In retirement he documented his WWII experiences methodically and went to great lengths to reconnect with fellow veterans to publish their stories. Last year I was fortunate to join him, and fifty other veterans, on a historic trip to Normandy to commemorate the 80th anniversary of D-Day (see recent Marin IJ article). He was a staunch defender of truth and liberty. Dad will be greatly missed but his long and impactful life was a blessing to us all.

In loving memory, Phil Dougherty & Patty Dougherty

• Switch to a new Medicare Part D drug plan for the next calendar year.
• Enroll in a Medicare Part D drug plan for the first time
• Cancel a Medicare Part D drug plan
• Change a Part C Medicare Advantage plan for the next calendar year
• Switch from Original Medicare to a Part C Medicare Advantage plan

Medicare Supplements are NOT Medicare Advantage plans nor are they a part of Medicare. Medicare Supplements are private policies that are designed to coordinate with Medicare to fill-in its gaps (deductibles and co-insurance).

Medicare Supplements can also be changed annually but during what’s called the Birthday Rule period. It is a minimum 60-day period that starts on your birthday. During this time, you can change to another carrier’s Medicare Supplement – on a guaranteed basis – that is valued to be equal to or less than your current policy (for example, Plan F to Plan G or Plan G to Plan G). If your birthday coincidentally falls during the AEP, then you can make a change in Medicare Supplements.

NOTE: You can actually “apply” for another carrier’s Medicare Supplement at any time, but if it is outside this Birthday Rule period or other Qualifying Event, your application is subject to medical underwriting and could be denied.

If you have any questions about the Annual Enrollment Period, the changes you can make or any related subject, don’t hesitate to send me an email. Also, don’t hesitate to reach out to me nearer to your birthday to see if a change in your Medicare Supplement is worth considering. Happy to share rates and information of competing plans.

All the best during this AEP & Holiday Season!

Phil Dougherty

OnlyHealthInsurance

Here are the important changes you need to be aware of:

• Medicare will eliminate the Coverage Gap (Donut Hole). This was the level that when reached typically resulted in higher drug costs.

• New $2,000 out-of-pocket maximum for all covered medications. A big change for Part D enrollees will be the $2,000 out-of-pocket maximum per year for medications. Once you have spent $2,000 in drug costs for covered medications, you are done for the year.*

• New Medication payment plan option. A new payment plan option will allow you to pay for medications over the course of the year in the form of a payment plan instead of up front. The new “opt-in only” plan allows someone to spread the payments out for the remainder of the months in the year.

With these rule changes that could significantly shift costs to Part D drug plans there are concerns that premiums will increase dramatically. To curb this fear, CMS created a voluntarily premium-stabilization plan that will subsidize drug plans who participate. We will learn very soon how well this will curb rate increases.

IMPORTANT!! You will receive an Annual Notice of Change from your Medicare Part D drug plan very soon. It will inform you of changes in your drug plan for 2025. This will include changes in plan premiums, deductibles and co-pays, and whether the plan will even be offered next year. It will also share whether your prescriptions will be covered and, if so, how much your share of costs will be. It is very important to read this notice thoroughly.

More to come!

Phil Dougherty, OnlyHealthInsurance

* This cap does not apply to out-of-pocket spending on Part B drugs. Medicare Part B covers drugs that are administered by a doctor, nurse, or other healthcare provider in an outpatient setting such as a doctor’s office.

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!

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).

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.