How They Relate: Original Medicare and Providers

One of the most common questions we get regarding Medicare Supplements (MediGap) is what providers can be accessed for care. Many assume that a Medicare Supplement from Blue Shield or Anthem Blue Cross requires using their respective doctor networks. In fact, Medicare Supplements don’t have their own provider network; you can see any Medicare contracted provider. It is the relationship between the provider and Medicare that is key and important to understand.

There are three different possible relationships a provider can have with Medicare, and they can directly impact what you pay for medical services. These relationships are called: Participating, Non-Participating, and Opt-Out providers.

A Participating provider is contracted with Medicare and has agreed to accept Medicare’s fee schedule (also known as “accepting assignment”) as payment in full for all Medicare covered services. They cannot charge more than assignment and patients would only be responsible for deductibles and coinsurance amounts. These providers must submit claims to Medicare for the patient and typically wait for Medicare to pay its share before billing the patient.

Non-Participating providers are also contracted with Medicare but do not accept Medicare assignment and may charge up to 15% above assignment (called excess charges) for services, but no more. They may ask for the full payment at the time of service and are not required to submit claims for patients.

Providers who have “opted out” have chosen not to work with Medicare. They cannot bill Medicare and Medicare will not pay for services (except for emergencies). Patients should be prepared to pay 100% of the bill. Providers who opt out do so for a minimum of two years at which point they can choose to remain as an “opt out” provider, contract with Medicare as a participating provider or as a non-participating provider.

For those of you with Medicare Supplement Plan F or Plan G, be reassured that in addition to deductibles and co-insurance, excess charges from Non-Participating Providers is covered in full. However, Medicare Supplements will not pay if Medicare does not pay first. Therefore, when seeing a provider that has opted out of Medicare, the Medicare Supplement will not pay benefits either.

Providers are required to tell you prior to receiving services, what relationship they have with Medicare. I hope this article helps in understanding how that may affect you.

All the best in the New Year,

Phil

PS: Don’t forget Travel Insurance on your next trip abroad! Contact us for a quote!

Inflation Reduction Act Brings Changes to Part D

The Inflation Reduction Act is bringing a series of revisions to the Medicare Part D Prescription Drug Program that will be phased in over the next six years.

The immediate modifications beginning January 1, 2023, include:

  • Insulin copays will be limited to $35/month for ALL Part D Prescription Drug Plans. Previously, the copay was only available in select plans.
  • Improved coverage for vaccines in Medicare Part D
    • Recommended vaccines (not covered under Medicare Part B) including Shingles and Tdap, will be free for people enrolled in a Medicare Part D prescription drug plan.
    • Medicare Part B already covers many vaccines including: the seasonal flu shot, pneumonia, and Hepatitis B

Other provisions are intended to reduce Part D spending. Here are highlights of changes to come:

2024: Eliminates the 5% co-insurance in the catastrophic level of Part D plans

2024 – 2030: Limits Medicare Part D drug plan increases to no more than 6% per year

2025: Establishes a $2,000 out-of-pocket cap on annual drug costs (currently no cap)

2026 – 2029: Implements negotiated pricing for certain high-cost drugs

We’ll keep you informed when more information about these revisions is released.

Lastly, with the forthcoming holiday season we want to remind our clients with plans to travel abroad to stay properly insured. Visit our travel insurance webpage or shoot Patricia an email (patriciad@dhis.com).

Medicare vs. Medicare Advantage

Most of you reading this have Medicare as your primary insurance with a Medicare Supplement to fill in gaps. We have been advocates for this type of arrangement for nearly 30 years for its high level of insurance and the extensive provider access it provides.

As we approach open enrollment season, you will undoubtedly be receiving a deluge of mailings, be exposed to TV advertisements, and even phone and text messages about Medicare related health plans that seemingly cover everything for a low, low price. These are most likely Medicare Advantage plans that fall under Part C of Medicare. These should not be confused with your insurance program. It is an entirely different way one receives their Medicare health benefits and I want to share with you some important differences.

Medicare Advantage is a strategy promoted by Medicare to transfer health care costs to the private market. In essence, you “transfer” your Medicare benefits (Part A, Part B, and Part D) over to a private insurance company who is then responsible for delivering your care. Medicare subsidizes these plans with your Medicare allotted benefits.

Medicare Advantage plans include hospital and medical benefits, and usually include prescription drug coverage. They most always include additional ancillary benefits and services such as vision, hearing, acupuncture, transportation, gym memberships, and more. By being subsidized by the government, premiums can be as little as zero dollars per month. So, what’s the catch?

The promotions often fail to accurately explain their restrictions and limitations. Provider access and financial exposure are the most misunderstood aspects of Medicare Advantage plans. First, many of these plans are HMO’s that restrict your provider access to a local network that require referrals to specialists from a Primary Care Provider (PCP). In some counties PPO style options are available that don’t require referrals but will have separate in and out of network benefit schedules. In a Medicare Advantage plan your share of costs may include deductibles, copays, and coinsurance. All MA plans will have a maximum out-of-pocket that protect you against major claim years BUT, I have seen MA plans with maximums over $7000 per year.

Compare this with Medicare as your primary insurance which gives you access to any Medicare contracted provider in the country. And, when combined with a Medicare Supplement, can provide virtually 100% coverage for hospital and medical expenses. Standalone Part D drug plans can be added to help with outpatient prescriptions. Although this combination can be higher in monthly premiums, you have the peace of mind knowing in a high-claim year your out-of-pocket costs can be minimal.

Marketing tactics purposely attempt to cause confusion in order for the “target” to reach for the phone. Phone calls with MA sales reps can lead to be more confusion and often failing to educate the consumer of the consequences of enrollment…losing your Medicare Supplement and Part D drug coverage (you can’t have both).

Medicare Advantage plans aren’t necessarily a wrong choice, but they are not the same insurance as what you are used to and they are not always easily interchangeable. Medicare Advantage plans are a different way to receive your Medicare benefits and in a way you may not want. Read the plan’s summary of benefits first before making your decision and call us if you have any questions.

Travel with Peace of Mind

Let the adventures begin! Travel is back to pre-pandemic levels according to several travel related sources. While you make your international travel arrangements, don’t forget to include travel medical insurance in your planning.

Alert! Original Medicare (Part A + Part B) does not provide coverage abroad. And Medicare Supplements offer a small benefit which we believe to be insufficient.

Travel medical insurance provides another layer of medical insurance as well as evacuation coverage for medical and emergency situations plus 24/7 support. Check out our new video below where we answer frequently asked questions regarding travel medical insurance.  And visit our webpage devoted to the products we recommend: https://www.onlyhealthinsurance.com/travel/

Or, give us a call for a free quote and advice!

These days more than ever “peace of mind” while traveling is invaluable. Let us help you arrange it with travel insurance.

Safe Travels!

Phil & Patricia

Ready To Travel?

Are you ready to travel?!  The eagerness to do so is certainly undeniable. Google Trends which provides broad insight into consumer behavior shows the interest in international travel trending skyward. Personally, I had a family trip to Europe fizzle in 2020 and I’m looking forward to rescheduling when the time is right.

For seniors ready to board or plan their next travel abroad, remember that Medicare’s coverage stops at the border. Most Medicare Supplements, insurance that fill in the gaps in Medicare, provide foreign travel coverage but for emergencies only and with a lifetime limit of $50,000. And, this doesn’t include valuable assistance services to help coordinate care or a medical evacuation. Be prepared to pay for services on your own and submit receipts upon return including translated doctor notes and invoices. The added complexity of a foreign claim often leads to processing and reimbursement delays.

…Enter Travel insurance. Travel Insurance can add another layer of medical coverage, evacuation benefits, assistance services and more. Claims can often be submitted online with less hassle. Coverage for pre-existing conditions are included in most cases as well as for COVID related medical treatment. Travel products include plans for single trips, long term stays and annual plans covering multiple trips. And, many people find premiums surprisingly affordable! We offer a variety plans from GeoBlue, a Blue Cross/Blue Shield affiliate, and have a web page devoted to their products where you can learn more, obtain a quote and enroll online!  But don’t hesitate to call or email me with questions or a quote.

Happy Travels! Phil Dougherty

two people sun bathing on a beach

The Annual Election Period for the 2021 Plan Year is approaching!

Dear Friends,

The Annual Election Period begins October 15 and runs through December 7, 2020 and is when you are allowed to change your Medicare Part D Prescription Drug Plan for the 2021 plan year or, if eligible, enroll in a plan for the first time.

We have enjoyed helping hundreds of clients during this time over the past ten years and we look forward to making our advisory service available this year as well. Our recommendations are largely dependent on the functionality and accuracy of Medicare’s online Plan Finder tool. Due to changes in the tool and the complexity of drug pricing, our analysis is more difficult and time-consuming, especially with complex drug lists. To keep our consulting fee the same ($175 per person) we ask that you complete our drug form thoroughly. To help in this regard, we’ve added an online form and the ability to pay by check or credit card. More on that below.

2021 Facts & Figures:

  • Next year there will be thirty-two plans available offered by eleven companies, same as 2020.
  • Of the two million Californians enrolled in Part D drug plans, eighty-five percent are covered by four carriers (AARP, Humana, SilverScript and WellCare).
  • Ten plans will lower their premiums and nineteen will see increases.
  • Overall, the average monthly prescription drug plan premium in CA will increase 1.45% to $45.75 per month.
  • SilverScript is introducing a new plan at $7.20 a month, the lowest premium plan available.
  • CMS has released a Part D Senior Savings Model that will cap the cost of many insulins. Recipients can expect a maximum copay of $35 for a one-month supply in those plans that participate.

If you would like to proceed with our service, which will include a plan analysis, recommendation and enrollment assistance, please complete our <<Online Drug Form>> and pay by credit card or mail a check to our new address below for $175 per person payable to OnlyHealthInsurance. If you prefer a paper form, just let us know and we’ll email or mail you one to complete and return with a check. Our last day for accepting new consultations is Friday, December 4th. Note: we do not sell or represent any Medicare Part D drug plans.

Whether you participate in our service or not, it is very important to review your plans renewal material and confirm that your current medications will be covered next year. Changes to your plan’s deductible, copays and premium will also be communicated to you in your renewal packet.

We will be supplementing information from other resources to complete our reviews and make our recommendations which are listed in the self-help section below.

Important for you do-it-yourselfers! The Medicare Plan Finder tool has a more intuitive interface and some enhancements that make it more user friendly. If you log-in or create a Medicare account, you can save your work for future use and view past drug purchases for reference. You can now enter up to five pharmacies to compare pricing and share of costs. Remember that Preferred pharmacies can provide some additional savings over Network pharmacies.

We appreciate the opportunity to assist you.

Respectfully yours,

Phil Dougherty, John Wheeler & Lois Whitley

OnlyHealthInsurance  

Self-help resources and free services:

www.medicare.gov – Using their Plan Finder tool  you can enter your medications and preferred pharmacies, review all plan options, and enroll online.

Call Medicare at 1-800-633-4227 – Medicare representatives are available 24/7 to provide free analysis, recommendations and enrollment over the phone.

www.q1medicare.com – Best private website on the subject of Medicare Part D. This site has the most information available with tools to compare plans by a number of sorting options and research drug plan formularies. You can also compare your current plan with its 2021 version. If you visit the site, be sure to choose CA from the list of states to show relevant plan options.

www.goodrx.com – A free price comparison resource for shopping prescriptions. Access coupons for discounted scripts at major pharmacies. Note: Cannot be used in conjunction with Part D plans.