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FAQ's & Facts
Welcome to my comprehensive guide, where I address the most frequently asked questions and share essential facts about the health insurance and Medicare industry. As a dedicated health insurance agent that focuses on Medicare, I understand the complexities and nuances that those over the age of 65 face when navigating this vital system. Here, we’ll explore key topics such as the growing statistics of Medicare Advantage plans, the critical aspects of the Medicare coverage gap, and practical tips for those enrolling in Medicare. My goal is to provide clear, accurate information to empower you in making informed decision about your healthcare. Whether you’re approaching your 65th birthday, already enrolled in Medicare, or assisting a loved one, this guide is designed to shed light on the often intricate world of Medicare and health insurance.
CA LICENSE #4191872
TX LICENSE #2852834
OK LICENSE #3001985352
FACTS
Medicare Alone May Not Cover All Of Your Costs
The 20% Gap in Medicare Coverage, often referred to as the “MEDICARE GAP” or “COINSURANCE,” is a significant aspect of Original Medicare (Part A and Part B) that affects how much the beneficiary has to pay out-of-pocket for healthcare services.
1. Medicare Part B Coverage – Under Medicare Part B, which covers doctor visits and outpatient services, Medicare pays for 80% of the APPROVED amount for these services. The remaining 20% is the responsibility of the beneficiary. This 20% is what’s known as the Medicare gap or coinsurance.
2. No Out-Of-Pocket Maximum – One key point to note is that Original Medicare does not have an out-of-pocket maximum. This means that if you have a year with particularly high medical expenses, you continue to pay the 20% coinsurance, NO MATTER HOW HIGH THE BILLS GET!
3. Impact On Beneficiaries – For many beneficiaries, this gap can lead to significant out-of-pocket expenses, especially for those who require frequent medical care or expensive treatments.
4. Supplemental Coverage Options – To help cover this gap, many people opt for additional insurance like Medicare Supplemental Insurance (Medigap) policies or Medicare Advantage Plans (Part C). These plans can help cover the costs that Original Medicare does not, including the 20%coinsurance.
5. Medicare Part A – It’s also important to note that while Medicare Part A, which covers inpatient hospitalization has a $1,632* per incident deductible, after 60 days you switch to a per day copay for days 61-90.
Understanding this 20% gap is crucial for Medicare beneficiaries to plan their healthcare finances and consider whether additional insurance coverage is necessary for their situation.
Major Health Insurance Carriers Offer A Variety Of Incentives To Insurance Agents For Selling Specific Plans
These incentives are part of the compensation structure for agents and are typically aimed at encouraging the sale of certain plans or retaining existing business. As you can clearly see by the wide dollar range of bonus structures in the example here, they reflect the competitive nature of the health insurance industry but also provide a cautionary view of what may lie ahead when choosing an insurance carrier.
- Medicare Client Commissions – Range between $100 and $600
- Specialty Broker Bonus – Up to $25,000 per plan
- Small Business Incentive – Up to $12,000 per plan
FAQ's
WHAT, WHEN, WHY?
Why do I need more than Original Medicare?
Medicare covers 80% of all approved Medicare charges leaving a 20% coverage gap. Plus, providers may bill 15% over the Medicare approved amounts.
When do I enroll?
The best time to enroll is to contact a licensed agent 3 months prior to you 65th birthday. There are many different variables and each person is different. Please speak with a licensed agent who knows Medicare to see if you need to enroll.
What are the enrollment periods?
Initial Enrollment Period: 3 months before your 65th birthday until 3 months after. This is when you will get the best rates and GUARANTEED ISSUE – pre-existing conditions cannot be reason to deny.
Special Enrollment Period: I am losing creditable coverage (group health insurance, retiring, moving, etc). You will have a limited time period to enroll. Usually 60 days.
General Enrollment Period: January 1 – March 31 – I did not enroll at my 65th birthday. Now what? You will activate your Part A/B and submit an application to cover the Medicare coverage gap. Coverage will be effective the following month, or the month Part B begins.
Open Enrollment Period: January 1 – March 31: If you are on a Medicare Advantage (MA) Plans and wish to change, you may do so during this time. The only changes/additions during this time are Medicare Advantage Plans.
Annual Enrollment Period: October 15 – December 7 – This is where you may add a Supplemental Medicare policy, change prescription drug plans, and change Medicare Advantage plans. Policies are effective January 1.
What is “Guarantee Issue” or “Guarantee Acceptance”?
There are limited time periods in which you will have guarantee issue. You can easily move from a Supplemental policy to an Advantage policy at AEP but moving from an Advantage policy (when you have gone this route due to the low monthly premium but are utilizing the health plan more due to health conditions) to a Supplemental can be difficult as you will generally need to go through health underwriting.
COSTS
Do I need to be aware of penalties/late enrollment fees?
YES! Penalties for not signing up for Part A/B or D when you become eligible (if you cannot show creditable coverage) can be stiff and last your lifetime. Part B is 10% of the monthly premium for each year you did not enroll, for life. Part D is 1% of the national monthly average premium, PER MONTH that you did not enroll, for life added to your Part D monthly premium.
How much will it cost me to have Medicare?
Part A typically has no premium, if you’ve worked 40 quarters throughout your life. $1,632* deductible for 2024 (per incident*). Part B for 2024 is $174.80/per month. $240 deductible for 2024 (one time per year). Part B and Part D premiums are based on IRMAA (Income Related Monthly Annual Adjustment). However, this is only 80% coverage with no out of pocket maximum and an additional 15% potentially.
I have a Medicare Supplement Plan F of G* and I am receiving bills, what do I do?
Please contact the provider for the services and ask them if they have your Plan F/G* card. Are they aware that Plan F & G* covers “excess charges”? Will they please remove the charges or re-bill under an approved Medicare code? If not, contact your insurance carrier and ask them for assistance. If this does not work, then contact Medicare and file a grievance. Plan G covers everything except for the one time per year deductible of $240 for 2024. You can google “Medicare Plan Chart” and find this information for your records or contact me and I will provide the chart to you.
PRESCRIPTIONS
Do I really need a review of my prescriptions annually? Following is a recent conversation with a loved one after I received my license.
Me: What prescription drug plan are you on?
Loved one: Oh, I have the best. I have X and pay x/mo.
Me: Would you let me a do review? (If I’ve collected medications.)
Me (con’td): If I had done a review for you for 2022, I would have saved you $600 this year on medications and reduced your monthly premium by $75.
Loved one: I’ll call you Oct 15.
What are my risks if I do not have my prescriptions reviewed?
Premiums fluctuate each year and so do formularies. One client had no prescription drug changes and wanted to stay on her current plan which was $7/mo and decreasing to $4.50/mo. Her out-of-pocket for the medication would have gone from $500 in 2022 to $2,000 in 2023 if she stayed on the same plan. Most agents do not conduct a yearly review of medications because the commissions are not worth the time. This is a service I provide to my clients.
How can I save on prescription drugs?
Medications are skyrocketing! There are 3 websites/companies that I recommend that are FREE to you and can potentially save YOU hundreds of dollars.
GlicRX – This company does not sell your information. You can use an app or get a card. If you are interested, please contact me and I will enroll you and get you the necessary information WITHOUT pressuring you for any other information. This is for ANYONE. Not just Medicare beneficiaries. FREE for you and I receive $1.50 for every prescription someone fills.
Costplusdrugs.com – pharmacy by Mark Cuban. Mail order. You can potentially save hundreds. Some medications are a fraction of using insurance. It’s worth checking.
Goodrx – download a coupon from your computer or download the app on your phone. They do sell your information so you could potentially get spam calls; however you could save hundreds. Example: recently a client needed an inhaler. $430 using insurance. $90 using Goodrx at their pharmacy of choice.