Category: Medicare

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Medicare Medicare A & B

Medicare Tips: Part B

Unlike Medicare Part A, which covers inpatient care in a hospital, skilled nursing or hospice facility, Part B covers through outpatient care, services from doctors and other providers, durable medical equipment and many preventative screenings.

  • Individuals already receiving Social Security benefits are automatically enrolled in Parts A and B effective the first day of the month you turn 65.
    • At age 65, individuals choosing to delay their Social Security benefit need to contact Social Security, online or your local office, to activate Parts A and B.
    • Individuals receiving Social Security Disability benefits are automatically enrolled in Parts A and B after 24 months.
    • At age 65, those covered through their individual or spouse’s currently employed group health plan (20 or more employees) may delay Part B WITHOUT PENALTY until they, or their spouse, are no longer employed and the employer coverage ends.
  • The standard Part B premium amount in 2026 is $202.90.
    • If your 2024 Adjusted Gross Income was above a certain amount, you may pay more – an Income Related Monthly Adjustment.
    • If your current monthly income is below a certain amount, you may be eligible for the Medicare Savings Program which will subsidize the Part B premium.
  •  Paying the Part B premium
    • If you receive Social Security benefits, your Part B premium (and the IRMAA adjustment, if applicable) will be deducted from your monthly Social Security payment.
    • If you are enrolled in Medicare Parts A and B and have deferred the Social Security benefit, Medicare sends a bill for the Part B premium and, if applicable, any IRMAA adjustment, which can be paid by check or online.

 

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Medicare Part D Prescription Drug

The New Law and Medicare Part D

The US House and Senate has passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year, increased to $2,100 in 2026.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

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Medicare

Get Questions Answered at “Medicare 101” Webinar

Are you going to be eligible for Medicare in the near future? Have you been enrolled in Medicare for awhile and want to better understand what it offers? Do you have a family member you help with Medicare issues?

If you answered yes, then “Medicare 101” is for you. This no sales-pitch educational webinar, led by multi-state licensed and Medicare Plan Specialist Dan Alcorn:

We’ll explore Medicare Parts A, B, C and D, the difference between a Medicare Supplement and Medicare Advantage plan, and more. After registration, you will receive the login instructions by e-mail.

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Case Studies Part D Prescription Drug

New York State EPIC and Mary – a case study

“… a huge thanks for cluing us in to the EPIC ..program.”
“…we now estimate yearly savings to be $7,000+/-” 
“…we’d never heard of this program until one of your newsletter emails..”

When Mary became eligible for Medicare I helped her enroll in the Medicare Supplement Plan G she selected as secondary to Original Medicare.

Then we searched and found a Part D prescription drug plan that included her specialty medication in its covered drugs, known as the “formulary.” Although the specialty drug was categorized at the highest cost sharing, tier 5, its being included saved the added step and hassle of requesting a “formulary exception.” 

John and Mary’s joint income is below $100,000 so she became eligible for the New York State EPIC program. 

As John’s note to me states, once Mary’s pharmacy cumulative copayments reached her EPIC 2020 deductible level, that tier 5 specialty drug copay was reduced to $20. John estimates this saves the household about $7,000 annually.

Of course I was thrilled to hear my mention of EPIC helped John and Mary like this. I encourage every client to confirm your New York EPIC eligibility and enroll. I have included the EPIC enrollment form below and am available to assist with any eligibility or enrollment process questions. 

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Medicare supplement

What is a Medicare Supplement Plan G?

Medicare Supplement Plan

Medicare Supplement Plan G, also called Medigap, coverage is very similar to Plan F. It offers great value for beneficiaries who are willing to pay a small annual deductible. After that, Plan G provides full coverage for all of the gaps in Medicare. It pays for your hospital deductible, copays and coinsurance. It also covers the 20% that Part B doesn’t cover.

Plan G is an increasingly popular supplement for several reasons.

First, it has great coverage. For Medicare Part A in-patient hospital stays, it covers all of your expenses. That includes the Part A hospital deductible, which is $1,556 in 2022.

Second, Plan G covers each of the gaps in Medicare except for the $233 annual Part B deductible. We can often find a supplement Plan G that saves quite a bit in annual premiums over Plan F, substantially more than the $198 annual deductible.

Compare for Yourself! New York State Department of Financial Services publishes the Medicare Supplement monthly premiums by county.  Yes, it is as simple as that. I represent several of the insurance companies listed here and can assist you with the application process, please call (518) 346-2115 or book a telephone or video appointment directly to my calendar.

Attn: New York Residents. Did You Know?

  • Enrollment Calendar: New York State residents enrolled in Medicare can choose or change to a Medicare Supplement / Medigap Plan at any time. That’s because New York is a “guaranteed issue” state.
  • Health Underwriting? New York State residents enrolling in a Medicare Supplement / Medigap Plan are not subject to health underwriting.
  • Pre-Existing Conditions? The six month pre-existing condition claims exclusion can be eliminated for New York State residents changing to a Medigap plan from other creditable coverage.
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Case Studies Part C Medicare Advantage Part D Prescription Drug

“Thank you for helping me change my insurance!”

This month I received this wonderful thank you note from Nancy. She had recently relocated and needed to find new doctors along with a Medicare Advantage plan covering those doctors and her medications.

Nancy was concerned that she would have to remain on her current plan and wait until the Annual Open Enrollment Period in order to find a new plan effective January 1 of next year!

Nancy was relieved when I let her know she was eligible for a plan change due to a Special Enrollment Period.

A Special Enrollment Period allows eligible individuals like Nancy who are enrolled in Medicare Parts A and B to make a Medicare Advantage or Prescription Drug Plan selection or change outside of the normal October 15 – December 7 time frame.

When are you eligible for the Special Enrollment Period? The 5 most frequent examples I see:

Summary:

The initial, annual and special enrollment periods are when individuals enrolled in Medicare Parts A and B can make Medicare Advantage, Medicare Supplement or Medicare Part D prescription drug plan. Please feel free to call Dan at (518) 346-2115 for a no-cost no-obligation consultation.

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Part D Prescription Drug Uncategorized

Part D Late Enrollment Penalty

Q: “Dan, I just received a letter stating I will have to pay a Part D late enrollment penalty next year for not having a drug plan during the months of February through December, 2017. What’s this all about?”

A: “Sam, after you turned 65 in October 2016 you had individual coverage with prescription drug benefits through January 2017. Now you’re enrolling in a Medicare Advantage plan with Part D coverage, effective January 2018. For those 11 months, February through December, that you went without drug coverage Medicare will impose a penalty for the late enrollment.”

Again, why do I owe a late enrollment penalty?

If, for any continuous period of 63 days or more after your Initial Enrollment Period is over you go without one of the following, you will have a penalty added to your Medicare Part D premium:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (HMO or PPO) with prescription drug coverage.
  • Creditable prescription drug coverage (a drug plan that pays at least as much as the Medicare standard – most often provided through an employer or the individual insurance exchange.)

 

How does Medicare calculate the late enrollment penalty?

The penalty is based on multiplying two factors.

  1. Medicare calculates 1% of the “national base beneficiary premium” ($35.63 in 2017; $35.02 in 2018) which for 2018 will be $.35
  2. Medicare determines the number of full, uncovered months you didn’t have Part D or creditable coverage. In the above instance, that was 11 months.
  3. The $.35 is then multiplied by the number of months. In our example of 11, that equals $3.85
  4. The monthly penalty is rounded to the nearest $.10 (the example would then be rounded to $3.90) and added to your monthly Part D premium.

Will the late enrollment penalty change?

Yes, annually.  When Medicare determines the national base beneficiary premium has changed, as in $35.63 in 2017 to $35.02 in 2018, the late enrollment penalty amount will be recalculated.

Do I pay the late enrollment penalty through Social Security?

No.  The penalty, rounded to the nearest $.10 is added to your Part D premium and collected by your private insurance company

 

Source: https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

Categories
Case Studies Part D Prescription Drug

“Having this EPIC plan was a miracle; an absolute miracle.”

Only a fraction of the nearly 3 million New York State residents aged 65 and older are enrolled in the state’s pharmaceutical assistance program known as New York EPIC.

When I meet with New York Medicare Part D clients, I ask if their individual income is below the $75,000 threshold, $100,000 if married. If so, I advise enrolling in EPIC even if they don’t take any or have only inexpensive medication.  Because, as Schenectady County, New York resident Beth says, “You never know.”

Beth shares her story. The $20,000 per dose medication.

In this 16 minute interview Beth shares her story of how she originally enrolled in EPIC and didn’t use it. She explains how her doctor prescribed a specialty medication. And how that medication was not included on her Medicare Part D plan formulary, its list of covered medications. And when she learned the drug would require a special exception approval from her Medicare Part D plan and costs $20,000 per dose, she was relieved to hear that EPIC would help. Listen in as Beth explains how affordable this $20,000 medication became after EPIC’s help.

Beth: “To me, having this EPIC plan was miracle, an absolute miracle. Because I wouldn’t have been able to get that drug and I would still remain very ill.”

If you reside in New York State, are age 65 or above, and have questions about how EPIC and your Medicare Part D plan can work together, please call (518) 346-2115.

Categories
Case Studies Medicare supplement

A conversation: Focus the fight against cancer instead of the HMO

Medicare Supplement Plan

In this nearly 16 minute conversation Greensboro North Carolina residents, Bob and Signe Foxworth, talk about their frustration and anxiety of trying, unsuccesfully, to obtain HMO approval for Bob’s preferred out of network prostate cancer treatment. Listen as Bob and Signe explain how peace of mind came when Dan counseled them to revert to Original Medicare and enroll in Medicare Supplement Plan N.
Signe: “As I recall, it was tremendous anxiety at the time. Because not being able to get the treatment sooner rather than later could have had fatal consequences … We had more anxiety fighting the (HMO) insurance company than we did about his illness… We were kind of at our wits end.”
Bob: “I got $20,000 worth of treatment for $20 … Everything was covered.”
Signe: “In this whole thing, the most precious thing is that peace of mind knowing that you are covered. Yes, you strain a little on your monthly budget But things happen unexpectedly and you are covered. It’s really beautiful.”

For a personal consultation regarding your Medicare choices, call Dan at (518) 346-2115
Categories
Medicare A & B

Switching Medicare Supplement (Medigap) policies

Medicare Supplement Plan

Reasons Why New Yorkers Switch Their Medicare Supplement (Medigap) Policies:

As a reminder, Medicare Supplement, also known as Medigap, are policies designed primarily to supplement (or fill the gap) Medicare benefits. You simply present your red, white and blue Medicare card to the provider or facility along with the Supplement / Medigap card to help with out-of-pocket costs; such as deductible and co-insurance amounts with Original Medicare Part A and Part B.

Currently, there are 10 standardized Medigap plans, each represented by a letter (A, B, C, D, F, G, K, L, M, N; both Plans F and G offer a high-deductible version). These plans are available in most states. While premiums will vary from state to state the standardized benefits of each lettered plan remain the same despite the insurance company or location. For example, Plan F benefits are the same in Florida as they are in New York.

Q: Is there an Annual / Open Enrollment Period?

Most people buy their Medicare Supplement / Medigap policy during the six month period after they first enroll in Medicare. After that, in many states, Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy.

Q: So How Do New York State Residents Have More Protection?

New York State laws and regulations continue this open enrollment period. A person enrolled in Medicare Parts A and B may purchase a Medigap policy at any time. Insurers may not consider an applicant’s health status, claims experience, or age. Laws in New York also prohibit insurers from basing Medigap premiums on age and charging a higher premium as they grow older. Also,

Q: But What About Pre-Existing Conditions; Are They Covered?

Medigap insurers may impose up to a six-month waiting period to be covered for any preexisting conditions a person may have. Federal law and New York State regulation define a preexisting condition as any condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
Under New York State regulation, the waiting period may be either reduced or waived entirely, depending upon whether an individual has had previous health insurance coverage. Medigap insurers are required to reduce the preexisting condition waiting period by the number of days an individual was covered under some form of “creditable” coverage so long as there were no breaks in coverage of more than 63 calendar days. Translation: If you are switching from a “creditable” plan that you have held consecutively for six months, New York regulation requires the new Medicare Supplement / Medigap plan to reduce or waive the six month pre-existing condition waiting period.

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