If you’re about to turn 65, or if it’s time for the Annual Enrollment Period, you’ve probably been inundated with marketing materials from insurance agents. You may wonder why all these people want to talk to you, or why you need them in the first place. Simply put, Medicare is confusing. There are thousands of options to choose from depending on your location, and enlisting the help of a licensed agent can help ensure that you have the best plan to fit your needs.
Why Licensed Agents who sell Medicare Plans Aren’t Door-to-Door Salespeople
Licensed insurance agents who sell Medicare cannot legally show up at your door or contact you unexpectedly. Medicare guidelines state that you, the client, has to know everything that’s going to happen ahead of time. Agents must schedule appointments with you in advance and clarify exactly what they will talk about with you in the meeting.
Licensed agents will not ask you for money. Rather, the insurance carrier you enroll with pays the agent a commission. You get the same insurance benefits at the same price whether you use a broker or not. However, using a broker comes with a host of benefits you won’t get if you enroll on your own.
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Benefits of Using a Broker for Medicare
Even if you already know what plan you want to sign up for, or even if you’ve already enrolled in a plan, it’s wise to talk to an insurance agent who knows what else may be out there for you. The world of Medicare is saturated with plans and policies, and you might be missing out! Your agent might be able to find a plan that covers a service you didn’t even consider such as fitness classes.
Not only will you see more plan options, you get a qualified professional who is an expert in Medicare. Your agent will only talk to you about plans that will work for you, so you’ll only get the coverage you need at a price you can afford. The broker will show up at your house already having vast knowledge about the plans that you can enroll in, saving you lots of time.
Should I use a Broker to get Health Insurance?
Agents legally need to be qualified to sell insurance before they can take action, which means they will have gone through months of training to know all there is to know about Medicare. Their job is to talk about several different options for you based on what kind of coverage you need, then help you select the best one.
All senior citizens must enroll in Medicare within their Initial Enrollment Period (IEP), which is the seven-month period surrounding their 65th birthday. If you miss that window, you may be charged a 10 percent penalty fee when you eventually do enroll. If you don’t enroll at all, you could spend hundreds of thousands of dollars more than you should on healthcare.
After your Initial Enrollment Period, you can make changes during the Annual Enrollment Period (AEP), which is every year from October 15 through December 7. If you haven’t met with a broker yet, this is a good time to do so. If you already have a broker, this is a good time to meet and discuss whether or not there is a better plan for you for the following year.
What Can I Expect to Happen During the First Meeting?
The agent will come prepared with materials that are loaded with information on different carriers and their policies. He or she will go over that information with you, and let you make a decision. He or she may also bring an enrollment form for your convenience in case you decide on a plan that day, but you are under no obligation to enroll.
The agent is not allowed to discuss plan options that you didn’t previously agree to discuss in the meeting. For instance, if you agree to speak about Medicare Advantage plans only, the agent will not try to sell you a vision plan. You will need to sign a “scope of appointment” form prior to the meeting that outlines what the agent can speak to you about.
How can I Prepare for the Meeting?
First, compile a list of your healthcare costs and needs, like what prescriptions you take and which doctors you like to see. Do you need coverage for specific medical conditions such as heart disease or have a family history of stroke or heart attack? Write that down. Also, think about your monthly budget. How much can you afford to spend on premiums? How much do your medical bills typically cost? Your meeting will run as quickly and smoothly as possible if you go in prepared.
Why You Should Choose Medicare Plan Finder
Everything we do at Medicare Plan Finder is geared toward our mission to serve the underserved. We want you to understand your coverage, so we provide you with valuable information on our social media pages and on this website. We put our agents through extensive training so they can better serve you. We work with a wide variety of Medicare insurance carriers so our agents can give you multiple quotes to choose from. We take the guesswork out of finding Medicare coverage so you can receive the best possible care.
Contact Us Today
It can be nervewracking to have someone come into your home and talk to you about your healthcare, but it really is the right decision. A licensed agent will take you through the enrollment process step by step and help make sure you have the right plan for you. Call 844-431-1832 or fill out this form to set up a no-obligation appointment today.
Contact Us | Medicare Plan Finder
This post was originally published on April 20, 2017, by Anastasia Iliou and was updated by Troy Frink on May 09, 2019, by Troy Frink.
Medicare Late Enrollment Penalty Exceptions
There are more than 10,000 Baby Boomers aging into Medicare each and every day. If you’re nearing your 65th birthday, you may have started researching what the world of Medicare is all about. There’s a lot of information out there, and it’s easy to get overwhelmed with all of the different parts and plans.
Have you heard of the Medicare late enrollment penalty? It’s crucial you enroll during your Initial Enrollment Period (IEP) to avoid this fee down the road. Fortunately, there are Medicare late enrollment penalty exceptions.
Part A Late Enrollment Penalty
If you have worked and paid Medicare taxes for 10 years, you will be automatically enrolled in Part A and will not have to pay a monthly premium.
If you aren’t eligible for premium-free Part A, and you don’t enroll during your IEP, your monthly premium will have an added penalty of 10 percent. This applies regardless of how long your delay was.
You will continue to pay the additional 10 percent for twice the amount of time you postponed enrollment. For example, if you deferred enrollment for two years, you will be required to pay the penalty for four years.
Part A Late Enrollment Penalty Exceptions
The only exceptions to the Part A late-enrollment penalty are if you have qualifying coverage through your employer or your spouse’s employer or if you qualify for a Special Enrollment Period. If you received a Part A penalty when you believe you had a qualified exception, read how to file an appeal here.
Medicare Part B Late Enrollment Penalty
Like Part A, many beneficiaries are automatically enrolled in Part B. If you are not automatically enrolled and do not enroll during your IEP, you will have a late enrollment penalty that is added to your monthly Part B premium.
The penalty can reach 10 percent or each year you were eligible for Medicare but did not enroll. For example, if you were eligible for three years before you finally enrolled, you will pay your monthly Part B premium plus an additional 30 percent of that amount.
This penalty is not temporary like Part A. You will continue to pay this additional fee every month until you are no longer enrolled in Medicare.
Medicare Part B Late Enrollment Penalty Exceptions
If you have qualifying coverage through your employer or spouse’s employer, you can postpone Part B enrollment without being penalized. In these scenarios, the employer plan is primary and Medicare is secondary. Many people will delay Part B while they are working so they don’t have to pay a monthly premium.
Be aware that smaller employers (less than 20 employees) act secondary and Medicare is primary. This means for those scenarios, you still need to enroll in Part B or be subject to a penalty down the road.
The last exception to the late enrollment penalty is if you are eligible for a Medicare Savings Program (MSP). MSPs are regulated by each individual state, and help low-income beneficiaries pay for some or all of their Medicare premiums, deductible, copayments, and coinsurance.
Medicare Part A and Medicare Part B Penalty Waivers
If you feel that you were improperly charged a late enrollment penalty fee for either Medicare Part A or Part B, you can file a waiver.
Begin by gathering proof of your Part B enrollment in the form of a copy of your application and your Medicare card.
Then, call the Social Security Administration (SSA) at 800-772-1213 (you can also visit the SSA website or visit your local SSA office).
Then, ask to use the “time-limited equitable relief” to eliminate your Part B penalty fee. You may or may not be granted this waiver based on your enrollment status.
How to File a Medicare Part B Late Enrollment Penalty Appeal
If you disagree with a Medicare decision regarding your Part B coverage, you can appeal. If you decide to appeal Medicare’s decision, first ask your healthcare provider or insurance carrier for any information that can help your case.
Look at your Medicare Summary Notice (MSN). It will list all of your billed services and supplies for a 90-day period. Your MSN will show you what Medicare paid and what you still owe.
Circle any items you disagree with on your MSN. Then write down why you disagree with the items.
Fill out Medicare Redetermination Request Form and mail it to the address listed on your MSN. Be sure to include your MSN with your Medicare Redetermination Request Form.
Medicare Part D Late Enrollment Penalty
If you sign up for Original Medicare (Part A and B) but do not purchase an additional prescription drug plan for 63 days, you will be charged a late enrollment fee. You can enroll in a Part D plan or Medicare Advantage plan with drug coverage to avoid the fee.
The Part D penalty is calculated by multiplying one percent of the national base premium by the number of uncovered months. The base premium for 2019 is $33.19. That means that if you are uncovered for 20 months your additional fee will be 20 percent of $33.19, or $6.64 per month. Your full monthly premium will then cost you $39.83 for prescription drug coverage.
Medicare Part D Late Enrollment Exceptions
If you qualify for the Medicare Extra Help program, you will not have a late enrollment penalty. Extra Help helps pay the cost of prescription coverage for low-income beneficiaries. This means you cannot be penalized even if you haven’t had coverage for more than than 63 days.
If you have creditable prescription drug coverage through an employer or union, you are not subject to a late fee unless you lose this coverage and continue to postpone enrollment.
However, keep in mind that you are responsible for providing proof of your creditable coverage. You should receive a letter from your employer or union after you quit your job or lose coverage.
Get Prescription Drug Coverage
If you’re looking to avoid late enrollment penalties, Medicare Plan Finder can help. Our licensed agents can show you which Medicare Advantage and Part D plans are available in your area.
Plus, they can answer any questions regarding pricing and which drugs are covered under which plan. Our agents work with all of the major carriers in your state so they can show you all of the available plans in your area with an unbiased approach. To schedule a no-cost, obligation-free appointment, fill out this form or give us a call at 844-431-1832.
This blog was originally published on July 06, 2017, by Anastasia Iliou and was updated on July 23, 2019, by Troy Frink.
Does Medicare Pay for Home Health Care?
Home health care is usually equally as effective as the care you would receive in a hospital or facility. If you have an injury or illness that prevents you from leaving your house, you’ll want to consider home health care.
Home health care coverage refers to not only in-home doctor visits and nurses, but also support for your family members who are taking care of you.
Medicare can cover the costs of your home nurse or doctor and can reimburse for caregiver services. However, if your relative is caring for you for the sake of saving money, it may be a good idea to take a look at what kind of coverage you might have for in-home doctors and nurses.
So, what does Medicare pay for home health care? The Original Medicare program covers hospital services under Part A, and it covers medical insurance needs such as doctor visits and limited home health care services under Part B.
Medicare Part C, or Medicare Advantage (MA) health insurance plans are from private insurers and can offer “extra” home healthcare benefits.
Medicare Home Care Benefits
Does Medicare Pay for Home Health Care? | Medicare Plan Finder
Over the past few years, home health care services have greatly expanded. More and more seniors prefer to receive the care they need at home instead of in a nursing home or other facility.
However, nursing homes and long-term care facilities can be more expensive than home health care, because home care eliminates the need for room and board.
Kaiser Health News reports that over six million American seniors require home care. That means that they need help with dressing, bathing, eating, and other daily activities. However, a basic Medicare plan may not provide enough coverage for home care.
Having a nurse or aide in your home can cost well over $40,000 per year. With long-term care insurance, you’ll pay a premium instead, and your yearly costs will total at just over $2,000.
You’ll need to determine how much coverage you need ($50 per day, $100 per day, etc.) and what you’ll be using it for. You can use a long-term care policy for anything from a full-time nurse to home modifications, like ramp installations.
What Medicare Covers
Medicare does pay for some home care services if leaving your house is a tremendously difficult process and you need assistance.
Parts A or B (Original Medicare) covers skilled nursing services on an inconsistent basis – at least one time every two months, but only up to once a day, and only for three weeks at a time.
“Skilled care” means that it has to be performed by a qualified health care professional, or at least under his or her supervision.
Medicare Parts A and/or B will also cover physical therapy for recovery from injuries or illnesses, occupational therapy to help you learn how to perform day-to-day tasks with or without tools, and social services for medical needs.
While Original Medicare will cover basic home care, additional services such as housekeeping and meal delivery fall under specific Medicare Advantage (Part C) plans.
Does Medicare Pay for Home Health Care by a Family Member?
Searching for Affordable Home Health Care | Medicare Plan Finder
Your doctor will probably recommend a home health care service to you if he doesn’t provide those services himself. Otherwise, Medicare has a Home Health Agency finder so you can locate the care you need in your area. When choosing an agency for yourself or for a loved one, make sure you’re asking the right questions, such as:
Are you Medicare (or Medicaid) certified?
Do you offer ____ service?
What are your hours and do they align with my needs?
Will you have emergency staff available on weekends and after hours?
Do you perform background checks on staff? Do you have credentials?
Will I have to pay anything out of pocket?
Once you’ve narrowed your choices down, you may want to inquire about an agency’s quality of care. Any home care agency who services Medicare clients and has serviced at least 20 patients will have a star rating.
Patient Care Star Ratings are based on patient health improvement and the outcome of home treatments and care.
How to Use Medicare’s Home Health Agency Finder
Click here to go to the Medicare Home Health Agency finder. Enter your zip code to search for home health agencies in your area and click “search.” We used 37209, which is the zip code for our corporate offices in Nashville, Tennessee.
Medicare Home Health Agency Finder Step 1 | Medicare Plan Finder
From there, you can filter search results by Medicare’s star rating and patient survey results. For demonstration purposes, we are only going to choose facilities with 5-star ratings.
Medicare Home Health Agency Finder Step 2 | Medicare Plan Finder
Once the agency finder returns your search results, click on the agencies you want to compare. In our case, the finder returned two results. In this instance, both Deaconess Homecare and Homecare Solutions are part of LHC Group Health Care, which has locations in 38 states. The agency’s proximity to your home may be a determining factor in your choice for home care.
Medicare Home Health Agency Finder Step 3 | Medicare Plan Finder
Then click “compare now.”
Medicare Home Health Agency Finder Step 4 | Medicare Plan Finder
Then the agency finder will show you comparison charts with general information, quality of patient care, and patient survey results. Use the comparison charts to help you make a decision about which home health agencies you want to contact.
Medicare Home Health Agency Finder Step 5 | Medicare Plan Finder Medicare Home Health Agency Finder Step 6 | Medicare Plan Finder Medicare Home Health Agency Finder Step 7 | Medicare Plan Finder
How Do I Qualify for Home Benefits?
To qualify for home benefits, a doctor will need to certify that you have a medical need. For example, your policy will not pay for your stair lift if you still can walk up the stairs on your own without too much difficulty.
As another example, if you only need a nurse to help you with something occasional, like blood transfusions, your policy will not pay for you to have a full-time live-in nurse.
Your doctor will have to meet you in person to determine that you are homebound and need skilled nursing care. After your initial certification, your doctor must recertify your home health care plan once every two months. A Medicare-certified home health agency (HHA) must provide the care.
When You Should Buy
Like other health insurance policies, you should buy a long-term care policy before you need it. Pre-existing conditions and your age can raise your premiums. If you buy while you’re still healthy, you’ll likely have lower costs. However, if you can’t afford the premium now, while you’re healthy, then it may be best to wait.
One of our licensed and experienced agents can help you figure out if a long-term policy is something you should buy now or wait for. If you think it’s time to buy now, we’ll help you find a great plan in your area.
This post was originally published on December 07, 2017, by Anastasia Iliou, and was updated on August 07, 2019, by Troy Frink.
Medicare HIV Coverage
Medicare is the government-run health insurance program for people 65 and older, and also for younger adults with qualifying disabilities. It has become a crucial source of health insurance for people who have HIV and AIDS.
The term Original Medicare refers to the federal program that started in 1965, and it describes Medicare Parts A (hospital coverage) and B (medical coverage). Medicare Part C refers to Medicare Advantage, a form of Medicare that is owned and operated by private companies, not the federal government. Medicare Advantage plans offer everything that the government Medicare program offers but can also offer additional benefits for people with HIV and AIDS.
HIV in the United States
HIV is an abbreviation for human immunodeficiency virus. The virus depletes your immune system by killing the white blood cells that fight off infection and illness. A compromised immune system means you are more likely to contract certain infections and even cancers.
More than 35 years have passed since the first documented cases of HIV in 1981. Advances in HIV prevention, care and treatment have transformed an HIV diagnosis from a death sentence to something manageable. The population of HIV positive people in the US has grown over time to 1.1 million people. Part of this is due to improved treatment options which make for longer lifespans, but it is also due to a large number of new HIV diagnoses. According to HIV.gov, there were about 38,700 new infections in 2016 alone.
Does Medicare Cover HIV Testing?
Medicare Part B covers one annual HIV screening for those 15-65 years old. Medicare will also cover testing if you’re older than 65 or younger than 15 if you have an increased risk for HIV. Certain factors do contribute to infection susceptibility. You are at an increased risk for HIV if you have:
Received donated blood prior to 1985: If you received a blood transfusion or blood products before 1985, it’s possible you’ve been infected with HIV because those products weren’t tested for infection. All blood products post-1985 are tested for HIV.
A mother who was HIV positive: Pregnant women who are infected with HIV can pass the disease to their children before they give birth, during labor or through breast milk.
Certain genes: Some people have fewer copies of a gene that fights off HIV, and some gene mutations can actually resist HIV. Genetic testing can determine whether or not you’re at an increased risk (fewer gene copies) or a decreased risk (resistant genetic mutation).
You should get tested every year, especially if you’re at risk. The first symptom of HIV is a fever accompanied with fatigue, swollen lymph nodes and sore throat. Regular testing for HIV can mean the difference between catching an infection early or letting it go untreated and progressing to AIDS. You will pay nothing if your doctor accepts your request.
Does Medicare Cover HIV Treatment?
According to the US Department of Health and Human Services, you should begin antiretroviral therapy (ART), using HIV medications to treat infection, as soon as you receive an HIV diagnosis. ART is not a cure for HIV, but the different medicines do help people live healthier, longer lives. HIV drugs prevent the virus from multiplying and therefore reducing the overall amount of HIV in the body.
When HIV replicates, sometimes the virus mutates and makes different versions of itself. Those variations can become resistant any current ART, so you must schedule regular check-ups with your doctor so he or she can reassess your treatment plan as needed. In 2006, Medicare Part D added prescription drug benefits by offering subsidized prescriptions for otherwise costly HIV medications including approved antiretrovirals (ARVs). Part D plans are not required to cover non-ARV drugs to combat HIV-related illnesses. Certain Medicare Advantage (Part C) plans also cover FDA-approved treatments for the facial wasting (lipoatrophy) that ARVs can cause.
Medicare Special Enrollment Period and HIV
Medicare has a Special Enrollment Period (SEP) which allows people with a qualifying disability to enroll in or change coverage at any time during the year. Most people have to wait for the Initial Enrollment Period (IEP) – the three months surrounding their 65th birthday month – to enroll in coverage, or the Annual Enrollment Period (October 15 – December 7) to change coverage, but an HIV diagnosis means you qualify for a Special Enrollment Period. A chronic, disabling condition such as HIV allows people to enroll in a Special Needs Plan (SNP). Plans for chronic conditions are called Chronic-Condition Special Needs Plans (C-SNP), and they can target one or more conditions.
Get Medicare Coverage for HIV
HIV treatment and testing have come a long way since the disease was first discovered in 1981, but it is still a serious autoimmune condition that can have dire consequences. With regular testing and preventive care, you can stay on top of your health. If you are diagnosed with HIV and qualify for the Special Enrollment Period, one of our highly qualified agents can help you find the right plan for you. Call us at 844-431-1832 or contact us here today.
Essential Medicare Benefits for All Medicare Plans
Prior to 1965 when Medicare was created, people over the age of 65 found it almost impossible to be covered by private health insurance companies after retirement. Original Medicare is the program the government created to cover essential medical needs like hospital stays and doctor visits. There are two parts: A and B.
The term Medicare has expanded since the 1960s to include other important services and programs in order to help people be as healthy as possible. Now, private health insurance companies can sell “Medicare Advantage” plans, often known as Part C. “Extra” Services such as vision insurance, hearing coverage and physical fitness programs typically fall under Part C.
Does Medicare Count for Minimum Essential Benefits?
The Affordable Care Act originally required that everyone have a health plan with the minimum essential benefits, which included:
Ambulatory outpatient services
Emergency services
Hospitalization
Pregnancy/maternity/newborn care
Mental health and substance abuse services
Prescription drugs
Rehabilitative services/devices
Lab services
Preventive/wellness services
Pediatrics (including dental and vision for kids)
If you had Medicare, you would have met the minimum essential benefits requirement. The federal government dropped the requirement that you have a minimum coverage level under the Affordable Care Act (also known as ACA or Obamacare) in 2019. However, certain states still impose penalties.
You meet minimum coverage requirements if you have coverage under Part A, Parts A and B together, or a Medicare Advantage plan (Part C). If you’re covered by any one of those plans, you will not have to pay the penalty for not having health insurance. If you were only enrolled in Part B, you would not meet the government-mandated minimum requirements.
When people talk about Medicare benefits, they are referring to Original Medicare plans. However, specific plans cover different things, and not all plans have the same coverage. Here’s what Original Medicare plans cover:
Preventive care
Annual wellness appointments
Doctor visits
Telehealth
Mental health
Ambulance transportation
Home health (limited)
Original Medicare plans do not cover prescription drugs – except in limited cases, such as for oral cancer medications. Most prescription drugs require a Medicare Part D coverage or certain Medicare Advantage plans.
Difference Between Part A and Part B
Medicare Parts A and B fall under Original Medicare. Part A is Medicare hospital insurance, and it covers hospital visits and stays. It does not cover ambulance transportation. (That’s included in Part B.) Part B covers doctor’s appointments, telehealth, mental health, preventive care, annual wellness visits, ambulance transportation, and limited home health.
Medicare Health Benefits
If you need more coverage than what Part A and Part B provide, you’ll want to look towards a Medicare Supplement plan or Medicare Part C. Part C plans can include:
Dental
Vision
Hearing
Fitness classes and gym memberships
Non-emergency transportation, such as trips to the doctor’s office
Meal delivery
And more!
Many people will find that Original Medicare benefits cover most of their needs as they age, but it’s important to consider the quality of life that can be obtained when you have access to a gym or have taxi fare to get to the doctor. We can’t think of anything more important than your health and well-being, and a Part C plan can provide the additional benefits you need to be healthy and happy.
Meeting with a licensed agent for Medicare
Medicare Advantage
While you aren’t required to enroll in Medicare Part C, it is a valuable asset for most people. Medicare Parts A and B cover only the most basic needs for health care. There are thousands of Medicare Advantage plans to choose from, and a qualified professional can help you sort through them and find one that suits your needs.
Medicare Advantage plans are private health insurance plans that cover every service Original Medicare covers. Advantage plans are often used along with government-run plans to ensure the patient has coverage for what he or she needs, which can include dental, vision, and even meal delivery.
Medigap
Medigap policies cannot be used in conjunction with Medicare Advantage. Medicare supplements pick up where Original Medicare falls off. Medigap plans can help with coinsurance, co-payments, and deductibles. These plans are strictly for financial coverage, and not health coverage.
How to Get More Benefits
If you need coverage for things that don’t fall under the Original Medicare umbrella, you need to know a few things before you enroll. Medicare Advantage (Part C) and Medicare Supplements (also called Medigap) can serve different needs, and either can be beneficial depending on your circumstances.
The Initial Enrollment Period (IEP) consists of the six months surrounding your 65th birthday and your birthday month. This is important to know because you must select a policy in that timeframe in order to be covered. If you do not enroll in Medicare Advantage during that time, the only other time you can do that is during the Annual Enrollment Period (AEP), which is every year from October 15 through December 7.
While most people who wish to make changes to their health insurance or get new coverage must enroll during the AEP, the Special Enrollment Period (SEP) allows people – even those younger than 65 – to enroll if they are diagnosed with specific, chronic health conditions. If you qualify for the SEP, you can add or change coverage once per quarter during the first three quarters of the year. Some people may have limited special enrollment periods that surround qualifying events. For example, if you move to a new service area where different plans are available, you may be granted a temporary (typically 60 day) special enrollment period.
Get Essential Medicare Health Benefits
A comprehensive Medicare plan can help you live your best life. If you’re ready to enroll in Medicare benefits and need assistance in selecting the right plan for you, we can help you find a plan that fits your budget and lifestyle. Call us at 844-431-1832 or contact us here today.
How Medicare and Medicaid Work Together
Medicaid helps lower the cost of Medicare for more than 12 million dual-eligibles. In fact, Medicaid is the nation’s largest public health insurance program for people with low income and covers more than 1 in 5 Medicare enrollees. Are you eligible? Here is everything you need to know about Medicaid, Medicare, eligibility, costs, and savings programs.
What is the difference between Medicare and Medicaid?
Medicare and Medicaid can be easily confused, but they are two separate government-operated programs. Medicare is a federal program that provides health coverage for seniors over 65 and other Medicare-eligibles, regardless of your income. Medicaid is a state and federal program that provides health coverage for those with low income. However, if you are dual-eligible, you are eligible for both Medicare and Medicaid. This allows you to expand your network to include Medicaid doctors and decrease your out-of-pocket healthcare costs.
Those who are over 65 and those who receive SSDI (Social Security Disability Insurance) are eligible for Medicare.
Medicaid eligibility is different in every state and is largely based on income level. Though this varies by state and marital status, if you know that you are under the Federal Poverty Level, there’s a good chance that you qualify for Medicaid.
Can you Have Medicare and Medicaid?
If you are dual-eligible, that means you’re eligible for both Medicare and Medicaid. That can mean that you are both low-income and over 65, both low-income and on dialysis for ESRD, or any other qualifier listed below.
When you have both Medicare and Medicaid, Medicare will cover you first. Your Medicaid will serve as sort of a backup plan when you need more coverage than Medicare can provide.
People who are eligible for both Medicare and Medicaid may qualify for a Dual-Eligible Special Needs Plan, or DSNP. DSNPs often come with very low or $0 premiums, and Medicaid often covers the resounding copayments. DSNPs are not available in every area, and each plan can be a bit different, so be sure to ask your agent.
Dual-eligible beneficiaries are sometimes eligible for a Medicare Savings Program (MSP) as well. An MSP can help you pay for your Medicare premiums. You’ll also be enrolled in Extra Help, a program that helps you pay for your Medicare prescription drug costs. You may hear Extra Help referred to as LIS, or Low-Income Subsidies.
Bonus: if you are eligible for both Medicare and Medicaid, you have a Special Enrollment Period (SEP). That means that you don’t have to wait for the Annual Enrollment Period (AEP) to enroll or make changes to your plan.
Get the care you need from Medicare and Medicaid
Medicare and Medicare Eligibility Check
Ready to find out if you are eligible for Medicare? Do you fall into any of the below categories?
I am over the age of 65 or will be turning 65 within the next few months.
I have ESRD (End-Stage Renal Disease/Kidney Failure) and am receiving dialysis treatment.
I have Lou Gehrig’s disease (amyotrophic lateral sclerosis or ALS).
I have received Social Security Disability Income for over 24 months.
I receive retirement/disability income from the Railroad Retirement Board.
Note that to qualify, you also must be a U.S. citizen.
Medicaid eligibility is going to depend largely on what state you live in. While Medicare is more federally regulated, Medicaid is mainly state-regulated. For example (2018), in Tennessee, a family of four can qualify for Medicaid with an income of less than $32,718 annually. However, in New York, a family of four can only qualify for Medicaid with an income of less than $32,319.
Some of the groups that most commonly pass the Medicaid eligibility check are U.S. citizens like:
Those under 21 with low income
Pregnant women with low income
Low-income parents of minors
Low-income women undergoing breast or cervical cancer treatments
Those who receive Social Security benefits
Individuals who live in nursing homes or receive other long-term care and require financial assistance
If you think you are eligible, you can access the Medicaid Application for every state from the Healthcare Marketplace website.
Medicaid Doctors and Costs
A great way to find providers in your area who accept Medicaid is by using an online search tool like “DocSpot.” From DocSpot, you’ll enter your city, your type of coverage (Medicaid), and the type of doctor you are looking for. DocSpot will populate results for you where you can read reviews and pick Medicaid doctors in your area that you can schedule an appointment with.
If you have both Medicare and Medicaid, you can expand your doctor network to also include those who accept Medicare. If you have Medicare Advantage (a Medicare plan offered by private companies instead of the federal government), you’ll want to use your plan’s website to search for a provider that accepts your coverage.
Your Medicaid, Medicare, and Medicare Advantage costs will all depend on your financial status and the type of plan you select.
Medicaid Prescription Drug Costs
Technically, prescription drug coverage is an optional federal Medicaid benefit. Since Medicaid is a state-based program, all states determine their own prescription drug coverage. Currently, all U.S. states provide outpatient prescription drug coverage to eligible Medicaid beneficiaries. Depending on your state, you will receive either free or heavily discounted prescription drugs when receiving Medicaid benefits.
Free Prescription Discount Card
Additional Medicaid Costs
Some Medicaid beneficiaries will be required to pay copayments for certain services. It all depends on your income. For example, for non-institutional care (such as a doctor’s office visit), anyone at 100% of the federal poverty level will have to pay a copay of $4.00. Anyone whose income is 150% above the federal poverty level will have to pay 20% of the costs. Keep in mind that the federal poverty level can change every year and also takes into account the number of people living in your household.
Medicare Extra Help Application
If you have Medicare but do not qualify for Medicaid, fear not! You may still qualify for financial assistance in another form: Medicare Extra Help.
Medicare Extra Help, otherwise known as LIS (Low-Income Subsidies), helps you cover your prescription drug costs that Medicare does not cover. To qualify for Extra Help, you must first have Original Medicare (Part A and Part B). You cannot have savings, investments, and real estate that total more than $28,150 (or $14,100 if you are single).*
Even if you do not qualify for full Medicaid benefits or if you don’t qualify for Medicare Extra Help, you can still qualify for a Medicare Savings Program. There are four Medicare Savings Programs:
Qualified Medicare Beneficiary (QMB)
Pays for Medicare Part A and B premiums, deductibles, coinsurance, and copayments. Also makes you eligible for Medicare Extra Help. To qualify for QMB, you:
Cannot exceed individual monthly income limit of $1,032
Cannot exceed married monthly income limit of $1,392
Cannot exceed individual assets limit of $7,560
Cannot exceed married assets limit of $11,340
Specified Low-Income Beneficiary (SLMB)
Pays for Medicare Part B premiums. Also makes you eligible for Medicare Extra Help. To qualify for SLMB, you:
Cannot exceed individual monthly income limit of $1,234
Cannot exceed married monthly income limit of $1,666
Cannot exceed individual assets limit of $7,560
Cannot exceed married assets limit of $11,340
Qualifying Individual (QI)
Pays for Medicare Part B premiums. Also makes you eligible for Medicare Extra Help. To qualify for QI, you cannot have Medicaid and you:
Cannot exceed individual monthly income limit of $1,386
Cannot exceed married monthly income limit of $1,872
Cannot exceed individual assets limit of $7,560
Cannot exceed married assets limit of $11,340
Qualified Disabled & Working Individuals (QDWI)
Pays for the Medicare Part A premium if you are working, disabled, and under 65 OR if you lost your premium-free Part A when you went back to work. You must not be receiving state medical assistance. You also:
Cannot exceed individual monthly income limit of $4,132
Cannot exceed married monthly income limit of $5,572
Think you are eligible for Medicaid? You can apply either online through the Health Insurance Marketplace or through your state Medicaid agency. To use the Health Insurance Marketplace Medicaid Application, click here.
Each state has its own Medicaid Application on its own Medicaid website. It may be a good idea to meet with an agent first so that you can get help with your application.
Complete your Medicaid application
Are you eligible for Medicare and Medicaid?
If you’re not sure whether or not you are eligible for Medicare and Medicaid, we can help. Give us a call and we’ll ask you a series of questions to help you find out if you’re eligible.
If you are eligible, we can send an agent to your home to help you sort through your health care options. Another perk of being eligible for both Medicare and Medicaid is that you can receive a Special Enrollment Period, meaning that you can make changes to your coverage during any time of the year and don’t have to wait for the Annual Enrollment Period in the fall.
Our agents are licensed to sell plans from multiple different carriers, so they can help you pick the plan that truly works best for you.
This post was originally published on March 15, 2018, and was updated on September 28, 2018, and updated again on April 3, 2019.
Understanding Medicare and Employer Coverage/COBRA
In 2019, there are more older people continuing their career after age 65 than ever before. In 1985, senior Americans made up 11% of the workforce, but today that number is as high as 20%. If you are nearing 65 and wondering how your job impacts your Medicare options, look no further! Here is everything you need to know about Medicare and employer coverage.
Active Employer Coverage
If you are 65 (or soon-to-be 65) and have employer health coverage, you’ll have the option to keep your current coverage or enroll in a Medicare plan. It’s important that you understand the different coverage options available to you so you can compare and find the most cost-effective alternative.
Can I keep my employer health insurance with Medicare?
Yes. If you are actively working, you have the right to remain on your employer’s coverage plan even if you are eligible for Medicare. If you choose to keep your employer plan, your Medicare benefits can coordinate with your current coverage.
If your company has more than twenty employees, Medicare is secondary. This means that your group plan will pay first, and then Medicare. Part A can coordinate with your employer plan to lower your costs regarding a hospital stay. Most working seniors should enroll in Part A regardless of other coverage because it will be premium-free if you have worked for at least 10 years. Part B is not premium-free, and you will pay a monthly premium based on your income. You can choose to delay enrolling in Part B if you prefer. You can avoid Part B (or Part D, prescription drug plan) late penalties by showing a creditable coverage letter (proof of last coverage) when you enroll at a later date.
If your company has less than twenty employees, Medicare is primary. This means that Medicare will pay first, then your group plan. When Medicare is primary, you need to enroll in Medicare Part A and B. You can delay enrolling in a Part D plan (prescription drug plan) and avoid a late penalty fee if your group plan has prescription coverage. However, it is important to compare costs because it can be cheaper to leave your group plan and enroll in a Medicare Supplement plan as your secondary coverage instead. These plans are a great way to help pay for your copayments, coinsurance, and deductibles.
Can an employer pay for Medicare supplemental insurance?
Your employer generally does not pay for any of your Medicare premiums. However, your employer can set funds aside for you to use towards health coverage. This is done through a form called “Section 105 Medical Reimbursement Plan” and is a tax-free reimbursement of your medical and other health expenses.
Some employers may prefer to pay for a Medicare Supplement plan for you because carrying an employee over the age of 65 on a group health plan can be expensive. Plus, you may be able to get more comprehensive coverage through a Medigap plan, like the popular Plan G, instead of your employer or union plan.
Do I need Medicare if I have employer insurance?
The short answer is “maybe.” If you are about to turn 65 and have health coverage through your employer (or your spouse’s employer), you should talk with your benefits administrator and find out if you’re required to enroll. If your employer doesn’t require you to sign up for Medicare, you don’t have to. Instead, you can sign up when you retire or otherwise lose your employer’s coverage during a temporary Special Enrollment Period (SEP). As long as you enroll during your temporary SEP, you can avoid any late-enrollment penalties. These penalties typically result in a higher monthly premium as a result of postponing enrollment.
Can I work full time while on Medicare?
Yes, you can work full time while on Medicare. As we mentioned above, your Medicare and employer coverage will differ depending on your company size. If you have specific questions for your unique situation, click here.
What benefits are not included in employer coverage?
Your employer coverage can differ depending on your group plan. Some employer group plans may cover dental, vision, and hearing coverage, but these benefits can also be found in a Medicare Advantage plan. MA plans also offer benefits like group fitness classes, meal delivery, and transportation. If you’re interested in learning more about an MA plan or looking to enroll, click here.
Employer Union Coverage
Employer union coverage is a bit different than employer coverage. Your employer or union should let you know if your coverage will continue once you turn 65. You should contact your group coverage provider to get more detailed information.
Medicare COBRAQualifying Events
COBRA is a continuation of coverage for someone who is no longer part of a company or union. Under COBRA, an employee has the option to continue group coverage for a limited amount of time, however, it is generally at your own expense.
If you enroll in Medicare BEFORE you become eligible for COBRA, you can keep your COBRA coverage. If you are not yet eligible for Medicare when you get COBRA, your COBRA coverage will end on the day that you become eligible for Medicare.
*Additionally, gaining or losing a job with health coverage is considered a qualifying event for you to have a Special Enrollment Period (SEP), but you do not have a SEP once your COBRA coverage ends.
Can you have both Medicare and COBRA?
It is possible to have both Medicare and COBRA if you already had Medicare when you became eligible for COBRA. In that case, Medicare will pay first, but you can use COBRA for additional costs.
If you are under 65 and on COBRA, you must enroll in parts A and B as soon as you become eligible. Failure to do so can result in a late enrollment penalty fee.
Find Your Best Coverage Option
If you are nearing 65 and still have health coverage through an employer, we want to help! Medicare and employer coverage can be confusing, and we understand that all situations are unique. Our licensed agents want to make sure you’re enrolled in the best coverage for your needs and budget. Plus, they are contracted with all the major carriers so they can help you enroll with an unbiased approach. They can help answer any questions about employer coverage, Medicare Advantage plans, Medigap, prescription drug coverage, and so much more! Click here to get in contact with a licensed agent or give us a call at 844-431-1832.
This blog was originally published on 11/30/17, but was updated on 4/2/19 and again on 7/11/19.
Special Enrollment Period Medicare
Most people are only eligible to enroll in Medicare during their Initial Enrollment Period (three months before and after your 65th birthday) or during the Annual Enrollment Period (October 15 – December 7). However, there are several circumstances that may allow you to enroll in a Special Enrollment Period Medicare plan, including Part B, Medicare Advantage, Medicare Supplements, or Part D, outside of the initial and annual enrollment periods!
If you qualify for a SEP, you should take advantage of your ability to get yourself into a better plan. This includes:
Switching to a new plan in your area
Moving from one Medicare Advantage plan to another
Enrolling in Medicare Advantage for the first time
Switching from a Medicare Supplement plan to Medicare Advantage
Adding or changing prescription drug coverage
Different Types of SEPs
There are two main types of SEPs – lifelong and circumstantial. Lifelong SEP means you qualify for a SEP every year, unless your eligibility changes. For example, if you were eligible for Medicaid, but your income increased drastically, you may no longer be eligible. Circumstantial SEP means you qualify for a special enrollment period one time, depending on your circumstances. For example, if you move to a new service area, you will be able to make changes one time, unless you qualify for a different reason at a later date.
Another way you can qualify for a SEP is through a 5 star Medicare plan. If you are not currently enrolled in a 5 star Medicare plan, but one becomes available in your area, you can enroll in a better plan without being penalized. To learn more, click here.
Lifelong SEP
To qualify for a lifelong SEP, you must fall into at least one of the following categories:
Be eligible for Medicaid or a Medicare Savings Program
Part of SPAP (State Pharmaceutical Assistance Program)
Many people who qualify for a lifelong SEP are eligible for a Special Needs Plan. You must live in an area that supports a SNP plan as they are not available everywhere. Then, to be eligible, you must have a special need. In the case of SNPs, special needs can mean Medicaid-eligible/low-income (D-SNP), institutionalized (I-SNP), or diagnosed with a severe or disabling chronic condition (C-SNP).
Circumstantial SEP
To qualify for a circumstantial SEP, you must:
Move to a new service area
Involuntarily lose your coverage (for example, if your plan stops accepting Medicare assignment)
Find a contract violation with your plan
Lose or gain a job with group health insurance
Move into or out of a facility
Leave imprisonment
Enter or leave a health facility
Gain or lose Medicaid eligibility
Gain or lose Medicare Savings Program or LIS eligibility
Have been automatically enrolled in Part D
Special Enrollment Period Medicare Part B
In some cases, you may have a Special Enrollment Period for Medicare Part B (and Part A). If you are covered by a group health plan from your employer (and you are still employed), you may be granted a Special Enrollment Period. This SEP will begin the month after your group health plan or your employment ends and will generally last for eight months.
In most cases, this means that even though you are passing your Initial Enrollment Period, you will not face a late enrollment penalty fee (due to your employer coverage still being active).
How long does the special enrollment period last?
Special enrollment periods typically last 60 days. This means you have roughly two months to change or enroll in a different plan. However, depending on your circumstances, you may be limited to the changes you can make and the time frame could differ. Your best bet is to speak with a licensed agent and discuss eligibility and plan options. To ask any questions or to speak with a licensed agent, fill out this form.
Is being eligible for Medicare a qualifying event?
Being eligible for Medicare is not a qualifying event for a special enrollment period. If you are about to turn 65, you are eligible to enroll through your initial enrollment period, not a special enrollment period. The only events that qualify you for a SEP are listed above. If you have any questions on if your situation applies, fill out this form, and we will be in touch with you.
Do I qualify for a Special Enrollment Period Medicare Plan?
We get it, enrollment periods can be confusing, and it can be difficult to know if you qualify. If you aren’t sure whether or not you qualify for a special enrollment period medicare plan, or which enrollment period you need to use to enroll, we can help you. We can also help you figure out if you are eligible for a SNP Medicare Advantage plan, LIS (otherwise known as Extra Help) or another health care savings program, which will allow you to change plans at any time. To set up a free appointment with a licensed agent in your area, call 844-431-1832. As always there is no cost to you and no obligation to enroll.
This blog was originally published on 4/17/17, but was updated on 3/29/19.
What Disabilities Qualify for Medicare Under 65?
Most people are not eligible for Medicare until they turn 65, but that’s not the case for those with a long-term disability or disease. Did you know roughly 9.1 million people under 65 with disabilities are enrolled in Medicare? It’s important to understand the role of Medicare in these qualifying conditions so you can have the best coverage including Medicare Advantage, Medicare Supplements, or Part D plans.
ESRD Medicare Coverage
ESRD Medicare coverage can provide coverage for permanent kidney failure that requires dialysis or a kidney transplant. To be eligible, you must be diagnosed with end-stage renal disease (ESRD) and qualify for SSDI (Social Security Disability Insurance) or Social Security retirement benefits/railroad retirement benefits based on your work history.
Original Medicare covers a kidney transplant, hospital inpatient dialysis, and outpatient dialysis from free-standing facilities and hospitals. However, Medicare does not cover surgeries or services leading up to dialysis. Fortunately, Chronic Special Needs Plans (CSNPs) can help. CSNPs are a type of Medicare Advantage plan for people with chronic health conditions – like ESRD! This is an excellent option if you are looking for more coverage beyond Original Medicare.
For more information on ESRD Medicare Coverage, click here or fill out this form to get in contact with a licensed agent to learn about enrolling in a Special Needs Plan.
ALS Medicare Coverage
If you have been diagnosed with ALS, also known as Lou Gehrig’s Disease, you will be automatically enrolled in Original Medicare (Part A and B) the first month you receive Social Security Disability Insurance (SSDI) or a railroad disability annuity check.
ALS Medicare coverage includes hospital, hospice, skilled nursing, and home health services through Part A. Preventative services, mental health, lab tests, x-rays, emergency transportation, and medical equipment are covered through Part B.
Once you are enrolled in Original Medicare, you are eligible to enroll in a Medicare Advantage or Part D plan. Medicare Advantage plans offer additional health benefits like hearing, dental, and vision coverage. Part D plans provide prescription drug coverage. Plus, you may be eligible to enroll in a Medicare Supplement plan. These plans work alongside Original Medicare and can cover coinsurance, copayments, and deductibles.
Want to learn more about Medicare Advantage, Part D, and Medicare Supplement plans that are available to you? Click here to get in contact with a licensed agent.
Other Qualifying Disabilities
You are automatically enrolled in Original Medicare (Part A and B) after you have received Social Security disability benefits for 24 months or have certain disability benefits from the RRB for 24 months. If you qualify, you will get your red, white, and blue Medicare card in the mail 3 months before your 25th month of disability.
The following is a list of qualifying impairments with relevant examples.
Musculoskeletal disorders (back injuries and joint/bone dysfunction)
Cardiovascular conditions (heart failure and coronary artery disease)
Senses and speech issues (vision and hearing loss)
Respiratory illnesses (COPD, cystic fibrosis, or asthma)
Neurological disorders ( cerebral palsy and epilepsy)
Immune system disorders (HIV/Aids, lupus, and rheumatoid arthritis)
Mental disorders (PTSD, Schizophrenia, autism, and anxiety)
Skin disorders (cellulitis and dermatitis)
Digestive tract problems (Crohn’s disease, hepatitis, and liver disease)
Kidney problems (ESRD and genitourinary problems)
Cancer (Breast cancer, prostate cancer, etc.)
Hematological disorders (sickle cell disease, hemophilia, and bone marrow failure)
Please note, each condition and qualifying situation is unique, and we can not guarantee qualification or coverage. If your impairment is not on this list, you may still be eligible for disability benefits under other SSA guidelines.
I’m Disabled and Don’t Have Insurance. Can I get Medicare Now?
Sometimes. If you have a qualifying disability, like ALS or ESRD, you may be able to get Medicare now. Alternatively, if you receive SSDI (Social Security Disability Income) for at least 25 months, you can get Medicare.
How to Enroll in Coverage Beyond Original Medicare
Health costs can quickly add up. It’s great that Original Medicare is available with qualifying disabilities to people under 65, but what about coverage beyond Original Medicare? Medicare Advantage, Medicare Supplements, and Part D plans can add additional benefits and help you save on out-of-pocket costs. However, different states have different laws and some plans may not be at the best possible rate. A licensed agent is your best bet to compare your different options and enroll in the coverage you need at the price you want. Call us today at 844-431-1832 or fill out this form to get in contact with a licensed agent.
What are Medicare MSA Plans (Medicare Medical Savings Accounts)
A Medicare Medical Savings Account, or MSA, is one of six different types of Medicare Advantage plans. Medicare Advantage plans are private Medicare plans that cover everything Original Medicare covers but can add in additional benefits like dental, vision, hearing, physical fitness, non-emergency medical transportation, and more. The MSA plan type creates a non-taxable financial account for your healthcare costs.
How do Medicare MSA Plans Work?
If you’ve previously had a healthcare plan through an employer or the individual marketplace, you may have heard of an HSA, or Health Savings Account. Medicare MSA plans are similar to HSA plans. The plan you choose will include a bank account with a set amount of money in it. You can use that money to pay for your healthcare costs. If you use all of the money in your account and need more, don’t worry: once you meet your plan’s deductible (a set limit on what you can spend), you will be fully covered. If you don’t use all of the money in your MSA, it will carry over to the following year. This way, you can continue to build on your account. The money in your MSA is not taxable.
MSAs are also different from other Medicare Advantage plan types, like HMO (Health Maintenance Organizations) and PPOs (Preferred Provider Organization) in that you do not have to select a primary physician. Depending on your plan, you may still have a network, but it wouldn’t be nearly as strict as another plan model.
The Cost of an MSA
You will not have to pay a monthly premium specifically for your Medical Savings Account, but you will have to pay a premium if your plan includes additional Medicare Advantage benefits. Regardless, you will still pay your Part B premium.
Your plan determines the amount of money that goes into your account each year – this depends on the plan you choose. Once that is settled, you cannot go in and deposit additional monies. You will have a card that functions somewhat like a debit card for your medical expenses. When you use the card, the money will be taken from your account and given to the doctor. You will receive a statement each month that tells you what money has been taken out of your account and for what purpose. You can ONLY use this card for medical expenses. If you use the card for non-medical expenses, you will then have to pay a 50% tax penalty.
What do Medicare Advantage MSA Plans Cover?
Medicare MSA plans and other types of Medicare Advantage plans start by covering everything that Medicare Part A and Medicare Part B cover. Then, individual Medicare Advantage MSA plans often add benefits like dental, vision, long-term care, additional home health, and more. MSAs are different from other types of Medicare Advantage plans in that they typically do not cover prescription drugs.
In 2017, the Kaiser Family Foundation released data that only 3% of people enrolled in a Medicare Advantage plan selected an MSA option. The MSA plan type is typically better for those who are healthy, not taking expensive prescriptions, and more worried about cost savings than additional benefits.
Medicare Medical Savings Account Eligibility
Most people who are eligible for Medicare can enroll in a Medicare Advantage MSA plan. There are a few exceptions:
Those who have another form of health insurance coverage (employer or group coverage, individual health plan, TRICARE, etc.)
Anyone eligible for Medicaid
Those with ESRD (End-Stage Renal Disease) and those who are in hospice
Non-citizens and those who live outside of the United States for more than half of the year.
If you aren’t sure whether or not you can enroll in an MSA, or if you would like to talk to a professional about your various plan options, send us a message now or give us a call at 844-431-1832.
