● If you only have original Medicare when going to a MD or other outpatient treatment the provider would just be paid 80% of the allowed amount for their services! Thus, you pay 20%.
● You can avoid these expenses, which can be big, by buying a Supplement. Buying means your plan pays MDs and other treatment or service providers the part of the approved amount MediCare di not paid!
How they work:
● The MediCare system reviews all medical treatment and services and "assigns" an amount * * which can be paid for each!
** Discounted, often deeply, from retail!
● MDs and other providers who sign up to participate with MediCare agree to accept just 80% of the approved amount.
Note: This requirement is called accept "assignment".
● Receive any Outpatient treatment or service — MediCare sends a quarterly statement which will show the 20% you have to pay the provider.
Note:Original MediCare has an annual deductible on all Part B services. It's $226 during 2023.
● Are "admitted" to a hospital — MediCare coverage when an inpatient is quite good! The approved amount for all medically necessary treatment & services is paid — you just pay Part A's deductible. It's $1,600 in 2023 and paid each time you are admitted.
Bottom line — if you have to pay 20% of the many outpatient treatments you might receive in a complex situation it could quickly be a Big Risk to income & savings!
● Buying protects your income & savings from having to pay what MediCare did not!
● Your Supplement company:
- > Works with MediCare's system and pays providers for you the 20% MediCare did not pay.
Note: The amount you pay varies based on coverage in the Supplement you select. For example, in Plan N you pay a $20 co-pay for each MD office visit.
- > Pays Part A's deductible each time "admitted to a hospital.
● Be able, when needed, to see any provider here in CT or in another state who accepts MediCare. The is important to many.
● No longer pay 20% of a lot of treatment bills coming in the mail following unexpected medical situations!
● Have a company to pay providers for you thus protecting your income & savings!.
[Supplements are often called MediGap Plans.]
Note: 9 out of 10 people with a Medicare Supplement say they are happy!
● When you go to a MD's office or other provider you show them your Supplement plan ID card and Medicare ID card. They usually scan them.
● The provider submits their charges for your treatment/service to a MediCare claims administrator.
● Your Supplement company can access your expenses in the Medicare claim administrator's system based on the approval provided in your plan's application.
● The Supplement company sends an explanation of their payments, which shows the amount, if any, to pay a provider.
# 1 -Medical treatment providers often 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.
# 2 - When making an appointment with a new provider, whether 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 plans from your Supplement company.
No! Supplements were developed to pay the 20% of the amount allowed for any treatment and service MediCare determined to be medically necessary.
Bottom line: Thus, if MediCare pays your supplement plan will pay.
The Supplement plan pays the provider, based on your plans coverage. For example, in Plan G & Plan N they do not pay Part B's deductible at the beginning of each year. It's $226 in 2023.
● Federal regulations authorized the National Association of Insurance Commissioners (NAIC) to develop the coverage in each Supplement plan.
● When initially developed plans were given "lettered' names". Plan A has the least coverage, B, C. etc. have more.
[Confusing since the parts of MediCare also have letter names. ]
● Over time the NAIC has made coverage updates. In 2010 several coverage changes were made.
● Federal regulations instruct each state legislative body to approve the plan coverage the NAIC recommends. This means coverage in a specific letter Supplements in CT will generally be the same as that lettered plan in most states.
● State legislature's generally incorporate NAIC coverage recommendation in their legislature regulations. They do however add their specific eligibility requirements.
Note: CT is one of a few states that does not use medically underwriting at 65 or older.
● In 2019 federal regulation restricted the availability, to certain individuals, of any plan with full coverage of Part B's annual deductible:
-> Individuals who turned 65 in January 2020 or after, are called newly eligible and can not buy a plan, which pays Part B's deductible, such as Plan F.
Note: Individuals who were 65, prior to Jan. 2020, are not restricted.
Here in Connecticut state legislation and regulations authorized the CT Insurance Dept. (CID) to ensure all Supplement companies:
● Offering Supplements follow the following state and CID requirements:
-> a person enrolling, whether male or female who is 65 or 95, will be charged the same monthly cost.
-> any offered plan is available to individuals living in any CT County.
-> questions about a person's health history can not be asked.
-> proposed monthly increases are submitted to the CID. When approved, increases become effective. Often January 1st.
Note: Communications about Medicare Supplements from CID, on Medicare.gov, and from federal agencies often refers to them as MediGap plans.
● Must offer at least Plan A to under age 65 individuals who qualified for Social Security disability after 24 months and become eligible for MediCare.
● Permit individuals who sign up for a Medicare Supplement to:
-> receive their new coverage the 1st of the next month after applying.
-> be able to change (normally) to another plan with their company at any time or to 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 .
● First — Plan N - One companies N is over $100 a month 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. [$226 for 2023]
-> 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. How are they are the lowest monthly cost Supplements?
-> Coverage is the same as Plan F or G but you pay the first $2,490 (deductible for 2022) of any Part B medical treatment or services received each calendar year.
-> Any additional Part B medical related expenses are paid by he company.
-> High deductible plans are a good option for someone who was using a high deductible plan when under 65.
● Note: High F is not available to newly eligible individuals [65 in Jan 2020 or later] However, they can buy the new HD Plan G with the same deductible.
What to do? Individuals can:
-●- Get part of the cost of outpatient medications paid by — Buying what MediCare calls a Prescription Drug Plan (PDP). They are Medicare's Part D.
PDPs are developed by and purchased from a private company. Availability is based on the County a person lives in.
Note: There are 9 PDP companies and 24 plan options available in New London County in 2023 !.
When can you purchase a PDP?
-●- When turning 65 individuals have what is called the PDP Initial Eligibility Period (IEP). It's the same 7 month time as signing up for MediCare.
How to sign up! — The PDP sign up rules indicate individuals:
-●- can select the plan with the best coverage for their medications during their IEP
-●- cannot sign up whenever they want if did not sign up in the IEP.
-●- can sign up once a year during the Oct 15 to Dec 7 Annual Election Period (AEP).
-●- the only other time a change can be made is if they have a life change event such as after moving and thus qualify for a Special Election Period.
What happens at a local Pharmacy?
-●- A co-pay or cost sharing percent is charged based on the Tier level the PDP company placed the medication in. Some plans have an annual deductible to pay first. Often the deductible is only on certain Tiers.
A couple points on - I don't take any medications!
First - a look at what the "rules" say:
-●- The regulations establishing Medicare’s Part D set it up as a voluntary program!
-●- However, if you do not have "credible" prescription coverage, such as from an employer a monthly late enrollment penalty (LEP) is added for each month an individual did not have coverage when they do sign up.
-●- How much is the LEP: The penalty is 1% of the average monthly cost for Medicare's Part D plans which is $33.37 in 2022. So Part D's LEP in 2022 is 33 cents each month.
Second - a look at why you need a PDP:
-●- A study from the National Poll on Healthy Aging found 77% of older adults with health insurance were using two or more prescription medications.
-●- The study, based on data from 960 people age 65-80 found 62% had Medicare Part D, revealed of those who take two or more prescription medicines, 51% also take between two and four non-prescription medications including supplements, and 15% took five or more.
The focus will be to
● Understand your situation!
● Review Supplement plans, answer questions, and select the best plan for you.
Medicare regulations require calls to discuss PDP benefits to be recorded. However, we can meet to talk and review plans which is more efffective when an enrollment period is available.