Today many kinds of medical treatment and services are received as an outpatient!
● However, if you receive treatment just using MediCare's Part A & B (original Medicare) your MDs or other outpatient providers would not be paid 100% for their services!
Why? Lets look at the way MediCare's system works — it:
● Reviews all medical treatments and services and "assigns" an amount to pay for each.
● Asks MDs and others, as part of agreeing to participate, to accept just 80% of the approved amount **. They have to accept "assignment".
** Discounted, often deeply, from retail!
● You would be responsible for 20% of MediCare's approved amount for each outpatient treatment or service you receive.
Note: You also have to pay Part B's annual deductible. Its $198 in 2020.
● If admitted to a hospital — MediCare pays the approved amount for all medically necessary services — you just have to pay Part A's deductible each time you are admitted. It's $1,408 in 2020.
Bottom line — paying 20% for all your many outpatient treatments could quickly be a Big Risk to income & savings!
You have protected your income & savings!
The Supplement plan company will:
● Work with the MediCare system and pay your outpatient treatment or service providers most or part of the medical treatment / service invoices MediCare did not pay.
Note: The amount of payment varies based on coverage in the Supplement you have.
● Pays Part A's deductible each time admitted to a hospital ($1,408 in 2020).
Note: MediCare pays the hospital — the approved amount — for all authorized treatment and services.
● Many say — being able to see any MediCare providers here in CT or in another state, when they want or need to is important.
● You do not have a lot of treatment bills coming in the mail to pay! — following unexpected medical situations — thus it protects your income & savings!
● 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.
● 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 they did not receive based on the coverage in your plan.
Note: The details in your plan application gave the company approval to access your expenses.
● The MediCare system sends you a quarterly coverage summary 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: Medical treatment providers send you lots of invoices following a visit. Do not pay any of these provider invoices when they come. Wait to see the actual amount you are responsible for, if any, on the supplement statement.
No! The company will 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. Nor, since they accept MediCare, can they say they do take plans from your company.
● Federal regulations authorized the National Association of Insurance Commissioners (NAIC) to develop the Supplement plans and the coverage each plan will offer.
● 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, the coverage in 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 who turned 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 who enrolled, prior to Jan. 2020, in a plan that is now restricted can keep it.
In Connecticut state legislation and regulations 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.
● Permit individuals who sign up for a Medicare Supplement to:
-> receive their new coverage the 1st of the next month after applying.
-> be able to change (normally) to another plan with their company at any time or to another company.
Note - All companies offering a specific lettered plan in CT provide the same coverage - but:
-> the monthly cost companies charge for a plan can vary considerably from the same plan from another company!
● 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 the 20% MediCare did not pay. When going for treatment you pay:
-> 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. Only a few companies offer them.
-> How is their monthly cost lowest? Coverage is the same as Plan F or G but you pay, at the beginning of each calendar year, the first $2,350 (for 2020) of any medical treatment or services received.
-> Any medical related expenses above the deductible not covered by Medicare are paid by he 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] However, they can buy the new High G with the same deductible.
What can you do? Buy what MediCare calls a Prescription Drug Plan. (PDP) Owning means part of the cost of your outpatient prescriptions will be paid.
PDPs are Medicare's Part D and when at a Pharmacy:
● You pay co-pays and cost sharing based on the Tier level of your medication. Some plans also have a deductible to pay first on certain Tiers.
Buying a PDP is voluntary but if you do not have "credible" prescription coverage, such as from an employer. The penalty is added when you do sign up.
PDPs are developed by and purchased from a private company. Availability is based on the County you live in.
Note: There are 27 options in New London County as of Jan 2021 !.
When can you purchase a PDP?
● When turning 65 there is what is called the Initial Eligibility Period to apply for a PDP plan. It is a 7 month time at the same time you can sign up for MediCare.
● Once enrolled a person can only change to another PDP plan 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.