SSI Blog
Medicare Part C (Medicare Advantage) is a cost-saving option for many seniors to cover out-of-pocket expenses associated with Medicare. These plans include many additional benefits that Medicare does not. Putting together similar coverage using Part A and B would require adding a Part D plan to be comparable.
Insurance Companies
With Part C Plans, individuals receive Part A and B coverage from an insurance company, not Medicare. In exchange, the government makes payments to them to cover the cost. Insurance companies negotiate with local hospitals and doctors for reduced rates. Unlike Medicare, you will be required to use this specific network of providers with these plans.
Coverage
Individuals continue to receive Medicare Part A and B coverage, as well as additional benefits not provided by Medicare. Most plans include benefits for prescriptions, dental, vision, fitness programs, and even hearing. Plans use a network of providers, and as a member, you agree to use the hospitals, doctors, and pharmacies in the service area. You can use providers who are not, but it will cost you more. It’s important to review your plan’s network requirements, If you don’t, you may be responsible for the total costs of services.
Cost of Plans
There are several different plans to choose from, with varying premium amounts. Many companies offer $0 premium plans with additional benefits. Plans with no premium may be a cost-effective option, but they do have expenses like deductibles, and copays. The co-payment is in place of the 20 percent coinsurance you would pay under Medicare. Plans are required by law to put a max amount you will spend out-of-pocket for deductibles and copays each year.
Factors To Consider
Does the plan pay the Part B premium?
Does the plan provide extra benefits (prescription, vision, dental)?
What is the yearly deductible amount?
What is the cost for each doctor visit (copayment, coinsurance)?
What are the requirements and costs of network providers and out-of-network?
What is the out-of-pocket maximum?
Enrollment
You can enroll in Part C (Medicare Advantage plan) during specific times of the year. Enrollment periods were created to make it easy to get the coverage you need. However, outside of these dates, Medicare often requires that you stay with the plan you have until the following year. There are exceptions and in some cases, you may enroll outside of designated periods.
Initial Enrollment
The best time to enroll is during your Initial Enrollment period, or when you are first eligible to receive Medicare. Every senior in IL has an Initial Enrollment period that begins 3 months before you turn 65 and ends three months after. If you are disabled, your Initial Enrollment period begins 3 months before your 25th month of benefits and ends 3 months after your 25th month of benefits.
Annual Enrollment
Once you join Medicare, you can enroll in a Medicare Advantage plan during Annual Enrollment, October 15 through December 7 of each year. During this time, you can enroll, change or drop a plan. If you miss the December 7 deadline, you may have to wait until the following year unless you qualify for a Special Enrollment.
Open Enrollment
If you are not satisfied with your plan, January 1st to March 31st is the time to make changes. You can change from Part C back to Medicare, or change a Part C plan to a different one. All changes take effect the following month.
Special Enrollment
Medicare realizes that there are some situations that make it difficult to meet the enrollment periods. A Special enrollment was created to provide all seniors with the same opportunity.
References:
Medicare Advantage Stats: http://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/
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SSI Blog
Most seniors in Illinois choose Medicare Supplement Plan G, due to the low out-of-pocket costs, and coverage for foreign travel. All plans offer a basic level of protection, but there are many different costs and coverage levels between them.
Standardized
Companies are required by law to sell standardized plans. Plan G from one company must include the same coverage as Plan G from another. However, Insurance companies are not required to charge the same amount for plans.
Coverage
Offers 100% coverage for Part A deductible ($1600) as well as coverage for the remaining charge of days 61-90 in the hospital after Medicare pays. For days 91 and beyond, 100% of eligible expenses and 365 extra days of coverage after lifetime reserves are used. Provides coverage for the remainder of any Medicare-approved amount (after Part B deductible is paid in full), 100% of Part B excess charges.
Med-Select Option
Plan G is available in both standard and Med-Select Options. Both offer identical coverage but have different provider requirements. With the standard plan, you can use any provider that accepts Medicare. In the Med-Select option, you pay a reduced premium by using Hospitals in the network for all non-emergency care. It is important to check that your local hospitals are listed before selecting this option. You must live within 30 miles of a network hospital.
Resources:
https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html
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SSI Blog
Medicare does not provide coverage for medications. There are two ways to receive prescription coverage, enroll in a Part D plan or receive coverage through Part C.
Cost
The average cost of plans in 2023 is $43.00 per month. High-income Medicare beneficiaries can expect to pay an income-related monthly-adjusted amount, in addition to the premium. Most pay the standard amount. If you do not enroll when you are first eligible, you may be subject to a penalty. The Extra Help financial assistance program is available for qualified individuals.
Deductible
Most plans will have a yearly deductible and a maximum out-of-pocket cost. After that amount is met, Medicare will pay up to 75 percent of prescription costs. There are plans available that offer first-dollar coverage with no deductible and the coverage starts immediately.
Copayments
Most plans will have copayments or coinsurance. Medicare ensures that copayments are no more than 25 percent of the full cost of a prescription, and plans are required to pay no less than 75 percent.
Copayments Waived
Live in a long-term care nursing facility and are enrolled in both Medicare and Medicaid.
Plan waives the copayment for certain medications.
The pharmacy opts to waive the copayment for specific medications.
Once your plan reaches a max limit, of $4,660 in 2023, then you enter the coverage gap when Medicare will stop paying. Leaving you responsible for 100 percent of your prescription cost.
Creditable Coverage
As a policyholder, you have the right to know whether or not your current plan meets the standard of creditable by Medicare. All companies offering policies are required by law to notify individuals about the status of benefits, and whether or not their plan meets the standard of Medicare. To be creditable, the policy must pay as much as Medicare.
Creditable Requirements
Provides coverage for brand name and generic.
Reasonable access to retail providers.
Pays an average of 60 percent of prescription cost.
No annual benefit maximum.
The amount payable will be at least $2,000 annually.
Integrated coverage, no more than a $250 deductible per year, no annual maximum, and no less than a $1,000,000 lifetime combined benefit maximum.
Differences
Most plans have different requirements. Some require prior authorization from your doctor before certain medications can be filled. Others impose limits on how much you can get at one time. Certain plans require you to try lower-cost drugs before a prescribed medication will be covered. Each plan’s formulary is different, make sure the medications you currently take are covered, and your pharmacy is a participating provider.
Enrollment
The best time to enroll is when you are first eligible, during your Initial Enrollment period. If you don’t need coverage now, joining during this period ensures you avoid paying a penalty. Not everyone needs to enroll when they are first eligible, there are many seniors who delay without paying a penalty. Many employer-provided insurance plans offer coverage that is considered creditable coverage by Medicare. If you do have prescription coverage you do not need to join. If you lose coverage (employer benefits end or COBRA ends) you only have a certain amount of time to enroll. The insurance provider will let you know if your coverage is creditable. Keep this documentation safe as you will need to show it to Medicare.
Penalty
If you go without coverage or another creditable plan for 63 days or more after your initial enrollment ends, then enroll later, you may owe a penalty. Amounts are calculated by multiplying the premium amount by the number of full months you went without creditable coverage. Penalties are added to your monthly premium for as long as you have coverage. If you went 6 months without coverage, your penalty would be .06 (for 6 months without coverage) times (Part D premium). Penalties are recalculated annually.
Resources:
https://www.medicare.gov/part-d/costs/part-d-costs.html
https://www.medicare.gov/part-d/coverage/rules/drug-plan-coverage-rules.html
https://www.medicare.gov/sign-up-change-plans/get-drug-coverage/get-drug-coverage.html
http://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/
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SSI Blog
Medicare Supplement Plans help seniors pay the out-of-pocket costs associated with Medicare. Plans were designed to supplement your coverage. Individuals continue to receive Parts A and B with additional benefits. Some plans will pay your Part A and B costs, while others only partially. There are nine plans available in Illinois (A, B, C, F, G, K, L, and N).
Standardized Plans
The government standardized all plans. Requiring the same plans to include the same coverage regardless of the company that sells them. This makes it easy to compare the cost without keeping track of coverage.
Choices
If a current medical condition requires you to visit a doctor on a regular basis, research plans that pay the full Part B coinsurance or copayment. While it’s not always possible to know the level of healthcare you will need in the future, reviewing each plan’s specific coverage is important. If you will be traveling out of the country, there are plans that provide coverage for foreign travel.
Cost
Each plan offers different coverage and premiums that vary. It’s important to note the price of the plans between companies, due to they are not required to charge the same amount. You may be able to find the same plan at a lower price.
Guaranteed Issue
There are times outside of open enrollment when individuals may have a Guaranteed Issue Right, eligible without underwriting. If you chose to delay enrolling in Part B because of group coverage, your eligibility period will be delayed until you enroll in Part B. Instead of having six months, you only have 63 days.
Qualifying Events
Employer-provided health insurance coverage is ending.
Joined Part C when first eligible, but, within the first year, would like to return to Medicare.
Dropped a Medicare Supplement to join Part C for the first time and been in the plan for less than a year.
Previous policy or Part C ends through no fault of the individual.
Enrolled in Part C, but moved out of the network service area.
Enrollment
The best time to enroll is when you’re first eligible, during your open enrollment period. This six-month period of time starts when you are 65 or older and enrolled in Part B. During this time, insurance companies must sell all plans at the best available rate, even if you have a pre-existing condition. If you wait more than six months and miss your enrollment, you may not be able to obtain coverage. If you are accepted, the same plan could cost more.
Annual Enrollment
If you miss your open enrollment or don’t have a Guaranteed Issue Right, you may be able to enroll during Annual Enrollment. Companies during this time are allowed to use underwriting as a deciding factor to determine whether to sell you a policy and how much it will cost.
Changing Plans
If you realize that you’re paying for coverage you don’t need, or need more, changing plans may be a good option.
References:
https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html
https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/switching-plans/switch-medigap-.html
https://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights-scenarios.html
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SSI Blog
Medicare is divided into parts, which are differentiated by letters of the alphabet. If you will be turning 65 in the near future, take some time to understand Medicare Part A and B and what it covers, and the costs involved.
Part A
Part A provides hospitalization coverage, including hospital stays, skilled nursing facility care, home health care (skilled nursing, physical therapy), and hospice care. For most individuals, Part A is free, there is no charge for coverage as long as you meet a few requirements. As long as you are a permanent resident of the United States and you or your spouse paid Social Security taxes while employed, enrollment is automatic. There are deductibles and co-insurance that you are responsible for.
Not Covered
Private room
Personal care items (shampoos, toothpaste, etc.)
Television, phone charges
First three pints of blood
24-hour home care
Meals and homemaker services not related to treatment
In-home personal care (bathing, dressing, etc.)
Part B
Part B covers expenses that are necessary to treat or prevent a disease or condition. Fees that occur outside of room and board while in the hospital are those related to diagnostic testing, preventative care, and supplies needed to diagnose or treat. Fees for visiting the doctor are also included. Part B also provides coverage for many tests and screenings. The standard monthly premium for 2023 is $164.90 (or higher depending on your income). Most people who get Social Security benefits pay this amount.
Not Covered
Elective and cosmetic surgery
Alternative medicine – acupuncture, homeopathy
Vaccinations and immunizations
Prescription and Non-Prescription drugs
General dental work, dentures
Long term care
Hearing aids and exams for fitting
Eye examinations for prescribing glasses
Out-of-Pocket
There are out-of-pocket costs associated with Medicare, deductibles, coinsurance, and copays. Many seniors choose to supplement coverage to cover costs. You do not have to accept Part B, and you may opt-out by signing the back of your card and returning it by mail. If you are still working and receiving coverage from your spouse or through an employer, accepting Part A, but delaying Part B may make sense.
Enrollment
Typically, the best time to enroll in Part A and B Is when you are first eligible, during your Initial Enrollment Period. Unfortunately, If you do not qualify for Part A and need to enroll for Part B and miss your enrollment, you may have to wait until the General Enrollment Period, Jan 1-Mar 31, with coverage starting on July 1.
Penalty
if you don’t enroll in Part B at this time, you will be responsible for a penalty for each 12-month period you were eligible for but didn’t enroll. A 10 percent penalty will be reflected in your premium and will continue for as long as you receive benefits. If you have coverage through your spouse, you may delay enrollment without a penalty. You may be eligible for a Special Enrollment where you won’t be charged a penalty. If you are subject to the penalty, in addition to a premium increase, you may have to wait until January (General Enrollment Period) to enroll for coverage that begins in July. The monthly rate for Part B is based on your income. Using the standard premium of $164.90 for 2023, multiply the number of years you were not covered, but eligible by 10 percent. Multiply that number by the premium. Add that sum to the rate for your new premium.
Effective Dates
In the event you have not enrolled automatically and choose to enroll in Medicare yourself, effective coverage dates vary based on the month you sign up. If you sign up during your Initial Enrollment Period (the 7-month period of time beginning 3 months before your 65th birthday and ending 3 months after your 65th birthday) effective start dates are shown below.
The same month you turn 65, coverage begins 1 month after you enroll.
1 month after you turn 65, coverage begins 2 months after you enroll.
2 months after you turn 65, coverage begins 3 months after you enroll.
3 months after you turn 65, coverage begins 3 months after you enroll.
References:
https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-how-to-sign-up-for-part-a-and-part-b.html
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