1-800-MEDIGAP jeff.cline@me.com

Medicare and Turning 65

Medicare Open enrollment generally starts October 15th through December 7th and your plan will start January 1, 2018.

During open enrollment Medicare eligible individuals can review the new plan coverage’s and pricing for 2018. During the enrollment period you have the option to drop a Medicare Advantage plan and enroll into a Stand Alone Medicare Prescription Plan or Part D, change from one Medicare Advantage Plan to another. At this time you might want to review your options of purchasing a Medicare Supplement Plan.

Medicare Supplement or Medigap plan are sold by an insurance company using a standard benefit schedule that is approved by CMS. All Medicare supplement Plans must have the same benefits schedules, but do not have to offer every plan that CMS has approved. Medicare Supplement Plans are not allowed to have a prescription drug plan attached. Years ago Medicare PART D was sold with Medicare Supplement plans, but this has since change.

Purchasing a Medicare Supplement or Medigap plan in most states required the insured to answer health questions and some insurance companies have the right to decline coverage based off the information that is given, but there are a few companies that offer a guaranteed issue Medicare Supplement, this means that you do not have to answer health questions.

Purchasing a Medicare Supplement and have a preexisting condition does not mean you cannot purchase a plan , it just depends on what condition you are being treated for and what your current health situation might be, such as, are you diabetic and take high blood pressure medication? Are you in the middle of physical therapy? It really depends each company has a different stance on certain conditions. If you are worried about Medicare excluding you for a medical condition they do not. Depending on certain medical conditions or financial positions, you might be eligible for Medicare and Medicaid.

Medicare Supplement companies offer discounts for having a spouse that has the same insurance company or another type of policy in the same household. Medicare Supplement plans might offer discounts on vision services, gym discounts, hearing tests and possibly dental. The insurance companies can add benefits to the standardized plan, but must us the base policy designed that CMS has approved.

Many people seem to think they can only change Medicare Supplement plans during the Open Enrollment which is not true ion most states. Medicare Supplement plans can be changed at any time, but it is not advised to change to often do to a possible health condition change or premium cycles that could have a negative effect on you purchase.

Supplemental plans are sold by insurance companies that indemnify you or assigned to your medical provider. The plans are designed to pay if Medicare pays, if Medicare does not pay the plans generally do not pay. Some plans offer a more robust preventative service or add ons that others don’t, so it’s a go thing to shop. Most insurers are prices within a $10 to 30$ of each other, so it is best to look to see what’s available.

Working with an Independent Broker will offer the best insight if your broker is honest. The broker can spreadsheet your options to show multiple pricing and compare benefits. Many career type agents are generally not authorized to do so, but some may to give their customers the best possible option.

If you are leaving your employer and are past your Medicare initial enrollment age of 65 and have not yet enrolled into Medicare Part B, you will have a Special Enrollment or a SEP, meaning that you have had credible coverage offered through your employer.

A Special Election will allow you to purchase a plan outside of the normal enrollments period, Open Enrollment or your Initial Election Period. You will want to find other coverage before the 60 day period you are allowed to find other coverage without having to qualify medically or being declined because you are out of the enrollment period.

If you are under 65 and have certain disabilities or on SSI for 24 you will automatically be eligible for Medicare. In Most states you can purchase a Medicare Supplement policy with in your Initial Election Period or in some states you have a guaranty issue each year. Generally once you take a Medicare Supplement you will have to stay on that plan until your next election period three months prior to your 65th birthday the month of your birthday and 3 months after your 65th birthday.

If you under age 65 and on Medicare Disability you can change your Part D coverage and or your Medicare Advantage plan during the Annual Election Period each year. Enrolling into a Medicare Advantage plan does not require underwriting so you will be able to purchase any plan in your plan service area. A plan service area is generally based of the zip code you live in and if for some reason you move from the plan service area you will have a SEP, Special Election to purchase a plan in that service area you have moved to.

Medicare Supplement Insurance purchased as an Attained Age Policy vs. Issued Age Policy  

Purchasing a Medicare Supplement policy that a rating structure known as Attained age will go up in premium dollars as you get older. An Issued Policy that has be sold will have a higher premium initially but will not increase due to growing older. For instance if you are 65 and purchase a Medicare Supplement policy that is rated as a Issued Age policy, you will be paying the same amount as a person enrolling ten years later at the same age, minus any inflationary increases. Insurance companies are allow to increase the policy only based off inflationary increases, not by age.

The Issue Age policy will cost more but in the future you will be much relived knowing that your premium will be somewhat stable in comparison to a person that purchased a Medicare Supplement Attained age, but most policies are sold as Attained age.


What company offers the best Medicare Supplement Policies and Rates?

There are many Medicare Supplement companies that offer Supplement policies, but there are great differences between some of the insurance companies. Some insurance companies will offer only a few of the approved plans for sale or it might differ between states and what they offer. You can generally find a company that offers Medicare Supplement Plans F, G High Deductible Plan F and Plan A.

The High Deductible Plan F works very similar to the Plan F, but has an annual deductible of $2200 per calendar year, once you’re out of pocket has been meet the policy will then pay 100% for the remainder of the year. This plan will fit the needs for a person looking for a lower premium, but having the guaranty that the most they will have to pay in claims is $2200. You don’t have to meet the deductible before anything is paid, Medicare will pay once your meet the certain deductible that Medicare charges, such as Medicare Part a $1316 for 2017 and Part B is $183 annually. Medicare will then pay 80%, once your $2200 has been meet by paying 20% for your responsibility your coverage will then be at 100%.

The Medicare Supplement Plan F is the most comprehensive plan sold, but also the most expensive due to the fact it pays 100% right out of the gate. The plan has no deductible and your only responsibility is paying the premium each month. According to the Federal Government the Plan F will be removed for sale in 2020, ruling HR22. This means that a plan offering first dollar of coverage will be removed for sale by insurance companies. The ruling is put in place to lessen the amount of unneeded visits to the doctor’s office and plan some of the responsibility on the insured.

The Medicare Supplement Plan G has gain popularity by rate and by the coverage it offers. The Plan G pay similar to the Plan F with only one exception, it does not pay the Medicare Part B deductible of $183.

All Medicare Supplements are designed to pay if Medicare pays, so if Medicare pays the plan pays, but if Medicare does not pay, generally the plan will not pay.

Most Medicare Supplement companies offer discounts, some type of vision discounts and possibly gym discounts. Companies are allowed to offer other incentives in their plans, but they must at least follow the standardized schedules of coverage for the plan purchased.

As a Medicare Eligible individual you have many options available to you for coverage options and many under 65 insured’s do not. Most people after enrolling on to a Medicare plan or Medicare Supplement will have to pay huge deductible or premiums. At this time a person can budget about $250 a month, this covers your Medicare Part B premium of $134 for 2017, the Plan premium and your Medicare Part D premium. Most folks that are on a group employer policy or an individual policy will traditionally pay much more unless your employer pays all premium or a good portion of it.


Where can I purchase a Medicare Supplement? 

Medicare Supplement companies can be found by simply search the internet for a companies that offer this type of insurance or you might receive a piece of mail with a number to call ,a sales person may even stop by your home. There are many agents out here that just want to push a policy based on rate, buying on rate is not always the best practice due to the fact that many insurance companies offer the get you in the door type pricing and then over the course of the next few years your good idea became a bad idea, because your premiums will spiral out of control and if you develop any type of health condition you might have to stay with that plan or move on to a Medicare Advantage plan during the next Annual Election Period. Changing plans is not always good unless you can pass underwriting and currently do not have a medical condition that would exclude you from coverage. If you are on a group or individual policy you might talk to your current insurance carrier to see what type of rate and policy can be offered.


If I am still working after age 65 can my employer pay my Medicare premium?

Employer are allowed to pay or reimburse a employees Medicare premiums on the group health plan pays secondary to the employer sponsored plan and has fewer than 20 full time employees and as long as it follows the rules of the ACA design requirements. Al thing must be taken into consideration if an employee is encourages to waive the group coverage, this can raise legal issues and discrimination rights.


Can I qualifying for Medicare Part A without 40 quarters of work history under my spouse?

If you did not work 40 quarters in your life time and pay into Social Security you may be eligible under your spouse’s work history if you have been married for at least a year prior to applying for Medicare and your spouse in eligible for Social Security or you are divorced but married to an eligible individual for 10 years or more and if you are widowed and married for none months and not be remarried. It is always best practice to call your local Social Security office and see if you can be eligible without having the work experience, 40 quarters. If you have a same sex spouse you can now possible become eligible of the same sex spouses work history, this ruling was recently added to Medicare.


What does Medicare Part A costs?

If you have working 40 quarters in your life time Medicare Part A costs nothing, but if you only have worked for 735 to 10 years in the United States your premium for Medicare Part A for 2017 will cost $227 monthly, if fewer than 735 year you will need to pay $413 monthly


Once on Medicare, your inpatient Medicare Part A charges will be $1316 for each stay with a gap of 60 days or more. If you are hospitalized for over 60 days your charge will be $3269 a day up to 90 days and then 658 per day using 60 reserve lifetime days. This is where the Medicare Supplement plan come in and help pay all or most of your Medicare Part A charges.

If you have Medicare Part A and admitted to a skilled nursing facility your Medicare will pay the first twenty days and them a charge of $164.50 a day up to day 100 after the 100th day you will be private pay or if you have a Long Term Care policy it might pay. Remember if Medicare pays the plan pays, but if Medicare does not pay the plan does not pay. Under Medicare Part A there is no charges for Home Health Care, but Home Health Care may be somewhat limited. It generally will coverage a check in and possibly some therapy if needed, but it will not pay to have a care giver cook, clean or bath, this would have to be sought out by a private company that offers Home Health Care.

Hospice Care is covered under Medicare Part A with a very minimal copay for outpatient drugs and respite care

Does Medicare pay for vaccinations?

Under Medicare Part B certain vaccinations are available if ordered by your doctor. The Flu vaccine, pneumonia and Hepatitis B vaccination are paid through your Medicare. It you have other vaccinations that your doctor has ordered other the above your Medicare Part D plan should pick up the charges, but you will need to cheek to see if your pharmacy is in network to provide the vaccinations. It is always best practice to check with your pharmacy to make sure they can bill the insurance company and your pharmacy is in network or you might have to pay the full charge.


What is the Late Enrollment Penalty under Medicare?

A Late Enrollment penalty is accessed by Medicare fi you miss your Initial Election Period and do not sign up for Medicare when you are first eligible. There are two different late enrollment penalties, one for Medicare Part B and one for Medicare Part D.

The Medicare Part B penalty can be very costly if you wait too long. The penalty is 10% annual for each 12 month period you miss unless you have credible coverage through your employer or your spouse’s employer. The penalty will stay with you as long as you have Medicare, so it is best to get it when either you leave your employer coverage or if your spouse leaves employer coverage. You do not have to take Medicare Part B until you are ready if you have credible coverage, but if you don’t you will have to apply when you are first eligible.

Your Part B basic premium for 2017 is $134, but if your income is over a certain limit, such if you are married and file jointly making over $170,000 you will have to a much higher Part B premium of $187.50. Your penalty if accessed will be based only on the base Part B premium of $134.

What is the Medicare Part B premium for 2017?
Medicare Part B premiums for 2017 are $134 for the base premium, but certain incomes will be charges more.

Individual Filing                                 Joint Filing                        Married and Separated                        You pay

85000 or less 170000 or less 85000 or less 134
85000 up to 107000 170000 and up to 214000 NA 187.50
107000 up to 160000 214000 up to 320000 NA 267.90
160000 up to 214000 Over 320000 up to 428000 Above 85000 and up to 129000 348.30
Over 214000 Above 428000 Above 129000 428.60

How can I appeal a Part D late enrollment penalty?

As mentioned above, by not applying or having credible coverage when you are first eligible you will receive a LEP or a Late Enrollment Penalty based of the number of months you are with our credible drug coverage. Credit Drug coverage can be through an employer plan or an individual plan as long as it is as good as or better than the original model of coverage set up by Medicare. The Part D late enrollment penalty is 1% of the national average or up to 12% per year if you don’t not have coverage for instance


If you did not purchase a plan when you were first eligible and were without coverage for 89 months your penalty will be 8% of the nation average. An example $25 (national average) x .08 = 2.00 penalty plus the plan premium ($32) = $34 (your premium will be) this penalty will follow you as long as you have Medicare Part D.


You can appeal the LEP is you can show proof that you have had credible coverage from an employer plan or individual plan by either documentation of premiums paid , a letter from the insurance company or the employer. The LEP is then sent to a mediator that settles all LEP’s if it cannot be resolved between you and the insurance company. This company is called MAXIMUS they can be reached at

MAXIMUS Federal Services

3750 Monroe Ave. Suite 704

Pittsford New York 14534-1302

Or call 866 589 5241 a form can be completed and sent the address shown

MAXIMUS will have the final say in the matter, it is best to provide the most documentation possible when you submit your appeal.


How can I get help paying for my Medication under Medicare Part D?

The Federal Government has an assistance plan in place for individual who qualify based off income, this program is called EXTRA HELP and you can apply by going to Social Security .go or visit with your local Social Security office.

The Extra Help program is a known as Low Income Subsidy and it is overseen by The Social Security Administration. Extra Help can lower your Part D premium, copays and possibly your Part B premium depending on the level of Extra Help you are awarded.  The Extra Help program is income an asset driven so there are guidelines you must meet. IF you think you might be eligible it is always good to check, all they can say is no, so there is no harm.


Medicare and Medicaid and Part D coverage

If you are eligible for Medicare and also qualify for Medicaid your prescription drugs are covered under Medicare Part D and Extra Help program. If you are on Medicaid and become eligible for Medicare you will automatically be enrolled in a Part D plan in your service area if you do not enroll into a plan.

If you have Medicare and then become eligible for Medicaid or SSI you will also be automatically be enrolled into a plan to cover your Prescription Drugs. You will receive a notice from Medicare alerting you are eligible for Extra Help, under this scenario you can change drug plans using a constant SEP which allows you to change drug plans outside of the normal allowed times.



What If I have a Retiree Drug Plan and enroll into Medicare Part D?

If you have a retiree drug benefit and decide to enroll into a Part D plan you might put yourself in bad position where one or none of the coverage’s will work or you might be dis enrolled from the medical portion of your retiree insurance, so it is best to call your HR at the former employer before enrolling into a Part D coverage.

Most retiree coverage’s will count as credible coverage, your HR Administrator must give your notice is your coverage is not credible, meaning it is not as good as the model that Medicare has set forth to follow. If your coverage is found not credible this will give you an SEP to find a plan that will fit your needs.

 What is Medicare Advantage?

A Medicare Advantage plan is an alternative to Original Medicare Parts A and B and sometimes include Medicare Part D.

Medicare Advantage Plans must offer the benefits as Original Medicare does, but may offer additional coverage, such as, hearing exams, dental and vision. Some plans even offer gym discounts. Medicare Advantage plans are sold by private insurance company that are contracted with the Federal Government and paid a fixed amount per enrollee.

There are different types of Medicare Advantage plans:

HMO Health Maintenance Organization

PPO Preferred Provider Organizations

PFFS Private Fee for Service

SNP Special Needs Plans

MSA Medical Savings Accounts

You will still need and are enrolled in Original Medicare and must continue to pay your Part B premium.

The plans must include and limit out of pocket expenses for Part A and B services, but capped at $6700

The Out of Pocket maximum is where your responsibility of making co pays ends. You can include your Part D with a Medicare advantage plan or a PFFS plan, but cannot include a Part D plan with a Medical only Medicare Advantage plan. You must purchase a MAPD (Medicare Advantage Prescription Drugs) if you wish to have a Part D coverage included. These plans are very heavily regulated because they are overseen by the Federal Government.  This is done for the insured’s protection. Agents must be certified each year to sell Medicare Advantage plans of any kind. The agent must also be certified with the insurance company and the product they are selling. You can search Medicare Advantage plans by going to Medicare.gov and entering your zip code, this will tell what plans are available in your service area. The service is the count in which you live in and you must only enroll in a plan for that area or you will be dis enrolled. Your agent will seek out the coverage options and should present them only using the approved sales material and cannot alter the material in any way. You can keep notes on your material during the appointment, but the agent cannot. An agent cannot come to your door without a prior Scope of Appointment form completed so that you know what type of and what plans you will be discussing during your appointment. The agent cannot talk about any unrelated products, such as, Life insurance, investments or long term care. Any other products will have to be completed on another appointment.


Will Medicare Cover Air Ambulance?

Your Medicare will cover air transportation in limited circumstances if it is medically necessary and the ground ambulance cannot get to your location or if there is a great distance or other obstacles that would hinder you from receiving care immediately. The transportation service by air must be Medicare approved.

What medical equipment does Medicare cover?

Medical equipment is covered under your Medicare Part B, if you don’t have a Medicare Supplement you will have to pay the Medicare Part B deductible first if it has not been meet. The deductible for 2017 is $183 and then you are responsible for the other 20% that might be charged by the supplier. If you have a Medicare Supplement it is likely it will pay the additional 20% and possibly the deductible depending on what plan you own.

Medicare will help pay for medical that you might need such as durable Medical Equipment

Wheel chairs




Seat lifts

Hospital beds

Home Oxygen and diabetes testing strips


Does Medicare cover everything?

Medicare does cover many services, but there are some health services that are not covered by Medicare.

Generally vision, dental and earing are not covered by Medicare unless it’s medically necessary to do, not for cosmetic purposes. If you are out of the States there is some medical coverage that can be paid or reimbursed by Medicare but not all countries are approved to have coverage’s offered. Countries that are outside of the US are considered for coverage The US Virgin Islands, Guam, The Northern Mariana Islands and American Samoa and the District of Columbia. You may have to submit an itemized bill to be reimbursed. Purchasing travel is the best way to protect yourself financial and it is very affordable. Medicare Supplement policies within the first 60 days of your trip, the coverage is at 80% of charges for certain medically necessary emergencies. The supplement company will not pay the first $250, this is your deductible. Foreign Travel is limited to $50,000 of Life time coverage under your Medicare Supplement policy.  Personal care or custodial care, such are bathing, dressing, non-medical services are also not covered, such as phone, television


Can I buy a Medicare Supplement online?

Yes you can purchase insurance via the internet through a broker or by call a insurance company that offers direct sales, but speaking to a broker will allow you to get pricing from many different companies and other benefits that might be offered over and above another.


How does Medicare work with other insurances?

If you are on Medicare and have other insurance, the payer or the primary insurer or also known as MSP, Medicare Secondary Payer. If you have group health insurance and are eligible for Medicare, depending on the group size, your group insurance will be the primary or first payer of the group is over 20 employees.

Under the MSP rules, when a current employee is eligible for Medicare due to age and the group health plan must follow the rules of the MSP. Your employer cannot offer you incentives to not enroll under the group health this would be a violation that can cost the employer $8908 per violation.

When the group health plan is the primary payer but not pay in full for the service provided, Medicare will pay is portions and general y leave the insured in a very good position where some if not all the bill has been paid.

What is Retiree Drug Subsidy under Medicare Part D ?

Eligible employers that sponsor group health plans with retiree prescription drug benefits can obtain a Retiree Drug Subsidy, which is exempt from federal income tax.* The subsidy is available to employers with creditable prescription drug coverage that covers retirees who are entitled to enroll in Part D but who elect not to do so. The subsidy is meant to encourage employers to maintain or begin offering retiree prescription drug coverage.

Subsidy payments equal 28 percent of each qualifying retiree’s allowable prescription drug costs attributable to gross prescription drug costs between the applicable cost threshold and cost limit. Gross costs are costs incurred for Part D, which are any drugs that can be covered under the Medicare prescription drug benefit. Gross costs include dispensing fees but exclude administrative costs. Allowable costs are actual incurred costs.

*Under the Affordable Care Act (ACA), employers that receive the subsidy cannot take a tax deduction for the subsidy amount. This change became effective in 2013.

Under Medicare Part D, what is required of an employer who wishes to apply for the Retiree Drug Subsidy?

Each plan sponsor that seeks the Retiree Drug Subsidy must electronically complete the application through the Retiree Drug Subsidy Center. Applications for the Retiree Drug Subsidy are due at least 90 days before the beginning of the plan year, unless CMS approves a request for a 30-day application deadline extension. Plan sponsors must apply each year they wish to claim this subsidy.

What insurance card do I show when I go to the doctor if I have a Medicare Advantage plan?

If you join a Medicare Advantage plan you will show the doctor office or hospital your Medicare Advantage card not your red white and blue Medicare card. This is because for the current plan year your Medicare Advantage plan will be responsible for your Medicare claims.

Before joining a Medicare Advantage plan you need to ask many questions

Can I use my doctor? It depends on if you r doctor is contracted with the plan

Are all my providers still in network or part of the network? This can change on a yearly basis so you will have to look each Annual Election Period

Is my specialist in network? You will need to check with the directory or call the number on the back of your card.

Are my prescription drugs on the formulary? You will need to check in the formulary or call the company but most drugs can be found or an exception can be made, but your doctor will have to send in a request to have a certain drug offered to you under the plan.

Can I live in one state and see a doctor in another? Most generally no, but it depends on the contracting and what type of plan you have. A PPO plan will have more flexibility than an HMO that only uses plan doctors and hospitals, no exceptions. Will I lose my retiree coverage if I chose a Medicare Advantage plan? It is very possible that can happen it is always best to call you HR or past HR department to check things out.

Can I use my Medicare card at the VA?

The quick answer is no. Medicare Does not coordinate benefits with the VA. If you see a doctor at the VA that will be billed through the VA to you or whatever level of VA coverage you have depending on the length and type of service you have had in the past. You can however get your medications from the VA and use Medicare for your medical along with a supplement. IF you wish to have a medical procedure done at the VA you must be VA benefit eligible.

What preventive services does Medicare cover?

Medicare will cover an initial one time examination also known as the Welcome e to Medicare physical with in the first twelve months after you enroll into Medicare Part B.

The preventive list includes

Review of your medical and social history

Review of any depression or thither medical health

Review of the ability to function at home safely and within the community

Height and weight and blood pressure check body mass index and vision testing

Education or counseling related to risk factor and what the doctor found during the testing process

Education or counseling about other preventive services available to you a check list is an example of a written plan created by your doctor along with a check list is an example of a written plan your doctor may to you

Discussions a bout health car directives

You can also talk about health directives and for legal purposes if you no longer decide or have the ability to make health care decision s for yourself

An EKG may be ordered, but you Part B deductive may have to be paid or billed to you first before Medicare will covers

Abdominal Aortic Aneurysm AAA screening if you receive a referral because you are risk for this. Medicare will cover the testing that is done by ultra sound with no deductible or co insurance

The preventive service physical is not a head to toe physical, but it will cover many of the services needed. If you wish to have other testing done you will need to have a discussion with your doctor and also see if Medicare will pay the claim, because if not you will have to pay the entire bill if the testing is not Medicare approved.

If you have a Medicare Advantage plan you will also need to see if your doctor and hospital are in network and if not you will be billed or make a higher co pay.

Retiree Health Care

With the cost of health care continually on the rise, employees may be unsure of how they will pay for health care when they retire. Not all of these costs can be covered by Medicare, but not all of them can be covered by employers either—leaving retirees to pay the rest.

Originally, Medicare was the primary insurer for the working aged (those individuals who are age 65 and older but continue to work for an employer of 20 or more employees). As the expenses of Medicare rose, Congress began to look for ways to shift the cost burden to private insurance companies.

In 1980, Congress enacted the first set of Medicare Secondary Payer provisions that transferred the responsibility of paying primary health care benefits for the working aged to private employer health plans. The laws were later refined to permit the government to recover overpayments from the person, the employer plan, the provider, any third party or “any entity that would be responsible for payment with respect to such item or service.”

Employer and Retiree Roles

Individuals who are eligible to make contributions to health savings accounts (HSAs) can use HSAs as a tax-advantaged way to save for health care costs in retirement. However, HSAs have strict contribution limits and many individuals are not eligible for HSA contributions. Thus, many individuals have no tax-efficient means to save for health care costs except through retirement plans, which aren’t designed to cover medical costs. Individuals who don’t have employer-sponsored health coverage must pay increasing amounts for medical care.

Due to having more retirees with longer life expectancies and higher health care costs, employers are reviewing and redesigning their retiree health care programs. Employers are faced with the liability for retiree health care costs, and so they are exploring options for tax-effective funding. Some employers are shifting significant health coverage costs to retirees; others have stopped sponsoring retiree health benefit programs altogether.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003, which became effective in 2006, provides a nontaxable subsidy to employers that continue to maintain retiree health plans that provide prescription drug coverage. The subsidy can be

Excluded from an employer’s income and is equal to 28 percent of the allowable costs. However, the subsidy is available only for costs incurred by an individual who is eligible under an employer’s plan and who was eligible to obtain prescription drug coverage under the Medicare program but did not elect such coverage. Also, to receive the subsidy, the employer’s coverage must be creditable, which means it must be at least as generous as the Medicare prescription drug coverage.

Role of Medicare

Medicare entitles individuals who are age 65 or over and eligible for Social Security benefits to receive hospital coverage and, at an additional cost, coverage for doctor’s services, outpatient care and other medical services. These are the two parts of Medicare, known as Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare also has a prescription drug benefit (Part D).

Part A Coverage

Part A of Medicare pays for inpatient hospital care and services and covers skilled nursing home services. Inpatient care includes medically necessary nursing, drugs, diagnostic or therapeutic care, supplies, equipment and appliances. Home health care or hospice care may also qualify for reimbursement by Medicare. Part A is subject to per-benefit period deductible and to coinsurance for each day of care beyond the sixtieth. There are limits on the number of days allowed for skilled nursing care and psychiatric hospitalization.

Part B Coverage

Part B applies to physician and professional services. Covered services include ambulance, X-ray and diagnostic tests, ambulatory surgical care, outpatient hospital care, physical and occupational therapy, durable medical equipment and physician charges. This coverage is voluntary and costs the beneficiary a monthly premium.

Because of the deductibles and co-insurance amounts required under both Parts A and B, a large percentage of Medicare beneficiaries have some type of private supplemental health insurance to fill specific gaps in the Medicare coverage system.

As currently structured, Medicare has several significant exclusions, namely, long-term custodial care and elective care.

Medicare Part D

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 created the Medicare Part D Voluntary Prescription Drug Benefits Program. The program is the primary payer of prescription drugs for Medicare-eligible individuals who are no longer employed. A subsidy is available for low-income beneficiaries.


Medicare as a Secondary Payer

For individuals who continue to work past age 65, Medicare is usually the secondary payer. For spouses 65 or older, even if the employee is under age 65, Medicare is usually the secondary payer.

Employers are required to offer employees age 65 or over the same group health plan coverage that is available to younger employees. The employee and spouse have the option of choosing to enroll in the employer plan, Medicare or both. If they choose to enroll in Medicare, the employer may not offer secondary coverage. However, if they choose to enroll in the employer’s plan, Medicare is usually the secondary plan.

This does not require employers to offer health plan coverage if they do not normally do so. However, it does mean that employers must extend the coverage to employees who work past age 65 if the employer offers a health plan.

Coordinating Retiree Benefits with Medicare

Coverage and premium costs change, yet employers do not want to absorb the full burden of hospital, medical and prescription drug costs so long as Medicare coverage is adequate. Many employers have found that coordinating a retiree medical plan with Medicare is the least expensive way to provide coverage to retirees age 65 and over.

The three most common methods of coordinating retiree medical benefits with Medicare are the following:

  1. Carve-out method This method enables a company to limit plan liability to the difference between the amount covered by Medicare and the amount the company’s plan would normally pay;
  2. Standard coordination method This method requires the plan to pay the usual benefit, not exceeding the amount of an expense that has not been paid by Medicare – this provides the most generous net benefit of the three choices; and
  3. Government or Medicare exclusion method This method allows a plan to reduce the amount of an expense not covered by Medicare by applying the plan deductible and coinsurance amounts to determine the actual benefit payable.

Can I have Medicare and purchase a Market Place plan?

The Health Insurance Market plan was established for uninsured and underinsured to purchase affordable health insurance or also known as the AC Plans sold on the Market Place are known as Qualified Health Plans QHP’s

If you are on Medicare or soon be you may be curious hoe the ACA will affect you. If you current have Medicare and no spousal coverage through an employer you will not need to make any changes. You are not eligible to enroll in the QHP because you are already co0vered under Medicare. For one it is illegal to have Medicare and be enrolled in a QHP

You are not able to get tax credit to pay for your plan unless you qualify for Extra Help which is designed to help people on Medicare with little income or assets.

The is no guaranty if you drop Medicare and enroll in a Market Place plan, this actually will be more costly and besides you have already paid for Medicare Part A through your working years why pay twice? Medicare Advantage and Medicare Supplement plans are not sold through the Market Place. You will need to contact a Broker or call Medicare.

If you are on a Market Place Plan and become eligible for Medicare You will have disenroll from the QHP to coordinate with your Medicare start date. You will need to call 800 319 2596 and let the Market Place know that you will be eligible for Medicare in the near future. If you are on a Market Place plan with a spouse the spouse can stay on the plan but your tax credit may be adjust and further documentation may be needed to make sure there is a smooth transition and your spouse’s coverage will be cancelled by mistake.

The Market place plan will not affect your coverage if you are on a employer plan through your spouses, depending on the size of the group Medicare will be primary or a secondary payer. There are different rules for p[people wanting to purchase a QHP if you are being treated for End Stage Renal Disease for those who need to pay a Medicare Part A premium , if you are under age you may still be able to enroll into a Market Place plan and receive a tax credit. You will need to call the plan and Social Security to see what options you have.

Should I enroll into Medicare if I have End Stage Renal Disease and have coverage under my employer sponsored plan?

No, If you have a good employer sponsored group health plan you do not need to purchase a Supplement of another Medicare plan your health plan will most generally pay first and then Medicare second if you employer has over 20 full time employees.

If you do not immediately sign up for Medicare when you are first eligible you will not be penalized, because you will have credible coverage that is as good as or better than Medicare. Once you are ready to leave employment you can then enroll into Medicare Part B and a Supplement or an Advantage plan that fits your needs. You will then need to inform Social Security that you wish to enroll into Medicare and what the start date should be. The start date will always be the first of the following. If you decided to work past age 65 you’re Part A and Part B start dates may be different. This is not a problem and is very common for individuals to be working past age 65.

After any one born after 1954 your full retirement date will be 67, at this time for most individuals aging into Medicare the full retirement age is 66. You can start drawing Social Security age 62, but it is not advisable, it is best to call Socials Security to get a full understanding of how taking Social Security will affect you in the future.

Can I keep my COBRA insurance coverage if I go onto Medicare?

The Consolidated Omnibus Budget reconciliation Act of 1985 is a law that was passed by Congress to allow employees to continue their group health coverage for a limited period of time after leaving their job voluntary or involuntarily. If you become eligible for Medicare and you are currently on COBRA you will need to enroll into Medicare Part B immediately, because COBRA does not count as a Special Election if you decided to stay on COBRA full its full term and then leave to go onto Medicare.

If you are eligible for COBRA and already on Medicare, you must be allow Ed to take COBRA it will be secondary to Medicare. Meaning it will pay after Medicare unless you are being treated for RSRD and if you have high medical expense it may be best to be on COBRAD for specifically because your prescriptions may be very costly, but if you can find a good part D that covers your drugs at a reasonable rate then Medicare may be the way to go. It is best to sit with a professional and get these things figured out before just heading into something.

Many of the COBRA plans will not allow you to take just the drug coverage it’s all or none. However you will have to pay a penalty if you did not enroll into a PART D plan when you became first eligible because COBRA is creditable coverage in CMS’ eyes.

Is my Broker giving me bad information on a Medicare Advantage plan?

If you suspect tour broker of the plan is giving you bad information it is best to call your doctor’s office and verify they are in network. There are some signs of being misled if the broker or plan tells you to: sign up for a Medicare Advantage plan like a PPO or HMO to get your PART D coverage, this is not true!

You will pay a higher a larger Part B premium if you don’t sign up for a Medicare Advantage plan or if they tell the only way to get plan information is if they stop by your home. This is also false you call cl lth plan directly and get the information you can also verify the plan by looking at the Medicare website or by calling Medicare directly.

If the plan covers certain services and makes it sound like they are offer additional services which they are not. A Broker must use the marketing material and cannot change the material the plan has approved through CMS. IF the plan or broker tells you the doughnut hole will be covered and it is not. Most brokers will be up front and honest, but yes there are a few that will put the pressure of or mislead an individual just to make a buck, this does not happen with us or any of the brokers we work with. We are not affiliated with CMS or represent Medicare we are license agent that must certify each year to offer Medicare plans to qualified individuals. We as Brokers are paid directly from the insurance company and not by you!

What does Medicare cover on Outpatient Therapy and Speech Therapy?

Therapy Services are available under Medicare to help you regain your ability to walk or any other type of physical need, speech pathology or occupational therapy. Either if it’s a temporary need to preventative to keep matters form getting worse Medicare will help you cover some of the expenses incurred from the above types of therapy.

If you needed therapy your doctor will order the services are needed to help you, this that you will have a treatment plan and be trained by a technically therapist. Your services can be performed in a hospital, outpatient or skilled nursing setting depending on the level of care that is required. For 2017 Medicare will cover $1980 worth of physical and speech therapy combined and $1980 for occupational therapy if needed. IF it is necessary for you to have addition therapy treatment your doctor or therapist will need to contact Medicare and advise them you need additional services for recovery. If Medicare denies the claim you can always appeal the issue and if not it can be sent to MAXIMUM to be reviewed.

Will Medicare help pay for Cardiac Rehabilitation?

If you have a heart condition and a doctor supervised program to rehabilitate your heart Medicare will cover rehabilitation if you have any of the below illnesses

Has a Heart Attack I the last month, by Pass surgery, Stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting which widens the artery so blood can pass through more easily or a heart and lung transplant. Depending on what you were treated for t your doctor will put a rehabilitation program together for your recovery.

Your doctor may put together a plan, such as, nutritional, physical exercises program and other assessments depending on the level of recovery that is needed. Medicare will pay up to s2 one hour sessions per day and up to 36 sessions over 36 weeks if it’s medically necessary. If the services are received in the doctor’s office Medicare will pay up to 80% once your Medicare Part B deductible has been meet.  IF for some reason you are hospitalized you will be covered under Medicare Part A, but have to pay a deductible of $1316 in 20174.

Medicare and Prescription Drug Cost and pricing?

In 2013, the United States spent $329.2 billion on prescription drugs—eight times more than the $40.3 billion spent in 19901. Although prescription drug spending has historically been a small proportion of national health care spending compared to hospital and physician services, in recent years, it has grown rapidly.


In 2014, prescription drug spending in the United States increased 13.1 percent—the largest increase since 2003. This jump was due to a number of factors—a major one being a 30.9 percent increase in spending on specialty medications, which are high-cost drugs used to treat complicated conditions like hepatitis C, cancer and rheumatoid arthritis2. The growth in prescription spending was also due to more people being insured and gaining prescription drug coverage as a result of the Affordable Cart Act (ACA).

The 2014 increase marked a departure from previous years’ prescription drug trends.

Annual prescription spending growth declined from 18 percent in 19993 to 5 percent in 2007  due to variety of factors, including greater usage of generic drugs, changes in the types of drugs being used and more tiered copayment prescription plans. Spending fell 3 percent in 2008 as a result of the recession and safety and efficacy concerns .

Following years of decreasing rates, drug spending increased in 2012 by 3.8 percent6. It then grew by 5.4 percent in 2013, again due to a multitude of reasons, such as greater patient usage and rising costs for traditional and specialty drugs2.



Changes to the Prescription Drug Payer Mix

The portion of prescription drug spending paid by private insurers increased from 27 percent in 1990 to 43.5 percent in 2013, contributing to a reduction in the amount people paid out of pocket, which ropped from 56.8 to 16.9 percent. During this same time, Medicare spending increased from 0.5 to 27.5 percent7.


The implementation of Medicare Part D in 2006 dramatically altered payer mix, as Medicare expenditures soared from 1.9 percent in 2005 to 17.7 percent in 2006. Medicaid’s expenses, on the other hand, fell from 17.7 percent to 8.5 percent during this time because Medicare replaced Medicaid as the primary insurer for individuals covered under both programs7.


Reasons behind Prescription Drug Trends

A multitude of factors led to changes in prescription drug costs, as outlined below.


In 2014, traditional prescription drug spending increased 6.5 percent, while specialty drug spending climbed 30.9 percent. Even though specialty medications only account for 1 percent of all U.S. prescriptions, they made up nearly 31.8 percent of 2014 drug costs (up from 27.7 percent in 2013) 2. Specialty drug spending is projected to experience double-digit growth over the next three years—increasing 22.6 percent in 2015, 22.3 percent in 2016, and 21.3 percent in 20172.

Types of Drugs Used

From 2013 to 2014, the utilization of traditional prescriptions decreased 0.1 percent. Usage of specialty drugs, though, increased 5.8 percent2. Approximately 49 percent of the drugs that gained Food and Drug Administration (FDA) approval in 2014 were specialty drugs. This trend is likely to continue as more specialty drug therapies are in the development pipeline. Furthermore, many brand-name medications command a high price today because they are patented. When these patents eventually expire, it will allow generic versions to enter the market, which has historically helped reduce medication expenses.


Failure to Follow Physician Orders

Reductions in drug utilization may mean that patients aren’t adhering to the drug treatments recommended by their doctors. A failure to fill prescriptions can have serious effects on patient health and lead to more costly medical problems down the road. A recent study found that 31 percent of prescriptions go unfilled and individuals over the age of 52 were more likely to fill their prescriptions than their younger counterparts. Women were more likely fill their prescriptions than men, and, unsurprisingly, drugs with higher copayments were less likely to be filled8.


ACA’s Impact on the Pharmaceutical Industry

The ACA implemented various provisions designed to help monitor the pharmaceutical industry, including imposing an annual fee on importers of branded prescription manufacturers and importers whose branded sales exceed $5 million. This annual flat fee started at $2.5 billion in 2011 and will increase to $4.1 billion by 2018. The ACA also created a process for gaining FDA approval of biosimilar, or interchangeable, versions of brand-name drugs. Brand-name drugs, though, are given 12 years of exclusivity before biosimilar drugs can be approved.

In addition, the ACA requires non-grandfathered health plans to include prescription drugs as one of the “essential health benefits,” and all forms of birth control must be covered without cost-sharing. Over the next few years, rebates and discounts will also be available to certain Medicare Part D beneficiaries.

Many health plans have responded by creating drug formularies, which exclude certain drugs from coverage, and step therapy requirements, which require individuals to try more cost-effective treatments before “stepping up” to more costly drugs. In addition, some insurance plans have increased patients’ out-of-pocket responsibilities by imposing separate prescription deductibles (see graph below) and requiring certain medications to have a prior authorization. Prior authorizations may be required when an insurer believes a less expensive drug may work just as well as the more expensive drug the doctor prescribed.

Medical Therapy Management

Under this model, pharmacists or other health professionals provide care to people who take medications for different medical conditions. MTM programs are available at no cost to those enrolled in a Medicare drug plan. The goal of the program is to improve medication adherence and optimize drug therapy, which, in the long run, can help reduce health care costs. On average, the return on investment for MTM programs is estimated to be about 2:1 to 3:1 10.

Employer Group Waiver Plans (EGWPs)

EWGPs are Medicare Part D programs that are intended to help employers better manage prescription costs for retirees. While this option was available in the past, the ACA now allows employers to contract with third-party administrators rather than just CMS. With an EGWP, employers may be able to reduce health expenses for Medicare-eligible retirees compared to more traditional retiree drug subsidy programs.

Medicare Rebates and Discounts

Some businesses have elected to partner with organizations known as pharmacy benefit managers in order to negotiate with pharmaceutical manufacturers to receive rebates and discounts on prescription drugs based on factors like volume and market share. Similarly, some employers have joined together to create prescription drug purchasing pools in order to increase their purchasing power when negotiating lower prices for prescription drugs.

Employers are not the only ones seeking to reduce costs when it comes to pharmaceuticals. As employees’ out-of-pocket responsibilities continue to grow, rather than paying for a brand name, more people are asking for cheaper or generic versions of drugs. Consumers are also using the Internet and phone apps like Lowest Med and GoodRX to make price comparisons between local pharmacies and to locate available coupons. Some consumers are also looking to mail-order pharmacies to handle 90-day supplies of their medications, which often offer lower drug prices.

CMS projects that from 2012 to 2022, annual expenditures on prescription drugs will grow by 75 percent to $455 billion. Outpatient prescription drugs will account for about 9 percent of total health care spending. By 2022, the ACA is expected to add an additional $15.3 billion in annual drug expenditures.

Furthermore, CMS projects that from 2015 to 2024, prescription drug spending will grow, on average, 6.3 percent annually, which is slightly higher than its projections for health spending (which will increase at an average rate of 5.8 percent per year).MS notes that during this time, new specialty drugs will enter the market and there will be fewer generic drugs launched. These projections are subject to change.

Why my drug are costs different each month when I take the same medications?

 The amount you pay to a Medicare drug plan will change this year and throughout the next few years. You r drug plan can change the pricing on drugs at any given time which might increase your co pays it might also depend on what coverage period you are in when purchasing the plan. During the deductible period you will have to pay the full cost the your drugs at 100% until you meet the drug plan deductible and this can vary from plan to plan, but no deductible can be higher than $400 for the year 2017. During the Initial Coverage Period begin your deductible and during this time you will pay a portion or all of the costs of your drugs. The initial coverage stage will last until you retail drug cost reaches $37000, for 2017 he once you meet this amount you will be in the coverage gap. The GAP or Doughnut Hole will last until you reach $4950 an during this will you pay 40% of Brand name drugs and there will be a 49% discount on generic drug until you reach an out of pocket of $4950 for 2017. Once you meet the Out of Pocket maximum you will then be in the catastrophic phase of your drug plan and this will last until the end of the calendar year.

Hearing Loss and Treatments

The two most common types of hearing loss are sensorineural hearing loss and conductive hearing loss.

Sensorineural is also called nerve deafness, this is the most common type of hearing loss, affecting one out of five people by age 55. It usually comes on gradually, but rarely results in complete deafness. People who have this type of hearing loss can hear speech but often have difficulty understanding it, especially with background noise.

There are a range of causes for sensorineural hearing loss, including: Exposure to loud or persistent noise, Meniere’s disease (an abnormality of the inner ear), Meningitis, or viruses such as mumps or measles, Heredity, Head injuries, Blows to the ear, Birth defects, Circulatory problems, Allergic and metabolic defects

Sensorineural hearing loss is irreversible but can usually be helped with the use of hearing aids.

Conductive—This occurs when the ossicles, the three tiny bones of the ear, fail to conduct sound to the cochlea, or inner ear. It can also occur when the eardrum fails to vibrate in response to sound because of a mechanical problem, such as fluid in the ear or disruption of the ossicles.

There are several causes of conductive hearing loss, including:

  • Infection
  • A buildup of earwax
  • Fluid in the middle ear
  • A punctured eardrum

People with conductive hearing loss can be treated successfully with medicine or surgery, as well as with hearing instruments. Some people have both sensorineural and conductive hearing loss; these people can be treated with hearing aids as well.

Some other conditions that cause hearing loss or adversely affect people’s hearing are:

Presbycusis—This is hearing loss due to normal aging, and therefore most common for elderly people. It is caused as hair cells become old and brittle or are destroyed. Presbycusis is generally a type of sensorineural hearing loss but sometimes can be a conductive hearing loss.

Tinnitus—Also known as “ringing in the ears,” it is the sensation of sound that does not exist. About one third of all adults experience tinnitus at some point, and 15 percent of adults require medical evaluation for their tinnitus. It can be caused by a number of factors including earwax buildup, eardrum perforation and ear infections.

Hearing loss is often so gradual that it goes unnoticed by the sufferer and is discovered by family, friends or a routine hearing test. The following symptoms may indicate hearing loss: Nervous tension, irritability or fatigue from the effort to hear, The belief that people are mumbling or not speaking clearly, Straining to understand conversations in social settings or at work, Frequently misunderstanding or needing to have things repeated, Watching people’s faces intently when listening, Increasing television or radio volume to the point where others complain, Recurrent ear infections, constant ear ringing or dizziness, Some people have an increased risk of experiencing hearing loss, such as:

Those with a family history of hearing loss, People with diabetes, or heart, thyroid or circulation problems, those who are exposed to high noise levels from things like tractors, factory machinery, firearms or power tools, without proper ear protection

A hearing aid is an electronic, battery-operated device that amplifies and changes sound to allow for improved communication.

In-the-ear (ITE) hearing aids fit completely in the outer ear and are used for mild to severe hearing loss, but are not usually worn by children because the casings need to be replaced as the ear grows.

Behind-the-ear (BTE) hearing aids are worn behind the ear and connected to a plastic earmold that fits inside the outer ear. BTE aids are used by people of all ages for mild to profound hearing loss.

Canal aids fit into the ear canal and are available in two sizes. The In-the-canal (ITC) hearing aid is customized to fit the size and shape of the ear canal and is used for mild or moderately severe hearing loss. A Completely-in-canal (CIC) aid is largely concealed in the ear canal and is also used for mild to moderately severe hearing loss.

It is difficult to protect yourself from hearing loss due to aging or certain other conditions. However, it is possible to protect yourself from noise-induced hearing loss. Be aware of the sounds that can be dangerous to your ears and take steps to avoid or reduce them.

Keep the volume turned down on your stereo, phone and television.

Make sure the noise in your workplace does not exceed federal regulations.

Wear earplugs with at least 20 decibels of protection when you are exposed to loud noises.

Regular hearing tests can alert you to hearing loss as soon as it starts, allowing you to enact preventative measures.





Call 1-800-MEDIGAP