Medicare Providers Blog and Resources

Guest Post by Christian Worstell The point of having insurance is to save money. And when it comes to Medicare, saving money isn’t just about what insurance plan you have. It’s about when you get it.  Unfortunately, too many Medicare beneficiaries cost themselves money by not enrolling at the right time. Not only can this mistake create a gap in your coverage and leave you paying out-of-pocket until the matter is resolved, but it can also increase your premiums once you finally do get signed up.  That’s right: Medicare imposes late fees on beneficiaries who miss various enrollment deadlines or don’t meet certain requirements. And it’s one of the less understood aspects of Medicare.  Consider this statistic from an annual Medicare literacy survey: 80 percent of Medicare beneficiaries are unaware of the late enrollment penalty for Medicare Part D prescription drug plans. Let’s discuss the Part D late enrollment fee and, more importantly, how you can avoid paying it.  What is the Medicare Part D Late Enrollment Penalty? Medicare Part D is the portion of Medicare that covers most prescription medications. Part D plans are sold by private insurance companies, and while having a Part D plan is technically optional, there can be consequences if you don’t have one or similar drug coverage. When most people become eligible for Medicare, they’re typically granted an Initial Enrollment Period (IEP). This seven-month enrollment period begins three months before you turn 65 years old, includes the month of your birthday, and continues for another three months. This seven-month period is typically your first opportunity to enroll in the various parts of Medicare. It also might be your last shot to enroll without paying any late fees.  If you go 63 consecutive days without creditable drug coverage at any time after your Initial Enrollment Period is over, you will be on the hook for a late enrollment penalty if you choose to one day sign up for a Part D plan.  Creditable drug coverage is any coverage that on average provides at least the same level of benefits as Medicare drug coverage. That can include drug coverage from an employer, union or nearly anything else, as long as the coverage pays at least as much on average as Medicare’s standard drug coverage.  In other words, once your Initial Enrollment Period ends three months after you turn 65, you better have a plan in place (literally or at least figuratively). Because once the enrollment period closes, the clock starts ticking on the 63-day window for you to enroll in a Medicare Part D plan without a late enrollment penalty.  You can also find yourself in the penalty box if you have creditable drug coverage, allow it to expire, and then go at least 63 days without replacing it. How much is the late fee? The Medicare Part D late enrollment penalty is 1 percent of the national base beneficiary premium for every month you were eligible for creditable drug coverage but did not have it.  The national base beneficiary premium can be thought of as the “average” Part D premium. While it’s not technically the average premium, it’s a close approximate. The national base beneficiary premium for 2022 has been set at $33.37 per month. (The average Part D plan premium in 2022 is $33 per month.) The late enrollment penalty calculation is rounded to the nearest $0.10. So for 2022, the late enrollment penalty is 33 cents for every month you did not have creditable drug coverage. 33 cents? What’s the big deal? This is where the math gets interesting. The penalty is not just a one-time fee. You will have to pay the fee every month that you remain enrolled in Part D. That means if you are late to enroll in a Part D plan and then maintain Part D coverage for the next 20 years, you’ll be paying that late fee every single month for the next 20 years or more.  Here are some other examples to consider: Let’s say you went four months without creditable drug coverage. Your monthly penalty is now 4% of the national base beneficiary premium, or $1.33 per month in 2022. Again, that may not sound like much, but over the course of the year, it comes out to $16. Over five years, you would have paid $80 in late enrollment fees. Over the course of 20 years, you’re throwing away $320.  Now let’s say you went one full year without creditable drug coverage, which pushes your late fee to $4 per month in 2022. Paying that penalty for one year costs you $48. Over 10 years, it’s $480. And over the course of 20 years, you’ll be saying goodbye to $961.  If you went three years without creditable drug coverage before finally enrolling in a Part D plan, your late penalty would equal $2,883 over the course of 20 years. That’s a seven-day cruise to the Bahamas that you just gifted to Uncle Sam.   To make matters worse, the national base beneficiary premium typically changes every year. And the penalty you owe is not locked into the rate at which you first acquired your penalty. It’s tied into the current year’s rate. If the national base beneficiary premium goes up, so too does your penalty.  One might argue that delaying your Part D enrollment could actually save you money. After all, if you go six months without paying any Part D premiums, the money saved will be more than the applied late fees.  That may be true for a certain period of time. But eventually, those monthly late penalties will catch up to and surpass any money that you saved by not paying a premium for a short time.  Plus, what happens if you are prescribed a medication during that time when you don’t have drug coverage? You can’t just suddenly sign up for a plan whenever you want. Most beneficiaries are limited to enrolling only during the Annual Enrollment Period each fall. If you were to get sick or injured and prescribed a medication in March, you’re out of luck for several months until the next AEP. And even then you must wait until January 1 for that coverage to take effect. Given the out-of-pocket cost for prescription drugs without insurance, is that a gamble you want to take? How do I avoid paying the Part D Late Enrollment Penalty?   Some people who get saddled with Part D late enrollment penalties may do so because they aren’t taking any medications at the time of their Initial Enrollment Period. After all, if you don’t take any drugs, why would you bother signing up for an insurance plan that covers them? But the reality is that even if you aren’t taking any medications now, there’s a good chance you will be in the future. According to the Kaiser Family Foundation, almost 9 out of every 10 Americans aged 65 and over take at least one prescription drug. For comparison's sake, only three-quarters of those ages 50 to 64 take at least one medication, signaling that your odds of needing a prescription spike right around the time you’ll be signing up for Medicare.  Most Medicare Advantage (Medicare Part C) plans include prescription drug coverage, and many plans are available for a $0 monthly premium. This means that even if you don’t take many prescription drugs now, signing up for a Medicare Advantage plan with drug coverage could come with minimal costs to you now and help protect you from potential Part D late enrollment penalties down the road. Make sure you have a plan in place for your Medicare drug coverage. And remember, timing is everything. Christian Worstell is a licensed insurance agent and a senior staff writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options. His work has been featured in outlets such as Forbes, Yahoo! Finance and The Washington Post, and he is a frequent contributor to health care and finance blogs. Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, North Carolina.

Guest Post by Cobi B. Gantz Given COVID’s continuing challenges, it can be hard to imagine traveling abroad now. However, if you are planning ahead for an upcoming trip and are on Medicare, it is important to note that the specific plan you are on can have a significant impact on the type of coverage you are eligible while traveling. What is Medicare? Medicare is the federal health insurance program that is designed for people who are 65 or older and qualifying younger people with disabilities. Those who qualify also include people who have End Stage Renal Disease. Medicare was first created in 1965 and is administered by the Centers for Medicare and Medicaid Services. Most people who are eligible for Medicare get their plans in two main ways — Original Medicare and Medicare Advantage. We have provided a quick overview below:  Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Part A covers inpatient hospital stays. It also includes care in a skilled nursing facility, hospice care, and some home health care. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. A Medicare Supplement plan (Medigap) helps offset Original Medicare's out-of-pocket costs. People who choose original Medicare will often choose to obtain a separate Medicare drug plan (also known as Medicare Part D or a PDP) in order to ensure they have coverage for their prescription drugs.  *Medicare Part D covers the cost of your prescription drugs. It is a federally created program and most people who opt for Original Medicare (Part A and B) also choose a Part D plan; however, it's optional. Medicare Advantage is also known as Medicare Part C. Medicare Advantage offers another way to get your Medicare benefits through private insurance companies. Many Medicare Advantage plans include prescription drug coverage as part of the plan. However, when it comes to travel, there are some limitations to note which we will address below.  How do various Medicare plans impact travel coverage? As there are a number of Medicare coverage options, it is important to note whether the plan you are on includes coverage during your upcoming travel. If you’re planning to travel internationally after COVID subsides, consider getting expert advice from a licensed Medicare Advisor to confirm benefits during your trip. Medicare coverage and international travel Original Medicare does not cover health care while you’re traveling outside the United States. (The U.S. Virgin Islands, Puerto Rico, Guam, American Samoa, and the Northern Mariana Islands are considered part of the United States.) If you are traveling abroad and have a Medicare Supplement plan, you may receive some coverage. Plans C, D, E, F, G, H, I J, M, or N typically cover foreign travel emergency care if it begins during the first 60 days of your trip. These plans pay 80 percent of billed charges for certain medically necessary care after you meet a $250 yearly deductible. This benefit has a lifetime maximum of $50,000. Medicare Advantage Plans typically don’t cover care outside the United States. They also usually don’t cover non-emergency care you get outside of your plan’s network. However, these plans are required to cover any emergency and urgent care needs people have anywhere in the United States without imposing additional costs or coverage rules. Medicare coverage and domestic travel If you have a Medicare Advantage Plan, triple check coverage from state to state. These plans are required to cover emergency care in America but are not required to cover routine care. In some cases, you may be able to visit out-of-network providers but will have to pay more to see them. Your plan or a Medicare Advisor can help you to find an in-network provider in the area where you are traveling. People with a Medicare Supplement plan, also known as a Medigap plan, can receive care from any doctor nationwide who accepts Original Medicare. While most doctors accept Original Medicare and Medicare Supplement plans, some do not. Ask the doctor’s office or hospital staff before your appointment.  Try to get your prescriptions ahead of your trip. Or, take the time to double-check that your destination (if based in the United States) has a pharmacy that has “preferred in-network” status with your drug plan to help reduce the cost of your co-pays.  Before you plan travel, consult with a Medicare advisor in order to confirm your current plan includes coverage during your travel. Cobi B. Gantz is the CEO of Chapter, a Medicare Advisor company that offers Medicare education and assists with Medicare enrollment.

Guest Post by Lindsay Malzone Choosing a Medigap plan, also known as Medicare Supplement, can be confusing. From letter plans A–N, it can all go over your head. To help you through this process, we've broken down three steps to selecting the right plan for you.  Medigap is not one-size-fits-all. Each plan has its own set of standardized benefits. Before purchasing a policy, it’s crucial to do your research. Evaluating your overall financial and healthcare needs can not only help save you money in the long run but get you the right coverage so you’re not scrambling when you need it most. Step 1: Set a monthly budget When setting a budget for what you’re comfortable spending per month on your healthcare premiums, it’s important to take into consideration both your current and future finances. If you choose coverage that meets your budget now, but might not in the future, you may not be able to switch plans due to pre-existing conditions. Remember, monthly premiums vary based on several factors, including your age, location, gender, and tobacco use.  Spending more money now in monthly premiums could keep more money in your rainy-day fund.  Step 2: Consider your current and future health If you are relatively healthy now, you may consider basic health coverage. This is where it gets tricky. You only get a once in a lifetime Medigap Open Enrollment Period. (Unless you’re under 65, then you get two.) Three months before you turn 65, your Initial Enrollment Period begins. This is when you can enroll in Part A, Part B, as well as Part D (prescription drug coverage). This is a seven-month window that ends three months after your birthday. Your Part B effective date is what initiates your once in a lifetime six-month Medigap Open Enrollment Period. This is when you can enroll in any Medigap plan without going through medical underwriting. Outside of this time frame you can still enroll in a Medigap plan at any time of the year, you’ll just have to answer health questions. Some pre-existing conditions can get your coverage denied. It's better to prepare for the worst now since pre-existing conditions can prevent you from getting the coverage you need in the future. Learn more about what each Medicare part covers, enrollment, and cost. Step 3: Compare Medigap letter plans A–N Once you’ve figured out your monthly budget and how extensive you want your coverage to be, you can begin comparing different letter plans. Medigap plans are lettered A–N. The core policy benefits found in Plan A are included in all letter plans. There are first-dollar coverage plans, high-deductible plans, and cost-sharing plans that come with copays. The higher the monthly premium, the less you pay out of pocket when you use the benefits. Below, we’ll discuss the most popular plans.  Only those who were eligible for Medicare prior to 2020 are eligible to enroll in the only first-dollar coverage plan, Plan F. This is also the plan that will cost you the most in monthly premiums. If you’re looking for lower premiums without losing benefits, than the high-deductible version is a great alternative. Both options have been discontinued and are not available to new beneficiaries.  The next best option, and plan that’s available to all beneficiaries, is Plan G. Outside of the monthly premium, you’re only responsible for paying the Part B deductible, which is $203 in 2021. The Part B deductible amount for 2022 will be announced by November. Plan G also comes with a high-deductible version.  The last Medigap plan we’re going to mention is Plan N. This plan is considered a cost-sharing plan. In exchange for a lower monthly premium, you pay small copays when you visit your doctor or go to the hospital. You picked a Medigap plan, now what? This is where having a licensed Medicare agent on speed dial can be helpful. Beneficiaries don’t have access to tools that can compare Medigap plans in their state with all the carriers’ side by side. There are quoting tools out there that give you generic quotes, but not quotes tailored to you.   Find an agent that doesn’t work for one carrier. You want an agent that works with multiple carriers and can give you non-biased expert advice. Medigap plans do not cover prescription medications that you pick up at your local pharmacy. That’s where Part D comes into play. Once you select a Medigap plan, your agent can also compare Part D plans in your area. Make sure to let your agent know what medications you’re taking. They will ensure they’re covered in your plans drug formulary. Lindsay Malzone is the Medicare expert for MedicareFAQ. She has been working in Medicare since 2017. She is featured in many publications and has become the expert in the Medicare industry. Her passion is providing Medicare beneficiaries with the resources they need to make an educated decision on their healthcare needs and provide them the opportunity to learn about Medicare in a non-sales environment. You can also find her over on YouTube where she publishes Medicare-related video content regularly.

Guest Post by Lindsay Engle Technology offers increased access to health care via telehealth and telemedicine. For years, expanding telehealth has been a priority in the United States, especially to improve health care in rural areas. Yet, due to the global health crisis, these services are more widely available than before through Medicare. Beneficiaries should be aware of what types of virtual care receive coverage. What's covered Telehealth is a broader term that includes telemedicine, which refers to virtual, clinical services. Its use began as a way for people who live in rural areas to access medical professionals whose care was previously unavailable to them. Further, utilizing this technology reduces the burden on health care workers. Since the beginning of the pandemic, and even before, Medicare has been expanding telehealth coverage. As the goal is to replicate an in-person office visit as much as possible, telehealth visits must happen in real-time. The visits most commonly take place over video conference. The only exceptions are in Alaska and Hawaii, where Medicare pays for the use of asynchronous store-and-forward technology. One of the first questions participants have is what virtual services Medicare covers. Telehealth services that receive coverage from Medicare include: Doctor visits, including preventive health visits Evaluations for physical therapy and occupational therapy Speech therapy Psychotherapy and other mental health services Treatment for substance abuse disorders COVID-19 evaluation To receive this care, the patient must be at home or in a permitted facility. However, there is no location restriction for the practitioner. The practitioner then determines whether subsequent care is necessary. Telehealth receives coverage through Part B of Medicare. Part B is outpatient coverage, which also pays for standard doctor visits. The Medicare Telehealth Parity Act of 2017 expanded telehealth under Medicare. Telehealth is part of Medicare's chronic care management program, which provides care for such conditions as cancer, diabetes, and arthritis. Virtual services offer patients a way to check in easily with their physicians and prevent future hospital stays. As of 2019, CMS made some changes that made telehealth more widely available, including the ability for those in need of renal dialysis to receive these services at a facility or home. Additionally, the services are available to those suffering from an acute stroke no matter their location. Medicare also covers remote patient monitoring for chronic and acute conditions. Remote patient monitoring utilizes technology to obtain patient data, such as heart rate and blood pressure. Physicians can review and analyze this data to make recommendations for health care. Medicare telehealth costs Those with Original Medicare pay 20 percent while Medicare covers the remaining 80 percent. If you have a Medigap plan, that 20 percent also receives coverage. Before scheduling a telehealth appointment, make sure Medicare covers the service that you need. The cost of telehealth services varies due to several factors. The best way to find out how much you'll be paying is by speaking to your provider. To keep telehealth costs low, make sure your provider accepts Medicare assignment. If you have an Advantage plan, make sure they are in your network. The amounts that doctors charge vary, and the type of facility where your doctor practices can also influence the price. Although telehealth is convenient, its costs are comparable to those for in-person health care. Thus, the pricing is consistent with the contention that telehealth is an equivalent form of care. Yet, some health care providers have been waiving their telehealth costs during the COVID-19 pandemic. Medicare Advantage plans and telehealth Since 2020, Advantage plan participants have access to a wide range of telemedicine benefits. These plans may offer more of this type of benefit than Original Medicare, meaning that they include services not covered by Part B. However, what's covered may differ by plan. The best way to find out what your Advantage plan offers is to check with your carrier. Expansion of telehealth coverage during COVID-19 During the global health crisis, the Centers for Medicare and Medicaid Services (CMS) is increasing its coverage for telehealth services. The Coronavirus Aid, Relief and Economic Security (CARES) Act makes this possible. Due to temporarily relaxed HIPAA guidelines, beneficiaries and doctors can now use their smartphones and tablets to communicate. Audio-only telehealth services are allowed under these waivers, which will continue until the end of the public health emergency. Generally, Medicare will only reimburse a live videoconference. The waiver also makes these remote services available to new patients, rather than only established patients, as outlined previously. Adjustments such as these increase the number of people telehealth can help at this time. This expansion is essential to slow the virus's spread, as it protects the patient and others with whom they might otherwise come into contact. Many providers waive fees for telehealth appointments to screen for COVID-19. Several changes will be here to stay beyond the pandemic to make health care more accessible. These include telehealth for group psychotherapy, neurobehavioral status exams, and home visits with patients and/or family. Medicare covers virtual check-ins and E-visits during the pandemic to treat COVID-19 and for other medically necessary purposes. These are not technically telehealth services, but they involve technology and receive coverage through Part B of Medicare. Through a virtual check-in, you can use audio or video to communicate, and your practitioner can respond via phone, secure text message, email, patient portal, or audio/visit. E-visits involve the use of a patient portal to talk to providers. It's necessary to speak with your practitioner before starting either virtual check-ins or E-visits. Also important to note is that virtual check-ins cannot be related to visits from the past week or lead to an appointment the next day (or soonest available). Practitioners can also remotely assess images or videos provided by the patient. Both virtual check-ins and E-visits are only for established patients, unlike telehealth visits, which new patients can access during the pandemic waiver. The future of telehealth and Medicare Medicare beneficiaries are generally at a higher risk for contracting COVID-19, so the program must offer protections. As technology improves and the pandemic continues, telehealth will become a mainstay in health care. The convenience of remote health care is sure to leave its mark on the population, and Medicare will likely adjust to accommodate more of these services in the near future. 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 expert columns. She has a passion for sharing her expertise about Medicare to beneficiaries so they can better prepare for health care costs after retirement. You can find her on YouTube where she is featured on a channel for Medicare beneficiaries to become educated on all their options. For more on telemedicine, visit these BestCompany.com articles: What to Expect from Telemedicine Telemedicine: What You Need to Know

If you opted for Medicare Part A and Part B, you don't have coverage for prescriptions. Fortunately, you can purchase a separate plan from a private insurer to cover your medications.  If you delay enrollment in a prescription drug plan or lapse in coverage, you'll be charged higher premiums for the delay. If you anticipate needing medications in the future, it can be smart to buy and maintain a plan sooner rather than later. As you look for the best fit, here are five things to evaluate before choosing a prescription drug plan: Pharmacy Network Drug Formulary Cost Medicare Star Ratings Customer Reviews 1. Pharmacy Network Prescription drug plans have pharmacy networks. Be sure that there's an in-network pharmacy in your area before you buy a plan. If you fill prescriptions out-of-network, you may not have coverage for your medications. Generally, prescription drug plans also cover mail delivery. Opting into this service makes getting your medications convenient and saves you a trip to the pharmacy. "Coverage for mail delivery of prescription drugs has become an important plan feature in 2020 with the elevated risks of going inside a pharmacy due to potential COVID-19 exposure," says Christian Worstell, licensed health insurance agent. 2. Drug Formulary Checking the drug formulary is perhaps the most important part of evaluating a prescription drug plan. The drug formulary is the list of medications that your plan covers, so you need to check to see if your medications are covered by the plan. "To make this process easier, write down a list of your drugs that you use regularly or ones that you may need if you have a medical episode. Also, consider any potential changes in your health this year that may require medication next year. Drug Name Dosage (750 mg, 1 mcg, etc.) Frequency (2 times per day for 30 days = 60 pills per month) Optional — Why do you take this medication? Optional — Which doctor prescribed this medication? Keep this list in a safe place and try to remember to update it when your meds change. This is also useful for a family member should you need help picking up or managing your medications," says Bethanie Nonami of Real Talk Medicare. Multiple medications treat the same illness or symptom. Medicare categorizes medications based on what they treat. Plans are not required to cover every drug that treats a diagnosis, but must cover at least two of those medications. "Every year, Medicare defines a list of covered drugs. But every plan doesn’t offer every drug that is available to us or approved by Medicare. Every year the list of formularies change.  You should do your due diligence to verify with your plan or proposed plan for 2021, if your drugs are covered," says Nonami. If you have prescriptions that are working for you, you'll want to be sure that your prescription drug plan covers these specific medications.  Even if you plan to keep your current prescription drug plan during an Annual Election Period, double-check the formulary because the drug list can change. "You can search online to verify the Formularies that your Medicare Insurance plan covers. The Formulary List is a list of what drugs are covered. This comprehensive list that often breaks the drugs out by Tiers, Drug Dosages, Requirements, and Limits. Your insurance company has their own version of a Formulary List, which may also be called a Prescription Drug List (PDL). In fact, many insurance companies have multiple Formulary Lists. Before you look for your drugs triple check the Formulary List for two critical components: First, make sure you are looking at the PDL for the next plan year of 2021, not the current year.   Second, please make sure that you are viewing PDL for your plan for your state. Plans, coverages, and limitations may vary by state," says Nonami. If there are prescriptions that are not covered by your plan that you'd like to have covered, you can look for another plan or work through your plan's prior authorization for step therapy.  You may have to start with a less expensive, generic medication to see if it's effective first. Your doctor can also work with your insurer for an exception to allow you to start directly with the more expensive medication with coverage if the generic one would cause adverse health effects or if it's medically necessary to start with the more expensive drug. 3. Cost Aside from evaluating the monthly premiums, you also need to consider the out-of-pocket costs. Medications are categorized in tiers, and each tier has different cost-sharing rules. Look for how your prescriptions are categorized under your plan and project your out-of-pocket costs for your medications. "Do you prefer a higher monthly premium in exchange for a lower deductible or cost-sharing? Or would you rather pay less upfront per month but pay a little more for each prescription? There's no universal right or wrong and each plan shopper should ask themselves how they would most prefer to spend their money," says Worstell. You'll also need to consider the coverage gap. Your plan has limits on the amount it contributes to your prescriptions. When the insurer has reached its limit, you'll be charged higher copays for your medications until the gap is closed. 4. Medicare Star Ratings The Centers for Medicare & Medicaid Services rate Medicare prescription drug plans each year. These ratings score the quality of prescription drug plans by considering clinical recommendations and plan member feedback. Five is the highest rating. New plans are not rated. "Plan quality should not be ignored either. Each year, plans are rated on a scale of one to five stars for quality and customer experience. Shoppers should pay attention to a plan's rating before buying," says Worstell. 5. Customer Reviews Customer reviews also offer insight into the customer experience with Medicare prescription drug plans. While reviews are sorted by company, reading reviews can help you understand how an insurer treats its Medicare plan members.  Pay attention to what plan reviewers mention. Private insurers offer Medicare Advantage, prescription drug, and Medicare supplement (Medigap) insurance plans. Weigh what reviewers writing about prescription drug plans say over what Medicare Advantage or Medigap members say.  Note what year the reviews are from. Prescription drug plans can change, so the most recent reviews are the most helpful, even though the plans may change each year. You can trust the reviews on Best Company because we do not repress reviews. All reviews that pass our verification process are published — positive or negative. Our verification process helps prevent the publication of fake reviews. Medicare Customer Reviews Learn more about Medicare companies by looking at the customer ratings and reviews. Learn More

When you become eligible for Medicare, you have lots of decisions to make. You can opt for Original Medicare, which is managed by the Centers for Medicare & Medicaid Services, or a Medicare Advantage plan offered by a private insurer. If you're looking for a Medicare Advantage plan — whether it's your first time enrolling in Medicare or you're participating in Medicare's Annual Election Period — here are six things you need to consider before buying in a Medicare Advantage plan: Provider Network Drug Formulary Cost Additional Coverage Medicare Star Rating Customer Reviews 1. Provider Network Unlike Original Medicare, Medicare Advantage plans have set provider networks. These networks can be specific to your plan and to your area.  "The first and most important factor are networks.  You want to make sure your regular doctors accept your plan and your preferred healthcare facilities nearby are also in their network. You should compare PPO and HMO plans to see where you have the best access to care," says Adam Hyers, Hyers and Associates, Inc. If your Medicare Advantage plan has an Health Maintenance Organization (HMO) network structure, you'll only have insurance coverage when you visit in-network providers. If you have a Preferred Provider Organization (PPO) network structure, you'll have the flexibility to visit out-of-network providers with higher out-of-pocket costs. If you're considering a Medicare Advantage plan, be sure to check your provider network to make sure there are doctors in your area who can give you the care you need. Most insurers offer an online "Find a Provider" tool that allows you to search for doctors in your area that accept your plan. Since networks can change, it's worth reaching out directly to doctor's offices to double-check that they'll continue to accept your plan in 2021 before you enroll in it again. 2. Drug Formulary Most Medicare Advantage plans include qualifying prescription drug coverage. If your Medicare Advantage plan offers this coverage, you don't need to purchase a separate plan to cover prescriptions. As you evaluate Medicare Advantage plans, check the drug formulary to make sure that the medications you need are covered. Even if they're covered on your current plan, they may not be covered for 2021. If there's a medication that you think may work better than your current medication, you should also look for that drug to be listed on the formulary and how cost-sharing works. "Some Medicare Advantage plans will give you better pricing on your prescriptions than others.  All other things being nearly equal, prescription costs can be a differentiating factor," says Hyers. In addition to checking that your medications are listed on your plan's formulary, you should also pay attention to what tier they fall under. Each tier has different cost-sharing rules. Some tiers have higher out-of-pocket costs. Understanding how your drugs are categorized will help you anticipate costs. The insurance company should provide you with the drug formulary before you enroll in a plan. You may be able to find it online as you learn about plans online. 3. Cost As you look at Medicare Advantage plans, you'll want to consider the out-of-pocket costs and any monthly premium amounts you'll have. "Many Medicare Advantage plans these days are offering a $0 premium, so the deductible and copayments or coinsurance requirements are deserving of a closer look," says Christian Worstell, licensed insurance agent. Low monthly premiums are especially friendly when you're on a fixed income dealing with a rising cost of living. "Before you enroll in an Advantage plan, it’s important to understand why these plans have low to zero dollar premiums. They come with many additional out of pocket costs in the form of copays, deductibles, and coinsurance. Medicare pays the Advantage carrier around $1,000 per month to take on your risk. Then they collect cost-sharing from the beneficiary as they use the benefits," says Lindsay Engle, Medicare expert. Knowing that you'll likely be taking more responsibility out-of-pocket for your care, project your prescription and medical services costs based on what you predict you'll need. Consider the copays or coinsurance, the annual deductible, and out-of-pocket maximum. Understanding these costs will help you find a plan that will protect your budget and meet your needs in the long-run. 4. Additional Features Medicare Advantage plans are required to cover the same services that Medicare does. With prescriptions, Medicare groups similar medications and plans have to cover at least one drug per group. Medicare Advantage plans often include additional coverage. Some plans offer some dental, vision, and hearing coverage. Medicare Advantage programs may also include fitness programs, access to telemedicine, and other features. Keep in mind that the additional coverage offered by Medicare Advantage may not be as robust as choosing a separate dental or vision plan. However, the additional coverage and features can be nice perks of choosing a Medicare Advantage plan. Some Medicare Advantage plans are Special Needs plans. These plans are tailored to meet the specific needs like dual eligibility for Medicare and Medicaid or chronic illness. If you have specific needs, looking into a Special Needs plan may be beneficial. 5. Medicare Star Rating The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans annually for the quality of their services. These ratings consider clinical recommendations and plan member feedback. These quality ratings can help you understand the care quality offered through Medicare Advantage plans.  New Medicare Advantage plans are not rated. 6. Customer Reviews Customer reviews can also help you evaluate how well insurers treat their members. Each member's experience will vary based on their personal needs, location, and plan; however, reviews can also help you gauge the quality offered by an insurance company. You can trust reviews posted on Best Company because we have a verification process to ensure that reviews are left by real people. We also don't suppress reviews, so you can get an unfiltered understanding of the customer experience with insurers. As you read customer reviews, pay attention to what reviewers say about their plan. Private insurers offer Medicare Advantage, prescription drug, and Medigap plans. Give more weight to reviewers that have a similar plan to the one you're looking for. This will help you get a better sense of how good the plans you need are from the insurer. Medicare Customer Reviews Learn more about Medicare companies by looking at the customer ratings and reviews. Learn More

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

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.