The Insurance Solutions Experts
Know your Medicare Options
By: Sharon Boncek and Daphne Hennessey
Before you turn 65, you need to start looking at your Medicare benefits and options. Medicare should send you information in the mail and let you know how to enroll. You can also go online at www.medicare.gov . You can sign up for Original Medicare from this site. It also has a lot of useful information but it can be overwhelming.
If you or your spouse have worked at least 40 quarters in your lifetime then you are eligible for Original Medicare Part A – this is the part that covers hospitalization. For the majority of Medicare Beneficiaries there is no cost for Part A. Medicare and/or Social Security will inform you if there is a cost for Part A.
In addition to Part A you will have an option to enroll in Original Medicare Part B – this is the part that covers certain doctors' services, outpatient care, medical supplies, and preventive services. There is a cost for Part B. Medicare and/or Social Security will inform you of the cost since it does vary depending on your income from 2 years ago. If you have other creditable coverage ie Employer Coverage, TriCare, VA benefits then you do not need to enroll in Original Medicare Part B until you lose or drop out of the creditable coverage. If you do not enroll in Original Medicare Part B when you are 1st eligible and do not have other creditable coverage, you will have to pay a penalty for each month that you were without coverage.
After enrolling in Medicare Parts A & B, you should look at additional coverage that will help cover what Original Medicare does not. These options include Medigap Plans also referred to as Medicare Supplements, Medicare Advantage Plans and Stand Alone Prescription Drug Plans.
First we will talk about Medigap/Medicare Supplements. These are Standardized plans in all states except MA, MN, WI. You may have heard friends or family talking about Plan C, Plan F, Plan G, Plan N, etc all of these are Medigap plans. Depending on which plan you choose they will help cover your Original Medicare Part A and/or B deductible along with the 20% that Original Medicare does not cover. You can find a chart of the different plans at https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies . Please note that Plan F will be going away for new Medicare Beneficiaries as of 1/1/2020. For these plans you can see any Doctor/Hospital that accepts Medicare and assignment from Medicare. If you go to other providers you would still have some coverage but would pay more out of pocket.
Second is Medicare Advantage Plans also referred to as Part C. These plans are offered by Private Insurance Companies and include PPO, HMO, PFFS and HSA plans. The majority of plans include a prescription plan and could include coverage for dental, vision and hearing. Theses plans do have a Network of providers and you need to be aware of the Networks to avoid having excessive Out Of Pocket costs. A network is a group of doctors, hospitals, and medical facilities that contracts with a plan to provide services. There are various ways a plan may manage your access to specialists or out-of-network providers. For example, if you see a provider who is outside your plan’s network, you may have to pay a higher co-payment or coinsurance than you would for an in-network provider. You could also be responsible for paying the full cost of your visit out-of-pocket, depending on what type of Medicare Advantage Plan you have. Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan. It is important to note that not all Medicare Advantage Plans work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.
Third is a Stand Alone Prescription Drug Plan also referred to as Part D. You must have a prescription plan to avoid paying a penalty. You can have creditable prescription coverage with an Employer plan or VA benefits and would therefore not have to pay a penalty. These plans are offered by Private Insurance Companies. . Part D plans generally have networks of pharmacies that they contracted with to provide you with covered medications. Use a preferred, in-network pharmacy to fill your prescriptions. Many pharmacy networks include both preferred and non-preferred pharmacies. You typically pay less for your prescriptions at preferred pharmacies. Most plans also include a mail order pharmacy. This service allows you to order your medications 3 months at a time and the cost is typically lower than if you had the prescription filled at a local pharmacy.
Why is it important to go to an in-network physician?
By: Jona Baldwin
Although lots of insurance plans do cover out of network doctors, it is still better to consider in network when possible. Here’s why:
An in-network doctor under your plan means that a contract has been signed between the insurance company and the doctor you are seeing. The insurance company has agreed to pay a certain amount for services for each procedure code the doctor is licensed to perform. By signing this contract, the doctor agrees to not ‘balance bill’ a patient meaning, they cannot send a patient a bill for the difference of what insurance pays and what they would like to charge for that particular code. Outside of your copay, deductible and coinsurance, you are not obligated to pay additional fees for seeing this doctor.
When seeing an out of network doctor, this means that the doctor and insurance company have no contract. This also means that this doctor can charge any amount he feels appropriate for each procedure code he sees patients for, whether this be an office visit/consultation or surgery. Although your insurance plan may have a percentage (your coinsurance), that they pay for this doctor, it is a much smaller amount. If you see ‘80/20’ for instance for an out of network doctor, this does not mean that your insurance will pay 80% of this doctor’s fees. What this means is that they will pay 80% of what they have deemed ‘reasonable and customary’, after you have met your deductible of course. The difference between the percentage paid for the allowable amount and the amount the doctor charges is your responsibility.
Reasonable and customary amounts, sometimes also called ‘allowable amounts’, are the amounts paid by insurance per geographical area for medical services. This amount is determined based upon what other doctors in that area charge per service. Often times, these amounts are low.
In conclusion, seeing an in-network doctor when possible is always the most effective way to make sure you are protecting yourself from more out of pocket expenses than you planned for. In-network providers can be found on your carrier’s website by using their provided links to search doctors, clinics, and hospitals or, your agent can assist you before choosing your plan.
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