Medicare Advantage or Medicare Part C is another way to receive Medicare. “Original Medicare” is a combination of Medicare Part A and Part B. It is called “Original Medicare” because that was its first plan in the late 60’s. Medicare Part A was hospital insurance and Medicare Part B was added later. It included doctor visits and outpatient procedures. Some people call it traditional Medicare. It became “Original Medicare” when a new form of Medicare was created–Medicare Advantage, also called Medicare Part C. What is the advantage of Medicare Advantage over Original Medicare?
The Advantage of Medicare Advantage vs Original Medicare
Let’s explain “Original Medicare” first. Medicare Part A covers hospital stays. The Part A has a deductible. It is currently $1,340 for every hospital stay for the same event in a 60 day period. If a completely unrelated event lands you in the hospital, e.g., car accident, heart attack, stroke, etc., even within the first events 60-day period, you will still pay the $1,340 deductible for those unrelated events. That kind of deductible schedule could add up to a significant cash outlay in a year. Likewise, Medicare Part B exposes you to a great deal of risk. While Medicare Part B pays 80% of doctor and outpatient costs, your 20% co-insurance has no cap on it. There is no maximum out-of-pocket. Sky is the limit. If you have a million dollars worth of bills under Part B, 20% is $200,000.
The Advantage of Medicare Advantage is a maximum out-of-pocket. The highest maximum out-of-pocket for Medicare Advantage plans in 2018 is $6,700. Some plans maximum out-of-pocket are much less, depending on the area, the company, and the type of plan. However, the easiest and clearest difference between Original Medicare and Medicare Advantage is a definite limit on what you pay out of your pocket. Medicare Advantage has a maximum out-of-pocket. Original Medicare does not.
Each Medicare Advantage Plan has its own schedule of co-pays, deductibles, and co-insurance. One co-pay that is standardized in all plans is the emergency room visit. In 2018, the emergency room visit co-pay is $80. I would rather pay $80 with a Medicare Advantage plan rather than 20% of any amount on Original Medicare. I broke my arm a number of years ago biking. My emergency room visit was $3,000. The advantage of Medicare Advantage I think is an $80 co-pay rather than 20% bill–$3,000 x 20% = $600.
Part D Prescription Drug Included
With Original Medicare, you still need to get a Medicare Part D prescription drug plan, even if you don’t take any medications. Otherwise, you will be penalized when you eventually do enroll in a Medicare Part D plan. The Part D plan is generally included in a Medicare Advantage plan at zero or little cost. If you purchase a Part D plan, you may pay between $21–$100 per month. The advantage of Medicare Advantage is paying zero or very little for your drug plan.
Vision and Dental
Most Medicare Advantage plans have additional benefits, such as vision, dental, and over the counter items. How would you like to get your teeth cleaned twice a year at zero cost? That is all most people are interested in when it comes to dental usually. They don’t want to spend $50 a month on a dental plan when cleanings are all they really want or need.
Compared to Original Medicare, the advantage of Medicare Advantage makes complete sense. It limits your maximum out-of-pocket, combines Part D at little or no cost most times, includes extra benefits, like dental and vision. There are usually many plans in your area. Here is Omaha there are eleven Medicare Advantage plans among five insurance companies. You should be able to find something that fits your needs among that variety. Call us to find out 402-614-3389.
What is Medicare? A basic question. Or rather, why should anyone care about Medicare? The reason people should care is that most bankruptcies are medical bankruptcies. In other words, if you wish to protect your retirement nest egg from bill collectors, Medicare is important to know about. There are few things that are more disturbing than a pile of medical bills sitting on the kitchen table. The golden years could be tarnished with worrying about actual or potential medical expenses. Medicare–if implemented proper–will protect you from a potential catastrophe. It is critical for people entering into retirement to understand what is Medicare.
What is Medicare?
Medicare is a Federal health insurance program for people who are 65 and older (or on Social Security disability). It began in 1965 when President Johnson signed it into law. It was designed to provide medical covered to the elderly at a reasonable price. In 1965, few people had health coverage once they stopped working. As a result, many seniors fell into poverty because of burdensome medical expenses. Medicare was a solution to a national problem.
Medicare is divided into two parts: Medicare Part A and Medicare Part B. Medicare Part A has everything to do with the hospital. It doesn’t cost anything because you paid for it during your working years. It was one of the deductions in your payroll taxes. Medicare Part A covers a 100% of the medical expenses incurred in the hospital, but there is deductible that many people are not aware of. The Medicare Part A deductible is currently $1,288. This is NOT an annual deductible. It is a deductible per benefit period, and a benefit period is 60 days. So each event has a deductible, and the time for the event is 60 days. In other words, you could have multiple events and pay multiple deductibles because the event is not limited to just a 60 day period. Each new event, even if it overlaps with another event, has its own 60 day timeline. While rare, it could happen, and probably more importantly, you could pay the Part A $1,288 deductible more than once in any given year.
Medicare Part B, however, does cost something. For most people going on Medicare and Social Security in 2016, the Medicare Part B premium is $121.80 per month. It is generally taken out of your Social Security check. Medicare Part B covers doctors’ visits and outpatient procedures, such as X-rays, blood work, emergency room visits, etc. Medicare Part B covers 80% of the cost. Your portion is 20%. The 20% coinsurance, however, is unusual. There is no cap. There is no maximum out-of-pocket. Most group plans you were ever on probably had a maximum out-of-pocket. It may have been $1,000, $2,000, even $10,000, but at some point, you stopped paying and the insurance company covered everything. Medicare Part B does not have that, so 20% of a big number will be a big number. You keep paying your 20% coinsurance as long as the bills come in.
These are the basic building blocks to what is Medicare. You must understand Medicare, Medicare Part A, and Medicare Part B to understand the rest that follows. In the next blogs and videos, we will cover how to get Medicare, how to cover the Part A deductible, and how to fill the unlimited 20% gap in Part B coverage.
Delay Medicare Enrollment
Many people work past 65. They continue on with them employer group coverage. They delay Medicare enrollment. At 66+, they wonder what to do about Medicare.
How to Enroll after 65
Here is what to do. Go to Medicare.gov. Click on “Forms, Help, Resources” on the top right. Then click on “Medicare Forms” on the left middle. You will see the enrollment forms in the middle of the page in PDF form. There are two forms: one to enroll in Medicare Part B and a second for your employer to sign off on your coverage. You fill out the enrollment in Part B. Give the second form to your employer. Your employer will verify that you have had health coverage as good as Medicare since you turned 65. They will sign the form. It is important for you to write in the date that you wish your Medicare Part B to start. Give yourself enough time to find a Medicare plan and prescription drug plan. (There are much shorter and restrictive time limits when you have delayed Medicare Part B enrollment.) Drop the forms in the mail or hand deliver them to the local Social Security office.
Medicare Employer Enrollment Forms
Why do you want to involve your employer with your enrollment in Medicare Part B? If you do not have your employer verify that you had health coverage from the time you could have enrolled in Medicare until the time you did take Part B, Medicare will assume you did not have creditable coverage and will asset a penalty. The penalty is a 10% increase in Part B premium for every year you did not have coverage. That can be significant over time and completely unnecessary. Delay Medicare enrollment at your own risk. Get the form. Your employer is required to verify. The human resource department will know exactly what to do. It is a very simple matter.
At Omaha Insurance Solutions, we help clients who delay Medicare enrollment all the time. We can get this done quickly and easily. Give us a call 402-614-3389. We can email you the forms, walk you through filling them out, and explain what to do.
A distressed prospective client told me that Medicare did not cover mental health treatment. I stammered a bit because the subject had never come up before, and I was surprised. I said that it did. She had read that it only covered a one time welcome visit to Medicare. I then showed her in the Medicare & You Handbook on pages 40 and 59 where it detailed the coverage. There is the welcome to Medicare screening, an annual screening, and complete medical coverage. She was surprised and relieved there was Medicare mental health care.
Seniors Need Mental Health Care
Mental health is a serious problem in society, and it is growing among seniors. The World Health Organization documents how important among seniors this issue is. Depression is under reported, little recognized, and often an untreated illness; but Medicare mental health cares for beneficiaries with mental health concerns, like depression. It probably does it better than most employer plans do.
Medicare Mental Health Part A
Medicare Part A deals with the hospital. The same rules around hospital deductibles and co-insurance apply to psychiatric hospitals as to other hospitals. There is, however, one difference. Medicare only allows a lifetime amount of 190 days for a stand alone psychiatric hospitals.
Medicare Mental Health Part B
Medicare Part B covers psychiatrists, counselors, treatment groups. Again the same 20% co-insurance applies as to any other Part B doctor visit. If you have a long standing relationship with a psychologists before Medicare, you may keep that relationship going after you go on Medicare if the medical professional takes assignment for Medicare.
Medicare Supplements will cover Medicare mental health issues and professionals the same as other fees in accordance with your particular Medicare supplement plan. Medicare Advantage will have the same co-pays for psychiatrists and psychologists as for other specialists.
No need to be stressed or depressed about Medicare mental health. You are covered.
A gentleman called me who was losing his group health coverage from a former employer. He was a retiree from a Fortune 100 company. You would recognize the name of the company immediately. As part of his retirement package, he had a very generous health plan for himself and his wife. He had been on it for decades, but the company could no longer afford to maintain it. They canceled the plan, so my client found himself cast out into the Medigap world at 92 not knowing what to do, and he didn’t realize that he would need a Medigap guarantee issue to be get a plan.
Medigap Guarantee Issue Solution
When you are a Medicare beneficiary and you loss group coverage, you have what is called a guarantee issue period. It is a very limited opportunity that has an exasperation date on it. It is an incredibly important guarantee for those who have pre-existing conditions.
What is Medigap Guarantee Issue?
What is guarantee issue for a Medigap policy? How does it work? What should you do to make sure you don’t miss out? Guarantee issue for a Medigap policy applies to a number of situations. I will just speak to one—when you involuntarily lose your group health coverage while on Medicare Part A & B. Guarantee issue means that an insurance company must offer you a Medigap plan—usually plans A, B, C, & F—without asking health questions. They must sell it to you no matter your health condition. For those with pre-existing conditions that would exclude them, this is a treasure. (Each state may handle guarantee issue situations somewhat differently, but this is the general concept.)
How Does Medigap Guarantee Issue Work?
How does guarantee issue work for a Medigap policy when you have involuntarily lost your group health coverage? The company that is ending group health coverage will usually give you sufficient time to find other coverage. You are able to purchase a supplement as early as 90 days ahead of time. After coverage has ended, you usually only have 63 days to find coverage without going through underwriting. If you miss that time frame and you have a serious health issue, you will not find a Medigap policy. You will only have Medicare.
What Should You Do to Get Your Medigap Guarantee Issue?
What should you do if you are losing your group plan that covers your Medicare deductibles and coinsurance? First get educated about Medicare. Second get a quote and start looking for a Medigap plan. Third see if you can pass underwriting so you are not restricted to the more expensive plans, but please don’t doddle. There is a clock ticking in terms of your guaranteed issue period.
To summarize, you have a special opportunity to get a Medigap plan when you lose your group plan. The special opportunity is that you do not have to answer health questions for a defined period and the insurance company has to sell you a plan. You need to be aware of the rules and follow them so you do not miss out. Still try underwriting so you have more options, but you have the guarantee provision to fall back on. There are rules and time limits around guaranteed issues. Make sure you fully understand these rules and the ramifications. Call to find out the facts so you don’t miss out. 402-614-3389 OmahaInsuranceSolutions.com
I quoted a prospective client a Medicare supplement rate that was significantly less than the plan he was currently on. When I explained that he would have to go through Medicare supplement underwriting and answer some health questions because he was no longer in his Open Enrollment, he wasn’t happy.
Why was he upset? Because he remembered how time-consuming and intrusive it was to apply for life insurance. A nurse came to his home, weighed and measured him, took blood and urine, and asked a bunch of questions. Then, they got reports from the various doctors and a letter about a certain health issue.
The client claimed there was no amount of money that could induce him to go through all again. That’s understandable. However, when I said I could probably do the Medicare supplement underwriting in sixty seconds or less, his tone changed.
How can Medicare supplement underwriting be so simple, though? Let me explain.
Medicare Supplement Underwriting
How is Medicare underwriting defined in Omaha? In short, it’s a simple process used by insurance companies to learn more about you and your health. There’s no need for medical exams or doctor’s visits – all you’re doing is answering a basic set of health questions.
What are the Health Questions for Medicare or Medigap Supplement Underwriting?
The questions can be grouped broadly into four categories:
- Knock-out questions
- Height and weight
- Current health issues
- Smoking status
If you answer “yes” to certain knock-out questions, then you can’t get Medigap or a Medicare Supplement – here’s how it works.
Medigap Underwriting Questions: What Are Knock Out Questions?
They are questions relating to serious medical conditions. If you have this serious medical condition, you are ineligible for a Medicare supplement or “knocked out” of consideration.
To clarify, you can’t be denied Medicare, but a private insurance company can deny coverage for a supplement outside of your Open Enrollment Period.
What are some examples of knock out questions? They vary, but they include:
- Are you currently confined to a wheelchair, nursing facility, or hospital bed?
- Do you currently receive assistance bathing, transferring, toileting, eating, dressing or need the assistance of a walker?
- In the last two years, have you received treatment for cancer, leukemia, heart attack, congestive heart failure, multiple sclerosis, chronic kidney disease, diabetes with hypertension, stroke, etc.?
Why Does Medicare Ask Questions About Height and Weight?
The second category of questions has to do with height and weight. This is always a difficult question. If I asked my wife her weight, it would be very quiet and cold in the Grimmond household for a while. However,height and weight is an important determiner of future health, so it has an impact on price.
What Are Current Medical Issues?
Current issues cover existing medical conditions and related future treatment. For example, you may have a diagnosis for a future treatment, like a knee replacement or cataract surgery.
For Medicare supplement underwriting purposes, you’ll probably need to address these medical issues before you can change supplements or the insurer simply won’t cover that procedure for the first six months.
You may have had respiratory issues in the past that do not exclude you now, but if you are currently being treated for the issue, they could prevent you from getting the supplement for a time.
Why Am I Asked About Smoking Status?
There is plenty of medical evidence about the health risks associated with smoking, which also includes chewing.
I met with a gentleman who described himself as a non-smoker, but when I pointed out he had a circle print on his back jeans pocket, he fessed up that he dipped occasionally. In medical underwriting, even occasional dipping means you’re still considered a tobacco user.
Smoker/Non-smoker is the one health question that can be asked during Open Enrollment.
Medicare Supplement Underwriting is Easy
Why does this matter to you? Because your answers determine whether the insurance company accepts or denies you. It determines your health category and consequently your monthly premium. Underwriting is not a difficult or a daunting task with a skilled insurance agent such as myself. It just takes a few minutes of your time, and you may be able to save yourself some money and maybe improve your coverage as well.
Medicare Supplement Underwriting Omaha Insurance Solutions
The key thing to understand is that not all insurance companies have the same underwriting guidelines. Some may be laxer or more restrictive than others. They may be lenient on one condition or more severe on another. That is when an experienced agent can help you with getting the best outcome for your underwriting. He can guide you to the company that will be most favorable to your condition for the best possible price.
Call OmahaInsuranceSolutions.com 402-614-3389 for help with your Medicare Supplement underwriting in Nebraska
A prospective client called me about saving money on her Medicare supplement. I asked her the basic supplement health questions and gave a quote. We set up a time to meet. At the meeting, I started going through the standard health questions on the application. When I came to the question about recommended future treatments, she said no, but the way she answered bothered me. So I asked it a different way. “Did the doctor suggest that you have anything done, like cataract surgery, knee or hip replacement?” Then she lit up. “My hips are really bad,” she said. “He thinks I should replace them sometime.” “So when you say sometime, are you talking about in a year or two?” “Oh no,” she said. “In the next couple of months.” I closed my notebook. We were done.
Supplement Health Questions Broken Down
Recommended treatments by a physician could potentially cause a problem when you switch supplements. Three things to know: 1.) what is a recommended treatment, 2.) why does it matter, 3.) what should you do about it.
Most of the time when we see the doctor it is because we are sick right now. She makes a diagnosis and recommends an immediate treatment. ‘Take this pill now.’ ‘Have open heart surgery next week.’ Sometimes the diagnosis leads to a recommendation for treatment sometime in the future. ‘Your knees are deteriorating. You should have a knee replacement in the next year or so.’ When your doctor puts a recommendation in your medical records for a future treatment, that is a big deal. To an insurance company, that means there will be a future big bill for whoever is insuring you at that time.
Understand the Supplement Health Questions
The problem is that you could get stuck with the bill instead of the insurance company if you don’t follow the rules. If you have something done that was recommend before you got the new policy, like cataract surgery within six months after getting a new Medicare Supplement, the insurance company will probably not pay their share of the expense. The health questions in the application are designed to disclose recommended treats and prevent the new insurance company from getting stuck with the bill. They would likely refuse payment and call for doctor’s records to see if there was a recommendation for treatment before you signed the application. After six months, you are less likely to have any trouble. They cannot hold back paying for treatment indefinitely. The bottom line is, if you have any recommended treatments, finish them up before switching supplements.
Manage the Supplement Health Questions
This problem, of course, can be avoided. Check with your doctor. See if he is recommending any treatments and see if he put that in your medical records. Check with the insurance company if you recently switched supplements. Doctor’s offices will not usually check with an insurance company on a supplement because they will assume the insurance company will pay when Medicare pays. If you recently switched supplements, call and ask ahead of time if there will be any issues about a procedure. It is always good to cross your T’s and dot your I’s when it comes to new insurance plans.
Ask an Expert about Supplement Health Questions
A mistake around a recommended treatment when changing Medicare supplements could result in bills to you for thousands of dollars. Know whether you have any recommendations from a physician for future treatments in your records. Understand what that means in relationship to a new Medicare supplement. Talk with someone who can ask you the right questions when you are making a change to your supplement coverage 402-614-3389. OmahaInsuranceSolutions.com
For two years, my father was on dialysis. Those were tough years. When I got a client on dialysis, I wanted the best for him. Kidney dialysis is one of the pre-existing conditions that usually excludes you from a supplement. My client had a one-time opportunity. I was going to make sure he got it!
Obama Care Confuses Pre-Existing Conditions
Pre-existing conditions are confusing when it comes to Medicare. The ACA (Affordable Care Act) a.k.a. Obama Care made it more confusing because ACA covers pre-existing conditions, but ACA is not Medicare. Different rules govern Medigap policies. ACA applies to everyone 64 and younger. Medigap policies are for everyone 65 and older.
Medicare Has No Pre-Existing Conditions
Medicare itself cannot deny coverage to anyone because of pre-existing conditions. Medicare means Original Medicare. Original Medicare is Medicare Part A for hospital and Part B for doctors and outpatient. Medicare Part D cannot be denied for pre-existing conditions no matter the condition or cost of the medications. Medicare Part C (or Medicare Advantage) must accept you as well, but for one exception–ESRD (End Stage Renal Disease). You can be denied entrance to Medicare Advantage if your kidneys are permanently shut down and you are on dialysis. All Medicare beneficiaries may enroll in a Medicare Advantage plan, except for that one pre-existing condition.
Medigap Has Pre-Existing Conditions–Sometimes
An insurance company, however, can deny you a Medicare Supplement/Medigap plan because of pre-existing conditions, except during your Open Enrollment Period or Guaranteed issue. The rules around your Open Enrollment Period are confusing. You can enroll in Medicare when you turn 65 and enroll in Medicare Part B. That is called your Open Enrollment. The time period for that is 3 months before the month of your birthday, the month of your birthday, and 3 months after your birthday. The same term–Open Enrollment–is used for enrolling in a Medicare supplement, but the time period is different. Open Enrollment for a supplement is from the month of your birthday and five months after. Same term–Open Enrollment Period–but different time periods that apply to different things. Isn’t that nice!
During your Open Enrollment Period for a supplement, the insurance company may not ask you health questions. They must give you the best possible rate. Even your weight is not counted against you if you are a few pounds over the normative height/weight charts. You can be on chemo, dialysis, recovering from a stoke. It doesn’t matter. The insurance company MUST take you during this time period. AFTER the six month Open Enrollment Period, they can ask health questions when you go to purchase a Medicare supplement, and based upon your answers, the insurance company could rate or even deny you.
What are some of the health questions? Are you in a wheel chair? Are you an insulin dependent diabetic? Have you had a heart attack, stroke, or cancer in the past two years? All of these questions are “knock out” questions. If you answer in the affirmative, you will be denied a Medicare supplement. You cannot be denied Medicare, but you can be denied the ability to purchase a Medicare supplement at any price.
Know the Rules or Find Someone Who Does
The ACA changes that permit acceptance into a health plan with pre-existing conditions created confusion in the Medicare world. Beneficiaries need to clearly understand that a pre-existing condition can count you out of a supplement unless it is your Open Enrollment Period or Guarantee issue situation. It is critical that persons with serious health issues be vigilant about these Medicare rules and/or find someone who will be vigilant for you.
Don’t miss your Open Enrollment Period. If there are any questions, give us a call at 402-614-3389 or even call Medicare 800-633-4227. Make sure you understand the rules that apply to you.
Contact: Omaha Insurance Solutions
My father was a Korean War veteran. He served on a tin can-minesweeper along the Korean coast. The last 3 months of his life he spent in a VA Hospital. My brothers and I and our family’s kept vigil. I was sleeping next to his bed the morning he passed. After we grieved, the nurses prepared his body for transport. They covered it with the flag. As we walked down the hall, they blew a horn and announced over the PA system that another warrior had fallen. We escorted my father’s body to the elevator to be taken to the funeral home. A few days later at the cemetery, after the rifle volleys, after taps, the service man handed the folded flag to my brother—he’s a lieutenant coronel in the Army National Guard—and said, “On behalf of a grateful nation . . . .”
On behalf of a grateful nation, veterans are entitled to certain benefits, which includes medical care. VA benefits and Medicare work very well together to fill in the gaps in each and enhance overall medical care. VA Health benefits begin with the US Department of Veterans Affairs. You need to find out what benefits you qualify for. Qualification depends upon a number of factors: time and length of service, service related injuries, type of injuries, full or partial medical disability, etc. Your local Veteran Affairs office will help you. We have a superb office in Omaha Nebraska VA Benefits 800-451-5796. They will take you through the process to determine your level of coverage.
The next step is to truly understand the limitations of your VA Health Benefits. This is best done BEFORE you need them. Some questions to ask are: am I 100% covered, will I be reimbursed for coverage in non-VA facilities, do I have co-pays, etc. You may find that you are on your own for emergency care, especially if the local VA is not set up for critical illness, e.g., heart attacks, stokes, car accidents, etc. Many veterans I speak with are comfortable with the care they receive at the VA in Omaha and Lincoln; there are many veterans in the Omaha Metro area and Lincoln. Others will travel hours from rural areas to receive care here. If you are comfortable with VA care, that is great. Medicare can also give you other options and fill in gaps in your VA care. You may not wish to make the trip to the VA hospital from your home. You may have a family doctor that you would prefer to use. You may like the convenience of getting into the doctor’s office quickly. There may be a certain specialists you want who are not at the VA. Medicare will afford you those options as well as many others. The biggest issue I believe is that you will be covered for emergency care if you have Medicare Part A & B. Your local VA hospital may not be equipped to handle a heart attack, stroke, or car accident. The ambulance will take you to the emergency room at the hospital closest to you that is rated for your particular critical illness. The Omaha VA is not a trauma center. And the bill for the emergency room and hospital stay may be yours to pay if you don’t have Medicare, Medicare Advantage plan, or a Medicare supplement in place. My recommendation is always to find out the facts. You need to confirm the extent of your VA benefits. Get it in writing. Don’t be surprised by the gaps in your coverage.
Do not miss out on the coverage that you are likewise entitled to with Medicare. Medicare is excellent medical coverage. It can be your primary coverage, a supplement to your VA benefits, or a back up to your VA medical benefits. Medicare may enhance your medical coverage at little or no cost. I can help you understand your VA benefits in relationship with Medicare. I have many clients who are veterans. Some use Medicare primarily. Others have Medicare in place just in case. In any event, it is better to know your options 402-614-3389.