HOW DO YOU KNOW IF YOU’RE ELIGIBLE FOR MEDICARE?
If you are within three months of turning 65, then you may be eligible to enroll in Medicare Parts A and B. You may also be eligible if you are under 65 and have been on Social Security Disability Insurance for 24 months or have end-stage kidney disease or kidney failure requiring dialysis or a kidney transplant.
Marc Largent has been helping seniors in Greensboro, Winston Salem, and surrounding areas of the Triad navigate the Medicare system since 2015. Here at Largent Insurance, we can be a resource for you in learning the world of Medicare. Let’s begin…
WHAT IS MEDICARE?
Serving over 62 million people, Medicare is the government’s largest health insurance program. There are often a lot of frequently asked questions, so we’ll do I best to cover the bases. Medicare is run by the Centers for Medicare & Medicaid Services (CMS) and is divided into four parts:
Original Medicare (Medicare Parts A and B): Offered by the government, these parts cover hospital and medical insurance. Parts A and B combined make up “Original Medicare”. It has a deductible and coinsurance, but it does not cover everything.
Medicare Part A
- Helps cover things such as hospitalization, hospice care, skilled nursing and home health.
- Deductible of $1,408 (hospital insurance), skilled nursing coinsurance of $176 per day (days 21-100).
Medicare Part B
- Helps covers medical insurance and things such as doctors’ appointments, outpatient care, preventive services, physical/occupational therapy and home health.
- Annual deductible of $198 and a coinsurance of 20% for all doctors services the plan covers.
Medicare Advantage Plan (Medicare Part C)
Sometimes called an MA Plan, this combines Parts A and B and helps cover everything that Original Medicare covers and more. Medicare Advantage Plans also cover the following costs:
- Part A deductible
- Part A coinsurance (skilled nursing facility for days 21-100)
- Part B annual deductible (Medical Insurance)
- Part B 20% coinsurance for doctor services
It may also include additional benefits like Part D prescription drugs, eye care, dental, hearing and fitness/wellness services. Medicare Advantage Plans also have a yearly limit for out-of-pocket costs. These are purchased from private insurance companies, which we can help you with. You’re eligible for a Medicare Advantage plan if you’re enrolled in Parts A and B and live in the plan’s service area.
There are different types of MA Plans available to you. Read about them here.
Prescription Drug Coverage (Medicare Part D)
Part D helps pay for your prescription drugs. You can purchase a Part D Plan in addition to having Parts A and B (Original Medicare). Part D coverage can only be purchased from private insurance companies contracted by the federal government. These plans each have their own formularies that cover certain types of drugs, so it’s important to choose a plan that includes your drugs. You choose a Part D plan in one of two ways:
- As a stand-alone insurance plan that helps cover you drugs
- As a part of a Medicare Advantage plan that includes Part D coverage (MAPD)
Medicare Supplement Insurance
Also known as Medicare Supp or a Medigap Plan, these are health insurance policies sold by private insurance companies. You may want to choose this if you choose Original Medicare. It helps cover the gaps that Original Medicare does not cover such as coinsurance, deductibles and copayments. They do not include prescription drug coverage, but you can purchase a separate PDP plan. The one big plus is they cover visits to any doctor that accepts Medicare. In an essence, there are no networks.
IMPORTANT THINGS TO KNOW ABOUT A PRESCRIPTION DRUG PLAN
There are four stages to every prescription drug plan. (The amounts listed below are for 2020 and are subject to change.)
- Stage 1: the deductible stage. Until you reach your deductible you’ll pay the full amount for your drugs. Not all plans have a deductible.
- Stage 2: the initial coverage stage. This stage takes place after you reach your deductible. Now you will only pay part of the costs for all your drugs.
- Stage 3: the coverage gap stage. After you and your plan have paid a total of $4,020 you will now only pay a part of the cost for your drugs until you reach $6,350.
- Stage 4: the catastrophic stage. It occurs when you have paid $6,350 out of pocket and you are no longer in the coverage gap. At this time you will pay a set amount for all your drugs for the remainder of the year.
HOW TO DECIDE WHICH MEDICARE OPTION IS RIGHT FOR YOU?
These questions can be answered in meeting with our Independent Insurance Agents…
- What type of monthly premium can I afford to pay?
- Are the services I need covered by the plan?
- Can I see the doctors I want?
- Are my prescription drugs covered under the plan?
- What are my out of pocket costs?
- Can I go to the pharmacy I want?
YOU HAVE FOUR OPTIONS AVAILABLE TO YOU
- Original Medicare: Includes Part A hospital insurance and Part B doctor insurance from the federal government.
- Original Medicare + Medicare Supplement + Prescription Drug Plan
- Medicare Advantage Plan: Includes Part A and Part B, extra benefits and possibly prescription drug coverage. These plans can be purchased through private insurance companies, which we can help you figure out.
- Original Medicare + Prescription Drug Plan
WHY CAN’T I JUST RELY ON PARTS A AND B FROM THE GOVERNMENT?
- It only covers 80% of Part B services.
- It does not include coverage for prescription drugs.
- It does not have an annual out of pocket max for your hospital or medical expenses.
- There is no foreign travel coverage.
- No extra benefits such as: dental, vision, hearing, fitness memberships, and over-the-counter medications.
WHAT ARE MY NEXT STEPS?
Step 1: Enroll in Medicare Part A and Part B when you’re first eligible. This is done during your Initial Enrollment Period known as IEP. This is a seven month window of time that begins three months prior to your 65th birthday, the month you turn 65 and three months after your 65th birthday.
Step 2: You have two ways to proceed. Option 1 is to keep Original Medicare and add a Medicare Supplement and a Part D prescription drug plan. Option 2 is to purchase a Part C Medicare Advantage plan, which combines Part A and Part B, and often includes prescription drugs plus additional benefits.
If you’re already enrolled in Original Medicare, have a Medicare Advantage Plan or a Prescription Drug Plan, and would like to change plans, this can be done during the Annual Enrollment Period (AEP) each year which is between October 15 and December 7th. Generally speaking, outside of AEP you can only make changes under certain circumstances which would qualify you for a Special Enrollment Period (SEP). Below are some examples of an SEP:
- Moving out of your plans service area
- Leaving an employer group plan
- Having Medicare and Medicaid
You also have a Medicare Advantage Open Enrollment period known as OEP. During this time, if you have a Medicare Advantage plan and would like to move to a more suitable plan or disenroll from an MA Planm you can do that between January 1st and March 31st.
HOW DO I ENROLL IN MEDICARE?
If you’re already receiving Social Security benefits when you turn 65, then you will automatically be enrolled in Medicare. If you’re not collecting Social Security, then you will need to enroll in Parts A and B on your own. Social Security handles Medicare enrollment. You have a couple of options:
- Enroll online at www.ssa.gov/benefits/medicare
- Visit your local Social Security Office in person
WHEN CAN I ENROLL IN A MEDIGAP PLAN?
You can enroll during a 6-month Open Enrollment Period, which starts the month you turn 65, and if you have Medicare Part B. During this time, you can buy any Medicare Supplement plan sold in your state even if you have pre-existing health conditions. If you delay your enrollment and apply after your Open Enrollment Period ends, there is no guarantee you will be accepted into a plan. You will have to answer medical underwriting questions and could be denied for health reasons.
Feeling overwhelmed and confused? Don’t worry, Largent Insurance is here to walk you through the enrollment process and help you weigh your options. Don’t hesitate to contact us: please call us today at (336) 408-9402 or get in touch online.
