FREQUENTLY ASKED QUESTIONS - Q&A

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MEDICARE

Let's start here to review Original Medicare
Medicare Supplement - Medicare Advantage - Prescription Drug

Medicare provides health care coverage either through Original Medicare (Parts A and B) or through a health plan offered by a private company; sometimes referred to as Medicare Advantage plans.

What is a Medicare Advantage Plan?

Let’s review this to get a better understanding.

Original Medicare also called "fee for service Medicare" allows you to see any doctor or hospital that takes Medicare patients. You usually pay a deductible and part of the cost of the services you get. Medicare governs what health care providers can charge for the Medicare approved services covers. Since Original Medicare does not cover the prescription drug coverage you would need to join a prescription drug plan.

If you choose to join a Medicare Advantage (Medicare health plan), you still have Medicare Parts A and B, but your health care services are through a private plan contracted with Medicare. You continue to pay the Part B premium, plus any premium your plan charges. These plans usually cover the same areas as Medicare Part A and B and can also include a prescription drug plan or you can purchase it separately. Generally, you will use network providers, like doctors, hospitals, facilities and pharmacies and if you go out of network it will cost you more money. Here are the different types of Medicare Advantage health plans:
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Private Fee-for-Service plans (PFFS)
• Special Needs Plans (SNPs)
• Medical Savings Accounts

MEDICARE ADVANTAGE (PART C)

MEDICARE SUPPLEMENT

What is Medicare?
It is a federal health insurance program referred to as Original Medicare, which includes people 65 years of age, or older, certain people with disabilities who are under age 65 and those with end-stage renal disease (permanent kidney failure). It pays for a large portion of the health care expense but not all of it. The portion that Medicare does not pay is what the individual must pay for out of pocket such as coinsurance, co-payments, and deductibles. The gaps in Original Medicare coverage are commonly filled by a Medicare Supplement plan. Medicare in Texas and Texas Medicare plans are the same as Medicare in any state because it is a federal government that defines what the benefits are.

Medicare has four parts:
•Texas Medicare Part A: This covers area such as inpatient hospital, inpatient skilled nursing facility, home health, and hospice services. Most people do not have to pay for Part A due their contributions over 10 years.
•Texas Medicare Part B: provides covers outpatient and physician services. It also pays for other areas such as durable medical equipment, prosthetic devices, supplies incident to physician's services, and ambulance transportation. Most people pay monthly for Part B.
•Texas Medicare Part C: Are Medicare Advantage plans are offered by private insurance companies that serve as an alternative to Medicare. These plans can cover medical only or medical and dental. These plans are subsidized and regulated by the Federal government.
•Texas Medicare Part D: Prescription Drug Coverage plans are offered by private companies to provide coverage for prescription drug costs. These plans are subsidized and regulated by the Federal government.

Can you tell me more about Medicare Part A and Part B?
Part A referred to as hospital insurance, helps pay expenses for inpatient hospital care, some skilled nursing facility care, hospice care, and some home health care. The medical costs you incur with Medicare Part A include a large deductible per benefit period and copays if you are in the hospital for over 61 days. The benefit period for part A is your time in the hospital including 60 days after you are release.
Part B referred to as medical insurance, helps pay for outpatient hospital care, doctors' services, and some other medical services and supplies when they are medically necessary that Part A does not cover. The Part B deductible is based on a calendar year and is generally affordable. After the deductible is met you will be responsible for 20% of your Medicare Part B expenses. This can be quite expensive if you have any major medical treatments.

What is a benefit period?
A benefit period starts on day one of a Medicare approved inpatient stay and ends when you have been out of the hospital for 60 consecutive days. This also applies to a skilled nursing facility. After that a new benefit period begins and the beneficiary must pay a new inpatient hospital deductible. 

What is the General Enrollment Period?
This period is during the time period between January 1 and March 31 when a Medicare beneficiary is eligible to sign up for Part B coverage. The beneficiary’s benefits will begin on July 1 of that year, and the beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.

What is the Medicare Open Enrollment Period?
“Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65”
Open enrollment period is when the applicant is guaranteed a Medicare supplement insurance plan regardless of their current or past health history (generally, outside of this period the applicant must meet medical underwriting guidelines to qualify). Open enrollment is a six-month period from the date the beneficiary enrolled in Medicare Part B if age 65 or older (also includes a six-month period when you turn 65 if you were eligible for Part B benefits before age 65). No individual can be denied any Medicare supplement policy sold by any Medicare supplement issuer if the application is submitted during the six month period beginning with the first day of the first month in which an individual first enrolls for benefits under Medicare Part B at age 65 or older; or upon attaining age 65 for individuals that were previously enrolled in Medicare Part B prior to turning age 65. Additionally individuals under the age of 65 can purchase Plan A from any insurer during the six-month period beginning with the first month in which the individual first enrolled for benefits under Medicare Part B. Please note that, in, Texas, Medicare beneficiaries under age 65 have two open enrollment periods, one when they first enroll in Part B and a second one when they turn age 65.

What makes the open enrollment period so critical?
The open enrollment period starts the first day of the month you turn 65 and have Medicare Part B extending for 6 months from that date. This period is critical because no company can not offer you any Medicare Supplement Policy that they sell for any reason. After this your open enrollment period ends companies then are allowed to use medical underwriting and can accept or deny your application. This can make it very difficult and expensive, due to certain health conditions to obtain coverage after your open enrollment period expires.

There are several times when you can enroll in Medicare.
The first time when you can sign up for Medicare, is called the Initial Enrollment Period (IEP). You may join Medicare Parts A, B, C and D during this time. Your coverage will start no sooner than your birthday month.

Here’s how it works - You have a 7-month Initial Enrollment Period:
3 months before your 65th birthday, the month of your birthday and 3 months after your birthday.

When am I eligible for Initial Enrollment Period?
Initial Enrollment Period is when the client can apply for Part B or Part D for the first time. For many it starts 3 months prior to when the person meets Medicare’s requirement for eligibility and goes on for the next 7 months. However, for SSDI, Social Security Disability Insurance applicants the period begins the 24th month of the SSDI’s payments. The person is not liable for medical history review during the enrollment period yet once the period is over any prior conditions that will create exclusionary problems can apply. “Open enrollment is the 6 month period beginning on the first day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a six-month open enrollment period when you reach age 65.”

Am I automatically enrolled in Original Medicare?
You are automatically enrolled in Original Medicare Part A and/or Part B, if you are turning 65 and already getting Social Security or Railroad Retirement Benefits (RRB) benefits or will start collecting retirement at age 65.

• You will need to sign up for Medicare Part B at the time that you apply for retirement benefits, and Medicare Part A enrollment occurs automatically if you are eligible for Social Security retirement.

Do I need to sign up for Medicare?
If you aren't receiving Social Security or RRB benefits when you turn 65, you will have to sign up for Medicare A and/or Part B during your Initial Enrollment Period (IEP).

Do I have to pay for Medicare Part B and/or Part A?
Medicare Part B has a monthly premium. Most people don’t pay a premium for Part A, if they have paid Medicare taxes and worked at least 40 quarters (10 years) and. People that are still covered under an employer group plan or different plan may choose to delay enrollment in Part B.

I have Medicare Part A and Part B due to a disability and I would like to know which Medicare Supplement I can get since I am not 65 yet?

In Texas, insurance companies that offer Medigap policies are required to sell a Plan A to someone under 65 that qualifies for Medicare. Companies can offer additional plans as an option in addition to a Plan A to someone on disability.

What is a Copayment?
A set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, you may have to pay $10 each time you visit the doctor, with the understanding that the health insurance policy covers a large part or the remainder of the balance of the fee owed to the doctor. The copay amount is usually indicated on the prescription or insurance card. It is the portion the insured pays with the balance being paid by the insurer.

What does it mean to have Creditable Coverage?
Your current insurance company can guide you on weather their plans are creditable. When you are going from one health insurance plan to another the prior coverage will reduce pre-existing condition waiting period. However, if you didn’t have any health insurance coverage for more than 63 consecutive days, you cannot count them in the creditable coverage period.

What is a Deductible?
A deductible is the cost a person is required to pay for health services before the insurer or Medicare pays their portion. For instance, Medicare Part B requires one deductible that is paid on a calendar year basis and Medicare Part A has a deductible that must be met for each benefit period.

What is a Medicare Coinsurance?

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

What does a participating Texas Medicare provider mean?
A participating physician is enrolled in the Medicare program agreeing to accept assignment on all Medicare claims that are submitted. You may only be billed by these doctors for Medicare deductible and/or coinsurance amounts.

What does Centers for Medicare & Medicaid Services (CMS) do?

It's the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace.

How do I apply for Medicare in Texas? 

The Medicare laws and regulations are subject to change for Texas Medicare eligibility and enrollment at any time. Contact Social Security at  
1-800-772-1213 to discuss the Texas Medicare application or look up your local Texas Social Security offices.

How do I know if I am eligible for Medicare?
Generally you are eligible for Medicare if you are a U.S. citizen or have been a permanent legal resident for 5 continuous years, are 65 years or older or if under 65 are disabled and have been receiving either Social Security or the Railroad Retirement Board disability benefits for at least 24 months, or they get continuing dialysis for permanent kidney failure or need a kidney transplant, or they have Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's disease). You can also be dual-eligible which means you are on Medicare and Medicaid. If you have limited income, in some states, Medicaid will actually pay for the Part B premium and for many individuals who have worked long enough won’t have a Part A premium, and also pay any drugs not covered by Part D.

What is a Medicare Supplement (Medigap) plan?
A Medicare supplement insurance plan is a health insurance policy sold by private insurance companies (Texas Medicare carrier) to cover some or all of the "gaps" created my Original Medicare. In the end, a Medicare Supplement plan may help pay some of the Medicare approved health care costs that Original Medicare doesn't cover (deductibles, coinsurance and copayments). You are eligible for this plan if you have Medicare Part A and B and are at least 65 years of age (unless disabled). Since the Texas Medicare Supplement plans do not have an open enrollment period you can switch another Texas Medicare Supplement plan with another Texas insurance company at any point throughout the year as long as you qualify medically.

When can I buy Medicare Supplement Insurance?

The best time to buy a Medigap policy when you're first eligible. If you apply for Medigap coverage after your open enrollment period, the insurance company will have you to through their medical underwriting requirements. There isn’t a guarantee you will be approved, unless your eligibility is based on a special situation.

How many Texas Medicare Supplement Policies are there?
The modernized benefit policies are “A, B, C, D, F, High-Deductible F, G, K, L, M, and N.” Since they are standardized, by law each insurance companies plan offers the same basic benefits.

What is the most popular Texas Medicare Supplement Insurance plan?
Probably the most popular plan is probably Plan F. Most people choose Plan F because it covers all the deductibles and all the coinsurance. In order not to have any additional out of pocket costs it has to be a Medicare approved expense, and then you will pay nothing. Another popular is Plan G. The main difference between the two plans is that Plan G Medicare Supplement does not cover the Medicare Part B deductible.

Why do I need a Texas Medicare Supplement Insurance plan?
The original Medicare program is designed to provide health benefits but it does not cover the total cost of health care, or leaves gaps in coverage such as co-pays and deductibles for hospitalization, doctor visits and other medical services. Individuals that have enrolled in original Medicare program may decide that they need a Medicare Supplement often referred to as Medigap insurance because it provides supplemental health insurance coverage to fill in the gaps. Supplement plans may cost you more that the Medicare Advantage plans but once you pay the premium there will be less or no out of pocket expenses for most plans.
In both of Medicare programs Part A and Part B they have gaps in coverage that may be covered by supplemental insurance.

Here's an example of how having a Texas Medigap Policy can benefit you:
Say you were on Original Medicare only, you're out of pocket could consist of Medicare Part A 2017 deductible of $1,316 and Medicare Part B deductible of $183 deductible. Medicare will then pay 80% of the Medicare approved expenses. That can be a hefty unplanned expense! Now let’s say you have a Medigap policy, like a Plan F that picks up the Medicare Parts A and B deductibles as well as the 20% of Medicare Part B expenses. So by purchasing a Medicare supplement plan and combining it with Medicare your out of pocket expenses can end up being next to nothing. This type of advance planning for the unexpected covered medical expenses can be very advantageous.

Do Medicare Supplement policies (Medigap) cover everything?

No. Medigap policies don’t cover costs that are not approved by Medicare and generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Do Medicare Supplements cover all medical charges that Medicare doesn’t?
Medicare Supplements will not cover expenses if Medicare does not pay a portion of the bill. Generally, if it is not a Medicare approved expense then a Supplement will not pick up its portion, with some exceptions.

Is Medigap the same as a Supplement?
The Original Medicare Plan has health care areas that are not covered that are commonly referred to as “gaps.” Private insurance companies created supplemental insurance polices to fill gaps in the Original Medicare Plan. The Medigap or Supplement policies are sold to individuals who have Medicare Part A and Part B and are the exactly the same.

If I move what happens to my Medicare supplement plan?
Your Medicare supplemental plan is renewable and guaranteed; you will still have coverage if you move in state. If the move is into another state, the supplement insurer may have to go over different premiums due to the states plans. If you have a select insurance plan, which do include network restrictions, you will be asked to change your Medicare coverage. You will be given the opportunity to buy supplemental insurance A, B, C or F in the state you move to without having to medically qualify.

What is the best Medicare Supplement Insurance in Texas for me?
There's not one plan that fits all needs. There many areas to consider when selecting a Medigap Insurance. Your personal preferences consisting of current and future financial abilities, benefits, age and current health will determine what the best plan is. Contact us to help you determine which plan is best for you.
How do I get a quote Texas Medicare Supplement Insurance?
Simply request a quote and we will provide you with some plans from the top rated companies that we represent. Please feel free to call us at (469) 293-7080 or send us an email to help you with a Medicare Supplement. We will discuss Texas Medicare coverage and Texas Medicare Guidelines with you and determine what your needs are then review the various plans available for you. Texas Medicare supplement plans are made easy for you to understand how they work with Texas Medicare.

How do I determine which type of Medigap plan is best for me? 

Your personal requirements, needs and financial situation will determine which the best Medigap plan for you. There are many plans to choose from and many of the plan benefits overlap so review the coverage details, costs and additional or optional benefits offered by the insurance company. Contact us to help you determine which plan is best for you.

I want to switch to a different Medicare supplement policy; do I have to wait for it to start?
You generally do not have to wait to switch to a different Medicare supplement policy and can do so any month. However, if you had a Medicare Supplement plan for at least six months and you decide to go to another company your new plan must cover all preexisting conditions. If you are on a plan for less than six months, the new Medicare supplement policy must give you credit for the time the older policy covered you.

PRESCRIPTION DRUG BENEFIT (PART D)

What is a Medicare Prescription Drug benefit plan?

Medicare Prescription Drug benefit plan is also called Part D and PDP. This plan is a Federal government program to subsidize the costs of prescription drugs and insurance premiums for Medicare beneficiaries. This benefit was put in place on January 1, 2006.

Do I have to sign up for Part D?
Enrolling in a prescription drug coverage plan (Part D) is optional.

Who administers the Part D plan?
The Part D prescription drug benefit is administered through private insurance companies. Each company designs one or more plans to select from.

What does this plan cover?
Each plan has its own formulary, which is a list of covered drugs. These formularies include coverage of specific generic and brand name prescription drugs. Before you select a plan, review the formulary to determine if your current drugs are covered.

When can I sign up for Medicare Part D?
You want to sign up during your Initial Enrollment Period (IEP) to make sure that your coverage begins when you are eligible. If you do not join a Part D plan during your IEP, you may not be able to enroll until the fall Open Enrollment Period (October 15 through December 7) and pay a late enrollment penalty amount every year.

How much is the premium for Part D?
The plan costs vary depending on the year you are enrolling, the plan you choose and where you live.

What is the late Part D enrollment penalty?
It is a penalty amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over you don’t have a Part D plan, Medicare Advantage Plan (Part C), Another Medicare health plan that offers Medicare prescription drug coverage or Creditable prescription drug coverage.

How is the late Part D enrollment penalty calculated?
Medicare calculates the penalty by multiplying 1% of the national base beneficiary premium times the number of uncovered months you didn't have Part D or creditable coverage. The monthly penalty is added to your monthly Part D premium.


Example:
2017
In 2017, Medicare recalculated Mrs. Martinez’s penalty using the 2017 base beneficiary premium ($35.63). So, Mrs. Martinez’s new monthly penalty in 2017 is 31% of $35.63 or $11.05 each month. Since the monthly penalty is always rounded to the nearest $0.10, she pays $11.10 each month in addition to her plan’s monthly premium.
Here's the math:
.31 (31% penalty) × $35.63 (2017 base beneficiary premium) = $11.05
$11.05 rounded to the nearest $0.10 = $11.10
$11.10 = Mrs. Martinez's monthly late enrollment penalty for 2017

Source 


How do I sign up for Medicare Part D?
You have several options.
You can call 1-800-MEDICARE (1-800-633-4227) or the insurance company offering the Prescription Drug Plan directly.