Does Medicare Cover Insulin?

The cost of insulin has been soaring over the last decade. For diabetics on Medicare, the out-of-pocket costs can be overwhelming. The Centers for Medicare and Medicaid Services estimates that 1 in 3 Medicare recipients is diabetic and a large percentage of those diabetics require insulin to manage their health. 

The Medicare Part D Senior Savings Model

In May of 2020, the Centers for Medicare and Medicaid Services (CMS) approved a change to insulin prices based on The Medicare Part D Senior Savings Model. The goal of the model is to test a 5-year plan where private insurance companies and drug manufacturers cover a large portion of the price of insulin to make the cost of this critical medication more manageable for diabetics enrolled in Medicare. 

How Does Medicare Cover Insulin Cost under the New Model?

The model involves having private insurers offer Medicare Part D enhanced plans for insulin users starting in 2021. The enhanced plans will have a price cap for insulin. Manufacturer rebates will partially offset the difference between the actual cost of insulin and the price cap. These rebates will apply to insulin costs by the insurance providers who offer the Medicare prescription drug plans. The CMS projects manufacturer rebates will cover an estimated $250 million of insulin costs over the model’s 5-year test period.

To receive price cap savings, Medicare recipients must opt-in to an enhanced Part D prescription drug plan or a Medicare Advantage Plan that includes prescription drug coverage. Plan providers do not automatically enroll diabetic Medicare recipients in these enhanced plans because most Medicare beneficiaries are not insulin users. 

If you choose to opt-in to an enhanced plan, it caps Medicare copays in all four phases of the coverage year, including the donut hole. The four phases of the coverage year are:

• The deductible phase
• The initial phase 
• The coverage gap (or donut hole)
• The catastrophic phase 

How Much Does Insulin Cost under the New Model?

This is the easy part. If you enroll in a Medicare Part D enhanced plan that includes the price cap, then your co-pay for insulin will be no more than $35 for a 30-day supply. This price cap applies to the first 3 phases of your Plan’s coverage year. Once you reach the catastrophic phase, you are only responsible for a 5% co-pay.

The goal is to provide pricing stability for diabetic seniors, many of which are living on a fixed-income budget. The CMS estimates that cost savings for diabetics under the new pricing model could be as much as 66% per year. Their analysis shows that 2019 Medicare Part D Plan recipients frequently paid over $1,100 each year just for insulin. 

How Much is Insulin under a Basic Medicare Part D Plan?

The 4 coverage phases of a traditional Medicare Part D Plan results in a wide range of insulin costs over the year. So, budgeting for insulin under a traditional Part D plan can be stressful and difficult. 

For instance, during the first phase, Medicare recipients are responsible for the total cost of insulin until they reach their deductible. The initial phase follows, providing some price stability until you reach the coverage gap. Insulin costs are higher during the coverage gap (the donut hole) because you have a 25% copay for all prescription drugs until you reach the catastrophic phase. 

The new pricing model for enhanced Medicare Part D plans will limit the total cost to around $440 annually. This is great news for diabetic seniors on Medicare who desperately need insulin price stability. 

Additional Considerations 

There are a few limitations to consider before you choose to opt-in to a Medicare enhanced plan to benefit from the new insulin savings model.

Higher Premiums

Most Medicare enhanced prescription drug plans come with a higher premium to offset some of the extra costs incurred by insurance providers. The premium for enhanced plans is decided by the private insurance companies that manage them. In 2020, the difference in cost for premiums between average Medicare Part D plans and enhanced plans was at least $20 per month and sometimes more.

Other Restrictions 

If you are a Medicare recipient on an enhanced plan and receiving a Low-Income Subsidy (LIS) then you are not eligible for the new insulin price cap. Additionally, the new model doesn’t have provisions for a Part D drug plan management strategy referred to as “non-medical switching”. 

An example of non-medical switching is when your insurance company requires you to use a generic brand of prescription medication instead of the doctor-recommended name brand. The insurance plans that enforce non-medical switching do so to control medication costs.

The CMS allows Part D Plan providers to cover a wide range of insulin brands under the model’s price cap. However, those providers are not required to offer plan recipients a choice of insulin brands. As a result, if you choose to opt-in you may have to change insulins to receive the discounted price.

It’s important to note that Medicare currently covers approximately 15% of the total population. The Part D Senior Saving Model is only available to seniors over the age of 65 who are Medicare recipients. Diabetics who are below 65 and are struggling with the high cost of insulin are not eligible. 

The Take-Away

Without a doubt, the Medicare Part D Senior Savings Model is the first step to more affordable insulin costs for individuals and families living with diabetes.

If you are eligible for Medicare and require insulin to manage your health, you can research enhanced Medicare Part D plans and Medicare Advantage plans that provide insulin savings. Remember, you must choose to opt-in to a qualified plan to receive the discounted copay. If you find a plan with a monthly premium that fits your budget, be sure to review the plan’s formulary to make sure that your preferred insulin brand is included.

According to the Social Security Administration, over 69 million Americans currently receive some form of monthly benefits. Though many people think of Social Security as a retirement program, there are other circumstances that qualify for benefits. Those include seniors over 62, workers who have become disabled, and families who have lost a parent or spouse. 

Social Security for Seniors

Though all SSA recipients are eligible for a benefit increase in 2022, let’s focus on Social Security for Seniors. The total amount of Social Security income you’ll receive depends on:

• Your contribution to the program based on your lifetime earnings 
• The age that you choose to begin receiving benefits
• Your eligibility to receive a spouse’s benefit instead of your own 

Senior Cost of Living

As the pandemic enters its second year, the hits to the economy keep coming, with rising prices on many of our basic goods and services. If you’ve waited until retirement to begin traveling, you’ve undoubtedly noticed that prices for gas, hotels and rental cars are currently at record highs. Even the cost of services like Airbnb, Vrbo, Uber, and Lyft are soaring. And it’s not just the travel industry seeing these types of increases. It seems like everyone is raising prices to compensate for much of their lost 2020 revenue.

It’s not just above-average inflation pushing prices higher in so many areas of the economy. Changing business models, heightened demand, and delays in the supply chain are all contributing factors. Here are some goods and services you’re likely to be paying more for in the coming months:

• • Gas: According to data from AAA, customers will continue to pay more than $3 per gallon at the pump for the foreseeable future. The national average price per gallon has not been this high since 2014.

  • Cars: Due to supply chain delays and economic uncertainty, car dealerships have a fraction of the vehicles they typically have on the lot. According to JD Power, the average new car price hit a record $38,255 in May 2021, up 12% from the same period a year ago. And fewer new cars means fewer used cars available for purchase. As a result, retail used car prices are up 20%. Higher wholesale prices are heading in a direction that says more significant increases are on the way.

• Rideshare: With a massive shortage of drivers, riding with Uber or Lyft can cost up to 40% more than the previous year.Even loyal rideshare customers are using taxis again to save money. 

• Restaurants: Menu prices are up 4% in full-service restaurants and over 6% at restaurants with counter service. Rising costs related to gas and employee pay are significant contributors to why restaurant prices are steadily increasing.  

• Groceries: According to the USDA, grocery store food prices are expected to rise as much as 3% this year. In 2020, the cost of meat soared nearly 10% due to plant shutdowns and rising transportation prices. And now, in 2021, it’s fresh fruit prices that consumers will need to keep an eye on.

• Hotels and vacation rentals: After staying close to home for so long, travelers are flying, hitting the road, and booking cruises again. We already know gas prices are up, so we expect to pay more for airline tickets and road trips. However, you may be shocked at the room rates you’ll be paying at hotels and private vacation rentals. 

• Homes: A real estate boom is underway, with homeowners entertaining multiple offers, routinely selling over the asking price. According to the National Association of Realtors, the median existing-home sale price was $363,300, up nearly 25% from 2020. Unfortunately, rents are also up everywhere, as the median cost for a one-bedroom apartment tops $1200 a month.

What is COLA?

In theory, the Social Security Cost of Living Adjustment (COLA) helps protect SSA benefits from inflation and is driven by changes in the consumer price index. The Consumer Price Index (CPI) is an economic measure that examines the weighted average of prices of everyday consumer goods and services, like transportation, food, and medical care. 

National average prices are used and calculated as the percentage increase between average prices in the third quarter of the current year and the previous year’s third quarter. 

For decades the average COLA has hovered around 3%, giving retired seniors and other SSA recipients a modest bump in their monthly amounts.

Social Security Adjustment

In 2021, the Social Security adjustment was a measly 1.3%, the smallest cost-of-living adjustment (COLA) since 2017. Considering that recipients were initially faced with a freeze in their benefits, many considered themselves lucky to have received any increase at all. 

The average monthly Social Security benefit payable in January 2021 increased by $20, from $1,523 to $1,543. In addition, the average monthly benefit for a couple receiving benefits rose $33, from $2,563 to $2,596. And the maximum Social Security benefit for a worker retiring at full retirement age increased from $3,011 per month to $3,148, an additional $137 a month.

As the economy continues to improve and employees get back to work, SSA recipients can expect a significant increase in their 2022 benefit checks. According to the September Kiplinger Letter forecast, the COLA may be as high as 6% in 2022, the most significant jump since 1982, when benefits increased by 7.4%.

With a 6% COLA, that same $1,523 check we mentioned earlier increases to $1,614. The average monthly benefit for a couple who receives benefits jumps from $2,563 to $2,716. The maximum Social Security benefit for a worker retiring at full retirement age increases a $3,011 check to $3,191. 

Social Security for Older Adults

Every little bit helps when it comes to making ends meet on a fixed income. So, what do you need to do to get the adjustment? Absolutely nothing. The benefits increase is effective on January 1, 2022 and will automatically appear in your check or direct deposit.

By Dana Barrett

What is Special Enrollment?

Special circumstances in life can create an opportunity for you to make changes to your Medicare Advantage plan or your original Medicare coverage outside of the regular annual enrollment period.

Special Election Periods (SEPs) exist to provide consumers with the flexibility to change, add, or drop Medicare coverage due to relocation, job loss, or any of several other special circumstances that might trigger the need to make an unexpected policy change. Rules about when you can make changes and the type of changes you can make differ based on each circumstance. Let’s take a look at some specific reasons you would need to make Medicare or Medicare Advantage plan changes during a SEP.

What life changes are covered under a SEP?

A Special Election period most commonly applies in your being eligible to enroll in or change original Medicare or a Medicare Advantage plan because you are relocating.

I just moved to a new home but it’s in the same state, am I eligible?

The answer is yes. Even if you stay within a few miles of your old home, moving to a new address may put you in a service area or in a new county that gives you access to Medicare Advantage plans you weren’t eligible for at your old address. This is because Medicare Advantage plans are offered by private insurers on a regional basis. 

Other relocation situations that make you eligible for a SEP include moving back to the U.S. after living abroad, or moving into or out of a skilled nursing facility. 

When is the SEP if I am moving?

Notifying your plan before you move:

• 1 month before your move and up to 2 months after

Notifying your plan after you move:

• The moment you let them know, and for the next 2 months

If I lose my non-Medicare coverage but I’m over 65, do I qualify for special enrollment?

There are a variety of reasons you could find yourself without medical coverage if you aren’t currently enrolled in Medicare. You may be retiring from a job where you had private insurance through your company and are over 65 years of age. As someone who suddenly finds themselves without insurance but eligible for Medicare, it makes sense to research original Medicare vs. Medicare Advantage plans to see if there is a Medicare Advantage plan available in your area that comes close to matching your prior insurance coverage, or that might better fit your current budget and needs. 

Do I need a Medigap plan if I sign up for Medicare?

If you are considering enrolling in original Medicare, you should also look into Medigap vs. Medicare Advantage. A Medigap plan is designed to reduce your out-of-pocket expenses by bridging any “gaps” above and beyond what original Medicare covers. You aren’t able to purchase a Medigap plan if you choose a Medicare Advantage plan.

Medicare Advantage plans are also designed to reduce your medical costs, but they do so by providing more comprehensive policies with copayments that are far less than the standard 20% you’re required to pay with original Medicare coverage. Unlike original Medicare, Medicare Advantage plans provide an annual spending cap and they usually include dental and vision care.

Both Medicare Advantage and Medigap plans are sold regionally, and you’ll have access to the best rates and policy provisions if you sign up during your initial enrollment window. 

 What other losses of coverage situations qualify for a SEP?

• You lost your Medicaid coverage.
• You left a Program of All-inclusive Care for the Elderly (PACE) program.
• Changes to or loss of another prescription drug program.
• You left a Medicare Cost plan.

My Advantage Plan changed its contract with Medicare, do I qualify for special enrollment?

Medicare Advantage plans are sold by private insurers who are required to follow the rules and regulations set by Medicare. Sometimes the private insurance companies offering an Advantage plan choose to end that specific plan or decide to leave Medicare altogether. Alternately, Medicare can also choose to end a contract with a private insurer.

If you are enrolled in a Medicare Advantage plan that is being terminated for any of these reasons, you qualify for a special election. In this case, the special election period starts 2 months before coverage ends and continues one month after.

It’s important to note the insurance company managing your plan is required to notify you in writing if your plan is being terminated, and they have to continue your coverage until the end of the calendar year in which you are enrolled. 

What is a 5-star Special Enrollment Period?

A 5-star special enrollment period only applies to Medicare Advantage plans. Medicare collects member satisfaction ratings to evaluate overall performance for Medicare Advantage plans. As a result, they issue 5-star ratings to certain plans that are exceptional. Consumers can use these ratings to compare the pros and cons of Medicare Advantage plans in the same way we use Yelp to evaluate a new restaurant. If the area where you live has a 5-star Medicare Advantage plan or drug plan then you can use a SEP to switch to the 5-star plan. Be aware you are only allowed to make that change once between December 8 and November 30th.

Are there other specific situations that are SEP eligible?

There are many personal situations and life circumstances that fit the SEP bill. For instance, if you qualify for extra medical support through the Medicaid program or the low-income subsidy program you qualify for a special election period. Additionally, if you find yourself with a chronic health condition you may be able to find a Chronic Needs plan that is available in your area. The case may also be that you are currently enrolled in a special needs plan, but the medical condition that qualified you for the plan no longer exists.

As mentioned earlier, the specific time period for the SEP will differ in each of these cases based on the special circumstances you are faced with. A full list of Special Enrollment Periods and the circumstances that trigger them can be found on the  Medicare site.

What is Durable Medical Equipment?

Hospitals, healthcare facilities, and home healthcare workers use a wide variety of Durable Medical Equipment (DME) and supplies to care for their patients and keep them safe and comfortable. This list of items includes, but is not limited to: monitoring systems, glucose meters, thermometers, syringes, specialty bags, wound care supplies, wheelchairs (electric, lightweight, or standard), portable commodes, walkers, mobility ramps, bath benches, catheters, adult diapers, and latex gloves.

Medicare does not cover all of the items listed; however, they may cover the cost of certain Durable Medical Equipment and supplies that meet their requirements. Learn more about what types of DME are covered, what you will expect to pay, and where to find Medicare-approved providers.

What does Durable Medical Equipment Coverage Pay?

Medicare Part A covers some of the Durable Medical Equipment costs for individuals who need it in a skilled nursing facility or hospital. If the equipment is medically necessary and purchased from an approved supplier, Medicare Part A will pay 80% of the approved DME after you’ve met the annual deductible. The patient or their supplemental insurance will be responsible for paying the remaining 20% and any amount over the allowable limit.

Medicare Part B covers Durable Medical Equipment and supplies used to treat patients in their own homes, even if they are not confined there. In addition to a private home, a personal care residence, such as an assisted living facility, can be considered a “home.” Home medical equipment must be medically necessary, prescribed by a Medicare-enrolled physician, and purchased from a Medicare-approved supplier. Medicare Part B pays for 80% after you’ve met the annual deductible. The patient or their supplemental insurance is responsible for the remaining 20% and any amount over the allowable limit.

Medicare Part C, also known as Medicare Advantage, is required to provide the same coverage as Part A and Part B. If you have Part C, your plan will pay at least 80% of the allowable limit for qualified Durable Medical Equipment.

What Type of Durable Medical Equipment Does Medicare Cover?

Think of Medicare’s Durable Medical Equipment coverage as having two tiers. DME is covered when determined to be medically necessary, and some DME is not covered despite being medically necessary. For example, grab bars in a shower may be recommended by a physical therapist as required. Still, Medicare does not consider them to be medical equipment and will not cover their cost. Generally, if an item can withstand repeated use, is primarily designed for medical use, and is appropriate for use in the home, it will most likely be covered. DME items that Medicare covers:

• • Air fluidized beds
  • Blood Lancets
  • Blood sugar test strips
  • Blood sugar monitors
  • Canes
  • Commode chairs
  • CPAP devices
  • Crutches
  • Diabetic test strips
  • Home oxygen equipment
  • Hospital beds
  • Infusion pumps
  • Nebulizers Patient lifts
  • Orthotics
  • Powered wheelchairs
  • Prosthetics
  • Suction pumps
  • Traction equipment

• Walkers

Medicare Wheelchairs

For seniors to remain independent, they need to have mobility. Medicare Part B covers power-operated vehicles (scooters) and manual wheelchairs as one of the most requested pieces of Durable Medical Equipment (DME) that your doctor can prescribe. To qualify for a wheelchair, you must have a face-to-face examination and a written prescription from a Medicare-approved doctor or healthcare provider. With that prescription, Part B will cover power wheelchairs deemed medically necessary.

Medicare DME Costs

If your Durable Medical Equipment supplier accepts assignment, you pay 20% of the Medicare-approved amount once you reach the Part B deductible. Medicare pays for different kinds of DME in different ways, depending on the type of equipment. You may be required to rent or buy the equipment based on their policy. Some plans give you the flexibility to choose whether you want to rent or buy.

For Medicare to pay the cost of your DME, your prescribing doctor and suppliers must enroll in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in the Medicare program. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. 

What Type of Durable Medical Equipment Does Medicare Not Cover?

In most cases, Medicare does not cover medical supplies, like catheters and syringes used once and thrown away. However, Medicare does make exceptions for specific medical supplies for treating or managing qualifying medical conditions, like lancets and test strips for diabetics. Some diabetes supplies are also covered under Medicare Part D prescription coverage. And in some instances when you qualify for home health care, Medicare may cover certain disposable items, such as intravenous supplies, gauze, or catheters.

Durable Medical Equipment Providers

Approved Medicare Suppliers have agreed to accept the Medicare-approved price for a specific item of DME. Purchasing from a participating Medicare Supplier ensures the individual will not pay more than a 20% co-pay for the Medicare-approved price for an item. 

Medicare Suppliers enrolled in Medicare’s program and will accept Medicare as a form of payment, still have the flexibility to set their own prices, By purchasing from a Medicare-approved DME Supplier, the individual may or may not spend the least amount out-of-pocket.

There are also DME Suppliers that Medicare does not approve. If one purchases from these suppliers, Medicare will not pay any portion of the cost. So before purchasing DME, it is important to know that purchasing Durable Medical Equipment from a Medicare-approved supplier does not guarantee the lowest price. You can find Medicare suppliers and compare prices using Medicare’s searchable database to search by item type and zip code.

Renting vs Buying With Medicare

Are you thinking about buying or leasing your DMEs? Typically, the decision is made by Medicare and in most cases, they will choose to rent. In most cases, Medicare will only buy inexpensive DME or equipment that needs to be custom-made for an individual. Renting often works in the patient’s favor since they won’t be charged for replacement or repairs if the item is defective. The Medicare-approved supplier will inform you if the item they need is available for rent or purchase.

No one can predict what the future holds for them health-wise, so it’s best to be prepared by staying active, maintaining your health, and keeping informed of the Medicare options that best suit your needs.

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Baby Boomers were born in an era when deals were still sealed with a handshake. You negotiated terms face-to-face for major purchases like cars, property, and insurance before signing on the dotted line. Business has changed, however, as territories have grown and customers have become more transient. Now you’re much more likely to sign up for services like Medicare over the phone.  

Medicare Signup

After paying into the system your entire working life, you’re probably already aware that at 65, you are eligible for Medicare health insurance. So, if you’re close to turning 65, it’s time to start making decisions about the kind of health insurance coverage you think you’re going to need. Even if you continue working and are covered by your employer’s health insurance plan, you may still be eligible for some Medicare benefits.

Understanding the basics of how Medicare signup works will help you make the best decisions moving forward. The chances are that you have friends and relatives who have already enrolled and are eager to dispense advice. Remember that one size does not necessarily fit all with Medicare, so it’s worth a little research to ensure that you’re choosing the coverage that will work best for you.

It helps to have an advocate that you can contact by phone to help you understand the alphabet soup of Medicare Plans A, B, D, and on and on. Getting the most out of your current coverage and helping you find additional services—as needs change—is what Senior Angel does. Call (800) 516-9929 to speak to a licensed agent about Medicare over the phone 

You also need to know that Medicare will not send you any notification as a reminder to sign up. So, get ready. Mark, your calendar ahead of time, do your research and be prepared to begin the Initial Enrollment Period (IEP) three months before your birthday. The mechanisms of the government move slowly, so by starting early, you can ensure that you’ll have your card in hand by the time your eligibility date rolls around.

Medicare Over the Phone, or Online

If you’re the patient sort with some free time, then you may want to call the Medicare phone number directly at 1-800-MEDICARE (1-800-633-4227) to begin the enrollment process. Once you get through, you’ll be able to schedule an appointment to speak with a Social Security representative.

If you’re considering a Medicare Advantage Plan to bundle all your coverage, then you can always call an approved insurance provider directly to discuss the options that they provide. Contacting private providers will get you details about their options and premiums. But will they have the best coverage for you? They may not, but you can bet that they’ll try their best to sell you what they have.

Senior Angel is not an insurance company where agents push plans that work best for their companies. Instead, they’ll take the time to determine your needs and help you comparison shop for a policy that works best for you. Talk to a licensed agent at 800.516.9929 for an objective look into hundreds of options offered by dozens of different insurers. 

If you prefer, you can also begin the relatively simple process of applying for Medicare online by starting here https://www.ssa.gov/benefits/medicare/. 

Pros and Cons

There are pros to signing up for Medicare in the comfort of your own home, like no crowds, no waiting, and no worries if you leave a required document at home. This leads us to the only con. Whether you sign up for Medicare by phone or online, you’ll still need to present certain sensitive documents for verification, including:

• Your original birth certificate or a certified copy 
• Proof of U.S. citizenship or legal residency 
• Your Social Security card if you’re already receiving SSA benefits
• Health insurance information 
• Tax information 
• Military documents 
• And a Part B enrollment application

If you’ve applied by phone or online, the bad news is that you have to mail original versions of these documents to Social Security, where they will make certified copies, then return the originals to you. To ensure that the process is smooth and secure, it’s probably best to start the process online or on the phone then make an appointment to present your documents in person. The SSA agent will have them verified, copied, and then you can return home with them safely in your possession.

Medicare Help

Medicare signup can be daunting the first time, so don’t hesitate to reach out for help with all the decisions you’re going to need to make before enrollment. There are hundreds of plans and options available, so you’re going to want to choose carefully. For free assistance with navigating the process, call a licensed Medicare expert at 800.516.9929.

Since Senior Angel doesn’t work for any specific insurance company, they can help you make the most informed decisions with your initial Medicare enrollment or help you make changes to existing coverage. If you’re on a tight budget, their experts can help you get the best coverage without breaking the bank.

Together, Original Medicare or Part A and Part B cover about 80% of the typical healthcare costs seniors face—leaving a few significant gaps in coverage. Contact the experts at Senior Angel to help you explore Medicare Supplement (Medigap) plans designed to help lower costs and extend coverage. You’ll find peace of mind knowing that you won’t leave behind a mountain of unpaid medical bills for your loved ones to deal with.

Unlike some other senior healthcare options, Medicare Supplement plans offer the advantage of flexibility, giving you the freedom to enroll in or change your Medicare Supplement policy at any time. And because Medicare Supplement policies are guaranteed for renewal so you can’t lose coverage if you develop a new or worsening health condition. Senior Angel can help you find the protection you can count on year after year.

There is never a charge for services provided by Senior Angel, so what are you waiting for? Call 800.516.9929 to get started. You have nothing to lose but high premiums, unnecessary extra costs, and gaps in your coverage.

By Dana Barrett

As each year begins, the new year ushers in the open enrollment period for making changes to your Medicare. You may be considering whether it’s time to switch from original Medicare to a Medicare Advantage plan, which is often referred to as Medicare Part C. To better understand how that choice could impact your care, we’ve outlined some pros and cons of Medicare Advantage and how it compares to original Medicare.

Signed into law, the Balanced Budget Act of 1997 included the creation of Medicare Choice programs. This private insurance alternative to the federal government’s original Medicare plan was renamed Medicare Advantage as part of the Medicare Modernization Act of 2003. The main goal in creating Medicare Advantage was to improve choices for Medicare recipients, as well as enhance benefits to include additional services such as vision and dental care, while also reducing out-of-pocket costs. 

What is Original Medicare?

Original Medicare is a federal medical insurance plan for citizens over the age of 65, as well as certain people under the age of 65 with physical disabilities, including folks on dialysis due to permanent kidney failure. Original Medicare is divided into 4 separate parts. 

At no charge, Part A covers hospitalizations, hospice care, and long-term care in skilled nursing homes. It also includes some types of in-home health care. Medicare Part covers certain physicians and outpatient care, some preventative care services, approved EKGs, X-rays, lab tests, as well as durable medical equipment. Be aware that Medicare Part B premium does not come free.

When you’re enrolled in the original Medicare plan you have the freedom to choose your doctors, the fees for their services are paid as they’re incurred. You’ll pay a deductible at the beginning of each year, and you usually end up paying about 20% of the cost of the Medicare-approved service out-of-pocket. If you need prescription drug coverage, you can enroll in Medicare Part D. Under Part D, prescription drug coverage includes generic as well as brand-name medications.

Medicare Advantage Plans

As previously mentioned, Medicare Advantage is covered under Medicare Part C. With Medicare Advantage, you choose from a variety of plans that bundle services including Part A and Part B Medicare, as well as expanded care that can also cover prescriptions drugs, dental care, hearing and vision. The private insurance companies that provide Medicare Advantage plans have yearly contracts with Medicare and are legally required to abide by Medicare’s coverage rules. 

If you sign up for a Medicare Advantage plan, you’re still required to pay the original Medicare Part B premium. However, instead of paying the standard 20% coinsurance amount not covered by original Medicare, you’ll only be responsible for the Advantage plan’s copayment amount, if there is any. Medicare Advantage Plans have copays and provider networks that vary based on each specific plan and what services are “bundled” including which of the extra services are included. 

Original Medicare vs. Medicare Advantage Plans

An attractive feature of Medicare Advantage plans is most provide you with more comprehensive coverage by including additional services like vision care and dental, which aren’t included with original Medicare. Some plans even cover gym memberships 

There is a variety of Medicare Advantage plans to choose from. The most common are HMO’s and PPO’s. HMOs are designed to keep costs down. HMO plans will have a broad network of providers available for you to choose from.Medicare Advantage networks are typically defined by geographic region or state and you must reside in that area for a minimum of 6 months to qualify for the plan.

PPO Advantage plans also include networks that provide the most cost-effective medical care. However, with a PPO you can also choose a physician who accepts original Medicare but may be out-of-network. If you go this route, a smaller portion of your costs will be covered by the plan.

Alternately, with original Medicare, you’re open to choose any doctor who accepts original Medicare, and the cost will be exactly the same for covered services (approximately 20%) no matter whom you choose. Keep in mind some doctors limit how many original Medicare patients they’ll accept in their practice so it’s important to check with the provider first. 

Another benefit of Medicare Advantage is in reducing out-of-pocket expenses. If you’ve been enrolled in original Medicare, then you’re aware that having Medicare doesn’t necessarily cover 100% of all your medical bills and the plan does not limit out-of-pocket expenses. Alternately, Medicare Advantage Plans have caps for out-of-pocket costs every year. Once you reach that threshold, you pay nothing for the rest of the year. If you find yourself with a serious long-term illness, the additional costs incurred with original Medicare could be financially devastating.   

Medigap vs. Medicare Advantage

If you have original Medicare, there are supplemental policies you can purchase to offset out-of-pocket medical expenses instead of choosing a Medicare Advantage plan. These plans are referred to as Medicare Medigap policies, or more commonly “Medicare Supplemental Insurance”. 

Private insurance companies offer both Medicare Advantage plans and Medigap policies. However, Medigap is only available to people enrolled in original Medicare. Medigap plans fill the “gap” to cover the extra expenses incurred by original Medicare recipients after Medicare pays. This includes coverage for fees such as copayments, coinsurance and deductibles. 

An important point regarding enrolling in a Medigap plan is that these plans no longer cover prescription drugs. That coverage was phased out of Medicare Supplemental Insurance at the end of 2005. Additionally, unlike Medicare Advantage, Medigap policies don’t offer coverage for dental services, hearing, or vision care. However, some Medigap plans provide foreign travel health care coverage if you find yourself with a medical emergency while traveling outside the United States. 

Clearly there are many variables to consider when making decisions about Medicare. It makes sense to start with a list of your medical needs and review any budget limitations. If you want to simplify your medical coverage with a health care plan that bundles a wide variety of medical care including dental and vision, then a Medicare Advantage plan may be the most cost effective. Speaking with a licensed agent can help with your research and finding an option that’s the best fit for you and your health. 

We all have unique health conditions that determine the type of medical insurance we need. If you are a Medicare recipient, then you have many plan options available to you. Most Medicare beneficiaries would prefer to find an insurance plan that offers the most benefits for their medical needs while lowering out-of-pocket costs. 

There are pros and cons to deciding between a Medicare Advantage Plan, or a Medicare Supplemental policy (Medigap) that complements your Original Medicare (Parts A and B) coverage. Here are some things to consider when choosing a plan that’s right for you.

The Pros and Cons of Medicare Advantage Plans

Medicare Advantage (Part C) Plans are an alternative to Original Medicare. These are regional insurance plans that are designed to provide a wide range of benefits, including various health and wellness options not offered with Original Medicare. Medicare Advantage plans are offered by private insurance providers. However, they must cover at least the same benefits covered by Medicare Parts A and B to be approved by Medicare. 

One of the best things about Medicare Advantage is the ability to personalize your insurance coverage to meet your healthcare needs. Original Medicare only offers two options – Medicare Part A (hospitalization) and Medicare Part B (physicians and services). Medicare Advantage (Part C) offers a variety of plans designed to fit a wide range of budgets. Some of the choices available are:

• HMO: A low-cost, network-based option with coordinated care that requires a referral for out-of-network specialists.
• PPO: These are plans that provide flexibility in choosing either in-network or out-of-network providers but have slightly higher premiums than an HMO plan.
• SNPs: Special Needs Plans are designed for folks who have a chronic health condition who may need specifically tailored healthcare services.

Medicare Advantage Plans can be tailored to include additional services that Original Medicare does not cover. Some of the extra benefits offered with Medicare Advantage plans include:

• Dental Care
• Vision Care
• Hearing screenings
• Prescription Drug Coverage
• Hospice Care
• Silver Sneakers fitness plans

Additionally, some Medicare Advantage plans go as far as providing free transportation for doctor’s visits and trips to the pharmacy.

Coordinated Health Care 

Medicare Advantage Plans are regional. Meaning for most plans you are required to receive care from approved in-network providers in a specific area. Also, with an HMO Advantage Plan, you’ll need prior authorization for certain procedures and tests, and referrals for specialists. 

Other Advantage Plans, especially PPOs, allow you to see out-of-network physicians and specialists but those services are covered at a lower rate and may have higher premiums.

Pros and Cons of Medicare Supplemental Plans

If you have Original Medicare Parts A and B, your standard copay is 20% for most medical services. If you have a medical condition that requires frequent doctor visits or routine medical services, your out-of-pocket costs could be substantial and unpredictable from year to year. 

Medicare Supplemental Insurance plans (Medigap policies) are designed to fill in the “gaps” and reduce the out-of-pocket costs that Original Medicare doesn’t pay. This includes covering expenses such as copays, deductibles, and coinsurance. Similar to Medicare Advantage, these plans are also offered by private insurance providers.

Medigap policies are not “stand-alone” coverage plans. You must be enrolled in Medicare Parts A and B to be eligible for a Medigap policy. There are 10 standardized Medigap policy types available in most states. The plan types are labeled with letters A through N. There is a different level of coverage offered based on which plan type (by letter) you enroll in and these coverages are standardized.

Medicare Supplemental plans don’t include any of the extras like dental, vision, and hearing that Medicare Advantage Plans provide. Additionally, Medigap policies do not cover the cost of prescription drugs or copays for prescription medication. However, the same private insurance companies that provide Medigap policies typically offer separate Medicare Part D Prescription Drug plans. 

With Original Medicare, there are no restrictions on which doctors or medical service providers you can see. You have the freedom to choose any provider, anywhere in the country, as long as they accept Original Medicare. This is true for Medigap plans as well. There are no in-network restrictions and no referral requirements. Some Medigap policies also offer the added benefit of coverage for emergency medical care when you are traveling overseas. 

Premiums and Other Costs 

The premiums for Medigap plans tend to be more expensive than the premiums for Medicare Advantage, especially when you consider many Medicare Advantage Plans have $0 premiums. Regardless of which Medigap letter plan you choose, premium costs will vary by insurance provider and location. Also, with some Medigap Plans your premium will increase as you age. 

The copays for Medicare Advantage Plans are very reasonable and all plans have a set yearly out-of-pocket maximum. For 2021, the out-of-pocket maximum is set at $7,550. This means that your total out-of-pocket cost will never exceed this amount for the year. Medigap plans in most states do not set a yearly out-of-pocket limit. 

The Takeaway

There are many things to consider when comparing Medicare Advantage vs. Medicare Supplemental plans. If your goal is to combine all your healthcare needs – including extras like dental and vision, under one umbrella then a local Medicare Advantage Plan may be the best choice for you. Keep in mind Medicare Advantage Plans limit coverage to the area where you live, and may only cover in-network physicians and services. If your primary care physician and specialists are not in the plan’s network, you may have to change doctors. 

If your goal is to stabilize your out-of-pocket medical expenses with Original Medicare, then the benefits of Medicare’s Medigap policy might be right for you. Original Medicare and Medigap policies offer the freedom to choose any healthcare provider in the nation that accepts Original Medicare. However, premiums and out-of-pocket costs may be more expensive than opting for a Medicare Advantage Plan. Additionally, Original Medicare doesn’t cover important health benefits such as dental and vision care.

What they are and how to take advantage of the benefits

The subject of healthcare can be a complicated one. No matter if you’re looking for the right doctor or navigating insurance, managing your health can sometimes feel like a part-time job. So, when a program exists that’s not only logical but also accessible, it only makes sense to utilize the benefits. We’re talking here about some of the healthy eating programs that are now part of Medicare Advantage plans. But before we go any further, it’s important to understand the difference between Medicare Advantage and traditional Medicare.

Medicare Advantage

Simply put, Medicare Advantage (also known as Medicare C or MA), is a type of health insurance plan that provides Medicare benefits through a private sector insurer. The plans have been around for roughly 25 years and were brought about as both an alternative to the fee-for-service Medicare plan, and a means for Medicare to benefit from the efficiencies and cost savings achieved in the private sector.

Original Medicare only provides for inpatient hospital services and outpatient treatment (known as Part A and Part B services), causing beneficiaries to purchase supplemental plans for things like dental coverage and prescriptions. Medicare Advantage plans are far more comprehensive. They not only cover Parts A and B, but they can also include a wide variety of other benefits. One such benefit is healthy eating programs, an umbrella term that encompasses various advantages depending on the plan you choose and the state where you live. We’d like to tell you about two types of healthy eating programs currently available in certain Medicare Advantage plans.

Healthy Food Cards

A healthy food card looks and functions pretty much like a standard debit card. The difference is instead of drawing money from your bank account when you use it, it draws from an account set up for you by your insurance company. Depending on the company and the plan, money is put into the account by the insurance company either weekly, monthly or quarterly. Here’s the catch. The card can only be used to buy food. Healthy food to be exact.

What constitutes healthy food? For the most part, it’s foods you already know to be healthy. Fresh fruits and vegetables, meat and fish, eggs and other dairy products, whole grains and nuts, plant-based fats and oil, supplemental drinks and much, much more. The only other catch is that cards can only be used in participating stores. But not to worry, your insurance company will have a list of both national chains and locally owned stores taking part. Once you receive your healthy food card, simply activated it and do some shopping. Head to an approved location, pick up approved products, swipe the card at the checkout counter and save money on your food bill.

If you’re asking yourself why your insurance company would give you money to eat healthy the answer is a simple one. The better you eat, the healthier you will be. The healthier you are will ultimately translate to a lighter load for both your insurance company and the healthcare system in general. That is what you call a win/win situation. To learn more about the benefits of healthy eating and for information about setting up an eating plan that best suits you, be sure to visit MyPlate.gov.

Post Discharge Meal Care Programs

In the spirit of improving your health by eating healthy food, many Medicare Advantage plans now contain meal care programs dedicated to your diet and nutritional needs after you’ve been discharged from a hospital or nursing facility. More simply put. Healthy meals, at no cost to you, delivered to your home while you recover.

If you have been approved for a medically necessary stay at either a hospital or nursing care facility, the goal is always to get you home and on the road to wellness. Aside from following your doctor’s advice, a complete recovery upon being discharged typically depends on rest, relaxation and the proper nutrition. Achieving that trifecta isn’t always easy, even when you’re not recovering from a medical condition. This is exactly why Medicare Advantage plans are stepping in and helping out. The best part – it requires literally no work on your end.

Typically, once you are discharged and back at home a representative from the company providing the meals will contact you. He or she will confirm your address and discuss any dietary restrictions, allergies and food preferences you may have. The representative will also tell you how to store the meals, as well as how to prepare them. At that point, all that’s left is to wait for the meals to arrive.

On average, meals are delivered between 24 and 72 hours of your welcome call. One week’s worth of meals at a time arrive on your doorstep via a 3rd party delivery service. The meals are fully cooked and prepackaged, and everything arrives in a box with cooler inserts, so there is no need to be present for their arrival. All you need to do is properly store them and heat according to instructions once you’re ready to enjoy. If that weren’t enough, most of these programs allow for 2 meals per day for up to 28 days! That’s means no need for you to worry about purchasing food, nor cooking it, for literally one month.

To Your Health

The lesson to be learned here is two-fold. First and foremost, proper nutrition is vital to maintaining your health. The sooner you take control of your dietary habits, the better you’ll feel and the better your chances will be to stay healthy well into the future.

Just as important is understanding there are programs in place that will not only guide your healthy eating but will also make it much more affordable. Be sure to look into the Medicare Advantage plans available in your state. If you are already a beneficiary of one, be sure to inquire about their healthy eating programs. And lastly, here’s to your health.

By Dana Barrett

Does Medicare Cover Dental Services?

As we age, so does the condition of our teeth, eyesight, and hearing. Dental care can be expensive, especially crowns and bridges, which run in the thousands of dollars. Hearing aids and eyeglasses are also costly, so why are these vital services not covered by Original Medicare?

The Importance of Routine Dental Care

More and more evidence suggests tooth decay and gum disease can lead to a whole host of other health concerns such as cardiovascular disease and memory issues. Also, denture wearers with no natural teeth can struggle with nutritional deficiencies. A mouth full of cavities and gum disease can aggravate health conditions, including heart disease and diabetes. 

Undoubtedly, a lack of regular dental care can delay the diagnosis of more severe health conditions, leading to expensive emergency department visits. Original Medicare only covers dental procedures if they fall within a strictly defined set of circumstances.

Medicare Vision and Hearing Care

Original Medicare doesn’t cover preventative services such as routine eye exams or the expense associated with purchasing eyeglasses or contact lenses. Medicare Part A covers specific eye procedures but only when there’s hospitalization for a condition with eye trauma.

Medicare Part B includes glaucoma screenings and cataract surgery, as these conditions are covered under the umbrella of “general health.” Part B Medicare also includes screenings and tests necessary for the treatment of macular degeneration and diabetes.

Older adults are prone to hearing loss; however, hearing exams and hearing aids are not included in Original Medicare. The only time a hearing evaluation is covered is if it’s a “hearing and balance exam” to diagnose another health condition such as vertigo or a balance disorder. 

Legislative Changes to Medicare

The Social Security Act excludes routine dental, vision, and hearing services from Original Medicare unless they fall under a very narrowly defined set of circumstances.

The federal government has begun to acknowledge the importance of these screening procedures in health maintenance for Medicare recipients, and in 2019 Congress drafted and approved House Resolution 3 (H.R. 3).

H.R. 3 is intended to make changes to Medicare dental insurance and includes improvements in routine eye care and hearing coverage for Original Medicare (Part B) recipients. 

Dental services, routine exams, x-rays and screenings would be covered under Part B benefits starting in 2025. Tooth extractions, fillings, and restorations would also be covered. Original Medicare recipients would still be required to pay the standard 20% as an out-of-pocket expense.

Dental procedures like root canals or dentures are also included but at a much lower rate. Under H.R. 3, the recipient would be responsible for 90% of the out-of-pocket cost but would drop down to 50% over several years. 

Annual vision exams and hearing exams would become standard through Part B Original Medicare. A hearing aid purchase would also be covered under part B, with a 20% copayment. Additionally, there would be an $85 allowance towards the purchase of eyeglasses or contact lenses. Be aware H.R.3 isn’t approved yet. It is still waiting to be voted on in the Senate.

So how can I get these benefits from Medicare now?

The good news is that you can switch from Original Medicare to a Medicare Advantage plan (Medicare Part C) which offers extra coverage for these services. About 75% of Medicare recipients currently have Medicare dental insurance through a Medicare Advantage Plan. Many of these dental plans offer routine care, which can include:

• Annual exams
• Cleanings and X-rays
• The filling of cavities 
• Root canal treatments
• Extractions
• Periodontics
• Crowns and Bridges
• Dentures and Implants

Some plans only offer preventative services, while others include more comprehensive dental care. Coverage will be subject to annual limits. 

Dental Discount Cards

Dental discount cards are another option to help offset the cost of dental services. These discount plans are available in most areas, and many major insurance carriers offer their own dental discount memberships for consumers instead of dental insurance. The goal of these programs is to provide immediate discounts for dental services at the time of your visit. Still, they can only be used within a network of participating providers.

It’s important to note that a dental discount card is not part of Medicare. The way the discount card plan works is a network of dentists who agree to charge fixed discounted rates for specific dental procedures covered by the program. Discounts average anywhere from 10% to as deep as 60% for most covered services.

 To join a discount card plan you’ll pay an annual fee; however, these plans don’t require a deductible or copay and there is no annual out-of-pocket cap. The recipient must pay for dental services at the network rates and only with participating providers. You can check with your dentist to see if they are part of a discount plan network, or you can research dental discount cards online.

Medicare Advantage for Eye Care and Hearing

Most Medicare Advantage plan recipients enroll in vision care plans to help reduce the cost of purchasing glasses and contact lenses and have coverage for annual eye exams and fittings. The rates at which these services are covered differ between plans, so be sure to check the plan details when you enroll.

Around 75% of Medicare Advantage customers have hearing coverage. Suppose you’ve been referred to a specialist for a hearing problem. In that case, it makes sense to check with that provider to see which Medicare Advantage plan they accept before making changes to your Medicare Advantage coverage.

Hearing aids are also covered by Medicare Advantage and are available for different price ranges. Basic models typically run from $1,500 – $2,000, but more specialized devices can cost much more. Medicare Advantage plans that offer hearing coverage will cover some or all of that cost. 

 If you need assistance locating Medicare Advantage plans with the added services of dental, vision, and eye care in your area, press the link below and one of our representatives can help you.

Having the right healthcare coverage has never been more important. While your current Medicare plan may have worked well in the past, how do you know it’s still the best option going forward?

Not only will your health and prescription needs change, but so do the costs and coverages offered by each provider. That’s why it’s essential to speak with your agent before the upcoming Medicare Annual Enrollment Period (AEP) so you’ll be prepared. 

Let’s take a closer look at the key dates and details you need to know.

When Is It?

The Medicare Annual Enrollment Period takes place from October 15th thru December 7th. Changes made during this period go into effect on January 1st.

What You Can Do

During the AEP, also known as Medicare Fall Open Enrollment, you can make the following changes to your coverage:

• Exit Original Medicare (Part A and Part B) and sign up for a Medicare Advantage plan (Part C).
• Exit your Medicare Advantage plan (Part C) and sign up for Original Medicare (Part A and Part B).
• Change from one Medicare Advantage plan to another.
• Change your Medicare Advantage plan from one that doesn’t offer prescription drug coverage to one that does.
• Change your Medicare Advantage plan from one that provides prescription drug coverage to one that doesn’t.
• Sign up for, change, or remove a Medicare Part D prescription drug plan.

Why It Matters

Each year, the insurance companies offering Medicare Advantage plans (Part C) and prescription drug plans (Part D) make updates to the prices and coverages available. These range from which providers and pharmacies are considered in network, to the types of medications covered and the associated costs involved. 

Because these changes can have a significant impact on the type and cost of care you receive, it’s important to review them. 

Know What’s Changing

Regardless of the type of Medicare coverage you have, you will receive a detailed explanation of the modifications being made to your existing plan prior to open enrollment 2021.

If you’re already enrolled in a Medicare Advantage plan, your current provider will send out an Annual Notice of Change (ANOC), an Evidence of Coverage (EOC), or both. These will contain the important details you need to know about what’s changing in the upcoming year. They usually arrive in September.

If you’re enrolled in Original Medicare (Part A and Part B), then you will receive the Medicare & You booklet. It comes out each September and contains the pricing and coverages going into effect next year. Then you can examine and compare them to the Medicare Advantage (Part C) options available in your area. 

What to Look at Specifically

Here are some of the key factors to evaluate:

• Are your current healthcare providers considered in network?
• What types of visits are covered and at what cost?
• Is your preferred pharmacy in network?
• Are the medications you’re taking covered? 
• Have the overall plan costs and coverages changed so you will be paying more (or less) out of pocket?

Why Make a Change

Once you examine the upcoming changes to your current plan, it’s a perfect time to see what other plans have to offer. 

You may discover Medicare Advantage options that are better suited to your current health needs while also saving on premiums or medical visits in the process. 

In addition, if you have a prescription drug plan (Medicare Part D), you will want to find out whether other plans in your region offer better pricing for the medications you require. 

Once you have selected the best Medicare plan for you, you’ll be all set to sign up during the Medicare Fall Open Enrollment beginning October 15th.

(Prescription Drug Plan Note: If you choose to remove your Medicare Part D prescription drug coverage and later opt to re-enroll, you could be charged a late-enrollment penalty. This goes into effect if you lack coverage for 63 consecutive days or longer.)

Other Medicare Enrollment Periods

While it’s best to take advantage of the Medicare Annual Enrollment Period so your coverage will be in place at the start of the new year, that’s not always possible. If you need to make changes outside of the Oct 15th thru December 7th timeframe, here are some opportunities to do just that.

• Special Enrollment Period (SEP) – Life happens, and Medicare understands this. For example, if you’re newly married, divorced, or have moved outside of your current plan’s jurisdiction. Perhaps you’ve begun (or completed) a stay in an extended-care facility. Sometimes Medicare may terminate its contract with your provider. These are just a few of the situations that would qualify. This enrollment period will allow you to update your coverage. 
• Initial Enrollment Period (IEP) –  When you first become eligible for Medicare, this is the period when you can sign up. It starts three months before your 65th birthday month and continues through three months after it. This provides you with seven months to complete your enrollment. 
• General Enrollment Period (GEP) –  This enrollment period spans from January 1st through March 31st. It is for individuals who did not sign up during their Initial Enrollment Period and do not qualify for a Special Enrollment Period.   
    
• Medicare Advantage Open Enrollment Period (OEP) – This enrollment is available from January 1st thru March 31st. You may use it to move from one Medicare Advantage plan to another Medicare Advantage plan or to make changes to your prescription drug coverage.
  
  In addition, you may change from a Medicare Advantage plan to Original Medicare (Parts A and B). However, you cannot switch from Original Medicare to a Medicare Advantage plan during this period. So if you want to sign up for a Medicare Advantage plan, update your coverage during the Medicare Annual Enrollment Period, from October 15th through December 7th.
  
  If you make changes during the Open Enrollment period, they will go into effect on the first day of the month following the receipt of your request by your new provider.

Next Steps

While there are many factors to keep in mind, the bottom line is you have the power to choose the best Medicare option available to you. Think about your health care and prescription needs over the past year and the procedures you may have planned for the future. Find out more about the plans available and identify which one will best meet your needs going forward. Then sign up during the Medicare Annual Enrollment Period, and enjoy peace of mind for the year ahead!