● If you went to an MD or other outpatient service just using Part A & Part B (original Medicare), the MediCare system would just send the Provider 80% of the amount MediCare approved for your treatment/service!
● This means - - you have to pay 20%! Today so many medical treatments/services are now provided outpatient so when you buy a Supplement plan you gain financial protection. How?:
- > The company pays MDs and other treatment or service providers the 20% you owe.
- > You save time not contacting the Provider to pay what MediCare did not pay!
[Supplements are often called MediGap Plans.]
How payments work:
● The MediCare system reviews all medical treatment and services and "assigns" the amount * * which can be paid for each!
** Discounted, often deeply, from retail!
● MDs and other providers who participate with MediCare agreed, when they signed up, to accept just 80% of the approved amount.
Note: This requirement for providers is called 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 their charges for your treatment/service to a MediCare claims administrator
● Your Supplement company accesses the MediCare claim administrator's system to pay your expenses based on the approval you provided in your plan's application.
● The Supplement company sends individuals an explanation of their payments following any treatment. It will show the amount, if any, the provider will be paid.
Note: When just using Original MediCare for treatment, many plans also pay MediCare Part B's annual deductible for you. It's $226 for 2023.
When "admitted to a hospital:
When in an "inpatient status" in a hospital. MediCare coverage is quite good! All medically necessary and approved treatment & services will be paid.
Note: — You would be responsible to pay Part A's deductible if just using original MediCare. It's $1,600 in 2023. FYI:
● It is not an annual deductible but is charged each time "admitted to a hospital.
● Your Supplement company pays the hospital the deductible for you.
Some additional background on Medicare Supplements:
● 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.
● One point - vital to many - You can see any provider here in CT or in another state who accepts MediCare when needed.
● 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 plans from your Supplement company.
● 9 out of 10 people with a Medicare Supplement say they are happy!
● Buying protects your income & savings from paying the part of the treatment you received 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 coverage in the Supplement you selected. For example, Plan F pays 100% of what Medicare does not, and Plan N has a small deductible, then a $20 co-pay for each MD office visit.
No! MediCare pays for any treatment they determine to be medically necessary. Supplements then work with the MediCare claim contractor and pay the 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 & Plan N do not pay Part B's deductible at the beginning of each year. So you pay - It's $226 in 2023.
A look at the Federal regulation of Medicare Supplements:
● They authorized the National Association of Insurance Commissioners (NAIC) to develop and send to all states how each Supplement plan will cover medical treatments/services.
● They instruct each state legislative body to approve the NAIC's recommended coverage. This means coverage in a specific letter Supplement in CT will generally be the same as that lettered plan in most states.
A look at the NAIC role with Medicare Supplements:
● The NAIC gave 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 coverage updates such as 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, to specific individuals, of plans with full coverage of Part B's annual deductible.
-> Thus, individuals who turned 65 in January 2020 or after, called newly eligible, can not buy a plan, which 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 specific eligibility requirements established for their states.
Note: CT is one of a few states that does not use medical underwriting when older than 65.
A look at Connecticut's role in Medicare Supplements:
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, 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: CID communications about Medicare Supplements on Medicare.gov and from federal agencies 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.
-> be able to 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 January 2023, Plan N is available from $160 a month up to $400
● 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. [$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. They are the lowest monthly cost Supplements.
-> Coverage is the same as Plan F or G, but you pay the first $2,700 (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 to do? Individuals can buy a Prescription Drug Plan (PDP)
-●- Buying means the plan will pay part of the often costly outpatient medications. —
-●- PDPs are Medicare’s Part D developed by and purchased from a private company. Availability is based on the State a person lives in.
Note: There are nine PDP companies available in CT in 2023 offering 24 plan options! And in New London County, the area I help individuals in!
When can you purchase a PDP?
-●- When turning 65, individuals have what is called the PDP Initial Eligibility Period (IEP) to buy a plan.
[It’s the same seven-month time individuals have to sign up for MediCare’s Part A & B.]
How to Buy a Plan! — The PDP sign-up rules tell us individuals:
-●- can review and select a plan with the coverage that fits their medications during their IEP
-●- cannot sign up whenever they want after the IEP.
-●- can sign up or change plans once a year during the Oct 15 to Dec 7 Annual Election Period (AEP).
-●- can 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?
-●- A co-pay or cost-sharing percentage 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 of points on the comment I often hear - 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 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 for each month an individual did not have coverage after their IEP!
-●- How much is the LEP: The penalty is 1% of the average monthly cost for Medicare’s Part D plans which is $32.74 in 2023. So, Part D’s LEP in 2023 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 aged 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 CMS marketing regulations for Prescription Drug plans state a website page, like this one, that does not mention company names, benefit details, or costs is considered Medicare Communications.
The regulations also have requirements to disclose (inform) to Medicare beneficiaries that:
● John is appointed and certified by six of nine Prescription Drug Plan companies with plans available in New London County. The other three do not offer their plans through MediCare insurance professionals. However, by using Medicare.gov. John can share insights with clients about the 24 plans available from all nine companies!
● Help with plan choices in New London County is also available by contacting:
+ Medicare.gov and
+ CT's State Health Insurance Program (SHIP).
< - - > However, they are not licensed or certified professionals.
Meet & Talk to:
● Understand your situation!
● Review Supplement plans and select the plan, which meet your situation.
Medicare regulations require phone calls to discuss enrolling in a PDP to be recorded. However, meeting, when an enrollment period is available, to talk and review plans is more effective.