One of the biggest fears people have when they come to my office, for example, is backbreaking medical bills. A major concern is: ‘Will Medicare cover . . . . ? You can then imagine how clients react when Medicare does not cover a bill.
Fortunately, I do not get many frantic phone calls from clients who are upset because Medicare denied a claim. Medicare denials, however, do happen. Most of the time, a Medicare denial is simple to handle. At other times, there needs to be a formal Medicare appeal process.
First of all, what is a Medicare denial of coverage? A denial is when Medicare, the Medicare Advantage plan, or the Medicare Part D prescription drug plan refuses to cover and pay for a particular procedure or medication.
This denial may come in many forms. The Medicare denial letter may come before the procedure. The doctor’s office calls to get prior authorization, and the procedure is denied. The denial may come after the procedure is performed, and Medicare denies payment. The patient may be in the midst of the procedure, such as staying in a hospital, skilled nursing facility, or receiving home health care. Medicare refuses to cover additional time in the institution.
Understanding How Medicare Coverage Works
One time I had a client who had a serious shoulder problem. The doctor recommended an MRI. The Medicare Advantage plan denied the treatment. They suggested a less expensive treatment to repair the situation–physical therapy.
The client called me to complain. After a few phone calls with the insurance company, they explained physical therapy was far less expensive, and it may achieve the same result without being so intrusive as surgery.
The purpose of the MRI was a preliminary to surgery. The client later said he had no intention of having surgery at his age. He simply wanted to know what was wrong with his shoulder.
Most situations can be easily resolved without going through the Medicare appeal process.
Medicare and the insurance companies will almost always take the least expensive and intrusive route when prescribing treatments. A denial is not always a denial.
Medicare sends a quarterly statement, the Medicare Summary Notice (MSN). It lists all the procedures you have had in the past quarter, the cost, and the payment. The MSN is not a bill. It is a notice that people with Original Medicare get in the mail every three months for their Medicare Part A and Part B-covered services. The MSN shows all services and supplies billed to Medicare during a 3-month period, what Medicare paid, and the amount you owe. It will also show denials.
Another client of mine was denied access to a Skilled Nursing Facility (SNF). She had had a knee replacement. Usually, patients go directly home after a knee replacement. In her case, the rehabilitation was not going well. Her home was a small apartment with pets. She lived alone. When Medicare denied the request, we had the doctor put she was a “fall risk” in the letter to Medicare, and he laid out the reasons. The appeal was quickly granted.
Many times it is not an issue of denial of coverage; it is poor communication. In this instance, we did not even use the formal Medicare appeal process. It was just a letter of clarification from the doctor.
Medicare Appeal Process
If you disagree with the Medicare coverage determination, you can appeal the decision. An appeal is a formal way of asking Original Medicare (Part A & Part B), the Medicare Advantage Plan, or the Part D plan to review and change the coverage decision.
A Medicare appeal is different than filing a grievance or complaint with Medicare. Grievances deal with the quality of coverage, the listing of medications on formularies, or access to medical personnel and institutions.
An appeal asks Medicare to pay for a procedure it denied. For example, an appeal may ask Medicare to extend a patient’s stay in a skilled nursing facility beyond her situation’s customary period. An appeal may ask Medicare to approve a more expensive procedure than is ordinary for the situation.
As a Medicare beneficiary, you have a right to file an appeal. There are five levels to an appeal. Medicare Advantage and Part D plans mirror the same process. If you are dissatisfied with the decision at the last level, you may proceed to the next level. The denial letter includes instructions on how to apply.
Medicare Redetermination Form For Appeal Process
Once you are aware of a Medicare denial of coverage with which you disagree, you need to act. You have 120 days to respond.
Download and complete the Redetermination Request Form. The form goes to the Medicare contractor, or you can write your own letter. Remember to include all the essential information. You will receive a Medicare Redetermination Notice within 60 days after Medicare, or the contractor receives the letter. If you disagree with that decision, you have 180 days to appeal to Level 2.
A Qualified Independent Contractor (QIC) administers the 2nd Level of appeal, not Medicare or the insurance company contracted with Medicare. It is a third party that reviews the case. The appeal process is the same as the previous. There is a designated form—the Medicare Reconsideration Request Form. The decision is rendered in 60 days or less.
If you disagree with the decision from the 2nd Level, you may proceed to the 3rd Level, which is the Administrative Law Judge Hearing. You have 60 days to make this appeal.
Of course, there is a specific form for this appeal, and it is sent to the Office of Medicare Hearings and Appeals (OMHA) Central Operations. The address is on the form. If you are not satisfied with this decision, you may appeal to the 4th Level within the 60 days allotted.
The 4th Level in the Medicare appeal process is like the others. The council has 90 days to respond. If you still are not satisfied, you may take your appeal to a district court within 60 days.
The 5th and final Level is the Federal District Court Judicial Review. Cases that make it this far usually significantly impact Medicare when won. This is the “supreme court” of the Medicare world.
Please, call when you have questions about appeals. We can help steer you in the correct direction. You can also call Medicare directly. They are open 24/7. They will mail or email you the required forms as can we.
If your appeal is to an Advantage or Part D plan, you call them directly. Their appeal process mirrors the Medicare appeal process and is usually less formal. You can also call the local SHIP (State Health Insurance Assistance Program) office to assist you.
Many times speed is essential in a decision. The Medicare beneficiary may request an expedited review.
For example, you are in a hospital. The doctor thinks you need an additional three days because your body is not recovering from the treatment at the average speed. It is three days beyond what Medicare allows. Medicare will deny payment. The hospital files the Medicare Redetermination Form requesting three extra days. They also request an expedited review, which means Medicare will make a decision within 72 hours. An expedited review for medications on a Part D plan is 24 hours.
The Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) is the department that will help with appeals.
No one likes no. My five-year-old granddaughter does not like no. My wife certainly does not like no. Most of my clients don’t like no, but we hear it, even from Medicare at times.
No, however, does not necessarily mean we are done. There is a process. I am happy to help clients navigate the hurdles and obstacles of the Medicare appeal process. Sometimes there is no need for the process. It is just a matter of talking to the right person or better communication.
Getting Medicare and your Medicare insurance to work for you is what training and years of experience enable us to do. We will walk you right through the Medicare appeal process.
I remember when the hospital staff explained my mother’s Medicare coverage to me. I kept asking, “What does Part A cover? How is Part B different?” I couldn’t remember anything. I’m sure the stress of my mother dying had a lot to do with it, but it seemed like I was a child going back to school trying to learn my A, B, C’s. I should have called the Medicare coverage helpline at 800-633-4227, but I didn’t know.
The Alphabet of Medicare Coverage
Understanding the building blocks of how Medicare works begins with understanding the Medicare alphabet. We start with A. A is not for Apple but for Medicare Hospital coverage. When Medicare first started in 1965, there was only hospital coverage. Hospital costs are generally the largest. Seniors in the 1960s were being devastated by hospital medical costs and the availability of insurance at the time. Congress created Medicare.
Medicare Part A costs nothing if you have worked and paid the Medicare tax for at least 40 quarters (or 10 years). The quarters do not need to be consecutive, only total up to 40 quarters.
Medicare Part A Hospital Coverage
Part A covers the hospital 100% for 60 days after the deductible is met. Currently, the Part A deductible for 2022 is $1,556. This deductible is per event in a 60 day period. It is possible to have more than one deductible in 60 days if the medical issues for hospitalization are unrelated. For example, you had a heart attack one month and fell off a ladder the next month. Two unrelated events sent you to the hospital within 60 days, and so you paid two $1,556 deductibles. Not likely, but certainly possible.
Part A Coinsurance
If you continue to remain after the first 60 days in the hospital, you have a $389 copayment per day from day 61-90. Again, hospital stays of that length are infrequent. Nonetheless, you are still responsible for that cost if it occurs and you have no other insurance, like a Medigap plan.
Part A Lifetime Reserve Days
If you go beyond 90 days, there is a bank of “lifetime reserve days” from which you can draw. You have a total of 60 lifetime reserve days. These lifetime reserve days are exactly what it means. Once the 60 days are used up, you have no more. You pay 100% of the inpatient hospital costs after the 90 days going forward.
Medicare Hospital Coverage
Part A covers everything that happens in the hospital during your stay, except some doctor visits. As for the copays, coinsurance, etc., a Medicare Supplement (Medigap) policy may cover those costs. Medicare Advantage/Part C configures the copays in various ways depending upon the policy. Medigap and Medicare Advantage are covered in detail in other blogs.
Medicare Part B Coverage
Part B covers everything other than inpatient stays at the hospital, even if a procedure takes place at a hospital. Medicare Part B coverage excludes medications usually unless the medications are the type administered in a doctor’s office or through durable medical equipment, such as insulin through an insulin pump.
Medicare Part B coverage is for doctor visits and outpatient procedures. The doctor visits can also be the doctor visits while in the hospital.
Part B Costs
Medicare Part B coverage does cost something. Currently, the Part B premium is $170.10 for 2022 for most people. The Part B premium had the most significant increase in Medicare’s history from last year, $148.50.
For approximately 4% of the Medicare demographic, the Part B premium is more because of your income. Please, confer our blog on the IRMAA Tax.
Part B covers 80% of the doctor and outpatient costs without limit. There is no upper dollar limit on Medicare benefits as long as the procedures are “medically necessary” and occur at a Medicare-approved facility or with a doctor who accepts Medicare assignment. On the flip side, however, you also have a 20% coinsurance you must pay, which has no cap or limit. That is drastically different from what you probably experienced with your employer’s health plan. Most plans have a maximum out-of-pocket (MOOP). Those MOOPs may be as high as $10,000 or $15,000, but you have a cap at some point. Medicare Part B coverage is an unlimited 20% coinsurance. There is no cap or limit. Another reason to get some sort of additional insurance coverage.
Medicare Part C Coverage
Keeping with the alphabet theme, Medicare Part C coverage is next. The Balanced Budget Act of 1997 (BBA) established a new Part C for the Medicare program. Part C was known then as Medicare+Choice (M+C) program, which started in 1999. Many times clients will ask if Medicare Part C or Advantage are new. There have been many iterations of Medicare Advantage with variable names. Part C was only in limited markets when it first began. Omaha, Lincoln, Council Bluffs, eastern Nebraska, and Western Iowa were not the hotbeds where the Part C programs were initiated or grew. Of course, that is changed.
The Medicare+Choice was renamed Medicare Advantage (MA) under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The MMA updated and improved the choice of plans for beneficiaries under Part C and changed the way benefits are established, and payments are made. The MMA broadened Medicare Part C coverage. MMA enabled Medicare Advantage to also include Medicare Part D prescription drug coverage for the first time.
Medicare Advantage Design
Medicare partnered with health insurance companies to create Medicare Advantage plans. The Part C plans need to offer at least as much as Original Medicare Part A & B in the overall actuarial cost sense, but they could also offer more, such as dental, vision, hearing, etc. Medicare regulates and monitors the plans. Medicare Part C coverage must be as good as Original Medicare.
The Part C plans are Medicare. That is why it is called “Medicare Part C.” Medicare Advantage is Medicare administered by a private insurance company approved by Medicare.
Medicare Part C/Medicare Advantage is usually offered at little or no premium over the Medicare Part B premium payment. The plans, however, have copays and coinsurance with a maximum out-of-pocket for the total copays.
Medicare Part D Coverage
The final letter in this Medicare alphabet is Part D for Medicare prescription drug coverage. Until 2003 Medicare did not sponsor prescription drug coverage, though some supplements had their own private programs. After the MMA legislation, Medicare worked with insurance and pharmaceutical companies to establish drug plans that provided medications at reasonable rates and distributed the costs fairly among participants. The premium for each plan varies.
The Dreaded Donut Hole
The Medicare coverage for Part D plans has four phases. To start, there is the deductible. The current deductible on most plans in 2022 is $480. During the second or initial phase, the beneficiary covers about a fourth of the actual cost of the medications once the annual deductible is met. The plan pays the other three-fourths.
If the client and the plan payout $4,430 in copays and cost from the plan, then the Medicare beneficiary moves into the 3rd phase, which is the Gap (or Donut Hole). At this point, the pharmaceutical companies discount the medications to 25% of their actual cost. The beneficiary then pays the total cost of the drugs until he reaches $7,050 of combined payments out of his pocket.
Then he has crossed over to the 4th and final stage–Catastrophic. In the catastrophic phase, you will pay the greater of 5% of drug costs or $3.98 for generic and $9.98 for non-generic medications. You will pay these amounts until the end of the year. On the first of the year, the whole cycle starts over.
What Medicare Covers and What Medicare Does Not Cover
Medicare coverage is easier to define by saying what it does not cover.
No Long-Term Care
Original Medicare–just Part A and Part B–does not cover long-term care or is sometimes referred to as custodial care. Medicare covers skilled nursing facilities, and skilled nursing facilities are mostly long-term care facilities. But the purpose of the skilling nursing facility with Medicare is in the service of curing an illness and is only temporary. Skilled nursing facility care is limited to 100 days. It is not custodial care.
Custodial care is needed when you can no longer perform activities of daily living, such as bathing, toileting, transferring, dressing, eating, etc. Medicare does not cover long-term care for custodial purposes.
Medicare does not cover routine dental care, such as teeth cleaning, fillings, extraction, crowns, root canals, etc. Yes, many Medicare Advantage / Part C plans cover dental but not Original Medicare Parts A & B. This is a common confusion.
In keeping with the dental theme, Original Medicare does not cover dentures. Some Medicare Advantage plans do. Medicaid in many states covers dentures, but Medicare does not, though you may purchase a separate and private dental plan for that purpose.
No Cosmetic Surgery
Original Medicare does not cover cosmetic surgery. Breast augmentation, hair implants, botox injections are not on the list of Medicare authorized treatments. That being said, there are exceptions depending upon circumstances. In other words, how “medically necessary” the treatment is.
One of my clients called me ecstatic because she was approved for breast reduction. I must admit breast reduction was not one of the things I gave a great deal of thought to. I remember my grandmother explaining to me once in an unusual turn of events the challenges well-endowed women have, but it was never something I thoroughly appreciated. However, my client explained to me why it was “medically necessary,” and Medicare concurred. The breast reduction was approved, but generally speaking, there is no Medicare coverage for cosmetic surgery.
Original Medicare does not cover acupuncture. I never would have imagined how popular acupuncture is, but I have gotten that question many times over the year. Medicare Part A or B do not cover acupuncture, though more and more Advantage plans offer some acupuncture, usually in conjunction with chiropractic care.
No Hearing Aids
Original Medicare does not cover hearing aids or their fitting. Anyone who has even a remote experience with hearing aides knows how incredibly expensive hearing aides are. Neither Part A nor B covers hearing aides. Again many Advantage plans do cover various aspects of audiology and hearing aids. Thus the mass appeal of Medicare Advantage over Original Medicare.
No Routine Foot Care
Original Medicare does not cover “routine foot care.” Yes, Medicare covers feet and the rest of your body, but “routine foot care” is a particular thing. Primarily routine foot care involves cutting or removing corns and calluses, trimming, cutting, or clipping nails, and hygienic and preventive maintenance, like cleaning and soaking your feet. This type of care is vital for some people with specific health issues to prevent infection or damage to their feet. Routine foot care is absolutely critical for those with diabetes and neuropathy to avoid infection and other problems that could result in amputation. Neither Part A nor Part B covers routine foot care. Many Medicare Advantage / Part C plans do cover routine foot care.
One of my clients was quite a large man. He was also diabetic with many other complications. He could not trim his own toenails. He very much needed podiatric care. As a matter of fact, he was embarrassed by the whole situation and neglected the trimming for a while. As you can guess, his toes became infected, which resulted in losing some toes.
While these are not small or unimportant areas of health, Medicare does not cover them. Medicare, however, covers virtually everything else that is “medically necessary.”
Medicare Coverage For Experimental Treatments
Experimental treatments or clinical trials, however, are in their own category. Medicare may cover experimental treatments. Though that being said, most “experimental” treatments are voluntary programs supported by funding from pharmaceutical companies or other institutions. Those can only be spoken to on a case-by-case basis. Medicare may cover some or all of the treatment depending upon the type of treatment. Indeed, those aspects Medicare typically would be covered.
Many years ago, a man was referred to me because he had had some difficulty around this issue of clinical trials. He had been on a Medicare Advantage plan with a previous agent. He could only get into the clinical trial without paying for a large part of it was to return to Original Medicare. After much difficulty with Medicare, Medicare granted him an exception to return to Original Medicare without waiting for the Annual Election Period in October.
The next problem was finding a Part D prescription drug plan that would cover his medications. That’s where I came in. That matter was straightforward, but the difficulty he had getting some Medicare coverage for the experimental treatment was interesting and scary, which ultimately prolonged his life by many years.
More Information in Other Blogs
There is much more to say about Medicare. There is, even more, to say about Parts A, B, C, & D; however, over 2,000 words in just this article is more than enough for anyone to read about the wonders of Medicare in a brief sitting. I recommend searching in the search tool at the top of the blog section for more information on each Part of Medicare and the sundry-related topics, but before going on, you must understand the foundational building blocks of Medicare.
When you need help understanding Medicare, give us a call at 402-614-3389, or the Medicare coverage helpline is 800-633-4227. Medicare is open 24/7.
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.
100’s of Supplements to Pick From
Insurance companies offer hundreds of different Medicare supplements, Medicare Advantage plans, and Medicare Part D prescription drug plans. Picking Medicare plan means choosing between Medicare supplements and a Part D prescription drug plan OR Medicare Advantage/Part C. Next picking Medicare plan means choosing the plan type. Medigap plans range from plan A through the alphabet to plan N, which doesn’t include a Part D drug plan. The drug plans can be a little simpler because you can use the Medicare tool to narrow down the selection. The Medicare calculator bases the plan selection upon the prescriptions you enter into the system. The calculator picks the Medicare Part D plan that will cost the least in total costs for you. On the other side, Medicare Advantage plans consist of a wide variety of co-pays, co-insurance, deductibles, and maximum out-of-pocket costs and amounts that may or may not include a Part D plan.
Foreign Language of Medicare
Medicare itself is like a foreign language of Part A, Part B, and Part D with rules around enrollment that includes penalties when you do not comply. The Medicare.gov website is meant to be helpful, but the shear amount of information, jargon, legalese makes it a barrier to entry rather than a door. Even the Medicare handbook is hundreds of pages. Its size makes the evaluation of information almost impossible.
The Pain of Picking Medicare Plan
As a consequence, picking a Medicare plan is a frustrating and painful process for people. That is why I take people through a 3-step process. 1.) There is a brief, foundational explanation of Medicare and how it works. 2.) Look at ALL of the plans, but in an organized and ordered fashion. The first step helps you evaluate the plans. I share the story behind each company from my fifteen years of insurance experience because each company has a history in the market. 3.) I find out about you. Everyone is unique. Some people are risk takers. Others are not. Some have health concerns that are foremost of mind. Others do not have any.
The logic of the process enables people to narrow down choices and make the best one for them. I ask questions as we go along. Test and probe. Explain aspects of the plans as we go through each. Constantly test for understanding. So the process of picking a Medicare plan becomes clearer as we move through it. I generally meet with people twice. The first time is usually months before they can do anything. There is no pressure to make a decision or ‘buy right now.’ Clients have time to think, collect more information, verify what they’ve learned, talk with confidants. The next time we get together is to review with updated information. That is the time for picking a Medicare plan. By then you are comfortable and confident with your decision because your decision is well informed. It is logical. The decision is made over time without pressure. You know what you are doing when you pick your Medicare plan.
If you would like to go through this process, there is not cost or obligation. Call 402-614-3389 to find out more.
We’ve all experienced that less than happy holiday vacation spent ill. What’s worse is getting sick abroad and worrying about Medicare insurance coverage. If you’re planning a winter getaway, check out and share our healthy Medicare travel tips to ensure your vacation goes off without a hitch.
Whether you’re going foreign or domestic, Medicare travel tip #1. Always research your destination. Even learning about a stomach bug going around could help save your trip. Also be sure to take a look into potential health facilities by contacting the U.S. embassy in the country you’re going to visit or by getting help from your hotel. Know and have the contact information for the hospitals and urgent care centers that could be available to you during your trip.
Common Traveling Illnesses
Important Medicare travel tips is to know what to avoid on your trip. Here are some common illnesses you can bring back from your vacation:
- Malaria – Often found in tropical climates, Malaria is contracted though an infected mosquito bite. Although the disease has flu-like symptoms, it may become deadly. The CDC (Centers for Disease Control and Prevention) has the need-to-know information on Malaria for travelers.
- Traveler’s Tummy – One of the most common maladies foreigners experience when traveling abroad. Traveler’s tummy is common throughout Asia, Africa, Latin America and the Middle East. You can learn more about the gastro-intestinal sickness and how to avoid it from the CDC.
- Zika Virus – Zika is something we’ve all heard about on the news in the past year. Symptoms can range from flu-like to joint pain and rashes. It’s been linked to Asia, Brazil, Central America, Mexico, The Caribbean and The Pacific Islands. This CDC Infographic has tips on preventing Zika while traveling abroad.
You can read up on what to specifically watch out for depending on where you’re going on the travel section of the CDC website.
Check Your Coverage
Compare Plans and Explore Your Options
Your health coverage will vary depending on your Medicare plan. Original Medicare will usually only provide coverage within the U.S. Some Medigap plans have travel coverage. Some Medicare Advantage Plans may as well, but you’ll have to check your specific plan.
If you need some help navigating your Medicare coverage options, our agents can help and are available all year-round.
Doctor Knows Best
Before traveling, meet with your doctor to have a check-up, talk about any health concerns you may have, if you’ll need any vaccinations, etc. Your physician should be able to inform you on any must-know health concerns in regards to wherever you’re going.
Pack Smart Most Important of Medicare Travel Tips
Pack weather-friendly, and don’t forget your necessary prescriptions and medications in your carry-on luggage. That is the most important of Medicare travel tips. If you’re traveling by car, keep your meds in an easy-to-access designated location. If you have any special medical supplies that you need to use, get a note from your doctor that explains why you need them. It’s better to be safe than sorry! If you need help thinking through these Medicare travel tips or you want to invest in travel insurance, give us a call at OmahaInsuranceSolutions.com 402-614-3389
With these tips, you should be enjoying your vacation in no time. Happy travels!
One of the most common questions we receive is: “Am I eligible for Medicare?” Well, there’s no black and white answer to Medicare eligibility. Your Medicare eligibility may depend on several different situations. Luckily, we make Medicare easy—this post will show you how and when to apply for Medicare based on your unique situation.
You become eligible for Medicare when you turn 65 (or younger if you have certain disabilities or diseases). If you or your spouse ha worked in the U.S for more than 10 years, you qualify for Medicare benefits.
Make Comparing Medicare Plans a Breeze
Medicare has four parts: Medicare Part A , Part B, Part C and Part D. Parts A and B include doctor and hospital insurance. Together, Parts A and B are referred to as Original Medicare.
You can apply for Original Medicare the year you turn 65, but only if you meet one of the below requirements:
- You’re eligible to receive Social Security benefits or Railroad Retirement benefits.
- You’re already receiving your retirement benefits from Social Security or Railroad Retirement.
- You or your spouse are covered for Medicare through government employment.
Medicare eligibility doesn’t mean you have to start using it. People are different—some may be ready and waiting to get their Medicare benefits and some may not need coverage yet. If you’re getting ready to turn 65, read on to see your Medicare options.
I’m Turning 65 This Year…
If you’re turning 65 soon, you may want to do one of many things depending on your situation:
- You’re retired
- You want to retire
- You have other health coverage
- You are still working and don’t want to retire yet
See the options for your situation below.
…and Want to Apply for Medicare
If you’re planning to receive retirement benefits before or at the age of 65, apply for Medicare at the same time or at least 3 months before your birthday. That way you’ll become automatically enrolled in Medicare when you turn 65.
…and Am Still Working
If you’re still working when you turn 65, you might want to keep your current health coverage provided by your employer. You can keep your current coverage and still apply for Medicare Part A (most people don’t have to pay a premium for Medicare Part A, so you won’t have to incur a cost).
However, you may consider deferring Medicare Part B to avoid the monthly premiums. We recommend checking with your employer to see how your current coverage may work with Medicare Part B before you make any decisions.
…and Am Covered by My Spouse
If you’re still getting health coverage from your spouse that’s working, refer to the paragraph above.
…and Did Not Pay Medicare Taxes While Working
There are some cases where individuals are 65 and older and a permanent resident of the United States, but they (or their spouse) did not pay Medicare taxes while working. If this is your situation, you still have options.
- Medicare Part A with premiums
- You can purchase Medicare Part A.
- Medicare Part A without premiums
- You’re receiving Railroad Retirement
- Kidney transplant patients/dialysis patients may still be able to receive benefits per special circumstance.
I’m Over 65 and Haven’t Enrolled in Medicare
If your 65th birthday has come and gone, you still have several options and opportunities to receive your healthcare.
- If you’re within 3 months of your 65th birthday, you still qualify for enrollment under your initial enrollment period.
- Otherwise, you can wait until general enrollment (January 1 – March 3).
Medicare Changes Part B Deductible
Medicare changes came out in December. The Medicare changes Part B deductible was an increase. The Medicare Part B deductible for 2016 was $166. The 2017 Part B deductible is $183. While the $17 increase is small in dollar terms, it was a 10% increase. That’s big!
Part B Deductible
What is the Medicare Part B deductible? Medicare Part A and Part B have various deductibles and co-insurance costs that you pay. While Medicare covers the majority of medical cost, you have some significant responsibility, especially if there are frequent and/or high dollar medical need. Part B covers doctors visits and outpatient procedures, which is everything other than the hospital. Medicare will cover 80% of those costs. Your portion is 20%, but before the 20% starts, you have an annual deductible. The key to the Part B deductible is that it is an annual deductible. You pay the Part B deductible only once per year, which is different from the Part A hospital deductible.
Plan G Vs. Plan F
Medicare Supplement Plan G is becoming the most popular supplement plan available. Plan G covers all the Medicare Part A deductibles and Part B co-insurance EXCEPT the Medicare Part B deductible. You pay that directly to the provider after the Medicare discount. Once that is satisfied for the year, you pay nothing else out of pocket.
You may ask, ‘why don’t I do Plan F where the Part B deductible is also covered?’ If you were on a Plan F, your monthly premium would include the cost of the Part B premium and the increase. You also would pay a substantial fee to the insurance company for them to write the check for $183 for you. By being on Plan G as opposed to Plan F, you avoid the sizeable annual increase and the additional fee for paying the Part B deductible.
While the Medicare changes Part B deductible was not large in dollar terms, the reality is the cost of Medicare will continue to rise along with all medical costs. It is important to have an agent who can help you understand your plan and find the plan that best fits your needs at the lowest cost. Give us a call at 402-614-3389 for a free evaluation.
Medicare Changes Part A Deductible
Medicare changes for 2017 came out in December. One of the changes was for Medicare Part A. Part A is the hospital side of Medicare. It does not cost anything because you paid the Medicare Part A premium during your working years. It was part of your payroll taxes. The premium is zero if you have enough quarters of work and paid in to Medicare; however, Medicare Part A has a deductible. The deductible was $1,288 for 2016. The Part A deductible for 2017 is $1,316.
Remember the Medicare Part A deductible is for each event within a 60 day period. If you revisit the hospital 61 days later OR there is a different and separate event resulting in admittance to the hospital, you pay the $1,316 again.
Increases Passed On To You
The significance of the increased Part A deductible will be an increase in the cost of your Medicare Supplement. Most Medicare supplements cover the Part A deductible as many times as it may occur in a given year. Because the insurance company will now be on for more deductible, it will have to offset that expense and risk with higher premiums. Your premium may not increase significantly, but it does cost the insurance company more. Consequently it will ultimately cost you more.
Medicare Advantage Is Different
For those on Medicare Advantage plans, you are not directly effected. Your hospital co-pays, as well as the other co-pays, are determined by your individual plan. They are already set for 2017. Any increases may result in increases in hospital co-pays down the line because, like supplements, someone needs to pay for the additional expense. The actual co-pay is determined by your Medicare Advantage plan, and they are now set for 2017. Check the changes to your Medicare Advantage plan for 2017. You received your notification of changes in October. If you cannot find it, call the customer service phone number on the back of your card. They will send you a new statement of understanding with all the 2017 co-pays, deductibles, and co-insurance.
Consult with your agent or give us a call to see how any changes to Medicare may affect your situation.
Medicare Part B
Medicare changes almost every year. Medicare changes for 2017 are significant. The Medicare Part B monthly premium is the change that hits people first. For Medicare beneficiaries who were on Medicare before 2016, the increase will be from $104.90 to $109 per month. For those who began Medicare Part B in 2016, the premium will move from $121.80 to $134. There are some minor variations on these numbers out there. Eventually Medicare will catch everyone up to the same amount. I am getting a lot of calls as clients see the higher premium. For those with annual individual incomes above $85,000 and joint incomes above $170,000, the increases are much larger.
Part B Premium Increase
The reason for the increase is the rising cost of Medicare. Fewer persons are working in relationship to the number of new beneficiaries going on Medicare. The baby boomer population turns 65 at a rate of 10,000 per day in our country. The cost of health care also consistently grows at a rate well above inflation. The CPI (Consumer Price Index) is currently about 2%. It is safe to say that Medicare Part B premiums will continue to rise in coming years.
Protection Again Medicare Changes
Medicare Part B premium is just one of the costs that are going up. Other deductibles, co-insurance, and co-pays are increasing as well. More and more of the burden of health care is being placed upon consumers, so it makes it even more critical that you select the plan that best fits your needs and budget each and every year. It may make sense to take on some deductibles, co-pays, and/or co-insurance so that the monthly premium is not so burdensome, especially if your monthly income is limited. Medical emergencies do not occur regularly, but premiums do. You must pay them every month. One of the most common calls I get is ‘how do I reduce my monthly health care expenses?’
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.