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Although there are millions of people on Medicare, many find it a confusing subject especially since there are so many different parts to it. For individuals approaching 65 or anyone who or just wants to understand more about how this insurance works, here’s a brief answer to the question; what is Original Medicare and what does it cover.

What Is Original Medicare

The federal government established Original Medicare, a federal health insurance program, in 1965. The following individuals may qualify for Medicare benefits:

• People age 65 or older
• Certain younger people with qualifying disabilities
• People with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s disease)

There are 2 parts of Original Medicare: Part A and Part B.

Medicare Part A

Medicare Part A is sometimes referred to as hospital insurance. It provides coverage for:

• Inpatient hospital care (once the enrollee is formally admitted)
• Skilled nursing facility care (following a qualifying hospital stay)
• Home health care (limited and medically necessary services)
• Hospice care for individuals with a terminal illness

For most people, Part A is free,there is no premium payment as long as eiither the beneficiary or thier spouse worked and paid Medicare taxes for a minimum of 10 years.

Please note: Although Part A covers hospital stays, it doesn’t cover long-term care such as; nursing homes, custodial care or unlimited days in a hospital or facility. There are limits to what it pays; beneficiaires must pay a portion of their expenses (cost-sharing), such as deductibles and coinsurance and copays.

Medicare Part B

Medicare Part B is also known as medical insurance. It provides coverage for the following:

• Doctor visits and outpatient medical care
• Preventive services such as; wellness visits, flu shots and cancer screenings
• Durable medical equipment (DME) this include things like; walkers, wheelchairs, oxygen as well as some diabetes supplies and more
• Lab tests and diagnostic imaging
• Mental health services
• Some home health care

Unlike Part A, beneficiaries do pay a monthly Part B premium. Fo rmost people, this is a standard amount although higher-income beneficiaries may pay an additional cost.

Click here to learn more about Part B eligibility

Part B coverage includes an annual deductible (this amount is adjusted annually). Typically beneficiaries pay 20% coinsurance for most covered services; in other words, Medicare pays about 80% of the cost leaving enrollees responsible for the remaining 20%.

What Original Medicare Doesn’t Cover

Original Medicare provides coverage for many medical expenses; although, they do not cover everything. Some important things to know about what Medicare does not cover:

• Prescription drugs (beneficiaries must enroll in separate Part D plan)
• Routine dental, vision, and hearing care
• Long-term custodial care
• Most care received outside the U.S.

In order to fill some of these coverae gaps, many people purchase additional insurance. Some of the plans people choose are; Medicare Supplement (Medigap) plans, Stand-alone PDP (prescprion Drug) plans, Medicare Advantage (Part C) plans. Beneficiaries also may opt for ancillary coverage like dental, vision and hearing or cancer heart attack and stroke plans.

Medicare agents; learn how to sell ancillary products with Medicare – watch a quick video.

Original Medicare provides valuable health coverage for millions of Americans, but it’s important to understand what it cover and what it doesn’t. Knowing the basics helps beneficiaries make informed decisions and avoid unexpected costs.

To answer the question; what is the Medicare GEP; The Medicare GEP is an opportunity for individuals who missed their initial chance to sign up for Medicare Part A and/or Part B to enroll. It runs from January 1 to March 31 each year. This allows eligible individuals to enroll in Medicare coverage, though late penalties may apply.

Who needs the GEP

The GEP is for individuals who did not sign up for Medicare during their IEP (Initial Enrollment Period) and do not qualify for an SEP (Special Enrollment Period).

When does coverage begin

As of 2023, individuals who enroll in Medicare during the GEP will have their coverage begin the month after they enroll. Prior to 2023, coverage did not begin until July 1, which led to significant delays in accessing benefits.

Late enrollment penalties

Individuals who sign up during the GEP may have to pay an LEP (late enrollment penalty). This can increase monthly Medicare costs:

Part A penalty

For those who must pay a premium for Part A, the monthly premium could increase by 10%. This will be in place for twice the number of years they were eligible but didn’t sign up.

Part B Penalty

The monthly Part B premium will increase by 10% for each full 12-month period the beneficiary was eligible but didn’t enroll. This penalty is permanent and remains in place for as long as they have Part B.

Medicare Advantage, Part D and Supplement enrollment

If an individual enrolls in Medicare during the GEP, they can sign up for a Medicare Advantage (Part C) or a Medicare Part D prescription drug plan at this time. Coverage for these plans begins on the month following the enrollment. Although late enrollment in Part D or Medicare Advantage plans that include prescription drug coverage may include a lifelong penalty.

Medicare supplements can be a little more difficult to get after the individual’s Medigap open enrollment has passed. When this is the case, some states require enrollees to undergo underwriting which can lead to denial or higher premiums.

Avoiding the need for the GEP

Beneficiaries can avoid using the GEP (General Enrollment Period) and getting potential LEPs:

Sign up for Medicare during the Initial Enrollment Period, which starts three months before the 65th birthday and ends three months after.

Those who have employer-sponsored coverage should confirm whether they qualify for a Special Enrollment Period (SEP) when that coverage ends. If they do, be sure to enroll before the SEP ends.

The Medicare GEP is an important opportunity for those who miss their initial chance to enroll in Medicare. However, because of potential late penalties and delays in coverage, it’s best to sign up during the Initial Enrollment Period or a Special Enrollment Period when possible. Understanding enrollment deadlines helps ensure that beneficiaries get the healthcare coverage they need and avoid unnecessary costs.

What Does Medicare Part A Cover

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Medicare Employer Information Form

Medicare Part A Coverage –

Are you working and Medicare eligible with insurance either through your own or your spouse’s employer?  If this is the case, you should consider taking Medicare Part A (hospital Insurance).  In most instances, there is no cost to you for the extra coverage Part A provides.  We have included a link at the bottom of the page with the Medicare Employer Information Form.  This form helps both you and your employer start your Medicare Part A coverage.

Should you take Medicare Part B coverage?

Before you sign up for Part B coverage there a few things you need to be aware of.  First of all, Part B is medical insurance, this coverage is not free and you will be charged a monthly premium.  You also need to know; when you are Medicare eligible your employer insurance may change to some extent. Check with your human resources department or benefit coordinator so they can explain any changes in coverage or concerns you have. You will also need to double check insurance information with the Social Security Administration and Medicare.

Health insurance is very important to us all.  You don’t want to make mistakes with your healthcare coverage, as that could be costly.  Each person has different needs, therefore it is entirely up to you to decide what coverage is best for you.  You also have to decide if the costs will be reasonable with regard to your coverage needs.

Primary and Secondary Insurance –

In fact, if you have primary insurance coverage with your employer, most likely you do not need Part B. If you are not satisfied with the coverage your employer provides, you may want to think about Part B coverage.  If you choose to add Medicare Part B to your employer insurance you need to find out which insurance will be primary and which one secondary.  Primary insurers will pay your approved medical claims first.

Secondary insurance will normally pay the part of your expenses left over after the primary has paid.  The amount secondary insurers pay can be either all or some of the unpaid balance. This amount may be the remaining 20% of the doctors fee after primary has paid.  If you are not enrolled in a primary insurance plan, but only a secondary plan, you will have little to no coverage.  When employer insurance becomes secondary you may be better off if you take Medicare both Parts A and B.

Enrollment Period

Medicare offers a Special Enrollment Period without penalty when you first qualify for coverage.  You may enroll in Medicare, without penalty, at any time while you have group health coverage. This enrollment period is also good for eight months after you lose your group health coverage or you (or your spouse) stop working, whichever comes first.

Sometimes your employee coverage will automatically move into a Medicare Advantage Plan (private health plan).  If you have health coverage from either a union, a current or a former employer when you become Medicare eligible.  You can keep the Medicare  Advantage Plan or switch to either Original Medicare or a different Medicare Advantage Plan.  You should know that if you switch plans, Your employer or union could lessen or even terminate your health benefits or the benefits of your dependents.  Discuss any healthcare plan changes you may want with your employer or union to make sure your coverage is safe.

Click the link below for the employer medicare Forms.

Employer Medicare Forms

Medicare A and B Benefits

Medicare A and B Benefits become available to most people when they turn 65.   Other people become eligible due to a state disability after 2 years.   Most people are automatically enrolled in Part A and pay no premium for it.  In fact, the majority of people (if they are drawing social security payments) are enrolled in part B.  In most cases, there is a cost of 104.90 a month for each person who is enrolled.  Some people pay more for part B, this amount is based on their income.  In some instances if you qualify for assistance, there will be a lower cost to no cost for Part B coverage.  This is also based on your income level.    You must apply through your state for this assistance in order to qualify for it. Read more

The original Medicare A and B benefits are updated every January.  The benefits do not change drastically from year to year but they usually increase slightly . The changes are made areas such as the Medicare Part A Inpatient Hospital Deductible, daily skilled nursing home copy, annual Medicare part B deductible, etc….. Read more

People that are about to turn 65 or are newly eligible for Medicare have choices about how they want to cover the gaps in Medicare. They can go with a Medicare Supplement plan, an Advantage plan, a part D plan or just Medicare A and B. This guide provides the basics on Medicare and the coverage choices available.

It may seem confusing at first but choosing the right option is not that difficult once you have a basic understanding of the programs. The attached document will certainly be a good start.

For more specific questions or information needs please email Edward Crowe at Edward@Croweandassociates.com or call at 203-796-5403.

Medicare Buyers Guide EC

Choosing Medicare Supplement or Medicare Advantage

Choosing Medicare Supplement or Medicare Advantage plans can be both confusing and frustrating. Many seniors simply go with a company name they are familiar with (Most commonly AARP). A plan that a relative or friend suggested or they just stay in their current plan because that is what they have always had. The end result is usually a bad choice of plan for the given situation. The reality is that there is not one “best plan” for everyone. To choose the best plan for the situation, it is important to know all the options available.

Here is a quick overview of the options available to Connecticut residents and the strengths and weaknesses of each…..

Medicare Supplement Plans:

Medicare Supplement plans are secondary plans you can purchase from a private insurance company to help cover the gaps in Medicare part A and B.  In all states, the plans offer standard benefits.  Plans provide different levels of coverage.  This depends on which plan you choose. The plan benefits cannot change.  This means any company that offers a plan must offer the exact same benefits. For Example Plan N with Anthem BCBS is exactly the same as Plan N with AARP (United HealthCare). The only difference is the rate that the private company charges for them. Please keep in mind, the rate can vary greatly.  One company in CT charges $184.00 a month for plan J while another charges over $300.00 for the exact same plan.

Supplement plans are best for a person who uses a high volume of health care services. Supplement plans tend to be costly but have very little out of pocket expense. If someone is consistently receiving a high volume of medical services, it may be wise to look at a supplement.  It may also be wise to use a supplement as some doctors that will not accept Medicare Advantage plans. In such a case, a Medicare supplement plan will provide coverage when an Advantage plan will not.

If you are in the market for a supplement plan it goes without saying that AARP should be considered.

They currently have the best rates available.  If you are considering plan F, you should purchase plan J instead. Plan J cost less, has all the benefits of F and some additional benefits as well.

The drawback to a supplement in the monthly premium cost compared to the premiums of Medicare Advantage plans. Also, supplements do not come with Rx coverage which must be purchased separately if it is needed.  If you are not a high volume user of medical services, it is warranted to look at the available Medicare Advantage plans.

One last thing to mention with supplements is that some people are simply more comfortable with them.  For some seniors the most important thing is to be able to see any doctor and not worry about copays or anything associated with managed care.  The person who feels this way may be willing to pay the extra monthly premium for this luxury.

Medicare Advantage Plans:

Medicare Advantage Plans are a low cost way to for seniors to obtain health care coverage. Advantage plans provide benefits equivalent to Medicare Part A and B with most plans providing additional benefits beyond what is covered by A and B. The plans can come with or without Rx coverage build into the plan design. Medicare advantage plan administer your benefits instead of Medicare Part A and Part B which makes the plan primary. Premiums range from $0 monthly premium to $179.00 month premium depending on the plan selected.

Medicare Advantage Plans do have some drawbacks compared to supplements such as the fact that you need to stay in network in most cases (There are PPO plans with out of network benefits)  There are also copays associates with services.  The higher premium plans have very low or no copays for many services but the lower premium plans ($0 premium) tend to have more out of pocket costs on things such as hospitalization)

Here is a breakdown of the plans available in Connecticut for 2009….

AARP Medicare Complete:

Positives– $0 monthly copay, Rx coverage build in with Medical, very low copays to primary doctors and specialists and out of network coverage.
Negatives– The network can have a lack of physicians in network in certain parts of the state, New Milford and some other key hospitals are not participating and the hospital copay is stiff at $225 a day for a total of 17 days.

Aetna Golden Medicare:

Positives-The Golden Medicare plans offer a national network which is nice for people who travel out of the Connecticut area. The Physician and hospital network is now one of the largest in Connecticut.  The $59 plan is the lowest cost plan on the market that still covers Inpatient hospitalization at 100%. There are a number of different plans to choose from including PPO options that provide out of network coverage, the $0 premium plan offers strong benefits compared to the rest of the $0 premium plans in the market.
Negatives-Some drugs fall into the 4th tier when they are only 2nd tier with other plans.

HealthNet:

Positives- Strong provider network, many high dollar drugs are on the 2nd tier.
Negatives-At current premium levels, the benefits are not competitive with other carriers in the Connecticut market. The Navy plan has weak benefits ($150 copay for 5 days inpatient hospital) for the high premium charged ($179.00)

Evercare (Secure Horizons/United Health):

Positives-$0 premium plans with low physician copays and Rx coverage, Chronic conditions plans coverage more conditions than any other in the state, only Dual Eligible Plan (Medicare and Medicaid) offered in CT market.
Negatives- High out of pocket costs for inpatient hospitalization, weak network can be difficult to deal with from an administrative standpoint, weak out of network benefits compared to AARP Medicare Complete

Be cautious of anyone who is only able to sell one or two of the companies listed above.  If they only offer a few plans, they may not know everything available that could best fit your needs.  Find someone who has the ability to work with all plans available in Connecticut in order to see all of the choices.  Although there are a number of plans available, each person has their own needs.

Image by Jose R. Cabello from Pixabay