Today many kinds of medical treatment and services are provided outpatient!
● However, when just having MediCare's Part A & B (original Medicare) your MDs or other outpatient providers are not paid 100% for their services!
Why? The way MediCare's system works — it:
● Reviews medical treatments and services and "assigns" the amount to pay for each.
● Asks MDs and others, as part of agreeing to participate, to accept just 80% of this amount *. They have to accept "assignment".
* Discounted, often deeply, from retail!
● You are responsible for 20% of each outpatient treatment or service you receive.
Note: You also have to pay Part B's $198 annual deductible.
● When you have any in hospital treatment — MediCare pays the assigned amount for all medically necessary services — you have to pay Part A's $1,408 deductible.
Bottom line — paying 20% for all your outpatient treatment could quickly be a Big Risk to income & savings!
Buy a Medicare Supplement to protect your income & savings!
When you own a Supplement plan the company:
● Works with the MediCare system and pays outpatient treatment or service providers most or part of the medical treatment / service invoices MediCare did not pay.
● Pays the hospital Part A's deductible. ($1,408 in 2020)
Note: MediCare pays the hospital — the assigned amount — for all authorized treatment and services.
● The big reason many buy — they can see any MediCare providers here in CT or in another state, when they want to or may need to.
● Another important reason to own — your income & savings is protected — from a lot of treatment bills coming in the mail! — following an unexpected medical situations!
● The company pays providers, depending on coverage in the person's Supplement, all or part of the treatment MediCare did not - the so called Gap.
[Supplements are often called MediGap Plans.]
Note: 9 out of 10 people who have a Medicare Supplement say they are happy!
● The provider's office will want to see and perhaps copy your Medicare and Supplement plan ID cards. They do not ask for any office charge!.
● The provider submits the treatment charge for your visit to a MediCare claims administrator.
● Your Supplement company:
-> receives any expenses being charged to you from the MediCare claim administrator
-> reviews the treatment and then pays your provider the part of the treatment expense covered by your plan they did not receive.
Note: Your approval for the company to access your expenses was in the details of the plan application.
● The MediCare system sends you a coverage summary quarterly when you have treatment.
Note: The summary has a - Maximum You May Be Billed - column with a code by the amount indicating it was sent to the Supplement company.
● The Supplement company also sends an explanation of their payments.
Note: The medical treatment system sends you lots of invoices following a visit. Do not pay any of these provider invoices. Wait to see the actual amount you are responsible for, if any, on the supplement statement.
No! They pay the amount covered by your plan for any treatment MediCare determined to be medically necessary
When you own a Supplement:
● You can receive treatment from any provider, in any state, who elected to participate in MediCare.
BTW — When making an appointment just tell the provider you have MediCare. Providers do not have to know what Supplement company you have.
● Federal regulations authorized the National Association of Insurance Commissioners (NAIC) to develop certain plans and the coverage each plan will offerr.
● When plans were initially developed they received "lettered' names". A has the least coverage, B, C. etc. have more.
[Confusing since the parts of MediCare also have letter names. ]
● There have been coverage updates over time.
● Federal regulations instruct each state legislative body to approve the NAIC's recommended plans and implement them in state regulations.
● Thus, a Supplement with a specific letter in CT will be the same as that lettered plan in most states.
● A recent federal regulation effective Jan 2020 restricts the availability of certain full coverage plans to people turning 65 in Jan 2020 or later:
-> The new requirement states anyone 65 in January 2020 or after, called newly eligible, can not buy a plan, which pays Part B's deductible, such as Plan F.
Note: Individuals enrolled in a now restricted Plan prior to Jan. 2020 can keep it.
In Connecticut state legislation and regulations have authorized the CT Insurance Dept. (CID) to ensure all Supplement companies:
● Who offer any lettered Supplement in CT follow these state and CID requirements:
-> a person enrolling, whether male or female or 65 or 95, will be charged the same monthly cost.
-> any offered plan is available to individuals living in any CT County.
-> questions about a person's health history can not be asked.
-> when a monthly increase is proposed the company submits it to the CID. When approved, increases are often effective January 1st.
Note: CID often refers to Supplements as MediGap plans.
● Individuals who sign up for a Medicare Supplement:
-> receive their new coverage the 1st of the next month after applying.
-> can normally change to another plan at any time, whether with their company or to another.
Note - All companies offering a specific lettered plan provide the same coverage - but:
-> the monthly cost charged by different companies can vary considerably.
● First — Plan N - One companies N is over $100 a month less than their full coverage F.
Why is N less? You & the company share in what MediCare did not pay such as:
-> Part B's annual deductible [$198 for 2020];
-> a $20 co-pay for each MD office visit;
-> a $50 co-pay if any emergency room visits.
● Second — High Deductible Plans such as HD F & HD G. These are the lowest cost Supplements in CT but only available from a few companies.
-> Why? Coverage is the same as Plan F or G but, a person does not share but pays, at the beginning of each calendar year, their providers the first $2,350 (for 2020) of any treatment received.
-> Any medical related expenses above the deductible are fully paid by the company.
-> High deductible plans are a good option for someone who was using a high deductible plan when under 65.
● Note: High F is not available to newly eligible individuals [65 in Jan 2020 or later] but they can buy the new High G with the same deductible.
What to do? Buy what MediCare calls a Prescription Drug Plan (PDP) to cover part of the cost of outpatient prescriptions It's Medicare's Part D:
● A person pays co-pays and cost sharing based on the Tier level of the medication.
● Buying a PDP is voluntary but if a person does not have "credible" prescription coverage, such as from an employer, a penalty is added when they do sign up.
● PDPs are developed by and individuals purchase them from a private company. Availability is based on the County you live in.
Note: There are about 25 options in New London County.
When can you purchase a PDP?
● When turning 65 there is what is called the Initial Eligibility Period to apply for a PDP plan.
● Once enrolled a person can only change during the Oct 15 to Dec 7 Annual Election Period (AEP) unless they qualify for a Special Enrollment Period, such as after moving.
The focus when talking will be to
● Understand your situation and interest!
● Review the Supplement plans, answer questions, and select the best plan for your interest & budget.
We can also talk about Medicare PDP options and select, when enrollment is available, a plan to fit your medical situation.