There are 3 options you have when it comes to determining what type of Medicare plan is the ideal and best plan for you:
OPTION #1 IS ORIGINAL MEDICARE
This is a traditional 80/20 Healthcare Plan, managed and overseen by the US Government and the Centers for Medicare Services which are part of the United States Department of Health and Human Services. Under Original Medicare, Medicare pays for 80% of all Medicare Covered and Medically necessary procedures. And you, the Medicare Beneficiary are responsible for the remaining 20%. There are No Deductibles, No Minimums, No Maximum Out of Pocket Expenses and no limit to how much your 20% can add up to.
OPTION #2 IS JOINING A MEDICARE ADVANTAGE PLAN
This is again an 80/20 Health Plan, offered by private insurance companies instead of the Government. These plans are primarily made up of HMO (Health Maintenance Organizations) and PPO (Preferred Provider Organizations) plans. The majority of MA (Medicare Advantage) plans have a network in which you must stay in in order to receive the lowest costs and to ensure that your services are covered. Many Medicare Advantage Plans may let you see Doctors outside of their networks, however; they will not pay for these services. And their networks are mostly limited to the County or Region you live in.
Because Medicare Advantage plans are offered by private insurers, each insurance company sets the rules for their plans, and they decide what they will pay for and what they won't. You will always pay your 20% Co-Insurance for any and every procedure you have until you meet your particular plans MOOP (Maximum Annual Out-of-Pocket) expenses for the year. The MOOP vary by plan and range from $2,800 to over $10,000 per year. Meaning you can easily be responsible for $5,000 - $12,000 or more in annual Out-Of-Pocket expenses.
Medicare Advantage Plans market their plans to Medicare Beneficiaries and often try to incentivize their plans by including what they call Dental, Vision and Hearing Benefits or by offering a few plans that will actually rebate you part of your Monthly Part B Deductible each month. These companies are very good at making things sound unbelievably good. And more often than not, when you really break down the benefits of these added services, they typically are not the complete healthcare plans that most people believed them to me.
OPTION #3 ORIGINAL MEDICARE WITH A MEDICARE SUPPLEMENT
In my humble and professional opinion, this is the way to go. There are 11 Different Medicare Supplements plans nationwide. The most popular Plans available to new Medicare Beneficiaries are Plan G and Plan N. With Medicare Supplement Plan G your Medicare Supplement will pay the entire share of your 20% with Original Medicare, with no deductibles. So, the best way to compare Medicare Supplements is to realize that your Premium is your Maximum Out-Of-Pocket Expense or MOOP. Plan G's in Arizona, Nevada and Texas will run between $95 - $135 per month. if you use an average of $120 per month, your pay $1,440 in Annual Premiums, but your plan pays for everything else. Not only that, many Medigap Policies also pay the Medicare Part A Deductible $1,600 for each time you are admitted into the hospital. And you can see any Doctor you choose, anywhere in the US! This is the most predictable and comprehensive Healthcare plan you could choose, and it gives everyone the convenience, flexibility and peace of mind they deserve?
MEDICARE AEP (ANNUAL ELECTION PERIOD) OCTOBER 15TH - DECEMBER 7TH
When it comes to the Annual Election Period or “AEP,” being on schedule is very important. For the 2023 plan year the Medicare AEP began on October 15th and ran through December 7th. For those interested in taking on the coverage for Medicare Advantage, the enrollment timeframe is available from January 1st to March 31st, 2023. This is the Medicare Advantage Open Enrollment, otherwise known as “MA OEP.” It’s important to remember that this is available to those already enrolled in Medicare Advantage plans. This is also the time frame in which one can adjust from Medicare Advantage to the Original Medicare plan. In addition, there is the option for those are near the inception of their Medicare eligibility who can take advantage of the Initial Coverage Election Period, or “ICEP.” This time is designated for those who are newly eligible for Medicare to begin enrolling in the Medicare Advantage Plan for the first time. This happens at a different time of year than the Medicare Advantage Open Enrollment (MA OEP). It’s important to identify when the right time is for you to enroll as there are very few exceptions that fall into the Special Election Period. These exceptions are limited to specific life events such as marriage or losing other health coverage elsewhere.
The principal criteria for determining eligibility with Medicare is age. In order to qualify you must be 65 years of age. If you are not yet 65 there are some specific conditions that would make you eligible like Lou Gehrig’s disease or End-Stage Renal Disease (ESRD). If you have one of these conditions or have additional questions about your eligibility, contact The Health Exchange Agency directly to discuss your specific options. Specified conditions are important to disclose in order to properly qualify an individual for coverage during an ongoing health concern.
Qualifying may be easier than you imagine. After you’ve checked off the “65 years” bucket, you’ll need to evaluate a few other things. It’s important that you’ve had Medicare-covered Employment for a minimum of 10 years leading up to your enrollment. This means having at least 40 quarters of employment that has paid out Medicare taxes. If you (or your spouse) did not pay these Medicare taxes, you still may be eligible. There are additional criteria that would be the determining factor for your qualification.
In addition to the aforementioned criteria, another important qualifier is the citizenship or permanent residency status that you currently have. You must have either the US Citizenship or Permanent Residency for a minimum of 5 years in order to move forward in your enrollment process. If this sounds like you, you’re ready to enroll. Taking the next step and signing up for Medicare may lead you to some new questions, be sure to gain clarity on questions you may have about the process.
While Medicare has three major criteria for the enrollment of its beneficiaries, it’s important to note that the individual circumstances of each person can make a difference in eligibility. If you’re unsure based on your current status, we have answers to your questions. While you may still be working part-time or full-time or carry insurance privately, Medicare still may be an important option for you to consider. The benefits of having a supplementary plan assist in ensuring that you don’t end up paying out of pocket for costs that could otherwise be covered. The Health Exchange Agency specializes in assisting men and women like you each day with their Medicare enrollment, you don’t have to do this alone. We’re here to help and know that with the right personalization of the process, you’ll get the exact coverage you want and need. You are at or nearing the age of Retirement (65) and you may still be covered by your own Health Insurance or by your Employer or through the VA. You have heard about Medicare for years, but you also know Medicare has Part A, Part B, Part C and Part D. Family members and friends may have mentioned Medicare Supplement Plans and Medigap Plans, Medicare Advantage Plans and probably Prescription Drug Plans. All of these questions and things to consider probably seem a bit overwhelming at times, but we have tried to break things down and make it a little bit easier to decipher and understand.
The 4 PARTS Of MEDICARE
Original Medicare is Medicare Part A and Medicare Part B
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement or a Medigap Insurance policy help pay for additional things such as:
As of January 1, 2020, Medigap plans sold to new people with Medicare aren't allowed to cover the Part B deductible. Because of this, Plans C and F are not available to people new to Medicare starting on January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) prior to January 1, 2020, you’ll be able to keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans.
Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care if/when you travel outside of the United States. If you have Original Medicare and you buy a Medigap policy, here's what happens:
Are the most desired Medicare Plans and they have the most flexibility, you can see any Doctor Nationwide who accepts Medicare patients. There are well over 800,000 Doctors who accept Medicare that equals out to over 96% of all physicians! All of these doctors will accept any Medigap Policy that you enroll in, regardless of the Insurance Company you choose to partner with. All of the Medicare Supplement Plans are identified by a Alphabetic Letter such as Plan A, B, C, D, F, G, K, L, M, N.
Medicare Advantage Plans are offered by private insurance companies. Each of these companies receives a lot of money from the government for every Medicare beneficiary they enroll. And make no mistake about the fact that every Medicare Advantage insurer is a for profit entity. They will do everything they can to manage/micro-manage your care while turning a profit. Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you're always covered for emergency and urgently needed care.
Most Medicare Advantage Plans offer coverage for things that aren't covered by Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships). Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other health-related services that promote your health and wellness. Plans can also tailor their benefit packages to offer these new benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat those conditions. Check with the plan to see what benefits are offered and if you qualify. Most include Medicare Prescription Drug Coverage or Medicare Part D. In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. In 2023, the standard Part B premium amount is $164.90 (or higher depending on your income).
If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service. But you have the right to appeal the decision.
You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, the plan must tell you in writing.
You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:
Medicare Part D is prescription drug coverage. Medicare Part D is optional, and it’s available only through private insurance companies that contract with Medicare.
Medicare Part D prescription drug coverage was created by the Medicare Modernization Act (MMA) of 2003 and implemented in 2006. The goal of Medicare Part D is to help make prescription drugs available and affordable for Medicare beneficiaries.
Anyone with Medicare coverage—either Medicare Part A (hospital insurance) or Part B (medical insurance) or both parts—may be eligible for a stand-alone Medicare Part D prescription drug coverage. You can’t be turned down because of your health status or income.
TWO TYPES OF MEDICARE PART D PRESCRIPTION DRUG PLANS
You can get your Medicare Part D coverage from either of these types of plans:
You can change Medicare Supplement/Medigap Plans anytime but you need to remember that after your IEP (Initial Enrollment Period) there is no guarantee that you will be accepted by an Insurance Company and you may be subject to Underwriting depending on your current state of health.
You are limited to when you can change your Medicare Advantage Plan. The Annual Enrollment Period (AEP) Period is in the Fall from October - December. There are other times you may make a change such as moving out of a coverage area or to another state.
We are always available to answer your calls and to give you the best, straightforward answers to all of your healthcare questions. If you would like to engage us to represent you and your interests please know that we get paid by the various Insurance companies and that we would never charge our clients for any services.
The best form of knowing that we helped you is by you referring us to family and friends who need help understanding the fundamentals of Medicare and you have our promise that we will treat them with the same level of care and respect that we have given to you and to each of our clients.
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