Today many medical treatments and services are provided outpatient!
● MediCare however, does not pay MDs or other outpatient providers 100% of what they consider the cost of 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 *. It is called accept "assignment".
* Discounted, often deeply, from retail!
This means if you are only using MediCare and receive:
● Any outpatient treatment or services you are responsible for 20% of each!
Note: You also have to pay Part B's $198 annual deductible.
Bottom line — paying this could quickly be a Big Risk to income & savings!
● Any in hospital treatment — the assigned amount is paid for all medically necessary services — you have to pay Part A's $1,408 deductible!
Buy a Medicare Supplement, its one of the Medicare Health Plans, and works with the MediCare system.
When you own the Supplement company:
● Pays providers of outpatient treatment or services most or part of the medical treatment / service invoices MediCare did not pay.
● Pays the hospital Part A's deductible. ($1,408 in 2020) MediCare would have paid the assigned amount for all authorized treatment and services.
● Allows individuals, who want to or may need to see a provider in another state, to get their treatment paid.
● Generally pays providers all or part of a person's treatment MediCare did not - the so called Gap.
[Supplements are often called MediGap Plans.]
● Protects your income & savings — from a lot of treatment bills coming in the mail following an unexpected medical situations!
Note: 9 out of 10 people who have a Medicare Supplement say they are happy!
When you own a Supplement:
● You can receive any treatment MediCare has determined to be medically necessary from any provider, in any state, who elected to participate.
BTW — When making an appointment just tell the provider you have MediCare. Providers do not have to know what Supplement company you have.
● The provider's office will ask to see your Medicare and Supplement plan ID cards. They do not ask for any office charge!.
● The treatment charge for your visit will be submitted by the provider to a MediCare claims administrator.
● Your Supplement company:
-> gets any expenses being charged to you from the MediCare claim administrator
Note: The approval to access your expenses was in the details of the plan application.
-> then pays your provider all or part of the treatment expense they did not receive.
● The MediCare system sends you a coverage summary quarterly when you have treatment.
Note: There is a - Maximum You May Be Billed - column on the summary with a code by the amount. This indicates it was sent to the Supplement company.
● The Supplement company also sends an explanation of their payments.
Note: Do not pay any of the many provider invoices they send you. Wait to see the actual amount you are responsible for, if any, on the supplement statement.
● Federal regulations authorized the National Association of Insurance Commissioners (NAIC) to develop the coverage to included in the different plans which can be offered.
● Plans were given "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.
● The federal regulations instruct each state legislative body to approve the NAIC's recommended coverage and implement the plans in state regulations.
● A supplement here in CT with a specific letter will be the same as that letter in most states.
● A new federal regulation was effective Jan 2020. It restricts the availability of certain plans with full coverage to people of a certain age:
-> Thus, anyone who became 65 in January 2020 or after, called newly eligible, can not buy a supplement, which pays Part B's deductible such as Plan F.
Note: Individuals who enrolled in a now restricted Plan prior to Jan. 2020 can keep it.
Connecticut state legislation and regulations authorize the CT Insurance Dept. (CID) to ensure:
● All companies offering supplement plans in CT follow these state and CID requirements when any lettered plan is offered.
-> the same monthly cost will be charged to a person enrolling whether they are male or female or 65 or 95.
-> the selected plan will be available to individuals living in any CT County.
-> questions on a person's health history can not be asked.
-> any proposed monthly increases are to be submitted to the CID. When approved, increases are often effective January 1st.
Note: CID often refers to Supplements as MediGap plans.
● Individuals enrolling in a Medicare Supplement:
-> receive their new coverage the 1st of the next month after applying.
-> can normally change their current plan to another 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 company offers N for over $100 a month less than their full coverage F.
Why is N less? You & the company share in paying providers what MediCare did not 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. They are only available from a few companies but are the lowest cost Supplements in CT.
-> Why? Coverage is the same as Plan F or G but, a person pays, at the beginning of each calendar year or after they enroll, 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.
MediCare Part B nor the Medicare Supplement which backs it up do not cover prescription medications purchased at a local pharmacy!
What to do? Buy what Medicare calls a Prescription Drug Plan.(PDP) It's Medicare's Part D and:
● Covers part of the cost of a outpatient prescription by charging co-pays and cost sharing based on the Tier level of the medication.
● Buying a PDP is voluntary but if a person did not have "credible" prescription coverage, such as from an employer, a penalty is added when they 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 you can apply during what is called the PDP's Initial Eligibility Period.
● Once enrolled a person can only change during the Oct 15 to Dec 7 Annual Election Period (AEP) unless a person qualifies for a Special Enrollment Period, such as when 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.
Content on Medicare-Health-Plans-Southeastern-CT is © 2018 to 2020 by John C Parker, RHU, LTCP - All Rights Reserved.
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