Medicare & Your Coverage Options

Qualifying for Medicare by turning 65 years of age, receiving 24 months of disability, or retirement after age 65 will trigger an extremely important stage called Medicare Open Enrollment. Medicare Open Enrollment allows the recipient a one-time health free look at all the Medicare coverage options that are available. Open Enrollment occurs 3 months before and 3 months after you qualify for Medicare. After this time period, late enrollment may require you to pay penalties, answer health questions, or do without coverage until another enrollment period. This is why it is so important to consult with an experienced professional several months before you qualify for Medicare. Failure to consult with an experienced independent broker will result in making uninformed healthcare decisions. This outcome over time may cost the Medicare recipient money and lead to certain dissatisfaction with their healthcare plan as they get older.

Medicare Open Enrollment requires the individual to make several important healthcare decisions. One of the most common concerns is whether or not to enroll in Part B of the Medicare coverage. Most citizens are entitled to Part A at no charge which covers the hospital, hospice, skilled nursing and home health services. Medicare Part B is optional and costs $144.50 a month in 2020. To participate in additional Medicare coverage options the recipient must enroll in Part B. However, Medicare recipients do not have to enroll in Part B in order to qualify for Part D prescription drug coverage

Those who continue working after age 65 and have creditable employer coverage do not have to enroll in Part B. They can wait until retirement to enroll without penalty. Part B covers physicians services provided at your local doctors office or in the hospital. The recipient of these services covered by Medicare Part B is responsible for 20% coinsurance and $197.00 annual deductible. There is no limit on the Medicare recipient’s out-of-pocket expenses for Part B services.

For most people, relying on Medicare Parts A & B for insurance coverage is not a viable option. There is too much financial exposure with the Part B coinsurance portion of the coverage. This initiates another extremely important healthcare decision which must be made during the Open Enrollment process. Do I enroll in Medicare Part C or Medigap? Medicare Part C, more commonly known as Medicare Advantage, limits your financial exposure by setting annual out-of-pocket maximums. The out-of-pocket maximum denotes the most a Medicare recipient would spend in any one year.

Medicare Advantage plans are administered by private health insurance companies that are contracted by Medicare. These Medicare health plans must offer all services covered under Parts A & B of Original Medicare. Most plans include a Part D prescription drug coverage and you must be enrolled in Part B to participate. Medicare Advantage plans are low premium healthcare plans with networks of doctors, maximum out-of-pockets, coinsurance, and copays. Most Medicare Advantage companies offer HMO’s, PPO’s and Special Needs plans.

Enrolling in a Medicare health plan with a HMO requires that you receive healthcare from a select group of doctors who are contracted to participate with the network. Prior authorizations to see physicians are required and you must also utilize hospitals within the network to receive plan coverage except in emergencies. PPO’s have a more expansive group of participating doctors and hospitals. Medicare PPO recipients are not required to receive prior authorizations from their primary care physician before seeing a specialist. Special Needs Plans are for those individuals who are currently being treated for a chronic condition or those who have low income status. For example, a chronic condition could include health issues with the heart, lungs or blood sugar.

Medigap, also known as the Medicare Supplement, are premium based plans offered by private insurance companies with very few copays, no out-of-pocket maximums, and most do not include networks. Coverage under this option is provided by Medicare, Medigap and a separate Part D prescription drug plan. You must enroll in a Part D plan when you qualify for Medicare to avoid paying a penalty for future enrollments. Medicare recipients are exempt from the late enrollment penalty if they have creditable coverage through an employer plan.

Once you have chosen the Medicare coverage option that best suits your needs, it’s time to evaluate the companies and coverage benefits. Medicare Advantage plans are evaluated on a case by case basis. Drug costs and network doctors are the most important factors in determining what Medicare health plan you choose. This is evaluated by accessing each company’s drug calculator and physician directory. Professional consultation should lead you to the company with the best benefits and the least amount out-of-pocket annual costs.

Medigap offers standardized plans set forth by Medicare. These plans consist of A,B,C.D,F,F(high deductible),G, and N. Most Medigap recipients in 2020 are advised to choose a Plan G or N. Plan G has the 2020 Medicare annual deductible of $197.00 dollars which must be met before all healthcare costs are to payed by the plan. In addition to Medicare’s annual deductible, Plan N requires a $20.00 dollar copay at the doctor’s office and a $50.00 dollar copay in the emergency room. At this point, research is required to choose the best company with the best rates for each one of these plans.

In conclusion, it is important to seek consultation from an experienced professional who is an independent broker. Open Enrollment is a one-time opportunity to make an informed decision about the many options available. Making an informed decision also involves Medicare Part B and D enrollment as well as understanding the coverage options. These decisions are made with each individuals certain set of facts. Failure to consult with an experienced independent broker may cost the Medicare recipient money and lead to certain dissatisfaction with their healthcare plan as they get older.

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