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The differences between Medicare and Medicaid

When we explain the differences between Medicare and Medicaid, we have to start with the fact that these are two very different programs.

Both programs provide an important service to the group that it serves.  Each of these programs receives funding and is run by different parts of the government.

To sum it up:

1. Medicare is a program put in place by the federal government to provide health coverage for individuals 65 and over as well as qualified individuals with disabilities.
2. Medicaid is a program that is provided by both state and federal governments for qualified individuals who have limited income and little financial means.

Assisted Living FAQs

Because many people have questions about assisted living, we are providing answers to the most asked Assisted living FAQs in the post below.

What is an assisted living facility:

Assisted living facilities provide individuals assistance with the ADLs (activities of daily living).  These activities include; meal preparation, bathing, dressing as well as medication management to name a few.  All these activities are categorized as custodial care.

Click here to learn more about the activities of daily living

What is the difference between Medicaid and Medicare in assisted living coverage:

There are definitely difference in how Medicare and Medicaid provide coverage for assisted living.

1.  Medicare does not provide any coverage for assisted living facilities. Although it does short-term stays in a skilled nursing facility for rehabilitation purposes as long as specific requirements are met.  This criterion includes the exclusion of the need for long-term care.
2. In some states, qualified Medicaid enrollees may receive help from a waiver program they provide with the costs for personal care as well as some other support services beneficiaries receive in an assisted living setting.  This assistance can reduce the total cost of assisted living quite a bit.  However, Medicaid does not offer help with the costs of room and board in an assisted living facility.

Click here for more details on Assisted living coverage

Is there a way to get financial assistance for assisted living:

As stated above, several states provide help with assisted living costs for anyone who has limited financial resources and qualifies for help such as Medicaid.

Veterans may qualify for help through programs offered through their local VA.  These programs and VA benefits may offer help with the costs of assisted living.

Although Medicare does not cover assisted living facilities, it will cover cost for medical treatment provided by doctors or hospitals as well as some approved skilled nursing facility care. If prescription drugs are needed, they are covered by Medicare Part D.

Medicare Advantage open enrollment period

Everyone has probably heard about the Medicare annual enrollment period, but there is another opportunity to change your MA plan.  This is opportunity is available during the Medicare Advantage open enrollment period or the MAOEP.

The MAOEP basics:

1. This enrollment period starts on January 1 and ends on March 31 each year.  During this time MA/MAPD enrollees can make plan changes.
2. During this time MA/MAPD enrollees may switch to a different Medicare Advantage plan or back to Original Medicare.
3. If you make a change during this period, it will go into effect the first day of the following month after your application is submitted.

A few details about the Medicare Advantage open enrollment period:

Beneficiaries who switch from a Medicare Advantage plan to Original Medicare are eligible to purchase Prescription Drug Plan (Part D) coverage.

It is important to note; beneficiaries who have Original Medicare and Part D coverage cannot use this enrollment period to change their coverage.  This Enrollment period is exclusively for Medicare Advantage enrollees.

Another important thing to understand is; if you want to change from a Medicare Advantage plan to Original Medicare during this time, you may not have guaranteed issue rights for Medicare Supplement coverage. This depends on the state you reside in (there are only 4 guaranteed issue states) or how long you have had a Medicare Advantage plan.

Learn more about Medicare Supplement plan guaranteed-issue rights.

Most beneficiaries make plan changes during the AEP that runs from Oct 14 through Dec 7 each year.  It is the best time to change plans.  If you change during this time and you are not happy the MAOEP gives you a chance to change back or to another plan.  If you wait until the MAOEP, you cannot change plans again until the following AEP.

It is important to consider all your options carefully.  A licensed insurance agent can help you see all your options side by side and make an informed decision.

Keep in mind; making a plan change during AEP and having your new plan start in January is really the best way to keep your annual out-of-pocket cost down.  If you start the year with one plan and then change plans a few months later, you will have to start over with a new deductible and out-of-pocket maximum.

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Does Medicare pay for assisted living

Many people have asked the question; does Medicare pay for assisted living.  The answer to this question differs depending on the type of Medicare coverage you have.

Original Medicare:

Medicare A & B (Original Medicare) does not cover the costs of assisted living.  Because assisted living is not considered medically necessary, it is not covered by either Part A or Part B.  Although, Medicare will provide coverage for approved short-term stays in skilled nursing facilities after inpatient hospital stays. Once the patient has reached 20 days in skilled nursing, there is a $200 a day coinsurance charge.  After 100 days, the beneficiary is responsible for 100% of the cost.

Original Medicare does cover some home health care services as well as hospice care.  Although Original Medicare does not cover assisted living, it does cover all approved medically necessary services under Parts A and B.  This includes hospital stays, medical procedures, screenings and visits to the doctor.

Medicare supplement plans:

Medicare supplement plans are used with Original Medicare. In general, they help cover the deductibles, co-pays and co-insurance that remain after Original Medicare pays its portion. It is in place to supplement Original Medicare.  Therefore, it does not cover assisted living or long-term-care.

Medicare Advantage Plans:

Medicare Advantage plans provide the same coverage as Original Medicare, Parts A and B.  MAPD plans are offered through private health insurance companies.  Most of these plans include prescription drug coverage as well as additional benefits.

Medicare Advantage plans do not cover assisted living costs. However, there are some plans that cover specific services that are similar to assisted living facilities.  These services may include providing coverage for assistance with the activities of daily living, such as transportation to doctors’ appointments and even meal delivery.

Assisted living coverage for dementia patients:

People who have dementia, are eligible for help from Medicare to pay for hospital stays, home health care, skilled nursing home care, hospice care, cognitive assessments and necessary medications. Some eligible patients with Alzheimer’s and dementia may receive payment assistance for care planning. Original Medicare does not provide payment for dementia care however, both Medigap and Medicaid may provide help paying for it.

Ways to pay for assisted living:

The cost of assisted living varies greatly depending on where you live and what the facility provides as well as what each individual requires in terms of care.

1.  One of the best ways to pay for assisted living is through a long-term care policy.  Unfortunately, by the time most people think about it, they are older may not be easily affordable for most individuals. If you are fortunate enough to purchase it while you are young enough that the prices are reasonable, there are many options to choose from.  Look carefully at all the rules and conditions before choosing a policy.
2.  Some people have the foresight to put a large sum aside for such instances.  You may have access to funds from savings, pensions of other sources.
3. Many states provide Medicaid waiver programs that can help pay for medication management, on site therapy or support services in a residential setting.  Medicaid does not pay for the cost of room and board.
4. Eligible veterans may receive assisted living benefits through their local VA.  This benefit may also be available to veterans through some approved non-VA facilities.
5. One more option is through funds obtained through a reverse mortgage.  Unfortunately, if you stay in an assisted living facility for over a year and your home is vacant, the reverse mortgage has to be paid back, this is often done by selling your home.  It is best to speak with a qualified financial counselor before taking this step.

Medicare commissions 2024

If you are a Medicare agent or thinking about going into the Medicare business, you should be aware of the Medicare commissions 2024.  We are happy to announce that CMS has released the maximum broker commission amounts for 2024.

It is important to note; insurance providers do not have to offer the maximum commission amounts.  It is just a guideline decided by CMS each year, what each insurance provider pays out is up to them.

The good news is; the amounts have gone up for the 9th consecutive year!

Maximum commissions for Medicare advantage plans 2024:

It is important to note: all commission rates are not the same.  They vary by state they are available in.

In the sates of both CA and NJ, the initial commission rates have increased from $750 per member for the year to $762 per member for the year.  This is an increase of 1.6% YOY.  The renewal commissions for CA and NJ have gone up from $375 per member for the year to $381 per member for the year.  This also adds up to an increase of 1.6%.

The states of CT, DC and PA have had an increase in initial MA commissions from $678 per member for the first year to $689 per member for the first year. This adds up to an increase of 1.62% YOY.  Renewal commissions for CT, DC and PA have increased 1.77%. Renewal commissions will go up from $339 per member per year to $345 per member per year.

Both Puerto Rico and the U.S. Virgin Islands initial MA commissions have gone up from $411 per member for the year to $418 per member for the year, this amounts to an increase of 1.7% YOY.  The renewal commissions have increased from $206 a member for the year to $209 per member for the year, this is equivalent to an increase of 1.46%.

In all other states not listed above, the initial MA commission amounts have increased 1.66% YOY from $601 per member for the year up to $611 per member for the year. Renewal commissions have also increased at a rate of 1.66% from $301 per member for the year to $306 per member for the year.

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Maximum commissions for PDP plans 2024:

The commission rates for PDP plans are the same in all states.

Initial commission rates for PDP plans have gone up by 8.7% YOY.  This means commissions have gone from $92 per member for the year to $100 per member for the year.  Commissions for PDP plan renewals have also been increased by 8.7% YOY. Commissions have ow gone from $46 per member each year to $50 per member each year.

Click here to see CMS carrier commission chart for 2024

Take a look below to see the 2023 & 2024 commission rates side by side.

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Medicare sales permission to contact

When you have a potential clients you need to keep all the CMS guidelines in mind before you begin.  You need to be compliant and use a Medicare sales permission to contact.

What is Permission to Contact:

This process helps stop agents from contacting beneficiaries through the use of dishonest sales tactics. Unfortunately, in the past, some agents have pressured Medicare beneficiaries to get a Medicare sale.  Permission to contact is one way to help deter uninvited agents to approach beneficiaries when they are not prepared.

To avoid non compliance, it is important the beneficiary gives permission for the agent to contact them before you try and meet, call or email them for Medicare Advantage or PDP sales.

Here are some ways you can contact a potential client:

1. You can return their call if they request you do so.
2. Through email as long as there is an opt-out option clearly provided.
3. If they respond to a business replay card.
4. When they fill out an online contact form.

Here are some ways you cannot contact a potential client:

1. Do not knock on a potential client’s door without an invitation.
2. You are not permitted to send texts to anyone without their permission.
3. Directly contact through social media

When is permission to contact required:

Anytime you want to contact a potential client, you should obtain permission to contact.  This is very important if they may be considering a Medicare Advantage or Prescription Drug Plan enrollment. Please note; even if you contact a potential client for a Medicare Supplement plan which does not require permission to contact, they will most likely need a Prescription Drug Plan to go with it, therefore it is always a good idea to have permission to contact.  Be sure to include the following disclaimer “This is a solicitation of insurance” on the Permission to contact form.

Please note: If you are contacting your own clients; you do not need permission to contact.

It is acceptable to email potential clients as long as you include an opt-out option.  You cannot send anything that could be considered marketing material.  Marketing material includes specific plan information such as premiums, co-pay amounts or other benefit information. All communications must meet CMS guidelines as well as  CAN SPAM Act requirements.

How long is the permission to contact good for:

Once you have collected the permission to contact, you have 12 months to contact that beneficiary.  If you do not contact them within that time, you must collect another PTC before contacting them.

A couple more things to note:

If you employ a third party marketing organization for lead generation, it is important that they are compliant with all the CMS rules.  Do not forget, it is your name on the materials they are sending so you are the one who is ultimately responsible for what goes out to the public.  Beneficiaries need to be told either verbally, in writing or electronically depending how they are contacted, that their information will be given to a licensed Medicare agent who will contact them.

Do not confuse permission to contact with a Scope of appointment.

You still need to collect a scope of appointment from the beneficiary once you are able to set up a meeting or call to go over plan options.  It is important to follow all guidelines for Medicare sales in order to maintain compliance and maintain your ability to offer Medicare plans.

Download a generic scope of appointment form

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Medicare HMO vs. PPO plans

If you are considering a Medicare advantage plan, you will need to weigh Medicare HMO vs. PPO plans.  The first thing we need to do is explain that HMO stands for Health Maintenance Organization plans.   On the other hand, PPO stands for Preferred Provider Organization plans. Each of these plans provide its own set of benefits.  The plan you choose will impact your healthcare experience.

Understanding the Basics:

Medicare HMO and PPO plans operate within the broader framework of Medicare.  Both types of plans cater to the healthcare needs of Medicare beneficiaries.  Although the share the goal of providing essential healthcare coverage, they function differently in terms of network flexibility, cost structure, and coverage options.

Medicare HMO Plans:

HMO plans typically require beneficiaries to choose a primary care physician (PCP).  The PCP coordinates their care as well as provides referrals to specialists within the HMO network. This approach supports a structured healthcare management system.  This ensures a comprehensive and coordinated approach to treatment.

Additionally, Medicare HMO plans often come with low premiums and lower out-of-pocket costs when compared to some PPO plans. They also may provide some benefits such as a Part B giveback that PPO plans typically do not. However, the trade-off for these cost savings is the restricted network access.  This may limit the choice of healthcare providers and facilities.  In most cases HMOs do not cover medical care received outside the HMO network, except in emergencies or urgent care situations.

Medicare PPO Plans:

On the other hand, PPO plans offer more flexibility in choosing healthcare providers and facilities.  This allows beneficiaries to seek treatment both in and out of the PPO network. Although there is a network of preferred providers, beneficiaries can still access care from out-of-network providers.  It is important to note; out of network services will have a higher cost to beneficiaries than in-network.

In general PPO plans may have a higher premium and greater out-of-pocket costs when compared to HMO plans. Nonetheless, the flexibility to see specialists or visit healthcare facilities without referrals can be advantageous.  This is helpful for those who require specialized care or have established relationships with trusted providers.

Key Considerations for choosing a plan:

When deciding whether an HMO or PPO plan best suits your needs, there are several key factors to consider:

1. What are your healthcare needs – Think about your healthcare requirements, this includes how often you require the care of a specialist.  You may need to go out-ot-network for some providers.
2. Cost Considerations – Compare the premiums, deductibles, and co-pays associated with both plans. Do not discount potential out-of-network costs for either plan.
3. Provider Network – Research the size and quality of the provider network. It is important to consider the availability of preferred doctors and specialists within each plan.
4. Network area – If you frequently travel or reside in multiple locations throughout the year, it is important to consider the geographic area of coverage available.
5. Prescription Drug Coverage – It is very important to research the prescription drug coverage provided by each plan.  This is imperative if you require regular medications.

Making the Right Choice:

Ultimately, the decision between a Medicare HMO and PPO plan hinges on your individual healthcare needs, financial circumstances, and preferences.

While HMO plans offer cost-effective, structured care within a limited network, PPO plans provide greater flexibility at a higher cost. Carefully evaluate your healthcare priorities and compare the specifics of each plan to make a well-informed decision.

It is a good idea to consult with a trusted healthcare advisor.  A licensed Medicare agent can help you review plan documents thoroughly and find the best option for you. A well informed agent can also answer your health coverage questions and is available to you when you need them.

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Medicare Advantage Pros and Cons

If you watch T.V., you have probably heard about Medicare Part C also known as Medicare Advantage plans. Private insurance companies contract with Medicare to offer Medicare Advantage plans. These plans must provide the same level of coverage as original Medicare. If you are considering a MA/MAPD plan, you should think about the Medicare Advantage pros and cons before signing up.

Because your healthcare is a very important decision, there is a lot to consider when choosing between Original Medicare and a Medicare Advantage plan.

 We will go over some of the features Medicare Advantage plans offer that may or may not provide the type of coverage you are looking for.

Medicare Advantage Pros:

Low premiums and cost shares

Many Medicare Advantage plans offer $0 plan premiums. There are plans with a premium, but they are usually quite reasonable.  It is important to note; you must continue to pay your Medicare Part B premiums when you enroll in a Medicare Advantage plan.  If you opt for Original Medicare and a supplement, the premium will cost you substantially more and you will also need to purchase a separate PDP (prescription drug plan).  Paying for two plans can add up especially compared to a $0 MAPD plan that also provides prescription drug coverage.

Some in-network doctor’s visits have a low or no cost share with a MAPD plan.  While the same visit with Original Medicare may leave you with a 20% co-insurance payment.

Medicare Advantage plans provide an annual maximum out-of-pocket expense limit. This means, when you reach the maximum, your plan pays 100% of your covered medical expenses for the rest of the year. You pay nothing.  There is no maximum out-of-pocket cap with Original Medicare.  In other words, there is no limit to what you could spend for medical treatment in any given year.

Comprehensive coverage

Medicare Advantage plans provide the same benefits Original Medicare, both Part A & Part B, offers. MA plans also provide additional benefits not offered by Original Medicare. Some MA plans offer vision, hearing, dental, OTC and more.  MAPD plans offer comprehensive prescription drug coverage.

Beneficiaries of MAPD plans only need 1 plan and 1 card for medical, hospital and prescription coverage. This is a convenient way for beneficiaries to cover all their needs.

Several Value-added benefits:

Medicare Advantage plans provide many additional benefits above and beyond what was already mentioned.  Some plans include fitness benefits like gym memberships or incentives for active lifestyles. Many plans offer rides to and from medical appointments to ensure you get the care you need. MA plans may also offer incentives for wellness visits or preventative services they may also cover chiropractic services or acupuncture.  These services are not usually covered by Original Medicare.

Please note:  additional benefits vary by plan and provider.  Beneficiaries should check their plan’s summary of benefits to view the full range of benefits available.

Some Medicare Advantage plans operate as managed care networks or HMOs.  This means beneficiaries must use in-network providers who often work together to coordinate care and can in turn save beneficiaries money. Plans also offer telehealth consultations with healthcare providers.

Medicare Advantage Cons:

Must use only in-network providers

Beneficiaries enrolled in Original Medicare or Original Medicare and a Medicare supplement plan can use any provider who accepts Medicare assignment.  On the other hand, enrollees in Medicare Advantage plans are limited to seeking care with in-network providers. Any services received out-of-network can be either denied coverage or may result in a higher co-pay amount. Additionally, the cost of your care may not apply to your out-of-pocket maximum.

Additional costs

Medicare Advantage plans may include additional costs.  These costs include co-pays, deductibles and co-insurance. These out-of-pocket costs can add up if you visit the doctor often.  The costs depend on the plan, provider, and the services received.

See below for some situations that can raise the out-of-pocket cost for a MA plan:

1. Beneficiaries may have a copayment for doctor’s visits.  Co-pays also apply to some prescription drugs.
2. In some instances, there may be coinsurance cost for some services.  This may apply to specialist visits or DME (durable medical equipment).
3. Out-of-network charges.  Anytime a beneficiary visits an out-of-network provider there may be higher out-of-pocket costs (co-pays, coinsurance or the entire cost) for services received.
4. Many plans have an annual deductible.  Beneficiaries must meet the deductible before some medical expenses are covered. This may also include cost of specific the prescription drugs.  This will depend on the tier of each medication.

Please remember; beneficiaries should be aware of the MA/MAPD plan’s summary of benefits to understand the potential costs associated with any plan.

Prior authorization

Because Medicare Advantage plans try to assure their plans are not misused, beneficiaries may need to have prior authorization for hospital stays, home health care, and some medical procedures as well as medical equipment. This may include a primary care doctor’s referral before a specialist visit is approved.

Additionally:

Because there is so much to consider, it is a good idea to seek the advice of a licensed Medicare agent when considering all your plan choices and comparing all the benefits that are important to you.

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Humana OTC catalog 2024

If you are a member of participating Humana Medicare Advantage plans you will have the added benefit of the Humana OTC catalog 2024.  In 2024, CenterWell Pharmacy will provide members of participating plans OTC products.

If you want to verify that your plan provides an over-the-counter benefit, you should check your plans summary of benefits or call the customer service number on the back of your card.  You can also call this number to check your Health and Wellness allowance.

Download a copy of the OTC catalog

There are a few different ways to place your order:

1.  Order via mobile app.  Just go to either the APP store for Apple devices or from Google play for Android devices.  Once you are there, search for the CenterWell Pharmacy app and download it to your mobile phone.  With the app, you an order products whenever you like as long as you have an available balance.
2. Place an order online.  You will need to go to CenterWellPharmacy.com Once you are in, you can either create an account by following the prompts or log in to an existing account.  You will then choose Over-The -Counter (OTC) items from the “Shop OTC & Supplies” drop down.
3. Mail your order in.  If you choose this option, please allow for extra time.  Be sure to submit your order by the 2oth of the month to avoid orders going toward the following months benefit.  If you have a quarterly benefit amount, submit your order no later than the 20th of the last month of each quarter (March, June, September and December).  Fill out the order form you find in the OTC catalog and mail it to:  CenterWell Pharmacy, P.O. Box 1197, Cincinnati, OH 45201-1197.
4. Send your order via fax. Send your order form to: 800-379-7617.

Things to know before you order:

Be sure you know your plan’s allowance.  Check the summary of benefits for your plan to find this information.  If you have a plan with a rollover allowance, any unused balance carries over to the following month or quarter.  Please note; all balances expire on December 31, 2024.  If you do not have a plan that offers a rollover, you must use your benefits by the end of each month or quarter depending on your plan.
Orders that exceed the plan’s allowance will require payment by check , money order or credit card.  Orders include sales applicable sales tax.
Orders that contain multiple items may arrive in more than one shipment.
If you have an OTC allowance or Healthy Options allowance, you must activate your prepaid card before making purchases from the catalog.  Activate your card either by phone at 855-396-0691, 24 hours a day, Seven days a week or go to HealthyBenefitsPlus.com/Humana.

If you have questions about your OTC benefit; call 855-211-8370 (TTY:711).  Customer care specialists at CenterWell pharmacy are available M-F from 8 AM until 11PM, and Saturday from 8 AM until 6:30PM EST.

Learn about Medicare Part D changes

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Medicare Part B costs 2024

For many people the updated Medicare Part B costs 2024 is important information to have.  Although, most people do not think about the cost of Medicare Part A because most Medicare beneficiaries receive their Part A benefit for free.  As long as they have worked for at least 40 quarters in a Medicare covered job as decided by the department of Social Security. The premium payment for Medicare Part B is quite different than Part A due to the fact that most people do have to pay for Part B coverage.

What’s is Medicare Part A & Part B:

Part A

Part B

2024 Part B costs:

In 2024, the premium for Part B will increase from $164.90 monthly to $174.70.  This is an increase in cost of $9.80 per month.  The annual  medical deductible for Part B will also increase in 2024.  It will go from $226 in 2023 up to $240 in 2024.  This is a price increase of $14.

Click here to learn more about Medicare premiums and deductibles

It is important for beneficiaries to stay up to date with all the changes in their Medicare coverage as well as costs.  Having all the facts gives beneficiaries the opportunity to plan their healthcare expenses more effectively.

Here are the costs associated with Part B

1. The premium is the first cost you need to be aware of.  As we stated above; the monthly premium for Medicare Part B will increase to $174.70.  This is an additional cost of $9.80 per month from 2023.
2. More costs associated with Part B include; deductibles and co-insurance.  For 2024 the deductible will increase to $240 in 2024.  This is up from $226 in 2023. Once your deductible is met, you are left to pay about 20% of any Medicare  Part B approved expenses.
3. If you do not sign up for Part B on time, you may be stuck with a LEP (late enrollment penalty).  Make sure you know when to sign up for Medicare Part B and be aware of any special enrollment periods in order to keep from paying a penalty. Learn more about late enrollment penalties.
4. Individuals with high incomes may be subject to an IRMAA.  If this is the case for you, you may pay a higher Part B monthly premium than other individuals.

Click here to watch our YouTube video on Medicare Part B IRMA and IEP, SEP rules

How to save on Medicare Part B costs:

There are many programs available to provide help to beneficiaries pay their Medicare costs. Programs such as; Medicare Savings Programs, Extra Help for Medicare Prescription Drug Plans as well as state programs that provide payment assistance for Medicare premiums, deductibles, and coinsurance.

It is a good idea to contact a licensed Medicare agent for advice with enrollment in a Medicare plan. This can provide you with all the information you need to make the right coverage choices that fit your personal needs.

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