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About Medicare PPO Plans MEDICARE PREFERRED PROVIDER ORGANIZATIONS HOW MEDICARE ADVANTAGE PPO PLANS WORK? A Medicare PPO Plan is a type of Medicare Advantage Plan (Medicare Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.   WHAT ARE THE LIMITATIONS WHEN IT COMES TO DOCTORS WITH A PPO PLAN? HOW MEDICARE ADVANTAGE PPO PLANS WORK WITH DOCTORS In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. Each plan gives you the flexibility to see doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.   DO ALL MEDICARE PPO PLANS COVER PRESCRIPTION MEDICATIONS No, not all PPO plans include prescription drug coverage. Many do, but you will need to confirm, as plans are specific to certain areas. In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't enter a Medicare Prescription Drug Plan (Medicare Part D).   DO YOU NEED TO CHOOSE A PCP WITH A PPO PLAN? You don't need to choose a primary care doctor in PPO Plans. Many plans still recommend identifying a Primary Care Provider, but enrollment in the plan is not required .   WILL YOU NEED REFERRALS TO SEE A SPECIALIST WITH A PPO PLAN? In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.   OTHER IMPORTANT INFORMATION ABOUT PPO PLANS A PPO Plan isn't the same as Original Medicare (Medicare Part A and Part B) or a Medicare Supplement Insurance (Medigap) policy. PPO Plans usually offer more benefits than Original Medicare, but you may have to pay extra for these benefits.   HOW DO MEDICARE ADVANTAGE PPO PLANS WORK? Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all-in-one” alternative to Original Medicare. Private companies approved by Medicare offer them .  If you join a Medicare Advantage Plan, you still have Medicare.  These "bundled" plans include Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and, in most cases, a Medicare Prescription Drug Plan (Part D). WHAT IS COVERED UNDER MEDICARE PPO PLANS? All Medicare Advantage Plans must offer the same coverage as Original Medicare. And the majority of MA and MA/PD plans include Dental Benefits, Routine Vision Care, Hearing, Hearing Aids, and a Health Club Membership through companies like SilverSneakers, Silver&Fit, and Renew Active. .     ARE THERE ANY RULES WITH MEDICARE ADVANTAGE PPO PLANS? Medicare pays a fixed monthly amount to the companies that offer Medicare Advantage Plans for your care . These companies must comply with Medicare rules. Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like: Whether you need a referral to see a specialist If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care These rules can change each year.   HOW MUCH DO MEDICARE ADVANTAGE PPO PLANS TYPICALLY COST? What you pay in a Medicare Advantage Plan depends on several factors. Where you live is the most significant factor. Some PPO plans have a $0 Premium, but they typically have higher MOOP amounts. Overall, PPO Plans can cost $25 - $175 per month, depending on the plans available in the county you live in.   DO MEDICARE ADVANTAGE PPO PLANS ALL COME WITH PRESCRIPTION DRUG COVERAGE? Most Medicare Advantage Plans include Prescription Drug Coverage Medicare Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that: Can’t offer drug coverage (like Medicare Medical Savings Account plans) Choose not to offer drug coverage (as some Private Fee-for-Service plans do). You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply: You’re in a Medicare Advantage HMO or PPO. You join a separate Medicare Prescription Drug Plan.   WHICH INSURANCE COMPANY HAS THE BEST PPO PLANS? In my experience, Aetna has the best PPO Networks and plan options . MEDICARE PPO PLANS ARE NOT ACCEPTED BY EVERY HOSPITAL   Did Anyone Mention To You That The Mayo Clinic Hospital & Barrow Neurological Hospital Do Not Accept ANY Medicare Advantage Plans? This is because Medicare Advantage Plans have strict Networks you need to use. If you go out of the Network, you will pay for services out of your own pocket.   It is true.  Many specialty hospitals, such as Cancer Treatment Centers of America, partner with only a few select Medicare Advantage Plans. This is why you need to read the fine print: unfortunately, most Medicare Agents are too focused on making the sale and intentionally side-step the truth.  If you do not ask, they do not volunteer information that will make them or their plan look bad.    In all fairness, Mayo Clinic in Rochester, Minnesota, accepts all Medicare Advantage plans in Minnesota, but that is not the case in Arizona or Florida.

Michael T. Braden, August 29, 2024 LONG-TERM CARE INSURANCE Braden Medicare Insurances Long Term Care Insurance Poster WHAT IS LONG-TERM CARE? Long-term care insurance can be an emotionally charged topic. It’s not exactly something you want to talk about at the dinner table. After all, no one wants to think about themselves or their loved ones being unable to live on their own. But  if you want to make a sound financial decision and protect your nest egg, long-term care insurance is essential ! To illustrate this, consider Steve and Rachel. They weren’t always prudent with money, but they worked hard and built a nest egg of $300,000 . When Steve was 67 years old, he developed Alzheimer’s disease. At first, it wasn’t too bad. Rachel used some of their nest egg to hire a home care specialist to help with Steve for a few hours each day. But as his condition worsened, Steve had to go into a nursing home. Sadly, after five years in the house, Steve passed away. Rachel, now 72, is as healthy as she could be for her age, but she has to work full time because her husband’s stay in the nursing home devoured most of their nest egg.  Unfortunately, Steve and Rachel’s story isn’t unique. It happens to many people every year. But with long-term care insurance in place, you can keep it from happening to you!       LONG-TERM CARE INSURANCE   UNDERSTANDING LONG-TERM CARE Long-term care insurance is nursing home or assisted living insurance. It covers long-term care (LTC) services that some people will need as they age or become ill and require help with daily tasks such as getting dressed, bathing, and more. And long-term care can get expensive—   expensive.  According to the Alzheimer’s Association, the estimated cost of end-of-life care in 2019 ranged from $233,000 to $367,000. Most health and disability insurance won’t cover long-term care, but long-term care insurance will. Finding an independent insurance broker who shops among several long-term care companies and provides quotes can save you thousands of dollars and unnecessary worry .   WHAT DOES LONG-TERM CARE INSURANCE PROVIDE? Nursing Home Care Assisted Living Facilities Adult Daycare Services In-Home Care Home Modifications Care Coordination NOTE: Not all policies are the same, so talk to your independent insurance agent to find the best fit for your needs.   WHY WE BELIEVE EVERYONE SHOULD HAVE A LONG-TERM CARE INSURANCE POLICY Did you know that over 14 million adults needed long-term care services in 2020? Purchasing Long-Term Care Insurance   can give you peace of mind and protect the nest egg you worked so hard to build. You’ll know that if you become ill, you can afford the care you need and still have enough money in your nest egg for you and your spouse to eat. Plus, your kids won’t be burdened with huge payments for your care.  Now you may be thinking:  What about government programs? Can’t they help?  Don’t make the mistake of believing Medicare will cover long-term care costs.  It doesn’t. And while Medicaid—the government program designed for people who genuinely don’t have any money—will cover long-term care expenses, it should never be your first choice. Legal Point: It’s common for people to try to cheat the system by moving assets out of their parents’ name to get the government to pay for LTC without touching those assets. That is considered fraud—a federal crime—and the government will prosecute you!  Don’t fall into that trap.   TRADITIONAL LONG-TERM CARE INSURANCE Traditional long-term care insurance is a no-frills, standalone insurance policy. All it does is offer to pay for long-term care services when you need them. That’s it! When does a traditional policy kick in? The policy is triggered when you can no longer perform two out of six activities of daily living  (such as dressing, bathing, eating, or transferring to a wheelchair) or suffer from severe cognitive impairment. After a 30–90 day waiting period, your benefits should begin .   HYBRID LIFE INSURANCE POLICIES AND LONG-TERM CARE POLICIES Another option is a policy that combines life insurance with long-term care coverage. With a hybrid policy, you can access the death benefit—the money that your beneficiaries would receive in the event of your death—while you are still alive to pay for long-term care. If you do not need care, your heirs receive the full payout.  Rates are considered  “non-cancellable,”  which means premiums are fixed for life. But brace yourselves—the price tag for a hybrid policy is usually  thousands  of dollars more expensive than a traditional policy. That’s because you’re also buying life insurance, which you might not even need, along with LTC  coverage. Unlike traditional long-term care insurance, premiums for hybrid policies are  not  tax-deductible. Similar to whole life insurance, insurance companies invest the money in your hybrid policy. The problem is they’re not making sound investments, and your returns will likely barely keep pace with inflation. Those lost earnings could make hybrids the most expensive long-term care policies of all. That’s why hybrid policies should generally be a last resort. The only time you might consider buying one is if you can’t qualify for a traditional long-term care insurance policy due to medical underwriting.  Other than that, purchase long-term care insurance and life insurance separately—don’t try to marry the two! WHEN SHOULD YOU BUY LTC INSURANCE Okay, Dave suggests waiting until age 60  to buy long-term care insurance because the likelihood that you will file a claim before then is slim .  You’ll want to buy a long-term care policy as a 60th birthday present to yourself.  Statistically, 95% of LTC claims are filed for people over age 70. You may assume you’ll pay less if you buy your policy at age 50 and lock in a lower monthly premium, rather than waiting until age 60. But Dave will never tell you to buy something based on the monthly payment . That’s what broke people do, right? It’s about what  you need  when  you need it.   IT MATTERS WHEN YOU BUY YOUR POLICY While it might seem cheaper to buy LTC at age 50, the numbers tell a different story. An estimated LTC premium for a healthy 50-year-old man is $1,657   per year. If the policy remains in effect until this person is 95, he can spend approximately  $74,565  in LTC premiums. For a healthy 60-year-old man, an estimated premium is  $1,811 . If he keeps the policy until he’s 95, it could cost him $63,385 in total. You can already see how buying at age 60 is a better deal! But what would happen if, instead of buying LTC at age 50, you invest that $1,657  each year until age 60? You could have roughly $30,000! If you keep that money invested until age 95 and never add to it, you could have over $1.3 million. That’s not too shabby! Many people worry that if they wait until age 60 to buy LTC, they’ll develop a medical condition that could prevent them from qualifying for coverage or significantly increase their premiums. If you have a family history of illness at a young age, or you are losing sleep because you’re worried about getting sick and not being able to afford care, then buy LTC when you can afford it. The peace of mind is worth more than any cash you’ll save on premiums. Do not buy LTC at a young age because you think you’ll save money by doing so . As shown above, that’s not true.   WORK WITH AN INDEPENDENT INSURANCE AGENT/BROKER OK, what’s the best way to find long-term care insurance? Go to an independent insurance agent. They’ll shop among several different insurance companies to find you the best price based on your particular location, situation, age, health, and other factors. Long-term care is a significant decision, so make sure you have a professional on your side!   A LITTLE-KNOWN FACT THAT COULD MEAN A LOT LATER Initially, the cost for women was less than for men for an LTC policy.  However, insurance companies began to notice that married women were the primary caregivers for their husbands, and thus they outlived their husbands most often, often by many years.  They also found that, because the wives were the primary caretakers, the men spent significantly less time in long-term care facilities, as they were cared for at home.  But after they were gone, their wives tended to spend more time in a long-term care facility because no one was left to care for them.  This is sad, and I wish children and grandchildren of aging parents understood the importance of repaying the debt our parents undertook when they cared and nurtured us from birth until we left home.  It can be difficult, but it is worth having family discussions so our parents never feel unwanted or forgotten. It really is the least we can do. I know many parents retire to warmer areas to enjoy their retirement years, but having a long-term plan for their parents is something all children should want.   The last thing I want to leave you with is to consider one of the many Riders offered for LTC Policies.  (A rider can add valuable benefits, but you must determine which riders are worth the extra cost. Some riders add to the price without a corresponding increase in benefits. You can purchase various Add-ons or Supplements to your long-term care Policy if you know what to look for.  Here are what we at Braden MSI Insurance Services believe are the top 2 Riders for any LTC Policy. Just a few things we believe everyone should consider.   SPOUSAL BENEFIT RIDER We believe that the Spousal Benefit Rider is one of the "most significant riders. " This enables each spouse to tap the other's pool of benefits. As a result,  each individual could purchase, say, a three-year plan of protection,  which would be significantly less expensive than a five-year benefit." Adding a spousal rider to your long-term care insurance policy might increase the cost by about 15 percent, but it would give both policyholders access to five or six years of benefits.   INFLATION RIDER No matter which long-term care policy you buy, everyone should buy an Inflation Rider.   This option is essential and valuable. These riders help ensure that your long-term care insurance benefits keep pace with the escalating cost of health care. Generally , two riders are offered: one that covers inflation up to 3% annually, which is the more affordable and more popular option .  However, a Compound Rider that automatically increases by 5% will double the initial daily benefit every 14 years.  So, as an example, if you purchased a policy at age 60 with a $100 per day benefit, that daily benefit would be $200 per day when you are 74, in comparison to $154 per day if you chose the 3% Inflation Rider. Because this coverage is so essential, insurance regulators in many states require that any purchaser of a long-term care policy explicitly reject the inflation rider if they don't want it. Nearly all long-term care insurance policies have some form of home health care included in a basic LTC policy. . The most common long-term care policies are classified as "tax-qualified."  That means they follow consumer-protection guidelines set by the National Association of Insurance Commissioners and the Health Insurance Portability and Accountability Act (HIPAA). That also means that when you use a benefit, it is not considered taxable income. In the past, some insurers offered home health care as a rider. All tax-qualified basic long-term care insurance policies now cover some home health care. If you are among those rare few with a non-tax-qualified policy, ask your insurance agent if you have home health care coverage.

Michael T. Braden, August 6, 2024 GENERAL MEDICARE New Information About Medicare MAKING SENSE OUT OF MEDICARE IS A SYNOPSIS OF MEDICARE, SPECIFICALLY DESIGNED FOR INDIVIDUALS APPROACHING AGE 65, AND WHO ARE NEW TO MEDICARE As many of you are finding out or have already surmised, Medicare can be complicated. It is not that it is difficult, but up until Age 64, we never had a class on it. No one from Medicare or the Social Security Department offers any courses on it, so everyone is left to fend for themselves. What makes matters confusing to the public is that it is different from any Healthcare we have ever had, and it uses words, concepts, and acronyms we have never seen or heard of before. However, once you have a chance to work with someone who not only understands Medicare but also has the requisite skills and attributes to teach and explain it to others, it becomes much less daunting. In this article, I have tried to encapsulate Medicare in a basic but friendly format that should help everyone feel more knowledgeable and more confident. In Medicare and the Medicare process. In Business, my day usually begins with a fresh Legal Pad, and then I start listing by Projects and my To-Do List. I thought this would be a great way to present our Braden Medicare Insurance Making Sense of Medicare article. MAKING SENSE OUT OF MEDICARE ARTICLE PAGE 1 of 5 MAKING SENSE OUT OF MEDICARE ARTICLE PAGE 2 of 5 MAKING SENSE OUT OF MEDICARE ARTICLE PAGE 3 of 5 MAKING SENSE OUT OF MEDICARE ARTICLE PAGE 4 of 5 MAKING SENSE OUT OF MEDICARE ARTICLE PAGE 5 of 5 Michael Braden's Business Card

Michael T Braden December 12, 2023 GENERAL MEDICARE STEM CELL THERAPY AND OTHER CUTTING-EDGE RE-GENERATIVE PROCEDURES In this article, we look into Stem Cell Therapy and the procedures covered by Medicare. As many of you have heard, Stem Cell Therapies and Regenerative Therapy are gaining popularity for treating mobility-related ailments. Two of the most well-known companies offering these treatments are QC Kinetix and Regenesis. Many companies have clinic locations across the US offering advanced biological treatments for Knee, Hip, and Shoulder Pain. Even though commercials you may have heard on the radio, in other print advertisements, or on television sound terrific, not all of them have been approved by the United States Food and Drug Administration. There are several different "types" of Stem Cells. Some Stem Cells can only be used as Blood Cells while others can be used as fresh, new cells that can be injected into different parts of your body; they may grow new cartilage that has worn down in our bodies' joints over time, particularly with athletes. The hope is to eliminate the need for hip and knee replacements by using "Our Bodies Natural Healing Powers"..............with injections of stem cells, either our own that can be taken from our bone marrow or plant-based stem cell cultivation. Companies such as QC Kinitix and Regenexx offer impressive claims in their advertising and have had positive results; there are no guarantees that the procedures will work for everyone. This is the # 1 reason these therapies are not covered by health insurance other than HSA (Health Savings Accounts). This leaves the success and viability of these companies to rely on their patients to pay Out-Of-Pocket for these treatments, which are great if they work but can prove quite costly if they do not work. These companies and hundreds more continue to apply to the FDA to approve Case Studies so there will be more thorough and quantitative data to evaluate and make further recommendations. STEM CELL THERAPY STEM CELL THERAPY STEM CELL THERAPY TREATMENTS THAT ARE COVERED BY MEDICARE Yes, Medicare Covers Stem Cell Therapy, but only in specific cases. The first important consideration is that Medicare stem cell therapy coverage is only available if your doctor deems the procedure medically necessary. Furthermore, Medicare coverage for stem cell therapy will only apply to services approved by the Food and Drug Administration (FDA). Your Medicare Part A benefits help cover inpatient costs, while Medicare Part B will cover a portion of your outpatient costs, but the only treatments approved are those consisting of blood-forming stem cells. Here are the Medicare-approved options available for your healthcare: Hematopoietic Stem Cell Transportation (HSCT) Autologous Stem Cell Transplantation (AuSCT) While such therapies are FDA-approved for certain cancers, blood disorders, and auto-immune disorders, they are not approved for other health issues. This includes the use of stem cells that come from your own body. The Office of Tissues and Advanced Therapies (OTAT) showcases the FDA-approved options for stem cell therapy that your plan may cover. Having stem cell therapy covered by Medicare is possible in certain situations to treat only a few disorders at present, particularly. Ongoing stem cell treatments are up-and-coming for osteoarthritis, particularly in treating damaged cartilage in the knee, shoulders, and hips. However, the Food and Drug Administration (FDA) has not approved these treatments. This is not to say that they will not continue to approve new therapies in the future, but there is no concrete timetable for approvals. Since Medicare strictly adheres to only approving procedures and treatments that are FDA-approved, they have not approved Stem Cell Treatments on a large scale. There are many reasons for patients to require stem cell therapy and different methods involved with the procedure. Furthermore, it’s vital to understand which healthcare providers offering stem cell therapy accept Medicare benefits. Learn more about how to cut your costs and receive the benefits that fit your individual needs by having Medicare pay for stem cell therapy. STEM CELL THERAPY STEM CELL THERAPY IS MOST POPULAR FOR PEOPLE EXPERIENCING MOBILITY ISSUES WITH THEIR KNEES, SHOULDERS, AND HIPS Because the FDA does not approve knee stem cell therapy, your Medicare benefits won’t cover them. While it makes sense that people look for alternatives to knee replacements, as many suffer from osteoarthritis in their knees and look for solutions to help with the pain, until the FDA approves this healthcare, your benefits won’t cover it. Did you know that many treatments will be in the neighborhood of $500 - $15,000 with absolutely no guarantees whether they are going to help you in relieving your pain? Medicare only approves treatments, medications, and therapies approved by the Food and Drug Administration (FDA). Currently, there are no FDA-approved procedures/treatments for treating Osteoarthritis of the Knee, Hip, or Shoulder. WILL MEDICARE APPROVE STEM CELL THERAPY FOR CHRONIC BACK PAIN? The FDA doesn’t approve stem cell therapy for back pain so that Medicare benefits won’t cover these medical expenses. However, Medicare does cover other types of back pain treatments. Considering the cost of stem cell treatments for back pain, which is around $5,000 to $7,000, and the risk that can come with receiving non-FDA-approved healthcare, alternatives are essential to consider. Many advances, including Using Sound Wave patterns and Electrical Impulse Patterns to confuse the nerves and significantly reduce certain back pain afflictions, have either been approved or approved for testing by has not yet approved the FDA and Medicare. Any Doctor who accepts Medicare will be able to inform you if you may be a candidate for one of these studies. WHAT ABOUT STEM CELL THERAPY FOR ARTHRITIS? Medicare won’t cover stem cell therapy to treat arthritis because the FDA does not yet approve this application. This means if you agree to receive such treatments, you are doing so at your own risk at your own risk, and you’ll be footing the bill yourself because Medicare does not cover these costs currently. While Medicare doesn’t cover stem cell therapy for arthritis, there are other treatments other treatments that exist. Furthermore, there may be available clinical trials that offer Medicare coverage, but you’ll need to ensure they are approved by the program beforehand. ARE SOME STEM CELL INJECTIONS COVERED UNDER MEDICARE? Yes, some stem cell injections are provided by your Medicare benefits. However, Stem cell therapy treatment is an inpatient hospital stay that can last as long as 3 to 4 weeks. Such treatments are covered by Medicare Part A. Yet, outpatient stem cell therapy will fall under your Medicare Part B coverage and have a shorter duration. You need to be sure that A) Your Doctor Accepts Medicare and that B) They attest that these procedures are Medically Necessary. The main point to remember regarding Stem Cell Injections is that your Medicare coverage is granted, but only if the injections are FDA-approved. There are several applications for stem cell injections for therapy, but there are only certain applications that are covered by your Medicare coverage. WHAT ABOUT AUTOLOGOUS STEM CELL TRANSPLANTS? Yes, Medicare will cover Autologous Stem Cell Transplantation (AUSCT). Autologous therapy can help treat acute leukemia that’s in remission and advanced Hodgkin’s Disease, along with assisting in replenishing stem cells destroyed while being treated for cancer via chemotherapy and radiation. DOES MEDICARE COVER NEUROPATHY? WHAT ABOUT STEM CELL INJECTIONS TO KEEP NEURPOTHY FORM PROGRESSING? Medicare approves peripheral neuropathy, but the use of stem cells is where the water starts getting a little muddy. That's because to be covered by your Medicare coverage, your healthcare procedure must be approved by the FDA. While Medicare covers several applications for stem cell therapy, neuropathy does not fit the guidelines. DOES MEDICARE COVER REGENERATIVE STEM CELL THERAPY? Medicare does not cover regenerative stem cell therapy as the FDA has not yet approved such healthcare. There is a wide range of potential future applications, but the FDA has yet to support them. Please refer to this link about Regenerative Treatments in the FDA’s Consumer Alert on Regenerative Medicine, covering everything from the treatment of COVID-19 to epilepsy and much more. IS STEM CELL THERAPY FOR SOME CANCER TREATMENTS APPROVED BY MEDICARE? Yes, Medicare does cover some stem cell therapy; however, it does not cover every form. Yes, some Stem Cell therapies have been approved by Medicare benefits for cancer, but so far, the FDA has only approved certain cancers, such as lymphoma and leukemia. There is growing optimism for expanding Stem Cell Therapy along with the availability of coverage through Medicare. Clinical trials continue to advance modern medicine even further every day. IS HEMATOPOIETIC STEM CELL TRANSPLANTS COVERED OR ACCEPTED BY MEDICARE? Yes, Medicare can cover Hematopoietic Stem Cell Transplantation (HSCT). Still, coverageBefore only applies to those with specific conditions, such as leukemia, severe combined immunodeficiency disease (SCID), or treatment of Myelodysplastic Syndromes (MDS). Coverage for HSCT for MDS is only available if the treatment is part of a Medicare-approved clinical study. Whether or not the treatment is delivered through a study, strict guidelines dictate if and how you are covered. Before receiving HSCT, you’ll want to speak with your healthcare provider to review whether your treatment meets the guidelines. STEM CELL THERAPY COST COMPARISON WILL YOUR MEDICARE SUPPLEMENT PLAN COVER YOUR STEM CELL THERAPY? A Medicare Supplement (Medigap) plan covers the same healthcare services as Original Medicare. Therefore, a supplemental policy will cover any FDA-approved Medicare-approved stem cell therapy. A supplemental policy will cover any FDA-approved Medicare-approved stem cell therapy Medicare Part B covers 80% of the cost, but you’re still responsible for the remaining 20%. Your Medicare Part A benefits will cover you if you receive stem cell therapy as an inpatient in an inpatient setting. However, it’s important to remember that Medicare Part A has a deductible and other cost-sharing expenses for which you’re responsible. If you have a Medicare Supplement, you can cover these leftover healthcare costs. Depending on your Medigap letter plan, you may have zero cost-sharing to pay for stem cell therapy. Stem cell therapy prices can range from $5,000 to $50,000 if not more. When Medicare approves the service, Medigap will also always pay. This is important because it can eliminate guesswork when predicting out-of-pocket costs. Every Medicare beneficiary should be aware that just because Medicare approves things, they will not be readily approved by their Medicare Advantage company.

Medicare Beneficiary Discussing His X-Rays With His Dental Professional Dental health is very important for everyone, but especially for older Americans. An infection or decay can have severe effects on other parts of the body. I have always believed that if you take care of your teeth, they will take care of you. Now it is true that heredity is a factor. But, if you get 2-3 cleanings a year, your Dentist can spot a cavity in its earliest stages, and a simple filling is not expensive. For this reason, you may want to ask your Dentist about the in-house plans they offer for preventive care. ORIGINAL MEDICARE DOES NOT COVER ROUTINE DENTAL Almost everyone understands that Original or Traditional Medicare does not offer coverage for routine Dental, Vision, or hearing. This means that seniors who prefer the Quality and Choice that comes with Original Medicare, especially when coupled with a Medicare Supplement/Medigap policy, are usually forced to look for Dental and/or Vision insurance on their own. THERE ARE TWO MAIN TYPES OF DENTAL INSURANCE PRODUCTS TRADITIONAL DENTAL INSURANCE Traditional Dental Insurance requires a monthly premium and they typically cover Dental expenses from an In-Network Dental provider in amounts from $1,000 - $2,000. These plans typically do not always cover Orthodontics or Endodontics and they usually require a waiting period of 6-12 months for Major Dental work such as Root Canals, Crowns, Bridges, Implants, etc. DENTAL SAVINGS PLANS The other form of Dental Coverage is not Dental Insurance in the Traditional way as described above. This other form of Dental coverage are Dental Savings Plan. For many people, they provide more coverage for major services, without the high cost of many Dental premiums. Many plans are available for about $100 per year. The idea is that you use their network of Dentists, but you will generally pay 40-60% less than someone without insurance. And, there are no maximums, so if a Root Canal and Crown costs $3,000 and you have a traditional Dental Insurance plan, with a $1,00 Annual Maximum Benefit Amount, you are still on the hook for $2,000. And, with a Dental Savings Plan, the rate may be $1,500. You not only save on the procedure, but you save by not having somewhere between $500 - $700 in monthly premiums throughout the year. Many people like Nerd Wallet, Suze Orman, and Dave Ramsey are bullish on these plans. DVH PLANS One of the latest trends for Seniors is plans that bundle Dental/Vision/Hearing together, these are often referred to as DVH plans. Most major companies have these available, and they are more advantageous for individuals who do use prescription eyewear. OUR DENTAL INSURANCE CARRIERS AETNA AMERITAS BCBS CIGNA DELTA DENTAL HUMANA MANHATTAN LIFE MUTUAL OF OMAHA TDA DENTAL UNITED HEALTHCARE

Michael T. Braden, March 23, 2023 MEDICARE SUPPLEMENTS & MEDIGAP Medicare Supplement Plan G and Medigap Plan G are the same thing. Medicare Plan G has been the Gold Standard for Medicare Supplements since 2020. EVERYTHING YOU NEED TO KNOW ABOUT MEDICARE SUPPLEMENT PLAN G IS MEDIGAP PLAN G THE SAME AS MEDICARE SUPPLEMENT PLAN G? Yes, Medigap Plan G and Medicare Supplement Plan G are the same. When Medicare Supplement Plans were first introduced, they were marketed as a "way to fill in the gaps left over from Original Medicare," which is how they came to be referred to as Medigap Plans. Currently , and since 2020, Medicare Supplement Plan G has been the most popular and the most purchased Medicare Supplement plan , and it is not even close. As of January 1, 2020, Medicare Supplement Plan F was the most popular plan; however, it is no longer available to anyone who was not 65 before 1/1/2020. Since then, Plan G has taken over. As of 2022 , estimates indicate that Nationwide Plan F accounted for 53.2% of the Medicare Supplement Market, followed by Plan G at 37.9%, Plan N at 7.8%, and the remaining eight plans at 2.1%. Since the change in Plan F availability, nearly 70% of all Medicare Supplement policies sold are Plan G, and over 25% are Plan N. WHAT EXACTLY IS MEDIGAP PLAN G & IS IT THE SAME AS MEDICARE SUPPLEMENT PLAN G? Healthcare Professionals Consider Medicare Plan G the Gold Standard in Medicare Coverage. When Paired With Original Medicare, You Can receive Services From ANY Hospital and ANY Doctor in the US. Yes, Medigap Plan G and Medicare Supplement Plan G are the same. When Medicare Supplement Plans were first introduced, they were marketed as a "way to fill in the gaps left over from Original Medicare," which is how they came to be referred to as Medigap Plans. Currently , and since 2020, Medicare Supplement Plan G has been the most popular and the most purchased Medicare Supplement plan , and it is not even close. As of January 1, 2020, Medicare Supplement Plan F was the most popular plan; however, it is no longer available to anyone who was not 65 before 1/1/2020. Since then, Plan G has taken over. As of 2022, estimates indicate that Nationwide Plan F accounted for 53.2% of the Medicare Supplement Market, followed by Plan G at 37.9%. Plan N accounted for 7.8%, and the remaining eight plans accounted for 2.1%. Since the change in Plan F availability, nearly 70% of all Medicare Supplement policies sold are Plan G, and over 25% are Plan N. The only difference (Besides Price) between Plan F and Plan G is that Plan F pays your Annual Part B Deductible ($226 in 2023) for you. If you have Plan G, you pay for this yourself . Medicare Plan G coverage is very similar to Plan F, which is no longer available to new Medicare enrollees on or after January 1, 2020. PLAN G IS THE MOST COMPREHENSIVE MEDICARE OPTION AVAILABLE TODAY! Plan G offers excellent value for Medicare beneficiaries willing to pay a small annual deductible. After that, Plan G provides complete coverage for all of the gaps in Medicare. It covers your Medicare Part A hospital deductible ($1,600.00), copays, and coinsurance . It also covers the 20% that Medicare Part B doesn’t cover. Doctors and other healthcare providers must accept a Medigap Plan G if they accept Original Medicare. Plan G policies can be used across the U.S. because they do not have network limitations, and premiums can be very reasonable for the coverage you receive. Medicare Supplement Plan G covers your percentage of any medical benefit that Original Medicare covers, except for the outpatient deductible. It helps cover inpatient hospital costs, such as the first three pints of blood, skilled nursing facility care, and hospice care. It also covers outpatient medical services , including doctor visits, lab work, diabetes supplies, cancer treatment, durable medical equipment, X-rays, ambulance services, surgeries, and more . This means Plan G closes the coverage gaps of Original Medicare, and all Plan G products must provide you with the same coverage. Medicare pays first, then Plan G pays the remaining amount after you pay the once-annual deductible. In addition, Plan G Medicare Supplements offer up to $50,000 in foreign travel emergency benefits (up to plan limits). SMALL DEDUCTIBLE = BIG SAVINGS WITH PLAN G Medicare Plan G, also known as Medigap Plan G, is increasingly popular for several reasons. First, Plan G covers all gaps in Medicare coverage, except the annual Part B deductible. This deductible is only $226 in 2023. In fact, if you have a Plan F that has been in place for years, we can probably help you with premiums by looking at Plan G. When we help you shop rates at Boomer Benefits, we can often find a Supplement Plan G that saves quite a bit in premiums over Plan F, usually substantially more than the $226 deductible that you’ll pay out. You pocket the difference. Second, it has excellent coverage. For hospital stays, it covers all your hospital expenses. Most importantly, it pays the hospital deductible, which is over $1,600 in 2023. It also covers the high daily copayments you might incur for a hospital stay longer than 60 days. It provides an additional 365 days in the hospital after your Medicare benefits run out, and it covers your skilled nursing facility co-insurance, too. Medigap G covers all but the first $226 in outpatient care expenses, which is the Part B annual deductible. You will pay that the first time you have outpatient care for that year. After that, Supplement G covers all the remaining charges. Medicare will pay 80% of your outpatient costs, including emergency care, and your Supplement will pay the other 20% for medical procedures. Once Medicare covers a service, the Medigap Plan G policy must pay the remaining balance. Medigap Plan G does not cover the Part B deductible or any service not covered by Medicare. For example, Medicare does not cover routine dental, vision, or hearing; therefore, Plan G won’t cover those services. If you are starting your research into Medicare Supplements, you might also read what Medicare covers before choosing which supplemental coverage is right for you. Medicare Supplement G is more expensive than Plan N, simply because it covers more. It is our experience that clients are thrilled with everything they get from Plan G, which usually costs more than Plan N because it covers more. People appreciate the security and peace of mind that a comprehensive policy like Plan G provides . It isn't easy to put a price tag on peace of mind, but with Medicare Supplement Plan G, everyone is thrilled . PREDICTABILITY, CALM, CONFIDENCE, KNOWLEDGE, AND NO STRESS IS WHAT PLAN G IS ALL ABOUT! Most people do not like surprises, and they especially do not like surprise medical bills in retirement. With Plan G, you know you will never pay more than your Annual Part B deductible. I like to use the example that your Plan G Premium is your Maximum Out-of-Pocket Expense, because once you pay your monthly premium for Medicare Supplement Plan G, you will never pay anything more than the Annual Part B Deductible, which was only $226 in 2023. Therefore, we are willing to pay the higher premium . Want to know which insurance companies offer the best Medicare Plan G policies? Why You Should Consider Medicare Supplement Plan G. Lower premiums are a great start, but there is another reason why Medicare Plan G has become a consumer favorite. This is because Medigap Plan G is also a long-term rate saver. Medicare Supplement Plan G has a lower year-to-year rate increase trend than Plan F. In recent years, we’ve seen Medicare Plan G increase by 3% or less with some carriers. This is considerably lower than the year-to-year rate increases on Plan F. Different ways to apply for a Medigap Plan G policy. Most enrollees will use the Medigap Open Enrollment period to apply for coverage . When you enroll during this window, you will not be required to answer health questions on the application, and the insurer cannot deny coverage . It is a six-month window from your Part B effective date. Those who qualify for Medicare before 65 due to disability will have an additional Open Enrollment window when they turn 65. However, you may be required to answer health questions, and your approval is not guaranteed outside that window. You may be denied coverage due to specific health conditions. WHAT PLAN G COVERS Medicare Supplement Plan G covers your percentage of any medical benefit that Original Medicare covers, except for the outpatient deductible. It helps cover inpatient hospital costs, such as the first three pints of blood, skilled nursing facility care, and hospice care. It also covers outpatient medical services , including doctor visits, lab work, diabetes supplies, cancer treatment, durable medical equipment, X-rays, ambulance services, surgeries, and more . This means Plan G closes the coverage gaps of Original Medicare, and all Plan G products must provide you with the same coverage. Medicare pays first, and then Plan G pays the remaining amount after you pay the once-annual deductible. In addition, Plan G Medicare Supplements offer up to $50,000 in foreign travel emergency benefits (up to plan limits). IF YOU ARE IN A HURRY AND HAVE DECIDED, PLAN G IS FOR YOU. Please get in touch with Braden Medicare today. Our licensed agents can explain how this policy often keeps premiums lower over the long term and will meet your needs. We can also check Plan G rates from over 26 health insurance companies to see who offers the lowest rates in your area. CLOSING ARGUMENTS  Plan G is typically the most cost-effective Medigap plan, as the only out-of-pocket cost is the Part B deductible. Overall, Plan N costs less with lower premiums. But it is best for people who visit the doctor 5 times or less annually.  As long as Medicare covers the service, Plan G will cover the remaining costs once the deductible is met.  If you don’t enroll in Plan G during your Medigap Open Enrollment window, you may need to answer health questions depending on where you live.

HOW MEDICARE SPECIAL NEEDS PLANS WORK HOW MEDICARE SPECIAL NEEDS PLANS WORK DIFFERENTLY FROM OTHER MEDICARE ADVANTAGE PLANS How Medicare Special Needs Plans Work is a completely different manner of care than regular Medicare Advantage plans. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.   HERE IS MORE INFORMATION ABOUT HOW SPECIAL NEEDS PLANS WORK DIFFERENTLY DO SPECIAL NEEDS PLANS INCLUDE A NETWORK OF APPROVED PROVIDERS, AND CARE FACILITIES LIKE MOST MEDICARE ADVANTAGE PLANS? Yes, as a general rule/guideline, you must get your care and services from doctors or hospitals in the Medicare SNP network, except: Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away. If you have End Stage Renal Disease (ESRD) and need out-of-area dialysis The reason Special Needs Plans exist is to better serve individuals with a Team approach to their care. Having multiple "Specialists" in their networks is vital to these individuals receiving the best possible care possible. It is also an efficient way to coordinate resources for the Insurance companies. Medicare SNPs typically have specialists in the diseases or conditions that affect their members.   ARE PRESCRIPTION DRUGS COVERED UNDER MEDICARE SPECIAL NEEDS PLANS?  Absolutely, since these individuals typi cally require more specialized care, ALL of the Special Needs Plans must include Prescription Drug coverage. All SNPs must provide Medicare prescription drug coverage.   ARE PRIMARY CARE PROVIDERS MANDATORY? CAN I CHOOSE MY OWN SPECIALIST AS MY PCP?   For the most part, all Medicare Special Needs Plans do require you to have a primary care doctor. And, some plans require you to have a care coordinator to help with your health care.   ARE REFERRALS REQUIRED IN ORDER TO SEE A SPECIALIST WITH SPECIAL NEEDS PLANS? I n most cases, you must receive a referral to see a specialist with Special Needs Plans. Certain services don't require a referral, like these: Yearly screening mammograms An in-network pap test and pelvic exam (covered at least every other year)   OTHER IMPORTAN THINGS EVERYONE SHOULD KNOW ABOUT MEDICARE SPECIAL NEEDS AND CHRONIC SPECIAL NEEDS PLANS INSURANCE COMPANIES MUST LIMIT MEMBERSHIP TO ONLY QUALIFIED INDIVIDUALS  People who live in certain institutions (like a nursing home) require nursing care at home, or  People who are eligible for both Medicare and Medicaid, or  People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time. WHAT ARE THE BENEFITS OF HAVING A SPECIAL NEEDS PLAN? Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders. If you have Medicare and Medicaid, your plan should ensure that all of the plan doctors or other health care providers you use accept Medicaid. If you live in an institution, make sure that plan providers serve people where you live.    A CLOSER LOOK AT HOW THESE MEDICARE ADVANTAGE SPECIAL NEEDS POLANS WORK HOW CAN YOU JOIN A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN (SNP) You have Medicare Part A and Medicare Part B. You live in the plan's service area. You meet the plan's eligibility requirements, like one of these CHRONIC CONDITIONS SPECIAL NEEDS PLANS (C-SNP) TO QUALIFY FOR A C-SNP PLAN, YOU MUST HAVE DOCUMENTATION FROM YOUR DOCTOR VALIDATING YOUR CHRONIC CONDITION. CHRONIC CONDITIONS ARE RECOGNIZED AS BEING DISABLING AND ARE NOT REGARDED AS "TEMPORARY" CONDITIONS. Chronic Alcohol and/or other Dependence Disorders Autoimmune Disorders Cancer (excluding pre-cancer conditions) Cardiovascular disorders Chronic Heart Failure Dementia Diabetes Mellifluous End-Stage Liver Disease Chronic Kidney Disease End Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis) Severe Hematologic Disorders HIV/AIDS Chronic Lung Disorders Chronic and Disabling Mental Health Conditions Neurologic Disorders Stroke COPD INSTITUTIONAL SPECIAL NEEDS PLANS (I-SNP)  You live in an institution (like a nursing home), or you require nursing care at home. DUAL ELIGIBLE SPECIAL NEEDS PLANS D-SNP)   You have both Medicare and Medicaid. NOT EVERYONE CAN GET A MEDICARE SPECIAL NEEDS PLAN Each Medicare SNP limits its membership to people in one of these groups, or a subset of one of these groups.For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure. The plan might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan's drug formulary would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition and have all their care coordinated through the Medicare SNP.  WHAT IS INCLUDED IN MEDICARE ADVANTAGE SPECIAL NEEDS PLANS THAT MAKE THEM SPECIAL Medicare SNPs cover the same Medicare services that all Medicare Advantage Plans MUST cover. Most every Special Needs Plan includes the same benefits as other Medicare Advantage plans, things like: Health Club Memberships Dental Coverage Vision Coverage Hearing Coverage Transportation To Doctors Appointments OTC Allowances Medicare SNPs may also cover extra services tailored to the special groups they serve, like extra days in the hospital. Contact your plan to learn exactly what benefits and services the plan covers. ARE THERE ADDITIONAL COSTS IF YOU QUALIFY FOR A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN? If you have Medicare and Medicaid, most of the costs of joining a Medicare SNP will be covered for you. Contact your Medicaid Office for more information and to see if you qualify for Medicaid benefits.If you don't have both Medicare and Medicaid (or get other help from your state paying your Medicare premiums), your exact costs will vary depending on the plan you choose. In general, you will pay the same basic costs of having a regular Medicare Advantage Plan. WHAT EXACTLY IS A CARE COORDINATOR WITH SPECIAL NEEDS PLANS? Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. A care coordinator is someone who helps make sure people get the right care and information.For example, a Medicare SNP for people with diabetes might use a care coordinator to help members do these things: Monitor their blood sugar Follow their diet Get proper exercise Schedule preventative services (like eye and foot exams) Get the right prescriptions to prevent complications A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members access community resources and coordinate their different Medicare and Medicaid services.   WHEN CAN YOU LEAVE A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN? You can stay enrolled in a Medicare SNP only if you continue to meet the special conditions served by the plan. HERE IS AN EXAMPLE THAT MAY HELP: Mr. Johnson joined a Medicare SNP that only serves members with both Medicare and Medicaid. Mr. Johnson loses his Medicaid eligibility. Medicare requires Mr. Johnson's plan to disenroll him unless he becomes eligible for Medicaid again within the plan's grace period. The grace period is at least one month long, but plans can choose to have a longer grace period. If you lose eligibility for the plan, you'll have a Special Enrollment Period to make another choice. This Special Enrollment Period starts when your Medicare SNP notifies you that you're no longer eligible for the plan. It continues during the plan's grace period, and if you're disenrolled from the plan at the end of the grace period, it continues for 2 months after your coverage ends. It's very important to review your coverage options at this time to make sure you continue to have the Medicare health and prescription drug coverage you want. FINAL THOUGHT I serve and have had the honor to serve and service many clients with Special Needs and Chronic Special Needs. I can tell you that the experience of the Medicare Beneficiary and their family members is much higher if tehy are members of a SNP or C-SNP Plan. The quality and access to care is night and day from a normal/regular Medicare Advantage HMO or PPO plan. If you have an older friend or family member, please ask them if they have ever heard od SPN or C-SNP plans.

Medicare Private Fee-For-Service Plans MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLANS HOW MEDICARE PRIVATE FEE-FOR-SERVICE PLANS WORK A Medicare PFFS Plan is a type of Medicare Advantage Plan (Medicare Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay to doctors, other health care providers, and hospitals, and how much you must pay for care.     IN SOME CASES, YOU CAN RECEIVE CARE FROM ANY DOCTOR, OTHER HEALTH CARE PROFESSIONAL, OR HOSPITAL If you join a PFFS Plan that has a network, you can also see any of the network providers who have always agreed to treat plan members. You can also choose an out-of-network doctor, hospital, or other provider who accepts the plan's terms, but your costs will usually be lower if you stay in the network. Note: With a Medicare Private Fee-For-Service Plan, you can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will. DO PFFS PLANS INCLUDE PRESCRIPTION DRUG COVERAGE? Prescription drugs may be covered in PFFS Plans. If your PFFS Plan does not include Prescription Drug Coverage, you are allowed to purchase a Stand-Alone Medicare Part D Prescription Drug Plan from any Part D Plan that is available in your Service Area. Medicare Advantage PFFS Plans are the only Medicare Advantage plans that can work with a Stand-Alone Medicare Part D Prescription Drug Plan.   DO I NEED TO PICK A PRIMARY CARE PROVIDER WITH PFFS PLANS? You don't need to choose a primary care doctor in PFFS Plans.     ARE REFERRALS NECESSARY WITH PFFS PLANS IF I NEED TO CONSULT WITH A SPECIALIST? No, you do not need a referral to see a specialist with PFFS Plans.   OTHER ITEMS YOU SHOULD KNOW ABOUT WHEN LOOKING AT MEDICARE ADVANTAGE PFFS PLANS Some PFFS Plans contract with a network of providers who agree to always treat you, even if you’ve never seen them before. Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before. For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms. In an emergency, doctors, hospitals, and other providers must treat you. Show your plan membership ID card each time you visit a health care provider. Your provider can choose at each visit whether to accept your plan’s payment terms and conditions . You can’t use your red, white, and blue Medicare card to get health care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future. You only need to pay the co-payment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service. ARE PFFS PLANS EXPENSIVE? Typically, PFFS plans do require a monthly premium. There are not many Medicare Advantage PFFS plans available everywhere. Still, they are extremely popular with many Medicare beneficiaries due to their ease of use and the flexibility that allows members to stay in control of their own healthcare while still receiving the additional "perks" offered by Medicare Advantage plans.

Michael T. Braden, August 30, 2024 MEDICARE ADVANTAGE Can you leave a Medicare Advantage Plan and return to Original Medicare? CAN YOU CANCEL YOUR MEDICARE ADVANTAGE PLAN? Yes, you can cancel your Medicare Advantage plan. You need to qualify for one of the four Medicare Enrollment Periods during the Medicare Plan Year. The short answer is yes ; however, you can only do this during certain times of the year, and there are a few trap doors you need to navigate. But if you are truly unhappy or dissatisfied with your Medicare Advantage Plan, this Article is definitely what you need to read. Leaving a Medicare Advantage plan can be difficult outside of an applicable enrollment period. Yet, if your timing is right, canceling your Medicare Advantage plan can be a seamless process.   WHAT ARE THE TIMES DURING THE YEAR WHEN I CAN CANCEL MY MA/MAPD PLAN?   Medicare Advantage plans are typically annual contracts between the beneficiary and the Insurance company. These plans can be tough to cancel. Let's say you chose an MA or MAPD plan during your IEP (Initial Enrollment Period), then you decide that you and Medicare Part C are not a good match.  In that case, you can cancel your Medicare Advantage plan and return to  Original Medicare as long as you still have time left in your IEP Window.  However, once your Initial Enrollment Period ends, you are locked into your plan until the next enrollment period,  which could be months away. Medicare Advantage enrollment periods include the Annual Enrollment Period, Medicare Advantage Open Enrollment  Period, and, in some instances, Special Enrollment Periods.  Remember: there are different Enrollment Periods during the Year. Anyone can use the New Year OEP (OPEN ENROLLMENT PERIOD) and the Fall Annual Enrollment Period (AEP), and some Medicare Beneficiaries may qualify for a Special Enrollment Period (SEP) depending on their situation and where they live.   Remember, no one can change or cancel their current Medicare Advantage (Medicare Part C) Plan unless it is during a valid Enrollment Period!    The Medicare Advantage Open Enrollment Period is different from the Annual Enrollment Period, which runs from October 15th to December 7th. The Medicare Open Enrollment Period (OEP) runs from January 1st through March 31st.       CANCELLATIONS DURING A SEP(SPECIAL ENROLLMENT PERIOD) It is not uncommon for Medicare beneficiaries to qualify for a Special Enrollment Period. Beneficiaries have access to Special Enrollment Periods when specific life events occur that require a change in coverage.  Several events can entitle a beneficiary to a  Special Enrollment Period ,  including (but not limited to) moving out of your plan’s service area,  qualifying for Medicaid or a low-income subsidy, and loss of group coverage.  If you qualify for a Special Enrollment Period, you can switch or cancel your Medicare Advantage plan.    LIKE MEDICARE ADVANTAGE BUT WANT TO FIND A BETTER MEDICARE ADVANTAGE PLAN? If you like the idea of a Medicare Advantage plan but find your plan’s coverage to be lacking, there are times when you can switch from one Medicare Advantage plan to another. You can do this during the  Annual Enrollment Period or the Medicare Advantage Open Enrollment  Period.    HOW TO CHANGE PART C PLANS DURING THE FALL ANNUAL ENROLLMENT PERIOD The   Medicare Annual Enrollment Period (AEP)   runs from October 15 through December 7 each fall . This enrollment period allows you to change from one Medicare  Advantage plan to another if you wish to do so. The plan you enroll in during this period will take effect on January 1 of the following year.   OPTIONS EVERYONE HAS FROM JANUARY 1ST - MARCH 30TH DURING THE MEDICARE OPEN ENROLLMENT PERIOD (OEP) If you miss the Annual Enrollment Period or are dissatisfied with the plan you enrolled in during that period, the Medicare Advantage Open Enrollment Period begins shortly after. Each January, this enrollment period is available to those who already have a Medicare Advantage plan.  During this time, you may make one change to your Medicare Advantage plan. So, if you wish to switch Medicare Advantage plans, you may do so during this time.    HERE IS HOW YOU CAN GO BACK INTO ORIGINAL MEDICARE AFTER YOU LEAVE YOUR MEDICARE ADVANTAGE PLAN Like switching from one Medicare Advantage plan to another, you can only switch from Medicare Advantage to Original Medicare during an enrollment period. The Annual Enrollment Period and the Medicare Advantage Open Enrollment Period allow you to change Medicare Advantage plans. These enrollment periods will also allow you to cancel your Medicare Advantage plan .  When canceling your Medicare Advantage plan, you automatically revert to Original Medicare. This is because Medicare Advantage plans absorb your risk from Original Medicare. Thus, you will automatically receive  Medicare Part A  and  Medicare Part B  coverage when you cancel your Medicare Advantage plan. In some instances, you might be eligible to cancel your Medicare  Advantage plan and revert to Original Medicare without an enrollment period. However, you must qualify for one of two trial-right periods to do this.  Suppose you enrolled in a Medicare Advantage plan when you first became eligible for Medicare. In this case, you can use a trial right to return to Original Medicare. Likewise, imagine you left a Medicare  Supplement plan to enroll in a Medicare Advantage plan for the first time. In that case, you can also use a trial right to return to Original  Medicare. Keep in mind that both trial rights are only valid within the first year of enrolling in a Medicare Advantage plan.    CHANGING FROM HAVING A MEDICARE ADVANTAGE TO HAVING A MEDICARE SUPPLEMENT/MEDIGAP PLAN Suppose you decide your Medicare Advantage plan’s network restrictions and high out-of-pocket costs are not for you. If so, you may be eligible to cancel your Medicare Advantage plan and enroll in a  Medicare Supplement plan.  However, there is no way to switch directly from Medicare Advantage to Medicare Supplement . Once you revert from Medicare Advantage to  Original Medicare, you become eligible for a Medicare Supplement plan without a lapse in coverage.  When you return to Original Medicare using a Special Enrollment  Period or a trial right, you automatically qualify for guaranteed issue rights to enroll. So, you can enroll in a Medicare Supplement plan without underwriting health questions. However, if you return to  Original Medicare during a typical enrollment period, you must answer health questions to enroll in a Medicare Supplement plan.  VALID MEDICARE ENROLLMENT PERIODS AVAILABLE DURING A MEDICARE PLAN YEAR.   MOST COMMON QUESTIONS WE RECEIVE ABOUT CANCELLING MEDICARE PART C PLANS   IF I DO NOT LIKE MY MEDICARE ADVANTAGE PLAN, CAN I  CANCEL IT at ANY TIME? No,  you cannot cancel your Medicare Advantage plan at any time. You must be enrolled in a valid enrollment period to cancel your Medicare Advantage plan.  During this time, you can cancel or switch your Medicare Advantage plan.    IF I ENROLL IN A MEDICARE STAND-ALONE MEDICARE PRESCRIPTION DRUG PLAN, WILL THAT CANCEL MY MA/MAPD PLAN? If you are eligible to enroll in a Medicare Part D plan, your Medicare  Advantage plan will terminate once your Medicare Part D plan becomes active. However, before enrolling in a Medicare Part D plan, you must verify that you are eligible to enroll in a Medicare Supplement plan to avoid any coverage lapses.    IF I THINK AN AGENT MISREPRESENTED MY MEDICARE ADVANTAGE, CAN I CHANGE BACK TO TRADITIONAL MEDICARE? If you are unhappy with your Medicare Advantage coverage, you can cancel your plan during a valid enrollment period.    CAN I CANCEL MY MEDICARE ADVANTAGE PLAN IF I RELOCATE? If you move to a new state where your Medicare Advantage plan does not provide coverage, you will be eligible for a Special Enrollment Period.  This window will allow you to change or cancel your Medicare Advantage plan.

Michael T. Braden, April 17, 2024 GENERAL MEDICARE Medicare Assignment refers to a Doctor who has signed on and agrees to accept Medicare's Fee Structure and see Medicare Patients. DO ALL DOCTORS ACCEPT MEDICARE, AND WHAT IS MEDICARE ASSIGNMENT? What do we mean by Do All Doctors Accept Medicare? The Term "Accepts Medicare" refers to Doctors who have signed an agreement with the Government to see and treat patients, using the national Medicare Fee Schedule for the rates they charge for a given appointment, treatment, or service. No, not all doctors in America accept Medicare. A few do not take it, but the overwhelming majority of physicians and other Healthcare professionals accept Medicare. However, there are many instances in which a Doctor Accepts Medicare but does not belong to any Medicare Advantage network . Did you know that there are more than 1,000,000 Physicians in the USA? And, about 9.46 Doctors out of 10 accept Medicare Assignments. The largest group of Healthcare Professionals who do not accept Medicare are Psychologists, Pediatricians, and Psychiatrists. MORE FACTS AND INFORMATION CONCERNING DOCTORS AND MEDICARE According to the Kaiser Family Foundation, the states with the lowest percentages of physicians accepting new Medicare patients include Utah and Oregon (79%), followed by California, Nevada, Washington, Alaska, Maine, and Maryland (80-82%), and followed by Montana, New York, and Connecticut, at between 83% and 84%. The data suggest that the percentage is lower in states with a Medicare Birthday Rule. MORE PROOF THAT DOCTORS AND PHYSICIANS ARE NOT FOND OF MEDICARE ADVANTAGE PLANS If your doctor, hospital, clinic, specialist, or other healthcare provider accepts Medicare Parts A and B, they must accept any Medicare Supplement plan from any insurance company. That is because it is legally required. Doctors are not required to accept Medicare Advantage plans or Medicare Part C patients/members. The latest nationwide estimates indicate that only 46% of doctors in the United States receive any Medicare Advantage plans . And, many of those only take 1-4 plans. Doctors do not favor Medicare Advantage plans, as evidenced by the percentage of doctors who report this year after year. Just over 20% of all Medicare Advantage (Medicare Part) plans have a physician/provider network comprising 70% or more of the available licensed doctors in their areas. 43% of Medicare Advantage plans have networks that include only 30% to 69% of the total number of licensed physicians in the places where the plans operate. A little more than one in three Medicare Advantage plans have networks that include fewer than 30% of all available licensed physicians in the areas where their plans are available—Area physicians who accept Original Medicare. A complete 35% of Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage. Doctors dislike the pressure they receive from Medicare Advantage Plans to lower their fees continually, and they also do not like telling Medicare Beneficiaries that they will need multiple referrals for a procedure they believe is Medically Necessary. They are frustrated by hearing complaints from Members. Can Doctors Refuse To Accept Medicare Advantage Plans, even if they accept Medicare? EYE-OPENING STATISTICS Medicare enrollees aged 65 and older are the fastest-growing demographic in the U.S. 17% of the U.S. population was age 65 or older as of 2020, and that share is projected to exceed 22% in 2039. Just 3 years ago, 5 million people aged 65 or older were living below the Federal Poverty Level in the US. And, if that isn't startling enough, an additional 2.6 million people considered themselves to be nearly broke or almost poor. Combined, that is virtually the same number of people who live in the entire state of Maine! These are the demographic groups most likely to enroll in a Medicare Advantage plan because they cannot afford the premiums associated with a Medicare Supplement (Medigap) plan.       HOW OFTEN DO DOCTORS DECIDE NOT TO ACCEPT MEDICARE? In 1990, only about 3% of doctors opted out of Medicare, but recent reports indicate a decrease in that number. In 2020, approximately 1% of doctors opted out. Factors such as hospitals acquiring medical practices and new doctors preferring to join medical groups (which involve them in Medicare) contribute to this trend. Medicare-age patients are the most significant and fastest-growing demographic of medical patients. In addition, Original Medicare and Medigap plans pay within days or weeks of receiving a bill. Months faster than the average turnaround of private health insurance or Advantage plans. In all states except Alaska, Colorado, and Wyoming, the percentage of physicians who have opted out of the Medicare program is less than 2% . Do all physicians accept Medicare? No, but almost 94% of ALL doctors accept Medicare. The biggest group of Doctors who historically do not accept Medicare are Pediatricians, Naturopathic doctors, Homeopathic Doctors, psychologists , and Psychiatrists. IS IT HARDER TO FIND A DOCTOR ACCEPTING NEW MEDICARE PATIENTS RIGHT NOW? According to KFF, an independent source for health policy research, polling, and news, most non-pediatric office-based physicians accept new Medicare beneficiaries and new private insurance patients. An analysis of 2019 National Electronic Health Records Survey (NEHRS) data found that 89% of physicians accepted new Medicare patients that year. Similarly, 91% of physicians accepted new patients with private insurance. Among primary care physicians, acceptance rates were slightly lower but still comparable: 83% accepted new Medicare patients versus 86% accepted new private insurance patients . The analysis also revealed that the percentage of non-pediatric office-based physicians accepting new Medicare patients remained consistent between 2011 (88%) and 2019. If you need Medicaid services, however, you may have more trouble finding a primary care doctor who accepts your insurance. Only 45% of primary care physicians accept new Medicaid patients, according to KFF. Nearly one in every three Primary Care Physicians in the United States currently are not accepting "new" Medicaid Beneficiaries. WHY DO DOCTORS ACCEPT MEDICARE IF IT PAYS THEM LESS? There are ongoing discussions about the adequacy of Medicare payments to physicians and concerns about potential access issues if Medicare rates were implemented. However, cash flow is key to a medical office's survival. Unlike other types of health insurance, Original Medicare pays within 2 weeks of receiving a bill. Most Medigap plans pay over 85% of claims within 48%. That generates positive cash flow, which is key to any medical office's sustainability. Medical providers are not required to accept Medicare. The decision to accept or not accept Medicare is up to each doctor or healthcare provider. WHERE CAN YOU GO TO FIND DOCTORS WHO ARE CURRENTLY ACCEPTING NEW MEDICARE PATIENTS? We are often asked by clients what the best practices are to find physicians who 1) Accept Medicare and 2) Are currently accepting new patients. Below are some of our top recommendations . To find a doctor who accepts Medicare, you can: Here is the link to a free Physician Finder Search Tool  on the Medicare Website: https://www.medicare.gov/care-compare/  If you have had any doctors in the past who you liked, the best course of action is to call their office and let them know you are either a current or former patient , and you are about to enroll in Medicare, and ask them if their office accepts Medicare.   Consult your primary care physician, who may be able to recommend other doctors who accept Medicare patients.  Ask friends who may be on Medicare whether their doctors are accepting new patients.  If you have a Medicare Advantage plan, use the Provider tool on the insurance company's website. Remember , however, that fewer than half of doctors licensed in the United States accept Medicare Advantage; the number is approximately 45%. Once you find a doctor who says they are accepting new patients, call the doctor's office to verify that A) The Doctor is still associated with your specific Medicare Advantage plan, and B) they are accepting new patients.  Hopefully, you worked with or are currently working with a licensed, independent Medicare Broker or Medicare Agent. We encourage you to ask them for help with anything, whenever you need it, including assistance with finding doctors. Brokers will always make time to talk and help you as much as they can. WHAT DOES IT MEAN TO YOU IF A DOCTOR ACCEPTS MEDICARE ASSIGNMENTS? When a medical professional chooses to work with Medicare, they have two options for annual contracts: Participating Provider or Non-Participating Provider. A Participating Provider agrees to accept the Medicare-approved rate for services and bills Medicare directly, not the patient. This agreement is known as Medicare assignment. When a doctor agrees with an assignment, they are referred to as a "Participating Provider". By law, doctors and physicians who accept Medicare Assignments are not permitted to charge anyone with Part B Excess Fees/Charges. A significant advantage for physicians who accept Medicare assignments is that Medicare handles the entire Billing Process. For Physicians who accept Medicare, the physician only needs to submit a Medicare claim . Medicare then sends payment to the Physician, and they automatically send a notice to the Medicare beneficiary's Medicare Supplement /Medigap plan to pay their portion. Medicare electronically communicates with every Medicare Supplement/Medigap Insurer and provides them with all the instructions they need to follow. Including who to pay, when to pay them, and who the payment is on behalf of. IS IT A BIG PROBLEM IF MY DOCTOR DOES NOT ACCEPT MEDICARE ASSIGNMENTS? When a physician intends to bill the patient more than the Medicare assignment rate, they may elect to contract as a Non-Participating Provider with Medicare. Being a non-participating doctor in the Medicare program means they are not required to accept assignments, and are authorized to charge Medicare Part B Excess Fees if they choose to do so. Many surveys suggest that less than 25% of Doctors actually charge the additional 15%. This is obviously not a good look and is one of those situations where nobody wins. This is a less-than-ideal scenario for all the parties involved. So here is what Medicare has done to incentivize doctors to accept Medicare's Fee Schedule: To begin with, Medicare will reimburse non-participating providers 5% less than they pay participating providers. Then, non-participating providers may bill only up to 15% more than the Medicare reimbursement rate. Ultimately, the physician will receive only 9.25% more than by accepting a Medicare assignment. A significant benefit for every Medicare Provider is that Medicare handles and coordinates all billing . This saves a Doctor's Office many hours a month and a considerable amount of money every year. In fact, this is one of he significant "Benefits" of Accepting Medicare. If a Physician determines that it is not in their best interest to "Accept Medicare," they are labeled a non-participating provider . The consequence of being a Non-Participating medical provider is that Medicare will not handle billing as a one-stop process. Although the doctor’s office will still be required to submit a bill to Medicare, Medicare will not forward the bill to Medigap plans. Since the doctor lacks a contract with Medigap plans, they cannot bill them either. Instead, they usually require patients to pay for services up front and then seek reimbursement directly from their supplemental insurance company . This is the worst-case scenario for the Medicare Beneficiary because they typically must complete two separate CMS Form 1940s, one for Medicare and one for the Medicare Supplement Carrier, to be reimbursed. Accordingly, we strongly encourage each of our clients to see Doctors, Physicians, Clinics, and Hospitals that accept Medicare Assignments. A physician's office must notify you ahead of time or display a conspicuous sign that alerts you to a potential excess charge. DO ALL DOCTORS ACCEPT MEDIGAP/MEDICARE SUPPLEMENT PLANS? If a doctor accepts Original Medicare and Medicare assignment, they must take any Medigap plan you have, from any insurance company. Note that they don’t bill the Medigap plan; Medicare does. According to a Kaiser Family Foundation report, Medicare enrollees without supplemental insurance face challenges finding physicians who accept Medicare without a supplemental plan . It is recommended that these patients consider purchasing Medicare supplement insurance. WHAT HAPPENS WITH MEDICARE ASSIGNMENT IF I HAVE A MEDICARE PART C PLAN? Not all doctors accept Medicare Advantage plans. Part C Advantage plans have networks of doctors and healthcare providers who have agreed to take the plan’s terms and conditions. These networks vary between different Part C plans. ARE THERE MINIMUM NUMBERS OF DOCTORS THAT MEDICARE ADVANTAGE PLANS NEED TO HAVE IN THEIR NETWORKS? One significant disadvantage of Medicare Part C is that its networks are often small, resulting in minimal coverage in some regions of the country. The weakness of Advantage Plans is their limited network. A little over one in every five Medicare Advantage Plans has a network that consists of 70% of doctors who accept Medicare in their area. 43% of Advantage plans have networks that include only 30% to 69% of area physicians who accept Original Medicare. A complete 35% of Advantage plans have networks limited to less than 30% of doctors who accept Medicare in their area of coverage. When you have a Medicare Advantage plan, you need to review the plan’s provider directory or contact the plan directly to verify if your preferred doctors and healthcare providers are in-network. Seeing an in-network provider typically results in lower out-of-pocket costs and ensures that the services are covered by your Advantage plan for a Medicare-approved amount. HOW MANY DOCTORS IN THE UNITED STATES ACCEPT MEDICARE ADVANTAGE PLANS? In surveys conducted by the well-known Kaiser Family Foundation (KFF), less than 50% of doctors who are contracted with Medicare accept some Advantage plans (aka Medicare Advantage). Even then, they may not receive your plan. Doctors' networks vary by Medicare plan and may change annually. Medicare enrollees without supplemental insurance face challenges in finding Physicians who accept Medicare without a supplemental plan . It is recommended that these patients consider purchasing Medicare supplement insurance. WHY DO SO MANY DOCTORS NOT ACCEPT MEDICARE ADVANTAGE PLANS? Doctors do not  usually accept all Advantage plans, nor are they required to do so. These Medicare plans have their own networks of doctors and healthcare providers who have agreed to accept the terms and conditions of specific plans. Provider networks and health coverage can vary across Advantage plans. Unlike Original Medicare, Part C plans enter into separate annual contracts with physicians and healthcare networks for medical services. In many cases, Physicians generally earn less from Medicare Advantage plans than they would from Original Medicare. However, they typically reduce their Marketing and Advertising budgets because of the potential business they may receive from MA plans. Most established Doctors do not accept Medicare Advantage plans. They do not want to rely on an Insurance company to dictate their terms , and, frankly, they are not accepting of the constant low-ball tactics that MA plans to impose on them, and they know all the horror stories they hear directly from their patients. WRAPPING THINGS UP I hope you enjoyed this article and that you have a clear understanding of what it means for a physician to "Accept" Medicare Assignment. If you have any questions about Medicare, please text, email, or call us at any time that is convenient for you.

Michael T. Braden, May 7, 2024 GENERAL MEDICARE What Does It Mean To Have Prior Authorization For Medicare? WHAT IS PRIOR AUTHORIZATION FOR MEDICARE SERVICES AND PROCEDURES Medicare uses Prior Authorization to ensure that certain medical services or prescription drugs meet specific coverage criteria before they are approved and paid for. Prior Authorization rules are implemented as cost-saving measures. Medicare wants to ensure that every Medical Procedure is medically necessary for the beneficiary's health. Did you know that before a physician can provide services to a patient, it may be necessary to receive Prior Authorization Approval from Medicare? Your doctor can provide certain services; prior authorization from Medicare may be required. Depending on the Medicare plan you are enrolled in, you might need prior approval to see a specialist, have a procedure, or receive certain medications. PRIOR APPROVAL IS JUST LIKE IT SOUNDS? Prior authorization is a process in which your healthcare provider requests and receives approval from Medicare before they can be sure your plan will cover a service. This requirement is to ensure the services or medications you receive are medically necessary and appropriate for your condition. Typically, prior authorization is required for services or medications that are either A) Expensive, B) A procedure that is categorized as being an Elective Procedure, and may not be Medically Necessary , or C) a Procedure that is deemed as being overused by Medicare, based on Millions of Claims. The idea and concept are simple enough: your Doctor or NP submits documentation to Medicare to make sure that Medicare knows that your request is Medically Necessary , and asks for approval before the procedure is performed. Once the physician submits the request, Medicare will review the submission and determine whether to approve or deny coverage. If approved, Medicare will cover its portion of the cost of the service or medication. If the prior authorization is denied, the patient or healthcare provider may appeal the decision. However, a denial may result in the patient being responsible for 100% of the cost . PRIOR AUTHORIZATION FOR MEDICARE PART A 95% of the time, PA (Prior Authorization) is not necessary if you are admitted to a Hospital. But, if you must submit a prior authorization for a Part A covered service, you can obtain the forms to send to Medicare from your hospital or doctor. Often , your hospital will send the documents itself . However, it is essential to understand who is responsible for submitting the paperwork, so that the responsibility does not slip through the cracks. Examples of Medicare Part A. Services that may require prior authorization include:  Care at a Skilled Nursing Facility (SNF) and/or Rehabilitation Facility  Care or Procedures at an In-Patient Hospital  Medicare- At-Home, home healthcare services If prior authorization is necessary, the process is simple. Your Doctor or health care provider initiates the process by submitting the appropriate Prior Authorization Request Forms to Medicare. This includes an outline of the treatment plan that your Doctor has for you. PRIOR AUTHORIZATION FOR MEDICARE PART B As part of Original Medicare, you’ll rarely need to obtain Prior Authorization (PA) for Medicare Part B services. However, there are a few instances in which you may need to get approval before receiving care. Medicare Part B  covers the administration of certain drugs when given in an outpatient setting. Some prescription drugs you receive may require your doctor to submit a Part B Drug Prior Authorization Request Form. Your doctor will provide and complete this form with detailed information regarding why the medication is necessary for your diagnosis. Once the request gets approved, you can begin receiving the medication. One medication that comes to mind is Evenity . It is a year-long commitment, and Evenity is the only known drug to help regrow bone density. This is primarily for women who have been diagnosed with Osteoporosis. There are other examples, such as newly released or Experimental Drugs for Dementia. PRIOR AUTHORIZATION FOR MEDICARE PART D Often, some Medicare Part D Prescription Drug Plans  can require prior authorization for coverage on specific drugs. Different policies have varying rules, so you’ll need to contact the carrier directly to confirm coverage. Most Part D plans have forms you can download online. The online option is a helpful way to print the documents and take them to your doctor. Your doctor can help you correctly complete the form. Additionally, recipients may contact their Part D plan directly to request a mail-in form. You can find the number for Member Services on your plan’s member ID card. PRIOR AUTHORIZATION FOR MEDICARE ADVANTAGE PLANS To obtain out-of-network, specialist, and emergency care, Medicare Advantage recipients may need prior authorization. Unfortunately, if Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full price up to you. In 2021, over 35 million Prior Authorization requests were submitted on behalf of Medicare Advantage plans. The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs. However, each Medicare Advantage plan is different. If you are enrolled in a Medicare Advantage plan, contact your plan provider to determine whether and when prior authorization is required . Your plan provider should also have downloadable forms outlining your covered services. *Note: Many Medicare Advantage Plans do not have enough Skilled Nursing Care Facilities in their Networks, or you do not get a good vibe from them. If this happens to you, remember that your stay at an SNF will be paid only if you use an SNF in your plan's network. If you go outside of your plan's network, you will most likely be responsible for paying for your stay out of pocket. This is one of the most frequent complaints among Medicare Beneficiaries who choose Medicare Part C over Original Medicare. DO YOU HAVE TO GET APPROVAL FROM MEDICARE DIRECTLY? Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information. Your provider is responsible for requesting permissions. Please ensure they have all the information needed for submission, and that everything is complete and correct before submitting . If your provider believes your treatment is medically necessary, they can contact your plan and request an exception if you get denied. The provider must support the request with a statement. Once approved, your plan pays without prior authorization. HOW MUCH TIME DOES IT TAKE TO GET AUTHORIZATIONS APPROVED? The time it takes to receive a decision on your Prior Authorization Request varies based on the following: Medicare is usually swift (48-72 Hours), but if you have a Medicare Advantage plan, the decision may take much longer . You need to remember that Medicare Advantage Companies are operating "For Profit". Wait times for a decision are longest during the 4th Quarter. For expeditious authorization, your doctor must provide detailed information, explaining exactly why the treatment is necessary. Providing as much detailed information as possible will ensure the reviewer has all the necessary information to approve your case. Missing information, diagnosis codes, or reasoning may delay your authorization and could even result in a denial. WILL I NEED PRIOR AUTHORIZATION FOR AN MRI OR A CT SCAN? If the purpose of the MRI is to treat a medical condition, and all involved providers accept Medicare assignment, Part B would cover the inpatient procedure. However, a Medicare Part C beneficiary may need prior authorization to see a specialist, such as an orthopedist . If your CT scan is medically necessary and the provider(s) accept(s) Medicare assignment, Part B will cover it. Again, you might need prior authorization to see an out-of-network doctor if you have an Advantage plan. WHAT ABOUT PHYSICAL OR OCCUPATIONAL THERAPY? Most often, you’ll obtain prior authorization the same way, regardless of the service. Your doctor will document medical necessity and send forms to either Medicare or your plan for approval. DO I NEED PRIOR AUTHORIZATION IF I NEED TO SEE A SPECIALIST? If you have chosen a Medicare Advantage Plan, you may need to have a referral to see a specialist. If, on the other hand, you have Original Medicare, regardless of whether or not you have a Medicare Supplement, you can see any doctor who accepts Medicare, and nearly 94% of all doctors in America accept Medicare. STILL CONFUSED ABOUT PRIOR AUTHORIZATIONS? We have done our best to inform you all about Prior Authorizations in this article. But we know that for many people, Medicare is still very confusing. If you are still confused or would like additional clarification on the Prior Authorization process or anything related to Medicare, please feel free to email me directly at mike@bradenmedicare.com .

Michael T. Braden, March 13, 2021 GENERAL MEDICARE DOES MEDICARE PAY FOR ASSISTED LIVING? DOES MEDICARE PROVIDE FOR ASSISTED LIVING FACILITIES? No, Assisted living facilities are often referred to as Long Term Care Facilities. These facilities serve individuals requiring non-medical custodial care and assist with daily activities they cannot perform on their own . These ADLs (Activities of Daily Living) include Dressing, Bathing, Medication Management, getting in and out of a Chair or a Bed, Walking Independently, going to the Restroom, and eating . Many individuals have a separate Long-Term Care Policy they plan to use to cover the projected costs of Assisted Living in the future . That is because Medicare does not cover assisted living, and it was never designed to. It was envisioned as Health Insurance, not Custodial Care. Medicare usually pays for any of your Medical needs while you are a resident of any Assisted Living Facility/Long Term Care Facility. However, Medicare will not provide any assistance with the cost of rent or fees for an Assisted Living or Long-Term care Facility. For those who need assistance with the cost of staying in a long-term care/Assisted Living Facility, you can contact your state's Medicare Department. Care focused on activities of daily living is not considered medically necessary when it does not result from a medical condition. Thus, it falls outside the scope of the federal health insurance program. ISN'T EVERYTHING THE SAME WHEN IT COMES TO ASSISTED LIVING? In general, Nursing Homes or Skilled Nursing facilities are appropriate for individuals with complex medical needs that require constant monitoring and medical supervision. These patients are expected to recover in the near term, at which time they will be discharged to return home and skilled nursing care. They are expected to regain full functionality in relatively short order. Assisted Living is defined as a setting where residents are unable to perform all seven Activities of Daily Living. In ALFs (Assisted Living Facilities), residents receive only non-medical assistance and personal care. Typically, the only thing preventing most ALF residents is their inability to perform all seven Activities of Daily Living independently . These are the tasks that prevent the beneficiary from living safely and independently. WHAT YOU CAN EXPECT MEDICARE TO PAY FOR? MEDICARE PART A We all know that Medicare Part A is the portion of Medicare that covers Hospital inpatient care. Medicare Part A extends coverage to include restricted coverage for minor/brief recovery periods in both SNFs (Skilled Nursing Facilities). You must meet the minimum standards set forth by Medicare. You needed to have been in the Hospital for at least 3 days and have your Doctors and/or Hospital Administration attest that you require Skilled Nursing Care or Rehabilitative services as part of your recovery. If additional Occupational, Speech, or Physical/Occupational therapy is needed, Medicare will cover it. MEDICARE PART B Typically, we refer to Medicare Part B as the Outpatient side of the Medical coin. Medicare Part B covers Durable Medical Equipment, Preventive Care, Intravenous Drug Therapies in a Clinic, Hospital, or doctor's Office, Lab Work, Imaging, Outpatient Services, and preventive services . Generally, all of these Part B benefits will follow the Medicare beneficiary if they reside in an Assisted Living facility. Here is a brief image of how this might work: Examples include an Assisted Living Community collaborating with an Independent Home Health Care Company/Organization/Agency that offers physical therapy services, or scheduling on-site visits with a doctor . In certain situations, they may administer injections to residents with diabetes or perform bandage changes. Medicare would typically cover these medical services . MEDICARE BENEFITS IN ASSISTED LIVING COMMUNITIES MAY INCLUDE ANY OF THESE ITEMS BELOW:  Durable Medical Equipment, such as wheelchairs, oxygen, and walkers. There is an option for a battery-powered/ electric wheelchair; however, the Medicare Beneficiary must meet with the Doctor in person at the doctor's office to discuss.  Physical Therapy, Speech Therapy, and Occupational Therapy.  Intermittent or Part-Time Skilled Nursing Visits.  Social Services outreach to help beneficiaries adjust to and cope with issues arising from illness or accident. Caregivers who can offer assistance with non-skilled assistance in executing the Activities of Daily Living, which is arguably the most significant reason people are in a Non-Skilled Care Facility/Assisted Living environment. In some cases , having someone from an agency such as Visiting Angels or Home With Help can be the difference between staying at home and residing in a facility. Vital, non-skilled assistance with daily activities, which we all realize is usually the most significant part of assisted living care, is not covered by Medicare. This is why the general answer to “Does Medicare pay for assisted living?” is no. However, if you transition to an assisted living community, Medicare will continue to cover your prescription medications and any other medical services that were previously covered under your plan while you were living at home. WHAT IS THE LITMUS TEST TO QUALIFY FOR ASSISTED LIVING? ADL'S (ACTIVITIES OF DAILY LIVING) Individuals who have difficulty with, or need assistance with, activities such as bathing, dressing, grooming, toileting, eating, and mobility are often good candidates for assisted living. Activities of Daily Living Chart INSTRUMENTAL ACTIVITIES OF DAILY LIVING (ADLs) These are more complex activities, such as managing medications, handling finances, cooking, housekeeping, and transportation. If a person requires support with these tasks, assisted living can be suitable. SAFETY ISSUES Seniors who face safety risks living independently due to issues like falls, memory problems, or physical impairments may benefit from the supervised and secure environment of an assisted living facility. BECOMING ISOLATED FROM SOCIETY Assisted living can be beneficial for individuals who feel isolated or lonely living alone and would benefit from the facility's social interaction and community engagement . LACK OF DESIRE OR WILLINGNESS The individual should be willing to move into an assisted living community and be comfortable receiving assistance and care in a communal setting. PROS AND CONS OF LIVING IN AN ASSISTED LIVING COMMUNITY Overall, assisted living facilities offer a supportive , social environment that helps with daily activities and ensures safety and security. The trained staff provides care and assistance, and residents can enjoy recreational activities and transportation services. However, the cost is a drawback, and it may require adjusting to communal living and a potential loss of independence. Medical care is limited, and facility quality varies. You should make a decision based on your needs, preferences, and available options. ARE THERE DIFFERENT LEVELS OF AN ASSISTED LIVING COMMUNITY? The highest level of assisted living is often referred to as “memory care” or “special care units.” Memory care is a specialized form of assisted living designed to meet the unique needs of individuals with Alzheimer’s disease, dementia, or other memory-related conditions. Memory care units typically provide a higher level of supervision, security, and specialized care to ensure the safety and well-being of residents with memory impairments. Staff in memory care facilities receive additional training to understand the challenges individuals with memory loss face and to provide appropriate care and support. In memory care personal care units, the physical environment is often adapted to help residents navigate their surroundings more easily. They may have secured access , implemented memory prompts, and incorporated specific design elements to reduce confusion and anxiety. Activities and programs are tailored to engage and stimulate residents’ cognitive abilities, promote social interaction, and maintain a sense of familiarity and routine. Medicare does not pay for room and board or personal care services, but it will usually cover some of the medical costs residents may encounter. Typically, Medicare coverage is for outpatient care under Medicare Part B. Due to the specialized nature of memory care and the higher level of care it provides, memory care units may have higher costs than standard assisted living facilities. Families seeking memory care for their loved ones should carefully evaluate facilities, staff qualifications, and available services to ensure they meet their family member's specific needs . HOW DOES ASSISTED LIVING WORK/INTERACT WITH MEDICARE PART C? Some Medicare Advantage plans offer additional benefits to support caregiving, including adult day care, caregiver support, limited home meals , and transportation to medical appointments. The specific services covered, benefits, and limitations vary a lot from plan to plan. Not all Medicare plans are the same. The only way to know for sure is to review the benefits in your plan's Summary of Benefits (SOB ). If you do not already have a local Medicare Broker, I suggest looking for one nearby. You can ask for their help researching the specific benefits of your plan, and they may have better options for you in the future . It is in EVERY Medicare beneficiary's best interest to work with an Independent, Licensed Medicare Broker. NEITHER MEDICARE SUPPLEMENT PLANS NOR MEDIGAP COVER ASSISTED LIVING Medigap plans only pay the co-pays, deductible, and coinsurance of Medicare Part A and Medicare Part B. Assisted living coverage is not included in Medicare or a supplement. Even though Medicare Supplement Plans and Medigap Plans do not cover Assisted living, we at Braden Medicare believe that the best option for complete, comprehensive healthcare is Original Medicare with Medicare Supplement Plan G or Medigap Plan F, period, and it is not even close. DO ASSISTED LIVING FACILITIES ADMIT DEMENTIA PATIENTS? Assisted living communities are not covered, even for individuals who need Dementia care. However, there is an option called the Program of All-Inclusive Care for the Elderly (PACE) designed for older adults eligible for both Medicare and Medicaid. WHAT DOES IT COST TO STAY AT AN ASSISTED LIVING FACILITY FOR A YEAR? The average cost of assisted living is close to $130 per day and $3,900 per month. However, some assisted living facilities charge as much as $5,000-$10,000 per month, which is considered on the lower end of the price range. WHAT ARE PAYMENT OPTIONS FOR ASSISTED LIVING FACILITIES? Most individuals pay for stays in assisted living facilities out of pocket , relying on personal savings or income. Other standard financing options include Medicaid, which provides health care coverage to those with limited income and resources, and private long-term care insurance. Additionally, some people use financial instruments such as reverse mortgages, life insurance, retirement accounts, and annuities to cover the costs of assisted living. ARE THERE ANY OTHER PROGRAMS THAT ARE ASSOCIATED WITH OR COVERED BY MEDICARE? Medicare Part A covers skilled nursing care, but only under specific circumstances and for a limited duration. Care must be provided fewer than seven days a week and fewer than eight hours a day, for no more than 21 days, with some exceptions. OTHER CARE OPTIONS THAT COULD BE COVERED BY MEDICARE: HOME-BASED CARE LIKE HOME HEALTH AIDES However, Medicare does not cover 24-hour in-home care, meals delivered to your home, or homemaker or custodial services if those are the only services needed. HOSPICE AND RESPITE CARE Hospice provides care and support for terminally ill individuals, while respite care offers short inpatient stays for hospice patients, allowing their caregivers to rest. PACE PROGRAMS - ALL-INCLUSIVE CARE FOR ELDERLY SENIORS (PACE) It’s a Medicare/Medicaid program that helps people meet their healthcare needs in their own community, reducing the need for care facility placements. It covers services like prescription drugs, doctor visits, transportation assistance, home care, and necessary nursing home stays. ADDITIONAL OPTIONS FOR ASSISTANCE LONG-TERM CARE IS NOT PAID FOR BY MEDICARE OR THE VA Your Medicaid coverage depends on where you live and the specific benefits you receive. Depending on your medical condition or income, you might qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Social Security also offers “compassionate allowances” for people with certain severe conditions to help them get disability benefits more quickly. Private insurers offer long-term care insurance plans and may cover various types of long-term care. For those Medicare Beneficiaries who have served in the Military and have VA Benefits, TRICARE, or CHAMPVA, there may be additional programs to assist you with Assisted Living Benefits directly from the VA. We recommend contacting your local Veterans Affairs office to determine whether there are additional benefits you can apply for or are entitled to receive.