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Michael T Braden August 27, 2024 MEDICARE Q & A
ANSWERS TO THE TOP 10 MEDICARE QUESTIONS
We receive questions about Medicare every day, and we are happy to answer them for our clients and prospective clients. It got me thiniking though, that we should prbably share this information. So, we created the Top 10 Most Common Medicare Questions.
WHAT EXACTLY IS MEDICARE?
Medicare is the Federal Insurance Plan for individuals 65 and older and for those with Disabilities or ESRD (End Stage Renal Disease). Medicare is an 80/20 Health Plan.
THE FOUR PARTS OF MEDICARE
Medicare Part A (In-Patient Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (Out-Patient Medical Insurance)
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
Medicare Part C (Medicare Advantage)
Available as an Option to Original Medicare. These plans are offered by Private, Insurance Companies and are not managed by the Government. Medicare Advantage plans are supposed to offer everything Medicare does, and they do offer more benefits than Original Medicare. However, they also limit you to using Doctors that are only in their Network.
Medicare Part D (Prescription Drug Coverage)
Helps cover the cost of prescription drugs (including many recommended shots or vaccines).
3 WAYS TO RECEIVE MEDICARE
ORIGINAL MEDICARE
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). The Government pays for 80% of All Medicare Covered and Medically Necessary procedures while you the Medicare Beneficiary pays for the other 20% of health services not paid for by Medicare. You will typically pay for services as you get them. When you get services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).
ORIGINAL MEDICARE WITH A MEDICARE SUPPLEMENT
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy is designed to help "Fill-In" the gaps leftover my Original Medicare. Medicare Supplemental or Medigap Insurance can help pay some of the remaining health care costs, like co-payments, coinsurance, and deductibles. Some plans will pay for your entire 20% share of your Healthcare Costs, emergency medical care when you travel outside the U.S. as well as your Medicare Part A Deductible.
MEDICARE ADVANTAGE
Medicare Advantage is Medicare-approved plan from a private insurance company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover like some vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules. The plan must notify you about any changes before the start of the next enrollment year.
Medicare Advantage Plans are still 80/20 Health Plans but they are managed by private Insurers who have the final say in what services are covered and what services are not covered so you are at the mercy of your individual plan, just because something is covered under Medicare does not mean it will be completely covered or paid for by a Medicare Advantage plan.
Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services. And, the majority of Medicare Advantage plans are HMO plans, meaning that you typically must use your plans "Network" of Doctors and Hospitals in order to get your services paid for.
MEDICARE PART D
Helps Medicare beneficiaries pay for Prescription medications. These plans are offered by private insurance companies but they must operate under the rules set in place by Medicare which is part of the Department of Health and Human Services.
Each plan varies in cost and specific drugs covered, but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies.
Each Part D plan has different monthly premiums. You’ll also have other costs throughout the year in a Medicare drug plan. How much you pay for each drug depends on which plan you choose.
2. IS MEDICARE FREE?
Most everyone seems to expect that Medicare is completely free, unfortunately Medicare is not 100% free. Medicare is however, the most affordable Health plan in America and when coupled with a Medicare Supplement Plan G it is the most comprehensive coverage you can get. Most people will not pay for Medicare Part A due to the contributions made to Medicare during their working careers.
Medicare charges everyone a monthly Part B Deductible of $174.70 for 2024. EVERYONE must pay this whether they join Original Medicare, A Medicare Advantage plan or if they choose Original Medicare with a Medigap (Medicare Supplement) plan.
In addition to the Monthly Part B Deductible, Medicare also has an Annual Medicare Part B Deductible of $240. This means that your will receive a bill from Medicare for your first $240 in healthcare costs/services each year.
Medicare Part D Monthly premiums can range from $0.00 - $169.50 per month, not including the co-pays and co-insurance for your prescription medications.
3. WHEN DO I SIGN UP FOR MEDICARE
Everyone should start researching Medicare when they are 64-1/2. That gives them plenty of time to determine what Medicare Plan they believe will fit them the best, but; also for them to decide if makes more sense to stay with their employers plan(If they are working past 65) or to enroll in Medicare. It is extremely important that everyone who is 65 and that works for a company with less than 100 Employees enroll in Medicare at 65 to avoid Part B Penalties for not having Credible Coverage.
Credible Coverage is defined by Medicare as having the same minimum coverage as Medicare. Normally any employer with over 20 employees will be considered to offer Credible Coverage. Any Employer with 20 Employees or less is considered Non-Credible Coverage.
Other types of Non-Credible coverage past age 65 is Veterans Insurance (Champ, VA & Tri-Care), all Private Healthcare plans, COBRA, Retiree plans and FEHB (Federal Employee Health Plans) plans are considered not to be Credible.
4. ENROLLING IN MEDICARE
You can Enroll in Medicare by using the Social Security Administration, website at www.ssa.gov, by calling your local Social Security Office or by applying in person at the Social Security Administration Office closest to you. You can choose to enroll in Part A & Part B or both Parts A & B.
The process will take anywhere from 6-10 weeks to complete so starting 3-4 months before your turn 65 is advised.
Anyone who chooses to receive their Social Security benefits prior to age 65 will automatically enrolled in Medicare when they turn 65.
5. WHAT IS THE MEDICARE IEP
You can take advantage of your initial enrollment window as early as three months before you turn 65. For those on disability, your Initial Enrollment Period window will begin after receiving Social Security for 24 months, and then again when you turn 65.
This is one of the only scenarios where you will get two chances of an Initial Enrollment Period. The other scenario is if you retire, go back to work, get employer group coverage, and then retire again later. If you choose this, then you will qualify for a SEP (Special Enrollment Period).
If you missed your Initial Enrollment Period 7-month window for one reason or another, you could still enroll during the GEP (General Enrollment Period). Keep in mind, that if you enroll during the annual GEP, your Medicare will not start until July 1st.
Therefore, you could have a gap in coverage. If you didn’t maintain creditable coverage, you’d be subject to an endless Part B Premium penalty.
WHO QUALIFOES FOR AUTOMATIC ENROLLMENT INTO MEDICARE?
You qualify for automatic enrollment if you’re collecting Social Security benefits. You should receive your Medicare card about three months before your 65th birthday. If you’re not collecting Social Security by the time you age into Medicare at 65, you’ll need to actively enroll yourself and if you have Railroad Retirement Board disability for at least 24 months.
WHAT HAPPNES IF YOU MISS YOUR INITIAL ENROOLLMENT PERIOD?
Your effective date for Medicare Parts A and B depends on when you enroll. If you enrolled within the three months before your 65th birthday, your effective date is the first day of your Birthday month. If you enroll during the month of your 65th birthday, your effective date is the first day of the month after your birthday.
Should you enroll in the three months following your birthday, your effective date will be the first of the month either three, five, or six months after your birthday month. This number goes up for each month you wait. For example, if you were born on June 11 and you enrolled in Medicare during the month of August (two months after your birthday), your effective date will be November 1 (five months following your Birthday month).
DO YOU HAVE TO JOIN MEDICARE PART D?
Technically no, you do not have to do anything you do not want to do, however; if you do not choose to enroll in a Medicare Part D Prescription Drug plan within 63 days of your turning 65 or joining Medicare Part B, you could be subject to a 1% penalty which is about .39 cents per month for each month you went without a Part D plan, and that is not the worst part, this Part D penalty never goes away, so someone who blew off getting a Part D plan for say 2 years would pay about .39 x 24 Months meaning they would owe $9.36 in a Part D Penalty for as long as they are enrolled in a Part D plan.
ARE VACCINATIONS COVERED BY MEDICARE?
Medicare covers annual Flu Vaccines, Shingrix (Shingles Vaccine), Pneumonia, Hepatitis, Tdap, and Chicken Pox. If you are planning to schedule your Shingrix Vaccine (2 shots 3 months Apart) it is advisable to do it in September and the next shot in December. Why? Because there is a huge cost difference for Medicare Beneficiaries. It will cost $155-$210 for the Shingrix Vaccine if you have not met your annual Part D Deductible and usually between $10-$20 if you have reached your annual deductible. (Using Good RX you can usually pay around $155 for the Shingles (Shingrix) vaccine.
Under Medicare some Vaccines are accounted for using Medicare Part B while others are only covered through Part D. Ask your Broker or call the Member Services Number on the back of your Medicare Supplement or Medicare Advantage Card to be sure.
WHAT IS THE MEDICARE AEP (ANNUAL ENROLLMENT PERIOD)?
During the period from October 15th - December 7th you can choose a new Prescription Drug Plan for the next year (Beginning on January 1st), you can change your Medicare Advantage Plan or decide to stay with your current Medicare Advantage plan if it is still available. Your new plan will go into effect on January 1st. If you have a Medigap or Medicare Supplement plan, you do not need to do anything during the Annual Enrollment period.
DO I HAVE TO CHANGE MY MEDICARE SUPPLEMENT EVERY YEAR?
No, once you have a Medicare Supplement Plan your plan will never cancel or lose as long as you are making your monthly premium payments. And, Medicare Supplement plans can be changed any day of the year, there are no special periods to deal with if you have a Medicare Supplement. However, anytime you decide to switch or change your Medicare Supplement plan after your initial Guaranteed Issue period, you will have to answer Medical questions and be subjected to Medical Underwriting.
WHAT IS NOT COVERED BY MEDICARE?
General Annual Eye Exams at an Optometrists office are not covered. Medicare also does not cover Hearing Aids, Eyeglasses, Contact Lenses, Hearing Tests, or Dental coverage.
However, Medicare will cover procedures and treatments from an Ophthalmologist, such as Cataracts, Macular Degeneration or any other procedure that is deemed as being "Medically Necessary by your doctor, which could include TMJ and Ear Canals.