WHAT EVERYONE NEEDS TO KNOW ABOUT MEDICARE

Everyone has three options or three ways they can receive Medicare Insurance. When it comes to determining what type of Medicare plan is the ideal and best plan for you and for your family! 

 

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/ Medically necessary procedures. And you, are responsible for the remaining 20%.  There are No Deductibles, No Minimum, 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

Medicare Advantage Plans are Health Plans for Medicare Beneficiaries.  Also known as Medicare Part C.  These plans were signed into Law by President William Jefferson Clinton. They are meant to be offered as an alternative to Original Medicare. 

There are several types of Medicare Advantage plans available.  Most of them are HMOs (Health Maintenance Organizations) and PPO's (Preferred Provider Organizations). Many of these plans are popular with many Medicare Beneficiaries because of their generally low monthly premiums and the "additional" or "extra benefits" they offer that Medicare does not.  To be completely honest, these plans are not as good as Original Medicare and they are loaded with Co-Pays and Co-Insurance bills that add up in a hurry, especially if you are ever hospitalized. 

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 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 a co-pay or have a pre-set co-insurance in some instances for any and every procedure you have until you meet your particular plan MOOP (Maximum Annual Out-of-Pocket) expenses for the year.  The MOOP varies by plan and ranges from $2,800 to over $10,000 per year, depending on your plan and where you live.  This means you can easily be responsible for $5,000 - $12,000 or more in annual Out-Of-Pocket expenses. In the long run when you look at the details and magnify the small print, what you get are plans that look nice, but they nickel and dime you to death, they are limiting, often times their plans are not accepted at the finest hospitals (Mayo and Barrow Neurological). 

Medicare Advantage plans and Medicare Advantage plans with Prescription Drug coverage are often referred to as All-In-One Plans. They limit you to a set number of Physical Therapy appointments and force you to get 2nd, 3rd and sometimes even a 4th opinion.  You have no flexibility and you are never really in charge of your own healthcare.  It is more about your plan, and your Primary Care Doctor than it is about you. And, every year in the fall you need to choose a new plan for the next calendar year.

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. 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 believe them to be. Just be sure to read both the full Summary Of Benefits Section on every Medicare Advantage plan that catches your eye, along with the Explanation of Benefits. This is where you will find that what is advertised as a $2000 Dental Benefit is A) Limited and B) it is only $500 per Quarter and none of your unused amounts roll over to the next quarter. 

 

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 Supplement 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, you 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 of $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.

 If you are the type of person who wants the best coverage, with the most consistent billing with no surprises makes it easier to budget. With Original Medicare and A Medicare Supplement Plan F or Plan G you will have the best and most comprehensive Health Plan available.  And, it is portable. there are no networks and you can see any Doctor and go to any hospital in America that accepts Medicare, 

 

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 time frame 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 who 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 for 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 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 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

• MEDICARE PART A -  Which takes care of your Inpatient/Hospital Coverage.
• MEDICARE Part B -  Covers any and all of your Outpatient/Medical Coverage.
• MEDICARE Part C -  Uses Independent Insurance Companies to provide for your Medicare Part A & Part B Benefits..
• MEDICARE Part D -  D allows you to enroll in a company that provides Prescription Drug Services.

Original Medicare is Medicare Part A and Medicare Part B

MEDIGAP AND MEDICARE SUPPLEMENTS

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 helps pay for additional things such as:

• Medicare Co-payments
• Physician Coinsurance
• Plan Deductibles
• Many Medicare Supplements pay your entire 20% share of Original Medicare.
• It has no Networks and allows you the flexibility to see any Doctor and receive services from any Hospital in the United States.

 

NOTE

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:

• Medicare will pay its share of the Medicare-approved charges for covered healthcare costs.

• Then, your Medigap policy pays your 20% share leaving you with $0 to pay.

 

Medicare Supplement plans 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 which 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, and, N.

 

 MEDICARE ADVANTAGE PLANS ARE SUPPOSED TO COVER EVERYTHING THAT MEDICARE DOES

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 of 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:

• The provider gave you or referred you for services or supplies that you reasonably thought would be covered.

• The provider referred you to an out-of-network provider for plan-covered services.

 

MEDICARE ADVANTAGE PRESCRIPTION DRUG COVERAGE

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.

 

WHAT IS MEDICARE PART D ALL ABOUT?

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.

 

WHO IS ELIGIBLE FOR A MEDICARE PRESCRIPTION DRUG PLAN?

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:

• A Medicare Advantage prescription drug plan, covers both medical services and prescription drugs. You may find a Medicare Advantage plan particularly attractive if you prefer to receive all your Medicare benefits from one plan, like a health maintenance organization (HMO) or a preferred provider organization (PPO). Not every Medicare Advantage plan includes prescription drug coverage, so make sure the plan has this coverage before you sign up.

• A stand-alone Medicare Part D prescription drug plan, which provides only prescription drug coverage. This kind of plan can work alongside your Medicare Part A and/or Part B coverage.

• If you enroll in a Medicare Advantage plan, note that you continue to pay your monthly Medicare Part B premium. You also pay any premium the plan might charge.