Medicare Providers Blog and Resources

Guest Post by Jan Dubauskas Seniors are technologically savvy and engaged during the COVID-19 pandemic. Seniors are connecting with their health care and are thoughtfully considering which Medicare plans are right for their needs. In a recent survey of Medicare eligible seniors from Healthinsurance.com, respondents revealed, among other things, that they are concerned with the costs of health care and are avid readers of internet research. In fact, seniors are far more tech savvy than we may have expected. An incredible 78 percent of the survey’s seniors research their Medicare options online where they can find information on all of their top priorities, such as: Are my doctors in the insurance company’s network? What are the costs for prescriptions, copays? What is the monthly premium? And does the plan offer dental, vision, hearing, or fitness benefits? Researching online gives seniors the ability to thoughtfully research Medicare options, at their own pace, and find the right plan to fit their budget and needs. While an overwhelming number of seniors research their Medicare options online, we might expect that the same amount of seniors buy their plan online as well. However, it is interesting to note that only 44 percent of respondents actually purchase a plan online. Instead, seniors still favor the opportunity to work with an agent to make their final purchasing decisions, so much so that 56 percent either purchased a Medicare plan in-person with their agent or over the telephone. The coronavirus pandemic has caused seniors to carefully consider their in-person social interactions with family and friends as well as their exposure to crowds; and this is impacting their medical care. Many seniors have deferred medical treatment to avoid catching the virus at the doctor’s office. To maintain social distancing and stay healthy, six in ten seniors have only left their homes to go grocery shopping or to the pharmacy during the pandemic. And more than half of seniors have put off a dental appointment due to the pandemic. Fortunately, for seniors who had been avoiding the doctor’s office, the Center for Medicare & Medicaid Services (CMS) recently expanded telemedicine services to cover those with Medicare. By expanding telemedicine services, CMS gave seniors greater access to telemedicine to help them continue to receive the routine care that they need, at a price they can afford, from the comfort and safety of their homes. In an compelling twist, seniors are making use of CMS’s Medicare expansion of telemedicine. During the pandemic, 44 percent of the survey’s seniors have taken advantage of the opportunity to speak with their provider over the telephone or via video for routine matters. Considering that only 10 percent of seniors used telemedicine before the coronavirus pandemic, an incredible 340 percent increase in telemedicine use among seniors is an example of how seniors have adapted to the circumstances and embraced technology to help take care of their health care needs. As the health care debate continues in Washington, D.C., seniors are concerned about rising health care costs. Two-thirds of the survey’s seniors are worried about out-of-pocket medical costs, in spite of the cost limitations of their Medicare plans. And more than just out-of-pocket costs, 35 percent of the survey respondents are worried about contracting COVID-19 because they may be hit with a surprise medical bill. Seniors are users of prescription medications and have an acute awareness of the prices for prescriptions. Although Medicare covers many prescriptions, 89 percent of the survey’s respondents believe that prescription drug costs are too high, and one-third of respondents spend more than $50 per month on prescription drugs. In response to concerns with rising prescription costs, President Trump recently introduced four Executive Orders that, if enacted, would reduce kickbacks, allow for importation of drugs, and importantly for seniors, would ensure pricing parity with similarly situated countries for our Medicare Part B prescriptions. One of the benefits of a Medicare plan is that the costs of health care providers who accept Medicare are limited to Medicare’s schedule and have a limit on billing to seniors. In spite of these plan provisions, six in ten seniors are concerned about unexpected medical bills so much so that 36 percent of seniors have put off seeing a doctor because of cost. However, as far as future costs are concerned, only 50 percent of respondents say they have money set aside for their family to use for their future health needs.  Generally, seniors are pleased with their Medicare plans, so much so that 51 percent of respondents believe that the age to be eligible for Medicare should be lowered to 60. And of those who have a Medicare Advantage plan, more than two-thirds are happy with their plan. Seniors are becoming more tech savvy during the COVID-19 pandemic. Seniors are using technology to research Medicare plans and conduct telemedicine visits. And although seniors are social distancing, they are technologically connected and thoughtfully engaged with their health care. Jan Dubauskas is a health care expert, enthusiastic insurance pro, attorney and mom serving as Vice President of healthinsurance.com.

Guest Post by Dennis Ho The COVID-19 crisis has many people concerned about long-term care, whether they will need care for an age-related condition or one that strikes at random. If a person becomes too ill or disabled to care for themselves and needs long-term care, costs could add up quickly. According to the 2019 Lincoln Financial Cost of Care Survey, the national average cost for a home health aid is $25 per hour. Having an aid visit a few hours a week might be manageable, but if you need someone for 40 hours per week, costs could run $52,000 per year on average. According to the same survey, an assisted living facility averages $58,464 per year and a nursing home averages a whopping $110,595 per year. What most people do not know is that private health insurance and Medicare do not generally cover such care, and Medicaid will only pay when a person has depleted the vast majority of their assets, potentially leaving their spouse or family living in poverty.  The good news is that long-term care insurance (LTCi) remains a viable option. LTCi provides benefits to help pay for care if you need help with your daily living activities such as getting around, dressing, bathing or eating. LTCi offers the flexibility to pay for care without burdening one’s family, physically or financially. And because people who need long-term care get care on average for about three years, having insurance can mean protecting hundreds of thousands of dollars of your hard-earned retirement assets.  When you purchase a policy, you decide on the monthly benefit amount you’d like to receive if you need care and also a total benefit pool. For example, you might choose a policy that pays up to $6,000 per month for care with a total pool of $216,000. If you qualify for benefits, you can draw up to the monthly amount until your total benefits are exhausted. In the policy above, this means you could draw up to $6,000 per month to pay for care. If you used this full amount every month, you would have three full years of coverage before the $216,000 was exhausted. If you used less in any month, the difference would remain in the benefit pool and you could use it in the future. To help people learn more about long-term care insurance and to get a sense for the cost, Saturday Insurance offers a free online long-term care insurance assessment that’s available here. Shopping for coverage If you’re interested in exploring insurance, LTCi is available all the way up to age 79. Here are some tips to help you find coverage that’s right for you: Assess your coverage goals. How much does care cost in your area? What are your goals for insurance: Do you want maximum coverage so you could afford a nursing home or just basic coverage that will pay for home care? There are a range of insurance products available, so having a clear sense for your goals will make it easier to assess which products fit and which don’t. Set aside a clear budget. It’s easy to be scared into buying as much coverage as possible, but insurance won’t do you any good if you can’t afford to keep the policy. Also, you want to keep enough funds to support other retirement needs. A good rule of thumb is to spend no more than 10%–15% of your retirement savings on LTC insurance. Be open to a range of solutions. The two most popular types of LTCi policies are “Traditional Policies” and “Hybrid Policies.” The long-term care benefits work the same way, but how you pay for the policies, what benefits you receive if you don’t need care, and various other guarantees are different. Which one is right for you will depend on your personal situation and preferences, so make sure to explore both initially. This will give you the best chance of finding the right coverage for your situation. Related to this, make sure to work with an independent agent that can show you multiple options and not one that only offers products from one insurer. Buy from a reputable insurer. Since you might hang onto your LTCi policy for 30 years or more, it’s worth reiterating that you should only purchase from reputable and financially strong insurers. Don’t drag your heels. Long-term care planning is one of those topics that’s easy to put off. Yes, waiting a year or two probably won’t change the price dramatically, assuming insurers leave their current pricing unchanged. However, that’s a big assumption. Due to low interest rates and concerns about the risk, insurers across the industry have been raising their prices over the past few years. Buying earlier will give you the best chance of locking in the lowest prices. In addition, underwriting is fairly strict. If you develop certain health conditions, insurance might not be available at any price.  Perhaps the most important thing to know about LTCi is that it can be incredibly valuable for individuals and families in that the right policy will allow them to make their own decisions about how they will be cared for when help is needed. Dennis Ho is a life actuary and chief executive of Saturday Insurance, an independent, online insurance agency that helps people shop for life, disability, and long-term-care insurance. Prior to co-founding Saturday Insurance, Dennis spent 20 years in the insurance industry in a variety of actuarial, finance and business roles. He has been a contributor to Humble Dollar, Kiplinger, and other publications.

Guest Post by Lindsay Engle COVID-19 has made an impact on the world over the last couple of months, especially here in the United States.  As if choosing a Medicare plan before wasn't complicated enough, we now have a new monkey wrench — a global pandemic. It's time to pay attention when choosing Medicare coverage to ensure you’re making the decision that’s best for you long-term.  2020 Medicare Annual Election Period Guide We worked with MedicareFAQ to create this guide to help you be confident when you go through this year's Annual Election Period for Medicare. Download Guide Choosing coverage Understanding your Medicare coverage can be cumbersome. Like all major life decisions, there are a plethora of considerations to take, especially now with the pandemic looming overhead.  While it’s easy to impulsively choose the plan that seems to provide the best coverage at the lowest cost, you'll want to remember these seven things when beginning your Medicare journey and weigh all options thoroughly: Cost   Quality of care Coverages Prescription coverage Extra coverage Travel Doctor and hospital choices Costs Like most people, you’ll need to budget your finances accordingly. Health insurance is generally known to be costly, and many people who enroll in Medicare are on fixed incomes due to retirement. Cost becomes an even larger factor now, considering the drastic changes we’ve seen with our economy over the last several weeks and millions of Americans have lost their income as a result.  But with the continued spread of the coronavirus, health insurance costs are incredibly crucial right now. You'll want to consider how much you'll be paying in copays, deductibles, and premiums, and if you’ll have an annual limit. To help reduce some of your expenses, you can opt into buying a Medicare Supplement plan. Another option is looking into a Medicare Advantage policy — once you reach a specific limit each year, you won't be responsible for extra charges for the rest of the year.  However, there is a drawback to buying into an Advantage policy. Medicare Advantage plans have their own networks of doctors and hospitals, and if you end up seeing a doctor out of network, you could be on the hook for all costs.  Considering all possible costs before making a decision can help save you hundreds of dollars. Quality of care Another important thing to consider in times like these is the level of care you'll be receiving. You'll want to work with an insurance company that is taking the initiative to help its members. Many insurance companies are waiving fees for COVID-19 telehealth appointments right now, and doctors and hospitals are also taking many steps to help protect their patients. The quality of the care you receive can make all the difference in a stressful situation.  Coverages How comprehensive is your Medicare coverage? With many different plan options, this will be one of your biggest considerations.  COVID-19 can have a detrimental effect on people of all ages, but particularly those who are over 65. Should you wind up getting seriously ill, will your coverage be able to cover days or weeks in the hospital?  By choosing a plan with comprehensive coverage, you'll likely save yourself money. If you need a two-week stay in your local hospital, you could quickly rack up tens of thousands in bills. Part A and B don't generally cover everything you may need coverage-wise, so it’s usually a smart investment to buy a supplemental plan. Prescription coverage While there may not be any medications available for COVID-19 right now, that could change. Plus, you may already be on certain medications that need coverage. Medicare won’t cover your prescription costs, so there are a couple of different routes you can take.  You may choose to buy a Part D prescription drug plan, or you may decide to buy a Medicare Advantage plan with drug coverage. Perhaps you decide to forego a prescription plan. But if you end up skipping the drug coverage, you may regret that decision. Prescription drug costs can be abundant — some of the medications in today's market end up costing thousands every single month. If you're not in the position to pay enormous amounts in drug costs, a drug plan is the best way to go.  Extra coverage Not everyone who joins Medicare only has Medicare health coverage. Many people have prescription or health coverage through their employers.  If you are still working, there is the option to remain on your employer’s group health insurance plan, and how your Medicare benefits coordinate with this coverage depends on the size of the company. If you work for an employer with over 20 employees, your group plan will be primary, meaning they pay first, then Medicare, and if you work for a company with less than 20 employees, your Medicare plan will be primary. Regardless, it’s advised to enroll in Part A once eligible as the premium is free if you’ve paid enough Medicare taxes and it can help keep costs lower if a hospital stay becomes necessary. If you have small group insurance (fewer than 20 employees), you’ll also want to enroll in Part B to cover any outpatient costs. You’ll always want to compare the cost of your group insurance to the cost of Medicare + Medigap + Part D to see what makes the most sense in terms of coverage and price, and keep in mind that it’s illegal for employers to contribute to Medicare premiums. For additional information on choosing between Medicare and group insurance, visit this resource. Travel Traveling right now isn't what it used to be with the requirement of face masks, sanitizers, and temperature checks. While many have halted their travel plans for the foreseeable future, it’s a matter of time before we’re able to travel comfortably again.  When that time comes, it’s important to ask yourself if your health coverage will help to cover you if you were to get sick overseas. Medicare doesn't cover health care out of the United States, but that's not to say that supplemental coverage won't help ease some of those costs.  Doctor and hospital choices Finding a doctor that accepts your health coverage is paramount. In addition to doctors who take your insurance, health facilities need to accept it as well.  When you have a Medicare Supplement plan, you can go to any doctor that takes Medicare. If you have a Medicare Advantage plan, you'll have to stay within the network.  Despite being in the middle of a health crisis, doctors are continuing to see their patients. But it may not be in a traditional appointment setting. Many doctor's offices are implementing telehealth appointments, and although you may not be physically going to see the doctor, you'll still need to be sure they take your insurance. Preparing for the future For most of us, 2020 is unlike anything we've ever imagined, much less seen before. You may take some comfort knowing that many insurance companies are waiving fees.  Companies are going the extra mile to ensure all Americans have access to medical care, but hospitalizations can quickly deplete any health savings you may have. By considering a few things, you can prepare yourself for any turns this pandemic may bring.  COVID-19 is proving its strength every day. Arming yourself with excellent health coverage can make all the difference to the future of your health. Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare space since 2017. She is featured in many publications and writes regularly for other expert columns. She has a passion for sharing her expertise on Medicare to beneficiaries so they can be better prepared for healthcare costs after retirement. You can find her on YouTube where she has a featured channel for Medicare beneficiaries to become educated on all their options.

Guest Post by Lucas Siegel According to the U.S. Department of Health and Human Services, approximately 70 percent of baby boomers will require some form of long term care services at some point in their life. Whether this applies to you or a loved one, it's important to be prepared. To help you understand what costs you should expect and how you can cover these services, I've compiled a helpful guide on how to afford long term care. What is long term care? Long term care refers to a variety of services to help meet a person’s health or personal care needs when they are no longer able to live independently. Long term care may be warranted if an individual is unable to perform the following  six basic activities of daily living safely on their own: Eating — The ability to eat without assistance Bathing — The ability to clean oneself through hygiene activities such as showers, baths, shaving, and brushing teeth Getting dressed — The ability to change clothes without struggling with buttons or zippers Toileting — The ability to get on and off of a toilet without assistance Continence — The ability to control bladder and bowel functions Transferring — The ability to walk independently or move oneself to a mobility aid such as a wheelchair, walker, or scooter If an individual is unable to perform at least two activities of daily living, the U.S. government considers someone to be chronically ill which may warrant the need for long term care. There are several options available for long term care, including in-home care or assisted living facilities such as a nursing home. Why is long term care important? In-home care by family members may be enough for individuals who need minor assistance with daily activities, but people with more complex needs may require support from nurses and other caregivers. In these cases, long term care becomes essential to help the individual overcome daily challenges that arise from their ongoing health condition or disability. How much does long term care cost? The cost of long term care will vary by location and the unique needs of the individual, but on average the price is about $4,000 per month with state averages ranging from $2,844 to $9,266 a month. On an annual basis, this means long term care expenses total around $48,000 a year which is substantial for most families or individuals.  What’s even more concerning, is that the cost of residence in an assisted living facility has increased significantly since 2004. In 2004, the cost of residence in an assisted living facility was only $28,800 compared to the $48,000 in 2019. For those who want additional privacy, the cost of a private room nursing home jumped from $65,185 in 2004 to $102,200 in 2019. While the cost of home care hasn’t skyrocketed, the price has increased in this timeframe and the added costs are notable. How can I pay for long term care? The significant cost of long term care presents a challenge to those who will need it. To help you determine the best way to pay for long term care, we’ve provided several popular options: Savings and investment returns If you have enough money from savings or investment returns to cover the cost of long term care, that will be your easiest option. However, as of 2020 one third of Baby Boomers currently in, or approaching retirement have less than $25,000 set aside which wouldn’t cover even a single year of care. If you’re young and healthy, start saving early and aim to have at least $1 million by age 65 to cover all retirement expenses including long term care costs. Long term care insurance Long term care insurance may also be known as assisted living insurance, but both refer to a policy that is used to cover long term care costs if you end up needing them when you get older. It’s fairly uncommon, with only about 3 percent of Americans utilizing this option due to its high premiums.  According to Dave Ramsey, the average annual premium for this type of policy is $2,727 per year. This will vary by age and health of the policyholder, but the insurance works by awarding you a daily amount (typically $160 per day) that is used to cover long term care expenses should you ever need them. It’s important to note that there is typically a three-month waiting period from the time you need care until the coverage kicks in, and most insurers usually restrict coverage to between two and five years. Rent or sell a home If you have a home but need to move to an assisted living facility or into the home of a family member serving as a caregiver, you may consider renting or selling your house. The large lump sum you receive from selling can go a long way towards covering long term care expenses, but keep in mind you’ll also have to pay closing costs that may diminish your return. If you’d prefer to hold onto your home but will not be using it, you could also rent it out through popular rental services such as Airbnb or with the help of a property management company. This solution is completely turn-key due to the need for ongoing maintenance, so make sure to set aside a portion of the money you receive to cover these regular costs. Reverse mortgage If you’ll be utilizing an in-home caregiver or have a partner who will continue residing in the house after you’ve moved into a long term care facility, a reverse mortgage can be used to cover costs. A reverse mortgage works by having the homeowner borrow money against the home’s value — which is paid back after the owner decides to sell. The downside is that reverse mortgages also come with accumulating interest and fees in addition to the original borrowed amount that must be paid back when you sell. Sell a life insurance policy Many people are unaware that they can sell their life insurance policies to cover long term care and other retirement expenses. This is done through a process known as a life settlement.  Essentially, eligible seniors can work with a life settlement company that specializes in this process to help find a third-party buyer who will purchase the policy and award you with a lump cash sum. Upon completion of the deal, you’ll receive a large cash sum that can be used as you see fit and the third-party will assume all maintenance costs including monthly premiums until the original policyholder passes, at which point they’ll receive the death benefit amount. This is ideal for seniors with financially stable relatives, as it enables them to independently cover long term care expenses without sacrificing assets such as a home or requiring financial assistance from family members. Life settlements are typically reserved for individuals at least 80 years old, but younger individuals who require long term care may be eligible for a viatical settlement. Viatical settlements are reserved for individuals with a terminal or chronic illness. As noted earlier, the U.S. government considers someone to be chronically ill if they cannot perform two or more activities of daily living — meaning a chronically ill individual who requires long term care may qualify for a viatical settlement. Lucas Siegel is the founder and CEO of Harbor Life Settlements, a business that helps seniors discover the value of their life insurance policies by educating and connecting policyholders with investors to make life settlements fast, affordable, and transparent.

Guest Post by Kaylynn Evans According to a recent survey from the National Alliance for Caregiving and AARP, approximately 43.5 million adults in the United States serve as caregivers for elderly parents or children. Roughly 80 percent of that number are caregivers of people older than 50. One common denominator among all caregivers is that it can take a financial toll, but this can be lessened if you plan accordingly. Below are five key tips to help manage the financial aspect of caregiving for both you and your aging parents. 1. Make sure you have a Power of Attorney (POA) Once your parent’s health starts to decline, it’s important that another trusted family member can make financial decisions for them. There are many types of POAs, but the one you want is a Durable Power of Attorney. This would assign you the responsibility to manage all aspects of your parents’ financial and health matters. Some states require you to notarize power of attorneys, so be certain to check your state laws or consult with an attorney on this. 2. Plan for your own financial future You don’t want to neglect your own financial health while caring for your parents. Setting up your own retirement plan should be just as important as making sure your parents' financial needs are being met. Make sure you’ve set a budget and carefully monitor your expenditures, especially if you’ve had to give up a job to help take care of your parents. This is not the time or place to take on additional debt. You should have an IRA or 401k and consider long-term care coverage for yourself. 3. Have a clear understanding of their long-term care coverage Long-term care coverage pays for expenses not covered by traditional insurance and Medicare. This would include costs like long-term stays in a nursing home or a skilled nursing facility. Before coverage kicks in on most of these policies, the insurance company wants to see a “triggering” event. This would be a time when the insured can no longer perform routine daily tasks and would trigger the insurance to kick in and become active. Make sure you’re clear on what qualifying events or symptoms need to be present, especially with cognitive impairment. 4. Make sure your siblings are on board One of the most common causes of sibling resentment stems from caregiving for an elderly parent and managing their finances. It’s important to sit down and have a conversation with your siblings and be clear on who will do what. Some caregivers use a Caregiver Agreement that will stipulate who will care for the parents and what kind of monetary compensation they should receive. Try to plan doctor visits and any visits with nursing homes or assisted living homes with your siblings. It’s always a good idea to have more than one person on these visits to cover questions and make sure you’re all on the same page with the information you’ve received. Planning regular times to communicate with your siblings can help avoid any miscommunication frustrations and ensure that everyone is on the same page with your parents caregiving and financial management. 5. Plan for Medicaid According to Medicaid.gov, “12 million people are 'dually eligible’ and enrolled in both Medicaid and Medicare, composing more than 15 percent of all Medicaid enrollees.” Part of preparing for Medicaid coverage to kick-in means “spending down” what you already have. What is a Medicaid spend down? Geoff Williams, contributor to the US News Money website shares, “A Medicaid spend down is a financial strategy used when an individual's income is too high to qualify for Medicaid. To be accepted into the program, some of the individual's income must be spent down to ensure his or her income is low enough to qualify for Medicaid.” Guidelines vary by state, but one consistent requirement is that you submit your bills that use up the spend down to Medicaid for verification that you have met their requirements. Besides medical expenses and costs, some states will allow you to payoff accrued debts such as mortgages, automobile, or credit card debt. To help you navigate this complex process, find a planner that specializes in Medicaid coverage. Finances can be a source of frustration and stress, but if you plan accordingly by following these steps, you can ease a lot of those worries. Kaylynn Evans is the executive director of Vineyard Bluffton, an assisted living community opening in coming months in Bluffton, South Carolina, specializing in care for those suffering with memory loss. Kaylynn has more than twelve years of experience in healthcare, with nearly ten years of specialized experience in dementia care.

You're 65 years old. You've lived a long life, and hopefully, you're getting ready for retirement. One important part of transitioning to senior life is enrolling in Medicare. Medicare is the government program that offers health insurance to people over age 65. Medicare also offers coverage to people under 65 who have received disability benefits from Social Security or have been diagnosed with End Stage Renal Disease (ERSD) or Amyotrophic Lateral Sclerosis (ALS). Whatever your reason for seeking Medicare coverage, you need to become familiar with how Medicare's processes and plans work. They function a little differently than the kind of health insurance plans you may be used to. Whatever your current understanding of health insurance, it’s important to understand the parts of Medicare, what they cover, and how to enroll as you transition into your golden years. It's hard to fully summarize Medicare in one infographic. Medicare can be complex because it has several different parts that each work differently. The plan that makes the most sense for someone else may not make sense for you. Understanding how Medicare works will help you identify plans that work best for your situation. For more details on Medicare's history, eligibility requirements, and each part's coverage, cost, and enrollment process, click on the icons or text in the menu below.   History of Medicare Eligibility and Coverage   Part A Part B Part C Part D (If you're interested in learning more about Medicare Supplement Insurance (Medigap), check out "5 Questions to Ask About Medigap." Keep in mind that Medigap is only available with Original Medicare.) History of Medicare Medicare is a fairly recent federal health insurance plan. It was instituted in 1965. In its initial phase, Medicare only had two parts: Part A and Part B. Part A was hospital insurance. Part B was medical insurance. These two parts remain part of Medicare. They are sometimes referred to as Original Medicare or Traditional Medicare. Part C and Part D were added to Medicare in 2003 with the Medicare Prescription Drug Improvement and Modernization Act (MMA). Part C is a Medicare plan option that offers the same coverage that Original Medicare does in one plan that is administered by a private company. Medicare Advantage plans are not under contract with Medicare, but Medicare must approve the plans. Part D was first offered in 2006. It offers coverage for prescription drugs. It can be purchased by anyone with any part of Medicare, although some Medicare Advantage plans include prescription drug coverage. If your Medicare Advantage plan includes creditable prescription drug coverage, you are not eligible for Part D. Back to Menu Eligibility and coverage Medicare offers coverage to seniors age 65 and older. It also provides benefits to those younger than 65 in some cases. If you’re 65 years old or older, you or your spouse must be receiving or be eligible for Social Security or Railroad Retirement Board benefits. Alternatively, you or your spouse must have had Medicare-covered government employment to qualify. If you’re younger than 65 and have received Social Security or Railroad Board disability benefits, you may also be able to enroll in Medicare. You can also enroll in Medicare if you have End Stage Renal Disease (ERSD) or Amyotrophic Lateral Sclerosis (ALS) and meet certain additional requirements. Use Medicare.gov’s online eligibility calculator to check eligibility and estimate premium costs. The services Medicare covers is set by federal and state laws. Coverage decisions are also made by local companies that process Medicare claims. Back to Menu Part A Coverage Part A is hospital insurance. It covers medically necessary stays in the hospital and skilled nursing facilities, but not long-term or custodial care in a skilled nursing facility. It also covers hospice and some kinds of home health care, like physical and occupational therapy. Cost If you or your spouse have been employed and paid Medicare taxes for at least 10 years, you do not have to pay a premium for Part A. You also must be receiving or be eligible to receive Social Security or Railroad Retirement Board benefits. Medicare-covered government employment also counts. If you’re under 65, you may also be eligible if you’ve received Social Security or Railroad Retirement Board disability benefits for 24 months or have End Stage Renal Disease (ERSD) and meet other requirements to not be charged a premium. If you have to pay monthly premiums, there is a cap on the cost of Part A premiums. However, if you’ve worked and paid Medicare taxes for seven and a half to nine and three quarters years, you’d be charged less. Deductibles and premiums change year to year, so that’s something to watch. For example, the Part A deductible was $1,364 in 2019. Coinsurance amounts for hospital stays start after that (nothing for first 60 days; $341 per day for days 61–90; $682 day 91 and over up to 60 days). Enrollment Sometimes enrollment is automatic, but is managed through the Social Security office since many of the eligibility requirements are tied to receiving Social Security benefits. The enrollment process for Part A is automatic if you’re over 65 and receive Social Security benefits. If you won’t start getting Social Security benefits until after you turn 65, you’ll have to enroll yourself. You can apply online, over the phone, or in person. Back to Menu Part B Coverage Part B is medical insurance that covers medically necessary treatment, outpatient services, and preventive care. It also covers some prescriptions, mental health care, and ambulance services. If you need Durable Medical Equipment, like a walker, crutches, blood sugar monitors, and oxygen equipment, Part B covers that as well. Medicare doesn’t cover all health-related services, like long-term care, hearing aids, dentures, and acupuncture. For more information, check with Medicare directly to see if a health service is covered. Cost Part B premiums are automatically deducted from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefits payments. Monthly premium amounts are based on your income from two years ago and also vary year to year. The annual deductible is fairly low. For example, it was $185 in 2019. Once the deductible is met, you are responsible for a 20 percent copay. If you don’t enroll in Part B when you’re first eligible, a late enrollment penalty is typically assessed on the monthly premium. The penalty is determined based on how many 12–month periods you’ve gone without Part B. The premiums can increase by 10 percent per 12–month period. However, there are circumstances that allow people to enroll in Part B without the late enrollment penalty outside of the Initial Enrollment Period. For more details, you should contact Medicare directly. Enrollment To enroll in Part B, you must work with the Social Security Office and submit the Application for Enrollment Part B (CMS-40B). Before you can get Part B, you must also have Part A. Back to Menu Part C Coverage Medicare Part C offers both medical and hospital insurance under one plan. Part C health plans are also referred to as Medicare Advantage plans. These plans are managed by private companies and are considered the private option for Medicare. While Medicare Advantage Plans must cover the same things that Original Medicare does, the out-of-pocket costs, premiums, and network structures vary plan to plan. Medicare Advantage plans offer additional perks, like hearing aid discounts, dental coverage, vision coverage, and fitness memberships. These additional coverage options can vary by plan, so be sure to read through and understand what is included with a Medicare Advantage plan before enrolling. Some Medicare Advantage plans, typically HMO and PPO plans, also offer good prescription drug coverage. If you have one of these plans and enroll in a Prescription Drug Plan (PDP), you will be disenrolled from your Medicare Advantage plan and enrolled in Original Medicare. Medicare Advantage plans also differ from Original Medicare because they work more like traditional health plans with networks of physicians. There are also more plan–type options, including Private Fee-For-Service (PFFS) plans and Medical Savings Account (MSA) plans. MSAs are high-deductible health plans with a medical savings account that can be used to pay for medical services. There are also specialized Medicare Advantage Plans that are geared for people with chronic conditions or people who also qualify for Medicaid. These plans are called Special Needs Plans (SNPs). Cost The monthly premiums and out-of-pocket costs of a Medicare Advantage plan differ health plan to health plan. Carefully analyze each health plan you consider to be sure that it meets your medical and financial needs. Take the out-of-pocket expenses and premiums into account when making your decision. Enrollment You must enroll in Part C with an insurance company. You also need to review your plan each year during Medicare Annual Enrollment because companies can make changes annually. Some Medicare Advantage plans may be discontinued year to year, so it’s a good idea to review your coverage during this period. If you're happy with your plan, you don't need to re-enroll during the Medicare Annual Enrollment Period. When you’re first enrolling in Medicare, weigh your options carefully as you choose between Parts A and B and Part C. It can be a good idea to work with a licensed insurance agent to help you through the enrollment process. If you have other medical insurance from another source, check to see how enrolling in Medicare would affect that coverage. If you enrolled in a Medicare Advantage HMO or PPO and enroll in a Part D plan, you’ll automatically be disenrolled from Medicare Advantage and enrolled in Original Medicare. Medigap policies are also not applicable for Medicare Advantage plans. Back to Menu Part D Coverage Medicare Part D offers coverage for prescription drugs. These plans are also called Prescription Drug Plans (PDPs). While these plans are also managed by private insurance companies, they must meet a standard level of coverage determined by Medicare. Each plan has a drug list called a formulary that lists the drugs it covers and how drugs are classified into tiers. Each drug tier has a different level of cost-sharing. The cost-sharing for prescriptions is based on the drug’s tier. On a higher level, drugs are also categorized by type. While there may be several drugs that treat a condition, a drug plan would only have to cover two of them. Some plans may not cover the exact medication you take, but they will cover at least two alternatives that you can try. If you need a specific medication, make sure that it’s included in your prescription drug plan. Drug formularies can change year-to-year, they can also change during the year. If your plan changes the drugs it covers, you must be given written notice at least 30 days before the change’s effective date or at the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change. If this happens you can also request an exception or try a new drug. Cost Like most health insurance plans, Prescription Drug Plans (PDPs) have monthly premiums and cost-sharing rules. These costs will vary based on the plan you choose. Some Part D plans don’t have a deductible. There are limits to how high a Part D deductible can be. For example, it was $415 in 2019. Premiums If you do not have prescription drug coverage for a continuous 63 days or more once your initial enrollment period ends, you will have a late enrollment penalty fee assessed on your coverage. The late enrollment penalty fee increases your monthly premium by one percent for every month you were without prescription drug coverage. As monthly premiums can change year-to-year, so can your penalty because it is based on a certain percentage of your premium. If a penalty is assessed, you can appeal it by applying for a reconsideration decision. In some cases, the penalty may be removed entirely or reduced. To avoid this penalty, it’s a good idea to make sure that you have qualifying prescription drug coverage when you complete your Medicare initial enrollment. Coverage gaps One feature of Part D plans is that there can be coverage gaps. Coverage gaps are when the insurance company has hit the plan’s limit for what it pays in cost-sharing. Until the coverage gap is closed, you will have higher out-of-pocket costs for your medications. Typically, you will pay an additional amount of coinsurance or a certain percentage of what the insurance company typically pays under the plan. For brand name medications, the annual deductible, coinsurance, copayments, and discounts count towards closing the coverage gap. For generic medications, the copay and coinsurance are typically counted towards closing the coverage gap. Once you’ve closed the coverage gap, you’ll still have to make some coinsurance or copay payments. This is referred to as catastrophic coverage. There are limits on what you’d have to pay out-of-pocket for this catastrophic coverage. These limits can change annually and may vary by plan, so be sure to talk to an agent and understand your plan before enrolling. Enrollment While you do want to make sure that you avoid the late enrollment penalty, it’s important to understand how enrolling in a Prescription Drug plan would affect your other health insurance. For example, if you have coverage through Medicaid, COBRA, HUD, or something else, ask how enrolling in a PDP would affect your current coverage and make sure that your current health insurance would count as qualifying prescription drug coverage. These plans are offered by private insurance companies. To view Part D plan options and enroll, you can use the Medicare Plan Finder on Medicare.gov or work directly with a carrier. Back to Menu

Updated September 10, 2021. Just when you started to think health insurance made sense, you became eligible for Medicare! Medicare has its own processes, rules, and enrollment periods that can be tricky to understand at first. “Medicare has several different enrollment periods, so it can be confusing to keep track of everything and remember which enrollment period is for what,” says Lindsay Engle, Elite Insurance Partners, LLC Marketing Manager. The Medicare Open Enrollment is one of those periods. Here are five things you should know about the Medicare Open Enrollment: What is the Medicare Open Enrollment Period? Who does it apply to? What are the dates? What’s with the advertising? What do I need to do? What is the Medicare Open Enrollment Period? Over the years, you may have gotten used to the Open Enrollment Period for enrolling in health insurance every November. The Medicare Open Enrollment Period overlaps with those dates, so it may seem like it’s the same thing but for Medicare. The short answer: It’s not. If the Medicare Open Enrollment Period isn’t for enrolling in a plan, what is it for? The Medicare Open Enrollment Period gives you an opportunity to review and make changes to your current Medicare coverage: Switch between Original Medicare (Parts A and B) and a Medicare Advantage Plan (Part C). Change to a new Medicare Advantage Plan. Change your prescription drug coverage by switching to a new plan, dropping coverage, or enrolling in a plan for the first time. If you have a Medicare Advantage plan that offers qualifying prescription drug coverage, you do not need to enroll in Part D. If you do, you’ll be automatically disenrolled from your Medicare Advantage plan and enrolled in Original Medicare. As you evaluate your prescription drug coverage, check the formulary (drug list) to make sure the medications you need are covered. This will help you decide if you need to enroll in a new plan or keep your old one. Before opting out of prescription drug coverage, be aware that there is a late enrollment penalty if you are without creditable prescription drug coverage and enroll in a Part D plan later. Back to Questions Who does it apply to? While you can switch from Original Medicare to a Medicare Advantage plan during the Annual Election Period (AEP), the Annual Election Period primarily affects people with Part C (Medicare Advantage Plans) or Part D (Prescription Drug Plans). The Medicare Open Enrollment Period does not apply to Medicare Supplement Plans (Medigap). “While it is critical that they examine their Part D (drug) plan at this time every year, it is important that they understand that the Medigap, otherwise called Medicare Supplement plans, do not change and do not need to be changed during this time period. Each Medicare Supplement plan automatically renews on the policy anniversary and nothing can change with those policies,” says Christopher L. Westfall, Sr., from Senior Savings Network. Back to Questions What are the dates? The Medicare Open Enrollment Period runs each year October 15th through December 7th. Keep these dates in mind, especially because they are different from health insurance Open Enrollment dates, even though the periods overlap. Back to Questions What’s with the advertising? Health insurance companies do a lot of advertising during the Medicare Open Enrollment Period and during health insurance Open Enrollment. Because the dates overlap, you may feel like you’re being bombarded with health insurance ads. The Medicare Open Enrollment Period is a money-making opportunity for Medicare providers. During this time, Medicare beneficiaries can enroll in a new plan and switch health insurance companies. “I think the Open Enrollment Period (OEP) can be very confusing sometimes. There is so much advertising EVERYWHERE. It makes clients think that they have to change their plan or sign up for it again,” says Katherine Adams, founder of Creative Legacy Group. Don’t be confused by the ads. Make sure you understand your Medicare plans and how the Open Enrollment Period works. Review your current coverage to make sure that it will continue to meet your needs next year. Back to Questions What do I need to do? Now that you have a better understanding of what the Open Enrollment Period is, the next thing to figure out is what to do. Melissa Negrin-Wiener, Genser Cona Elder Law Partner, suggests taking these steps: “Read your Annual Notice of Change mailed to you every September informing you of any changes to your plan, such as changes in premiums, co-pays, pharmacies and prescription drug coverage. Review your coverage, costs, and doctors to determine if you should switch from traditional Medicare to a Medicare Advantage Plan. Review your medications and change your Part D plan if your prescriptions are no longer covered or your costs have increased.” Following these steps if you have a Medicare Advantage or Prescription Drug Plan will help you ensure that your Medicare coverage will be sufficient for next year. Doing nothing during the Open Enrollment Period does not mean that you won’t have coverage next year. In most cases, you'll be automatically re-enrolled in your current plans. However, if you want to be on the safe side, it doesn’t hurt to contact your health insurer to double-check your enrollment. Back to Questions Want more insight into the Medicare Open Enrollment Period? Check out these articles and our downloadable guide: "Ways to Prepare for Medicare Open Enrollment" "Pitfalls to Avoid During Medicare Open Enrollment"

Guest Post by Michael Z. Stahl October has several days dedicated to recognizing mental health. October 10th is World Mental Health Day and Depression Screening Day, and various worldwide organizations recognize all 31 days of October as Mental Health Month. But October also marks the start of the annual Medicare Open Enrollment season. Various Medicare plans change annually, so it is important that you have a clear understanding of what is — and is not — covered by Medicare when it comes to mental health care. Taking care of your mental health is an important part of life. Nearly one in five U.S. adults experience mental illness each year, according to the National Alliance on Mental Illness. The World Health Organization (WHO) estimates that approximately 15 percent of adults over 60 suffer from a mental health disorder. Mental health care includes services and programs that help diagnose and treat mental health conditions. Whether you are enrolling yourself, a spouse, a parent, or an older relative, keep these four things in mind during the Medicare enrollment process this month: 1. Medicare and inpatient care Medicare Part A, or hospital insurance, covers inpatient care for mental health, which can be provided in a general hospital or a psychiatric hospital that cares solely for people with mental health conditions. Your plan will cover the costs associated with the hospital room, meals, nursing care, therapy or other treatments, medications, and other related services and supplies. Be aware that Medicare Part A only pays for 190 days of inpatient psychiatric care during your lifetime. Medicare measures hospital inpatient care by “benefit periods.” A benefit period begins the day you are admitted for inpatient care; it ends once you’ve been released from inpatient care and have gone at least 60 days without skilled nursing care. The amount of coinsurance you’ll pay is based on the length of your stay. There is no limit on the number of benefit periods you can have when care is received in a general hospital. However, with a psychiatric hospital, one can have multiple benefit periods, but only within a 190-day lifetime span. Medicare Part B will provide some coverage for care and services by doctors or healthcare professionals in an inpatient setting. You would be responsible for paying 20 percent of the Medicare-approved amount for those mental health services while you’re considered a hospital inpatient. 2. Medicare and outpatient care Medicare Part B covers many mental health services one might seek in an outpatient setting, such as a clinic, doctor’s office, or therapist’s office. The following services and/or visits with healthcare professionals are covered: Psychiatrists and other doctors Clinical psychologists Clinical social workers Clinical nurse specialists Nurse practitioners Physician assistants Before scheduling the appointment, ask your healthcare provider if they accept assignment. These healthcare professionals must accept an assignment if they participate in Medicare. Medicare Part B also provides coverage for a variety of outpatient services such as the following: an annual depression screening diagnostic tests group or individual psychotherapy psychiatric evaluations  lab tests Counseling is included as a covered service, but it is specific to family counseling that has been solely recommended to help with your treatment. Marriage and relationship counseling would not fall under this category. Medicare Part B does cover certain prescription drugs that are not typically self-administered, such as injections administered in your doctor’s office. Of course, coinsurance and deductibles still apply. For most cases, once you pay your yearly Medicare Part B deductible, you are then responsible for 20 percent of the Medicare-approved amount if your healthcare provider accepts assignments. 3. Medicare Part D: Prescription drugs Prescription drugs can be a large component in treating mental health illnesses, conditions, and disorders. If you or a loved one require prescriptions as part of your treatment, you should enroll in a Medicare Prescription Drug Plan to get prescription drug coverage. Each plan has a list of drugs and prescriptions covered under that plan. While Medicare plans are not required to cover all drugs, they are required to cover antidepressants, antipsychotic and anticonvulsant medications (with minimal exceptions), which may be needed to stay mentally healthy. If you or a loved one take prescription drugs to treat mental illness, make sure that drug is covered before enrolling in a plan. If your provider thinks you need a certain drug that your plan does not cover, there are processes and appeal resources available. 4. What isn’t covered under original Medicare? If you are enrolled or shopping for Original Medicare (Part A and Part B), there are some mental health services that are not covered. For example, costs for transportation to and from mental health care services is not provided or covered. Sometimes, for individuals with mental health illnesses or disorders, it’s helpful to find support groups that bring people with similar diagnoses together. However, costs associated with getting to these group settings or any membership fees are not covered. (This is different from psychotherapy.) Additionally, testing or training for job skills that are not related to mental health treatment are also not covered. A licensed health insurance professional can help you navigate the nuances of Medicare coverage for mental health services. They can ensure you’re getting the best plan that fits all your needs. Mental health treatment is extremely important. So is the coverage that’s available to you or a loved one. Michael Z. Stahl serves as executive vice president of HealthMarkets—one of the nation’s largest independent health insurance agencies in the Medicare, individual and supplemental health, life, and small group insurance markets. He has a bachelor’s degree in economics from The Wharton School, University of Pennsylvania, and holds the chartered property casualty underwriter (CPCU), associate in insurance accounting and finance (AIAF), and associate in reinsurance (ARe). An avid Kansas City Royals fan, he lives in Dallas with his wife and children.