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Medicare Overview

If you’re reading this article, you or a loved one have probably become eligible for Medicare Health Coverage. Medicare is very different from what you may be used to in the employer sponsored market for health insurance, but there are options available that can provide you with very comprehensive coverage. To help you better understand Medicare, let’s talk about the different parts. For the sake of keeping things simple, I’m only going to talk about 3 parts, Medicare Part A, Part B, and Part D.

Medicare Part A provides coverage for Inpatient Hospitalization, Skilled Nursing Care, Hospice Care, and Home Health Care. Most people won’t have to pay a premium for Medicare Part A, but there is a deductible that you would be responsible for paying.

Medicare Part B covers physicians services and other outpatient treatment like labs, xrays, flu shots, mammograms, colonoscopies, etc. Although most people don’t have to pay a premium for Part A, Part B does require a premium. The amount an individual will pay for their part B premium is based on their income. In addition to the premium cost, Part B also has a deductible that will have to be met before any benefits are paid. Once the deductible is met, Medicare will pay 80% of the allowed amount for covered services. You, the beneficiary will be responsible for the other 20% plus any excess charges (link to what are excess charges article).

In 2006, Medicare Part D was established, and it provides drug coverage options for Medicare beneficiaries. Each Part D plan has a list of covered drugs called a “formulary”. Medicare beneficiaries must pay a premium for a Part D plan and most plans include copays and deductibles that the member would be responsible for paying. Before you decide to enroll in a Part D plan, be sure to review the plan’s drug formulary to be certain the drugs you take are on the list and determine what your out of pocket costs would be associated with those drugs.

If you have questions about Medicare that were not addressed in this article, let’s schedule a phone call to review your specific situation.

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Medicare Enrollment Checklist

  • Determine if you should enroll in traditional Medicare.
    • If you are eligible for Medicare because you’re turning 65 and will continue to work, there are a few things you need to consider. If you are covered under your employer’s plan, you may not need to enroll in Medicare Part B right now. However, it may be beneficial for you to start using the Medicare system for your healthcare needs as opposed to your employer’s plan. Talk to you HR rep about this.
    • If you aren’t working, consider enrolling in Medicare Part A and B to avoid paying late enrollment penalties later.
  • If you decide to apply for Medicare, know the deadlines.
    • If you’re now eligible for Medicare because you turned 65, you’re in what we call the initial enrollment period (IEP). There’s a 7-month window where you can apply for Medicare, it starts 3 months before you turn 65, and runs 3 months afterwards. For example, if your birthday is April 15th, you can apply for Medicare from January through the end of July.
    • If you have worked beyond your 65th birthday and was covered under your employer’s plan, you probably missed the IEP period, but you can still apply using a special election. You have 60 days from the termination of your employer coverage to enroll in Medicare. There’s a form you will need from your employer to show that you were covered under their plan. Talk to your HR rep about this.
  • Medicare Supplement or Medicare Advantage
    • Once you decide to enroll in Medicare, you will soon learn about the significant gaps in coverage that could leave you with huge medical expenses. Adding a Medicare Supplement plan or enrolling in a Medicare Advantage Plan could help lower some of this financial exposure. We’ll talk about the differences in these two types of covered in a different post, but right now it’s important that you understand what your options are. Learn more about the differences in the two plan types here.

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I’m Enrolled in a Medicare Advantage Plan and I got a bill that says I owe a provider. What should I do?

Medicare Advantage plans are continuing to grow in popularity among many Medicare beneficiaries, but many seniors struggle to understand the claims process and how many of their benefits are applied. Any time you see a healthcare provider, they’re going to file a claim to your Medicare Advantage plan and if you are responsible for any amount of the charges, you will receive a bill. If you receive a bill from your provider, how do you know if your truly owe that amount? Here are a few tips that will help you make that determination:

  1. Study your benefits. When you enrolled in your plan, you should have received a benefit booklet that details what your plan will pay for each service that would be rendered. For example, if you have a copay for visits to your Primary Care Physician, the amount you should pay will be listed in the summary of benefits booklet. If you receive a bill for a different amount, call the member services plan number listed on your ID card. If you have an agent that helped you enroll in your plan, you should be able to call your agent for help also.
  1. Review the Explanation of Benefits (EOB). When your Medicare Advantage plan processes your claims, they should periodically send you a statement that details the date that services were rendered, the charges they were billed, the amount they paid, and the amount you owe (if any). Compare the amounts listed on the EOB to any bills you receive from your healthcare providers. If there are any discrepancies, call Member Services to get an explanation before making any payments.
  1. Reach out to your agent for assistance. This is one of the reasons I always suggest Medicare beneficiaries work with a knowledgeable independent agent. If an agent helped you enroll in a plan, they should be able to assist you with problems or concerns. Also, a competent agent should have relationships with the Medicare Advantage plans that enable them to get answers a lot quicker than their clients could on their own. If you are working with a good agent, use them to your advantage.

If you have a unique claims issue and can’t seem to find the any help, reach out to us and let’s see if we can get you the help you need to resolve your issues.

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