informational. Please consult with us before making a purchasing decision to determine what is best for your individual situation. You can contact Keith Murray at 888-228-6119 or email@example.com.
Keith Murray is an independent agent and the owner of Integrity Senior Solutions Inc. He has over 20 years of experience working with Seniors to meet their insurance and financial needs.
©2016 Integrity Senior Solutions Inc
Medicare Supplement (Medigap) insurance policies do not provide prescription drug coverage. If you have a Medicare Supplement plan, you can still get drug coverage through a separate prescription drug plan through companies that offer drug plans like Silverscript, AARP, or Humana. Prescription drug plans are also known as Part D of Medicare.
Prescription Drug Coverage Under Legacy Medigap Plans H, I, and J
Up until 2010, Medicare supplement plans H, I, and J offered drug coverage as a part of their coverage. Those plans were eliminated in 2010 and replaced with plans K through N – none of which offer prescription drug coverage.
You can continue to receive your drug benefits from one of the discontinued plans if you still have it in force. But you cannot have a Plan H, I, or J and also have a Part D drug plan unless you have your insurance company to remove the prescription drug coverage from your Medigap plan. This could also change your monthly premiums.
Those legacy plans are not getting new, healthy enrollees coming into the plans, and that is a problem. You can expect the premiums on those three plans to continue to rise in the future. Insurance companies need new, healthy policyholders to help keep premiums low. That is not an option since those legacy plans are no longer available for sale.
There are better options available today if you are on an older plan. Check the rates for your area at the bottom of this page. You can also call our office at 1-888-228-6119 to speak with a licensed independent agent about your situation.
How To Get Prescription Drug Coverage
If you are enrolled in Medicare and have a Medigap plan other than H, I, or J, you have two options. First, you can enroll in a standalone Part D prescription drug plan. Your second option is to move to a Medicare Advantage plan. Although over 80% of Medicare Advantage plans have drug coverage included, most Seniors are not willing to give up the freedom and autonomy they have with a Medigap plan to go onto a Medicare Advantage plan with all of its restrictions. You cannot be enrolled in a Medicare supplement and a Medicare Advantage plan at the same time.
You can only enroll in a Part D plan under special circumstances, such as turning 65 or going onto Part B of Medicare for the first time. In both of those cases, you can enroll three months before or three months after the month that your Part B coverage begins. You can also enroll or change plans each year during the Annual Election Period (AEP). That period runs from October 15 through December 7. AEP restrictions apply to Part D or Medicare Advantage plans only. With your Medigap plan, you can make changes to your plan any time of year.
Enrolling in a Standalone Prescription Drug Plan
If you need a standalone Part D prescription drug plan, we recommend you call Medicare directly at 1-800-MEDICARE (633-4227). You can also visit them at http://medicare.gov. If you give them a list of your medications, they will give you the lowest priced plan based on what you are currently taking and where you live. They are totally unbiased and willing to help. One recommendation is to call them late at night or very early in the morning. They are available 24 hours a day.
The advice on this website is informational. Please contact us before making a purchasing decision to help determine what is best for your individual situation. You can contact Keith Murray at 888-228-6119 or firstname.lastname@example.org.
Keith Murray is an independent agent and the owner of Integrity Senior Solutions Inc. He has over 20 years of experience working with Seniors to meet their insurance and financial needs.
©2016 Integrity Senior Solutions Inc
Many customers want to go with a Plan N or Plan D, but are concerned about not getting the Excess Charges covered. I am often asked how those charges work and if they should be concerned about Excess Charges. This is a very complex issue, but I will try to make it as simple as possible without boring you with too much math and statistics.
**There are some states that do not allow any excess charges to be billed to the Medicare beneficiary. As of 2017, these states include Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont. If you live in one of these states, you can enroll in a Plan N or Plan D without any concern about having to pay excess charges.
Basically, there are three contract options for physicians when it comes to Medicare:
- Participating agreement (PAR)
- Non-participating agreement (non-PAR)
- Private contracting
Medicare has approved amounts for medical procedures and practices, also known as “assignment.” Participating (PAR) physicians sign an agreement with Medicare in which they agree to accept assigned costs as payment in full for all covered services for that calendar year. This means they accept the 80% from Medicare and the 20% payment from the patient or patient’s insurance as that full payment. The physician cannot charge the patient any more than the 20% This participation contract is for the duration of the calendar year, but the physician can go from PAR to non-PAR on an annual basis if they want to.
There are incentives for physicians to be a part of PAR:
- Medicare pays a 5% higher rate to PAR physicians than it does to non-PAR physicians for all services
- Medicare administrative contractors (MAC) provide toll-free claims processing lines to PAR physicians and process their claims more quickly.
- Directories of PAR physicians are provided to senior citizen groups and individuals who request them.
A non-participating physician has the option of whether to accept the Medicare assigned rate for services on a case by case basis. But if that physician does not accept it, the payment is lower.
The Medicare-approved amounts for services provided by non-participating (non-PAR) physicians (the 80% paid by Medicare and the 20% patient responsibility) are set at 95% of the Medicare-approved amounts that are paid to PAR physicians. However, non-PAR physicians are allowed to charge more than PAR physicians. This extra charge is known as the Part B Excess Charge.
Non-PAR physicians are limited to how much they can charge. This amount is set at 15% above the Medicare-approved amount for any given service. Because the Medicare-approved amounts for non-PAR physicians are 95% of the rates for PAR physicians, the 15 percent limiting charge is effectively only 9.25% above the PAR-approved amounts for any given service.
Taking into account the cost of running a business, and particularly the fact that physicians already make so little money when taking Medicare patients, it really is not worth it to try and make a few extra dollars by being non-PAR. Just a few bad debts, collections, or unpaid claims and they are losing money by doing so when the profit margin is so low at 9.25% above PAR rates.
Private Contracting Physicians
The Balanced Budget Act of 1997 gave physicians and Medicare patients the right to contract privately outside of the Medicare system for health care services. These private contracting decisions cannot be made on a case by case basis, though. Once a physician has opted out of Medicare, he cannot submit any claims to Medicare for any patients for a two-year period.
Very few physicians are opting out of Medicare. In fact, on a national level, the number of physicians billing Medicare has continued to rise at the same rate of growth as Medicare enrollment.
Over the past decade, more than 96% of all physicians and clinical professionals have signed participation agreements with Medicare. This means they are accepting Medicare’s payment schedule as payment in full for the services they provide to their Medicare patients.
According to the Center for Medicare and Medicaid Services, as of September 2013, among all US physicians in clinical practice, only 4,863 – less than 1% – have signed affidavits with Medicare informing them that they have “opted out” of the Medicare program completely. These physicians must tell their patients. They must have their patients sign a release stating that they understand that the physician has opted out of Medicare. It also must state that Medicare will not pay for any services provided by that physician.
Statistics From Aetna About Excess Charges
In August 2016, Aetna reported that 99.34% of the claims they process have no excess charges. Of that 0.66% of claims that do have excess charges, the average amount of the charge is less than $20.
- There are 8 states that have a ban on Part B Excess Charges. Those states are Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont (as of 2016).
- Fewer than 1% of all US physicians have opted out of Medicare
- More than 96% of US physicians accept Medicare Assignment as payment in full
- Of the less than 4% of physicians that are non-PAR, many of them do accept assignment on many claims. Accepting assignment helps to avoid the reimbursement penalty. This also helps to avoid the costs and hassle of collecting from the Medicare beneficiary. By being non-PAR, they have the flexibility to decide on a case-by-case basis
So although there is a possibility that you could receive Excess Charges, that possibility is very small.
The advice on this website is informational. Please consult us before making a purchasing decision to determine what is best for your individual situation. You can contact Keith Murray’s office at 888-228-6119 or email@example.com.
Keith Murray is an independent agent and the president of Integrity Senior Solutions Inc. He has over 21 years of experience working with Seniors to meet their insurance and financial needs.
©2017 Integrity Senior Solutions Inc
Sometimes the P words can get a little confusing. When adding to all the talk of deductibles and copays and all the things that go with making good insurance decisions, it can be a little overwhelming. Let’s talk about which is which. The Parts of Medicare are the actual divisions of the Medicare program. Medicare plans are the supplemental plans offered by insurance companies.
The Parts of Medicare
When talking about the parts of Medicare, it is in reference to how the Medicare program is divided into the separate parts, or divisions. Medicare is divided into 4 parts – Part A, Part B, Part C, and Part D.
- Helps cover inpatient care in hospitals
- Helps cover skilled nursing facility, hospice, and home health care
- Helps cover doctors’ and other health care providers’ services, outpatient care, durable medical equipment, and home health care
- Helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse
Medicare Part C (also known as Medicare Advantage)
- Medicare Advantage is a Medicare replacement program
- Offers health plan options run by Medicare-approved private insurance companies, not by Medicare
- You give up your rights to Medicare and give them to an HMO or PPO to make your coverage decisions for you
- Medicare Advantage Plans are a way to get the benefits and services covered under Part A and Part B
- Most Medicare Advantage Plans cover Medicare prescription drug coverage (Part D)
- Some Medicare Advantage Plans may include extra benefits for an extra cost
- Helps cover the cost of prescription drugs
- May help lower your prescription drug costs and help protect against higher costs in the future
- Run by Medicare-approved private insurance companies
Who Pays For What?
Parts A and B are funded by the Medicare program. There are some gaps in the coverage from Medicare, which is why it is important to get a supplemental coverage plan for Medicare – whether it is through employer group coverage or individual plans that you purchase.
Parts C and D – although completely controlled and governed by the Medicare program – provide care through private insurance companies like UnitedHealthcare, Humana, or Aetna. With a Part C plan, Medicare pays the insurance company to provide the coverage for you. All bills are paid by the plan. Each of the plans provided by individual insurance companies comes with its own copays and deductibles that you pay when you receive medical care. Each plan is different, so be sure you know what your share of the cost will be when services are rendered. The downside is that each plan has its own network of providers, so if you have a doctor you work with that you like, make sure to find a program that he or she participates in. There could also be limitations if you travel outside the coverage area for your plan.
Under Part D – the Medicare Prescription Drug Plan – you pay a premium to the insurance company for your coverage. Then you also pay a copay any time you fill a prescription.
Medicare Plans Explained
The Medicare supplement plans (Plans A-N) are individual insurance plans offered by the insurance companies. These plans were established by Congress and every company that sells them must sell the exact plan as regulated by Medicare. The plans are identical from company to company.
There are 10 different plans available for insurance companies to sell. The only difference in a Plan F policy from one company compared to a Plan F policy from another company is the price, the underwriting involved, and the agent assisting you. A Plan F from Mutual of Omaha is identical to a Plan F from UnitedHealthcare. In the Medicare and You book which is printed and distributed by Medicare each year, it says (in 2016 it is on page 100), “Different insurance companies may charge different premiums for the same exact policy.” They have different premiums, but the coverage is exactly the same. Sometimes the premium difference can be more than $150 per month!
The companies will base their rates on the underwriting required to be approved. A cheaper plan may be harder to get into if you have any health issues. Other companies may cost more, but may accept more applicants including those with pre-existing conditions. Here is a chart that shows the different plans that the companies have to abide by. All companies must offer Plan A and either Plan C or Plan F. Other than that, they can choose what to offer their customers.
You Have Choices
There are many choices with Plans A-N. These plans have a monthly or annual premium with the insurance company. Plan F is the most popular Medicare Supplement plan and has been for many years. With Plan F, you pay the monthly premium and all of your medical care is covered (with the exception of prescription drugs which require a separate Part D drug plan from the insurance company, if you so desire).
The premium is higher on these plans than a Medicare Advantage plan, but with a Plan F there are no additional co-pays or deductibles to pay for any Medicare-approved services – just a monthly premium which makes it easier to budget and maintain medical costs. Many Medicare Advantage plans have out of pocket limits of $6,700 per year. One major health issue and you could be paying big bills. You don’t have that exposure with a Medicare supplement plan, plus you can go to any doctor or hospital that accepts Medicare without worrying about networks. You can call 1-888-228-6119 to have your questions answered. There is no charge for our service.
The advice on this website is informational. Please contact us before making a purchasing decision to help determine what is best for your individual situation. Our service is FREE. You can contact Keith Murray at 888-228-6119 or firstname.lastname@example.org.
Keith Murray is an independent agent and the owner of Integrity Senior Solutions Inc. He has over 20 years of experience working with Seniors to meet their insurance and financial needs.
©2016 Integrity Senior Solutions Inc
There is a lot of information on the internet about Medicare Advantage and Medicare Supplement plans. That typically means there is some misinformation, too. I follow a lot of news sources on Medicare and read articles on the web. While gathering information for this article, the first two articles I ran across had glaring mistakes about what these two plans do.
I’ll get into those later, but the fact is that you need to learn about the programs and know what is best for you. You are the one to make the best decision for your situation. My goal here is to help educate and this article will be a little lengthy.
How Medicare Advantage Plans Are Structured
Medicare has a lot of co-payments and deductibles. It can be costly if you do not have insurance to fill the gaps – whether Medigap or Medicare Advantage. Medicare has four parts – A, B, C, and D. Part A typically covers most of your confined care – such as hospital, home health care, hospice, and skilled nursing facilities. Then there is Part B which typically covers your physician and other healthcare providers’ services, as well as some preventative care. There are other items covered under each, but for the sake of simplicity that is the easiest way to remember the two parts of Medicare. Part D is prescription drug coverage.
Medicare Advantage replaces your Medicare Part A and Part B services – and most of the time your Part D as well – and combines them into one policy with a private insurance company. This is what is known as Part C of Medicare. If you have a Medicare Advantage plan, you do not even have to carry your Medicare card around with you – just the card that the insurance company provides. You must still pay the Part B premium (as you do with Medigap plans).
If you enroll in a Medicare Advantage plan, you are giving up your rights as a Medicare beneficiary and handing them over to an HMO.
How Medigap Plans Are Structured
Medicare supplement plans do not replace your Medicare coverage under Part A and Part B. Instead, it covers the gaps in Part A and Part B that you would normally have to pay out of pocket if you have Medicare only. You can click here to see the cost information and deductibles on the Medicare.gov website. The Medicare supplement plans do just what the name says – they supplement your Medicare coverage, filling in the gaps of coverage.
Medicare Advantage PROS
Medicare Advantage plans usually have lower premiums than Medicare supplements. There are many areas where Medicare Advantage plans have no monthly premiums at all – only co-pays and deductibles. This is one reason the MA plans have gotten so popular.
Part D Inclusion
Nearly 80% of the Medicare Advantage plans available have the Part D included at no additional charge as an option for coverage. By including your Part D coverage with the Medicare Advantage (MAPD), you can keep your monthly premium lower and have one insurance card on your person for Medicare and for prescription drugs.
All Coverage From One Provider
As I just mentioned in the last point, MAPD plans allow you to have all your insurance coverage from one insurance company.
Almost all MAPD plans also include extra services such as limited dental, vision, and gym memberships at no additional cost. These extra services may be limited, but they are included even with many of the no-premium plans available today.
Medicare Advantage CONS
Medicare Advantage plans negotiate contracts with networks doctors, hospitals, and other healthcare providers. These networks are put in place in order to keep their costs low. This means that you must adhere to their networks or face substantially higher out of pocket costs. If you are in a HMO plan, you will be forced to pay all costs if you go out of network. Under a PPO plan, you would be faced with higher out of pocket cost-sharing. This has been in a issue in some instances where patients went in for surgery thinking everything is fine with their network coverage only to receive a huge bill from an anesthesiologist who was actually not in the network, or a patient who receives care in an emergency room from a physician not in their network.
Most of the time, the networks cover certain geographic regions. So if you need care while traveling or visiting family, it could become a problem. Also, Medicare Advantage plans offer no coverage at all for travel outside of the United States.
Your Co-Pays, Deductibles, Physicians, Networks, and Plan Can Change From Year To Year
I mentioned above that 78% of beneficiaries have access to zero-premium plans in 2015. In 2014 – just one year earlier – that number was actually 86%. Medicare Advantage plans are not guaranteed renewable which means that your deductibles and co-pays are not set in stone – your plan coverage can change from year to year. Not only can it change, but your plan can go away completely or your physicians can be out of network from one year to the next. You could be forced to scramble to find a new insurance plan as happened with AARP plans in Florida recently.
Worse yet, your physicians can actually leave the network in the middle of the year. This could be especially bad if you are in the middle of treating a condition. As more cuts to the payments that the government send to the insurance companies for Medicare Advantage patients are expected, the insurance companies are responding by saying they will have to further reduce the size of their networks.
Fluctuating Annual Costs
If you maintain good health, you can expect your costs to be much lower because of the low premiums of the MAPD plans. Your out of pocket expenses could remain low if you aren’t going to the doctor often. However, one major health problem or accident could worsen the emotional and physical toll by also hitting your bank account to the tune of up to $6,700 – the out-of-pocket maximum for 2015. If you are out of network with your HMO plan you could be responsible for the entire the bill.. The uncertainty of what your healthcare expenses will be from year to year makes it difficult to budget for those expenses.
Chemotherapy treatments are treated as an outpatient procedure. This means with most plans you could face a 20% co-payment for chemo treatments. Our son went through a fight with cancer when he was 11 years old, and I can tell you from experience those drugs are expensive. One particular drug was over $10,000 every time he took it.
You can see that at 20% co-payments, you could hit that $6,700 co-payment each year in a hurry. Cancer is not something you ever want to face, but being saddled with a lot of out of pocket costs on top of it could make it even worse. All you want to think about at that time is getting better, not having to worry about how you are going to pay for it.
Medicare Advantage plans and Part D prescription drug plans have only one window of opportunity each year for you to enroll. It happens from October 15 through December 7 each year. During that time, you can change plans or go from MAPD to original Medicare with a Medicare Supplement plan (or vice versa). There are Special Enrollment periods such as if you move in or out of your network coverage area. You have an Initial Enrollment Period three months before and three months after you first enroll in Part B of Medicare. Other than that, you cannot change plans or move back to original Medicare.
Medicare Supplement (Medigap) PROS
With a Medigap plans, you can go to any doctor, any specialist, or any hospital anywhere in the United States as long as they accept Medicare. As of the end of 2013, less than 1% of doctors had formally withdrawn from the Medicare program (42% of those were psychiatrists). That equates to over 99% of US physicians taking Medicare payments for their services. There are no networks to keep up with.
Another benefit is that the most Medigap plans (C, D, F, G, M, and N) cover foreign travel emergency up to $50,000 for travel outside of the United States. Medicare Advantage has no coverage outside of the US.
When you take a Medigap plan to supplement Medicare, the insurance company cannot change your coverage. They also cannot cancel your coverage unless you just don’t pay the premium. Even if Medicare quits offering your plan, your coverage will remain in force as long as you pay for it. I still have clients that are on the old Plan J that hasn’t been offered for sale since 2010.
The company also cannot raise your premium unless they do so for everyone on that plan in your state. So if you are diagnosed with a medical condition and have a lot of claims the insurance company cannot drop you. They also cannot raise your premiums because of it. And they can never single you out for a rate increase on a Medicare supplement plan.
Medicare Advantage plans that vary from company to company, year to year, or even from region to region. Medigap plans are identical from company to company. The Plan F you buy from Mutual of Omaha is identical to the Plan F from UnitedHealthcare or Aetna. So there is no confusion as to what your coverage is or what it might change to. The difference in premium between each company comes down to the claims they pay and the way they underwrite applicants.
No Claim Filing or Paperwork
All Medigap insurance companies offer electronic crossover filing with Medicare. This means that when your doctor or healthcare facility files with Medicare it electronically files automatically with your Medigap company. The company then pays the provider directly. Your doctor’s office does not even have to file with your insurance company. They simply file with Medicare and the rest is taken care of automatically. That means that you don’t have to keep up with any paperwork- it’s all automated for you and your doctor.
Easy To Budget Annual Costs
You won’t have any surprises with what your annual healthcare out of pocket costs are going to be with a Medigap plan. For Medigap plans, I definitely recommend Plan G over Plan F. This means you would have a $166 annual Part B deductible to pay (in 2016) and then all your other Medicare-approved care would be taken care of. If you or spouse end up in the hospital, you can look at each other and say, “This will only cost us $166.” That brings peace of mind.
Medicare does not approve cosmetic procedures and limits skilled nursing care (as does MAPD).
Medicare Supplement (Medigap) CONS
Higher Monthly Costs
You will have a monthly premium to pay each month with a Medicare supplement. Your costs may be higher on a Medigap plan if you rarely go to a doctor or seldom need healthcare. If you do run into a medical situation or currently have medical conditions that require a lot of care, the Medigap plan could come out substantially cheaper each year. That’s because the MAPD plans typically have a $6,700 maximum out of pocket. If you have a Plan G Medigap plan, the maximum annual out of pocket will be $166 (that is the Part B deductible for 2014-2015 that is not covered by Plan G) unless you have non-approved services done (cosmetic, etc.) or if you stay in a hospital more than 455 consecutive days.
No Part D Prescription or Dental Coverage Included
If you have a Medigap plan, you will need a standalone prescription drug plan. You could also get a standalone policy that would cover dental, vision, and hearing services. However, both of these have an additional monthly cost associated with them. The standalone dental, vision, and hearing coverage is typically much better than you get under a MAPD plan.
Policies May Be Underwritten
You have an open enrollment period for getting a Medicare supplement from any company you choose. This period starts six months before you enroll in Part B of Medicare and the six months after. Medicare Advantage and Part D allow a 3 month open enrollment before and after your date of first coverage under Part B. You will likely have to be underwritten to get a Medigap plan once you are out of your Open Enrollment period.
There are many pros and cons to each program. Every situation is different. There is no one size fits all solution. You can give us a call to get more personalized service to better understand your individual options. There is no charge for our service.
The advice on this website is informational. Please consult an independent insurance professional before making a purchasing decision to determine what is best for your individual situation. You can contact Keith Murray at 888-228-6119 or email@example.com.