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Medicare is a very important life milestone! It is vital that you understand how it works for you and what your entitlements and options are, as well as potential pitfalls such as lifetime late enrollment penalties for Parts B and D. You have choices about how to protect yourself from out-of-pocket costs between having a Medicare Supplement or a Medicare Advantage Plan (Part C of Medicare). We strive to give you all the information available to help you make informed confident choices regarding your healthcare while keeping it simple, ABCD! We are your LOCAL AND ACCOUNTABLE MEDICARE advisors! Our services are always FREE to our clients!

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First – What is Medicare?

In general Medicare is the Federal program that provides health insurance to US citizens and legal residents who have lived in the US for at least 5 years who are 65 and over. Citizens and legal residents under 65 with a qualifying disability, or any person of any age with End Stage Renal Disease (ESRD), Amyotrophic Lateral Sclerosis (ALS), or Lou-Gehrig’s disease can also qualify for Medicare.

Medicare is made up of parts A, B, C, and D. Parts A and B are often lumped together and referred to as Original Medicare. Part A is usually free based on a person having at least 40 credit hours of work history with Social Security. Part B usually has a premium. Because Part B has a premium- it is optional. However, it is recommended that one take Part B when qualified unless they have other creditable coverage, because enrolling in Part B later incurs significant cost penalties. In 2021, the premium for Part B is $148.50. The cost for Part B can be more or less, depending on your income.

What does Medicare Part A cover?

Original Medicare covers many essential services including: Part A helps pay for hospital stays and inpatient hospital care. It also covers inpatient mental health care, skilled nursing, hospice care, and some blood transfusions.

What does Medicare Part B cover?

Part B covers doctor and outpatient visits such as physician services, outpatient hospital, ambulance transportation, outpatient mental health, lab services, and durable medical equipment, outpatient physicals, physical and occupational therapy, speech therapy and some preventive care.

What does Medicare Part C cover?

Part C of Medicare is called Medicare Advantage. Because Original Medicare has deductibles and coinsurance with no protection against out-of-pocket costs, most people agree they need additional coverage beyond what Parts A and B offer. Medicare Advantage (or Part C of Medicare) is one way to get that additional coverage. Medicare Advantage Plans, like Prescription Drug Plans, are managed by Private Insurance Carriers who have contracts with Medicare. Medicare Advantage Plans bundle Parts A and B of Medicare. They must cover everything Original Medicare covers at least as well as Original Medicare. Sometimes they offer more coverage and more benefits than Original Medicare. For instance, Original Medicare does not cover Dental, Vision, or Hearing; and most Medicare Advantage Plans do. Medicare Advantage Plans often have $0 premiums and include Prescription Drug Coverage. In order to qualify for Medicare Advantage, you must continue to pay your Part B premiums.

What does Medicare Part D cover?

Part D covers Prescription Drugs and is provided by Private Insurance companies who have contracts with Medicare. It is important to enroll in Part D upon qualifying for Medicare to ensure that you do not receive a Late Enrollment Penalty later. Because Part D is offered through Private companies, the cost and coverage will vary from plan to plan. So, it is important to research different Part D plans to make sure you find the best fit to cover the medications you need. It is also important to review drug coverage each year because drug formularies, plan designs, and premiums change year to year. How you receive your drug coverage will depend on if you choose Original Medicare with a Medigap plan or opt for a Medicare Advantage Plan (Part C of Medicare).

What are Medigap Plans?

Another way to get necessary additional coverage is to purchase a Medicare Supplement (also called Medigap) plan. These plans are called Medigaps because they help fill the gaps in Original Medicare that are your deductibles, copays and coinsurance. These plans are offered by Medicare approved Private Companies. Medicare Supplements come in standardized plan designs A-N. To be eligible for a Medicare Supplement (Medigap) plan, you must be enrolled in Parts A and B and reside in the state in which you purchase the plan. In general, you must be at least 65 to qualify for this type of coverage.

What happens when I turn 65?

Most Americans who are 65 and older qualify for Medicare. If you are already enrolled in Social Security, you will be automatically enrolled in Part A and B to be effective the first of your birthday month. In this case, you should receive a Medicare Card in the mail about 3 months before your 65th birthday. Part A (Hospital Coverage) is free for most people. Part B (Outpatient Coverage) has a monthly premium. In 2021, the standard Part B Premium is $148.50 per month, which is usually taken out of your social security check. Because there is a premium for Part B, it is optional coverage. However, if you decline Part B, without having creditable coverage in place, you can be charged significant penalties if you choose to enroll in it later.

What if I’m turning 65 and not retiring yet?

If you are not taking Social Security yet; you will have to actively enroll in Medicare. It is best to do this starting 3 months before your 65th birthday. Social Security recommends first going on-line to ssa.gov to create a My Social Security Account. https://www.youtube.com/watch?v=xxLG6l4tvlA You can then click on the button to Apply for Medicare Only. You can also always call your Social Security Office to make a telephone or face to face appointment.

When do I apply for Medicare if I am not receiving Social Security?

Your Initial Enrollment Period (IEP) begins 3 months before the month you turn 65, includes your birthday month, and ends 3 months after your birthday month.

If you sign up for Part A and/or Part B within the first 3 months of your IEP, your coverage begins the first of your birthday month. If your birthday is on the first day of the month, your coverage will begin on the first of the prior month.

It is usually best to enroll within the first 3 months of your IEP, before your 65th birthday; because if you enroll in your birthday month or within the last 3 months of your IEP, your Part B coverage date will be delayed.

When do most people enroll in Medicare?

Most people take Part A when eligible because it is free. However, if you are contributing to an HSA (Health Savings Account) at work, it is important to know you cannot have an HSA and Medicare at the same time. So- if you want to continue your HSA, you will not want to enroll in Part A. It is also important to know that if you delay Part A, it will be effective six months retroactive to your eventual start date. You will want to discontinue your HSA at least 6 months before you start Part A to avoid tax consequences.

Many people who are still working, often decide to delay their Part B until later.
If you work for a company with at least 20 employees; and continue to maintain creditable Employer Health Coverage or have creditable coverage somewhere else (such as through your spouse’s work)- that is fine! You will be granted a Special Election Period (called loss of Employer Coverage) to enroll in Part B when you are ready. Sometimes people opt for Medicare when they turn 65 even if they are not retiring, because it might cost them less and cover more. This is fine too! You do not have to be officially retired to take advantage of your Medicare. It is important to compare all your options to make the best-informed decisions for yourself!

Under 65?

If you are under 65, you still may qualify for full Medicare benefits if:

  • You are entitled to Social Security Disability benefits for at least 24 months (can be nonconsecutive)
  • You receive a disability pension from the Railroad Retirement Board and meet certain conditions
  • You have ALS (amyotrophic lateral sclerosis), also called Lou Gehrig’s disease
  • You have End-Stage Renal Disease (ESRD)

If you are under 65, on Disability and transitioning to Medicare from a Marketplace Plan or Expanded Medicaid, we will help make sure you get a plan that has your doctors, specialists, hospital networks, and prescriptions covered! We will also review your eligibility and help you apply for Extra Help with Prescriptions and Medicare Savings Programs! We specialize in helping you get your Part B Premium paid and getting you Patient Assistance Programs to help make your Healthcare more affordable beyond Medicare. Our Medicare Advisors can help you navigate your transition from Medicaid or Marketplace Plan to make sure you have all the information you need to protect yourself from out-of-pocket costs such as Part B premiums, Network changes, Prescription Drug costs, and more.

What are the Medicare Plan choices?

As Independent Insurance Brokers, contracted with all major carriers in Ohio; Senior Benefit Advantage offers you unbiased advice about your Medicare options. We strive to serve you beyond your Medicare plan to offer ongoing assistance and support when you need us throughout the year. We also make sure you are armed with the information you need to make the best- informed choices at renewal time each year. We are compensated by insurance carriers, so our services are always free to our clients!

When do I enroll in a plan?

You can enroll within 3 months before your Medicare is first effective, or within 3 months after it is effective. This is called your Initial Enrollment Period. If you are older than 65 and losing coverage through work, you can enroll during a special enrollment period for loss of employer coverage. Your plan will be effective the first of the month after you enroll.

Note: If you are under 65 and qualify for Medicare- You can enroll in a Medicare Advantage Plan or continue Original Medicare with a Prescription Drug Plan. Once you are turning 65, you can decide to enroll in a Medigap plan with no health questions, or you can continue to be enrolled in Medicare Advantage. You always have the right to return to Original Medicare with a Prescription Drug Plan.

Note: Those who are turning 65 are in their Open Enrollment for a Medigap plan. This means you are guaranteed acceptance in the available plan of your choice with no health questions. Those who are enrolling in Part B after 65 because of losing Employer Coverage, are in their Guaranteed Issue Enrollment Period for a Medigap Plan with no health questions. The Open Enrollment and Guaranteed Issue periods start the month Part B is effective and last for 6 months.

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Medicare Plans In Plain English

Discussions about Medicare Insurance Plans are often confusing and full of jargon. You may feel overwhelmed by options, or confused about getting started, or worried about time limits. A Medicare agent near me serves as the bridge between the technical realm of Medicare, and your unique situation.

Put simply, you have choices about how to protect yourself from out-of-pocket costs between having a Medicare Supplement (also called Medigap) with or without a Prescription Drug Plan, or a Medicare Advantage Plan with or without Prescription Drug Coverage. Our Medicare Advisors can work with you to help you determine which is the best fit for your situation. Talk to our advisors to find out which type of coverage fits you best!

What is Medicare Advantage (MA)?

MA Plans cover everything Original Medicare covers, at least as well as Original Medicare (except hospice, which Original Medicare continues to cover). In addition, most Medicare Advantage Plans cover dental, vision, hearing, gym memberships such as Silver Sneakers, Over the Counter benefit allowances, transportation, and more. These plans have an out-of-pocket maximum protection. When you reach your out-of-pocket limit, your plan will pay 100% of your costs for the remainder of the year. This can save thousands of dollars in medical bills! Premiums for these plans are often as low as $0. In order to qualify for Medicare Advantage Plans, you must always continue to be enrolled in both Part A and Part B of Medicare.

The most common plan designs are HMO’s and PPO’s. An HMO (Health Maintenance Organization) usually allows you to get services from in-network providers only and a PPO (Preferred Provider Organization) allows you to get services from out-of-network providers at a higher cost-share than in-network providers. A Medicare Advisor can be very helpful in making sure you choose the plan that best fits your doctor, hospital and other provider preferences.

These plans can provide simplicity of all-in-one coverage as they can include Prescription coverage. Medicare Advantage Plans with Prescription Drug Coverage are referred to as MAPD plans. If you do not need prescription coverage, you are able to enroll in an MA only plan with no prescription drug coverage. Usually, however you cannot have both a stand-alone drug plan with a Medicare Advantage plan. You can also not have both a Medicare Advantage plan and a Medigap plan. A Medicare Advisor can be your guide to understanding the different options to make sure you are covered under the right plan.

What is a Medicare Supplement AKA Medigap?

This type of coverage is called Medigap because it helps fill the gap between what Original Medicare covers and what you pay in deductibles, copays and coinsurance. Original Medicare in general, covers 80% of eligible costs and you pay 20%. Medigap plans are designed to pay your 20%. Medigap plans are medically underwritten if you are not within an open-enrollment (turning 65) or guaranteed-enrollment (losing creditable employer coverage) period. They have no provider networks. You can see any doctor and go to any hospital, that accepts Medicare. They also provide some coverage outside the US. If you enjoy traveling, Medigap might be a good fit for you.

Unlike Medicare Advantage, Medigap does not however, cover Dental, Vision, Hearing and other value-added benefits because Original Medicare does not cover those items. Medigap plans are also associated with significantly higher premiums compared to Medicare Advantage Plans. Prescription coverage is separate in the form of a stand-alone Prescription Drug Plan (PDP).

What are Prescription Drug Plans (PDP)?

Prescription Drug Plans are managed by private companies who have contracts with Medicare. These plans must meet a minimum standard of coverage established by CMS, but they vary in premiums, plan design, and formulary. If you choose to enroll in a Medigap Plan, you will also need to choose a Prescription Drug Plan (Part D of Medicare). If you choose a Medicare Advantage Plan with Prescription Drug Coverage (MAPD), you will not need to choose a PDP plan as it is included in the Medicare Advantage Plan.

What is a Part D Late Enrollment Penalty (LEP)?

Sometimes if folks do not take any medications or they only take a few medications; they might not realize they need Part D (Drug Coverage). It is important to enroll in Part D even if you are not taking medication because enrolling later usually incurs a Late Enrollment Penalty (LEP). The LEP for Drug Coverage amounts to a cumulative 1% of the national base Medicare Part D premium (in 2021 $33.06) for every month from when you were eligible for drug coverage to when you enroll in drug coverage. For example, if you enrolled in Part D just 2 years (24 months) from when you were initially eligible, your penalty would be calculated as: 24 X .3306 = $7.93. That $7.93 would be added to your normal monthly PDP premium for the rest of your life and would be adjusted each year concurrent with the national base Medicare Part D premium. Unfortunately, some folks figure this out years after beginning Medicare when they may be prescribed an expensive medication for which they need a Drug Plan; and the penalty is a costly surprise.

What is a Formulary?

The drugs plans offer; are called drug formularies. Every plan must contain at least two drugs per drug category, however plans can choose which Part D drugs they will offer. Formularies can vary between plans and change during the plan year. So -it is very important to verify and manage your prescription coverage to make sure you are covered for what you need! Our Medicare advisors can help you find an MAPD or PDP that is the best fit for your medications and if the coverage changes, we can help you change your plan to one that meets your needs.

What is the “Donut Hole”?

It is the time of year when many of our clients contact us about getting help affording their name brand medications. Our clients who take medications such as Vascepa, Entresto, Eliquis, certain inhalers, Januvia, Janumet, and other name brand drugs for conditions such as High Cholesterol, Chronic Obstructive Pulmonary Disease (COPD), and Diabetes. Clients who take these medications, especially if they take more than one, usually end up in the dreaded donut hole around this time of year.

For those not familiar with the term “donut hole,” it is a euphemism that refers to the 3rd stage of Part D Medicare prescription drug coverage. You see, Medicare Part D has four phases of coverage that are the basis for all drug plans, whether you have a stand-alone prescription drug plan (PDP), or if your drug coverage is included in your Medicare Advantage Plan (MAPD). The first phase of drug coverage is the deductible phase. In 2021 the standard drug deductible can be as high as $445 (varies by plan), usually Medicare Advantage Plans have much lower deductibles for drug coverage.

The 2nd phase is called the initial phase of drug coverage. During this phase, you are permitted to pay the copay which, for a brand name drug, is usually around $35 to $45 (depending on the plan). During the initial phase, the plan is constantly adding what you pay for your drugs and what the plan pays for your drugs until the total in 2021 amounts to a whopping $4,130.

In 2021- The Donut Hole begins when costs have reached $4,130 and ends when year-to-date costs reach $6,550. During the Donut Hole (Coverage Gap) the manufacturer discounts the negotiated retail cost of the drug by 70%, while you pay 25% of the negotiated retail cost. The plan pays 5% in this phase, which does not count toward your year-to-date costs. You continue to pay 25% until your total year-to-date costs which include the plan’s deductible, copays and coinsurance paid in the initial phase, the manufacturer’s discount of 70%, and what you ACTUALLY- pay while in the donut hole reach- $6,550. This $6,550 threshold is also known as your True Out-of-Pocket Cost, or TrOOP.

But Wait – Do I Have To Pay?

Our Medicare consulting comes at no cost to you! We are compensated by the plans we represent and do not charge fees for any of our services. It is our goal to help you make confident and informed choices for your Medicare!

If you are new to Medicare, you are in the right place. Wherever you are in the Medicare Maze, we can help you find your way to Medicare coverage that makes sense! We can help eliminate confusion and connect the dots! We want to empower you to make confident, informed choices about your Medicare! Connect with a Medicare agent near me from Senior Benefit Advantage.

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We are compensated by the plans we represent and do not charge fees for any of our services.

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What If I’m Already On Medicare?

For those already enrolled in Medicare, there are still dozens of issues and questions that can arise. Sometimes the rules change, or important dates come up, or you simply have a question that you cannot answer on your own. That’s what our Medicare insurance advisors are here for.

How Do I Change Medicare Plans?

Generally, you can change your plan once each year during Annual Enrollment, Open Enrollment, or if you have a Special Enrollment circumstance. You can also change once per the first three quarters of the year if you are eligible for Extra Help with Prescriptions or have both Medicare and Medicaid. These Enrollment Periods are outlined below:

Annual Enrollment Period (AEP) – During the annual enrollment period — October 15 through December 7 — you can join, switch or drop a Medicare Part D prescription drug plan. You can also join, switch or drop a Medicare Advantage plan during this period. Your new coverage will start January 1.

Medicare Advantage Open Enrollment Period (OEP) – Each year, there is a Medicare Advantage Open Enrollment Period from January 1 – March 31. During this time, if you are in a Medicare Advantage Plan and want to change your health plan, you can switch to a different Medicare Advantage Plan with or without drug coverage or go back to Original Medicare with a Prescription Drug Plan.

Special Enrollment Period (SEP) – You can change your Medicare coverage when you experience certain life events, like moving, leaving a job or losing other insurance coverage. These life events may entitle you to a special enrollment period. Rules governing when you can make changes and what changes you can make vary by special enrollment period.

If you have Extra Help with Prescriptions or Both Medicare and Medicaid – you can join, switch or drop Medicare Drug Coverage (PDP or MAPD) once per quarter for the first 3 quarters of the year. If you make a change, it will begin the first of the following month. In the fourth quarter, October 15th-December 7th, all people with Medicare can make changes to their coverage. The changes are then effective January 1st of the New Year.

  • Medicare Supplement or Medigap Plans are not subject to Enrollment Periods. You can change your Medicare Supplement any time. However, Medigap Plans outside of Open Enrollment or Guaranteed Issue Periods are subject to health questions. And Prescription Drug Plans are subject to the same Enrollment Periods as Medicare Advantage Plans.
  • You cannot have a Medicare Advantage Plan and a Medigap Plan at the same time.

On Medicare And Have Questions?

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What about ongoing support for our enrolled members?

Our relationship with our clients does not end once you find the right plan. Medicare is confusing, plans change, new plans come available each year, doctors and hospitals can fall in and out of network, prescription costs and plan formularies can change. We are here to provide ongoing support for you when circumstances change, or you have questions. Our Medicare insurance advisors can be your source of advice and counsel when you need it, no matter where you are in the process.

We are certified with all major plans in the service area and are leading experts in working with Medigap, Medicare Advantage and Prescription Drug Plans. We tailor our services based on our clients’ personal circumstances related to financial eligibility, doctor and hospital networks, drug formularies, and other personal needs. If you are enrolled in Medicare and need continued support, connect with us today.

Official Website Resources:

Centers for Medicare and Medicaid Services (CMS)

The Federal agency that runs Medicare: Visit CMS.gov

Medicare.gov

This site is the ultimate source for information regarding Medicare!

This government website provides Medicare information on topics including costs, coverage, enrollment, Part D drug coverage, organizations in your state that can help answer your questions, and more. Visit Medicare.gov

Understanding the Extra Help with Your Medicare Prescription Drug Plan

This booklet is provided by the Social Security Administration provides information regarding the Extra Help program associated with Medicare Part D. Understanding the Extra Help With Your Medicare Prescription Drug Plan

Choosing A Medigap Policy: A Guide To Health Insurance For People With Medicare

If you’re thinking about buying a Medicare Supplement Insurance (Medigap) policy or you already have one, this guide can help you understand how it works. Download the Guide to choosing a Medigap Policy

Sign up for Medicare through the Social Security Website:

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