ORLANDO, Fla. – Open enrollment for Medicare begins Oct. 15 and navigating what seems like the infinite combinations of plans can be difficult and downright exhausting.
We asked our News 6 Insiders to submit any questions they had about the program and took them straight to Justin Jacobs, president and CEO of Health Plan Markets, to get the answers. Jacobs has more than 17 years of experience researching and helping clients choose the best Medicare plans for their specific needs.
What is the difference between HMO-POS and regular HMO? - Deborah Weigert
Jacobs: An HMO by definition means that you have a health plan that has created a network of doctors and hospitals. When you’re enrolled in an HMO plan, which means Health Maintenance Organization, you must use a network and typically you have to stay in that network, otherwise you’re responsible for 100% of the cost of anything that happens. HMO means you’ve got to stay in that network. Also, most HMO plans require that you have a referral. When you want to see a cardiologist or a neurologist, you would need to then get a referral from a primary care doctor and they would refer you to that specialist. The newer flavors coming out are the HMO-POS which means Point of Service. The POS agreement basically allows you to go outside of that HMO network if that doctor outside the network agrees to the terms and conditions of that health plan for that visit. The doctor’s not in network but they’re saying this one-time visit, ‘I’m in network, I agree to the terms, I can then go see that doctor.’ It gives a little flexibility to see the doctors not in the HMO network.
I hear people talking about getting extra help for groceries, but I don’t see anything listed for Medicare Advantage. (Is this true?) - Deborah Weigert
Jacobs: Absolutely, it’s true. Certain Medicare Advantage plans do have what’s called a ‘supplemental benefit’ where they give you credits, either on a Visa card or on your actual ID card where you can go to certain stores or call and have groceries delivered to your home, and you can get a credit for groceries on your health plan. Depending on your income, you may qualify for additional assistance and those benefits get richer and richer depending on how much help you actually need. For 2023, it seems to be a very hot topic because a lot of folks do need help with the inflation that’s happening right now, so groceries is a hot button. Ask your agent if your plan has a grocery credit included.
I am going to retire when I hit 65 in two years and I will get Medicare. My wife is getting Social Security now at 62. But when I get my Social Security at 65, can she get Medicare then too? She will be 64. - Craig Fausett
Jacobs: “Even though you turn 65, that doesn’t necessarily mean that you’re eligible for Medicare. You also must have 40 quarters or ten consecutive years of paying into Medicare taxes. So on your paycheck, everyone usually gets that nice Medicare tax taken out and that’s actually going into your Medicare fund, so you have to have 40 quarters of that paid into. Although you hit 65, if you’re short on quarters you might have to wait for 66 or 67 until you’re actually eligible for Medicare. Even though you’re married, Medicare looks at you as individuals. So, in that circumstance, your wife would also need to be eligible for Medicare when she turns 65 and has 40 quarters of payment into the Medicare system. However, some folks get Medicare before 65, like those with disability. If Social Security approves a disability for two years, for 24 months, at the end of the 24 months, you should receive Medicare and that can happen at any age. The youngest I’ve seen is 2 years old, born with a disability and they were eligible for Medicare.
I turn 65 in July 2023. When do I transition to Medicare, in calendar year 2023 or 2024? - Walter Thinnes
Jacobs: If you’re born on the first of July, you’re eligible for Medicare in June, but any other time in July, you’re eligible July 1. That also depends on if you have those 40 quarters. If you’re eligible for Medicare, once your 65th birthday approaches, you should get a packet in the mail that says you’re eligible for Medicare.
Do Medicare recipients get free eyeglasses up to a certain amount each year? - Garry Liang
Jacobs: If you’re on original Medicare, the answer is no. There’s no vision coverage, there’s no dental coverage. There’s very limited hearing, unless it’s an emergency or tied to a disease. You’re not going to get any of those benefits. If you’re on a Medicare Advantage Plan, there are plans that include vision, dental and hearing benefits.
Which Medicare plan is the best? How do I get the information to make my decision? - Ken Hunt
Jacobs: “That is a tough question, because each person has their own unique needs. What you need to do is analyze what you need in a health plan. Medicare Advantage has different parts, so depending on what you’re looking for whether it’s exceptional drug coverage or you’re looking for things like transportation or gym membership, it’s going to vary per person. You really have to first analyze what your needs are, what doctors you go to, what drugs you take, if you’re looking for specific benefits, that would be a great place to start. Then you have to go shopping. One of the things we do at Health Plan Markets is sit with our clients and we go through that analysis, answer those questions and make sure we find the best plan to fit your needs for the upcoming year.
The first thing you want to do is go to medicare.gov. That’s the official website from the federal government. They’ve actually cleaned it up, it looks a lot nicer this year, user friendly. You can start there. You’ll be able to see what plans are available in your area. You’ll first be asked your zip code so you can pull up all the different plans out there. You can do some research on those plans, such as the star ratings, and go from there.”
Jacobs said he recommends you work with an agent or broker who knows the terminology and can guide you through the process. For those not tech savvy, agents and brokers can help sign you up and guide you through the online process.
“Going alone, you can make some mistakes that will cost you in the end, like the penalties. The best part is that agents and brokers, they don’t cost you anything. They actually get paid by the plan you enroll in, so you get free customer service when you enroll with an agent.”
What is the yearly deductible for Part B? - Dan Warner
Jacobs: The yearly deductible coming into 2023 is going to be $226. What that deductible is, is if you have just Medicare alone without a health plan, before you go see a doctor or outpatient service, you need to pay the first $226 before Medicare starts to help you, then it goes to 20% coinsurance as your responsibility and Medicare picks up the 80%. It does change from year to year, so last year it may have been lower. It goes up typically 4-6% every year in that deductible. Most Medicare Advantage Plans cover that deductible for you.
Prescriptions: What is a donut hole? Why does it exist? Why do I have to pay over $8,000 before the plan starts paying again? - News 6 Insider
Jacobs: Back in 2005, Medicare came out with Medicare Part D and it’s easy to remember, D for drugs. So that was an additional program implemented back in 2005, adding prescription drug coverage to the Medicare equation. Fast forward, they didn’t quite know how that was all going to work between the beneficiary paying their portion, health plan paying their portion and the manufacturer paying their portion. So a few years later, they created the ‘donut hole’ to help control cost and to ensure that everyone is getting a fair deal between the beneficiary first, the manufacturer and the federal government. They created levels in between where you have different phases throughout the year. So Jan. 1, your phase resets and you start at zero dollars spent and then you have an initial coverage phase, and deductible phase before that, then you hit your copays, then the donut hole. The donut hole, this year has basically gone away where previously you were responsible for a large portion of your prescription drugs. Now, you basically pay your copays all the way through that donut hole now. It was created to control costs.
I don’t know the context of the question about paying $8,000. I’m glad to tell you that on supplements there’s really no limit. Whatever the supplement is paying, if there’s a percentage there, that percentage is there forever and ever that you’ll have to pay through the end of the year. With Medicare Advantage there’s this mechanism called ‘maximum out-of-pocket’ so in a given year, the maximum amount out-of-pocket will prevent you from paying anymore than that limit. This year, it’s about $4,600 depending on what plan you use, so you’ll never pay more than that for that plan in any given year out-of-pocket. There’s protections like that for Medicare Advantage, that’s not in Medicare or Medicare Supplements.
Pitfalls of Medicare?
Jacobs: One of the pitfalls of Medicare is that it only covers 80% after our deductibles. So you have yearly deductibles, you also have a Part D for drug deductible, then you also have a Part A deductible for hospitals, emergency services and things like that. So you have all these deductibles that happen and then Medicare comes to pay about 80% leaving you with about 20%. Having a health plan is essential. I would not recommend having just Medicare, unless there’s some kind of certain circumstance where your health has declined and you’re in a nursing facility or hospice.
Difference between Medicare Supplements and Medicare Advantage Plan?
Jacobs: The difference between Medicare Supplements and Medicare Advantage Plan is what we call ‘coordination of care.’ Quick example: If somebody goes to the hospital and they have a supplement, everything’s paid for, you don’t have to worry just like Medicare Advantage Plan. But when you get out of that hospital, there’s no coordination of care, they’re not going to call your doctors, they’re not going to help you with referrals, they’re not going to check your medications. They’re not going to do anything. They’ll pay the bill and you’re on your own. If you need follow up from a specialist or lab work, you’ll have to handle that on your own. The benefit of Medicare Advantage is in that same scenario, as soon as you hit the hospital and you show your ID card, they’re contacting your health plan, who’s then contacting your primary care doctor and now that coordination of care happens scheduling any additional appointments and follow-ups.
Most of the Medicare Advantage plans are zero premium, but depending on where you live, you may have to pay a small premium. Typically, there’s no premium, however you do have to continue paying Medicare Part B and this year it’s about $165 a month for the average person. It’s gone down from more than $170. (for the first time in history). So how is it zero dollars for premium? Medicare pays your health plan every month that you’re enrolled. They do it because it’s less expensive for them to pay someone to manage your care, then for them to do it themselves.
I get medical and vision treatment from the VA. I believe the only supplement I would need is dental. I’m a 10% disabled vet. Is it possible to just get that (dental) coverage? - News 6 Insider
Jacobs: Yes, you can purchase a stand-alone dental plan depending on your age. There (are) certain companies that will cover dental up to a certain age. We have some products we can look at that are not age-restricted, so yes, you can go and purchase a stand-alone dental plan. If dental’s a big decision for you, you’ll want to look at a Medicare Advantage plan. Some of them are offering unlimited dental coverage and that includes dentures, root canals or extractions. All that is being covered by Medicare Advantage for the first time.
Just because you have VA benefits, doesn’t mean that you’re stuck at the VA. A lot of people feel frustrated with the system at VA because they’re overwhelmed. There’s a lot of vets out there who just don’t get the health care they need or they’re sicker than others and going to the VA is not always the best experience, so some vets are actually looking for a private doctor or private network to supplement their veteran benefits and going to the VA clinics and hospitals. You can absolutely use both, Medicare and VA benefits.
I need to apply for Medicare. My husband died and I was on his group plan insurance and effective Sept. 30, 2022, I was let go from his policy since he died. I’m 69 years old and receive retire Social Security benefits. - News 6 Insider
Jacobs: From Sept. 30, if your policy actually ended on Sept. 12, officially with Medicare, you have 60 days to choose a new plan. If you don’t currently have Medicare, then you can go ahead and apply at socialsecurity.gov. I know it seems confusing to be going to the Social Security website for Medicare, but you actually have to go through Social Security to apply for Medicare. What they’re going to ask you is, ‘If you’re older than the age of 65, why did you not have Medicare coverage?’ and the answer you’re going to give them is that you had credible coverage through your husband’s employer. So that will eliminate any penalties for not having Medicare from the age of 65 and on and it will open up a special election period where you can enroll in Medicare Part(s) A and B. But you’ll also be given an opportunity to join a Medicare Supplement or Medicare Advantage of that time.
Medicare has several different penalties. The major one we run into a lot is if people do not have Medicare Part D drug coverage. In 2008, they mandated you must have prescription drug coverage. If you did not have prescription drug coverage, you’re penalized 1% every month you did not have it. Another penalty is for not having Medicare Part B, covering doctors and outpatient services and there’s a cost to it. This year it’s about $165, but most people see that and say, ‘I don’t want to pay $165 a month,’ so they decline Medicare Part B, which you can do. The only time I recommend you do that is if you have credible coverage through an employer or your spouse’s employer and that make sense. But some people see that $165 bill and they decline it and then a year or two years go by, and Medicare’s penalty is 10% every year you don’t have Part B and they tack it on to your premium when you enroll. So out of $165 a month, if you missed it for a year, you’re going to get a 10% increase so you’re going to pay an additional $16.50 a month just because you didn’t have it for the one year you were eligible.
Which Medicare advantage plan covers the most of Medicare Part B? - Sally Fernald
Jacobs: Medicare Part B is that outpatient services: the doctors, the specialists, the lab work, ambulance - those types of things are covered in Medicare Part B. Every Medicare Advantage plan that has a contract with the federal government must meet or exceed the same benefits Medicare offers, so it can’t go lower. It’s going to cover everything Medicare covers so that’s part of that question. All the Advantage plans cover Medicare Part B, so you don’t have to worry about that. The difference in the plans is going to be based on what we call copayments, so that’s where the shopping comes in. Is the specialist copay important to you? Because it can range from zero to $50 every time you see a doctor. Shop around.
I am 66 and still working full time and have full medical paid by employer. I do not have any Medicare. Should I sign up for Part A only or wait until I retire in a couple years? - Darrell Vandergriff
Jacobs: This happens a lot. We’re seeing more and more people waiting to retire (at) 67 or 70 years old. You can actually max out your Social Security benefits that’s up until age 70, so I see a lot of people being savvy about that. Do you have to take Medicare? The answer is no. You can delay when you enroll in Medicare and again as long as you have credible coverage through an employer and have some type of coverage that’s credible, then you will not have to worry about the penalties. Just make sure the coverage that you have currently is credible, so when you turn on your Medicare you won’t get hit with those penalties. At age 66 or 67, some people have already gotten their Medicare card and have declined that Part B that we talked about because they have coverage and that’s fine. Sometimes they choose to keep Part A. They can keep Part A, there’s no cost for Part A as long as you’ve worked those 40 quarters, and there’s no monthly cost for it. So I see a lot of people doing that: Keeping Part A and then they have their employer benefits, so that’s there for them so they have both coverage. That’s totally legal and fine to do.
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