Medicare Supplements in Connecticut
Supplements, private medical insurance plans, pay providers the 20% MediCare did not pay !
● If you use Part A and Part B (called original Medicare) to see an MD or receive outpatient service, the Medicare claims contractor sends the Provider 80% of the amount Medicare approved for your specific treatment/service!
● Since so many medical treatments/services are outpatient today, you must pay 20%! When you buy a Supplement plan, you gain financial protection.
How?:
- > The company pays the MDs and other treatment or service providers the 20% for you.
- > You save time not contacting the Provider to pay what MediCare did not pay!
[Supplements are often called MediGap Plans.]
How the MediCare system works:
● All medical treatment and services are reviewed and "assigned" the amount * * which can be paid for each!
** Discounted, often deeply, from retail!
● MDs and other providers who signed up to participate with MediCare agreed to accept just 80% of the approved amount.
Note: Providers have thus agreed to accept "assignment."
When going for any Outpatient treatment or service:
● You show the MDs or other providers' offices your Medicare and Supplement plan ID cards. They usually scan each.
● The provider submits a special invoice for your treatment/service to a MediCare claims administrator
● When buying a Supplement there are words in the application form that provides the company approval to access the MediCare claim administrator's system to pay your expenses.
● Following any treatment, the Supplement company sends individuals an explanation of the amount the provider will be paid.
Note: Plans purchased by individuals 65 before Jan 2020, will also pay MediCare Part B's annual deductible. It's $240 for 2024.
When in a hospital:
When an MD admits an individual to a hospital in an "inpatient status," MediCare coverage is quite good! All medically necessary and approved treatment and services will be paid.
Note: — Individuals just using original MediCare would be responsible for paying Part A's deductible. It's $1,632 in 2024. FYI:
● It is not an annual deductible but is charged each time "admitted to a hospital.
● A Supplement company will pay the hospital the deductible for you.
Some additional background on working with Providers when you have a Medicare Supplement:
● When making an appointment with a new provider here in CT or any state, tell them you have MediCare. Providers do not have to know what Supplement company you have. Nor, since they accept MediCare, can they say they do not take Supplement plans from your company.
● MDs & Medical treatment providers send an invoice right after your visit. Do not pay the amount on provider invoices. Wait to see the actual amount you are responsible for, if any, on the statement from your Supplement company.
● One point on why many individuals select a Supplement — they can see, any provider here in CT or in another state who accepts MediCare.
● 9 out of 10 people with a Medicare Supplement say they are happy!
Buying a Supplement <—> Means
● Your income & savings are protected from having to pay the part of the treatment that Medicare did not! The company:
- > Works with MediCare's claim contractor, determines the part of the allowed amount that was not paid,d and then sends this amount to the provider for you!
Note: The amount you pay will vary based on the coverage in the Supplement you selected. For example, Plan F pays 100% of what Medicare does not, and Plan N has a small deductible and a $20 co-pay for each MD office visit.
Are there any limits on the kind of treatment YOU can receive when using a Medicare Supplement?
No!
MediCare determines what treatments are medically necessary and will pay for approved treatments. Supplement companies then work with the MediCare claim contractor and pay 20% of any treatment and services MediCare did not.
Bottom line: If MediCare pays for treatment/service, your supplement plan will pay.
The Supplement plan pays the provider based on your plan's coverage. For example, Plan G and Plan N do not pay Part B's deductible at the beginning of each year. So you pay—it's $240 in 2024.
Medicare Supplements are mainly state-regulated and have some federal-level requirements such as —
Plans must provide guaranteed coverage when an individual turns age 65.
Federal regulation:
● Authorized the National Association of Insurance Commissioners (NAIC) to develop and send to all states proposed regulations on how each Supplement plan will cover medical treatments/services.
● Tasked the NAIC to instruct each state legislative body to approve the NAIC's recommended Plans. This means coverage in a specific letter. Supplements in CT will generally be the same as those in that lettered plan in most states.
● The NAIC decided to give plans "lettered' names." Plan A has the least coverage, and B, C., etc., have more.
[Confusing since the parts of MediCare also have letter names. ]
● Over time, the NAIC has made plan coverage updates. For example, in 2010, the two plans with limited prescription coverage were dropped when the federal Prescription Drug Plan program started.
● In 2019, federal regulation restricted the availability of plans with full coverage of Part B's annual deductible to specific individuals.
Thus, individuals who turned 65 in January 2020 or after are called newly eligible can not buy a plan that pays Part B's deductible, such as Plan F.
Note: Individuals who were 65 before Jan. 2020 are not restricted.
● State legislatures generally incorporate NAIC coverage recommendations in their legislature regulations. They do, however, add the eligibility requirements established for their states.
Note: CT is one of a few states that does not use medical underwriting for individuals when 65 or for those older than 65.
The state regulations established for Supplements — are mainly for Eligibility and Marketing.
A look at how the Medicare Supplements available in Connecticut are regulated:
CT's state legislation and regulations have authorized the CT Insurance Dept. (CID) to ensure all Supplement companies offering Plans in CT:
● Comply with these state and CID requirements:
-> A person enrolling, male or female or 65 or 95, will be charged the exact monthly cost.
-> Any company-offered plan must be available to anyone in any CT County.
-> Questions about an applicant's health history can not be asked.
-> Any proposed monthly increases must be submitted to the CID. When approved, increases usually become effective January 1st.
Note: CID communications about Medicare Supplements often refer to them as MediGap plans.
In addition, all companies offering Supplements in CT must:
● Offer at least Plan A to any under age 65 individual who becomes eligible for MediCare after qualifying for Social Security disability and has been covered for 24 months.
● Permit individuals who sign up for a Medicare Supplement to:
-> receive their new coverage after applying on the 1st of the following month.
-> change (usually) to another plan with their company at any time or another company.
Note - Coverage in any specific lettered plan in CT from any company is the same - but:
-> The monthly cost a company charges for a plan can vary considerably from what another company charges for that same plan. For example, in October 2024, Plan N is available from $155 a month up to $449
One way to lower monthly cost is to share in the 20% the plan pays! Two — plans to think about:
● First — Plan N - One company's N is over $100 monthly less than their full coverage Plan F.
Why is N less? You share with the supplement company in paying the provider the 20%; MediCare did not pay for treatment by paying Plan N's:
-> Part B's annual deductible. [$240 for 2024]
-> a $20 co-pay for each MD office visit;
-> a $50 co-pay if any emergency room visits.
● Second — High Deductible (HD) Plans. HD Plan F & HD Plan G are only available from a few companies in CT. They are the lowest monthly cost Supplements.
-> Coverage is the same as Plan F or G, but you pay the first $2,800 (deductible for 2023) of any Part B medical treatment or services received each calendar year.
-> The company pays any additional Part B medical-related expenses above the deductible.
-> High deductible plans are a good option for someone using a high deductible plan when under 65.
● Note: High F is unavailable to newly eligible individuals [65 in Jan 2020 or later]. However, they can buy the new HD Plan G with the same deductible.
What about medications?
MediCare Part B nor a Supplement Plan DO NOT COVER the prescriptions you buy at your Local Pharmacy.
What can an individual do? Buy what is called a stand-alone Prescription Drug Plan (PDP)
-●- PDPs are Medicare’s Part D.
-●- PDPs are developed by and individuals purchase them from private companies. Availability is based on the state where a person lives.
-●- Buying means the plan will pay part of what is often costly outpatient medications today.
Who can sign up for a PDP? Individuals who:
-●- Have Medicare Part A or Part B
-●- Live in the service area for the plan they are interested in
-●- Are a US citizen or lawfully present
-●- Complete an enrollment request during a valid election period
When can a PDP be purchased?
-●- When turning 65, individuals have a time * called their Initial Enrollment Period for Part D. (Part D IEP } to buy a plan.
[ * It’s a seven-month period that individuals have to sign up for a Part D plan.]
How to Buy a Plan! — The CMS rules for PDP tell us individuals can:
-●- Review and select a plan with the coverage that fits their medications when first eligible during their IEP
-●- Not sign up whenever they want after the IEP.
-●- Sign up or change plans once a year during the Oct 15 to Dec 7 Annual Coordinated Election Period (AEP).
-●- Make a change if they have a life change event, such as moving to a different area. Moving qualifies an individual for a Special Election Period (SEP).
What happens when going to a local Pharmacy?
-●- Individuals are charged a co-pay or cost-sharing percentage based on the tier level in which the PDP company placed the medication. Some plans have an annual deductible to pay first. Often, the deductible is only on particular higher Tiers.
A couple of points on the comment I often hear - I don’t take medications!
First - what do MediCare's “rules” say:
-●- Medicare’s Part D is a voluntary program!
-●- However, if an individual does not have “credible” prescription coverage, such as from an employer, a monthly late enrollment penalty (LEP) is added when they do buy a plan. It is applied each month an individual did not have coverage after their IEP!
-●- How much is the LEP: The penalty is 1% of what is called the Part D program base beneficiary premium. It’s $34.70 in 2024. So, Part D’s LEP will be 34 cents a month in 2024.
Another point on- why you need a PDP:
-●- A National Poll on Healthy Aging study found that 77% of older adults with health insurance used two or more prescription medications.
-●- The study, based on data from 960 people aged 65-80, revealed that 51% of those who take two or more prescription medicines also take between two and four non-prescription medications, including supplements. 15% took five or more.
Some background on recent legislative changes to the Medicare Part D program: The Prescription Drug Program initially had a Standard Plan with four parts that regulations called stages - Deductible - Initial Cover Level - Coverage Gap - Castropthic. Each stage had specific benefit amounts indexed to change annually, e.g., the maximum annual deductible a PDP Sponsor can use. It will be $590 in 2025,
Recent legislation implemented improvements in what beneficiaries themselves will have to pay for covered medications:
+ Insulin is limited to a $35 co-pay in 2023 and after.
+ In 2024, beneficiaries will have no additional cost if their costs reach the Catastrophic stage.
+ In 2025, the individual maximum out-of-pocket for covered medication will be $2,000
MediCare's Marketing Requirements
The Center for Medicare and Medicaid Services (CMS) regulations require John, when providing information about Prescription Drug Plans, to disclose (inform) to Medicare beneficiaries that:
● He is appointed and certified by six of the eight Prescription Drug Plan (PDP) companies with plans available in New London County and CT in 2025.
● They can also find help with plan choices in New London County by contacting:
+ Medicare.gov and
+ CT's State Health Insurance Program (SHIP).
< - - > However, this help will not be from a licensed or certified professional.
The new rules say an in-person discussion of plan coverage details or enrolling in a Prescription Drug Plan does not have to be recorded.
Note: CMS regulations also state that information describing prescription drug plans, such as the content on this website that does not mention a company name, plan benefit details, or is not marketing material, is considered communication material. Thus, this content does not have to be approved by CMS.
