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Medicare Part D

Medicare Part D is the federal government's prescription drug program that covers both brand-name and generic prescription drugs at participating pharmacies in your area. The coverage is available to all people eligible for Medicare, regardless of income and resources, health status, or current prescription expenses. Medicare prescription drug coverage provides protection for people who have very high drug costs.

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What is Medicare Part D?

We've put this section together to help answer some of your questions, but feel free to contact us with your questions.

Medicare Part D is the federal government's prescription drug program that covers both brand-name and generic prescription drugs at participating pharmacies in your area. The coverage is available to all people eligible for Medicare, regardless of income and resources, health status, or current prescription expenses. Medicare prescription drug coverage provides protection for people who have very high drug costs.

How does Medicare prescription drug coverage work?

Medicare Part D works in tandem with Medicare Parts A and B. Individuals entitled to Part A or enrolled in Part B can sign up for Part D to receive help paying for prescription drugs. Like other insurance, if you join, you will pay a monthly premium, which varies by plan, and (for most plans) a yearly deductible. You will also pay a part of the cost of your prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. Plans also vary in terms of the co-pays, prescription drugs that are covered (this is called the "plan formulary") and the pharmacies that may be used.

If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. Individuals enrolled in both Medicare and Medicaid ("Dual Eligibles") who have not already selected a Part D plan will be automatically enrolled in Medicare Part D by their state agency.

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If I am on Medicare do I have to enroll in Part D?

Medicare Part D is an optional plan. No one is required to enroll but if you are eligible and delay enrolling, you risk paying a penalty in terms of increased insurance premiums when and if you enroll at a later date.

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How do I get more information and enroll?

Enrolling in Medicare Part D is easy. Call us or click here for a free Medicare Part D quote. We can answer your questions and handle your enrollment over the phone or email/mail an application to you if you wish. Coverage becomes effective on the first day of the month after your enrollment.

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What is the Initial Enrollment Period (IEP)?

The Initial Enrollment period for Medicare Part D (IEP) is a one-time event when an individual first has the opportunity to enroll in Medicare. It occurs for most people when turning age 65. For people turning 65 the Part D IEP lasts seven (7) months (it begins three (3) months prior to your birth month, includes your birth month, and extends three (3) months after your birth month). In addition, people enrolling in Medicare Part B after their entitlement to Part A ends, may enroll in Part D using a Special Election Period (SEP). If no SEP is applicable they may enroll in Part D during the next Annual Election Period (AEP), however a penalty may be enforced which would increase their premiums for Part D.

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What is the Annual Election Period (AEP)?

The Annual Election Period begins October 15, and ends December 7. Anyone who already enrolled in a Medicare Part D plan may change plans during this period each year without penalty. Eligible individuals (people on Medicare) who chose not to enroll during their initial Open-Enrollment Period may enroll in Medicare Part D between October 15 and December 7 each year, but penalties will apply unless the individual had "creditable" prescription drug coverage*. Enrollments during this period have an effective date of January 01.

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What is a Special Election Period (SEP)?

You may qualify for a Special Election Period if:

*To avoid a penalty, individuals must apply for Medicare Part D within 63 days of losing "creditable" prescription drug coverage, which is coverage that is at least as good or better than the standard benchmark level of Medicare Part D Prescription Drug coverage as determined by the individual's coverage provider.

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Can I change my Part D plan after I enroll?

Once enrolled in a Medicare Part D Prescription Drug Plan individuals can only change their plan from October 15 to December 7 of each year, with an effective date of January 1 of the following year.

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Important Medicare Part D Dates to Remember

October 15
Annual Election Period begins. First day you may elect to enroll in a Medicare Part D Plan, effective next calendar year.

December 7
Last day you can enroll or change Medicare Part D Prescription Drug plans for the next calendar year, unless you qualify for an exception.

January 1
First day you can use your Part D Prescription Drug Plan (PDP) card for that plan year.

Some categories of beneficiaries are not bound by the lock-in rules and may enroll or disenroll from a PDP plan in other than the AEP. An individual may at any time, during a designated Special Election Period (SEP), discontinue the election of a PDP plan offered by an PDP organization and change his or her election to original Medicare or to a different PDP plan. Examples of situations which may entitle an individual to an SEP include the termination or discontinuation of a plan, a change in residency out of the service area, the organization violating a provision of a contract or misrepresenting the plan’s provisions, or the individual meeting other exceptional conditions as CMS may provide. CMS has also designated an SEP for individuals entitled to Medicare A and B and who receive any type of assistance from Title XIX (Medicaid), including full-benefit dual eligible individuals, as well as those eligible only for the Medicare Savings Programs. This SEP lasts from the time the individual becomes dually eligible until such time as they no longer receive Medicaid benefits. Individuals who are eligible for an SEP under the guidance for Part D enrollment and disenrollment may use that SEP to also make an election into or out of an MA-PD plan.

from Medicare.gov,Prescription Drug Coverage (2016), Prescription Drug Coverage: Basic Information (2016)

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Drug coverage (Part D)

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Medicare Supplement

Consider these facts in deciding if Medicare Supplement insurance for hospital and medical coverage is right for you:

Medicare Facts

What is Medicare?

Medicare is the US Federal Government Health Insurance Program for:

Medicare has Four Parts:

Part A (Hospital Insurance)

Helps Pay For:

Care in hospitals as an inpatient, critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities, hospice care, and some home health care.

Cost:

Most people get Part A automatically when they turn age 65. They do not have to pay a monthly payment called a premium for Part A because they or a spouse paid Medicare taxes while they were working.

If you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show "Hospital Part A" on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

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Part B (Medical Insurance)

Helps Pay For:

Doctors, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Cost:

Most people get Part A automatically when they turn age 65. They do not have to pay a monthly payment called a premium for Part A because they or a spouse paid Medicare taxes while they were working.

Medicare beneficiaries pay a monthly Part B premium. The monthly Part B premium for 2015 is $104.90 for Medicare beneficiaries with incomes under $85,000 (single) and $170,000 (married). In some cases this amount may be higher if you did not choose Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it, except in special cases. You will have to pay this extra 10% for the rest of your life. The annual deductible for Part B in 2015 is $147.
Enrolling in part B is your choice. You can sign up for Part B anytime during a 7 month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-772-1213 to sign up. If you choose to have Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not get any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should get your Medicare premium bill by the 10th of the month. If you do not get your bill by the 10th, call the Social Security Administration at 1-800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

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Part C (Medicare Advantage Plans)

People with Medicare can get their coverage through Original Medicare (the traditional fee-for-service program) or from Medicare private plans (the Medicare Advantage program also known as Medicare Part C). Depending on where you live, you may be able to enroll in a Medicare Advantage Plan offering one or more of the following types of health care: HMO, PPO, PFFS, MSA.

Original Medicare

If you choose coverage under the traditional fee-for-service Medicare program, you can generally get care from any doctor or hospital you want and receive coverage for your care anywhere in the country. However, traditional Medicare has high cost-sharing requirements and does not currently cover the costs of certain services. To help pay for uncovered benefits and to help with Medicare's cost-sharing requirements, many people in the traditional Medicare program have supplemental insurance, known as Medicare Supplements or Medigap Plans (these supplemental insurance plans fill in gaps that Medicare does not cover but unlike Medicare Part C and Part D, these plans are not part of the government Medicare program).

Medicare Advantage Plans

Medicare HMOs

Medicare HMOs cover the same doctor and hospital services as the original Medicare program, but out-of-pocket costs for these services are usually different. HMOs appeal to some people with Medicare because they may provide additional benefits, such as eyeglasses, which are not covered by the traditional Medicare program. Medicare HMOs may charge a premium that you would need to pay in addition to the Part B monthly premium.

You should be aware that Medicare HMO enrollees generally can only use doctors, hospitals, and other providers in the HMO's network. For an additional fee, some HMOs offer point-of-service (POS) benefits that partially cover care received outside the network.

If you join a Medicare HMO, you will usually have to select a primary care doctor who is responsible for deciding when you should see a specialist and which specialist you should see.

Most HMOs will not pay for unauthorized visits to specialists in the plan, providers outside the HMO's network, or for non-emergency care outside the HMO's service area.

Medicare PPOs

Medicare PPOs, or "Preferred Provider Organizations," are private health plans, much like Medicare HMOs. HMOs and PPOs differ in two key ways:

Regional PPOs became available under Medicare in 2006. These plans are similar to local Medicare PPOs, but serve a larger geographic area (either a single state or multi-state area) and must offer the same premiums, benefits, and cost-sharing requirements to all beneficiaries in the region. Regional Medicare PPOs offer all Medicare benefits, including the prescription drug benefit. These plans often but not always have a single deductible for hospital and physician services and an annual out-of-pocket limit on cost sharing for benefits covered under Parts A and B of Medicare. Keep in mind that the out-of-pocket limit will vary depending on the plan you select. As with local PPOs, individuals who sign up for a regional PPO will typically pay more if they go to providers outside of the network.

Private Fee-for-Service (PFFS) Plans

Private fee-for-service plans cover Medicare benefits like doctor and hospital services, much like Medicare HMOs and PPOs. Unlike Medicare HMOs and PPOs, private fee-for-service plans do not have a formal network of doctors and hospitals. Still, not all doctors and hospitals are willing to treat members of a private fee-for-service plan. If considering enrolling in a private fee-for-service plan, make sure your doctor and hospital are willing to accept the private fee-for-service plan's payments for services before you enroll. Also, be sure you understand a plan's benefits and cost sharing requirements before you enroll because private fee-for-service plans decide how much enrollees pay for Medicare-covered services and may charge higher cost sharing for certain health care services than the original Medicare program. While private fee-for-service plans are not required to offer the Medicare drug benefit, most do. If you enroll in a private fee-for-service plans without drug coverage, you can also enroll in a Medicare stand-alone prescription drug plan for your drug coverage.

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your provider is not required to agree to accept the plan's terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your provider does not agree to accept the terms and conditions of payment, they may choose not to provide health care services to you, except in emergencies. If this happens, you will need to find another provider that will accept the terms and conditions of payment. Providers can find the plan's terms and conditions of payment on the plan's website.

Medicare MSA Plans

A Medicare MSA Plan is a health insurance policy with a high deductible coupled with a Medical Savings Account (MSA). Medicare pays the premium for the Medicare MSA Plan and makes a deposit to the Medicare MSA that you establish. You use the money deposited in your Medicare MSA to pay for medical expenses. If you don't use all the money in your Medicare MSA, next year's deposit will be added to your balance. Money can be withdrawn from a Medicare MSA for non-medical expenses, but that money will be taxed. If you enroll in a Medicare MSA, you must stay in it for a full year.

Special Needs Plans (SNPs)

Special needs plans are private plans that provide Medicare benefits, including drug coverage for beneficiaries with special needs. These include people who are eligible for both Medicare and Medicaid, those living in certain long-term care facilities (like a nursing home), and those with severe chronic or disabling conditions.

For additional information about Medicare Advantage plans, call 1-800-MEDICARE, or get information about Medicare options in your area on the Medicare Personal Plan Finder website, http://www.medicare.gov/MPPF/home.asp.

Medicare Advantage and Prescription Drugs

All companies offering Medicare Advantage plans must offer prescription drug coverage in at least one of their plans. Medicare Advantage plans with drug coverage may vary in their premiums, deductibles, formularies and cost-sharing, depending on the type of Medicare Advantage plan you select.

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Know What You Want from a Medicare Plan

Whether Original Medicare alone, Original Medicare plus a Medicare Supplement plan, or a Medicare Advantage plan is right for you will depend on your unique needs and circumstances. Think about what is most important to you when you are healthy and when you are sick. Here are some topics to consider:

Receiving care from the doctor and hospital of your choice

Under original Medicare, you can use whichever specialists and hospitals you choose, whenever you need, and without a referral from another doctor, so long as they accept Medicare Assignment. Medicare private plan options could limit your ability to get care from the doctor or hospital of your choice, or there may be extra charges for out-of-network care. If provider choice is a priority, you should consider original Medicare with added protection from a Medicare Supplement insurance policy, sometimes known as Medigap, or from an employer-sponsored or union retiree health plan, if you are eligible.

Getting coverage of additional benefits to reduce your medical costs

If you are on a tight budget and are willing to limit your choice of doctors and hospitals, you may be able to reduce your health care expenses and get coverage of additional benefits through a Medicare Advantage plan. It is important to review the scope and limits of additional benefits when choosing among available plans. It is also important to look at how much your out-of-pocket costs will be if you get sick. For example, some Medicare private plans charge a copay for each day of an inpatient hospital stay, while original Medicare charges only a deductible but no daily copays for the first 60 days of a hospital stay.

Maintaining health care coverage while away from home

Under original Medicare, you will be covered for care anywhere in the United States. While private plans must cover emergency care for members outside the plan area, most do not cover other health care services while away from home. For example, Medicare HMOs have more restrictive networks of doctors and hospitals that limit coverage away from home.

Keeping supplemental coverage from a former employer or union

If you are considering joining a Medicare private plan (either a Medicare Advantage plan or a stand-alone prescription drug plan), you should talk to your employer or former employer to be sure you won't lose valuable retiree health benefits if you sign up for a private plan. Many employers offer retiree health coverage as a supplement to traditional Medicare; some also offer coverage through Medicare HMOs and other private plan options.

Coordinating with Medicaid benefits

If your income and assets are quite modest, you may qualify for Medicaid benefits or other special programs that will help pay some of your health care costs. For those who qualify, Medicaid often pays for valuable benefits, such as nursing home care, and also pays Medicare's premiums. If you are already covered by Medicare and Medicaid, you should find out what you must pay to join a Medicare private plan and whether Medicaid will cover the plan's copayments.

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Medicare Part D (Prescription Drug Coverage)

Medicare Part D is the federal government's prescription drug program that covers both brand-name and generic prescription drugs at participating pharmacies in your area. The coverage is available to all people eligible for Medicare, regardless of income and resources, health status, or current prescription expenses. Medicare prescription drug coverage provides protection for people who have very high drug costs. For more details see What is What is Medicare Part D.

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Medicare Eligibility

Who is Eligible for Medicare?

Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are a younger person with a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).

Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:

  • You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.
  • You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if:

  • You have received Social Security or Railroad Retirement Board disability benefit for 24 months.
  • You are a kidney dialysis or kidney transplant patient.

While you do not have to pay a premium for Part A if you meet one of those conditions, there are deductibles for Part A. In 2015, the Part A deductible for days 1-60 is $1,260, 61-90 is $315, 91 and beyond Coinsurance is $630, beyond lifetime reserve days is all costs.

You must pay for Part B if you want it. In 2015 the monthly premium for Part B is $104.90 for most with incomes under $85,000 (single) and $170,000 (married). The deductible for Part B in 2015 of $147. It is usually deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months.

If you have questions about your eligibility for Medicare Part A or Part B, or if you want to apply for Medicare, call the Social Security Administration. The toll-free telephone number is: 1-800-772-1213. The TTY-TDD number for the hearing and speech impaired is 1-800-325-0778. You can also get information about buying Part A as well as part B if you do not qualify for premium-free part A.

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Standard Plans

Standardized Medicare Supplement Plans for Most States(excluding MA, MN and WI )

Every company offering Medicare Supplement insurance must offer Plan A. In addition, companies may have some, all, or none of the other plans.

Basic Benefits (Included in Plans A - G):

✔ Inpatient Hospital Care: Covers the cost of Part A coinsurance and the cost of 365 extra days of hospital care during your lifetime after Medicare coverage ends.

✔ For medicare supplement plans, Medical Costs: Covers the Part B coinsurance (generally 20% of Medicare-approved payment amount) or copayment amount which may vary according to the service. For hospital outpatient services, the copayment amount will be paid under a prospective payment system. If this system is not used, then 20% of eligible expenses will be paid.

✔ Blood: Covers the first 3 pints of blood each year.

Options A B C D F* G
Basic Benefits

Part A: Inpatient Hospital Deductible

Part A: Skilled-Nursing Facility Coinsurance

Part B: Deductible

Foreign Travel Emergency

Part B: Excess Charges 100% 100%

* Plan F also has a high deductible option. If you choose this option, in 2015 you must pay $2,180 out-of-pocket per year before the plans pay anything. Insurance policies with a high deductible option generally cost less than those with lower deductibles. Your out-of-pocket costs for services may be higher if you need to see your doctor or go to the hospital.

Basic Benefits (Plans K- N):

Basic Benefits for Plans K, L and N include similar services as Plans A through G and M, but cost sharing for the basic benefits is at different levels.

Options K** L** M N
Basic Benefits

100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare Benefits end 50% Hospice cost-sharing 50% of Medicare eligible expenses for the first three pints of Blood 50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

100% of Part A Hospitalization Coinsurance plus coverage for 365 days after Medicare Benefits end 75% Hospice cost-sharing 75% of Medicare eligible expenses for the first three pints of Blood 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

Basic, Including 100% co-insurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Coinsurance

50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance

Part A: Deductible

50% Part A Deductible

75% Part A Deductible

50% Part A Deductible

Part B: Deductible
Part B: Excess (100%)
Foreign Travel Emergency

At-Home Recovery
Preventive Care NOT Covered by Medicare

$4,940 Out of Pocket Annual Limit (2015) ***

$2,470 Out of Pocket Annual Limit (2015) ***

**Plans K and L provide for different cost-sharing for items and services than Plans A through G and M. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be responsible for paying excess charges.

***The out-of-pocket annual limit will increase each year for inflation.

How to compare Medigap policies

Quick Compare

Compare Medicare Supplement Plans

As you approach retirement age, the ever rising cost of health care, makes understanding Medicare, its gaps in coverage and limitations, a very important consideration. Since 1965 Medicare has provided millions of American senior citizens with vital health care services. As good as Medicare is, it may not pay all the cost of being sick. Consequently, what Medicare does not pay becomes your personal financial responsibility.

Choose the Medicare Supplement plan that best meets your needs and your budget. Below lists four of the industry standardized Medicare Supplement plans and the benefits available under each plan. Additional plans may be available.

CHOOSE THE PLAN THAT'S RIGHT FOR YOU

COVERAGE WHAT MEDICARE SUPPLEMENT WILL PAY IN 2015 PLAN A PLAN C PLAN F PLAN G

Part A:
Medicare Eligible Hospital Expense

$1,260 Part A Deductible

$315 per day co-pay for days 61-90

$630 per day co-pay for days 91-150

100% Medicare - eligible expense after day 150 for an additional 365 days





















Skilled Nursing Care

$157.50 per day for days

21 - 100 for medical approved stays in a skilled nursing facility.

Blood

First Three Pints of Blood

COVERAGE WHAT MEDICARE SUPPLEMENT WILL PAY PLAN A PLAN C PLAN D PLAN F

Part B:

Physician Services and Supplies

$147 Part B Deductible

20% Medicare Eligible Part B Medical Expenses and first three pints of blood

Eligible Part B charges that exceed Medicare approved amount.















Emergency Care Received Outside the U.S.

After you pay a $250 calendar-year deductible, Insurance Plans pay you 80% of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of $50,000. Benefits are payable for health care you need because of a covered injury or illness..

Federal guidelines limit the amount a doctors can charge for benefits covered by Medicare. According to The Centers for Medicare and Medicaid Services (CMS) almost 90% of all doctors accept "assignments". That means they accept the Medicare approved amount as full payment for services rendered. Some plans may not be available in every state.

How to compare Medigap policies

Your Right to Buy

Your Right To Buy A Medicare Supplement Policy In Certain Situations

You have the right to buy the Medicare Supplement plan of your choice during your medicare supplement open enrollment period. Your medicare supplement open enrollment period lasts for six months. It starts on the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B. Once you enroll in Medicare Part B, the six months medicare supplement open enrollment period starts and cannot be changed. During this open enrollment period, an insurance company cannot deny you insurance coverage, place conditions on a policy (like making you wait for coverage to start), or change the price of a policy because of past or present health problems.

If you apply for a medicare supplement plan after your medicare supplement open enrollment period has ended, the medicare supplement insurance company is allowed to use medical underwriting to decide whether to accept your application, and how much to charge you for the policy.

There are a few situations involving health care coverage changes where you may have the right to get a medicare supplement policy after your medicare supplement open enrollment period has ended. In these situations, the insurance company cannot deny you insurance coverage, place conditions on the policy (like making you wait for coverage to start), or change the price of a policy because of past or present health problems.

If you lose certain types of health care coverage, you have the right to buy a medicare supplement policy outside of your medicare supplement open enrollment period. These rights are called "Medigap Protections." They are also called "guaranteed issue" rights because the law says that insurance companies must issue you a policy.

Medigap protections are important because without them, if you do not buy a medicare supplement policy during your medicare supplement open enrollment period, an insurance company can refuse to sell you a policy, or you may be charged more for the policy. In addition, if you drop your medicare supplement policy, you may not be able to get it back except in very limited circumstances.

You should not wait until your health coverage has almost ended before you apply for a medicare supplement policy. You can apply for a medicare supplement policy early (while you are still in your health plan) and choose to start your medicare supplement coverage the day after your health plan coverage ends. This will prevent gaps in your health coverage.

Summary of Medigap Protections

There are a few situations involving health coverage changes where you may have a guaranteed issue right to buy a medicare supplement policy.

For example:

  1. Your Medicare managed care plan, Private Fee-for-Service plan, PACE provider, or Medicare managed care demonstration project coverage ends because the plan is leaving the Medicare program or stops giving care in your area, or

  2. Your health coverage ends because of reasons other than a plan leaving the Medicare program, or
  3. You dropped your medicare supplement policy to join a Medicare managed care plan, Private Fee-for-Service plan, or PACE program and then leave the plan within one year after joining. Or you buy a Medicare SELECT policy for the first time and drop the policy within one year after buying, or
  4. You joined a Medicare health plan (like a Medicare managed care plan with a Medicare + Choice contract, or Private Fee-for-Service plan) or PACE program when you first became eligible for Medicare at age 65 and you leave the plan within one year of joining, or
  5. A change in your circumstances gives you the right to leave (disenroll from) your plan.

In order to get these medicare supplement protections, you must meet certain conditions. All rights to buy medicare supplement policies under the following situations include Medicare SELECT policies since they are a type of medicare supplement policy. For more detailed on your rights and protections, you may want to read Medigap Policies and Procedures.

The medicare supplement protections in this section are from federal law. Many states provide more medicare supplement protections than federal law. Call your State Health Insurance Assistance Program or State Insurance Department for more information.

If you live in Massachusetts, Minnesota, or Wisconsin, you have the right to buy a medicare supplement policy that is similar to the standardized policies you have a right to buy in other states.

Note: There may be times when more than one of these situations applies to you. When this happens, you can choose the protection that gives you the best choice of policies.

For example:

If both situations #1 and #4 apply to you, you may have the right to buy any medicare supplement policy.

  • Situation #1 limits your choices to only medicare supplement plans A, B, C, or F that are sold in your state.
  • Situation #4 offers you the best choice by allowing you to buy any medicare supplement policy that is sold in your state.

Guaranteed Issue Rights

Medicare Advantage Plans

Consider these facts in deciding if a Medicare Advantage Plan for hospital and medical coverage is right for you:

Medicare Facts

What is Medicare?

Medicare is the US Federal Government Health Insurance Program for:

Medicare has Four Parts:

Part A (Hospital Insurance)

Helps Pay For:

Care in hospitals as an inpatient, critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas), skilled nursing facilities, hospice care, and some home health care.

Cost:

Most people get Part A automatically when they turn age 65. They do not have to pay a monthly payment called a premium for Part A because they or a spouse paid Medicare taxes while they were working.

If you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 or older, you still may be able to buy Part A. If you are not sure you have Part A, look on your red, white, and blue Medicare card. It will show "Hospital Part A" on the lower left corner of the card. You can also call the Social Security Administration toll free at 1-800-772-1213 or call your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

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Part B (Medical Insurance)

Helps Pay For:

Doctors, services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Cost:

Most people get Part A automatically when they turn age 65. They do not have to pay a monthly payment called a premium for Part A because they or a spouse paid Medicare taxes while they were working.

Medicare beneficiaries pay a monthly Part B premium. The monthly Part B premium for 2015 is $104.90 for Medicare beneficiaries with incomes under $85,000 (single) and $170,000 (married). In some cases this amount may be higher if you did not choose Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it, except in special cases. You will have to pay this extra 10% for the rest of your life. The annual deductible for Part B in 2015 is $147.
Enrolling in part B is your choice. You can sign up for Part B anytime during a 7 month period that begins 3 months before you turn 65. Visit your local Social Security office, or call the Social Security Administration at 1-800-772-1213 to sign up. If you choose to have Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. If you do not get any of the above payments, Medicare sends you a bill for your part B premium every 3 months. You should get your Medicare premium bill by the 10th of the month. If you do not get your bill by the 10th, call the Social Security Administration at 1-800-772-1213, or your local Social Security office. If you get benefits from the Railroad Retirement Board, call your local RRB office or 1-800-808-0772.

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Part C (Medicare Advantage Plans)

People with Medicare can get their coverage through Original Medicare (the traditional fee-for-service program) or from Medicare private plans (the Medicare Advantage program also known as Medicare Part C). Depending on where you live, you may be able to enroll in a Medicare Advantage Plan offering one or more of the following types of health care: HMO, PPO, PFFS, MSA.

Original Medicare

If you choose coverage under the traditional fee-for-service Medicare program, you can generally get care from any doctor or hospital you want and receive coverage for your care anywhere in the country. However, traditional Medicare has high cost-sharing requirements and does not currently cover the costs of certain services. To help pay for uncovered benefits and to help with Medicare's cost-sharing requirements, many people in the traditional Medicare program have supplemental insurance, known as Medicare Supplements or Medigap Plans (these supplemental insurance plans fill in gaps that Medicare does not cover but unlike Medicare Part C and Part D, these plans are not part of the government Medicare program).

Medicare Advantage Plans

Medicare HMOs

Medicare HMOs cover the same doctor and hospital services as the original Medicare program, but out-of-pocket costs for these services are usually different. HMOs appeal to some people with Medicare because they may provide additional benefits, such as eyeglasses, which are not covered by the traditional Medicare program. Medicare HMOs may charge a premium that you would need to pay in addition to the Part B monthly premium.

You should be aware that Medicare HMO enrollees generally can only use doctors, hospitals, and other providers in the HMO's network. For an additional fee, some HMOs offer point-of-service (POS) benefits that partially cover care received outside the network.

If you join a Medicare HMO, you will usually have to select a primary care doctor who is responsible for deciding when you should see a specialist and which specialist you should see.

Most HMOs will not pay for unauthorized visits to specialists in the plan, providers outside the HMO's network, or for non-emergency care outside the HMO's service area.

Medicare PPOs

Medicare PPOs, or "Preferred Provider Organizations," are private health plans, much like Medicare HMOs. HMOs and PPOs differ in two key ways:

Regional PPOs became available under Medicare in 2006. These plans are similar to local Medicare PPOs, but serve a larger geographic area (either a single state or multi-state area) and must offer the same premiums, benefits, and cost-sharing requirements to all beneficiaries in the region. Regional Medicare PPOs offer all Medicare benefits, including the prescription drug benefit. These plans often but not always have a single deductible for hospital and physician services and an annual out-of-pocket limit on cost sharing for benefits covered under Parts A and B of Medicare. Keep in mind that the out-of-pocket limit will vary depending on the plan you select. As with local PPOs, individuals who sign up for a regional PPO will typically pay more if they go to providers outside of the network.

Private Fee-for-Service (PFFS) Plans

Private fee-for-service plans cover Medicare benefits like doctor and hospital services, much like Medicare HMOs and PPOs. Unlike Medicare HMOs and PPOs, private fee-for-service plans do not have a formal network of doctors and hospitals. Still, not all doctors and hospitals are willing to treat members of a private fee-for-service plan. If considering enrolling in a private fee-for-service plan, make sure your doctor and hospital are willing to accept the private fee-for-service plan's payments for services before you enroll. Also, be sure you understand a plan's benefits and cost sharing requirements before you enroll because private fee-for-service plans decide how much enrollees pay for Medicare-covered services and may charge higher cost sharing for certain health care services than the original Medicare program. While private fee-for-service plans are not required to offer the Medicare drug benefit, most do. If you enroll in a private fee-for-service plans without drug coverage, you can also enroll in a Medicare stand-alone prescription drug plan for your drug coverage.

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your provider is not required to agree to accept the plan's terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your provider does not agree to accept the terms and conditions of payment, they may choose not to provide health care services to you, except in emergencies. If this happens, you will need to find another provider that will accept the terms and conditions of payment. Providers can find the plan's terms and conditions of payment on the plan's website.

Medicare MSA Plans

A Medicare MSA Plan is a health insurance policy with a high deductible coupled with a Medical Savings Account (MSA). Medicare pays the premium for the Medicare MSA Plan and makes a deposit to the Medicare MSA that you establish. You use the money deposited in your Medicare MSA to pay for medical expenses. If you don't use all the money in your Medicare MSA, next year's deposit will be added to your balance. Money can be withdrawn from a Medicare MSA for non-medical expenses, but that money will be taxed. If you enroll in a Medicare MSA, you must stay in it for a full year.

Special Needs Plans (SNPs)

Special needs plans are private plans that provide Medicare benefits, including drug coverage for beneficiaries with special needs. These include people who are eligible for both Medicare and Medicaid, those living in certain long-term care facilities (like a nursing home), and those with severe chronic or disabling conditions.

For additional information about Medicare Advantage plans, call 1-800-MEDICARE, or get information about Medicare options in your area on the Medicare Personal Plan Finder website, http://www.medicare.gov/MPPF/home.asp.

Medicare Advantage and Prescription Drugs

All companies offering Medicare Advantage plans must offer prescription drug coverage in at least one of their plans. Medicare Advantage plans with drug coverage may vary in their premiums, deductibles, formularies and cost-sharing, depending on the type of Medicare Advantage plan you select.

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Know What You Want from a Medicare Plan

Whether Original Medicare alone, Original Medicare plus a Medicare Supplement plan, or a Medicare Advantage plan is right for you will depend on your unique needs and circumstances. Think about what is most important to you when you are healthy and when you are sick. Here are some topics to consider:

Receiving care from the doctor and hospital of your choice

Under original Medicare, you can use whichever specialists and hospitals you choose, whenever you need, and without a referral from another doctor, so long as they accept Medicare Assignment. Medicare private plan options could limit your ability to get care from the doctor or hospital of your choice, or there may be extra charges for out-of-network care. If provider choice is a priority, you should consider original Medicare with added protection from a Medicare Supplement insurance policy, sometimes known as Medigap, or from an employer-sponsored or union retiree health plan, if you are eligible.

Getting coverage of additional benefits to reduce your medical costs

If you are on a tight budget and are willing to limit your choice of doctors and hospitals, you may be able to reduce your health care expenses and get coverage of additional benefits through a Medicare Advantage plan. It is important to review the scope and limits of additional benefits when choosing among available plans. It is also important to look at how much your out-of-pocket costs will be if you get sick. For example, some Medicare private plans charge a copay for each day of an inpatient hospital stay, while original Medicare charges only a deductible but no daily copays for the first 60 days of a hospital stay.

Maintaining health care coverage while away from home

Under original Medicare, you will be covered for care anywhere in the United States. While private plans must cover emergency care for members outside the plan area, most do not cover other health care services while away from home. For example, Medicare HMOs have more restrictive networks of doctors and hospitals that limit coverage away from home.

Keeping supplemental coverage from a former employer or union

If you are considering joining a Medicare private plan (either a Medicare Advantage plan or a stand-alone prescription drug plan), you should talk to your employer or former employer to be sure you won't lose valuable retiree health benefits if you sign up for a private plan. Many employers offer retiree health coverage as a supplement to traditional Medicare; some also offer coverage through Medicare HMOs and other private plan options.

Coordinating with Medicaid benefits

If your income and assets are quite modest, you may qualify for Medicaid benefits or other special programs that will help pay some of your health care costs. For those who qualify, Medicaid often pays for valuable benefits, such as nursing home care, and also pays Medicare's premiums. If you are already covered by Medicare and Medicaid, you should find out what you must pay to join a Medicare private plan and whether Medicaid will cover the plan's copayments.

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Medicare Part D (Prescription Drug Coverage)

Medicare Part D is the federal government's prescription drug program that covers both brand-name and generic prescription drugs at participating pharmacies in your area. The coverage is available to all people eligible for Medicare, regardless of income and resources, health status, or current prescription expenses. Medicare prescription drug coverage provides protection for people who have very high drug costs. For more details see What is What is Medicare Part D.

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Medicare Eligibility

Who is Eligible for Medicare?

Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are a younger person with a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).

Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:

  • You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.
  • You or your spouse had Medicare-covered government employment.

If you are under 65, you can get Part A without having to pay premiums if:

  • You have received Social Security or Railroad Retirement Board disability benefit for 24 months.
  • You are a kidney dialysis or kidney transplant patient.

While you do not have to pay a premium for Part A if you meet one of those conditions, there are deductibles for Part A. In 2015, the Part A deductible for days 1-60 is $1,260, 61-90 is $315, 91 and beyond Coinsurance is $630, beyond lifetime reserve days is all costs.

You must pay for Part B if you want it. In 2015 the monthly premium for Part B is $104.90 for most with incomes under $85,000 (single) and $170,000 (married). The deductible for Part B in 2015 of $147. It is usually deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months.

If you have questions about your eligibility for Medicare Part A or Part B, or if you want to apply for Medicare, call the Social Security Administration. The toll-free telephone number is: 1-800-772-1213. The TTY-TDD number for the hearing and speech impaired is 1-800-325-0778. You can also get information about buying Part A as well as part B if you do not qualify for premium-free part A.

Medicare Costs

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Medicare.gov

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What Medicare covers

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What is Medicare Advantage?

We've put this section together to help answer some of your questions, but feel free to contact us with your questions.

Medicare Advantage Plans (also known as Medicare Part C) are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include Medicare Part D prescription drug coverage or you can enroll in a separate Medicare Part D prescription drug coverage plan. Medicare Advantage Plans include:

No health questions are asked (except the existence of End Stage Renal Disease or to qualify for certain Special Needs Plans). Acceptance is guaranteed for all Medicare eligibles every year during the appropriate enrollment period regardless of health conditions (except End Stage Renal Disease). Dual Eligibles -- people on both Medicare and Medicaid -- can enroll year-round. Most Medicare Advantage plans require you to pay a co-pay each time you see a doctor, receive medical treatment, or visit a hospital. The maximum out-of-pocket expenses you are required to pay are often capped on a per-year basis, but not always.

When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most cases there are extra benefits and lower co-payments than in the Original Medicare Plan. However, with PPO and HMO plans you may have to see doctors that belong to the plan or go to certain hospitals to get services or risk higher out-of-pocket expenses for going "out-of-network". PPFS plans enable you to see any health care provider that accepts Medicare assignment as well as the terms and conditions of the PFFS Plan.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer. Depending on where you live, some Medicare Advantage Plans have a $0 premium plan option, and some even reimburse you for part of your Medicare Part B premium. Some plans include dental and vision benefits in addition to coverage for hospital stays, doctor visits, diagnostic tests, inpatient and outpatient services, skilled nursing, and more. Some plans even include free health club memberships.

If you join a Medicare Advantage Plan, your Medigap (also known as a Medicare Supplement) policy won't work. This means it won't pay any deductibles, copayments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.

from Medicare.gov, Medicare Advantage Plans (2016)

Medicare Advantage Plans

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Original Medicare vs. Medicare Advantage

Medicare covers many of your health care needs. Today’s Medicare is working with private companies' health plans to provide different ways to get your health care coverage in the Medicare program. The Medicare health plan that you choose affects many things like cost, benefits, doctor choice, convenience, and quality. Your Medicare health plan choices include:

These plans may cover more services and have lower out-of-pocket costs than the Original Medicare Plan. Some plans cover prescription drugs (these plans are known as, MA-PD for Medicare Advantage-Part D). In some plans, like HMOs, you may only be able to see certain doctors or go to certain hospitals to get covered services.

from Medicare.gov, Medicare Options Compare (2016) & Medicare.gov,Medicare Plan Choices Overview (2016)

Your Medicare coverage choices

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Medicare Advantage Enrollment

How do I get more information and enroll?

Enrolling in a Medicare Advantage Plan is easy. To speak with a licensed insurance agent call or click here for a free Medicare Advantage quote and consultation. We can answer your questions and handle your enrollment entirely over the phone. If you prefer, we can mail, fax, email or personally deliver an application to you.

What is the Initial Coverage Election Period?

The Initial Coverage Election Period ICEP (not to be confused with the Initial Enrollment Period IEP for Medicare Part D) is a one-time event when an individual first has the opportunity to enroll in a Medicare Advantage (MA) plan. It occurs for most people when turning age 65 and enrolling in Medicare Parts A & B for the first time. This period begins three months before an individual is first eligible for both Medicare Part A and Part B, and ends on the later of:

The Initial Coverage Election Period for a Medicare Advantage (MA) enrollment election will frequently relate to either the individual's 65th birthday or the 25th month of disability, but it must always relate to the individual's entitlement to both Medicare Part A and Part B. When an individual enrolls in a Medicare Advantage- Prescription Drug (MA-PD) plan she/he used both the Initial Coverage Election Period and the Initial Enrollment Period (IEP) for Part D.

The Initial Enrollment Period for Medicare Part D Drug Plans (PDP) is the same as the Initial Enrollment Period for Medicare Part B (the seven month period that begins 3 months before the month an individual meets the eligibility requirement for Part B, and ends 3 months after the month of eligibility.

During the Initial Enrollment Period for Part D, individuals may make one Part D enrollment choice, including enrollment in an MA-PD plan. Individuals eligible for Medicare prior to age 65 (such as disability) will have another Initial Enrollment Period for Part D based on upon attaining age 65.

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What is the Annual Election Period (AEP)?

The Annual Election Period for coverage effective in a calendar year begins October 15 of the previous calendar year and ends December 7 of the previous year. During this period, anyone who is enrolled in Medicare may enroll for the first time in a Medicare Advantage Plan; or change from one Medicare Advantage Plan to another; or return to Original Medicare from a Medicare Advantage Plan. If during this period you enroll in a Medicare Advantage Plan that includes Medicare Part D prescription drug coverage then any prior Medicare Part D Plan coverage is automatically cancelled and replaced by the new Medicare Advantage Plan with prescription drug coverage — these plans are known as MA-PD plans (Medicare Advantage-Part D plans). Enrollments during this period have an effective date of January 01. The AEP occurs October 15 through December 7 every year.

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What is a Special Election Period (SEP)?

A Special Election Period means that you are allowed to enroll in Medicare Advantage after the IEP and/or AEP because you meet certain conditions set forth by the government. Below are some specific situations which might qualify you for a SEP.

You may qualify for a Special Election Period if:

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Can I change my Medicare Advantage plan after I enroll?

Once enrolled in an MA or MA-PD Plan you must wait to change plans until the next Annual Election Period (AEP) every year: October 15 - December 7.

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Some categories of beneficiaries are not bound by the lock-in rules and may enroll or disenroll from an MA plan in other than the AEP. An individual may at any time, during a designated Special Election Period (SEP), discontinue the election of an MA plan offered by an MA organization and change his or her election to original Medicare or to a different MA plan. Examples of situations which may entitle an individual to an SEP include the termination or discontinuation of a plan, a change in residency out of the service area, the organization violating a provision of a contract or misrepresenting the plan's provisions, or the individual meeting other exceptional conditions as CMS may provide. CMS has also designated an SEP for individuals entitled to Medicare A and B and who receive any type of assistance from Title XIX (Medicaid), including full-benefit dual eligible individuals, as well as those eligible only for the Medicare Savings Programs. This SEP lasts from the time the individual becomes dually eligible until such time as they no longer receive Medicaid benefits. Individuals who are eligible for an SEP under the guidance for Part D enrollment and disenrollment may use that SEP to also make an election into or out of an MA-PD plan.

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Important Medicare Advantage Dates to Remember

October 15
Annual Election Period begins. First day you may elect to enroll in a Medicare Advantage Plan effective in the next calendar year. The plan effective date will be 01 January.

December 7Last day you can enroll in a Medicare Advantage Plan for the next calendar year unless you qualify for an exception.

January 1First day your Medicare Advantage/Part D Prescription Drug plan is effective.

from Medicare.gov,Glossary Definitions (Oct 2011)

When can I join a health or drug plan?

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