North Shore Senior Healthcare Resource Center Frequently Asked Questions (FAQs)
Questions and Answers
1) What is Medicaid?
Medicare is a state and federal program that provides health insurance if you have very low income.
2) What is Medicare?
Medicare is a federal government insurance program for individuals who are age 65 or older, or individuals with certain disabilities, regardless of income or assets.
In simple terms there are three parts – hospital insurance; doctor’s medical coverage and prescription drug coverage.
The categories of Medicare Choices are:
Part A – (Hospital Insurance) covers impatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care
Part B (Medical Insurance) covers certain doctor’s services, outpatient care, medical supplies, and preventative services
Part C – Medicare Advantage (MA) Plans – Medicare through private insurers that covers all Medicare Part A and all Medicare Part B benefits and many have additional options (such as physical exams, hearing aids, dental services, worldwide emergency care, and over-the-counter drugs). MA plans also are required include an annual maximum out-of-pocket dollar cap (deductibles, coinsurance and copayments) on Part A and Part B. The Original Medicare does not have such a cap. You must qualify for Part A and be enrolled in Part B to enroll in a Medicare Advantage plan.
Part D – Prescription drug benefits available through private insurers.
Part E – Medigap Insurance (Medicare Supplement) – works only with Original Medicare and is sold by private insurance companies to fill the gaps in the original Medicare insurance.
3) How do I choose?
Before you can enroll in a Medicare healthcare plan such as Medicare Advantage (also known as Part C) or a Medicare Supplement (Part E) and also known as Medigap, and a prescription drug plan (also known as Part D) you will need to enroll in Medicare Part A (for hospital coverage) and Part B (for medical coverage). This process may take one to two months to receive your card, so try to give yourself at least three months to learn the options and start the enrollment process.
After enrolling in Medicare Part A and Medicare part B, generally there are two options: 1) enroll in Part E (Supplement) and Part D (Prescription Drug Plan) , or 2) enroll in a Medicare Advantage Plan.
The decision making process you’ve used to buy your health insurance in the past still applies when evaluating your Medicare options. Consider these relevant questions and then compare the plans that are available to you for the best fit.
Are you in good health?
What doctors/specialists do you see?
What medications do you take?
What pharmacies do you prefer?
How much can you afford to pay for monthly premiums or out-of-pocket costs?
What healthcare services are most important to you?
Are you eligible for other healthcare insurance?
Do you plan to travel out of the US?
Do you have a chronic condition?
Do you need financial assistance?
4) What does Medicare cost?
Part A: As long as you or your spouse paid Medicare taxes for at least 10 years (40 quarters), you will be able to receive Part A insurance without having to pay a premium. You will still be responsible for paying an annual hospital deductible (which was $1,408 in 2020) and a portion of the expenses for hospital stays that last longer than 60 days or nursing home stays beyond 100 days. For those individuals who do not automatically qualify for premium free Part A coverage, the monthly premium in 2020 is up to $4583 depending on an individual’s duration of Medicare covered employment.
Part B: In 2020 the standard monthly premium for Part B was $144.60 (or higher depending on income). Most people who get social security benefits pay less. As with Part A, you will pay an annual deductible for Part B ($198 in 2020). And some covered services require you pay a percentage of the charges or a co-payment amount approved by Medicare.
You’ll make these payments throughout the year in a Medicare drug plan:
- Yearly deductible
- Copayments or coinsurance
- Costs in the coverage gap
- Costs if you get Extra Help
- Costs if you pay a late enrollment penalty
Your actual drug plan costs will vary depending on:
- The drugs you use
- The plan you choose
- Whether you go to a pharmacy in your plan’s
- Whether the drugs you use are on your plan’s
- Whether you get paying your Medicare Part D costs
For 2020 the standard benefit requires the beneficiary to pay:
- a $435 deductible (2020)
- After you pay your plan’s deductible (if your plan has one), the amount you pay for each prescription is either:
- A . With a copayment, you pay a set amount (like $10) for all drugs on a tier. You may pay a lower copayment for generic drugs than brand-name drugs.
- . With coinsurance, you pay a percentage of the cost (like 25%) of the drug.
- The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $4,020 on covered drugs in 2020, you’re in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap. Once you reach the coverage gap, you’ll pay no more than 25% of the cost for your plan’s covered brand-name prescription drugs. You’ll pay this discounted rate if you buy your prescriptions at a pharmacy or order them through the mail. Some plans may offer you even lower costs in the coverage gap. The discount will come off of the price that your plan has set with the pharmacy for that specific drug. Not everyone will enter the coverage gap.
- Once you’ve spent $6,350 out-of-pocket in 2020, you’re out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get “catastrophic coverage.” It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.
Note: Beneficiaries generally have to pay a penalty to join a Part D plan if they do not have creditable coverage and do not enroll when first eligible for Part D.
The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.
Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($32.74 in 2020) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.
The national base beneficiary premium may change each year, so your penalty amount may also change each year.
Medigap: Benefits offered under a Medigap or supplemental insurance policy are standardized across the US, but the premiums, deductibles and co-pays can vary widely. North Shore Senior Healthcare or The Medigap Policy Search on the Medicare Website can help you compare the costs and benefits of the Medigap and Supplemental Insurance policies available to you.
5) When can I enroll?
There are five types of election periods during which individuals may make enrollment requests.
Annual Election Period (AEP)
OCTOBER 15th through DECEMBER 7th – During this time all Medicare beneficiaries are able to enroll in a Medicare Advantage Plan, or you can change from one Medicare Advantage plan to another “like” plan. This is the only period where you can enroll in a Medicare Advantage Plan for 2020 for membership in 2020
During the Annual Election Period:
Beneficiaries may add or drop MA and/or drug coverage, or return to Original Medicare.
No action is needed if the beneficiary chooses to keep his/her current plan. She/he should check for any benefit changes under the plan.
Beneficiaries may make more than one enrollment choice during the Annual Election Period, but the last one made prior to the end of the Annual Election Period, as determined by the date the plan or marketing representative receives the completed enrollment form, will be the election that takes effect.
The Medicare Advantage Disenrollment Period (MADP)
JANUARY 1 through FEBRUARY 14 – Medicare Advantage plan members may disenroll from any MA plan and return to Original Medicare between January 1 and February 14 of every year. A request made in January will be effective February 1, and a request made in February will be effective March 1.
MA and MA-PD enrollees may request disenrollment from their plan and return to Original Medicare and subsequently may enroll in a PDP or may simply request enrollment in a PDP, resulting in automatic disenrollment from the MA plan. (Exception: MA-only PFFS must request disenrollment first.)
Example: Mrs. Jones enrolled in Goodplan’s MA-PD during the AEP. However, she has decided that she wants to go back to Original Medicare. Mrs. Jones and either simply enroll in a PDP or can disenroll from Goodplan and enroll in a PDP. Either way, she will go back to Original Medicare with a Part D plan.
Special Election Periods (SEP)
An SEP IS AVAILABLE THROUGHOUT THE YEAR for those who qualify. Some of the common reasons that qualify a beneficiary to join an SEP include some (but not all) situations resulting in an SEP include:
Change in residence (moving out of your plan’s coverage area)
Involuntary loss of creditable drug coverage
Exceptional conditions such as
Gaining or losing Medicaid eligibility (note: dual eligible beneficiaries have a continuous special election period as long as they retain dual eligible status)
Gaining or losing the Part D low-income subsidy
Changing employer/union group health plan coverage
Enrollment based on incorrect or misleading information
Non-U.S. citizens who become lawfully present in the United States.
Timeframes for SEPs are variable, however, most begin on the first day of the month in which the qualifying event occurs and last for a total of three months.
The SEP ends when the individual utilizes their SEP to make an allowed change, or the time period expires, whichever comes first.
Contract Violations Marketing Misrepresentation Beneficiaries who have enrolled in a MA or Part D plan based upon misleading information are entitled to a SEP and must contact Medicare (e.g., call 1-800-MEDICARE).
EXAMPLE: Agent Badd mistakenly tells Mrs. Gomez that her oncologist is in-network for her HMO. Mrs. Gomez discovers the Oncologist is not in the network and therefore her services are not covered. Mrs. Gomez calls CMS, which arrangements for a SEP so that Mrs. Gomez can switch plans.
Open Enrollment Period For Institutionalized Individuals (OEPI)
The OEPI is continuous for eligible individuals who meet the definition of “institutionalized” to enroll in or disenroll from a Medicare Advantage Special Needs Plan for institutionalized individuals.
Initial Coverage Election Period (ICEP)
The ICEP for an MA enrollment election will often revolve around an individual’s 65th birthday or the 25th month of disability. It is always associated with one’s entitlement to both Medicare Part A and Part B. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the last day of the month preceding entitlement to both Part A and Part B or the last day of the individual’s Part B initial enrollment period (whichever date comes last).
Example: Mr. Young’s 65th birthday is June 20, 2020. He is eligible for Medicare Part A and Part B beginning June 1, 2020 and has decided to enroll in Part B beginning on June 1. His ICEP begins on March 1, 2020 and ends on September 30, 2020.
During the ICEP:
An eligible individual may enroll in an MA plan.
An individual may also choose an MA-PD when the IEP and ICEP occur at the same time.
The individual can make one enrollment choice under the ICEP. Once enrollment is effective, the ICEP is used.
6) When Can I enroll in a prescription drug plan (PDP)?
Enrollment Periods for Part D (prescription plan) Initial Enrollment Period (IEP) begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.
Individuals eligible for Medicare prior to age 65 (such as for disability) will have another IEP when attaining age 65.
During the Part D IEP beneficiaries may make one Part D enrollment choice,
Generally, individuals will have an IEP for Part D that is the same period as the Initial Enrollment Period for Medicare Part B.
Example: Mr. Landreth’s 65th birthday is October 23, 2020. He is currently working. He signed up for Medicare Part A benefits, effective October 1, 2020. However, he declined Part B, because he has employer based insurance. He is eligible for Part D since he has Part A and lives in the service area. Even though he did not enroll in Part B, his Part B IEP is still the 3 months before, the month of, and the 3 months following his 65th birthday – that is, July 2020 – January 2021. Hence, his IEP for Part D is also July 2020 – January 2021.
The MA ICEP and the Part D IEP occur together as one period when a newly Medicare eligible individual has enrolled in BOTH Part A and B at first eligibility.
7) What if I missed my opportunity to change during the annual enrollment period?
For Medicare Advantage benefiticaries, you can make one change during the Open Enrollment Period (OEP) which is January 1st through March 31st of every year.
Note: If you miss your Initial Enrollment Period and you don’t have employer health coverage, you cannot enroll for Medicare until the following January. Your coverage won’t start until July 1st, and you may face penalties for late enrollment. These penalties can add up to hundreds of dollars a year and will follow you for the rest of your Medicare life.
Special Enrollment Period (SEP) – You can delay enrollment in Part B without penalty if you were covered by employer health insurance through your or your spouse’s current job when you first become eligible for Medicare. You can enroll in Medicare without penalty at any time while you have group coverage for eight months after you lose your group health coverage or you (or your spouse) stop working, whichever comes first. Medicare begins the first month after you enroll.
8) What are some important dates to remember for the Annual Election Period?
Mark your calendars for the following:
October 1st – Begin to assess your needs and compare plans call your agent, SHIP office or Medicare to review your options
October 15th – December 7th Open Enrollment Period – this is the time to switch your plan if you so desire
January 1st – New coverage begins
9) Where can I go for help?
North Shore Senior Healthcare, LLC (local licensed agency)
Navigating Medicare can be overwhelming. Get the confidence and peace-of-mind that comes from having a personal, local and licensed consultant guide your decision making and enrollment. Call us today for an appointment.
Social Security Administration
10) Can I be denied for health reasons?
No, not if you are eligible for Medicare and guaranteed issue. In fact, you cannot be asked health questions unless they are necessary to determine eligibility to enroll (e.g., end-stage renal disease (ESRD), chronic care special needs providers (SNPs), low income subsidy (LIS)).
11) Do I have to be enrolled in Part A and Part B to enroll in a Medicare Supplement policy?
12) Does switching from one Medicare Supplement Plan to another allow me to avoid underwriting?
No. Switching from one Medicare Supplement Plan to another is not necessarily guaranteed issue. You may have to go through underwriting.
13) Enrollment discrimination is prohibited. What does this mean to you?
You cannot denied or discouraged from enrollment regardless of race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claim experience, medical history, genetic information, evidence of insurability, or sexual orientation.
14) Do I have a right to file a complaint?
Enrollees of a plan have a right to:
File complaints (sometimes called grievances), including complaints about the quality of their care;
Get a decision about health care payment or services, or prescription drug coverage; and
Get a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.
An enrollee or their representative may make the complaint orally, in writing, or via a CMS website at: https://www.medicare.gov/MedicareComplaintForm/home.aspx.