You don’t get Medicare because you want it. You must be eligible for Medicare. Medicare eligibility doesn’t mean you can enroll in Medicare whenever you wish. You can only enroll in Medicare during specific periods under particular circumstances.
These special times are called election periods, each governed by criteria and circumstances. You must meet specific criteria to be eligible for Medicare and can enroll in Medicare during a specific time period or circumstance.
Congress passed the Consolidated Appropriations Act of 2021 (CAA), which expanded, streamlined, and made Medicare eligibility and enrollment easier.
Two areas of change are very relevant to newbies going on Medicare in 2023.
The Last 3 Months of Medicare Initial Enrollment
You have probably heard you have seven months to enroll in Medicare—3 months before your 65th birthday, the month of your 65th birthday, and 3 months after your 65th birthday. This is referred to as your Initial Enrollment Period. The problem for years was a bizarre rule when you enroll during the last 3 months of this period that affected your Medicare eligibility.
The old rule was if you enrolled during the 3 months before your 65th birthday, Medicare started the month you turned 65. That remains the same. For example, your 65th birthday is in July. Your Medicare will start in July if you enroll in April, May, or June.
If you enrolled during the 3 months after your 65th birthday, Medicare did not start until 2 months later for month 5, 3 months later for month 6, and 3 months later for month 7. For example, if you enroll in August, Medicare starts in October. You enroll in October, Medicare starts in January. Crazy.
Now when you enroll during the last 3 months, Medicare starts immediately the following month. For example, if your 65th birthday is in July and you enroll in Medicare in August, Medicare starts September 1st instead of October 1st.
Or if your 65th birthday is in July and you enroll in Medicare in September, Medicare starts October 1st instead of December 1st.
This makes way more sense. It shortens the waiting time and prevents lapses in coverage from employer health plans ending on an immovable date. Not sure why this Medicare eligibility wasn’t fixed years ago.
Medicare General Enrollment Period Eligibility
Over the years, a few people came to me who missed enrolling in Medicare when they were first eligible. Consequently, they were assessed the famous Medicare 10% penalty compounded for each year without Medicare, but more importantly, their Medicare eligibility was affected. They could not start their Medicare health coverage until months later.
Quite often, they have no health coverage for months. They are entirely on their own, paying for any medical services out of their own pocket.
Imagine you are 67 and decide it’s time to get on Medicare. You retired a few years back but never signed up for Medicare or had any other health insurance. You cannot just show up at the Social Security office, sign up for Medicare and have it start the next month. You must wait until the General Enrollment Period from January 1st—March 31st. This is just for enrollment. Medicare then did not start until July 1st, and you could only purchase a Part D drug plan and/or Medicare Supplement. No Medicare Part C/Medicare Advantage until January 1st. Not sure about the confused thinking behind such a bad rule.
In 2023, when a Medicare beneficiary signs up for Medicare during the General Enrollment Period, Medicare coverage starts on the 1st of the following month. For example, if you sign up in February, Medicare starts March 1st. You don’t need to wait anymore until July 1st for Medicare to start.
People constantly complain about how confusing Medicare is. Medicare rules, however—believe it or not—remain very constant over time. These two rule changes from the Consolidated Appropriations Act of 2021 (CAA) are unusual because Medicare does not change much. These new rules about Medicare eligibility and enrollment periods are a welcome adjustment to how Medicare operates.
The Bottom Line On Medicare Eligibility & Enrollment
When you do not deal with Medicare rules daily, they feel overwhelming. I understand and sympathize. Also, understand Medicare eligibility and the ability to enroll in Medicare is critical. There is no room for mistakes.
You want to know how Medicare works, the rules, and the intricacies so that you have the best possible Medicare health coverage.
You can also just call us rather than trying to remember the Medicare eligibility and enrollment rules. We listen to your situation and provide the most up-to-date and relevant Medicare information.
Call 402-614-3389 to speak with an experienced insurance professional and licensed agent.
Medicare is superb health insurance. The coverage is the most comprehensive of any health plan. The cost is incredibly low for the consumer. The medication portion, unfortunately, which has been relatively new since 2006, is not as good as most employer-provided drug coverage, at least for the Medicare demographic. Consequently, Medicare continually evolves, so the 2023 Medicare changes for drugs are significant.
Does Medicare Cover Insulin?
Medicare has covered insulin for a long time, but the cost to consumers has gone through the roof over the years. Under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) announced Medicare changes in 2021 that covered 1,750 Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage. The plans would reduce insulin prices under the Senior Savings Model. Medicare beneficiaries would have access to a broad range of insulins at a maximum copay of $35 per month. The program, however, was voluntary.
The Inflation Reduction Act (IRA) law the Biden administration sponsored significantly changed Medicare for 2023. The IRA law set a cap of $35 for insulin that Medicare Part D prescription drug plans offered. The insulin price reduction act went into effect in 2023.
Not all, but many insulin medications to combat diabetes are capped at $35 per month.
Medicare Changes Insulin Prices in 2023
The $35 insulin cap is for both Medicare Part B and Part D. Most people get their insulin medications through their Medicare Part D prescription drug plan. They pay the monthly plan premium and a copay when they pick up their insulin. In the past, the copays were significant. Now insulins on Medicare prescription drug plans in 2023 changed to $35 per month.
What Are 2023 Changes to Insulin Covered by Medicare Part B?
Many others use insulin delivered through an insulin pump that people wear. The pumps are considered durable medical equipment and are billed under Medicare Part B. Part B has a deductible and an unlimited 20 percent coinsurance. However, when paired with a Medicare supplement, like Plan G, the 20 percent coinsurance is wholly covered. After a small Part B deductible is met, the beneficiary pays nothing for the pump or insulin.
What About Disposable Insulin Patch Pumps?
Insulet Omnipods are very popular. It is a disposable insulin “patch” pump. The disposable pump is a small wireless, tubeless pump worn directly on the body. Beneficiaries get the refills for the Omnipod under the Part D prescription drug plan, not Part B.
The Medicare change for 2023 is insulin refills will be $35 or less.
The patch pump, however, is considered a durable medical device, which falls under Part B. The device will be covered like any other durable medical equipment with no price controls. What you pay is determined by your plan.
How Does Medicare Change Deductibles in 2023 For Insulin?
Most Medicare Part D prescription drug plans and many Medicare Advantage plans with prescription coverage have deductibles. The deductibles aren’t going anywhere; they still exist. However, the deductible no longer applies to covered $35 insulin medications. In other words, Medicare beneficiaries do not have first to meet the deductibles of $505 before they start paying $35 for insulin. This is significant.
Many times the large deductible is an insurmountable obstacle for some clients when they go to the pharmacy to pick up their medication for the first time. They choose not to get their essential medication because of the cost.
I always show clients the prices when we meet. I’m not sure what happens from the showing to when some actually pick up the medication at the pharmacy, but I have fielded many a phone call–“I can’t afford $$$$!”
Medicare changed the rule for $35 insulin on January 1, 2023, to no deductible.
Reimbursement When Overcharged for $35 Insulin
Mistakes happen. If you are charged more than $35 per month for an insulin medication that is part of the program, the Part D plan must reimburse you within 30 days. The insurance company is responsible for the reimbursement. Contact the plan. The customer service 800-number is on the back of your Part D medical card.
Pharmacies Don’t Matter for $35 Insulin.
When I meet with clients, I always show how different pharmacies will affect drug copays. The effect of pharmacies on cost is essential to know if you wish to maximize your Part D plan and pay the least.
Drug plans sign contracts with different pharmacy chains and networks. As part of the deal, copays are lower if you go to one of the plan’s preferred pharmacies versus a non-preferred pharmacy.
Whether a preferred or non-preferred pharmacy, the insulin on the Medicare Part D plan will be $35. Many of my clients have a favorite pharmacy that may not be in the network—non-preferred. It is good to know, wherever you pick up your $35 insulin; it will be $35 insulin.
Not All Medicare Insulin Is $35
Medicare Part D prescription drug plans create formularies, a list of the medications the plan covers. The medications are put in tiers that determine copays and deductibles. Medicare requires the insurance companies to cover at least two medications in each category. Sometimes companies make choices, like covering Humalog insulin types but not Novolog insulin. The new law requires the plan to keep insulin at $35, but only insulins the plan carries. Not every brand or type. This is important in selecting a Part D plan. You need to know which brands and types of insulins are covered under a particular plan. And plans can change and often do change drugs on the formulary from year to year.
We always run clients’ medications when we meet to ensure they have the lowest cost plan for their specific list of medications. During Annual Election Period (AEP) Oct 15th–Dec 7th, we re-run clients’ medications to make sure they still have the best plan for them. If necessary, we change their plan.
No Medicare Change in 2023 for Non-Insulin Anti-Diabetic Drugs
While Medicare’s $35 insulin is a tremendous financial relief for Medicare beneficiaries who are diabetic, other medications are equally important to improve and maintain glycemic control. Some popular non-insulin and anti-diabetic medications are Trulicity, Bydureon, Ozempic, and Victoza. Oral and injectable (non-insulin) pharmacological options are available for treating diabetes. Medicare, however, did not change the pricing for these medications for 2023. They are not part of the price reduction program currently.
Special Election Period Because of $35 Insulin
The $35 insulin for Medicare beneficiaries is a new regulation, so Medicare has allowed a special enrollment period for “Exceptional Circumstances.” The rule is only for those who are on insulin. You have a one-time opportunity to change your Medicare Part D prescription drug plan from December 8, 2022, until December 31, 2023. The reason is to take advantage of the favorable pricing for insulin medications.
Again, the ability to change Part D plans is only for those on insulin medications, a one-time opportunity during this period.
True Out-of-Pocket Costs Carry Over
Each of the Medicare Part D prescription drug plans track the amount the beneficiaries pay and what the plan pays. These amounts determine where the beneficiaries are in the four stages. This calculation is called True Out-of-Pocket (TrOOP) costs.
Remember, there are four phases in pricing for Medicare Part D prescription drug plans: deductible, initial phase, the gap (or Donut Hole), and catastrophic phase. Switching Part D plans during the year does not mess this up. You do not start over again. The amounts, totals, and placement within Part D plan phases transfer to the new plan.
If you are in the gap phase in one plan, you will be in the same phase and place in the new plan. You did not lose your place or are forced to start over again.
Medicare Changes the Catastrophic Phase in 2023
The fourth phase in the four stages of tracking Part D prescription drug costs is called “Catastrophic.” When a beneficiary reaches the catastrophic phase, they and the plan have paid out approximately $7,400 in out-of-pocket costs between the beneficiary and the plan. The actual out-of-pocket for the beneficiary is $3,100. The prescription costs are usually minimal unless it is an expensive medication. The coinsurance in the catastrophic phase for expensive medications is an unlimited 5 percent, and 5 percent of a large amount is still significant for most pocketbooks.
The effect of the new legislation in 2024 is beneficiaries will no longer pay the unlimited 5 percent. The out-of-pocket cost will stop at a hard cap of $3,250 out-of-pocket max for beneficiaries. While still not a small amount, it is significantly less than what some beneficiaries paid who were on costly medications in previous years.
Medicare Part D Annual Limit In 2025
The Inflation Reduction Act (IRA) mandates that the annual limit of the Medicare Part D prescription drug will be $2,000 starting in 2025 and indexed for inflation yearly after that. Part D expenses are not currently capped. This Medicare change starting in 2023 is enormous.
I think of my clients on various insulins, anti-diabetic medications, Eliquis for the heart, Humira & Enbrel for rheumatoid arthritis. Their costs have been thousands of dollars for years. That will stop.
The Medicare Part D $2,000 cap is for all tiers of drugs. The limit is for all medications on the plan’s formulary, and the $2,000 limit is for all Medicare beneficiaries regardless of past or current income. IRMAA does not apply.
Inflation Cap on Part D Premiums
The law also includes a 6 percent limit on Part D premium increases. With current inflation around 6 percent now and medical costs usually at a higher rate of inflation growth than regular inflation, how the system will really work is yet to be seen.
Smoothing Part D Out-of-Pocket Costs
Another challenge with Medicare Part D prescription drug expense is the ups and downs of the costs.
One month the cost may be $1,000, and the next month is $100. Most consumers’ incomes are consistently the same each month, and large spikes in expenses create extreme hardship.
The IRA law offers an option for “smoothing” the payments evenly over the year.
In 2025 when the medication copays are set at a total out-of-pocket of $2,000 per year, “smoothing” would look like a $167 monthly payment for those on medications that reach the cost cap.
The smoothing idea aims to reduce prescription abandonment, dosage reductions, and delays in treatment because of high-cost specialty drugs. I had gotten phone calls too many times from the pharmacy when a client went to pick up a medication during the deductible phase. “I can’t afford $500 for this #%&* drug!” I explained their cost would not be $500 every month. They are in the deductible phase. Clients tell me they can’t afford the drug, so they leave it at the pharmacy. Not good.
The Bottom Line For 2023 Medicare Changes
The Medicare Part D prescription drug program has evolved since its inception in 2006. The Inflation Reduction Act (IRA) introduces significant changes to Medicare from 2023 to 2025. The law addresses the growing senior population dependent upon insulin and its rising cost. The IRA law reduces costs for those on limited incomes to afford critical life-sustaining medications.
It is essential to be aware of these new rules to benefit from them and get the proper medications to enhance your life’s quality.
Many years ago, I was still new to the Medicare insurance business. I had a few hundred clients but no high-income earners. I knew what Medicare IRMAA was, but I had never met someone subject to the IRMAA tax before. Doug was an improbable candidate. After many years and thousands of clients later, I definitely know what Medicare IRMAA is in 2023.
Don’t Judge A Book by Its Cover
Doug showed up at my office on a loud Harley Davidson hog. His hair was longer than mine, but that’s saying nothing. He was a big dude, and his leathers made him even bigger. We sat down and took care of Medicare business.
A few months later, when Doug’s Medicare started, I got a distressed phone call. “You said my Medicare premium was going to be this amount. It’s three times that!”
I was befuddled. I got my calculator out, but I couldn’t figure out why it was so high. Finally, I said, “Your income would have to be unusually high to be charged that much.”
Doug got quiet. “How high?” he asked. The first IRMAA bracket was $85,000 for a single person at the time. Doug guffawed and said, “Hell, my income is way more than that.”
Turns out Doug was not only a retired municipal employee with a pension and Social Security. He was also retired military with a 20-year pension. On top of that, he had built up a stock portfolio that kicked out around $30,000 in dividend income a year.
I should have taken the adage, ‘Don’t judge a book by its cover’ more seriously.
Since then, I always bring up income in my introductory meetings and how income affects Medicare Part B premiums. Zip code and fashion choices are no guaranteed ways to determine Medicare IRMAA in 2023.
What Is Medicare IRMAA in 2023?
IRMAA stands for Income Related Monthly Adjustment Amount. The government loves acronyms. Medicare IRMAA is a surcharge that high-earners pay for their Medicare insurance coverage to Social Security.
Everyone pays a tax for Medicare during their working years. The Medicare tax is included in the FICA (Federal Insurance Contribution Act) you pay, and that is recorded on your pay stubs. Your Medicare tax is currently 1.45%. It is graduated up for higher earners.
In 1966 when the Medicare program began, the cost to workers was $3 per person per month, which is approximately $30 in today’s dollars. The baby boomers are leaving the workforce in huge numbers, so fewer workers are paying the Medicare tax. Medicare tax revenue is dropping in relation to the number of beneficiaries.
As they leave the workforce, Baby Boomers enter Medicare. The number of workers paying in is contracting, and people taking out is ballooning. Expenses are climbing. The current demographics are crushing Medicare’s ability to provide the same level of services because expenses are outpacing tax revenue.
Medicare Prescription Drug Improvement & Modernization Act
In 2003 Congress passed the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). In the legislation, Congress addressed the coming shortfall in Medicare revenue. The answer was to raise the price of Medicare for the top 7 percent of earners. There are currently 65 million Medicare beneficiaries. IRMAA will affect approximately 4.6 million people in 2023.
I don’t say tax because, technically, it is not a tax.
Most Medicare beneficiaries pay less than 25 percent of the real Medicare cost. The current Part B premium is $164.90. That is only about a fifth of the actual cost. In the MMA, Congress increased the amount a citizen paid for their Medicare insurance based on their income. The IRMAA increases the percentage that upper-income Medicare beneficiaries pay. Instead of paying only 25 percent of the cost, they pay 35, 50, 65, 80, or 85 percent of the actual Medicare Part B cost. The additional revenue is allocated to offset Medicare’s budget.
How Do the IRMAA Brackets Work?
Medicare IRMAAs is an unusual calculation compared to federal income tax brackets.
You do not pay a federal income tax rate on everything you make. The government divides your taxable income into chunks — also known as tax brackets — and each chunk gets taxed at a progressively higher rate. The beauty of this is that no matter which bracket you’re in, you won’t pay that tax rate on your entire income. It is only the “chunk” in that bracket that is taxed at that rate.
Medicare IRMAA in 2023 utilizes a “cliff” style of assessment instead. That means if you are just $1 over the cut-off for the next tier of IRMAA, you will pay the higher amount. There are no brackets for each chuck of income like federal income tax and no graduation or progression in the amount you pay. The Medicare 2023 Part B IRMAA premium brackets change when you earn one dollar more above the line.
What Is Medicare IRMAA Based Upon?
The IRS and Social Security work with Medicare. Your income is based on your most recent tax filing. So, for example, you are going on Medicare in 2023. The most recent tax filing was in 2022 for 2021. Generally, IRMAA is based on a two-year lag in your income.
How Is Medicare IRMAA Calculated in 2023
Medicare IRMAA 2023 brackets are derived from your adjusted gross income (AGI). The AGI, however, differs from the MAGI (Modified Adjusted Gross Income) you usually think of when doing your taxes. AGI for IRMAA is a Medicare-specific form of MAGI. It is your AGI with tax-exempt bonds–both earned and accrued interest–added back. Interest from U.S. Savings bonds used for higher education is added back. Earned income from working abroad that was not added to gross income is included. MAGI (Modified Adjusted Gross Income) for Medicare is different than what is usually meant by MAGI for non-healthcare-related purposes.
You will be sent your Medicare IRMAA Initial Determination Notice soon after you enroll in Medicare Part B. Confirm the numbers SSA/CMS/IRS are correct.
Medicare Financial Planning
Examine the Medicare IRMAA 2023 brackets to see if you are close to any of them. What are your plans for the future? Will you withdraw from retirement savings this year or in future years? Will you sell your home at some point to downsize or move to a one-story home? Will you sell a large amount of stock, property, or other appreciated assets?
Any of these actions may increase your income substantially enough to move you into and/or up the IRMAA brackets requiring you to pay more. Knowing and planning for these events, you can move assets in smaller amounts over time to avoid large spikes in income and, consequently, increases in income tax and IRMAA.
How Do I Reduce Medicare IRMAA?
Charitable donations of cash, appreciated assets, and appreciated stock can reduce your taxable and IRMAA surcharge as well as contributions to 401ks, IRAs, and other qualified programs. Some minor adjustments may drop you down a bracket and save you some money.
What Are Medicare IRMAA Brackets for 2023?
Since 2007 some Medicare beneficiary’s Part B monthly premium included a surcharge based upon income. The Medicare IRMAA for 2023 is in the table below.
|Couple||IRMAA Surcharge Part B||
Total Monthly Premium
|Less than $97,000||Less than $194,000||$0.00||$164.90|
|$97,000 < $123,000||$194,000 < $246,000||$65.90||$230.80|
|$123,000 < $153,000||$246,000 < $306,000||$164.80||$329.70|
|$153,000 < $183,000||$306,000 < $366,000||$263.70||$428.60|
|$183,000 < $500,000||$366,000 < $750,000||$362.60||$527.50|
|Greater than $500,000||Greater than $750,000||$395.60||$560.50|
Since 2011, higher-income Medicare beneficiaries have paid a surcharge on top of their Medicare Part D premium. The Medicare IRMAA for 2023 for prescription drug plans is in the table below. This does not include premiums for specific Medicare Part D plans, Medicare supplements, or Medicare Part C/Medicare Advantage plans. The totals only reflect Part B premium and Medicare IRMAA 2023 surcharges. These IRMAA surcharges for Part D are a completely different idea from the Part D Gap (or Donut Hole).
|Couple||IRMAA Surcharge Part D||
Total Monthly Premium
Part B & Part D
|Less than $97,000||Less than $194,000||$0.00||$164.90|
|$97,000 < $123,000||$194,000 < $246,000||$12.20||$243.00|
|$123,000 < $153,000||$246,000 < $306,000||$31.50||$361.20|
|$153,000 < $183,000||$306,000 < $366,000||$50.70||$479.30|
|$183,000 < $500,000||$366,000 < $750,000||$70.00||$597.50|
|Greater than $500,000||Greater than $750,000||$76.40||$636.90|
Are There Exceptions to Medicare IRMAA Brackets?
No exceptions if your income falls within one of the tiers, but IRMAA has a two-year lag between when you filed your income tax and what Social Security Administration (SSA) assesses you. A lot can affect your income in that time, so SSA considers “life-changing events” when applying the IRMAA surcharge.
- Death of a Spouse
- Divorce / Annulment
- Work Reduction
- Work Stoppage
- Loss of Income from Property
- Loss or Reduction of Pension income
- Employer Settlement Payment
Death of a Spouse
Losing a spouse is tragic. The other effect is your income may be reduced because they are no longer bringing in income: Social Security and/or work income.
You will need to file the SSA-44 form with proof of death and an estimate of your new income for that year due to your loss.
The first IRMAA bracket is for income over $97,000 for a single individual. The first IRMAA tier for joint filers is over $194,000. Marriage may dilute your total income, so you fall below the IRMAA joint bracket. No need to overpay.
In that case, file the SSA-44 form with proof of marriage. Give an estimate of your new joint income. You will not need to pay the tax that year or less because you move down an IRMAA bracket.
Divorce / Annulment
Divorce or annulment can have the opposite effect. The IRMAA is based only on your income. You are now single, and your income may have been significantly reduced. Subtract your ex-spouse’s income. That may put you below the $97,000 threshold or lower your bracket. Don’t overpay.
In that case, file the SSA-44 form with the divorce decree and an estimate of your newly reduced income.
Many times as I help clients move toward Medicare and retirement, they continue to work. But, they work less. Or they get a part-time job.
If I ever retire, my part-time gig will be at the local golf course. I have had several friends and clients do that–for the free golf. The perfect retirement job!
If your income drops below $97,000/$194,000 or one of the other tiers, quickly complete the “Life-Changing Event” form so you only pay what is necessary. Complete the SSA-44 with proof, such as pay stubs, employer statements, or other reduced income documentation.
Work stops when you retire. It also stops when laid off or fired. The company is sold or shuddered. Illness or injury can stop you from working. All of which drastically affect your income.
Include any documentation, like correspondence from your company, public notices, and minutes from corporate board meetings, medical bills with your SSA-44 form to Social Security.
Loss of Income from Property
This one is undoubtedly applicable because of the COVID situation. Many landlords lost significant income when renters were not required to pay for long periods.
Income may be lost because of natural disasters, destruction of property through fire, or accidents. I remember a friend who had disease run through his hog confinements. He lost tremendous amounts of income for a year. Submit supporting documentation with SSA-44 to SSA.
Loss or Reduction in Pension Income
Some organizations will distribute a pension for a fixed period of time, such as 20 years. The pension income ends, and then you go on Medicare. The IRA, however, has that income included in your last tax return. You will need the appropriate documentation with the SSA-44 to appeal.
Employer Settlement Payment
Businesses close all the time. Some businesses do not end well. Suppliers are owed money. Banks and shareholders are owed money. Employees are stiffed for months of salary, commission, or other forms of remuneration. There eventually may be a lump sum settlement that comes, which raises your income in that year. Again, another life-changing event that will grant an exception. Documentation is essential.
Depending upon your IRMAA bracket, you will be paying at least $937 per year or more. Don’t pay that if you don’t have to. The appeal process is reasonably simple and straightforward if you qualify with one or more life events. No need to pay more than your fair share.
The Bottom Line On Medicare IRMAA in 2023
Medicare has rules. Lots of rules, including how much you pay if you are successful in our country. We are about helping you navigate the rules, and in the case of Medicare IRMAA for 2023, making sure you do not pay one penny more than is required.
If you fall into one of the Medicare IRMAA brackets, talk with your financial planner and tax consultant about minimizing the damage. Get started positioning assets well before 65 and have a plan to move yourself down the Medicare IRMAA brackets.
If you fall into one of the “Life Changing Event” categories, do not ignore the opportunity. Fill out the form, attach the documentation, and get your exemption.
We are licensed and experienced insurance professionals. This may be your first Medicare IRMAA rodeo this 2023. It is not ours. Give us a call and speak with a licensed agent at 402-614-3389.
Medicare has lots of rules and regulations. The insurance companies and the State Insurance Commissioners have even more laws. The Medicare supplement 30-day free look period is one of those rules.
Medicare Supplements are called Medigap policies because filling in the gaps is precisely what they do. They fill in the gaps in Original Medicare. Supplements fill in the Part A deductible and Part B coinsurance.
You pay a monthly premium for a Medicare Supplement, and as you age and medical costs increase, the private insurance companies that provide Medigap policies raise rates.
Some companies raise rates higher and faster than other insurance companies, so you may want to change policies. There are rules around changing Medigap policies, and knowing the regulations is essential, like the Medicare supplement free look period.
Medicare Open Enrollment Rules
People often think “Open Enrollment” or “Annual Election Period,” which is from October 15th—December 7th, is when you need to change your Medicare Supplement. You may change then, but it is not a particular time for that purpose. A person will still need to undergo health underwriting to qualify for the new supplement. Preexisting conditions may prevent the person from passing underwriting.
The Open Enrollment for Medicare Supplements is when you turn 65 and/or activate your Medicare Part B. During that period, you are exempt from answering health questions. The insurance company needs to offer you a supplement at the best possible rate no matter your health condition at the time.
The other time you can change Medicare Supplements is by filling out an application and answering the health questions. Most people pass underwriting, but not all. A recent heart attack, stroke, or bout with cancer is an example of why an insurance company would deny new coverage. There are other preexisting conditions that will disqualify an applicant. Of course, you can remain on your current supplement if you continue to pay premiums. Medigap policies are guaranteed renewable.
Medicare Supplement Free Look Period
When you change to a Medicare Supplement, you have a 30-day free look period. During that time, you can cancel the policy without any reason, and the insurance company must return your entire premium without question. If you have another Medicare Supplement, you may wish to continue paying the premium simultaneously. If you cancel the original plan, you may have to go through underwriting to reinstate it.
Medicare Free Look: No Fear
The free look period for a Medicare Supplement, like any insurance product, is to encourage the consumer to purchase because of less fear about changing one’s mind.
There are a few other instances when someone might change to a new Medicare Supplement, and the free look period would also apply in those instances.
Guaranteed issue is when someone is coming off an employer’s group health plan and already has Medicare Part A & B. You have 63 days to enroll in a Medicare Supplement without underwriting.
Another situation is enrolling in a Medicare Advantage plan for the first time. You have a 12-month window when you can change to a Medigap plan without underwriting.
Another rare situation is when an insurance company closes its Medicare Advantage plan in your service area. You are afforded a guaranteed issue opportunity for a Medicare Supplement.
Certain states have laws specific to them. You can change your Medicare Supplement on your birthday without underwriting (California, Oregon, Idaho, Nevada, Illinois, Louisiana), on your anniversary without underwriting (Missouri), and year-round without underwriting (New York, Connecticut, Massachusetts, and Washington). There is no such regulation in Nebraska or Iowa for Medicare Supplements.
Again with any of these transitions, the Medicare Supplement 30-day free look period applies.
Over the years, I have had clients change their minds at the last minute. To change with them, the Medicare Supplement, free look period, makes the process easier and less cumbersome.
You have 30 days to look. No fear.
Medicare has had an exciting history with prior authorization. Medicare prior authorization has become controversial over the years because of Medicare Advantage.
Have You Always Been Subject to Prior Authorization?
Health plans started using prior authorization in the 1960s. Hospital admittance grew after the creation of Medicare and Medicaid. At the same time, more employers began offering employees health insurance as part of their compensation package. Medical costs grew significantly, particularly hospital stays.
Insurance companies began implementing utilization reviews in the 1960s. Utilization reviews were a process to reduce the overutilization of resources and identify waste. Registered nurses initially performed utilization reviews in hospital settings. The skillset gained popularity within the health insurance industry as research grew around medical necessity, misuse, and overutilization of services.
Health plans reviewed claims for medical necessity and hospital length of stay. Health plans began to require physicians to certify the admission and subsequent days after admission to help contain costs. Prior authorization originated from the use of utilization reviews.
Fast-forward to the present day. You were subject to prior authorization when you entered the workforce and received employer-provided group health insurance as a benefit. The insurance company determines if it is “medically necessary” and covered by the policy your company purchased when you have any medical procedure. Then there is further discussion about the appropriate charges. Whether or not you were aware of it, prior authorization has always been part of your health insurance coverage.
Why Do Insurance Companies Use Prior Authorization?
Prior authorization is a medical management tool. Doctors and insurance companies work together to ensure that a specific treatment or service is the best option for the patient’s needs.
The purpose of prior authorization is to identify and discourage unnecessary and costly low-value services to reduce wasteful spending without impeding quality healthcare services.
Prior authorization, supervision, audits, and other compliance tools help identify and root out fraud, waste, and abuse in the healthcare system. The ultimate purpose is to reduce costs for the consumer and prevent unnecessary treatments.
The Department of Justice announced today (Feb 17, 2021) criminal charges against 138 defendants, including 42 doctors, nurses, and other licensed medical professionals, in 31 federal districts across the United States for their alleged participation in various healthcare fraud schemes that resulted in approximately $1.4 billion in alleged losses.
The charges target approximately $1.1 billion in fraud committed using telemedicine, $29 million in COVID-19 healthcare fraud, $133 million connected to substance abuse treatment facilities or “sober homes,” and $160 million connected to other healthcare fraud and illegal opioid distribution schemes across the country.
While most doctors, medical professionals, and medical facilities are honest and act with integrity, an element will always and continually seek illicit gain costing consumers and taxpayers untold amounts. This results in higher insurance premiums and medical costs. It is naive to believe all are good actors and that every recommended treatment and service is the best fit.
Why Does Original Medicare Not Use Prior Authorization?
In part, the Medicare prior authorization controversy is that “Original Medicare” does not require prior authorization for most procedures, and Medicare Advantage does. (Original Medicare is just Medicare Part A and Part B. The payment structure is called fee-for-service. Medicare Advantage (or Part C) is Medicare administered by a private insurance company contracted and approved by Medicare.)
At first glance, you probably ask, ‘Why does Original Medicare not require prior authorization’ because prior authorization is common practice in the health insurance world? No company will leave the decision to spend potentially tens of thousands of dollars, even millions, to one person without some oversight.
When Medicare was established, Congress included certain arrangements and excluded others. In Section 1862(a)(1)(A) of the Social Security Act:
“No payment may be made under Part A or Part B for any expenses incurred for items or service which . . .. are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed member . . ..”
The key phrase is “reasonable and necessary.” “Reasonable and necessary” has been interpreted over the years very broadly. If a submitted claim is in an allowed category and not excluded, the submission is “reasonable and necessary.”
The doctor authorizes an MRI of the shoulder because the patient complains of problems. MRIs are covered. This procedure is “reasonable and necessary” because it is not an uncommon practice, even if there may be less expensive diagnostic procedures or treatments.
As you can probably guess, this broad interpretation with no oversight or accountability will result in large amounts of fraud, waste, and abuse.
Why Is Medicare Advantage Prior Authorization So Controversial?
The short answer to why is that Original Medicare doesn’t require prior authorization. The controversy is some believe beneficiaries are being denied essential medical services and treatments. Beneficiaries and medical professionals do not even attempt to overturn denials because they believe the appeal process is so burdensome.
The facts, however, do not paint such a sad picture. The Office of the Inspector General reviewed a large number of Medicare Advantage Organizations (MAO), reviewing 448 million preauthorization requests in 2016. Of those, MAOs denied about 1 million preauthorization requests for a denial rate of 4 percent—4 percent is tiny.
The September 2018 Office of Inspector General report found that Medicare Advantage Organizations (MAO) overturned 75 percent of their own denials from 2014-2016, overturning approximately 216,000 yearly. During that same period, independent reviews discovered additional requests that had been inappropriately denied.
The most surprising finding, however, is that only one percent of beneficiaries and providers appealed their denial, which raised the question: how many were denied necessary treatment because the process is so arduous?
Unfortunately, the study does not give a coherent explanation of the denials. From my experience of doing Medicare planning for a decade with thousands of beneficiaries, doctors’ offices do not always submit requests with detailed documentation in support. When the request is denied, they blame the insurance company, and the effort stops unless the patient pushes the issue.
The other reason I find for denial is the doctor’s office uses the wrong billing code. Quite often, the insurance company does not give any explanation in those cases. The response is “denied.” The solution requires the doctor’s office to call and talk with the claims department about billing codes, documentation, and supporting tests. In the absence of these items, nothing happens.
The Department of Health and Human Services Office of Inspect General (OIG) conducted a study of Medicare Advantage Organizations’ (MAO) denial of prior authorizations during one week (June 1-7, 2019). In that week, there were 250 denials. The OIG discovered that 13 percent of these prior authorizations were incorrect. This amounted to 33 cases.
Later in the same report, they admitted the usual national average is 5 percent. No reason was given why the study was not expanded when the conclusions from their study did not coincide with other long-standing evidence, particularly when the study was so microscopic–one week and 250 cases.
In the same study, they did not review the cases where the prior authorization was approved when it should have actually been denied. There was also no control group to compare against. The OIG did not study fee-for-service Medicare billing for fraudulent or wasteful claims or denials on their part.
The New York Times piled on in an April 2022 article. They presented a very slanted view of the study, beginning the article with “Medicare Advantage plans often deny needed care, federal report finds.” Only toward the very end of the article did the author get into any of the facts of the report. The general impression during the first half of the article is Medicare Advantage denies its clients the necessary medical care they need.
Why Are Medicare Prior Authorization Denials Overturned?
Denials may be overturned for many reasons. First, there were errors on the part of the insurance company. The decision was incorrect.
Errors on the part of the doctor’s office or medical facility. They did not include sufficient documentation or incorrect information. The denial is reversed, then. The provider may add new information from additional tests in the appeal process that contributes to an overturn.
The overturn does not necessarily mean the MAO acted inappropriately, but the process and extra steps critics claim create friction in the system. Patients may wish to avoid going through the trouble of appeal. Doctors may not make recommendations because of a history of denials.
Did Medicare Ever Use Prior Authorization?
The Medicare practice of accepting bills from providers at face value without question as “reasonable and necessary” was an established and haloed practice from the beginning of Medicare. All parties who benefited the most—except U.S. taxpayers—were unmotivated to change until the wheelchair scandal.
In 1999 it was discovered that Medicare spent $8.2 billion to procure power wheelchairs and “scooters” for 2.7 million people. A large portion was paid to scammers because they discovered that Medicare not only did not require prior authorization for wheelchairs, but Medicare did not even review the authenticity of the claims.
A Washington Post article published in August 2014 highlighted the massive fraud of Medicare’s resources. The article chronicled the sensational scams and trials of many Medicare swindlers. The outrageous theft of public funds and the massive fraud shamed CMS to amend its regulations to finally require preauthorization for some “durable medical equipment,” i.e., electric wheelchairs.
Bureaucrats inside CMS admitted they knew how the wheelchair scheme worked as early as 1998. But it was not until 15 years later that officials finally did enough to curb the practice significantly. Durable medical equipment—electric wheelchairs—is the only exception to the “reasonable and necessary” practice. They must be preapproved.
Consequently, hundreds of millions of false and unnecessary claims were paid over many years in a massive Medicare fraud. Once the bureaucratic problem was fixed, and claims were more thoroughly reviewed, an enormous shift occurred. Medicare reimbursements for motorized wheelchairs fell from $32 million every month to $7 million—a 78 percent decrease.
The Medicare Claims System Is Designed for Fraud, Waste, & Abuse
By law, Medicare must pay most of its claims within 30 days. In that short window, it is supposed to filter out the fraud and uncover claims where the diagnosis or the prescription is bogus.
The system attempts to ameliorate the damage through a “pay and chase” policy. The bill is paid, then it is reviewed. Only a tiny fraction of claims — 3 percent or less — are reviewed by a live person before they are paid. The rest are reviewed only after the money is spent. If at all.
The whole Medicare claims process is set up as an honor system for the richest program managed by the U.S. government. It is a thief’s dream.
Medicare Prior Authorization Test Program
In March 2017, CMS (Center for Medicare & Medicaid Services) designed a test program for preauthorization for fee-for-service Original Medicare. In the month of March, the GAO (U.S. Government Accountability Office), in a Senate report, estimated a savings of $1.1 to $1.9 billion when preauthorization was used that month. The report estimated the federal government made an estimated $36.2 billion in improper payments for the Medicare fee-for-service program from July 2015 to June 2016.
The committee’s recommendation became the report’s title— “CMS Should Take Actions to Continue Prior Authorization Efforts to Reduce Spending.” The prior authorization programs created to monitor and measure improper payments were discontinued and never recommissioned.
Original Medicare Fee-For-Service vs. Medicare Advantage
The government created Medicare in 1965. It had been a long-time project of the Democratic Party. CMS (Center for Medicare & Medicaid Services), Department of Health & Human Services, and Social Security Administration are government agencies. Politicians of all political parties exercise control and funding over these agencies and programs. The agencies are staffed by thousands of bureaucrats and government union workers. A tremendous amount of various and conflicting self-interests, power, and money are all mixed together.
To save Medicare from ballooning budgets and to offer an alternative to citizens, the same politicians, programs, and agencies partnered with private insurance companies to control spending and improve patient care. What is now known as Medicare Advantage began back in the 90s.
The two ways of doing government healthcare for seniors are in competition. Politicians view the world through different ideologies and support policies and programs based upon their political views. Those who support the various political ideologies will support or attack these two platforms accordingly.
It is vital to find all the relevant facts, make your own comparisons and analysis, and determine where lies the truth and the better path.
When I meet with prospective clients, I begin with a brief explanation of Medicare. Then move on to the hundreds of plans. Drugs are next. This is hard. Clients must lay down their cards; some hold a straight flush of costly medications.
Inflation Reduction Act of 2022 Deals with Medicare Drug Changes
When Medicare Part D was first established, Medicare contracted with private plan sponsors to provide the prescription drug benefit. The private insurance company created the Part D Prescription Drug Plans (PDP), sold the PDPs, and managed the PDPs. Each company negotiated separately with the pharmaceutical companies the price of the medications and which medications would be included on the plan formularies–the list of authorized drugs.
The insurance companies had the leverage of their brand and how many customers they would bring to the pharmaceutical companies. They were also competing with the other insurance companies to get more medications at the lowest cost. The pharmaceutical companies, of course, were trying to maximize their revenues and profits.
Ideally, it was hoped that the competition and freedom of the market would keep prices low. However, patent laws create a temporary monopoly for pharmaceutical companies that develop these very effective and popular new drugs. The patent, and the consequent monopoly, benefit the nation and the world with the newest and best medications. Unfortunately, it is a substantial financial burden for those who need the medication.
The Inflation Reduction Act Creates Leverage for Medicare
When Part D was created in 2004, a law was established known as “non-interference.” Non-interference means that the Secretary of Health and Human Services (HHS) cannot negotiate drug pricing with pharmaceutical companies, pharmacies, and insurance companies. Instead, the prices would be determined exclusively between the insurance companies, pharmaceutical companies, and pharmacies competing amongst one another.
With the Inflation Reduction Act of 2022, Medicare changes the law. The Secretary of HHS is granted a narrow exception to the non-interference clause. The HHS Secretary can negotiate on behalf of the 84 million Medicare and 76 million Medicaid beneficiaries for the lowest prices for a very limited number of costly prescriptions. The category of medications is single-source brand-name drugs or biologics without generic or biosimilar competitors.
Inflation Reduction Act of 2022 Effects Medicare Change in 2026
The Drug Price Negotiation Program begins in 2026 and is limited to 10 Part D drugs. Another 15 Part D drugs will be added in 2027, 15 Part D in 20228, and 20 Part in 2029. The HHS Secretary will select the drugs from among the 50 highest total cost Part D medications.
The timeline for the negotiation process will span roughly two years. For those companies that do not comply, there is an excise tax. The tax penalty starts at 65% of the product sales in the U.S. and increases by 10% every quarter to a maximum of 95%. The other option is that company can remove all its medications from the Medicare and Medicaid market.
Is the CBO Accurate, Reliable, & Trustworthy?
The Congressional Budget Office (CBO) claims HHS Secretaries’ ability to negotiate prices with Part D producers will significantly reduce what Medicare spends over the next ten years. The CBO also claims that reducing the revenue to pharmaceutical companies will have little effect upon developing new and better drugs. These are all projections and opinions to support the policy change. There is no evidence.
Drug Manufacturers Are Penalized for Inflation
The Inflation Reduction Act of 2002 adds another Medicare change. The Act requires drug manufacturers to pay a rebate to Medicare if prices for single-source drugs covered under Medicare Part B and nearly all covered frugs under part D increase faster than the rate of inflation reflected by the Consumer Price Index (CPI). The rebate dollars will be deposited in the Medicare Supplementary Medical Insurance (SMI) trust fund.
Cap Out-of-Pocket Part D Spending
Medicare Part D currently provides catastrophic coverage for high out-of-pocket drug costs. Still, there is no limit on the total amount beneficiaries pay out of pocket each year. Under the current design, Part D enrollees qualify for catastrophic coverage when the amount that they pay out of pocket plus the value of the manufacturer discount on the price of brand-name drugs in the coverage gap phase exceeds a certain threshold amount. Enrollees with drug costs high enough to exceed the catastrophic threshold must pay 5% of their total drug costs above the threshold until the end of the year. This can be huge.
The Inflation Reduction Act of 2022 amends Medicare’s design of Part D. For 2024, the law eliminates the 5% coinsurance requirement above the catastrophic coverage threshold, effectively capping out-of-pocket costs at approximately $3,250 that year.
The legislation adds a hard cap on out-of-pocket spending of $2,000 per person in 2025. How this will be funded, other than with savings, is still being determined.
Inflation Reduction Act of 2022 Puts Medicare Insulin at $35
Insulin is probably the most common high-dollar medication that burdens many Medicare beneficiaries. Most plans relieve several insulin products, beginning with the Trump Administration and now Biden.
Currently, Medicare beneficiaries can choose to enroll in a Part D plan participating in an Innovation Center model in which enhanced drug plans cover insulin products at a monthly copayment of $35 in the deductible, initial coverage, and coverage gap phases of the Part D benefit.
Participating plans do not have to cover all insulin products at the $35 monthly copayment amount, just one of each dosage form and insulin type (rapid-acting, short-acting, intermediate-acting, and long-acting).
While Medicare is incredible health insurance, Part D prescription drug plans are the weakness because of the light coverage for higher-end medication. The Inflation Reduction Act of 2022 helps Medicare better service citizens with more reasonably priced medications.
We can ensure you have the plan that best covers your prescription drug needs at the lowest possible cost.
Call 402-614-3389 to speak with an experienced and licensed agent and insurance professional.
January begins a new calendar year for Medicare. What does that mean for your Medicare drug deductibles in 2023?
For most Medicare members with a Medicare Part D prescription drug plan, you have a deductible. The Medicare drug deductible for 2023 is currently $505. The Part D drug deductible for 2022 was $480, which means a 5% increase. The deductible is the amount you initially pay out of your pocket before the insurance plan begins paying for the prescriptions. Deductibles are vital because they keep the overall cost of medications low. Deductibles also prevent members from overusing Part D drug plans for trivial or unnecessary purposes.
2023 Medicare Drug Deductible Shock!
I mention the Medicare drug deductible for 2023 because I get distressed phone calls at the beginning of the year. Clients go to the pharmacy in January, February, and March and are shocked. They have a huge unexpected bill. I hear cries of ‘I can’t afford $500 every month for their medications!’
I remind clients that they are in the deductible phase of their Medicare drug plan. Once they meet their drug deductible, the medication cost will decrease significantly to around $45 per month per medication.
Since it is an entire year from the last time clients paid their drug deductible, it is understandable they forget.
For those paying the deductible all at once in January and for the first time, the deductible experience will be a new and eye-opening surprise.
Plan For the Unexpected
I don’t know about you, but $505 is a lot of money to pay out all of a sudden, especially if you were not planning on it. I’m usually all tapped out by January. My trophy wife, high-maintenance step-children, and grandchildren require a lot of maintenance around Christmas time.
Once you have met your Medicare Part D deductible for the year, your Tier 3, 4, & 5 medications will be the amount listed in your handbook during the initial phase before the Gap. Please, consult my other blogs about the GAP / Donut Hole.
Most people, however, will not fall into the Gap and will simply pay minimal copays for the remainder of the year. It is the deductible that is the big obstacle.
Clients ask, ‘Are there other Part D plans without a deductible?’ There are a few, but the monthly premiums are much higher, like $100 per month, and the copays are generally higher too.
Lowest Total Annual Medicare Drug Cost
When I run clients’ drugs through the Medicare Part D medication calculator, I look primarily at the total annual cost. The winning drug plan is the plan with the lowest total annual cost and with at least a 3 Star Medicare rating.
The calculator combines the monthly premium, deductibles, copays, and gap–if applicable–and spits out a total number for the year. That is the plan you want to use.
Look For Stars
As for the Medicare star rating, you want to have at least three stars. More stars are better. There is no point in having the cheapest Medicare drug plan if you never get your medications or the insurance company is so painful to deal with you need additional drugs to handle them.
Most Have A Medicare Drug Deductible
January to March is when Part D plans remind most people they have a deductible. Don’t be upset. There is nothing wrong. You must meet the Medicare drug deductible to get to the lower cost for your medications for the remainder of 2023.
If you have paid payroll taxes (FICA) for 40 quarters (or 10 years), you are eligible to apply for Medicare in Nebraska for 2022. You are eligible for Medicare Part A at zero premium and may purchase Part B at the current cost if your income is below the IRMAA (Income Related Monthly Adjustment Amounts) amounts.
The Easy Way To Apply For Medicare in Nebraska For 2022
If you are currently receiving Social Security benefits, you will be automatically enrolled in Medicare Part A for the hospital and Part B for doctor visits and outpatient services. You will then be given the option to cancel Part B if you wish.
You cancel Part B by signing the red, white, and blue Medicare card on the back and mailing it back to Medicare. Otherwise, Medicare Part A and B will start on the effective dates printed on the bottom right corner of the card. The Social Security Administration (SSA) will also start deducting the Medicare Part B premium from your monthly Social Security check.
Applying for Medicare in Nebraska in 2022 is easy that way. It is automatic. The other way is more challenging.
Online Application For Medicare in Nebraska for 2022
Applying for Medicare in Nebraska, Iowa, and throughout the country has become more difficult and complex with each subsequent month. The pandemic pushed the process almost entirely online. Social Security personnel were absent at Social Security Administration Offices throughout Nebraska, Iowa, and the whole country during that time. Offices were closed, and most employees were working remotely.
Identity theft, cyber security, and HIPPA regulations have pushed the Social Security Administration (SSA) to add more and more levels of security to the Medicare application.
I help my prospective clients apply for Medicare all the time. While eligibility for Medicare and Social Security benefits in Nebraska begins at 65, most people are not getting their Social Security benefit checks until much later. Instead, they are waiting until the full benefit age, which is around 66 and 8 months or older. So they need to apply for Medicare online.
I probably average helping five people a week apply for Medicare in Nebraska and Iowa. The level of difficulty each person experiences is amazing. I don’t know how other people do it on their own.
How Do You Apply For Medicare Benefits in Nebraska Online in 2022?
If you are eligible for Medicare in Nebraska, type ssa.gov into your address bar. Do NOT Google ssa.gov. You will end up at all kinds of websites trying to sell you Medicare plans. The Social Security Administration logo will be in the top left corner if you are successful.
Click on Menu in the top right section of the website. Go under Benefits and click Medicare. Then, scroll down the page until you see a bright blue button that says “Apply for Medicare Only.” Click on the button that will take you to a page with a gray button that says, “Start New Application.” Click it.
Follow the prompts. The most crucial part is your My Social Security login. This is the tricky part.
Hundreds of people swear they never set up an online Social Security account. Then, when we start the enrollment process, we discovered they have a My Social Security account, and SSA requires us to use it.
Logging in to your My Social Security account may become an insurmountable obstacle if you need to provide personal verification information, like the answers to the three security questions you had set up previously. At that point, you will be stopped out and need to call or go to the Omaha, Lincoln, or Council Bluffs Social Security Administration office to get access to continue applying for Medicare in Nebraska in 2022.
If you do not have an online My Social Security account, you create one. In creating the account, you will need immediate access to email and text. With that, you will be able to set up an online account.
Follow the prompts to set up the account.
Second Form of Identification When Applying for Medicare in Nebraska for 2022
Giving SSA a second form of identification, such as your driver’s license, is vital. SSA will text a link to your phone. Then you take a photo of your driver’s license to verify who you are. Taking the photo so the system receives it can be problematic. This is the most difficult part of applying for Medicare.
Your phone’s camera software may not work well with SSA’s system, the cellular or internet connection may be weak, or the SSA system may be in a bad mood that day. Many factors can go into making the system unworkable. Be warned.
If you cannot set up a second means of verification, you will probably have to wait for a verification code to be mailed to your physical address. Then you go back in to complete the enrollment process.
More than half of the time, the system works. We get the text verification and complete the My Social Security online account setup.
When you enter your My Social Security online account through the Medicare prompts, the system pulls up the application for Medicare. Fill in the details and complete the application. The application process will assume you want Medicare Part A for the hospital since it is free. The system will ask if you want Medicare Part B for doctor visits and outpatient procedures. Medicare Part B costs something. You have the option to say yes or no.
Check On Your Online Medicare Application
When you have completed the application, you can go back in and check on your Medicare application status. A newly created box is in your My Social Security account for Medicare. There will be three grey horizontal bars going across the page. When you complete the application, one bar will be blue. When all three bars are blue, a comment underneath will say you are approved. Congrats!
Above will be a “Verification of Benefits Letter” link. Click on the link. A letter will open up. In the body of the letter will be your Medicare number (MBI), which is made up of eleven digits consisting of a combination of numbers and letters. The letter will also have the dates when your Part A and/or Part B will start.
Sometimes clients tell me they want to wait for the Medicare card to come in the mail. Bad decision. It may take over a month for your Medicare card to show up in the mail, significantly decreasing your time to select, enroll, and get your medical cards from the insurance company before your start date.
Online Medicare Application Problems
Check your account two weeks after you apply for Medicare online, and keep checking it until you have a Medicare number.
If your account says your case was sent to Salinas, CA, for processing, you need to call your local SSA office to find out why. Salinas, CA, is a black hole.
There is a problem with your application that needs to be solved sooner rather than later, and the folks in Salina, CA, are not very proactive or even active in solving your problem–whatever it may be.
All of this above-said information works if your personal information is in good order with SSA. There may be problems of which you are only aware once you enroll. For example, your name is misspelled with SSA, your birthday is wrong, your address is out-of-date, your maiden name was not changed to your married name or back after a divorce, and your naturalization date or number is incorrect. You could also be flagged as a terrorist, Russian mole, or affiliated with the opposing political party–just kidding.
I’ve experienced all of these with clients–except the terrorist one. Making corrections takes lots of time. I had a gentleman born at a Japanese civilian hospital instead of the U.S. military hospital on the base where his father served, which created a whole set of problems that plagued him throughout his life.
Getting the correct documentation takes time if it can be found. Then SSA takes time to verify the documentation and may ask for more. Then there is the processing time, which could result in you missing your intended start date. That is why you start applying for Medicare in Nebraska as early as possible in 2022.
Calling the SSA Office
You, of course, can call the SSA office or stop in to apply for Medicare in Nebraska for 2022. If you contact them too early, they will not talk with you. Too early is more than 3 months before you turn 65. Then, when they talk with you, SSA generally will set the appointment a month or two later, so you are right up against your birth month and start date. This will work if there are no problems and everything else works smoothly, but this situation usually causes anxiety for most people.
My Experience Helping Clients Apply for Medicare
I’m an insurance agent. I am not an employee of the SSA, but I feel like an unpaid auxiliary staff member. My clients need help, so I’ve learned to navigate the SSA Medicare enrollment system through trial and error. It is a system that is continually evolving.
I’m happy to help my clients. The process creates a tremendous amount of empathy for my clients for what they have to go through. Not only are they confused with all the information and choices that come with going on Medicare, but they have a government bureaucracy that is an unfriendly and confusing obstacle to overcome. I try my best to help and give encouragement when I can’t do specific tasks for them, like finding an original birth certificate with a raised seal.
As the bugs get worked out of the SSA/Medicare system, and Medicare beneficiaries become more tech-savvy, the process for applying for Medicare in Nebraska for 2022 will become more efficient–I hope.
Until then, use this guide to navigate and find your way to the end of the Medicare application maze.
What Does A Medicare Insurance Agent Do?
When you sign up for a Medicare plan or Medicare supplement, you use a licensed insurance agent. An agent is a person who acts on behalf of someone. That someone may be the client or he may be the insurance company. He is licensed which means that the state certifies he has passed some basic testing and has rudimentary knowledge about insurance that allows him to represent a company or person. Medicare insurance agents come in many different types. What type of Medicare insurance broker is near you?
What Is A Captive Medicare Insurance Agent?
A captive Medicare insurance agent is the opposite of an independent Medicare insurance broker. He has a contract to represent one insurance company. He is not an insurance broker. Depending on the level of captivity, he must sell a certain amount of the company’s insurance products to remain an agent and continue to receive renewal commissions. He may or may not be able to sell any other insurance company’s products.
The difficulty with dealing with a captive agent who offers Medicare insurance products is a lack of selection and objective evaluation. He will probably say his products are “the best!” However, you have no way to compare and evaluate based upon the product information he shares. He is a one-trick pony. Physician Mutual agents. Blue Cross Blue Shield of Nebraska Agents.
From what clients have reported to me, many captive agents do not honestly represent themselves as exclusively with one company. They lead prospective to believe they can represent many companies when that is not the case. Some captive agents do not disclose they are in fact captive.
What Is A Medicare Supplement Insurance Agent?
Some agents sell almost exclusively Medicare supplements or Medigap policies. For those who sell over the phone, Medicare Supplements are the only Medicare products they can sell because of very strict regulations around Medicare Advantage and Medicare Part D. Medicare rules and regulations prohibit unsolicited calls to consumers about Medicare Advantage.
Consequently, these agents sell against Medicare Advantage constantly. They point out weaknesses in the product–whether real, exaggerated or imagined. Medicare Supplements are the best, of course, because they cannot offer an alternative.
With auto-dialers, Med Sup agents dial 10 to 15 prospects simultaneously. Call centers in Florida, South Carolina, and California carpet bomb the U.S. with millions of phone calls each day. During Annual Election Period (Oct. 15th–Dec 7th), the Med Sup call centers recruit a bunch of agents for the season. You will probably never talk with the agent again after he signs you up.
Other agents who sell Medicare Supplements exclusively face-to-face are controlled by agencies, managers, or marketing groups. If they sell a lot of one or two companies, their commission is higher. They can win sales trips abroad and bonuses. That is the motive behind their exclusivity. They are not truly Medicare insurance brokers.
What Is A Medicare Advantage Insurance Agent?
Some agents sell just Medicare Advantage plans. They are likewise semi-captive to an insurance company that feeds them leads. The insurance company may have a large market presence. Lots of consumers call in because they are familiar with the brand name and trust it. They enroll in the Medicare Advantage plan over the phone or online with an insurance agent at the company.
Some people, however, want to talk with a live person. The insurance company will send an agent out to the person’s home to explain the product in greater depth and enroll them in person. The agent, however, is obliged to just offer that company’s products in the most favorable light and not the competition. That is why the insurance company supplies the leads to the agents. These are not Medicare insurance brokers.
Independent Medicare Insurance Brokers Near Me
Independent Medicare brokers represent both sides of Medicare–Medigap policies and Medicare Advantage. Independent Medicare insurance brokers represent multiple companies, not just a hand full. He should be showing quotes and brochures from many different insurance companies.
Insurance companies that offer Medicare Advantage pay the agent the same amount, so there should be no preference based upon commission. An independent agent should receive the same percentage on the supplement side as well.
Medicare insurance brokers are only paid when you are a client. To keep you a client, you need to remain a happy client. A conscientious independent insurance agent should keep in touch and make sure his clients are happy with their current Medicare plans and change them when not.
Local Broker Vs. Call Center Agent
When you turn 65, that is when you first become Medicare eligible. You will be inundated with mail, phone calls, and even door knockers trying to sell you some Medicare insurance product. I hear complaints from my clients all the time about the oodles of phone calls and the blizzard of junk mail. They need to go into witness protection to avoid the solicitors.
Most solicitations will come from persons you will never meet. You do not know them. They are strangers calling from far away states. They may have been insurance licensed for only a year, a month, or just a week. The average insurance agent doesn’t last in the business even a year.
Do you want to share your personal information over the phone with a complete stranger? Someone you will never meet in person.
There is something reassuring about dealing with someone who is established in the local community. Proven. They will not disappear in a month. Connected to people and institutions you know. At least a Cornhusker!
You can use Google to find Medicare insurance brokers. Google seems to know everything. It is not a bad start.
An agent’s website gives you a feel for the agent and agency. Blogs and videos demonstrate his knowledge and expertise–or the lack.
Google reviews from clients–hopefully not family and friends–give some proof of professionalism and quality of service. Google is a 3rd party, so the reviews are not cherry-picked.
Referrals are another way. Most of my clients now come from my existing clients. So ask a friend, but check the person out. Go to the Better Business Burea and check the rating. Again, visit the website.
One new client told me she was at a work function. She’s employed in the healthcare field. Three other ladies–fellow nurses–were chatting around a table. She mentioned she was turning 65 and going on Medicare. She complained how the endless phone calls and junk mail made the whole process a headache. Immediately the three nurses volunteered “their Medicare guy” to her to help solve the dilemma. All four were surprised when they realized I was the Medicare agent for each of them.
The most important criterion I believe is experience. Being in the insurance industry, I have seen hundreds of agents come and go since I became an agent back in 2003. Like anything–stock trading, medicine, law–you need practice. While it may be very nice to help out a friend or nephew who is getting started in the business, your health insurance is a serious matter. You want a professional handling your money, your body, and your assets to have time in harness.
Let the market pick your Medicare broker. If the agent makes lots of people happy with his work, he is successful and stays in the business. Time in service with lots of clients is the first key.
While my doctor is younger than me for the first time, she didn’t just get out of medical school. I know she had a lot of practice before I showed up. I think Medicare insurance brokers near you need to have lots of years in the business and lots of clients. That way they are not practicing on you, and they will be there for you for years to come.
Again, visit their website, read their materials, list to their presentation. It is like listening to good or not so good music. After a while, you can tell whether it rings true.
Needed Changes to the Medicare Enrollment Process 2022
I have been a licensed insurance agent since 2003. I’ve seen a lot of changes to Medicare over that time. One of the problems that always baffled me was how difficult it was to enroll in Medicare. Let me put you in the front seat of the upcoming changes to Medicare for 2022 and 2023.
More than 11,000 persons turn 65 each day and become Medicare eligible. That is a lot of people enrolling in Medicare. The problem that Congress created a number of years ago was moving the full Social Security retirement age from 65 to 66 and so many months.
People are also living longer. Retirement is being pushed off because people don’t have enough saved. Consequently, many continue to work past 66 to just survive, so they remain on their employer’s group health plans. But, when they turn 65, they need to do something about Medicare enrollment.
How to Enroll with Upcoming Changes to Medicare in 2022 & 2023?
When you start your Social Security, Social Security enrolls you automatically into Medicare Part A and Part B when you turn 65. You have the option then to decline Part B. Many do if they are still working and have adequate health insurance from their employer.
Many people are not taking Social Security at 65, so Social Security does not automatically enroll them in Medicare. That number is even smaller than a few years ago.
So, people must actually choose to enroll in Part A at 65. If they are going on Medicare entirely and delaying Social Security, they must actively choose to enroll in Part A and Part B. A lot of people call Medicare complaining because of how hard it is to enroll in Medicare. Upcoming changes to Medicare in 2022 and 2023 will make the enrollment process simpler.
Enrolling in Medicare at The Social Security Administration Office
Enrolling in Medicare is a challenge, to put it kindly. I do this for a living. I like to think I have above-average intelligence and some good computer skills. However, I still find the Medicare enrollment process unnecessarily difficult and complicated.
Before the pandemic, you could go to your local Social Security office to enroll in Medicare. Depending on the office’s busyness and the staff’s competency, it was more or less complicated and very time-consuming. The primary issue was the time involved—driving to the office, waiting in line, being at the office during regular business hours when you are still working. Those were the usual challenges. As of the writing of this, the local Social Security offices are closed to visitors because of COVID. The only option now is to enroll online.
The other option for enrollment, which has become pretty much the only option now, is enrolling online. Enrolling online is not easy, even if everything goes smoothly.
In the past two years, the online process has evolved. A few months ago you took a photo of your state driver’s license. Social Security scanned your license into their system through your smartphone. The purpose was to identify you if you did not already have an active MySocialSecurity account. It was not a bad improvement over the old way, which was answering credit questions. That was an amazing bureaucratic mess in itself. I’m glad the credit questions are gone, but the technology for taking the photo of the driver’s license was faulty.
The latest method is a combination of email and text confirmation codes. This method works if there are no issues with your personal information.
The major challenge with this newest method is some of my clients do not have email or do not get emails and texts on their phones.
Challenges, however, go beyond just the mechanics of getting enrolled with Medicare. The problems are with when you can enroll, penalties when you don’t follow the rules, confusion about the rules, and penalties that are imposed as a result. Frustration has built over time as more and more baby boomers run into the wall called Medicare enrollment.
Someone must have heard that consumers were not happy because Congress made some significant changes to the Medicare enrollment process for 2022 and 2023.
What Are the Upcoming Changes to Medicare for 2022?
In December 2020, Congress passed the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act of 2020. Parts of this legislation will be effective beginning in January 2023.
The changes are in five areas:
- GEP (General Election Period)
- Part B Enrollment Exceptions
- IEP (Initial Enrollment Period)
- Advanced education for Medicare enrollment
- Expanded Kidney transplant patient coverage
What Are Medicare General Enrollment Period Changes For 2022 & 2023?
Sometimes people miss their Initial Enrollment Period (IEP), which occurs when they turn 65. If you do not have health insurance from 65 onward, you cannot enroll in Medicare until the General Election Period (GEP), January 1st—March 31st. The delay is part of the punishment for missing your IEP. You may also incur the 10% permanent late enrollment penalty.
The problem with the rules around GEP is that Medicare Part A and/or Part B does not start until July 1st after you enrolled sometime from January 1st–March 31st. Consequently, a person cannot get a Medicare Supplement or Part D plan until then. Medicare Part C/Medicare Advantage plans are delayed even further until Annual Election Period (AEP) in October. You are without comprehensive health coverage for many months after an already delayed enrollment.
The BENES Act changes GEP (General Election Period). Congress moved GEP from the first three months of the year to the last three months of the year—October 15th—December 31st—to coincide with the Medicare Annual Election Period (AEP), which is October 15th–December 7th. The hope was to reduce confusion and enable a newly enrolled beneficiary to get maximum coverage right away. For example, if you enrolled in November during the GEP, your Medicare would start on Dec 1st.
Medicare Changes in 2022 Allow For More Exceptions
Medicare enrollment periods are very restrictive and precise. The handbook that agents must learn runs to many pages for Medicare election periods when someone can enroll in Medicare or make changes to a Medicare plan. Often I cannot enroll someone in a plan or change their plan, even when the situation is terrible, because of the restrictive enrollment election criteria.
The new law allows the Secretary of Health and Human Service to initiate a particular enrollment period for Part B when exceptional circumstances arise. Of course, we all can think of the pandemic as the perfect example.
The Last 3 Months of The Initial Enrollment Period
Many people know that your Initial Enrollment Period (IEP) is three months before the month of your birthday, the month of your birthday, and the three months afterward. What people do not realize about this rule is there are additional rules for the last three months. This provision has been the bane of my existence—as well as a few clients—for years.
Staggered Medicare Start Dates Change in 2023
Sometimes people will delay enrolling in Medicare when they turn 65 to coincide with a spouse turning 65, a retirement date, the end of a school year, etc. The problem with enrolling after you turn 65 is the start dates are staggered.
For example, you are turning 65 in July, but your spouse is turning 65 in October and needs you to remain on the employer health plan so she can have health insurance. You want to enroll in Medicare for an October 1st start date so it coincides with your spouse, but you can’t.
If you enroll in August, your Medicare will start in September. If you enroll in September, your Medicare will start two months in November under the current rules. You will need to enroll in Medicare in August, so your Medicare starts in September. Your spouse will enroll during the three months before, so it starts on October 1st. You will need to double pay for insurance for one month because of the unusual Medicare rules.
The upcoming changes to Medicare in 2022 and 2023 do away with the silliness. Joe can enroll in September for October and not have to pay double for health insurance. I can’t tell you how many times this has been an unnecessary burden for my clients going on Medicare.
This change will allow people retiring at the end of their IEP (Initial Enrollment Period) to have a smoother transition from employer coverage to Medicare without a lapse in coverage or double paying.
Medicare Part B after 65
I find that Medicare does not explain very well how Medicare works when you work past 65 or beyond and have an employer health plan. I hear the standard response from Medicare and Social Security bureaucrats. They encourage people to enroll only in Part A and stay on their employer’s health plan as long as they are working.
In the past, that standard answer may have worked, but when more and more people are working past 65 and full Social Security retirement is 66+, reality changed.
Also, employer plans have steadily declined in quality during the past fifteen years. Health plan costs have increased and coverage has decreased significantly. I find the vast majority of employer health plans are inferior to Medicare Advantage or Original Medicare and a supplement.
Medicare Enrollment Deadline & Penalty
The most common issue around Medicare is initial enrollment, which is when people turn 65. Some people claim they didn’t know about their Medicare enrollment. I’m not sure how that is possible because most people’s mailbox is jammed full of mail announcing they are turning 65 and need to get signed up for Medicare.
The real issue around 65 is should I enroll in Medicare, and how do I quickly do that? I find a lot of legitimacy around that question.
The upcoming changes to Medicare in 2022 & 2023 through the BENES Act will include notifying people of Medicare eligibility. The notifications will start at ages 60 to 64. Medicare will send information to explain rules such as Medicare eligibility, timeframes for enrollment, Medicare penalties, delaying Medicare without penalty, Part B coordination of benefits, and other online resources will be included on the notice. The purpose is to alert beneficiaries, so no one misses their opportunity.
If your mailbox was not full enough when you turned 65, it will be stuffed to overflowing now.
Medicare For Kidney Transplant Patients
End-Stage Renal Disease (ESRD) is one of the ways you qualify for Medicare before age 65.
If you are under 65 and diagnosed with ESRD, you can enroll in Medicare for a specific number of months. For example, now if you qualify for Medicare based on ESRD and have a kidney transplant, your Medicare coverage will end 36 months after the month of your transplant.
The BENES Act of 2020 change will allow kidney transplant beneficiaries to continue their Medicare Part B coverage past 36 months if they have no other health insurance source. The purpose of this is so these beneficiaries will continue to have coverage for immunosuppressive drugs.
According to the Social Security Administration (SSA), Part B’s premium under these circumstances would be less than the base premium and not subject to late penalties.
When Does the BENES Act Take Effect?
The BENES Act will take effect on January 1, 2023, but like many laws, different aspects will be implemented over time to give all the institutions and organizations time to comply.
The two changes I think most important are General Election Period (GEP) and Initial Enrollment Period (IEP). Those will be implemented on the start date–January 1, 2023. The outreach program and kidney transplant patients will take about two years to enact the changes fully.
The number of people enrolling in Medicare is monster. I think all the Baby Boomers enrolling in Medicare have forced politicians and bureaucrats to streamline the Medicare system. Upcoming changes to Medicare enrollment in 2022 and 2023 are going to make life easier. Late enrollment penalties and complaints should decline significantly with the more efficient and user-friendly rules. The most vulnerable, like kidney transplant patients, will have better options.
Medicare and Medicare insurance, however, is still complicated. When you need help understanding the new BENES rules and all the others, give us a call at 402-614-3389 and speak with a licensed and experienced insurance professional.