Medicare Wants You To Live A Healthy Life
Medicare will be a different health insurance experience than when you were on your employer’s health plan. Many employer health plans try to reduce how often you use the program to keep down costs. In contrast, Medicare understands that more health issues arise in the Medicare age population. A big driver for Medicare is prevention, monitoring, and early detection. Medicare health screenings are the most effective ways for Medicare to keep its costs lower. Both Medicare and the insurance companies that manage Medicare Advantage plans are highly motivated to push beneficiaries to use the preventative programs to the maximum.
Medicare Health Screenings Could Have Saved My Parents
My father was a kidney transplant recipient. He also was COPD and had an endless list of other maladies. My mother kept an eagle eye on him, ensuring his screenings, physicals, and other monitoring took place on an unyielding schedule. Despite my mother’s vigilance, we believed my father would be the first to go.
My mother took care of herself, but she was a smoker most of her life. I couldn’t believe it when she called me to say she had stage 4 ovarian cancer. She was so careful. I assumed she did all the Medicare health screenings. She may not have been as vigilant for herself, unfortunately.
Mom courageously underwent all the treatments the doctors recommended, but in the end, a year later, cancer took her. My youngest brother was angry to the point of wanting to sue the doctors. I was befuddled that cancer would sneak up on my mom. I never pushed or prodded my mother about what she did or didn’t do about her health. You don’t question parents in my family, especially about personal things like that. The door is closed to children. I can’t help to think if she had done more Medicare health screening, the outcome may have been better.
Education to Prevention
Original Medicare and especially the Medicare Advantage plans encourage a healthy lifestyle. Medicare Advantage plans expend enormous amounts of resources to inform people about preventing disease through exercising, eating well, reducing body weight, and not smoking. These activities affect the health of everyone, but they significantly affect Medicare-age persons.
Medicare designs health screenings around regular, annual shots, frequent lab tests, and consistent screenings in important high-risk areas. Health monitoring for higher-risk individuals is critical to catch symptoms early on before the situation is more complex and less treatable. Education is essential for all these areas. Medicare Advantage plans aggressively share information with clients about all the benefits, tools, and opportunities that are available to Medicare beneficiaries. Sometimes my clients complain about how often the insurance companies will call to remind them about physicals and screenings, though they like the treats and rewards they get after performing mammograms, physicals, hemoglobin A1c tests, etc.
You can register at MyMedicare.gov to get direct access to preventive health information—24 hours a day, every day. You can set up your account and track your preventive services. Medicare has a 2-year calendar of the Medicare-covered tests and health screenings for which you’re eligible. You and Medicare can enter the dates of screenings and treatments. You have your own “on-the-go” report to see where you are with your screenings. You can even take the report to your doctor’s appointments to ensure you get all the benefits you can out of your Medicare prevention program.
Preventive services fall under Medicare Part B. The preventive services are usually at no cost with physicians who accept Medicare. If you are on a Medicare Advantage plan, consult the Evidence of Coverage for your Medicare Advantage plan for costs. The Evidence of Coverage lays out what is covered and the approximate costs. Most preventives are at zero cost.
Talk with your doctor about which screenings and tests are more relevant for your health circumstances. Medicare may or may not cover some of those screenings. Also, Medicare has a schedule of when these health screenings should occur and with what frequency. Any abnormalities may require more frequent testing. Other screenings may be less frequent because of your health history and situation.
Medicare Screening For Abdominal Aortic Aneurysm
Medicare covers a one-time abdominal aortic aneurysm ultrasound for people at risk. You’re considered at risk if you have a family history of abdominal aortic aneurysms, or you’re a man 65–75 and have smoked at least 100 cigarettes in your lifetime. Medicare covers this screening once in your lifetime if you get a referral from your doctor. You pay nothing for this screening if the doctor or other qualified health care provider accepts Medicare assignment.
Alcohol Misuse Screening & Counseling
Alcohol misuse screening is for Medicare beneficiaries who use alcohol but don’t meet the medical criteria for alcohol dependency. Medicare covers one alcohol misuse screening per year. If your primary care doctor or other primary care practitioner determines you’re misusing alcohol, you can get up to 4 brief face-to-face counseling sessions per year. The practitioner must provide the counseling in a primary care setting, like a doctor’s office. You pay nothing if the doctor accepts Medicare assignment.
Bone Mass Measurements
Medicare covers bone mass measurements to see if you’re at risk for broken bones due to osteoporosis. Osteoporosis is a disease in which your bones become weak and brittle. In general, the lower your bone density, the higher your risk for a fracture. Bone mass measurement results will help you and your doctor choose the best way to keep your bones strong.
I have several clients with varying levels of osteoporosis. Some are just in the monitoring phase. Others get Prolia shots in the doctor’s office because of the determination of the bones. The Medicare health screening for those at risk for osteoporosis must have one of these medical conditions:
- A woman whose doctor or health care provider says she’s estrogen-deficient and at risk for osteoporosis, based on her medical history and other findings
- A person with vertebral abnormalities as demonstrated by an X-ray
- A person getting (or expecting to get) steroid treatments
- A person with hyperparathyroidism
- A person taking an osteoporosis drug
The screening may be performed once every 24 months or more often if medically necessary. You pay nothing for this test if the doctor accepts Medicare assignment.
Medicare Breast Cancer Screening
Breast cancer is the most common non-skin cancer in women and the second leading cause of cancer death in women in the U. S. Every woman is at risk, and this risk increases with age. Breast cancer can usually be treated successfully when found early. Medicare covers screening mammograms to check for breast cancer before you or a doctor may be able to find it manually.
Women 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between 35–39. Once every 12 months. You pay nothing for the test if the doctor accepts Medicare assignment.
Your risk of developing breast cancer increases if any of these are true:
- You had breast cancer in the past.
- You have a family history of breast cancer (like a mother, sister, daughter, or 2 or more close relatives who’ve had breast cancer).
- You had your first baby after 30.
- You’ve never had a baby.
Cardiovascular Disease Screening
Medicare covers cardiovascular disease health screenings that check your cholesterol and other blood fat (lipid) levels. High levels of cholesterol can increase your risk for heart disease and stroke. These screenings will tell if you have high cholesterol. All people with Medicare are covered when a doctor orders the screenings–tests for cholesterol, lipid, and triglyceride levels. Medicare covers cardiovascular health screening once every five years unless history and other circumstances dictate more often. You pay nothing for this screening.
Cervical & Vaginal Cancer Screening
Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers. Medicare also covers a clinical breast exam to check for breast cancer as part of the pelvic exam. All women with Medicare are covered for a Medicare health screening for cervical and vaginal cancer once every 24 months, or once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal Pap test in the past 36 months. This also includes Human Papillomavirus (HPV) tests (as part of Pap tests) once every five years if you’re 30-65 without HPV symptoms.
Your costs, if you have Original Medicare, are nothing. You pay nothing for the lab Pap test and the lab HPV with Pap test. If the doctor accepts Medicare assignment, you also pay nothing for the Pap test specimen collection and pelvic and breast exams.
Your risk for cervical cancer increases if any of these are true:
- You’ve had an abnormal Pap test.
- You’ve had cervical or vaginal cancer in the past.
- You have a history of sexually transmitted diseases (including HIV infection).
- You began having sex before 16.
- You’ve had five or more sexual partners.
- Your mother took DES (Diethylstilbestrol), a hormonal drug, when she was pregnant with you.
Colorectal Cancer Screening
Medicare covers colorectal cancer health screening tests to help find pre-cancerous polyps (growths in the colon), so polyps can be removed before they become cancerous and help find colorectal cancer at an early stage when treatment works best. All people with Medicare who are 50 and older, but there’s no minimum age for having a covered screening colonoscopy.
- Screening fecal occult blood test—Once every 12 months for people 50 or older.
- Screen flexible sigmoidoscopy—Once every 48 months after the last flexible sigmoidoscopy or barium enema, or 120 months after a previous colonoscopy.
- Screening colonoscopy—Once every 120 months (high risk every 24 months), or 48 months after a previous flexible sigmoidoscopy.
- Screening barium enema—Once every 48 months (high risk every 24 months) when used instead of sigmoidoscopy or colonoscopy.
Multi-target stool DNA test—Once every three years if you meet all of these conditions:
- You’re between 50–85.
- You show no signs or symptoms of colorectal disease, including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test.
- You’re at average risk for developing colorectal cancer, meaning you have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.
- You have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
You pay nothing for the fecal occult blood test if you get a written referral from your doctor, physician assistant, nurse practitioner, or clinical nurse specialist. If your doctor accepts assignment, you pay nothing for the flexible sigmoidoscopy or screening colonoscopy.
Polypectomy During Colonoscopy
If a polyp or other tissue is found and removed during the colonoscopy, you may have to pay 20% of the Medicare-approved amount for the doctor’s services and a copayment in a hospital outpatient setting, unless you have a Medicare supplement or Advantage plan. Consult the plan for your costs.
The risk for colorectal cancer increases with age. It’s essential to continue with screenings, even if you were screened before you had Medicare. Your risk for colorectal cancer increases if any of these are true:
- You’ve had colorectal cancer before.
- You have a close relative who had colorectal polyps or colorectal cancer.
- You have a history of polyps.
- You have inflammatory bowel disease (like ulcerative colitis or Crohn’s disease).
Medicare Depression Health Screening
All people with Medicare are covered for depression screenings. Medicare covers one depression screening per year. The screening has to be done in a primary care setting, like a doctor’s office., followed-up with referrals and treatment. You pay nothing for this test if your doctor accepts Medicare assignment.
Medicare covers a blood screening test to check for diabetes for people at risk. Diabetes is a medical condition where your body does not make enough insulin or has a reduced insulin response. Diabetes causes your blood sugar to be too high because your body needs insulin to use sugar properly. A high blood sugar level isn’t good for your health. For people with diabetes, Medicare covers educational training to help manage their diabetes. Medicare covers people at risk for diabetes and gets a referral from a doctor. Based on the results of your screening tests, you may be eligible for up to 2 diabetes screenings per year. You pay nothing for this screening.
You’re considered at risk if you have high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar (glucose). Medicare also covers these tests if two or more of these apply to you:
- You’re 65 or older.
- You’re overweight.
- You have a family history of diabetes (parents, brothers, or sisters).
- You have a history of gestational diabetes (diabetes during pregnancy), or you’ve had a baby weighing more than 9 pounds.
Diabetes self-management training
This training is for people with diabetes to teach them to manage their condition and prevent complications. You need a written order from a doctor or other qualified health care provider. You pay 20% of the Medicare-approved amount after the yearly Part B deductible. This will be different if you have a Medicare Supplement or Medicare Advantage plan.
Glaucoma is an eye disease caused by high pressure in the eye. It can develop gradually without warning and often without symptoms. The best way for people at high risk for glaucoma to protect themselves is to have regular eye exams. Medicare covers people with Medicare at high risk for glaucoma. They may test once every 12 months. You pay 20% of the Medicare-approved amount after the yearly Part B deductible if you do not have a Medicare Supplement or Medicare Advantage plan. Your risk for glaucoma increases if any of these are true:
- You have diabetes.
- You have a family history of glaucoma.
- You’re African-American and 50 or older.
- You’re Hispanic and 65 or older.
There are many more Medicare health screenings that you may review on Medicare.gov.
Flu & Pneumonia Shot
Medicare covers more than screenings and monitoring as part of Medicare’s preventative program. Medicare tries to prevent illnesses, particularly illnesses that can severely affect people with other underlying conditions. Medicare offers flu, pneumonia, and Hepatitis B shots. The COVID shot will soon be officially part of the Medicare regimen. Flu, pneumococcal infections, and Hepatitis B can be life-threatening to an older person. All people 65 and older should get flu and pneumococcal shots. People with Medicare who are under 65 should also get a flu shot. This is especially important for chronic illnesses, including heart disease, lung disease, diabetes, or End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). People are at medium to high risk for Hepatitis.
All people with Medicare are covered for the shots once each flu season at no cost. The pneumonia shot is given once in a lifetime. A different second shot is covered 11 months after the first shot. Again you pay nothing if your doctor or other qualified health care provider accepts Medicare assignment for giving the shot.
Hepatitis B shots
Certain people with Medicare who are at medium or high risk for Hepatitis B are covered. Three shots are needed for complete protection. Check with your doctor about when to get these shots if you qualify to get them. Your costs on Medicare are nothing as well.
These are some of the factors that put you at medium or high risk for Hepatitis B:
- ESRD (End-Stage Renal Disease).
- Certain other conditions increase your risk for infection, like if you live with someone who has Hepatitis B or if you’re a health care worker and have frequent contact with blood or body fluids.
I will never know if my mother’s cancer could have been prevented with better screening, monitors, and tests. I hope my clients utilize all the tools and opportunities to live the healthiest life possible, especially those that cost nothing.
Medicare is a federal government program. Like anything government program, there are lots of rules and regulations. Medicare Open Enrollment has rules. Inattentiveness to those rules may result in unwanted penalties and painful costs.
What is Medicare Open Enrollment?
Open Enrollment Period, now called Annual Election Period (AEP), is from October 15th–December 7th. You can change your Medicare Part D prescription drug plan and your Medicare Advantage plan during that time. People still call Annual Election Period “Open Enrollment” even on the Medicare.gov website. The use of two names make for confusion, but the correct term is now Annual Election Period (AEP). The primary reason for the name change is that another period in the Medicare calendar is called “Open Enrollment.”
How Does Annual Election Period Effect Medigap Policies?
Medicare supplements can be changed year-round in Nebraska and Iowa. There is no particular time or “Open Enrollment” for Medigap. You simply have to answer some underwriting health questions during the application process for a new Medigap policy. Then, you are either approved, denied, or rated. The old Medigap policy is canceled, and you seamlessly move over to the new policy. However, when someone is on an Advantage plan, you must wait until Annual Election if you wish to change from Medigap to Medicare Advantage or from Medicare Advantage to Medigap.
When someone first comes on to Medicare, the expression “Open Enrollment” is commonly used. More confusion. Again, that is not correct. The proper phrase is “Initial Enrollment Period.” Your Initial Enrollment Period is when you either turn 65 and enroll in Medicare or when you activate your Medicare Part B sometime after you turn 65, usually after dropping an employer’s health plan. During your Initial Enrollment, you have a whole set of rules. You are not required to answer health questions when applying for a Medigap policy, and the insurance company cannot use your height and weight to determine anything about the policy. You are guaranteed a policy at the lowest possible rate.
Underwriting During Annual Election
There is no underwriting to change from your Part D prescription drug plan or Medicare Advantage plan to another. You are guaranteed acceptance.
Again, Medigap plans must be underwritten after your Initial Enrollment Period. AEP does not affect Medigap applications. The insurance company can accept you, reject you, or ask for a higher price–rate you.
Annual Reviews During Medicare Annual Election Period
With my clients, I send out a couple of letters and emails reminding them when AEP (Annual Election Period) is upon us. I ask clients to call if there are any problems or concerns about their Medicare plan. AEP is important because it is the one time clients can make adjustments to their plan. AEP is also a period when the insurance companies make changes to their plans. They sometimes increase copays, premiums, deductibles, and coinsurance. On the Part D plans, they can add or drop medications, change the copays, and move drugs to a different tier.
So I highly encourage clients to call for a review. Most of the time, the review is a ten-minute phone call. Other times, it requires making changes, meetings, and doing paperwork.
High Dollar Drugs
Those with expensive medications especially need a review. Clients will say, “My medications haven’t changed. Why call?” The answer is simple. The plans change every year. You could find a $600 medication no longer covered on your Part D formulary. I don’t know any clients who have an extra $600 a month jingling in their pockets they don’t need.
The insurance company can also move a drug into a higher and more expensive tier, include it with the deductible, or make other changes that result in painful increases. So I sayemphatically to my clients who take insulin, anti-diabetic medications, Eliquis or Xarelto, and many other high-dollar meds, call me! We need to talk during Annual Election.
On my part, it is easier for me to do nothing. Changing someone’s plan is work, especially when I have hundreds of people asking for help during the short election period, but I think of my parents. I know an additional $300 or $500 coming out of their monthly budget for medication would have meant real hardship for them. I don’t want that for anyone, especially my clients. Ensuring clients have the lowest cost prescription drug plan with a high Medicare star rating is my goal during the Annual Election Period.
Don’t Miss the Boat
Inevitably I get the call on December 8th, “Can I change my Medicare plan?” It is sad and angering. I’m always struck by the irony when they get mad at me. After all, they only had 10 weeks to do something.
How hard is it to remember it is Annual Election Period when your mailbox is loaded with postcards, brochures, and letters reminding you it is Medicare Open Enrollment? Life is busy, but you don’t notice the Joe Namath and Jimmy JJ Walker commercials running 24/7 selling Medicare Advantage plans with exaggerated claims and gross distortions of the truth? Ultimately we are all responsible for our actions or lack of action.
When Is Medicare Advantage Open Enrollment Period (OEP)
There is a second chance to make a change as far as Medicare Advantage goes. From January 1st–March 31st are Medicare Advantage Open Enrollment dates (OEP). A person on a Medicare Advantageplan can change from one Medicare Advantage plan to another Medicare Advantage plan. Again there are no underwriting questions. A person is allowed one chance and one change during OEP.
The reason for the second chance with Medicare Advantage is because people make mistakes. For example, you changed your plan during AEP. Your doctor is not in-network with the new plan. During OEP, you can change back to the other plan and keep your doctor. The same is true for medications. The new plan does not cover your medications, so you move to a plan that does during OEP.
Open Enrollment Mistakes
During OEP, people change because a fast-talking salesperson convinces them the other plan is way better, but in a rush to change, the beneficiary does not accurately confirm that all their medical professionals are in the network with the plan. They also may not correctly confirm that all their medications are on the plan’s formulary at the same or lower copays.
After the Medicare Open Enrollment deadline of March 31st, they find themselves in a bad situation. However, they cannot change back. You only get one chance to change during OEP.
Original Medicare During Medicare Open Enrollment
The other side of Medicare Advantage Open Enrollment is that you can drop your Part C plan and return to Original Medicare. Original Medicare is only Part A (for the hospital) and Part B (for doctor visits and patient procedures). You then receive a one-time opportunity to enroll in a Medicare Part D prescription drug plan. Again you get only one chance to enroll in a Part D plan. You can’t change your mind again a month later and switch to another Part D plan. After that selection, the only next time you can change will be during Annual Election Period in October, unless you have some sort of Special Election Period (SEP).
No Guarantee Issue During Medicare Open Enrollment
Once you return to Original Medicare, you may apply for a Medigap policy. In Nebraska & Iowa, you will need to answer underwriting questions about your health, give height & weight, and whether or not you use tobacco. The insurance company, at that point, determines if they will accept you at the offered price, charge a higher premium, or deny your application altogether.
Again, you will not be able to re-enroll in a Medicare Advantage plan until Annual Election Period in October.
Medicare Enrollment Mistakes
I remember a person who was referred to me. The family moved her into a skilled nursing facility because she could not take care of herself adequately after a fall. The skilled nursing facility said that Original Medicare was better than Medicare Advantage. The family dropped the Medicare Advantage plan and enrolled her in a drug plan. They thought they could get her a Medicare Supplement.
By the time they realized she would not pass underwriting for a supplement, she had moved out of the nursing home. She could not return to the Advantage plan until October’s annual election. She had the unlimited 20% coinsurance of Medicare Part B to pay for her many health concerns.
Skilled nursing facilities receive higher reimbursement from Original Medicare than from most Advantage plans. Their treatments receive less scrutiny from Medicare than the insurance company’s advantage plan’s managed care. They prefer that.
Her income and assets were meager, but the change ensured the money was dissipated more quickly, and the county and the taxpayer came in sooner to cover her medical expenses through state Medicaid.
When Does Medicare Advantage Open Enrollment End?
Every year during April, I get phone calls from clients. “What happened to my plan?” After some research, I found out that someone called and switched him to a different plan during the Medicare Advantage Open Enrollment Period.
One technique is for the salesperson to make the phone call sound official. “Mrs. O’Leary, this is Medicare Open Enrollment, and you have one chance to make sure you have the right Medicare plan. Which plan are you currently on?”
It doesn’t matter which plan the person is on. The point is to find out the current plan and explain how another plan is much better. These agents are flippers.
The agent flips the person from the plan they are on to a different plan, so they get paid. Getting paid is the goal.
It is all done by phone. The agent never meets the person. There is no follow-up or long-term relationship. Then, the agent moves on to the next person. The agent may not even be in the business after Medicare Open Enrollment ends.
Inevitably, I get the phone call on April 1st after Medicare Advantage Open Enrollment has ended, “What happened to my Medicare plan?” I have to tell them, “Sorry, Mama, the Medicare Advantage Open Enrollment deadline was Dec. 7th.”
Nothing Can Be Done Until Annual Election in October Usually
Over the years, I’ve had several clients tricked. Sometimes I’m able to repair the damage. Sometimes not.
The first time it happened to one of my clients was in 2013. The day before my client’s plan was scheduled to start, he got a call from one of these salespersons pretending to be from his Medicare insurance company. They acted as though they were checking in on him. As she was ending the call, she said there had been some recent changes, and a new and improved plan was available. She convinced him to enroll in the other plan. He didn’t think anything of it, so he didn’t call me.
Six months later, he was scheduled for surgery. He called me frantic a few days before the surgery because the doctor was not in-network. I always check things like doctors, so I was stumped.
To give you the short version, after some research, I discovered the agent had changed him from the Medicare Advantage HMO plan he had selected that covered all the doctors and hospitals in his area to a select HMO plan that only worked with one network in the Omaha area with the same insurance company. (I never use those sorts of plans for precisely this reason.) The agent did not confirm that his doctors were in the plan network. She probably didn’t care.
The happy ending was that he decided to go in the direction of a Medicare supplement, and I was able to make the switch immediately because he was still within his first 12 months of being on a Medicare Advantage plan–the 12-month rule. He got his surgery, and everything was covered. The story, however, does not always end so favorably.
How Long Does Medicare Advantage Open Enrollment Last?
Medicare Advantage Open Enrollment is a long season–3 months. The insurance agents’ and insurance companies’ marketing is intense. They have 3 months to flip people. They use every trick in the book.
Most of my clients call me when they get these kinds of phone calls. We dealt with clients’ issues and concerns during Annual Election, and so they usually have the right plan for their needs. Sometimes, however, it does make sense to change their plan because something new came up. But, Medicare Advantage Open Enrollment is definitely a time for the Barracudas.
Who Is Medicare Advantage Open Enrollment For?
Ideally, this period is for those who made a mistake with their Medicare Advantage plan–their doctor is not in-network, medication is not on the formulary, the price of a medication is in a higher tier, the copays or maximum out-of-pocket went up unexpectedly. They have a second chance to correct the oversights or select a better plan before the Medicare Advantage Open Enrollment Period ends March 31st.
The Reasons to Pay Attention During the Open Enrollment Periods
The three eternal truths of Medicare over time are:
- Medicare will change
- Medicare plans will change
- Your health needs will change
Not understanding Medicare rules, not knowing the plan costs, and not being attentive to the calendar may result in costly mistakes. Be advised.
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.
A number of distressed clients called me because they saw announcements on the news that Aetna and United Healthcare (UHC) were pulling out of individual states and would not be offering health insurance any more. It is true that Aetna and UHC are pulling out of some healthcare plans, but Aetna exits ACA NOT Medicare.
Aetna Exits ACA Not Medicare
Aetna individual plans are on the market place exchanges through the ACA (Affordable Care Act). ACA has nothing to do with Medicare, and Aetna and UHC, which are the largest Medicare plan providers, will continue to offer Medicare Supplement plans and Medicare Advantage plans in all the states. Aetna and UHC Medicare Part D and Medicare Part C plans will not be affected.
Why Are Aetna and UHC Pulling Out?
The plans that are on the exchanges are not inexpensive plans. They are loaded with all types of services. The pricing is also designed to transfer money from beneficiaries who have higher incomes to those who have lower incomes in the form of subsidies. That is why the majority of Americans are paying significantly more for less insurance. At the same time, the number of people on the exchange in health insurance plans are far less than the estimates the government initial provided. The numbers are low for two principle reasons. Fewer people are purchasing the product. Instead they are accepting to pay the penalty. Second the employer mandate was weakened and delayed each year by the president. The result is that less people were pushed on to the exchanges than anticipated. The overall result is that insurance companies who administer the ACA plans on the exchanges have consistently lost money each year. The share holders and boards decided to stop losing money by pulling out.
This has no direct affect on Medicare and your individual plans, even if it is an Aetna or UHC Medicare Supplement plan or Medicare Advantage plan. Aetna exits ACA NOT Medicare.
The leading cause of bankruptcies in the U.S. are medical bills. Coupled with the headlines “Medicare Going Bankrupt,” the question is: whose going bankrupt first? Health care and Medicare have been in the news and will be even more so as the political season kicks into high gear. Don’t let Medicare’s budget problems became yours.
Medicare Going Bankrupt
The headlines that state “Medicare Going Bankrupt” are not accurate. Medicare is divided into three parts: A, B, & D. Medicare Part B, which covers doctors and outpatient procedures, is covered by participants’ premiums and general revenues from the government budget. Medicare Part D, which covers drugs, is the same. They can never run out of money. Medicare Part A covers hospital expenses. Payroll taxes finance Part A. The Government Accountability Office report says that Part A will not be able to pay 100% of its bills by 2030 at present estimates. It will only be able to pay 86% of expenses which is a problem that can be easily solved in a couple of ways. Medicare going bankrupt is the wrong issue.
Rising Health Care Costs
Rising cost is the issue. Medicare benefits will be paid for. In the past, there were three ways to pay for the program. They are still the same. Increase taxes, increase the premiums, reduce benefits or a combination of all three. This year the premium for Part B was increased from $104.90 to $121.80 for new members. The Part A deductible was increased from $1,260 to $1,288. The Part B deductible was increased from $147 to $166.
You Pay It
Medicare costs will go up in the future, like all health care costs. The bottom line is you will be effected by what the government does or doesn’t do about Medicare. More of the cost for your health coverage will be placed in your lap, so it becomes even more important that you have the most efficient supplement to your Medicare. You need to manage your health care costs more efficiently, even if government doesn’t.
Don’t be a victim who is at the mercy of Congress or Medicare. Find the best coverage at the price you can afford before you are forced to search. Protect yourself from future Medicare benefit reductions with a more efficient supplement—one that covers those co-pays, deductibles, coinsurance but at a lower premium. FREE Quote 402-614-3389.
One of the most painful calls I get is from a client who is calling on behalf of a parent. They want to know if there is anything I can do for a parent who is paying huge monthly premiums for her Medicare supplement. The agent who signed them up is long gone. The supplement has increased over the years due to age and rate increases. Now the parent is in her 80’s and in poor health, and the monthly premium is financially crushing. Many times there is nothing I can do because their mom or dad cannot pass the underwriting questions to change to a supplement that would be significantly less. They missed out on one of the keys to unlocking Medicare–an agent who shops her policy each year.
Five Keys to Unlocking Medicare
There are five keys to unlocking Medicare. First you need to do some research yourself. The bible for Medicare is Medicare & You. It is the official Medicare Handbook that the Center for Medicare & Medicaid Services publishes each year. The Medicare.gov website is an endless source of resources. It is important to do your own research so you are familiar with the proper Medicare terminology. That way, you can better understand a serious discussion around Medicare.
The Big Key
Key number two: search for an experienced, independent agent. Experience means they have been doing this for years. Ask them when they got their insurance license. They should be able to spit that out without thinking. Ask if they do this fulltime. There are a lot of insurance companies and agencies who hire part-time people to increase their production. They give them little education or training. Even less support. Most drop out of the business after six or nine months. That probably is not the person you want. Ask if they are independent. Some insurance agents can only offer one company. They cannot shop the world of Medicare plans. Ask them to list the companies they offer. If they change the subject or only list one or two, you have your answer.
Key number three: ask questions. As I tell my clients who are aging into Medicare, you turn 65 once in a lifetime. I help people turning 65 going on Medicare four or five times in a day. I am excited when someone asks me a question I haven’t heard before. An experienced agent should be able to quickly and easily explain the details of Medicare, supplements, advantage plans, prescription drugs, etc. If not, you may wish to look somewhere else.
Price Compare Med Sups
Key number four: compare every year. I talk to my clients at least once a year. I want to know that everything is going well. Part of the conversation is the price of their supplement. With age and rate increases, what are you currently paying? I shop their supplement right then and there over the phone. I tell them if there is a plan of equal or better value at a lower price. That prevents you from getting into the situation in your later years of a plan with back breaking premiums.
Key number five: stay healthy! Go to the gym. Eat healthy. Chase grandchildren, pets, moving cars, anything that will get your heart rate up. One of the keys to unlocking Medicare supplements is your ability to pass underwriting questions so you can change plans and pay less. I can try different companies that have more liberal underwriting guidelines, but ultimately there are limitations for serious health issues.
Medicare and Medicare supplements are awesome health insurance, but to enjoy the greatest benefits from this awesome resource, you need to follow these simple five keys. Call me 402-614-3389 or the American Association of Medicare Supplements to find an experienced, independent agent near you.
If you saw a Benjamin Franklin $100 bill laying on the sidewalk, would you pick it up? If someone offered to pay your groceries for 2 months, would you take them up on that? If you had to fill out a coupon to receive six months of free gas for your car, would you send it in? Most people would, but most people never price compare their Medicare Supplement to save $100, $500, $1000 a year. One of the most common excuses and common Medicare myths is that it is not Annual Election Period (AEP), which is Oct 15th–Dec 7th, so ‘I can’t do anything.’
Common Medicare Myths
A common Medicare Myth I hear everyday is that you can’t change your Supplement except during Annual Election. That is true about Medicare Part D plans. Unless you have a special election, you cannot change your Medicare prescription drug plan until Oct 15th. The same applies to Medicare Part C/Medicare Advantage. You cannot change from one company or plan to another except from Oct 15–Dec 7th. Those are the CMS (Center for Medicare & Medicaid Services) rule.
Change Medicare Supplement Any Time
That, however, is not the case for Medicare Supplements. You can change your supplement every month if you wish. A Medicare Supplement is a contract with a private insurance company that fills in the gaps in your Medicare coverage. It pays the Part A hospital deductible. It pays some or all of the 20% co-insurance under Part B. All you have to do to change supplements is answer some health questions and fill out the forms. That’s it.
Compare prices. It takes less than 5 minutes. I do quotes for people all day. You can know in seconds whether you are overpaying for the exact same coverage, and you can do something about it. You can change right now. You can save $300, $500, $1000 a year right now. It is especially appropriate to check after you receive a rate increase from your insurance company. You aren’t stuck. Pick up the phone and find out your options.
This is still the land of the free, and in the Medicare Supplement world you are free to compare and change. Don’t be fooled by one of the common Medicare myths. You can make changes to your supplement at any time. Compare prices. If you would stop, bend over, and pick of a Benjamin Franklin laying on the sidewalk. You can take the time to check the supplement rates and even fill out an application 402-614-3389.
I learned to sing the alphabet before I learned to say it, and from that humble beginning, language opened up to me.
You can’t understand language without first understanding its alphabet. Medicare has a language, and Medicare has an alphabet. It begins with A, B, & D. They are the three essential components of Medicare.
A is for Medicare Part A. A covers the hospital 100% for 60 days but only after you pay a $1,260 deductible out of your pocket. Ouch! Part A is free because you paid for it during your working years. Eligibility for A is 3 months before your 65th birthday, the month of your birthday, & three months after. If you don’t enroll then, there will be a penalty.
B is for Medicare Part B. B covers doctor visits and outpatient procedures, such as, blood work, x-rays, emergency room, ambulatory surgeries, walkers, wheel chairs, oxygen tanks, etc. Part B does cost something. Currently $104.90 per month. Medicare Part B pays 80% of the costs. Your portion is 20%. Important fact about your 20% co-insurance is that there is no cap. As long as the bills roll in, your money rolls out. Bigger Ouch! The penalty for late enrollment for Part B is 10% for every 12 month period.
The final letter is not C. It’s D—D as in drugs. Medicare Part D was started in 2006 after people complained about the crushing cost of medications. Prescription drug plans are administered by private insurance companies approved by Medicare. Prescription Drug Plans (PDP) can range in cost from $20–$50 per month with deductibles and co-pays. There is a penalty for not enrolling in a Part D plan when you are eligible. It accrues each month you are not enrolled and is permanently added to your Medicare premium when you do enroll.
Medical expense can be astronomical. If the correct insurance is not in place with sufficient coverage, costs may surprise and overwhelm you. Not following the eligibility requirements could result in surprise penalties and permanent costs from Medicare. Call 402-614-3389 or email us at info@OmahaInsuranceSolutions.com for a free consultation to make sure all your letters are in place.
Markets are constantly changing. The Wednesday and Sunday additions of the Omaha World Herald are full of ads and fliers. Stores publicize sales, put up posters with markdowns, advertise deals, and promote special events. Prices and products are constantly changing. The market place does not stand still.
The insurance and Medicare market is no different. Aetna announced a 37 billion dollar bid with a capital B for Humana this week. Anthem Blue Cross is in talks about acquiring Cigna. Centene Corp agreed to buy Health Net Inc for $6.3 billion. The insurance landscape is changing.
These are big players, so when they move, the Medicare market will be affected. Some will argue that consolidation will reduce costs. Others will say that bigger and fewer insurance companies means monopolistic pricing. How it plays out is yet to be seen. Analysis will fill up hours of television and radio time with speculation about the Medicare market. The reality is insurance products, including Medicare supplements, will change. The changes will come primarily in the form of prices.
An endless list of variables go into Medicare supplement premiums. Creating and administering a Medicare Supplement product costs something. Medical claims come out of the premiums collected, so the premium needs to be high enough. In the end, the company must generate a profit for the shareholders. Otherwise, there is no point and the company’s assets will be sold off.
To generate those profits, the company needs to acquire clients. That is done in a number of ways. Slick advertising and marketing campaigns get prospects in the doors. Have you ever received any mail from an insurance company? During open enrollment (Oct 15th—Dec 7th), the Medicare commercials are like political adds at election time. They are endless. You can’t wait for them to stop.
The other way that insurance companies get prospects in the door is price. But how low can a company price the product? In other words, how lean can the company run its operation and still make a reasonable profit? If they guess wrong on pricing, it could be devastating for everyone involved—clients, employees, and shareholders.
If they lower the price too much and cannot meet claims and expenses, the company will be forced to raise premiums and drive away healthy clients. If they are too high, they will not have enough clients to create an adequate pool to assume the risk. Claims could further drive up costs and cause the company to raise premiums even higher.
So, like oranges, asparagus, and lettuce, the price of supplements are in a state of constant flux. Some of the factors are age. Price goes up with age. Rate increases are announced by the company because medical costs go up. And sometimes, there is even an occasional decrease.
Who is your shopper? Who will let you know what is happening in the Medicare market place? Who can find the lowest price supplement for you? I am Chris Grimmond the found of Omaha Insurance Solutions. I have worked for and with insurance companies for 13 years. I understand the Medicare market and how it works. We will shop your Medicare supplement and make sure you always have the best value for your dollar 402-614-3389