Getting the most out of Medicare!

Medicare is a big topic with multiple complexities. Even though you have been paying into it for years, you may know very little about it or how it works.  Everyone agrees that it can be difficult to understand the many different insurance plans available and the nuances that go along with each one.

What I do everyday is help people get a better handle on exactly how Medicare works. I explain, in understandable terms, how Medicare works and the different options that you have to best fit your medical and financial situation.

Medicare Part A and Part B

As the song goes, let’s start at the very beginning.  Medicare is available to people age 65 or older who are U.S. citizens or who are legal permanent residents, and either you or your spouse have worked for 10 years (or 40 quarters of a year). It is also available to people under 65 with certain disabilities, and people of any age with End-Stage Renal Disease and Lou Gehrig’s Disease (ALS). For details on Medicare eligibility, visit http://www.ssa.gov/medicare.

There are basically two parts to Medicare, Parts A and B. Together, these are also known as “Original Medicare.”  If you ever read anything about Medicare in the newspaper or hear about it on TV it is almost always to Parts A and B that they are referring.

Part A: Hospital Insurance

Part A helps cover inpatient care in hospitals, skilled nursing facility care, home health care and hospice care.

Most people do not have to pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working.  For this reason, most everyone who is eligible enrolls in Part A when they turn 65 even if they are still working and covered by an employer health plan.

In 2016, there is a $1,288 deductible for the first 60 days that you are and inpatient in a hospital or skilled nursing facility.  Medicare calls this your initial “benefit period.” This benefit period resets after 60 days once you are out of hospital care.  If you are in the hospital longer than 60 days there is a co-pay of $322 per day up to your 90th day.  There is no coverage beyond 90 days each year except 60 days called “lifetime reserve days” that you can use at any time.  But understand that once these are used up they are gone for good.

Part B: Medical Insurance

Part B covers your doctor appointments, specialists, outpatient surgeries or care, durable medical equipment, and some preventive services.

Part B differs from Part A in that there is a premium that all beneficiaries must pay each month.  The premium starts at $121.80 per month, and can be higher if your annual income is over $85,000 for an individual or $170,000 for a married couple.

Part B also has a $166 deductible, and it will cover about 80% of all costs with no annual maximum out-of-pocket expenses.  You pay the remaining 20% as coinsurance.

Additional Medicare Options and Medicare Supplements

If you are enrolled in Medicare Parts A and B, you can choose to buy Medicare Supplement Insurance, known as “Medigap” from a private insurance carrier.   There are several plans to choose from and I think it’s best to sit down talk to a professional like myself who has the experience and knowledge to ask the right questions and identify which plans you should consider.

Depending on the supplemental plan that you elect, it will cover some or all of the costs that are not covered by Parts A and B. These programs can also help you cover the uncapped 20% of your medical expenses. There are several Medicare Supplement options that range from Plan A all the way to Plan N.

Typically if your doctor accepts Medicare, he/she will also accept your Medicare Supplement Plan (based on the terms and conditions of the plan). Take important note that neither Medicare nor Medicare Supplement plans cover medications, so you will have to enroll in separate prescription drug plan or Part D plan to cover the cost of your prescription drugs.

Part D- Medicare Prescription Drug Plan

These plans are provided by private insurance carriers. Each plan has their own list of approved drugs (also known as formularies).  I carefully review each plan’s list when I meet with new clients to ensure that your medications are covered and more importantly to compare the coverage on each plan to make sure you do not pay too much.  The cost for these plans can range from anywhere between $20 to over $100 per month and you can click here to view the plans available.

Part C: Medicare Advantage

Part C is also known as Medicare Advantage. I get asked the most questions about this program.  It combines Parts A and B and may add additional benefits (i.e. vision or dental), and typically includes prescription drug coverage (Part D). These plans can be as low as $0 per month in many areas. You can click here to view the plans available in your area.  Keep in mind that while using Medicare Advantage Part C, you remain enrolled in both Parts A and B and you are still responsible for those monthly premiums.

Medicare Advantage will generally take the shape of either a PPO or an HMO. A PPO gives you in and out of network choices, while an HMO will give you only one network of providers from which to choose. If you go to in-network providers, you will receive the negotiated rate. Be sure to research the chosen plan’s list of providers to ensure that your doctor is available in that network.

These programs typically have maximum out-of-pocket expenses that can be up to $6,700 per year, not including prescription drugs (in-network). Out-of-network provider expenses can cost even more. However, compared with the prospect of having to pay an “unlimited amount” due to the uncapped 20% we discussed earlier, $6,700 does not sound too terrible.

The Bottom Line

To get the most comprehensive and cost-effective coverage possible, most people end up electing some version of the following two combinations:

  1. Medicare Part A&B, with a Medicare Supplement Plan and Part D (to cover prescription drugs), OR
  2. Medicare Part A&B, with a Medicare Advantage Plan (Part C), most of which include Part D (to cover prescription drugs)
  3. Understand that you will have either a Medicare Supplement Plan or a Medicare Advantage Plan, but not both.

Premium-wise, a Medicare Advantage Plan will typically be less expensive per year than a Medicare Supplement Plan. For example, the cost range of the premium in Maine (my home state) is from $0 to over $110 per month. However, a Medicare Supplement Plan gives you more flexibility as there is no insurance company’s network of doctors that you are required to use. The cost range of the premium in Maine and New Hampshire is generally $100 – $200, depending on your age.

I would suggest that when you are planning for retirement you should also take time to think about your plan for medical insurance.

Would you like my help?

If you would like to talk to me, ask a question or schedule a meeting at your home or a nearby meeting place, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.  The best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.

“My goal is to help people and I have found great joy in being able to offer my services to people who need my help.”

Book an appointment with Maine Medicare Options using SetMore

Medicare 101 – The Basics

What is Medicare:  Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Medicare is divided into four parts A, B, C & D.

Click here to learn more about the different parts.

Who is eligible?

You are eligible for Medicare if:

  • You are 65 or older
  • You are under 65 and have certain disabilities
  • You have End-Stage Renal Disease, which is permanent kidney failure that requires dialysis or a kidney transplant

What does Medicare cost?

Part A is free and Part B can be too if you qualify.  In most cases, you’ll automatically get Part A and Part B starting the first day of the month you turn 65 if you are already getting Social Security benefits.

If you don’t get Social Security benefits and you are 65 or older, you’ll have to sign up for Part A and Part B.  To sign up, call Social Security at (800) 772-1213.

To find out more about qualifications, click here.

What does Medicare cover: 

There are four parts to Medicare. They are:

Medicare Part A is Hospital Insurance and it:

  • Helps cover inpatient care in hospitals (room cost, hospital meals and supplies), including critical access hospitals, and skilled nursing facilities.  It does not cover custodial or long-term care.
  • Helps cover hospice care and some home health care You must meet certain conditions to get these benefits.
  • There is a $1,288 deductible for Part A, but once met, days 1-60 of hospitalization are covered 100%. After 60 days, you must pay a daily amount set by Medicare.  You can read more about the 2016 costs here.

Medicare Part B is Medical Insurance and it:

  • Helps cover doctors’ services, hospital outpatient care, and home health care.
  • Helps cover tests, shots and some preventive services to maintain your health and to keep certain illnesses from getting worse (flu shots, PAP tests).
  • There is monthly premium of $121.80, and a $166 annual deductible. Once the deductible is met, Part B generally pays 80 percent of the Medicare-approved amount for covered services, which means you pay 20 percent.

Part A and Part B together are commonly referred to as “Original Medicare”. Original Medicare is offered by the government, and again, in most cases you’ll automatically get Part A and Part B starting the first day of the month you turn 65 if you are already getting Social Security benefits.

Medicare Part C is Medicare Advantage Plans

Instead of getting Medicare Part A and Part B, you have a choice and you can purchase a Medicare Advantage Plan (also called “Part C”).  Medicare Advantage Plans are health plans run by Medicare-approved private insurance companies, and have different rules and costs, but offer at least the same benefits of Medicare Part A and Part B, and in some cases, offer more benefits such as a prescription drug plan.

Why would someone opt to buy a Medicare Advantage Plan over getting Medicare Part A & Part B?

When it comes to Medicare the decision is yours however, you may want to get a Medicare Advantage Plan instead of Original Medicare if:

  • You take prescription drugs. With a few exceptions, most prescriptions aren’t covered in Original Medicare. Many Medicare Advantage Plans include prescription drug coverage.
  • You want a cap on your out-of-pocket health spending. Original Medicare has no out-of-pocket maximum. You keep paying a portion of the cost of services as you use them. Medicare Advantage plans, by law, have an out-of-pocket maximum of no more than $6,700 per year. Once you hit that limit, the plan pays for all covered expenses.
  • You want an alternative to the 20-percent coinsurance charged by Original Medicare for most services. Medicare Advantage plans structure costs differently and may offer a lower (or higher) coinsurance, or may charge copays instead – which are fixed costs you pay for services. A trade-off could be a higher monthly premium.
  • You want coverage for vision and dental. Original Medicare doesn’t cover these services. Certain Medicare Advantage plans do.
  • To find Medicare Advantage plans in your area, click here.

Medicare Part D is Prescription Drug Coverage

There are two ways to get prescription drug coverage through Medicare – either as an add on known as Medicare Part D to your Original Medicare Plan (Part A and Part B), or as part of your Medicare Advantage Plan (Part C). There are several different Part D plans offered, and they vary in cost and medications covered. Also note that Medicare Part D is provided by private insurance companies that have contracts with the government, unlike Medicare Part A and Part B, which is provided directly by the government.

Each Medicare Prescription Drug Plan has its own list of covered drugs. Many Medicare drug plans classify drugs by tiers and each tier has a different cost associated with it. Before you choose a Prescription Drug plan, it’s best to look at the plan’s list of drugs to see if your medication(s) is covered, and how much it will cost.

To find out more about Part D coverage, click here.

What is Medicare Supplement Insurance (also known as Medigap)?

A Medicare Supplement Insurance (Medigap) policy is sold by private companies and can help pay some of the health care costs that Original Medicare doesn’t cover, such as copayments and deductibles.  Medicare Supplement policies fill in the gap between what Original Medicare covers and what it doesn’t. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share.

A Medigap policy is different from a Medicare Advantage Plan. A Medicare Advantage Plan is a way to get Medicare benefits. A Medigap plan simply supplements your existing Original Medicare coverage.  Medigap plans differ in price and coverage.

How can I find out more about Medicare and have my questions answered?

Would you like my help?

If you would like to talk to me, ask a question or schedule a meeting at your home or a nearby meeting place, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.  The best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.

“My goal is to help you and I have found great joy in being able to offer my services to people who need my help.”

Book an appointment with Maine Medicare Options using SetMore

Money-Saving Tips for Part D Drug Plans

Prescription drugs can take a big bite out of your budget.  Medicare prescription drug plans may offer cost-saving benefits that you may not be aware of.  It’s wise to talk to your agent or broker about how your plan works and how you can maximize the savings.  Knowing some of these insider tips could save you a lot of money.   Read on…

How to Get Discounts on Medicare Prescription Drugs

  • Prescription Drug Discount Program – Your Medicare Part D or Medicare Advantage plan might offer a prescription drug discount program. This could be a separate program from your plan benefits or it might be included in your membership.  Check your plan information or call your plan’s customer service number to find out more.
  • Pharmacy Discount Programs – Some pharmacies offer discount programs to regular customers.  Talk to your pharmacist and ask if they have a program you might qualify for.  Talk with your Part D or Medicare Advantage plan about how a pharmacy discount card might work with your plan benefits.
  • Prescription Discount Cards – Prescription discount cards are available through some companies and organizations. You can check online or ask your pharmacist for prescription discount cards that may be available to you. You may want to check with your Medicare Part D or Medicare Advantage plan to learn how a discount card might work with your plan benefits.
  • Pharmaceutical Assistance Programs – Many drug companies have programs that offer discounts on the brand-name drugs they make.  You can learn about programs by calling the company that makes your drug.  You may also visit Medicare.gov’s PAP page and look up your drug to see if there are programs available.  Many doctor’s offices have staff members who can help patients find these programs so ask your doctor for help.

How to Save Money with Your Medicare Drug Plan

  • Pick a Network Pharmacy – Your Medicare prescription drug plans may have a pharmacy network.  This is a group of pharmacies that offer extra savings and discounts to plan members.  Your plan might also have a special arrangement with certain “preferred” pharmacies that could mean additional savings.  Check your plan materials or call a plan representative for information about network pharmacies.  Some plans offer $0 co-pays on generic drugs at these “preferred” pharmacies so it worth asking!
  • Follow the Formulary – Your Medicare prescription drug plan probably has a formulary that lists the drugs it will cover.  Drugs on your plan’s formulary list cost you less than drugs not on the list.  Many formularies have tiers which divide drugs into groups based mostly on cost.  Usually, the lower the tier, the lower your co-pay may be.  You might be able to switch from a high-tier drug to one on a lower tier to help lower your costs.  Ask your doctor if this is an option for you.
  • Request an Exception – Your Medicare prescription drug plan can make exceptions so it sometimes pays to ask.   They can change your drug from a higher tier to a lower tier to help with your costs.   Check with your Medicare Part D or Medicare Advantage plan to learn how to request an exception.
  • Give Generics a Chance – Generic drugs are the same as brand-name drugs in safety, strength, quality and how they work.  They usually cost less, too!   The lower cost of generic drugs could help you avoid the Medicare Part D coverage gap or pay less when you’re in it.  Ask your doctor if this is an option for you.
  • Give Mail-Order a Try – Many Medicare Advantage and Medicare Part D plans offer a mail-order pharmacy service. Co-pays may be much lower than getting refills at the pharmacy. You may save even more by ordering a 90-day supply of your drugs at one time.

Review Your Medicare Drug Plan Each Year

  • Annual Open Enrollment Period – Each year both Part D Prescription Drug Plans and Medicare Advantage Plans change.  Sometimes they remove or add drugs from the formulary or move a drug from one tier to another – changing your cost at the pharmacy.  The Annual Open Enrollment Period runs from October 15th to December 7th Medicare allows you an opportunity to review other plans that are available to make sure each year you have the best coverage possible.   This is where the expertise of an insurance agent like myself  can be really beneficial.  You can call me and I’ll check all your medications against the plans available and tell you which ones will save you the most.   To do this yourself you can use the planfinder tool on Medicare.gov or for the same cost (zero!) you can call me and I’ll help you.  🙂

Would you like my help?

If you would like to talk to me, ask a question or schedule a meeting at your home or a nearby meeting place, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.  The best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.

“My goal is to help you and I have found great joy in being able to offer my services to people who need my help.”

Book an appointment with Maine Medicare Options using SetMore

Medicare’s Nursing Home Coverage

Medicare Part A covers institutional care in hospitals and skilled nursing facilities, as well as certain care given by home health agencies and care provided in hospices.

Any person who has reached age 65 and who is entitled to Social Security benefits is eligible for Medicare Part A without charge. That is, there are no premiums for this part of the Medicare program.

Medicare Part A covers up to 100 days of “skilled nursing” care per illness. However, the conditions for obtaining Medicare coverage of a nursing home stay are quite stringent.

Here are the main requirements:

  • The Medicare recipient must enter the nursing home no more than 30 days after a hospital stay (meaning admission as an inpatient; “observation status” does not count) that itself lasted for at least three days (not counting the day of discharge).
  • The care provided in the nursing home must be for the same condition that caused the hospitalization (or a condition medically related to it).
  • The patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. In order to be considered “skilled,” nursing care must be ordered by a physician and delivered by, or under the supervision of, a professional such as a physical therapist, registered nurse or licensed practical nurse. Moreover, such care must be delivered on a daily basis. (Few nursing home residents receive this level of care.)
  • As soon as the nursing facility determines that a patient is no longer receiving a skilled level of care, the Medicare coverage ends. And, beginning on day 21 of the nursing home stay, there is a significant copayment equal to one-eighth of the initial hospital deductible ($157.50 a day in 2015). This copayment will usually be covered by a Medigap insurance policy, provided the patient has one or there pay be a different copayment structure with a Medicare Advantage plan (Part C).

A new spell of illness can begin if the patient has not received skilled care, either in a skilled nursing facility (SNF) or in a hospital, for a period of 60 consecutive days. The patient can remain in the SNF and still qualify as long as he or she does not receive a skilled level of care during that 60 days.

Nursing homes often terminate Medicare coverage for SNF care before they should. Two misunderstandings most often result in inappropriate denial of Medicare coverage to SNF patients. First, many nursing homes assume in error that if a patient has stopped making progress towards recovery then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain his or her status (or to slow deterioration) then the care should be provided and is covered by Medicare.

Second, nursing homes may wrongly believe that care requiring only supervision (rather than direct administration) by a skilled nurse is excluded from Medicare’s SNF benefit. In fact, patients often receive an array of treatments that don’t need to be carried out by a skilled nurse but that may, in combination, require skilled supervision. In these instances, if the potential for adverse interactions among multiple treatments requires that a skilled nurse monitor the patient’s care and status, then Medicare will continue to provide coverage.

When a patient leaves a hospital and moves to a nursing home that provides Medicare coverage, the nursing home must give the patient written notice of whether the nursing home believes that the patient requires a skilled level of care and thus merits Medicare coverage. Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will issue a “Notice of Non-Coverage” terminating the Medicare coverage.

Whether the non-coverage determination is made on entering the SNF or after a period of treatment, the notice asks whether the patient would like the nursing home bill to be submitted to Medicare despite the nursing home’s assessment of his or her care needs. The patient (or his or her representative) should always ask for the bill to be submitted. This requires the nursing home to submit the patient’s medical records for review to the fiscal intermediary, an insurance company hired by Medicare, which reviews the facilities determination.

The review costs the patient nothing and may result in continued Medicare coverage.

While the review is being conducted, the patient is not obligated to pay the nursing home. However, if the appeal is denied, the patient will owe the facility retroactively for the period under review. If the fiscal intermediary agrees with the nursing home that the patient no longer requires a skilled level of care, the next level of appeal is to an Administrative Law Judge. This appeal can take a year and involves hiring a lawyer. It should be pursued only if, after reviewing the patient’s medical records, the lawyer believes that the patient was receiving a skilled level of care that should have been covered by Medicare. If you are turned down at this appeal level, there are subsequent appeals to the Appeals Council in Washington, and then to federal court.

If you need legal assistance you can contact the following elder law attorney’s in your state.

Elder Law Offices in Maine

Maine Center for Elder Law
www.mainecenterforelderlaw.com
Maine Elder Law Firm
www.maineelderlaw.com
Portland Office:
One Monument Way, 2nd Floor
Portland, ME 04101
Phone: 207-619-2529
Bangor Office:
33 Mildred Avenue
Bangor, Maine 04401
Phone: 207-947-6500
Kennebunk Office:
3 Webhannet Place, Suite 1
Kennebunk, ME 04043
Phone: 207-467-3301

Click here to find a law office in your area.

Find Elder Law Offices in New Hampshire 

I would be happy to answer any questions you might have about this, or any other Health Insurance topic.  I can be reached at 207-370-0143 or at  http://www.mainemedicareoptions.com/contact

Medicare Code Breakdown

Every beneficiary is given a Medicare number. This number is your Social Security number followed by a letter.  Your Medicare number is often referred to as a Medicare claim number.  The letter codes at the end of your Medicare claim number may appear on correspondence you receive from Social Security or on your Medicare card.  These letters represent how you earned your benefit, either through taxes you paid or taxes a spouse may have paid, etc…

 

A – Primary Claimant (wage earner)
B – Spouse (spouse of retired worker)
B1 – Aged Husband, age 62 or over
B2 – Young Wife, with a child in her care
B3 – Aged Wife, age 62 or over, second claimant
B5 – Young Wife, with a child in her care, second claimant
B6 – Divorced Wife, age 62 or over
BY – Young Husband, with a child in his care
C1-C9 – Child (includes minor, student, or disabled child)
D – Aged Widow age 60 or over
D1 – Aged Widower, age 60 or over
D2 – Aged Widow (2nd claimant)
D3 – Aged Widower (2nd claimant)
D6 – Surviving Divorced Wife, age 60 or over
E – Widowed Mother
E1 – Surviving Divorced Mother
E4 – Widowed Father
E5 – Surviving Divorced Father
F1 – Parent (father)
F2 – Parent (mother)
F3 – Stepfather
F4 – Stepmother
F5 – Adopting Father
F6 – Adopting Mother
HA – Disabled Claimant (wage earner)
HB – Aged Wife of Disabled Claimant, age 62 or over
HC – Child of Disabled Claimant
M – Uninsured -€“ Premium Health Insurance Benefits (Part A)
M1 – Uninsured – Qualified For (but refused health insurance benefits – Part A)
T – Enrolled in Medicare but temporarily delayed Social Security Retirement Benefits or Uninsured – Entitled to Health Insurance Benefits (Part A) under deemed or renal provisions
TA – Medicare Qualified Government Employment (MQGE)
TB MQGE – Aged Spouse
W – Disabled Widow
W1 – Disabled Widower
W6 – Disabled Surviving Divorced Wife
WA – Railroad Retirement

Still have questions?  Would you like my help?

 

If you would like to talk to me or schedule a meeting at your home or a nearby meeting place, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.  The best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.  

“My goal is to help you and I have found great joy in being able to offer my services to people who need my help.”

Book an appointment with Maine Medicare Options using SetMore

 

What’s the difference between HMO, PPO, POS, PFFS and SNP Plans?

When you’re shopping for health insurance, you have a lot of options to choose from.

Knowing the differences between plans can help you choose the one that’s right for your health care needs and budget.

As you look at plans, you may notice that some plans have letters after their names (HMO, PPO, POS, PFFS, SNP, Etc…) but what do they mean?
HMO stands for Health Maintenance Organization.
PPO stands for Preferred Provider Organization.
PFFS stands for Private Fee For Service.
POS stands for Point of Service.
and SNP stands for Special Needs Plan.
All these plans use a network of physicians, hospitals and other health care professionals to give you the highest quality care and keep your costs down. The difference between them is the way you interact with those networks.

Health Maintenance Organization (HMO)

  • An HMO is a type of health-care plan that generally requires you to select a primary care doctor.
  • In most cases, you need to get a referral to see a specialist.
  • If you don’t follow the plan’s rules for services, you may have to pay the full costs of care.
  • Except under certain circumstances, you’re typically not covered for services obtained outside of the plan’s network of Medicare providers.
  • While the rules of an HMO health policy may be relatively restrictive compared to other plans, the restrictions may be offset by lower plan costs.

Preferred Provider Organization (PPO)

  • With a PPO plan, you can generally go to any doctor or hospital, but will pay less if you use doctors and hospitals that belong to the plan’s network.
  • PPO health plans typically don’t require a referral for care by a specialist. However, if you use out-of-network health care providers or specialists, you may be required to pay a higher portion of the cost for covered services.
  • Compared to an HMO plan, a PPO plan may be less restrictive. However, the monthly premium for a PPO plan may be higher.

Private Fee-For-Service (PFFS)

With a PFFS plan, you will not need to choose a primary care doctor, and referrals are generally not required for treatment by specialists. However, not all Medicare providers accept the plan.
At one time, PFFS plans were the fastest growing segment of the Medicare Advantage market. These plans were very popular because they were not tied to a specific doctor or hospital network. In 2011, changes in Medicare law required certain PFFS plans to have networks of providers. So, if you are considering a PFFS plan, make sure you’re clear with that particular plan about which providers you can go to and what the requirements are.

Special Needs Plans (SNP)

Special Needs Plans (SNPs) are available for those who qualify with specialized health needs or who are in other specific situations (like living in a nursing home). These plans tailor benefits and coverage to meet the specific needs and conditions of the people they serve. You might be eligible for an SNP if any of the following conditions applies to you. This is not a complete list of all possible qualifications for an SNP.
  • You have a severe or disabling chronic condition, such as chronic heart failure or dementia.
  • You’re enrolled in both Medicare and Medicaid.
  • You live in an institution such as a nursing home.
For details about qualifying for an SNP, see Medicare.gov.

HMO Point-Of-Service (HMO POS)

An HMO Point-of-Service plan is a slightly different and less common version of the HMO plan. Unlike a traditional HMO, an HMO Point-Of-Service plan usually lets you go to an out-of-network provider, but at a higher out-of-pocket cost. This benefit can make the plan function more like a Preferred Provider Organization plan.

Which one is right for you?

When you compare insurance plans, keep in mind the type of health services you need, how often you get them, what medications you take, and the copayments or coinsurance amounts for these drugs and services under the different plans.

Need more help comparing the different health insurance plans?  I can help you.

You can use the BOOK APPOINTMENT button below to set up a time to speak with me on the phone or in person. I can also send you information ahead of time to get you started.
Have a question that needs to be answered right away? Just give me a call at your convenience.  You can talk to a licensed insurance agent at (207) 370-0143 or call toll free 866-976-9038.
Book an appointment with Maine Medicare Options using SetMore

National Senior Citizens Day – Aug. 21

When Do You Become a Senior Citizen?

Today is National Senior Citizens Day and with more and more Baby Boomers turning 65 each year, the question of when you become a senior citizen is a topic of great interest.
About half of people age 64 responding to a Del Webb Baby Boomer Survey in 2010 said the term “senior citizen” does not apply to them because they don’t “feel” like a senior.  Instead they describe themselves as still being active and young at heart.
In the same survey, 96 percent of 50-year-olds rejected the term and the 64-year-olds who embraced the term did so primarily for economic reasons, because they are now eligible for senior discounts.
Interestingly, when asked to pinpoint when “old age” begins, both the oldest and youngest Boomers selected ages well beyond them. The youngest boomers said a person becomes old at age 78, while the oldest boomers said old age begins at 80.

So what does the term “senior citizen” mean, and when exactly does an individual become one?

The term first was coined during a 1938 political campaign as a euphemism for “old person,” and now enjoys widespread usage in the common vernacular, legislation, and business. Some dictionaries define “senior citizen” as a person over the age of 65. In everyday speech, the term is often shortened to “senior.”
In legislation, the term applies to the age at which pensions, social security or medical benefits for the elderly become available.  In this country, traditionally you are eligible to retire with full Social Security benefits at age 66. Additionally, you can retire early at age 62 and receive a portion of – but not full – retirement benefits.  Because of increases in average life expectancy and stresses on the federal budget, however, Congress has passed legislation to gradually increase the full retirement age from 66 to 67 by 2027.
Many federally and state-funded programs also qualify individuals based on age. For example, Area Agencies on Aging across the state provide home-delivered meals and congregate meals to senior centers and apartment communities.  To participate, an individual must be at least 60 years of age or the spouse of someone 60 years of age.  In business applications, the term “senior” often is applied to special discounts and customer loyalty programs which vary by age and store.

“I truly enjoy working with folks over 65.  It’s the most rewarding job I’ve ever had!”

Educating people on Medicare and how it works gives me the opportunity to make a real difference in people’s lives. Medicare is so complicated and causes so much anxiety for some folks.  I am able to put them at ease and help them make sense of their choices.  It’s the most rewarding job I’ve ever had.  My goal has always been to help people and I have found great joy in being able to offer my services to people who need my help.
I also learn a lot from my clients! They have a wealth of knowledge to share and I enjoy hearing their stories.  It’s like going for a ride on a hidden time machine, taking me back to a simpler era and I’m always fascinated with the things I discover.
Whether you consider yourself a senior citizen or not you can celebrate National Senior Citizens Day today by spending time with one that you know, which may be your parents, grandparents, aunts, uncles, neighbors or friends. Let them know that they are special, appreciated and loved.  It may also be a good day to volunteer at a retirement home and share your smile with those who may not otherwise get a visitor today.
I hope you enjoy your day!  
-Todd
 

Should you buy direct or use an agent?

 
If you are reading this then you are most likely in the process of deciding not only if you need insurance, but whether you should enroll direct with the insurance plan online or meet with an insurance agent or broker.  A recent survey asked consumers which they were inclined to use.  When asked if they preferred to buy insurance online or from an agent, the first response was “online.”
 

The top three reasons given were:

  • Save money by cutting out the middleman
  • Ease of transaction
  • Speed of transaction

The survey then asked participants to use both methods to purchase insurance.

The results:

Save money by cutting out the middleman:
The study found that consumers rarely saved enough money to warrant bypassing an agent or broker’s help.  Rates are the same for everyone whether you enroll direct or get help from an agent.
 
Ease of transaction:
While the online experience was easier at first than direct contact with an agent, most agents were far more proactive in asking important questions that would allow them to give better recommendations, particularly when participants had multiple questions that required follow-up.
 
Speed of transaction:
The survey was evenly split regarding speed. Direct-to-consumer websites delivered fast results for the length of time required to sit down with an agent, while agents took more time with fact finding and matching a consumers needs to specific products.  However, the speed differences reversed when it came to making changes in coverage, documentation requests, and additional questions – agents were far more efficient and easier to reach for follow up.
 

Consumers who were part of the study also found that comparing insurance plans was not so simple.

Personally I was not too surprised when I read this study because I meet with people all the time who say they wish they had known about me years ago.  “You could have saved me so much time and money,” they’ll say.    
 
Comparing health insurances (especially Medicare Advantage plans & Medicare Prescription Drug plans) is very complicated and you really need someone who has experience and knows a lot about how these plans work.   As a broker I talk to my clients regularly about their experiences with the different insurance companies.  If one of them is not doing something right I hear about it.   The other benefit to working with an agent or broker – like myself – who is contracted with multiple insurance carriers is that they can help you with comparing plans so you can find the best plan for your needs.  To do this on your own you would have to meet with a representative from each insurance company and then they will only tell you the positive aspects of their plan.  You will have to discover any shortcomings as you experience them. With anything as significant as purchasing health insurance it’s always best to have someone on your side.
 
Just remember that there’s no one right insurance plan, or one perfect way to shop for something as important as insurance. The bottom line is that you need to identify your priorities, do your research, and find the best plan for your needs. You might be able to do this on your own, or you might need the help of a trained professional to make these decisions.
 
 

Would you like my help?

If you would like to talk to me or schedule a meeting at your home or a nearby meeting place, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.  The best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.  

“My goal is to help you and I have found great joy in being able to offer my services to people who need my help.”

Book an appointment with Maine Medicare Options using SetMore

 

 

Changing from Obamacare to Medicare

If you are currently enrolled in a Healthcare Marketplace plan and receiving monthly premium tax credits, be aware that you will no longer qualify for those credits when you turn 65 and are eligible for Medicare.

If you have a Marketplace plan now, you can keep it until your Medicare coverage starts. Then, you can cancel the Marketplace plan without penalty.

When to apply for Medicare

Once you are eligible for Medicare (at Age 65), you’ll have a 7 month Initial Enrollment Period to call Social Security and enroll.  This 7 month initial enrollment period begins 3 months before the month you were born, the month of, and 3 months after your 65th birthday.
In most cases it’s to your advantage to sign up for Medicare when you’re first eligible because once your Medicare Part A coverage starts, you won’t be able to keep any premium tax credits or other savings for a Marketplace plan based on your income. You’ll have to pay full price for the Marketplace plan.
If you enroll in Medicare after your initial enrollment period ends, you may have to pay a late enrollment penalty. In addition, after your initial enrollment period ends you can only enroll in Medicare Part B (and Part A if you have to pay a premium for it) during the Medicare general enrollment period (from January 1 to March 31 each year).  AND your Medicare coverage doesn’t start until July of that year.  This may create a gap in your coverage if you do not keep your marketplace plan and continue paying full price for the cost of the insurance.

Learn more about how and when to enroll in Medicare.

If you want coverage to supplement Medicare, you can get Medicare supplement (Medigap) insurance. You cannot supplement Medicare with a Marketplace plan. It’s against the law for someone who knows that you have Medicare to sell you a Marketplace policy. This is true even if you have only Medicare Part A or only Part B.

Learn about other Medicare options, like Medicare Advantage Plans.

Canceling your Marketplace plan

To cancel your plan online, follow the instructions that best describe your situation:

“I’m the only member of my household enrolled on my Marketplace plan. You’ll simply terminate the whole application.”

How to end coverage for everyone on your application

  1. Log into “My Account” at www.healthcare.gov
  2. Select “Visit the Marketplace for Individuals and Families.”
  3. Select the application you want to end coverage.
  4. On the far left side of the screen, select “My Plans & Programs.”
  5. Scroll down and select the red button that says “End (Terminate) All Coverage.”
  6. Select an effective date to end your coverage that’s at least 14 days from the current date and click the attestation.
  7. Select the red “Terminate Coverage” button.
  8. A red “Cancelled” or “Terminated” status should appear above the plan you ended.
You can also end your plan by phone at 1-800-318-2596 (TTY: 1-855-889-4325)
Available 24 hours a day, 7 days a week.

“My spouse and I are both enrolled in the same Marketplace plan, but only my spouse needs to cancel due to getting Medicare. I want to keep the Marketplace coverage for my spouse and end Marketplace coverage only for myself.”

How to end coverage for anyone other than the Applicant:

  1. Log into “My Account” at www.healthcare.gov
  2. Go to “Report a Life Change.”
  3. Select “Add or remove member of household” and then click “Continue” twice.
  4. Continue clicking “Save & Continue” until the “You’re applying for health coverage for these people” page.
  5. Select the “Remove” button for the person you’re removing from Marketplace coverage and continue through the application. Note: You must complete steps 5 and 6 for each person you want to remove from Marketplace coverage.
  6. On the household information screen, add the removed spouse or dependent’s information if they are still a member of your household.
  7. Click the green “Continue to Enrollment.”
  8. Complete the steps to choose or confirm a health plan. Note: Only the people who are still eligible to enroll in a health plan through the Marketplace will be asked to choose or confirm a plan before confirming enrollment.

In most cases, when you end coverage for only some people on your application, your coverage ends immediately.  Be sure not to cancel your Marketplace plan before your Medicare coverage begins. Otherwise, you may have a gap in coverage.

IMPORTANT NOTE:  When you end coverage for just some people on your application, their premium tax credit or other savings may change. You may need to update your household income after ending coverage for one or more people.

Becoming newly eligible or ineligible for premium tax credits or changes to other cost-savings may qualify them for a Special Enrollment Period.

You can also end your plan by phone at 1-800-318-2596 (TTY: 1-855-889-4325) 
Available 24 hours a day, 7 days a week.

Would you like my help?

If you would like to talk to someone about your options or schedule a meeting at your home or a nearby meeting place, you can call 207-370-0143 or use this form to ask a question.

The best part about working with me is that it will not cost you anything to meet and discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.  My goal is to help you and I have found great joy in being able to offer my services to people who need my help.

Call me today and I will explain all your options and help you compare plans so you can choose the coverage you need for a price you can afford.

Call me toll free at (866) 976-9038 or call direct at (207) 370-0143.

I look forward to hearing from you!

Book an appointment with Maine Medicare Options using SetMore

Beware Observation Status!

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find out they are not eligible for rehab in a nursing home after they are discharged.
Medicare rules state that you must spend 3 consecutive nights (midnights) in the hospital (not counting the day of discharge) as an “admitted” patient in order to qualify for nursing-home coverage. If you are under observation but not admitted, you will also lose coverage for any medications the hospital provides for pre-existing health problems. (Medicare drug plans are not required to reimburse patients for these drug costs.)

Some background on “observation” status.

Medicare beneficiaries who are under observation (which is considered outpatient care) often face higher out-of-pocket costs, including higher co-payments and charges for drugs that are not covered for outpatient stays.
The rule says that to be eligible for Medicare’s nursing home coverage, you must spend three consecutive midnights “admitted” in a hospital.  This means that days spent under “observation” do not count towards meeting this requirement.
Since an observation stay is an outpatient hospital stay is it covered under Medicare Part B (the medical insurance part of Medicare).  If you have Original Medicare, Part B covers outpatient services you receive and you typically pay 20 percent coinsurance for each medical service you receive in the hospital after you have met your yearly Part B deductible.
If you get your Medicare benefits through a Medicare Advantage plan, different costs and rules may apply. Each plan is different.  You will need to contact your plan directly to learn more about your plan’s coverage of hospital care.  It is important to know whether you are considered to be a hospital inpatient or an outpatient since your Medicare costs and coverage may be different depending on your status because your costs may be higher if you are a hospital outpatient.

If you are in the hospital, you or your family member should ask hospital staff whether you are an inpatient or an outpatient each day during your hospital stay, since this affects what you pay for hospital services.  Keep in mind that whether you are an inpatient or outpatient can also affect whether you will qualify for Medicare coverage of skilled nursing facility care.

However things are about to change – but only slightly!

Last week President Obama signed a new law passed by Congress called the “NOTICE Act”.  This new law will require hospitals to tell you of your outpatient status within 36 hours, or, if sooner, upon discharge.
Hospitals will have until next year (August 2016) to comply with the new law.  So you still need to be aware of your status when you or a loved on is in the hospital.  Nothing is changing today and once this law is implemented hospitals still have 36 hours to notify you so I would continue asking about your status daily so you are aware.

“The new law will not cure [some] problems, but will at least give patients a warning before they spend thousands of dollars on care that will not be covered by Medicare,” Jeff Marshall, an elder law attorney in Pennsylvania, said. “Some beneficiaries will likely decide to receive a different set of medical services after being notified of their observation status.”
If you would like to know how your plan pays for inpatient vs. outpatient care you can contact your plan by calling the phone number on the back of your insurance card or by calling 1-800-Medicare.   You may also contact us for a plan review to find out if you are getting the coverage you need at costs that are affordable to you.   Remember, Medicare Advantage plans and Medicare Prescription Drug plans change every year so it is always a good idea to review these changes and to look at what other plans offer to make sure you’re taking advantage of all your options.  

Would you like my help?

If you would like to talk to someone about your options or schedule a meeting at your home or a nearby meeting place, you can call 207-370-0143 or use this form to ask a question.

The best part about working with me is that it will not cost you anything to meet and discuss your options or to review the plans that are available.  I am paid by the insurance companies in the form of a commission if you enroll in a plan.  You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.  My goal is to help you and I have found great joy in being able to offer my services to people who need my help.

Call me today and I will explain all your options and help you compare plans so you can choose the coverage you need for a price you can afford.

Call me toll free at (866) 976-9038 or call direct at (207) 370-0143.

I look forward to hearing from you!

Book an appointment with Maine Medicare Options using SetMore

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