VA Benefits and Medicare

Learn how your VA Benefits and Original Medicare work

VA Benefits and Medicare: What You Need to Know

As a Medicare-eligible Veteran, you have options when it comes to healthcare. The transition to Medicare can be confusing, so this article will list a few points that all vets should know when they become Medicare eligible.  To confirm your options call the Veterans Administration directly at 1-877-222-VETS (8387).

VA Benefits and Medicare

It is important to note that Veteran’s (VA) plans and Medicare do not supplement each other. In other words: VA plans only cover care at VA facilities, and Medicare only covers care at Medicare assigned doctors and hospitals. These plans do not overlap.

Should You Enroll in Medicare Part A If You Have VA Benefits?

Yes. You can have both Medicare and Veterans (VA) benefits at the same time.  It is strongly recommended that all veterans enroll in Medicare Part A (Hospital Coverage) when they turn 65 and generally there is no additional cost for Part A. This will allow you receive hospital coverage should you go to a non-VA facility.  According to the VA’s website “[We] encourages you to keep your private [Medicare] health insurance.Source: VA.gov

Should You Get Medicare Part B If You Have VA Benefits?

Yes, It is strongly recommended that all veterans enroll in Medicare Part B (Medical Coverage) as well as part A when they are eligible. (Click here to learn more about when to enroll.) There is a monthly fee for Part B but it is worth it. If your VA Benefits are dropped at some point OR, and this is important, if your local VA facility does not cover all health services, you could pay 100% out of pocket for a serious illness. The VA highly recommends that you enroll in Part B as well. Please contact Veterans Affairs directly (1-877-222-VETS (8387)) with questions about specific care at Togus or another local facility.

Should You Get a Medigap or Medicare Advantage If You Have VA Benefits?

If you would prefer to see a local doctor or go to a local hospital or healthcare facility for your care then you should consider a Medicare Advantage or Medigap plan to supplement your Medicare coverage. Read more about these types of plans here.

Most people agree that veterans do not need a Medigap plan if they qualify for ChampVA. However, if you aren’t enrolled in ChampVA, a Medigap plan will fill in the gaps such as deductibles, copays, and coinsurance, as well as other benefits when seeking care outside of the VA, or outside of the U.S. and its territories. Make sure to speak with your Tricare or CHAMPVA representative before enrolling in any supplemental plan to ensure that it is actually beneficial for you. Here are two reasons why you may want to enroll in a private Medicare Supplement plan:

  1. You do not live near a VA facility

  2. You are enrolled in one of the VA lower priority groups, and could potentially lose your benefits*

* “There is no guarantee that in subsequent years Congress will appropriate sufficient funds for VA to provide care for all enrollment Priority Groups. This could happen if you are enrolled in one of the lower Priority Groups. This would leave you with no health care coverage.” Source: VA.gov

Learn More about Medigap Get a Medigap Quote

VA Benefits and Medicare Part D

The choice of whether to enroll in Part D is up to you. In most cases, you don’t need a Medicare Prescription Drug Plan, aka Medicare Part D, as VA plans may offer more coverage than Medicare’s Rx coverage. Remember that any prescription prescribed by a non-VA doctor needs to be approved by your VA doctor for the VA to approve it.  This may take extra time and your VA doctor can say that prescription is unnecessary. 

What about the Part D Penalty?

Good news! Your VA drug coverage is considered creditable coverage so the Part D late enrollment penalty does not apply to you. If you choose not to enroll in Part D when you are first eligible you can still enroll later on in Part D without paying a penalty.

For further questions about Medigap, Medicare Advantage or Medicare Part D, please call the number above or book an appointment to meet and discuss your options. 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 – your choice!

Book an appointment with Maine Medicare Options using SetMore

Please note: We are only able to give general information about Medicare related issues. If you have questions about your VA coverage, please contact Veterans Affairs directly.

Still have questions or want help comparing the different health insurance plans?  I can help you!

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. Or send me an email using this form –> https://www.mainemedicareoptions.com/contact

The best part about working with me is that it will not cost you anything to talk with me to discuss your options and review the plans that are available. I am paid by the insurance companies in the form of a commission when 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 talk 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

Top 5 Medicare Myths

Educate yourself on these common Medicare myths — both your health and your wallet will thank you.

Medicare is a great program. I know because I meet with people every day who are turning 65 and entering the Medicare system and looking for help and advice on where to start and what to look for.  Medicare saves you from having to pay enormously high private health-insurance premiums, and it protects you from catastrophic medical expenses. But if you’ve heard one of these common misunderstandings about Medicare, you will be glad you found this website.

1. Medicare enrollment happens automatically at 65

Everyone becomes eligible for Medicare at age 65, but actually enrolling in the program is up to you. The only way you’ll be automatically enrolled in Medicare is if you’re already receiving Social Security benefits when you hit your 65th birthday or if you are collecting Social Security Disability payments. In either of these cases, you’ll be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) as soon as you become eligible, although it’s still up to you to sign up for any prescription drug coverage, Medigap, or a Medicare Advantage plan. — That’s where I come in! smiley

Read more about How and When to Enroll.

2. You can enroll any time after age 65

This is not quite accurate. Your initial enrollment period for Medicare begins three months prior to your 65th birthday and ends three months after the month which you turned 65. If you don’t enroll during this seven-month period, you’ll have to wait for the next Medicare open enrollment period which happens between January 1 and March 31 and your Medicare benefit will begin on July 1st. And if you are enrolling in a Medicare plan it must be done prior to July 1st!

There are also penalties for late enrollment. If you don’t sign up for Part A during your initial enrollment window, then your monthly premium will go up by 10% for twice the number of years you could have been enrolled but were not. For example, if you file for Medicare Part A three years after you become eligible, then you’ll have to pay a higher premium for six years.

You should also sign up for Part B as soon as you’re eligible. If you don’t, your premium will go up 10% for every year you delayed — permanently.

Read more about How to Correctly Plan Your Enrollment.

3. Medicare is free

This is a big one! Especially with all the advertisements out there saying that plans have no cost or $0 monthly premiums.

Some parts of Medicare and some covered services are indeed free, but there are certainly some costs involved. Medicare Part A, which covers in-patient hospital stays, has no monthly premium if you worked (and paid Medicare taxes) for at least 40 calendar quarters (or 10 years) by the time you enroll. Medicare Part B, which covers outpatient doctor visits, routine bloodwork and similar expenses, has a premium of $134 per month in 2017, although high-income enrollees may pay higher premiums.

Other Medicare parts and plans have a wider range of premiums, often based on the type of plan and where you go for care. As for services, different Medicare parts and plans offer different levels of coverage for various medical expenses. Some expenses may be completely covered by Medicare, such as an annual wellness exam, while others require you to pay a co-pay or meet an annual deductible.

Read more about How can insurance can have a $0 premium?

4. Medicare covers all types of healthcare expenses

The different parts of Medicare cover different types of healthcare. Medicare Part A covers only hospital-related services, while Part B covers other types of medical expenses such as doctors’ visits and lab tests. Part D covers prescription expenses.

Part C, also known as Medicare Advantage, can cover additional services such as vision and dental care. Medigap plans help cover some of the costs that Medicare Part A and Part B don’t cover, but it doesn’t include prescription coverage, dental, vision, and so on. So the exact coverage you have will depend on which parts of Medicare and which specific plans you sign up for.

5. You may not qualify for Medicare

Happily, you cannot be rejected from Medicare coverage just for being sick or having a pre-existing condition. For that matter, pre-existing conditions won’t raise your premiums, either. This should continue to be the case for Medicare even if Congress repeals the Affordable Care Act’s pre-existing condition clause.

Still have questions or want help comparing the different health insurance plans?  I can help you!

You can use the BOOK APPOINTMENT(link is external) 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. 
Book an appointment with Maine Medicare Options using SetMore
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. Or send me an email using this form –> https://www.mainemedicareoptions.com/contact

Are you turning 65 and still working?  Read this.

There is no obligation to you and no cost to meet with someone.

Popular Donut Hole Questions

Popular Donut Hole Questions

During this time of year, many people will begin to enter the Coverage Gap or “Donut Hole” portion of their Medicare Part D coverage and find their coverage costs changing. 

If you have already purchased medications with a retail value of $3,700 you are in the 2017 Donut Hole.

Question:  I have purchased medications worth $3,390 toward my 2017 Donut Hole, my next brand-name drug purchase has a retail cost of $400, bringing me into the Coverage Gap.  Will I get a Donut Hole discount on the full $400 retail price or just the $90 that falls into the gap?

Your Donut Hole discount (which is 60% in 2017) only applies to the $90 portion of the retail drug price that falls into the Coverage Gap.  Since your purchase “straddles” two phases of coverage, you pay your cost-sharing for the Initial Coverage phase (for example, $40 for a Tier 3 brand drug) and the brand-name Donut Hole discount applies to the remainder of the retail price falling into the Donut Hole. 

Therefore, your total drug cost is the cost-sharing you paid in the Initial Coverage phase plus the discounted cost in Donut Hole. (Note: The combined cost of the Initial Coverage phase and the Donut Hole phase will never exceed your drugs total retail cost.) 

Question:  If I use only one brand drug that costs $347 and have a $47 co-pay, will I enter the 2017 Donut Hole?

Yes. If your retail drug costs average $347 you will exceed your Medicare plan’s Initial Coverage Limit of $3,700 and enter the 2017 Coverage Gap or Donut Hole in early-November. 

Only your plan’s retail drug costs count toward entering the Donut Hole. Your co-pay has no impact on entering the Donut Hole, but will impact when you exit the Donut Hole.  

Question:  I am in the Donut Hole and now have a new prescription that is not on my plan’s list of covered drugs.  Do I get a discount on my new medication and will my costs count toward getting out of the Donut Hole?

No. Only Medicare Part D prescription medications found on your plan’s formulary receive the 60% brand-name discount or 49% generic drug discount. Non-formulary medications and medications excluded from the Medicare Part D program, do not qualify for the Donut Hole discount and your non-formulary drug purchases do not count toward meeting your 2017 total out-of-pocket drug spending (TrOOP) limit of $4,950 — the amount you need to spend to exit the Donut Hole.

If you are using a non-formulary medication, you can ask your Medicare plan for a Formulary Exception which is a type of Coverage Determination. 

If your Medicare Part D plan denies your request, you have the right to appeal your plan’s decision.  For more information, you can click here to read about Formulary Exceptions. https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Exceptions.html

Do you have a question not answered here?

Click here to ask a question.

If you would like help comparing your needs against the many Medicare plans out there or if you just want to ask a few questions, you can call me directly at 207-370-0143 or use my simple form on the CONTACT 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 talk with me to discuss your options and review the plans that are available.  I am paid by the insurance companies in the form of a commission when you enroll in a plan.  You will not pay anything to meet with me and you will pay the same price for your insurance that everyone pays whether they had my help or not.

“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 Advantage (Part C)

Medicare Part C is available through Medicare Advantage plans, and is an alternative to Original Medicare (Parts A and Part B). Medicare Advantage plans are health insurance plans offered by private health insurance companies approved by Medicare. Medicare Advantage health plans (such as HMO, PPO or PFFS plans) are legally required to offer at least the same benefits as Original Medicare, but can include additional coverage as well, such as routine vision or dental benefits, health wellness programs, or prescription drugs.

One benefit of Medicare Advantage plans is that you can get your prescription drug benefits (Medicare Part D) included under the same plan, instead of having to enroll in a separate stand-alone Medicare Prescription Drug Plan. These plans give you the convenience of having your Medicare Part A, Part B, and Part D coverage through a single plan.

Medicare Advantage plan costs and coverage details can vary depending on the insurance company and county that you live in.

What are the different types of Medicare Advantage plans?

As mentioned, Medicare Part C coverage details can vary depending on the insurance company, so it’s always a good idea to compare the Medicare Advantage plan options in your specific location. The following are types of Medicare Advantage plans that may be available in your location:

Health Maintenance Organization (HMO) plans: These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.

Preferred Provider Organization (PPO) plans: Medicare Advantage PPO plans offer a network of doctors and hospitals for beneficiaries to choose from. Unlike an HMO, you have the option to receive care from health-care providers outside of the plan’s network, but you’ll pay higher out-of-pocket costs. Medicare Advantage PPOs don’t require you to have a primary care doctor, and you don’t need referrals for specialist care.

Private Fee-for-Service (PFFS) plans: This type of plan allows visits to any Medicare-approved doctor or hospital, as long as the plan’s terms and conditions of payment are accepted by the provider. Keep in mind that you’ll need to find providers that contract with the plan each time you are receiving treatment.

Special Needs Plans (SNPs): These plans limit enrollment to beneficiaries who have certain chronic conditions, are institutionalized, or qualify for both Medicare and state Medicaid (also known as dual eligibles). Benefits, provider options, and prescription drugs are tailored to meet the needs of the plan’s enrollees.

How do I know if I am eligible for a Medicare Advantage plan?

In order to be eligible for Medicare Part C, you must be enrolled in both parts of Original Medicare (Part A and Part B). Once you have Medicare Part A and Part B, you are generally able to enroll in a Medicare Advantage plan, provided you live in the plan’s service area and do not have end-stage renal disease (ESRD).

There are some exceptions where you may be able to enroll in a Medicare Advantage plan even if you have end-stage renal disease. For example, if you’re enrolling in a Special Needs Plan that targets beneficiaries with end-stage renal disease, you may be eligible to enroll in this type of Medicare Advantage plan.

To learn more about other situations where you may be eligible for Medicare Part C if you have end-stage renal disease, you can contact us using the contact page on this site. You can also contact Medicare at 1-800-MEDICARE (633-4227); 24 hours a day, seven days a week.

Those with other health insurance coverage (a union or employer-sponsored health plan, for example) should get more information about their existing coverage before enrolling in a Medicare Advantage plan. It is possible you could lose your existing coverage once you enroll in a Medicare Advantage plan. Furthermore, if you discontinue the other plan for Medicare Part C coverage, you may not be able to reinstate your original coverage if you change your mind. It is generally a good idea to check with your current benefits administrator before you enroll in another health-care plan.

If you’d like to learn more about Medicare Advantage plan options or if you’d like help finding coverage that may fit your needs, you can call me directly at 207-370-0143 or use my simple form on the CONTACT page of this site to send an email message. 

“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

Read more about other types of plans and options …

49 New Generic drugs

2017 Medicare Part D drug lists updated with 283 new drugs!

Medicare Part D rules allow insurance companies to update their prescription drug lists throughout the plan year and in the past few months, 283 new medications have been added to many drug plans. The April 2017 formulary data released by the Centers for Medicare and Medicaid Services (CMS) included 380 new national drug codes representing 250 drugs. The May 2017 CMS formulary data included 43 new drug codes representing 33 drugs.

Medicare’s Formulary Browser, located at Medicare.gov has also been updated with the April and May 2017 Medicare Part D formulary data.

49 New Generic drugs added!

These additions to the Medicare Part D insurance plans included a total of 25 new generic equivalent medications that represent 48 generic drug combinations. Some interesting additions to the 2017 drug lists include:

GLYBURIDE 1.25 MG / METFORMIN HYDROCHLORIDE 250 MG ORAL TABLET [Glucovance]

LOPINAVIR-RITONAVIR 80-20MG/ML [Kaletra] 

ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom] 

AMLODIPINE-OLMESARTAN 10-20 MG [Azor] 

APREPITANT 125 MG CAPSULE [Emend] 

CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE 1.2-5% [Benzaclin] 

CLINDAMYCIN-TRETINOIN 1.2%-0.025%

[Veltin, Ziana] 

DAPTOMYCIN 500 MG VIAL [Cubicin] 

DROSP-EE-LEVOMEF 3-0.02-0.451 [Beyaz, Safyral] 

ETHACRYNIC ACID 25 MG TABLET [Edecrin] 

ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] 

EZETIMIBE 10 MG TABLET [Zetia] 

FENOFIBRATE 150 MG CAPSULE [LIPOFEN] 

FLURANDRENOLIDE 0.05% LOTION [Cordran] 

IRBESARTAN 150 MG TABLET [Avapro] 

NILUTAMIDE 150 MG TABLET [Nilandron] 

OLMESARTAN MEDOXOMIL 20 MG TAB [Benicar] 

OLMSRTN-AMLDPN-HCTZ 20-5-12.5 [TRIBENZOR] 

OSELTAMIVIR PHOS 30 MG CAPSULE [Tamiflu] 

PARICALCITOL 1 MCG CAPSULE [Zemplar]

QUETIAPINE ER 150 MG TABLET [Seroquel] 

RASAGILINE MESYLATE 0.5 MG TABLET [Azilect] 

TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis] 

TOBRAMYCIN 10 MG/ML VIAL 

[Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate] 

VALGANCICLOVIR HCL 50 MG/ML [Valcyte] 

Check with your plan to find out what has changed or you can use the assistance tool below to get your free report.

Free Rx Review:

Name:

E-mail:

List your Prescriptions Below:

                

Having trouble using the form?  Click here.

Still have questions?

If you would like help comparing your needs against the many Medicare plans out there or if you just want to ask a few questions, you can call me directly at 207-370-0143 or use my simple form on the CONTACT 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 talk with me to discuss your options and review the plans that are available.  I am paid by the insurance companies in the form of a commission when you enroll in a plan.  You will not pay anything to meet with me and you will pay the same price for your insurance that everyone pays whether they had my help or not.

“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

 

What is a Special Needs Plan (SNP)?

Special Needs Plans are a type of Medicare Advantage plan that is specifically designed for people who meet certain eligibility criteria. These plans cater their benefits to serve the unique needs of its members.

There are three types of Special Needs Plans (SNPs) available:

Dual-Eligible Special Needs Plans (D-SNP) for individuals who are entitled to Medicare and who are also eligible for some level of assistance from a state Medicaid program or MaineCare.

Chronic-Condition Special Needs Plans (C-SNP) for individuals with one or more of the following conditions: diabetes, cardiovascular disorders, chronic heart failure and chronic lung disorders such as COPD.

Institutional Special Needs Plans (I-SNP): These plans serve those living in an institution (such as a nursing home) or who need nursing care at home.

If you fall into any of the categories above, you may have unique health-care needs that a Special Needs Plan may be better equipped to address.

For example, some Special Needs Plans offer a larger network of providers that specialize in treating your condition or lower costs for the prescription drugs typically prescribed for your particular illness.

Special Needs Plans benefits

Like other Medicare Advantage plans, Special Needs Plans are available through private insurance companies that are approved by Medicare. All Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B. Some Medicare Advantage plans may also cover benefits beyond what Original Medicare covers, and your Medicare plan options and benefits can vary, depending on where you live. You can read more about Medicare Advantage plans here.

Some Special Needs Plans include care-coordination services to help you better understand your condition and stick to your doctor’s treatment regimen. Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition.

Chronic-Condition Special Needs Plans may include provider networks with physicians and hospitals that specialize in treating the specific condition of its members, or they may have drug coverage that is tailored to include the prescription drugs that treat your illness.

If you’re enrolled in a Special Needs Plan for dual eligibles, there may be certain social services available to help you coordinate your Medicare and Medicaid benefits.

It’s important to note that you still get all the coverage that is otherwise included with Original Medicare, Part A and Part B, and Medicare Part D. The Special Needs Plan simply offers extra coverage to help you better manage your particular situation, whether that’s living in a nursing home; coordinating your Medicare and Medicaid benefits; or treating a serious chronic illness.

Getting help with costs

If you have both Medicare and Medicaid or if you have limited income, Medicaid may be able to cover some or all of your Medicare Advantage Special Needs Plan’s premiums and/or out-of-pocket costs. Depending on your income levels, you may qualify for a Medicare Savings Program, which can help pay for costs like premiums, copayments, coinsurance, or deductibles.

Contact your state’s Medicaid office for more information, or call 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week. Or contact me directly at (207) 370-0143 for help understanding all the benefits that are available to you.

Medicare Advantage Special Needs Plans costs

Depending on the Special Needs Plan, you will typically have the following costs:

  • Medicare Part B premium
  • Monthly premium for your Special Needs Plan (if your SNP requires it)
  • Extra monthly premium for prescription drug coverage (if your SNP requires it)
  • Extra monthly premium for additional benefits (if your SNP requires it)
  • Cost-sharing expenses, such as copayments, coinsurance, or deductibles*

*Please note: If you are a dual eligible, your Special Needs Plan can’t have higher cost-sharing requirements than you’d normally pay in Medicaid or Original Medicare, Part A and Part B.

Keep in mind that your specific costs may vary, depending on if you qualify for financial assistance or get both Medicare and Medicaid benefits.

Your out-of-pocket costs will also depend on the type of health-care services you need and how often you need them. Each Special Needs Plan is different so you should review the specific plan materials for the plan you’re considering to see exactly how much you’ll have to pay.

Make sure you pay particular attention to the differences in your cost sharing when you use the plan’s in-network doctors versus out-of-network doctors (if the plan allows you to go outside it’s network).

Enrolling in a Medicare Advantage Special Needs Plan

You can enroll in a Special Needs Plan once you’re first eligible for Medicare if there is a Special Needs Plan in your service area for your target group and you meet the eligibility requirements of that plan.

Most people are first eligible for Medicare during their Initial Enrollment Period, the seven-month period that starts three months before your 65th birthday, includes your birthday month, and ends three months later. If you qualify for Medicare because of disability, your Initial Enrollment Period starts three months before the 25th month that you are receiving Social Security or Railroad Retirement Board disability benefits and lasts seven months.

You can also enroll in a Special Needs Plan during the Annual Election Period from October 15 to December 7 of every year. During this period, you can enroll in a Special Needs Plan for the first time, switch plans, or disenroll from your plan.

Outside of these periods, you may be able to join a Special Needs Plan with a Special Election Period in certain situations. Some situations that may qualify you for a Special Election Period to enroll in a Special Needs Plan or make coverage changes include:

  • You are diagnosed with a severe or disabling condition: You can enroll in a Chronic-Condition Special Needs Plan for beneficiaries with your illness at any time, and your Special Election Period ends once you enroll in the plan.
  • You move into, currently live in, or leave a nursing home: You can enroll in a Special Needs Plan or switch plans at any time.
  • You qualify for Medicaid: If you have Medicaid or are newly eligible for Medicaid, you can enroll in a Medicare Special Needs Plan at any time.
  • You move outside of your Special Needs Plan’s service area: You can use a Special Election Period to switch to a new plan, or you’ll be automatically returned to Original Medicare.
  • Your Special Needs Plan leaves the Medicare program: You can use a Special Election Period to switch to a different Special Needs Plan.

Still have more questions?

Contact me for answers using this form –> https://www.mainemedicareoptions.com/contact

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

Have a question?  Need help understanding your options?  Call me.  I’m local and I can help you. 
Call (207) 370-0143 or call toll free 866-976-9038.
You can also use the BOOK APPOINTMENT(link is external) 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.  It’s up to you!
Book an appointment with Maine Medicare Options using SetMore

Do you need Dental or Vision Insurance?  Read this.

There is no obligation to you and no cost to meet with someone.

Having trouble paying for Medicare?

If you’re having trouble paying your Medicare Part B monthly premium then this article is for you.

If you are having trouble paying for your Medicare supplemental insurance or prescription drug costs then you need to read this article. –> Click here.

Medicare Savings Programs

Here is some information on Medicare Savings Programs, which can help you with the costs of both your Part B premium and your Part D prescription drug costs. These programs do not reduce the costs of your insurance premiums but may reduce some of the out of pocket costs such as co-pays to doctors, hospitals and ambulance as well as reduce your prescription drug costs.

Medicare Savings Programs (MSPs), also known as Medicare Buy-In programs, are state programs that assist you with paying your Medicare costs. The names of these programs may vary by state. In Maine the programs are often referred to as “Quimby” or “Slimby”.

These programs can pay up to 100% of your premiums, deductibles, coinsurance charges, and copayments.

There are three MSPs, (https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html#collapse-2625) each with different federal income and asset eligibility limits.

States can raise these limits to be more generous, which allows more people to qualify for the benefits.

All three MSPs cover your Part B premium, which means your monthly Social Security check will increase by the amount you currently pay for your Part B premium if you qualify for and enroll in one of these programs.

Qualifying Individual (QI)

QI pays for your Part B premium and provides three months retroactive Part B premium reimbursement from the month of application. Note: you cannot have Medicaid and QI.

Specified Low-Income Medicare Beneficiary (SLMB)

SLMB (“Slimby”) pays for your Part B premium and provides three month retroactive Part B premium reimbursement from the month of application. Note: you can have Medicaid and SLMB.

Qualified Medicare Beneficiary (QMB)

QMB (“Quimby”) pays for your Part B premium and Medicare deductibles, coinsurance charges, and copayments. If you have a Medicare Advantage Plan, QMB pays for your plan’s cost sharing.

The program also pays for your Part A premium if you do not qualify for premium-free Part A. It does not provide three months retroactive Part B premium reimbursements; benefits start the first of the month after the month you are approved for the program.

Note: you can have Medicaid and QMB, but you cannot buy a Medigap plan once you are enrolled in QMB. You can however enroll in a Medicare Advantage plan and take advantage of the additional benefits offered on those plans, such as Dental, vision and gym membership reimbursements.

To verify your eligibility, you need to verify that you meet the income and asset limits in your state.

In Maine

  • If you are single and your income is less than $1759 a month you may get help.
  • If you are married and your income is less than $2369 a month then you may get help.
  • If only one person in a couple wants the help, then the income limit may be as high as $2837 per month.
  • If you have earned income, the income limits may be higher.
  • Most assets do not Count. However, Liquid or cash assets greater than $58,000 for an individual and $87,000 for a couple will count. Liquid assets are those that are easy to convert to cash, such as checking/savings accounts, most retirement accounts, some annuities, etc.

You will apply at the Maine Department of Health and Human Services (DHHS).

In New Hampshire

See if you qualify: https://nheasy.nh.gov/#/screening

Apply online: https://nheasy.nh.gov/#/services/Medicare%20Beneficiary

For all Other States

To apply for an MSP, you will need to apply to your local Medicaid office or other state agency that receives MSP applications. You or a SHIP counselor can contact the local Medicaid office to learn how to apply. Many states allow you to submit your application online, through the mail, and/or through community-based organizations. Some states may require that you schedule an appointment and go in person to the Medicaid office to apply.  (https://www.medicare.gov/Contacts/)

What will you need to apply?

You will need to gather documentation for the application. The list of needed documents varies by state. Some examples of required documentation are:

  • Social Security card and/or Medicare card
  • Birth certificate or passport and driver’s license
  • Proof of address, such as a utility bill
  • Proof of income, such as a Social Security Administration award letter, pay stub, or income tax return
  • Information about assets, such as bank statements or life insurance policies

You should make a copy of any application before submitting it. Once you have applied, your state Medicaid program should send you a notice within about 45 days to let you know if your application was approved or denied.

If you are approved for the MSP, you should begin to receive benefits on the date listed on the notice you receive. If there are any issues with your benefit, or if you have not received any decision from your state within 45 days, you should contact the Medicaid office where you applied.

If you have any questions about how to apply or if you might qualify please contact us for help using this form –> https://www.mainemedicareoptions.com/contact

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

You can use the BOOK APPOINTMENT(link is external) 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

Are you turning 65 and still working?  Read this.

There is no obligation to you and no cost to meet with someone.

Dental & Vision Coverage

Medicare wasn’t designed to include coverage of routine dental care and coverage of expenses is very limited.

Here’s what you need to know.

For just over 50 years now, Medicare has provided health insurance coverage to America’s seniors. But dental coverage was never included in Original Medicare.

So even with a very solid health plan via Original Medicare + Medicare Supplement (Medigap) + Part D prescription drug coverage, dental care is an out-of-pocket expense.

Coverage for dental care is limited

Medicare’s coverage of dental expenses is limited to situations where the dental treatment is integral to other medical treatment (for example, an extraction prior to radiation treatment for oral cancer, or jaw reconstruction following an accident).

While health insurance plans generally pick up the tab for large medical bills, it’s rare to find dental coverage that doesn’t leave enrollees on the hook for significant bills if they need extensive dental work.

This is generally true across a wide range of plan types, including Medicare Advantage plans which often have added dental coverage or stand-alone dental plans which commonly have benefit maximums of $1,000 or $1,500 per year, and a single root canal can cost between $800 and $2,000, while an implant can be $2,000 to $3,000 per tooth.

But some coverage is better than nothing. Even with low benefit maximums, people who have dental insurance are more likely to receive routine preventive dental care, and are less likely to have untreated dental problems that get worse over time.

Sources of dental coverage

Some retirees can retain dental coverage from their former employer or a spouse’s employer. But there are other options available for seniors who don’t have access to employer-sponsored dental coverage.

Medicare Advantage is an alternative to Original Medicare for enrollees who want dental coverage. The three top plans in Maine offer some routine dental coverage and one plan offers additional comprehensive coverage.

If you’re considering Medicare Advantage instead of Original Medicare + Medigap + Medicare Part D, be sure to familiarize yourself with the pros and cons of both options.

Click here to learn more about the differences between Medicare Advantage Plans and Medicare Supplement (Medigap) Plans

Stand-alone dental plans are available for purchase, and some carriers offer dental plans that are specifically designed for seniors. But again, it’s typical for them to have relatively low annual benefit maximums (here’s an example of such a plan, offered by Delta Dental in Maine and New Hampshire – the benefit maximums range from $1,000 to $2,000 per year, depending on the plan selected, and the premiums range from $30 to $90 per year, including vision discounts).

For low-income seniors who are dual-eligible for Medicare and Medicaid, limited dental benefits (including dentures) may be provided by Medicaid, but coverage varies considerably from state to state.

Programs that can help

For seniors who have no dental coverage, a variety of programs can help them obtain dental care:

Dental schools will often provide treatment at a reduced price.

You can find a list of accredited dental schools in Maine or New Hampshire by clicking here: http://www.ada.org/en/coda/find-a-program/search-dental-programs

For low-income seniors, dental care is available on a sliding fee scale at community health centers. You can use this tool to find a community health center near you: http://findahealthcenter.hrsa.gov/

The Dental Lifeline Network (http://dentallifeline.org/our-state-programs/) coordinates dental care nationwide for elderly, disabled, and medically fragile populations. More than 15,000 dentists donate their time to provide dental care for patients who would not otherwise be able to afford treatment.

Many dentists offer payment plans, or will refer patients to a credit source, often with low initial interest rates. Read the fine print though, because interest rates can reach credit card-levels after the introductory period is over sometimes going up by as much as 30%!

Dental savings plans are readily available, without waiting periods or restrictions on their use. But they are not considered insurance, and they don’t pay anything on your behalf when you receive treatment.

Instead, dental discount plans simply utilize a network of dentists who agree to charge a reduced rate for plan members. And although some discount plans offer significantly reduced rates for routine care like x-rays and exams, they typically provide smaller rate reductions for more extensive dental work.

The good news is that they discounts are upfront and published before you enroll so you know what to expect. You can see the dental plans available in your area here.

Would you like 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 online form to send an email message. The best part about working with me is that it will not cost you anything to meet with me and have things explained to you. I am paid by the insurance companies in the form of a commission when you choose a plan and enroll. 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

Your Medicare coverage options

There are different ways to get Medicare health benefits.

  • Original Medicare (traditional fee-for-service coverage by the federal government) alone.
  • Original Medicare with supplemental insurance, like a Medigap or retiree plan or
  • A Medicare Advantage Plan

Original Medicare

If you are over age 65 then you are most likely eligible to enroll in Original Medicare (Part A and Part B). This is the traditional health insurance program run by the federal government. It allows you to go to almost any doctor or hospital in the country. Original Medicare covers most of the health services that you need. If you have Original Medicare, you can see any doctor or visit any hospital in the country as long as they accept Medicare payments.

Original Medicare does not over prescription drugs and there is no financial protection (out of pocket limit) with Original Medicare.

Medigap – Supplemental Insurance

To fill gaps in Medicare coverage, many people have additional insurance called supplemental insurance. You can get supplemental insurance from an employer or you can buy it from an insurance company in the form of a Medigap policy that specifically fills gaps in Medicare. Click here to learn more about Medigap plans.

Medicare Advantage (Part C)

Some people get their Medicare benefits through a Medicare Advantage Plan. Medicare Advantage Plans are sold by private insurance companies and offer Medicare benefits. A Medicare Advantage Plans can be a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point of Service (POS) plan, Provider Sponsored Organization (PSO), Private Fee-for-Service (PFFS) plan, Special Needs Plan (SNP), or Medicare Medical Savings Account (MSA). These plans must offer at least the same benefits as Original Medicare, but have different rules, costs, and coverage restrictions. Click here to learn more about Medicare Advantage Plans.

If you have health coverage from current employer or your union when you become eligible for Medicare, your coverage may automatically convert into a Medicare Advantage Plan. You have the choice to stay with this plan, choose Original Medicare, or switch to another Medicare Advantage Plan. Be aware that if you switch to Original Medicare or another Medicare Advantage Plan instead, the employer or union could terminate or reduce your health benefits, the health benefits of your dependents, and any other benefits you get from your company. Talk to your plan before switching to find out how your health benefits and other benefits will be affected. Click here to learn more about working after age 65.

Part D – Prescription Drug Plans

If you would like to get the Medicare drug benefit (Part D), you must choose Medicare drug coverage that works with your Medicare health coverage. If you prefer to have Original Medicare, choose a stand-alone drug plan that just offers drug coverage. Each of these plans are different and cover different drugs, they also negotiate their prices individually so the costs to you can vary widely. Choosing the right drug plan should be done with some assistance from a professional who understands these plans and can help you find the overall least expensive plan. Click here to read more.

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

How and When to Enroll in Medicare

You have several options when the time comes for you to enroll in Medicare. For some people, Medicare enrollment is automatic, while for others, it may depend on when and how they become eligible.

How to enroll in Medicare

You can enroll in Medicare Part A and/or Medicare Part B in the following ways:

  • Online at www.ssa.gov/medicare
  • By calling Social Security at 1-800-772-1213 (TTY users 1-800-0778), Monday through Friday, from 7AM to 7PM.
  • In-person at your local Social Security office. Find yours here: www.ssa.gov/locator/
  • If you worked for the railroad, enroll in Medicare by contacting the Railroad Retirement Board (RRB) at 1-877-772-5772 (TTY users 1-312-751-4701). You can call Monday through Friday, 9AM to 3:30PM, to speak to an RRB representative.

When to enroll in Medicare

There are a few situations where Medicare enrollment may occur automatically:
  • If you are receiving retirement benefits:
  • If you’re already collecting Social Security or Railroad Retirement Board retirement benefits when you turn 65, you will automatically be enrolled in both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).
  • If you are receiving disability benefits:
  • If you are under 65 and receiving certain disability benefits from Social Security or the Railroad Retirement Board, you will be automatically enrolled in Original Medicare, Part A and Part B, after receiving 24 months of disability benefits. The exception to this is if you have end-stage renal disease (ESRD). If you have ESRD and had a kidney transplant or need regular kidney dialysis, you can apply for Medicare. If you have amyotrophic lateral sclerosis (also known as ALS or Lou Gehrig’s disease), you will automatically be enrolled in Original Medicare in the same month that your disability benefits start.

If you are still working and don’t need Medicare Part B:

If you’re automatically enrolled in Medicare Part B, but do not wish to keep it you have a few options to drop the coverage. If your Medicare coverage hasn’t started yet and you were sent a red, white, and blue Medicare card, you can follow the instructions that come with your card and send the card back. If you keep the Medicare card, you keep Part B and will need to pay Part B premiums. If you signed up for Medicare through Social Security, then you will need to contact them to drop Part B coverage. If your Medicare coverage has started and you want to drop Part B, contact Social Security for instructions on how to submit a signed request. Your coverage will end the first day of the month after Social Security gets your request.
If you have health coverage through current employment (either through your work or your spouse’s employer), you may decide to delay Medicare Part B enrollment. You should speak with your employer’s health benefits administrator so that you understand how your current coverage works with Medicare and what the consequences would be if you drop Medicare Part B.

Medicare Part B late-enrollment penalty:

If you do not sign up for Medicare Part B when you are first eligible, you may need to pay a late enrollment penalty for as long as you have Medicare. Your monthly Part B premium could be 10% higher for every full 12-month period that you were eligible for Part B, but didn’t take it. This higher premium could be in effect for as long as you are enrolled in Medicare. For those who are not automatically enrolled, there are various Medicare enrollment periods during which you can apply for Medicare. Be aware that, with certain exceptions, there are late-enrollment penalties for not signing up for Medicare when you are first eligible.
One exception is if you have health coverage through an employer health plan or through your spouse’s employer plan, you can delay Medicare Part B enrollment without paying a late-enrollment penalty. This health coverage must be based on current employment, meaning that COBRA or retiree benefits aren’t considered current employer health coverage.

Medicare Initial Enrollment Period

For most people, enrolling in Medicare Part A is automatic. However, there are several instances where you may have to manually enroll in Medicare Part A and/or Part B during your Initial Enrollment Period (IEP), the seven-month period that begins three months before you turn 65, includes the month of your 65th birthday, and ends three months later.
Some situations where you would enroll in Medicare during your initial enrollment include:
  • If you aren’t yet receiving your retirement benefits:
  • If you are not yet receiving retirement benefits and are close to turning 65, you can sign up for Medicare Part A and/or Part B during your IEP. If you decide to delay your Social Security retirement benefits or Railroad Retirement Benefits (RRB) beyond age 65, there is an option to enroll in just Medicare and apply for retirement benefits at a later time.
  • If you do not qualify for retirement benefits:
  • If you are not eligible for retirement benefits from Social Security or the RRB, you will not be automatically enrolled into Original Medicare. However, you can still sign up for Medicare Part A and/or Part B during your IEP. You may not be able to get premium-free Medicare Part A, and the cost of your monthly Part A premium will depend on how long you worked and paid Medicare taxes. You will still have to pay a Medicare Part B premium.

Medicare General Enrollment Period

If you did not enroll during the IEP when you were first eligible, you can enroll during the General Enrollment Period. The general enrollment period for Original Medicare is from January 1 through March 31 of each year. Keep in mind that you may have to pay a late enrollment penalty for Medicare Part A and/or Part B if you did not sign up when you were first eligible.

Medicare Special Enrollment Period

You may choose not to enroll in Medicare Part B when you are first eligible because you are already covered by group medical insurance through an employer or union. If you lose your group insurance, or if you decide you want to switch from your group coverage to Medicare, you can sign up at any time that you are still covered by the group plan or during a Special Enrollment Period (SEP).
Your eight-month special enrollment period begins either the month that your employment ends or when your group health coverage ends, whichever occurs first. If you enroll during an SEP, you generally do not have to pay a late enrollment penalty.
The Special Enrollment Period does not apply if you’re eligible for Medicare because you have ESRD. Please also keep in mind that COBRA and retiree health coverage are not considered current employer coverage and would not qualify you for a special enrollment period.

Medicare Advantage plan enrollment

Medicare Advantage, also known as Medicare Part C, is another way to receive Original Medicare benefits and is offered through private insurance companies. At minimum, all Medicare Advantage plans must offer the same Medicare Part A and Part B benefits as Original Medicare. Some Medicare Advantage plans also include additional benefits, such as prescription drug coverage. You must have Original Medicare, Part A and B, to enroll in a Medicare Advantage plan through a private insurer.
You can enroll in a Medicare Advantage plan during two enrollment periods, the Initial Coverage Election Period and Annual Election Period.

Medicare Advantage plan Initial Coverage Election Period:

Most beneficiaries are first eligible to enroll in a Medicare Advantage plan during the Initial Coverage Election Period. Unless you delay Medicare Part B enrollment, this enrollment period takes place at the same time as your Initial Enrollment Period (IEP), starting three months before you have both Medicare Part A and Medicare Part B and ending on whichever of the following dates falls later:
The last day of the month before you have both Medicare Part A and Part B, or
The last day of your Medicare Part B Initial Enrollment Period.
If you’re under 65 and eligible for Medicare due to disability, your IEP will vary depending on when your disability benefits started.

Medicare Advantage plan Annual Election Period:

You can also add, drop, or change your Medicare Advantage plan during the Annual Election Period, which occurs from October 15 to December 7 of every year. During this period, you may:
  • Switch from Original Medicare to a Medicare Advantage plan, and vice versa.
  • Switch from one Medicare Advantage plan to a different one.
  • Switch from a Medicare Advantage plan without prescription drug coverage to a Medicare Advantage plan that covers prescription drugs, and vice versa.

Medicare Advantage Disenrollment Period:

You’ll have the opportunity to disenroll from your Medicare Advantage plan and return to Original Medicare during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. You cannot use this period to switch Medicare Advantage plans or make other changes. However, if you decide to drop your Medicare Advantage plan, you can also use this period to join a stand-alone Medicare prescription drug plan, since Original Medicare doesn’t include prescription drug coverage.
Outside of the Annual Election Period and the Medicare Advantage Disenrollment Period, you cannot make changes to your Medicare Advantage plan unless you qualify for a Special Election Period.

Medicare prescription drug coverage

Medicare prescription drug coverage is optional and does not occur automatically. You can receive coverage for prescription drugs by either signing up for a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage, also known as a Medicare Advantage Prescription Drug plan. Medicare prescription drug plans and Medicare Advantage plans are available through private insurers. Please note that you cannot have both a stand-alone Medicare prescription drug plan and a Medicare Advantage plan that includes drug coverage.

Initial Enrollment Period for Medicare Part D:

You can enroll in a stand-alone Medicare prescription drug plan during your Initial Enrollment Period for Part D. You are eligible for drug coverage if:
  • You live in a service area covered by the health plan, and
  • You have Medicare Part A AND/OR Medicare Part B.
Generally, your Initial Enrollment Period for Part D will occur at the same time as your Initial Enrollment Period for Medicare Part B (the seven-month period that starts three months before your eligibility for Part B, includes the month you are eligible, and ends three months later).
Once you are eligible for Medicare Part D, you must either enroll in a Medicare prescription drug plan, Medicare Advantage Prescription Drug plan, or have creditable prescription drug coverage (that is, drug coverage that is expected to pay at least as much as standard Medicare prescription drug coverage). Some people may choose to delay Medicare Part D enrollment if they already have creditable drug coverage through an employer group plan.
However, if you do not sign up for prescription drug coverage when you are first eligible for Part D, you may have to pay a late-enrollment penalty for signing up later if you go without creditable prescription drug coverage for 63 or more consecutive days.

Medicare Part D Annual Election Period:

If you did not enroll in drug coverage during IEP, you can sign up for prescription drug coverage during the Annual Election Period that runs every year from October 15 to December 7.
During AEP, you can:
  • Sign up for a Medicare prescription drug plan.
  • Drop a Medicare prescription drug plan.
  • Join a Medicare Advantage plan that includes prescription drug coverage.
  • Switch from a Medicare Advantage plan that doesn’t include drug coverage to a Medicare Advantage plan that does (and vice versa).
  • Outside of the Part D Initial Enrollment Period and the Annual Election Period, the only time you can make changes to prescription drug coverage without a qualifying Special Election Period is during the Medicare Advantage Disenrollment Period (MADP)–but only if you are dropping Medicare Advantage coverage and switching back to Original Medicare. The Medicare Advantage Disenrollment Period runs from January 1 to February 14.
Medicare Part A and Part B do not include prescription drug coverage, and if you switch back to Original Medicare during the Medicare Advantage Disenrollment Period, you will have until February 14 to join a stand-alone Medicare prescription drug plan.

Medicare Supplement Costs for Maine and New HampshireMedicare Supplement plans enrollment

Medicare Supplement Plans (or Medigap) are voluntary, additional coverage that helps fills the gaps in coverage for Original Medicare. The best time to enroll in a Medicare Supplement plan is during your individual Medigap Open Enrollment Period, which is the six-month period that begins on the first day of the month you turn 65 and have Medicare Part B. If you decide to delay your enrollment in Medicare Part B for certain reasons such as having health coverage based on current employment, your Medigap Open Enrollment Period will not begin until you sign up for Part B.
During your Medigap Open Enrollment Period, you have a “guaranteed-issue right” to buy any Medicare Supplement plan you choose. This means that insurance companies cannot reject your application for a Medicare Supplement plan based on pre-existing health conditions or disabilities. They also cannot charge you a higher premium based on your health status. Outside of this open enrollment period, you may not be able to join any Medicare Supplement plan you want, and insurers can require you to undergo medical underwriting. You may have to pay more if you have health problems or disabilities.
Medicare Supplement plans, like Medicare Advantage plans, are offered through private insurance companies, and are available for purchase through brokers like myself.

Do you have more questions?

Call me today at (207) 370-0173 or use the form on the CONTACT page by clicking here to send me an email to get answers to your Medicare questions or to discuss the Medicare plan options that may be right for you.
Book an appointment with Maine Medicare Options using SetMore
The best part about working with me is that it will not cost you anything to talk with me to discuss your options and review the plans that are available. I am paid by the insurance companies in the form of a commission when you enroll in a plan. You will not pay anything to meet with me and you will pay the same price for your insurance that everyone pays whether they had my help or not.

“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.”

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