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How to sign up for Medicare:  What you need to know about Medicare before speaking with an agent

Medicare is a government national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA) and is now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older but also for some younger people with disability status as determined by the SSA, including people with end-stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease).


Medicare Basics: 

Medicare is divided into four Parts: A, B, C and D. Part A covers hospital, skilled nursing, and hospice services. Part B covers outpatient services. Part D covers self-administered prescription drugs. Additionally, Part C is an alternative that allows patients to choose their own plans that provide the same services as Parts A and B, but with additional benefits. The specific details on these four plans are as follows:

Part A covers hospital (inpatient, formally admitted only), skilled nursing (only after being formally admitted to a hospital for three days and not for custodial care), and hospice services.

Part B covers outpatient services including some providers' services while inpatient at a hospital, outpatient hospital charges, most provider office visits even if the office is "in a hospital", and most professionally administered prescription drugs.

Part C is an alternative called Managed Medicare or Medicare Advantage, which allows patients to choose health plans with at least the same service coverage as Parts A and B (and most often more), often the benefits of Part D, and always an annual out-of-pocket expense limit which A and B lack. A beneficiary must enroll in Parts A and B first before signing up for Part C.

Part D covers mostly self-administered prescription drugs.

If you have Original Medicare Parts A and B, you can go to any doctor or hospital accepting Medicare as payment for their services if enrolled in original Medicare. However, outside of preventive screenings and tests usually covered under Part B of your original Medicare plan, you may need additional coverage to help pay for treatments not covered by Part A or Part B. 

This could involve enrolling in a Medicare supplement policy such as Medigap or a private provider-offered policy like an Advantage Plan or a stand-alone prescription drug plan like Part D to help bridge the gaps of coverage not provided under original Medicare.


Some people have alternative coverage:

Are you covered at work?

Employers offer their eligible employees the option to enroll in group health care plans that cover expenses related to medical services, prescription drugs, dental and vision benefits. Group health insurance plans help employers save on administrative costs associated with individual policies and provide employees who don't have insurance from another source or employer access to quality health care coverage.

If your group health plan is "creditable," you don't have to sign up for Medicare. Creditable is a term that only applies to Medicare, but in general, it applies to employers with more than 20 employees. Ask your employer if your plan is "creditable."

But suppose you decide to enroll in Medicare while working, depending on the employer plan. In that case, it may be able to supplement an employee's Medicare coverage by filling some of the gaps not typically provided by traditional Medicare.

Retiree benefits:

A great tool that many employers offer is a group Medicare supplement policy or a Medicare Advantage plan. These supplemental plans can help offset rising healthcare costs and make care more affordable for retirees enrolled in original Medicare. If a retiree does have additional coverage through their spouse's employer health plan, they may not need to purchase additional medicare supplement insurance. However, those considering retirement coverage options must consult with their employer's benefits coordinator and learn what kind of gap coverage the plan offers before making any decisions about medicare supplement insurance.

COBRA:

COBRA coverage from an employer plan is a beneficial option for those individuals who leave their job. This allows for the temporary continuation of health coverage offered initially in the job.

It is essential to be aware that there is an 8-month period after a job termination to enroll in Medicare, and if not done so that a LIFETIME penalty may be imposed when enrolling at a later stage. 

Further, if you are still within your initial enrollment period, it is crucial to enroll within this window to circumvent the penalty. Additionally, Medicare supplement policies can be attained up to 63 days after the loss of COBRA coverage.

When considering whether or not to utilize COBRA coverage from an employer plan, weighing the costs and benefits of doing so is essential. Seeking advice from qualified and certified Medicare Insurance Agents can assist an individual in making this critical decision about their healthcare needs and coverage options available for them post-employment. When making the best decision regarding COBRA plans, get pertinent information, including cost and coverage details, before moving forward.

If utilizing COBRA after you turn 65, proceed with caution. COBRA is not considered creditable coverage.

Medicaid:

Medicaid is a health coverage program the state and federal governments provide for low-income people. It covers many services that Medicare does, including hospital care, doctor visits, and prescription drugs. However, it goes beyond these primary benefits and offers additional services such as dental, mental health, preventative care, and more. The amount that Medicaid pays for your medical expenses will depend on eligibility requirements determined by your state.

In addition to covering your medical costs, Medicaid helps with out-of-pocket expenses such as deductibles and coinsurance. Moreover, if you qualify for Medicaid, you can use it instead of Medicare supplement insurance, which may be beneficial because it can provide better coverage or even save money compared to other private health insurance options. While Medicaid is not perfect since individual states determine eligibility requirements and benefits vary heavily between them, it can provide comprehensive health coverage for those with limited resources at a much lower cost than private plans.

Medicare Savings Programs (MSP) under Medicaid:

MSPs are an invaluable resource for those who qualify. These Medicaid-sponsored programs pay for Medicare premiums, deductibles, and coinsurance. This is helpful for seniors or people with disabilities who cannot afford the cost of Medicare coverage on their own. Additionally, these programs help individuals save even more money by allowing them to use the savings from the program to cover other expenses or to buy more coverage.

The three savings programs include the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualified Individuals (QI) program. Each program has different eligibility requirements, which vary based on income and medical expenses. Therefore, it's vital that you read through all of the available information so that you can determine if you're eligible for any of them. Once qualified, these programs can make a big difference in helping qualifying individuals save money while accessing the essential healthcare services they need.


Enrollment dates:

Enrolling in Medicare is a critical decision requiring you to know specific eligibility dates.

If you're turning 65, you can enroll up to 3 months before your birthday, the month of, and another three months after. In most cases, your coverage for original Medicare will start on the 1st of your birthday month. However, if your birthday falls on the 1st of the month, your coverage will start a month earlier. 

You should also know that coverage for any other plan, such as Medicare Supplement (Medigap) or Medicare Advantage, will also start on the 1st of the month after you enroll. You cannot back-date coverage, and coverage will not begin mid-month.

Take advantage of the pre-65 enrollment time, so you don't miss any coverage gaps. In addition to turning 65, there is an Annual Election Period (AEP) during which anyone eligible can switch plans or modify their existing coverage from October 15th through December 7th. But if specific circumstances arise, such as moving out of your plan's service area, Special Election Periods (SEP) allow for enrollment outside these standard windows.

Your Costs:

Original Medicare contains two parts: Part A and Part B. Patients must pay monthly premiums and other costs such as deductibles, copays, and coinsurance. The amount you have to pay may vary each year in January. For Part A, most people don't have to pay any premiums since they paid a tax during their working years. However, everyone must pay the premium for Part B to keep their coverage.

You need to pay a deductible before Medical begins chipping in for your medical expenses. This amount can differ depending on the type of care you receive, for example, inpatient hospitalization or a doctor's office visit outside a hospital setting. In addition, there might be services not covered by Medicare at all, meaning you will have to bear the total cost yourself. Therefore, checking with your doctor before receiving a service is important to ensure your plan covers it!


In addition to their premiums and co-payments, individuals with Original Medicare are also responsible for the total cost of any services that Medicare does not cover.

Medicare does not cover everything:

Unfortunately, the program does not cover many services that seniors consider "necessary".

For example, it does not cover vision exams, most dental services (including dentures), and hearing aids. It does not cover an annual physical exam.

Most notably, it also does not cover Long Term Care.

Most of these services are considered "custodial care." They include basic daily activities like help with walking, getting in and out of bed, dressing, bathing, toileting, shopping, eating, and taking medicine. Part A only covers up to 100 days of skilled nursing home care during a benefit period following a hospital stay. If you need long-term custodial care after your hospital stay has ended, Medicare will not pay for it. Additionally, it does not cover homemaker services or private-duty nursing care. 



Medicare Supplement Insurance (Medigap)

Once you have determined what benefits will best meet your needs, you can focus on selecting one of the available Supplement Plans (called Medigap) plans (A-N). Each plan offers different levels of coverage; they provide various services and vary in cost depending on where you live. Knowing how these plans differ is beneficial when choosing which one is right for you. Review the policy details, compare deductibles and co-payments between companies, and ensure that whatever plan you choose meets all your healthcare requirements. These steps will ensure you make the right decision for yourself and your budget when selecting a Medigap plan.

Medigap Open Enrollment:

Medigap Open enrollment for people aged 65 and older

Open enrollment is an important time for those eligible for Medicare coverage. During this six-month period, individuals 65 and older can sign up for a Medicare supplement plan, regardless of any health concerns. This open enrollment period begins when one enrolls for Part B coverage and requires that you already have both parts A and B coverage in place first before signing up. Moreover, you are also allowed to use your open enrollment rights more than once within the six-month window, ensuring that everyone receives as many opportunities as possible.

Open enrollment is also somewhat unique regarding other insurance policies or plans. Companies would otherwise be able to deny coverage due to pre-existing conditions. 


Still, with open enrollment, individuals can sign up regardless if they possess any health issue or not. This gives peace of mind, comfort, and security, knowing that even with existing conditions, you can get a policy without worrying or fearing rejection. Therefore, taking note of this information and acting quickly during the prescribed open enrollment window is essential to receive all the benefits from a Medicare supplement plan without hassle.

When talking with your Medicare Insurance Agent or Broker to compare policies, be aware of whether or not you are in your Medigap open enrollment period. During this period, insurance companies cannot deny you coverage or charge you more due to pre-existing conditions as long as you apply within six months from when your Medicare Part B starts. 


If this applies to you, it is essential that you let the company know when asking them for any relevant information regarding their plans.


Before buying a policy, remember to shop around and compare rates; there may be variations among insurers offering similar policies. Additionally, check whether there are any open enrollment windows and consider seeking advice from a licensed insurance counselor to determine which plan best suits your needs if needed. Once all of this is accomplished, purchasing a Medigap policy should be straightforward - buy from the insurance company of your choice with confidence.

Medigap Guaranteed Issue Rights:

The guaranteed issue right allows people to purchase a Medigap policy outside the regular open enrollment period. This applies to those who are over age 65 and have lost certain types of health coverage. People who lose Medicaid due to a change in financial situation can also benefit from this right, although only for a brief time. The right is good for 63 days after the official date that coverage ends or notice is given that coverage will end - whichever is later.

Some states also have Guaranteed Issue or "Open Enrollment" rights for people already owning a Medigap plan. This can be based on your birthday or your anniversary date, so be sure to ask your insurance agent or broker if your state offers this.

It's important to be aware of your rights when it comes to enrolling in a Medicare supplement plan since these plans can provide invaluable financial protection and comprehensive coverage. Although not everyone will be eligible for guaranteed issue rights, those who qualify should take advantage of this opportunity, where they can buy into the insurance without medical underwriting or pay higher premiums due to pre-existing health issues. Understanding how this works can help make sure you don't miss out on any benefits you may have earned.


Standardized Plans:

Medigap Basic Benefits:

Medicare Supplement plans are designed to provide additional health insurance coverage for those who qualify for Medicare benefits. These plans are offered by private companies and provide coverage for expenses not covered by original Medicare, such as co-payments, coinsurance, and other out-of-pocket costs. The 10 Medicare supplement plans (plans A, B, C, D, F, G, K, L, M, and N) offer various levels of coverage and vary in price depending on the provider.

Plan A is a basic plan that pays your daily co-payments for hospitalization expenses from the 61st through the 90th day of the Medicare benefit period. It also pays the co-payment for outpatient pain medications as well as coinsurance for inpatient respite care. Additionally, it provides coverage up to an additional 365 days after original Medicare benefits end. Plans K and L provide this cost at a different rate than Plan A. Lastly; these plans provide coverage for skilled nursing facility care coinsurance so you can get more specialized long-term care beyond what is usually offered by traditional Medicare policies.

Medicare supplement insurance plans are a great option for those looking for an additional layer of coverage for their healthcare costs. These plans are standardized and labeled with a letter of the alphabet, from A through N. Each plan has a different combination of benefits that cover expenses such as copays and coinsurance. Plans K, L, M, and N have different cost-sharing components that help with expenses such as deductibles. Plans F and G offer the most coverage, with Plan F covering all Medicare-approved services, and Plan G covering all except the Part B deductible (which is $226 in 2023). While every company must offer Plan A, they also have to provide at least one out of either Plans C or F if they opt to carry additional plans.

Having these ten standard Medicare supplement insurance plans provides more choices and access when it comes to finding the right coverage for individuals' needs. Knowing this information allows them to take steps towards selecting the right combination of benefits that suits their lifestyle best. The various levels of coverage available make the process much more manageable compared to trying to find Healthcare costs on your own in case medical emergencies arise unexpectedly.


What you need to know about Medicare Assignment

Medicare has created a system of "assignment" that allows providers to determine whether or not they will accept Medicare-approved rates for certain services. Doctors or other health care providers who "accept assignment" charge only what Medicare has determined is the approved amount for a given service. Any deductibles, coinsurance, and co-payments for the service are the responsibility of the beneficiary.

On the other hand, doctors or healthcare professionals who don't accept assignment may charge more than what Medicare has approved as reimbursement. This is called EXCESS DOCTER FEES.

This means that patients must pay any extra costs out of pocket at the time of their appointment and then submit bills to Medicare with hopes of being reimbursed in full or in part later on. It is important to ask your doctor if they "accept assignment" before you schedule any procedures or appointments so that you can get an accurate estimate of how much payment will be due upfront.

Many Medicare Supplement Plans do NOT COVER excess doctor fees, and there is no annual limit on these fees, so be sure to ask your insurance agent prior to enrolling in a Medicare Supplement Plan if it covers them.

30-Day "free look" period

Medicare supplement insurance plans offer a 30-day "free look" period, during which you can return your policy and get your money back with no questions asked. In order to take advantage of this period, make sure to keep track of the date you received the policy and read it carefully. If you decide you'd like to return it, use certified mail with a return receipt so that you have proof of the date you sent it. It's important to note that this free look period does not apply to Medicare Advantage plans. Furthermore, even if during the 30-day period you switch from a Medicare supplement plan to a Medicare Advantage plan, there's no guarantee that you'll be able to reinstate your old Medicare supplement plan later on.

Doing research on Medicare options can help ensure that any prospective plan is the right fit for your lifestyle and needs. Even if it means taking advantage of the free look period when getting an original policy, in the long run, spending time researching different policies will pay off by helping you identify the one that best suits your individual needs.

Renewals

Renewing a Medicare supplement policy is relatively straightforward, as these policies are "guaranteed renewable." This means that insurance companies cannot cancel your policy or refuse to renew it unless you intentionally made false statements on your application or failed to pay the associated premium. However, companies are allowed to raise premiums – and many raise them twice a year. They'll raise them when you have a birthday, and again if they raise them for everyone.

However, they cannot raise premiums for you just because you have a health change, and they cannot change your plan benefits.

Medigap policies give individuals peace of mind, knowing that they have coverage that lasts and can be renewed with little hassle. Since the government standardizes the plans, customers don't need to worry about the individual plan changing; the only potential alterations will come from the insurance company via increased premiums.

Those shopping for a new Medicare supplement plan can do so without worrying about losing their coverage from policy renewal issues.

Temporary Voluntary Suspensions

Suspending a policy can be a beneficial option for individuals who have become eligible for Medicaid. If you are covered under Medicare Supplement benefits, you can request that your premiums and benefits be suspended for up to two years. You must submit your request to the company within 90 days of becoming eligible for Medicaid. Sometimes, when one loses their eligibility for Medicaid before the two-year period, the policy will automatically reinstate itself. However, if one returns eligibility after two years have passed, they will need to reapply with the insurance company in order to reinstate the policy.

In terms of claiming on a suspended policy, coverage may become available again when one regains Medicaid eligibility and reinstates the Medicare supplement plan. An experienced insurance agent would be able to assist you in understanding what claims or services may still be available during this period of suspension due to your specific case's details and regulations within your state or county. If applicable, it is important to consider contacting your respective fraud department in case any false claims or fraudulent activity has occurred while your policy was suspended to protect yourself from any potential risk.


Medicare Advantage Plans (MA)

An MA plan (also known as Medicare Part C) can be an excellent option for individuals who want to join a private health plan and receive coverage for their Medicare benefits. It combines the traditional programs of parts A and B with coverage of additional services such as drugs, vision, hearing, or even fitness activities. Some plans even provide food benefits or reimbursement towards your Part B premium amounts (paid directly to Social Security). To be eligible for this type of plan, you must have both parts A and B of Medicare and live in an area where there are plans available.

The federal government contracts with private insurance companies and managed care organizations such as HMOs to offer these health plans. The amount approved each month by the federal government will then cover the cost of these services given to members enrolled in Medicare Advantage plans. According to a study done by the Kaiser Foundation, the national average amount that the insurance company receives was almost $1000 per month in 2019. (https://www.kff.org/medicare/press-release/payments-to-medicare-advantage-plans-boosted-medicare-spending-by-7-billion-in-2019/)

The member will have to pay co-payments, deductibles, and coinsurance based on the policies set by their chosen Medicare Advantage provider.

MA Open Enrollment vs. Annual Enrollment

The Annual Enrollment Period (Annual Election Period or AEP) for Medicare Advantage and Medicare Drug plans is October 15th through December 7th of every year. This period does not apply to Medicare Supplement (Medigap) plans. During this AEP, you can change from one Medicare Advantage Plan to another, enroll in a Medicare Advantage Plan or Drug Plan, or drop your plan all together. 

Anyone with Medicare Parts A or B can enroll in a Drug plan during this period. 

Anyone with Medicare Parts A AND B can enroll in a Medicare Advantage Plan during this period. 

If you want to switch to a Medicare Supplement Plan during this time, the company still reviews your medical history. It can decline you unless you are in your Medigap open enrollment period or have a Guaranteed Issue period.

The Medicare Advantage Annual Enrollment Period (OEP) only applies to people who have a Medicare Advantage Plan. During the OEP, someone can drop their plan or change to another plan ONE time. The OEP is from January 1st to March 31st of every year.


Medicare Select

Select plans are technically a type of Medigap policy aimed at providing more customized healthcare coverage. This writer considers it a hybrid between Medicare Supplement and Medicare Advantage. 

The reason? It typically requires users to use doctors and hospitals in the plan's network for routine care. This means that non-network options like out-of-network hospitals incur a greater cost for the user, except in cases of emergency.

Moves out of the plan's service area are still possible. However, the user can purchase a different Medicare supplement policy with fewer benefits if it comes from the same company offering them their current Select coverage. As an added benefit, if you've had the policy for over six months, you will not need to answer medical questions when switching plans.


Buying a Plan:

Shopping around for health coverage can be daunting, but there are a few tips to keep in mind when selecting a plan and buying it.

First and foremost, the best time to buy a Medigap policy is during your one-time, six-month open enrollment period. This window starts when you enroll in Medicare Part B at age 65 or older, and companies must sell any plan they offer without considering your health history during this period. Prices can vary depending on the type of policy and other factors, such as where you live, so shopping around is vital to ensure you get the best deal. If an issue-age policy fits your needs, premiums will be based solely on your age when the policy was purchased. It is of utmost importance to take advantage of open enrollment periods and shop for the closest deal that meets your needs and budget.

If you want to get a Medicare Advantage Plan or a Medicare Drug Plan, you'll need to get those plans during the 7-month period that:

  • Starts three months before the month you turn 65
  • Includes the month you turn 65
  • Ends three months after the month you turn 65

If you have one, you can also get these plans during a Special Enrollment Period.


Medicare Insurance Agents and Brokers

Medicare Agent vs. Medicare Broker:

These terms are often used interchangeably.  A Medicare Broker is an insurance agent who works with multiple insurance companies.  However, a broker is also an agent.  But a Medicare Agent is not necessarily a broker.  It's a good idea to ask your representative if they are an agent or a broker, so you can be sure that they are working on your behalf and not on behalf of the insurance company they work for.

We know this is a lot of information. The good news is that Our experienced and certified Medicare Agents can help! We have licensed members in your state, so contact one of them today. 




Important Disclosure: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.





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