Medicare Supplement OEP
The best time to buy a Medicare Supplement policy is during your Medicare Supplement Open Enrollment Period. After this period, your options to buy a Med Supp (Medigap) policy may be limited and the policy may cost more. Many people are not even aware of what the Medicare Supplement OEP is.
The Medicare Supplement Open Enrollment Period is an opportunity for individuals enrolled in both Medicare Part A & Part B to enroll in a Medicare Supplement (Medigap) plan without facing medical underwriting or higher premiums based on their health conditions. This means, insurance companies cannot deny you coverage or charge you higher premiums based on either your health status or pre-existing conditions. This is very important for individuals with pre-existing health conditions, as they can secure coverage at a reasonable cost without facing medical underwriting or risk being denied a policy.
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When is the Medicare Supplement OEP:
The Medicare Supplement Open Enrollment Period begins the first day of the month their Medicare Part B is in effect. For many people, this is the first day of the month they turn 65.
This is a 6-month period that starts the first day of the month you’re 65 or older and signed up for Part B. Once this time passes, there are fewer options to buy a Med Supp (Medigap) policy and the policy could cost more.
For example: If Medicare Part B coverage begins on June 1st. then, the Medicare Supplement OEP starts on June 1st and continues for six months. This means, it will end December 31st.
Those who delay enrollment in Medicare Part B due to creditable coverage through their large employer group plan will have their Medicare Supplement Open Enrollment Period when they lose group coverage and enroll in Medicare Part B.
Learn about your Medicare Supplement GI Issue rights
In some situations, there is a second opportunity for an OEP:
- If you are under 65 and have Medicare coverage due to a disability, there are 2 Medicare Supplement OEPs available to you. The first is when your Part B coverage starts before you turn 65. The next one starts when you turn 65.
- Some individuals enroll in Medicare Part B and then choose to go back to work and receive employer coverage so they stope their Part B at that time. Once they decide to retire again, they will re-enroll in Part B and therefore you start a new OEP.
Important:
You can enroll in a Medicare Supplement plan outside your OEP however, answering questions about your health history and medications is a regular practice. Your answers to these questions will determine if you the carrier accepts you into the plan or not. This means, the key to enrolling in a Med Supp plan is; passing underwriting.
To avoid underwriting altogether, it is best to apply for Medigap coverage during your Medicare Supplement OEP.
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Starting a Medicare Insurance Agency
If you enjoy helping others and want to start your own business, starting a Medicare insurance agency could be a good fit for you.
The first thing you need to have is a solid understanding of Medicare:
You should familiarize yourself with the Centers for Medicare & Medicaid services (CMS) and their rules and regulations. It is very important that you understand the various types of Medicare plans available and what they provide.
It is also a good idea to have Medicare sales experience. This will help you understand what it takes to be successful in the field and give you invaluable information to train your downline agents. Although there are some large Medicare agencies with owners that do not sell, they employ key people who do have sales experience that help ensure the success of the agency.
Some ideas to get you started:
- It is necessary to develop a business plan to help you get started
- Make sure you obtain all the necessary licenses and certifications to be complaint with all regulations.
- Establish a legal structure such as; sole proprietorship, partnership, limited liability company (LLC) or Corporation. It is best to consult an attorney of advisor to help with this.
- Obtain all the insurance coverage you need including E&O, liability and in some cases, workers compensation.
- Develop a marketing strategy to promote your agency and gain public visibility. Create a website, social media platforms, print media and networking events.
- Decide what staff you need to run a business and make sure they are trained and ready to go.
Agency Contract levels:
The amount each contract level receives is regulated by CMS. Each year, CMS puts a cap on the amount of commission paid for each sale. This amount varies by state.
The different levels of contracts include:
- Street level – carriers pay the compensation directly to the sub agent with the override paid to the agency. The amount of the override depends on the agency level.
- General agency or GA is the first agency level. Agents at this level receive compensation above street level as well as overrides on any business written by downline agents.
- Master General Agency or MGA. This level is achieved by meeting carrier requirements beyond that of the GA level for sales and downline agents.
- Senior General Agency or SGA. There are even more sales requirements as well as a higher number of downline agents needed to achieve this level.
Please keep in mind, the number of subagents and sales that each carrier requires to reach the different contracting levels is determined independently by carrier.
If you have either a GA, MGA or SGA contract, your sub agents can still receive street level compensation with your agency receiving the override compensation. Most carriers pay the street level compensation directly to the sub agent while the agency receives the override payment.
More information about starting a Medicare Insurance agency:
Some agencies work with LOA (licensed only agents). This means, the insurance carrier pays all compensation to the agency. The agency then pays a agreed upon amount to the agent. This model is commonly used by agencies who provide either low or no cost leads to their agents. When this is the case, compensation levels can vary greatly, depending on what type of leads are offered. Some agents receive compensation well below street when this is the model used. With this set up, agencies generally own the book of business and may or may not pay out renewals.
Other agencies offer their agents street level contracts. If this is the case, the agents receive compensation directly from the carrier as well as referrals. In this instance the agent owns their own book of business. Agent who are aware of the street level compensation amounts will rarely decide to work LOA under an agency.
You need agents to make up your agency::
To bring in new agents, you need to have something to offer them. Provide them with leads or a lead program. Make sure you offer training to them as well as be available to answer any questions they may have.
It is also a good idea to provide free tools that can help make writing business easier for them. Like online quoting and enrollment tools.
Click here to learn more about what to offer your downline agent
A proven training program helps your new producers build the confidence to get up and running. Training also helps low producing agents increase sales. Many agents complain about uplines that do not provide the guidance they need to make sales. Many agents are just looking for the support they need to become successful.
Most agencies use several strategies to recruit new agents. Before you bring in anyone, decide if you are looking for agents who are already licensed and experienced or you want to bring on someone with no experience so you can train them from the ground up. Whatever you decide, be sure you bring in someone who has the potential to help your agency grow.
How do I build the agency’s book of business:
The most important part of a Medicare business is finding qualified prospects and enrolling them in policies. That is where finding a good source for leads is very important and finding the best way to work them. Some agents do well on the phone while others may be great at presentations. Maybe you like mailers. This is something that you need to figure out. Leads do not come with a guarantee. Weather you make those sales or not depends on your ability.
The best lead source is word of mouth. When you take good care of your clients, they tend to tell their friends and relatives. This is free lead source and are invaluable. That is why we cannot stress enough; know your stuff! Learn the plans and the enrollment periods. Be aware of the marketing rules and everything in between. This way you can ensure your clients get the best possible coverage and will stay on your books.
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How Do Medicare Commissions Work?
What attracts many agents to Medicare sales is often two-fold. One, they enjoy helping people. And want to work with Medicare beneficiaries to assist them finding the coverage that is right for them and their family. Two, the commissions that can be earned through Medicare insurance sales.
Agents are paid commissions when they sell a Medicare insurance policy to a beneficiary, and often a smaller commission again if that beneficiary re-enrolls next year. Agents are paid directly from the insurance carriers, meaning that, although they are independent and often broker a wide variety of companies and policies, they are being paid for selling a company’s product. This is one of the reasons why transparency is so important for building trust with beneficiaries.
How Much Can I Make?
One of the most common questions asked by new agents is, “how much can I make on commissions?” And the answer is: that depends! Their compensation for Medicare Advantage, Medicare Part D (prescription drug coverage), and Medigap or Supplemental insurance is directly tied to the amount of enrollments and client retention they achieve. The Centers for Medicare and Medicaid Services (CMS) sets the maximum commissions annually. Within those maximum amounts set by CMS, insurers determine what they will pay agents for commissions, which can be different based on which product or contract they are selling.
CMS sets the maximums on a national scale, but they can also differ based on cost-of-living locally and other factors. For example, in 2022, CMS set the national maximum for a first time enrollment as $573 per beneficiary. But in California, where cost of living is significantly higher than in most other parts of the country, the maximum first time commission was $715 per beneficiary. For stand-alone prescription drug coverage plans, or Part D plans, the commission does not vary. The first time enrollment commission is $87 regardless of location.
For renewals, CMS does set their values for commission lower than for first-time enrollment. The same for what are known as switches, which is when beneficiaries choose different plans within the same insurance carrier. For Medigap, or Medicare Supplement plans, the commission amounts are not set by CMS. Rather, they are a percentage of the annual premium of the plan. Often, that percentage is close to 20% of the annual premium of the plan.
While commissions are not the only motivation for an ethical agent, they can certainly help increase an agent’s income with hard work.
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How To Become A Medicare Agent
Although there are many facets to becoming a licensed Medicare agent, the job description at a glance is rather simple. You are marketing Medicare insurance to two groups of people: those who are 65 years or older and eligible for Medicare benefits, and those who are under 65 years old, disabled, and also eligible for Medicare benefits.
Here are seven simple steps:
Get your health insurance license
It goes without saying that agents should be well-versed, experts even, in all things Medicare. Some of the most common topics to study are deductibles, compliance, health care laws in your area, claims, and the general ins and outs of how Original Medicare works, as well as Medicare Advantage. There are courses that offer Medicare training, which must be state-specific. For most states, the prospective agent must take a course to study for the health insurance license. The course is led by an instructor, lasts about a week, and has an exam that must be passed at the end of the course. The other option is self-studying to take the same exam.
Some courses also offer life insurance certifications simultaneously – many agents choose to take advantage of this opportunity as the marketing group for Medicare and life insurance is often very similar.
Complete the AHIP Medicare training
Once licensed, the next requirement is passing (with a 90% minimum) the annual Medicare training and certification through America’s Health Insurance Program (AHIP). The Center for Medicare and Medicaid Services (CMS) is the agency that regulates Medicare plans, the agents who sell them, and the insurance carriers and brokers. AHIP certification typically starts in June and certifies those who pass for selling the following year. The exam is currently a cost of $175. Our agents take AHIP at the discounted rate of $125. Click here for details.
Errors and Omissions Insurance
Even with the best of intentions, every agent will make a mistake eventually. This coverage, known as Errors and Omissions Insurance (E&O), will help in the event that a client decides to take legal action against you. If they feel that you gave misleading or incorrect information and decide to litigate, these policies can cover between one and three million dollars in coverage. Their cost however, is only $300 to $500 a year. Most carriers will not work with agents who do not have Errors and Omissions Insurance. Purchase E&O here.
Contract with a Medicare Field Marketing Organization (FMO)
A Field Marketing Organization is a company that distributes health insurance plans to agents and agencies on behalf of the insurance carriers. Once contracted with an FMO, that organization will be able to help you get contracted to sell with multiple insurance companies, which increases both your clientele options and potential income. Some FMOs provide E&O insurance, as well as other benefits.
Get contracted with multiple Medicare companies
Each insurance carrier requires its own individual contract to sell their products. Most carriers require the following criteria be met before contracting with an agent:
- A copy of the agent’s health insurance license
- Proof of an E&O policy
- Legal questionnaire written by the carrier
- A background check
- Some carriers require their own specific annual certifications that pertain to their plans.
Complete annual certifications
Depending on the state, you may be required to complete additional continuing education training and certifications annually. These are essential to keeping your license active in your area. Some of the most common ones are hours of Ethics and Anti-Money Laundering Training and hours in your area of concentration as an agent, whatever that may be.
Maintain continuing education when required
Your FMO will provide additional information as to what is required to maintain your contract with them. Most states have individual continuing education requirements.
Through these relatively simple steps and some effort on your part, a career in Medicare sales as a licensed Medicare Insurance Agent is well within your reach.
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What is the Part D Penalty for Late Enrollment?
What is the Medicare Part D Penalty for late enrollment? A part D late enrollment is when a beneficiary is without Medicare part d prescription drug coverage or other creditable prescription and medication coverage for a period of 63 days or more. It is a penalty fee for those who are uninsured. Generally, the policyholder will have to pay the penalty for as long as they hold the prescription drug coverage.
The cost of the part D late enrollment penalty changes yearly because it is calculated based on national averages. Medicare calculates the fee by multiplying 1% of the “national base beneficiary premium” by the number of months that the policyholder did not have Part D of Medicare (or other creditable coverage). In 2023, the national base beneficiary premium was $32.74.
How Does a Policyholder Know If They Have to Pay?
Once the beneficiary joins a Medicare part D drug coverage plan, the plan will then calculate their late enrollment penalty.
Reconsideration
Sometimes, insurance companies can make mistakes. If the policyholder does not agree with the application of this penalty, then the drug plan can send information on how to request what is known as a “reconsideration.” However, by law, the late enrollment penalty is considered part of the beneficiary’s Medicare premium. The premium must be paid (including the penalty). Otherwise, the beneficiary runs the risk being unenrolled from their coverage.
If the reconsideration ends up being decided in the policyholder’s favor, meaning that the late enrollment penalty is not valid, then the Medicare drug plan can and will remove the late enrollment penalty fee. The plan will then send documentation to the policyholder explaining what happened and whether or not they are eligible to receive a refund. On the other hand, if the Medicare Part D contractor evaluates the reconsideration and finds that the late enrollment penalty is valid, then they will instead send the beneficiary documentation explaining why they must pay the penalty as part of their Medicare premium.
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Myths About Life Insurance
Life insurance is one of the most misunderstood types of insurance policy. Misconceptions and partial truths circulate in the public imagination. Here are the top five myths about life insurance, and the real information:
It is Expensive
Many people are surprised by how affordable term life insurance can be. Price policies vary from person to person, which is why people are encouraged to shop around when they apply. Different companies may offer different costs for a plan. But, the average yearly cost of a $500,000 policy (20 year term) for a 30 year old female is $252 a year. That calculates out to less than $25 a month.
Only the Elderly and Parents Need Life Insurance
Another common misconception: the beneficiary of a life insurance policy does not have to be a child. Parents are not the only people who need life insurance. Partners can be beneficiaries, as well as anyone else who depends on the policyholder. And, the sooner one applies for a policy, the cheaper the policy is likely to be. The one factor that determines how much the policyholder pays is their health; health is likely to decrease as a person ages.
It’s Difficult to Apply for Term Life Insurance
Like many other things, the internet has changed how people apply for term life insurance. In the past, people may have needed to see a doctor in person to qualify for term life insurance policies. With the rise in telehealth accessibility, the vast majority of companies have ways of applying for policies over the phone or online.
My Employer Offers Me Enough
For those people who have access to a life insurance policy through their work, the coverage is still likely to not be enough for their family. The median workplace life insurance policy is approximately one year’s salary. It is best to consider workplace life insurance a supplement to a life insurance policy rather than the entirety of the coverage. Online tools exist to calculate how much coverage your family may need, but one guideline is to aim for five to ten times the policyholder’s annual salary.
I Only Need Life Insurance If I’m Working
Even if a policyholder isn’t employed outside the home, the value of the labor they provide in the home is enough reason to consider a life insurance policy. Despite life insurance typically being thought of as a replacement for lost income, it can be vital to pay for childcare or housework, especially if the policyholder is the one performing those tasks now. Plan coverage with all of the family’s contributions in mind, not just working benefits.
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When To Take Social Security Benefits
Although it may seem like a very black-and-white decision, the age at which to take social security benefits can depend heavily on a beneficiary’s life circumstances. Individual situations determine when to take social security benefits.
Some people may start taking their benefits as early as age 62, while others may wait until full retirement age (or 70 years old). A general rule of thumb is that waiting longer to take the social security benefits makes more sense for many people. However, rules of thumb don’t cover everyone. Some factors to consider when making this decision are cash needs, life expectancy, marital status, and employment status.
Generally, the decision to wait or to take these benefits can be broken down like so.
When to take Social Security – It may be helpful to take benefits earlier if:
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The beneficiary is no longer working and needs the social security benefits to make ends meet.
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They are in poor health and may not survive to their full retirement age.
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The beneficiary is a lower-earning spouse and their higher-earning spouse can wait to take their benefits at a later date.
Consider taking benefits later if:
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The beneficiary is still working and makes enough to make their benefits taxable.
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If either the beneficiary or their spouse is in good health and they expect to exceed the average life expectancy, it makes more sense to wait for increased benefits.
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The higher-earning spouse can ensure that their surviving spouse receives higher benefits by waiting to take their social security benefits until they have reached their full levels.
Overall, it is typically beneficial to wait as long as one can to take social security benefits because of how they increase when delayed. At age 70, when the benefits are at their maximum, those who are in good health will find this the most opportune time to take the benefits. Of course, every situation is different and speaking to a trusted financial advisor is really the way forward for anyone who is questioning this choice.
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Medicare and Medicaid Dual Eligible
Although Medicare and Medicaid sound very much alike, they are different programs. Their similarities are that both help people secure healthcare and both are federally funded. Some people are qualified to receive benefits from both Medicare and Medicaid and can choose to do so. This group of beneficiaries is considered to have dual eligibility – Medicare and Medicaid dual eligible.
Medicare vs Medicaid
Briefly, here are some of the major differences between the two programs.
Medicare is a federally funded health program that provides insurance for people who are 65 and older at a reduced cost. Some people who are under 65 but have certain disabilities may qualify as well. Medicare is offered by the federal government. The cost of Medicare will depend on the coverage the beneficiary chooses and may include premiums, down payments, copays, and co-insurance.
Medicaid is a joint federal and state funded health insurance program. It seeks to provide health care and resources to vulnerable populations such as those on limited income, pregnant people, and children. Medicaid is offered by state governments and therefore the cost to the beneficiaries will vary by location.
How to Get Medicare and Medicaid
In order to receive benefits from both Medicare and Medicaid, a beneficiary must qualify for both of these programs. For instance, someone who is over 65 years old and is also on a lower or limited income may qualify to receive both Medicare and Medicaid. The two programs may be able to work together to cover the majority of health costs. Some specific plans exist for those people that are dual eligible as well, such as the Dual Special Needs Plan (D-SNP). Because Medicaid requirements are dependent on location and state governments, however, Medicaid eligibility will vary.
There are beneficiaries that are considered part duals and full duals. Part duals are called this because Medicaid pays for some of the expenses that they accumulate under their Medicare plan. It may also pay for some cost-sharing amounts categorized by Medicare, like deductibles or copayments. Part duals can include people who are disabled and working, or have an income level above the state poverty line but below 125% of federal poverty level.
Full duals, on the other hand, are entitled to Medicaid coverage for services that Medicare does not cover, such as longer-term services and supports. Duals with lower income and assets will fall under full Medicaid benefits as well as their Medicare eligibility. Because this group of people can account for much of the federal and state spending in these programs, they are studied by researchers and policymakers to determine budgets and planning.
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Medicare Advantage Enrollment Trends
There are continually increasing populations of people who become eligible for Original Medicare and Medicare Advantage plans each year in the United States. Since 2006, the amount of enrollees for Medicare Advantage plans has grown steadily. In 2022, more than 28 million people are enrolled in a Medicare Advantage plan, accounting for nearly half or 48 percent of the eligible Medicare population. This number also accounts for nearly half of the federal Medicare spending. Let’s explore the Medicare Advantage enrollment trends.
In 2022, the average Medicare beneficiary has access to nearly 40 Medicare Advantage plans, which is the largest number of plans available in over a decade. This looks like 2.2 million new beneficiaries between 2021 and 2022, which is an eight percent increase in enrollees.
Employer Group Versus Individual Plans
In 2022, of the 28.4 million beneficiaries enrolled in Medicare Advantage. The smallest percentage were enrolled in special needs plans, at a mere 16%. The next smallest group of beneficiaries was those enrolled in union-sponsored or employer-offered Medicare Advantage plans. These account for 18% of the total. The largest group of beneficiaries by far is those in individual plans – open for general enrollment. This group makes up 66% of the 28.4 million beneficiaries. That is about two thirds of this group, or approximately 18.7 million people. Since 2021, that is an increase of about 1.3 million enrollees. However, the share of those in individual plans open for general enrollment has not increased. It remains steady at about two thirds of the enrollment since 2018.
Medicare Advantage Plans By State
The share of Medicare beneficiaries who are enrolled in Medicare Advantage Plans varies greatly by state and has a very wide range of percentages across the country. However, in 25 of the states, at least half of those eligible for Medicare Advantage plans are enrolled in them. The more rural a state is, the more likely it is to have lower funding for Medicare and lower enrollment in Medicare Advantage plans. South Dakota, North Dakota, Wyoming, and Arkansas are the states with the lowest Medicare Advantage enrollment, which is less than twenty percent, or fewer than one fifth of eligible beneficiaries. Puerto Rico, on the other hand, has the highest percentage of enrolled beneficiaries, with 93% of Medicare beneficiaries also enrolled in a Medicare Advantage plan. This is largely thought to be due to policy choice, as many people in Puerto Rico are dually enrolled automatically in Medicare and Medicaid.
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Medicare easy pay form
The Medicare Easy Pay form is a quick option for individuals who are either still working or not collecting social security yet for some other reason. This option will ensure you never miss a Medicare payment. This is a great way to avoid the complications that could occur if you neglect to pay your Medicare premium.
Once you receive a bill from Medicare, you can sign up for Medicare easy pay. Medicare easy pay automatically deducts your Medicare premiums on the 20th of each month from either your checking or savings account.
Learn more abut signing up for Medicare A & B
There are 2 ways to enroll in Medicare easy pay:
- The fastest option is online. You can either log in to an existing account or create an account. Once you log in, click on “My Premiums” and follow the links from there to sign up and fill out the online form.
- Another option is to Click here to download the Medicare easy pay form. This option takes longer (from 6-8 weeks) for your deductions to begin. In the meantime, you need to be sure you pay your premiums in a timely manner. You can do this either online through your account or by using the paper bill you receive. Mail the completed form to: Centers for Medicare & Medicaid Services, Medicare Premium Collection Center, P.O. Box 979098, St. Louis, MO 63197-9000.
Once easy pay begins:
- Each month you receive a statement that tells you how much will be deducted from your bank account.
- The premium is deducted from your bank on the 20th each month. Your bank statement will show a payment marked “CMS Medicare Premiums”.
Click here to download Understanding your Medicare easy pay statement.
If your payment is rejected, you will receive a notice that provides instructions to get the payment in to Medicare. Once your account is up tp date, your easy pay will start up again as scheduled. Medicare will send you a notice if the premium amount changes. The new rate will automatically be deducted from your account on file.
More Medicare easy pay information:
What to do if you need to change the banking information for our automatic payments: simply log into your Medicare account and choose “My Premiums” and “see of change my Easy Pay” form there you can complete a quick online form.
If you do not like to do online forms, you can mail a completed SF-5510 form. Click here to download the Medicare easy pay form. Be sure that you indicate the change you want to make on the form. You can mail the form to the address indicated above. Again, this will take a long time to update (possibly 6-8 weeks). It can take about 4 weeks to stop Medicare easy pay deductions.
If you are having trouble with the Medicare easy pay; please contact 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 for assistance.
Medicare AEP 2023
Medicare AEP 2023 (Annual Enrollment Period) is an important time of year for both Medicare beneficiaries and agents. During this time of year, beneficiaries can make changes to their Medicare coverage for the upcoming year. For agents, it is an opportunity to help clients choose a Medicare plan that fits their individual healthcare needs and budget.
There are many things agents can do to prepare for AEP:
Review the latest CMS guidelines
It’s essential for agents to stay updated with the latest guidelines from CMS during AEP. Agents should review all current information, including plan changes, cost sharing, and formulary updates. They can access this information either on the CMS website, the Medicare & You handbook, and other reliable sources. This includes carrier websites once they release the new plan information.
Be Sure to get all your certifications done on time
One of the most important certifications each year is the annual AHIP certification. The AHIP for the 2024 AEP will open on June 20th, 2023. This test will be good for the rest of this year and in 2024.
You also need to complete product training and certifications for each carrier that you are contracted with so you are ready to sell on time and have a good understanding of the products that you are offering.
Reach out to clients
Agents should reach out to their clients before AEP to remind them about the upcoming enrollment period and to schedule appointments to go over their plan options for next year. Once AEP starts, they can also provide their clients with educational resources to help them understand their options and make informed decisions.
Understand your clients’ healthcare needs
Agents must understand the healthcare needs and preferences of their clients to recommend the best plan for them. They can do this by asking their clients questions about their current healthcare coverage, medication needs, and healthcare providers. Agents can also review their clients’ medical history to ensure they choose a plan that meets their specific needs.
Identify plan options
Once you understand the clients’ healthcare needs, it is easier to find the plans that offer the best choices for each individual. You should always consider the client’s budget, preferred doctors, and prescription medications when reviewing the available plans. You can quickly compare the costs and benefits of different plans with the use of an online quoting and enrollment site such as; Sunfire or Connecture. This will help clients make informed decisions by showing them a side-by-side plan comparison.
Stay organized
The AEP can be a busy time for agents, and staying organized is crucial to ensure you provide quality service to your clients. Agents can use tools such as calendars, spreadsheets, and customer relationship management (CRM) software to stay on top of appointments, deadlines, and client communications.
The Medicare AEP is an essential time for agents to maintain their book of business and be sure their clients are happy with their Medicare coverage for the next year. It is also important that your clients feel they can contact you with any questions or problems they may with their Medicare coverage throughout the year.
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Medicare Coverage While Out of the Country
Do beneficiaries have Medicare coverage while out of the country? To put it simply: medical coverage outside of the United States for Medicare beneficiaries is extremely limited. The definition of “outside of the United States” means outside of the continental United States and its territories. There are only three situations in which coverage under Medicare can be provided to a beneficiary outside of the United States.
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The beneficiary is in the United States and has a medical emergency, but the closest hospital or facility that can treat them is a foreign one (a foreign one meaning one outside of the country) rather than a local one.
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The beneficiary is traveling through Canada in order to get to or from Alaska and the closest hospital or facility that can treat a medical emergency is a Canadian one. Medicare determines on a case-by-case basis who qualifies for this, because it is dependent on the travel being considered “without reasonable delay.” Without reasonable delay is an arbitrary definition, and must be determined individually.
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The beneficiary lives in the United States but the closest hospital that can treat them is a foreign one, regardless of medical emergency. The foreign hospital has to be closer than the closest United States hospital to be considered for Medicare coverage.
Even in these exceptional situations above, Medicare will only pay for Medicare-approved services. Medicare Part A will cover hospital care when the beneficiary has been formally admitted to a hospital. Medicare Part B will cover emergency ambulance and doctor services that occur before and during the hospital stay. If administered outside of the United States, dialysis services are not covered. Additionally, prescription drugs outside of the United States are not covered.
Managed Care Plans
For those beneficiaries who have a Medicare Health Plan like Medicare Advantage rather than Original Medicare, the previous three situations are still the exceptions under which they will cover foreign medical services. Medicare Advantage plans, although privately held, still have to follow the guidelines and laws set by the federal government.
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