Everything You Need To Know About Medicare

EVERYTHING YOU NEED TO KNOW ABOUT MEDICARE

MEDICARE INSURANCE OPTIONS

Everything you need to know about Medicare starts here: there are three ways to receive Medicare coverage: Original Medicare, Medicare Advantage, and Medicare Part D. Each option has its own benefits and costs. 

 

OPTION 1 IS ORIGINAL MEDICARE

This is a traditional 80/20 Healthcare Plan, managed and overseen by the U.S. Government and the Centers for Medicare & Medicaid Services, which are part of the U.S. 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 intended to serve as an alternative to Original Medicare. 

There are several types of Medicare Advantage plans available.  Most of them are HMOs (Health Maintenance Organizations) and PPOs (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.  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 HMO (Health Maintenance Organizations) and PPO (Preferred Provider Organizations).  Most MA (Medicare Advantage) plans have a network you must use to receive the lowest costs and ensure your services are covered.  Many Medicare Advantage Plans may allow you to see Doctors outside their networks; however, they will not pay for these services. Their networks are mostly limited to the County or Region where you live.

Because private insurers offer Medicare Advantage plans, each insurer sets the rules for its plans and decides what it will and will not pay for.  You will always pay a copayment or meet a preset coinsurance for any procedure until you reach your plan's MOOP (Maximum Out-of-Pocket)for the year.  MOOP varies by plan and ranges from $2,800 to over $10,000 per year, depending on your plan and location.  This means you could be responsible for $5,000 to $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, you get plans that look nice but nickel-and-dime you to death; they are limiting, and their plans are often 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 require you to obtain 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. Each fall, you need to select a new plan for the following 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 rebate a portion 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) only $500 per quarter, with none of your unused amounts rolling over to the next quarter. 

 

OPTION 3 IS ORIGINAL MEDICARE WITH A MEDICARE SUPPLEMENT/MEDIGAP PLAN 

Everything you need to know about Medicare when it comes to choosing Original Medicare and pairing it with a Medicare Supplement policy. 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.  The best way to compare Medicare Supplements is to recognize that your Premium is your Maximum Out-of-Pocket Expense (MOOP). Plans G in Arizona, Nevada, and Texas will cost $95-$135 per month. If you use an average of $120 per month, you pay $1,440 in Annual Premiums, and your plan covers everything else.  Not only that, but 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 can choose, and it provides everyone with the convenience, flexibility, and peace of mind they deserve.

If you want the best coverage and consistent billing with no surprises, it makes budgeting easier. 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

 EVERYTHING YOU NEED TO KNOW ABOUT THE MEDICARE AEP

When it comes to the Annual Election Period or “AEP,” being on schedule is very important. For the 2023 plan year, the Medicare AEP ran from October 15th through December 7th. For those interested in taking on Medicare Advantage coverage, the enrollment period is available from January 1st to March 31st, 2023. This is the Medicare Advantage Open Enrollment period, also 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 timeframe during which one can switch from Medicare Advantage to Original Medicare. 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 newly eligible for Medicare to enroll in a 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 essential 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 apply only to specific life events, such as marriage or loss of other health coverage elsewhere.

 The principal criterion for determining Medicare eligibility is age.   To qualify, you must be 65 years of age.   If you are not yet 65, certain conditions may make you eligible, such as 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 must be disclosed to properly qualify an individual for coverage during an ongoing health concern. 

Qualifying for Medicare may be simpler than you think. Once you reach age 65, you should consider a few additional factors. It is crucial to have had at least 10 years of Medicare-covered Employment before enrolling, which equates to a minimum of 40 quarters of employment with Medicare tax contributions. Even if you or your spouse did not make these tax payments, you could still meet the eligibility requirements. Other criteria will ultimately determine your qualification.

In addition to the aforementioned criteria, another vital qualifier is your current citizenship or permanent residency status.   You must have either U.S. citizenship or Permanent Residency for at least 5 years to proceed with your enrollment.   If this sounds like you, you’re ready to enroll.   Taking the next step and signing up for Medicare may raise new questions. Be sure to clarify any questions you have about the process.

While Medicare has three primary criteria for enrolling beneficiaries, individual circumstances can affect 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 carrying private insurance, Medicare may still be an essential option 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 with their Medicare enrollment each day. You don’t have to do this alone.   We’re here to help, and we know that with the correct 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 your own Health Insurance may still cover you through 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 considerations may seem overwhelming, but we have tried to break them down to make them easier to understand.

 

 EVERYTHING YOU NEED TO KNOW ABOUT MEDICARE & THE 4 PARTS THAT MAKE UP MEDICARE

• MEDICARE PART A -  Which takes care of your Inpatient/Hospital Coverage.

• MEDICARE Part B -  Covers any 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 allows you to enroll in a company that provides Prescription Drug Services.

  
  

Original Medicare = Medicare Part A and Medicare Part B

MEDIGAP AND MEDICARE SUPPLEMENTS

Original Medicare covers much, but not all, of the cost of 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 Co-Insurance

• 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 Medicare enrollees aren't allowed to cover the Part B deductible. As a result, Plans C and F are not available to new Medicare enrollees starting January 1, 2020. If you already have either of these two plans (or the high deductible version of Plan F) before 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 out-of-pocket.

 

Medicare Supplement plans are the most desired Medicare plans and offer the most flexibility; you can see any Doctor Nationwide who accepts Medicare patients.

There are well over 800,000 Doctors who accept Medicare, representing 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 Medicare Supplement Plans are identified by an alphabetical letter, such as A, B, C, D, F, G, K, L, M, and N.

 

MEDICARE ADVANTAGE PLANS ARE SUPPOSED TO COVER EVERYTHING THAT MEDICARE DOES

Private insurance companies offer Medicare Advantage Plans.  Each of these companies receives substantial government payments for each Medicare beneficiary it enrolls.  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 services not covered by Original Medicare, such as vision, hearing, dental, and wellness programs (e.g., 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 the plan deems not medically necessary, you may be responsible for all costs. But you have the right to appeal the decision.

You (or a provider acting on your behalf) can request in advance whether the plan will cover an item or service. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, it must notify 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.

 

THE 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 includes it before you enroll.

  
  

• 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.