Tag: Medicare Part B

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Part C Medicare Advantage

About Those Nursing Home Denials and Appeals

Earlier this month, Wall Street Journal published an article about a federal investigation(i) update into Medicare Advantage insurers’ rejection rates for patients seeking nursing home stays.  

The OIG review found that only 13% of prior authorization denials issued by Medicare Advantage organizations actually met federal Medicare coverage rules. Stays in post-acute facilities were highlighted as one of the most prominent service types improperly denied, meaning these vital nursing home and rehab stays likely would have been approved under traditional, government-run Medicare. (Medicare typically covers a nursing-home stay if patients need skilled care after a hospital admission of three days or more.)

The investigation noted that most people don’t appeal when the Medicare Advantage insurer denied their doctor’s request for access to a skilled nursing facility.  There is likely a number of reasons why that is the case; people give up, arrange for alternative care, pay out of pocket or simply don’t realize the initial denial is not the final word. 

However, of the 18% of patients who did appeal, nearly all of them were able to overturn the initial denial. 

Prior Authorization and Appeals

Medicare Advantage plans are when a private company, not the federal government, is managing and coordinating your Medicare Parts A and B benefits. Since these plans were introduced in 1999, and modified in 2003 to include drug coverage, the presumption has been these private companies can do a better job at improving health outcomes while saving the taxpayers money. 

In doing so, the private insurance company managing your benefits has the right to request “prior authorization” of a service provided by a Medicare participating provider or facility. The insurance company must post a list of services that require prior authorization and make a decision within seven days. Beginning in 2027 the companies must publish the percentage of PA requests approved vs. denied as well as the average and median time it took to make the decision.

An individual enrolled in a Medicare Advantage plan, or the physician requesting the service, can appeal; the formal way to ask the company to change the coverage decision. 

In Short..

Medicare Advantage plan insurance companies are under intense pressure from the federal government (and in some cases, corporate shareholders) to reduce cost while improving health outcomes. That means more scrutiny (another term for managed care) and prior authorization requirements. Physician groups now employ an army of people whose only job is to appeal the Medicare Advantage insurance company authorization denials. If individuals, too, join the appeal the reporting shows the denials can be overturned.   

(i)Health and Human Services Office of Inspector General (OIG)

Categories
Medicare A & B Part D Prescription Drug

Changes to the NY Medicare Savings Program in 2026

If you are enrolled in Medicare Parts A and B and have limited income you may be able to get assistance with your Medicare health care costs through a Medicare Savings Program (MSP) administered through each state’s Medicaid office: https://www.health.ny.gov/health_care/medicaid/program/update/savingsprogram/

If eligible, you will receive help paying the Medicare Part B premium, (currently $202.90) and are automatically enrolled in Extra Help, the federal program that helps with Medicare prescription drug (Part D) costs such as monthly premium, drug deductible and prescription copays.

The Medicare Savings Program has two eligibility levels – with additional benefits available to those with the lower income. You do not choose which program to apply for – you will be enrolled in the level program that corresponds to your income.

2026 New York Monthly Income Limits (*)
Program Individual Couple
QI Up to $2,494 Up to $3,375
QMB Up to $1,856 Up to $2,509

(*) Eligibility is based on your income after subtracting for eligible health insurance premium deductions such as i) Medicare Supplement, ii) Part D drug plan, iii) dental, iv) vision, and iv) long term care premiums. The Part B premium ($202.90) or any IRMAA surcharges deducted from your Social Security award cannot be used to lower your income. 

  • (QI) Once enrolled as a Qualified Individual with individual monthly income at or below $2,474 you will no longer have the Medicare Part B premium deducted from your Social Security check.  And you may receive up to three months of retroactive reimbursement for Part B premiums paid before your MSP effective date and within the same year of the effective date.
  • (QMB) If your individual monthly income is at or below $1,856 you would be enrolled in the Qualified Medicare Beneficiary Program and, like QI, will no longer have the Medicare Part B premium deducted from your Social Security check.
    • This program also pays for Medicare Parts A and B deductible and cost sharing however no retroactive Part B reimbursements are available to QMB enrollees.
  • FYI: If your individual monthly income is at or below $1,856 and your assets are below $33,308 you may apply separately for Full Medicaid you may enjoy the same benefits as QI and QMB plus some additional benefits such as:
    • County based transportation to and from medical appointments.
    • Dental and vision allowances approved by NY State Medicaid

Once approved at the QMB or Full Medicaid level, you may want to consider a Medicare Advantage DUAL (Medicare / Medicaid) plan. On top of the benefits described above, these plans include additional benefits like dental, vision, fitness membership and even an allowance for healthy food. Ask your local agent about the Medicare Advantage DUAL plans we offer for individuals enrolled in QMB or Full Medicaid.

Your local agent can help you with the request. Start by downloading the form below. Then, along with a copy of your Medicare ID card, we’ll need documents to confirm your date of birth, residency and income. If you are paying another health insurance premium, such as i) Medicare Supplement, ii) Part D drug plan, iii) dental, iv) vision, and iv) long term care premiums, you will need to provide some proof of that expense. Your local agent will work with you in getting this to your county’s Department of Social Services and follow up with you during the approval process which can takes up to 45 days.

>> To download application form: click here

Include the following verification documents with your Medicare Savings Program application:

  • A photocopy of the front and back of your Medicare card(s) (red, white and blue card).
  • Proof of Date of Birth, such as State Driver’s license, U.S. Birth Certificate, U.S. passport, Permanent Resident Card (“Green Card”), or NYS Benefit Identification Card.
  • Proof of Residence, such as lease/ letter/ rent receipt with your home address from landlord, utility bill (gas, electric, phone, cable, fuel or water), property tax records or mortgage statement. These documents must be dated within 6 months of when you signed the application.
  • Proof of income, such as paycheck stubs (4 weeks), a letter from employer, pension information indicating amount and frequency of payment, income tax return, award letter for any unearned income benefit such as Social Security, unemployment, or veteran’s benefit, or letter from renter, boarder or tenant.
  • Proof of any other health insurance premium that you pay other than Medicare, such as Medicare Supplement, Medicare Advantage, Part D prescription drug, dental, vision or long term care policy.
  • If you are not a U. S. citizen, you must provide documents indicating your current immigration status such as I-551 Permanent Resident Card (“Green Card”), I-766 Employment Authorization Card.  

Check with New York State Department of Health for an online listing of each county’s Local Department of Social Services:     https://www.health.ny.gov/health_care/medicaid/ldss.htm

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Categories
Medicare A & B

Your 2026 Medicare Part B and D Premiums

May Be Increased. Or Eliminated.

The 2026 standard monthly premium for Medicare Part B beneficiaries is $202.90.

However, your 2026 Medicare Parts B and D premiums could be higher or lower – based on your prior or current income.

  • Higher? Yes. If the Modified Adjusted Gross Income (MAGI) on your 2024 tax filing exceeded $109,000 ($218,000 joint) your 2026 Medicare Parts B and D premiums are increased. This will be withheld from your 2026 Social Security benefit. Here is more information about the Income Related Monthly Adjustment Amount (IRMAA) for Parts B and D
  • Lower? Yes. If your current annual income is below 186% of the Federal Poverty Level you will be eligible for the Medicare Savings QI Program, regardless of assets, and will not be paying any Part B premium.

 

  • If you are being charged IRMAA and had a life-changing event that resulted in a reduction in your income, you may be eligible for a reduction in IRMAA. Call Social Security at 1-800-772-1213 for instructions on how to file an appeal via the SSA-44 form.
  • Plan ahead. Assuming the law is not changed, check with your financial planner or tax preparer to confirm whether your 2025 tax filing will trigger a 2027 IRMAA.
  • Or, if your current monthly income is below $2,426 individual / $3,279 couple one of our agents listed below and we can review whether you are eligible for the Medicare Savings QI Program.

 

Questions?

Our licensed, independent and certified agents are available to answer your questions about Parts A, B, IRMAA and other Medicare topics. Send us a note below to request an individual consultation.

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Categories
Medicare supplement

Why Choose a High Deductible Medicare Supplement Plan?

Medicare Supplement Plan

“Ask the Experts TV” asked about the Medicare Supplement High Deductible Plan G. Click and watch the video from the February 17 livestream interview here:

reason 1: Lower your MAXIMUM annual out-of-pocket

The annual maximum out-of-pocket is the amount you could potentially pay in medical co-pays after which your plan covers 100%.

Most Medicare Advantage plans include an annual maximum out-of-pocket amount for medical co-pays, ranging from $6,000 to $9,250. With a Medicare Supplement High Deductible plan, your maximum out-of-pocket is $2,950.

So, you would be lowering the amount you would pay before your plan covers 100% – reducing your potential exposure by thousands of dollars.

reason 2: Lower YOUR COMBINED annual premium and deductible costs

Let’s do some math:

Traditional Plan G:
$4800 annual premium (avg. $400/month) check your county
+ $283 Part B deductible
$5083

High Deductible G
$900 annual premium (avg $75/month) check your county
+$2950 maximum (Parts A and B deductible and 20% cost share)
$3850

Smart Tip: Set aside $250 saved in monthly premium payment for the $2950 to cover the Parts A and B deductible and 20% share. Depending on your medical claims you should have money left over on December 31.

NY STATE RATES APPLICATION
IS this Like with other deductibles and I pay the first $2,950 in medical bills?

No. After you pay the Parts A and B deductibles, Medicare pays its share of claims (usually 80%) and you pay the 20%. Once your deductible and 20% share reaches $2,950, then your supplement plan pays 100% for the rest of the year. Think of it as a $2,950 cap on your out of pocket costs.

2026
Part A deductible per period $1,736
+ Part B deductible $283
+ Part B co-share 20%
= Maximum Out of Pocket $2,950

Will hospitals and doctors will accept my High Deductible plan?

Yes, if your provider participates in Original Medicare for your primary coverage, they will accept your Medigap supplemental coverage; including plans with deductibles like Plans G, N and High Deductible. This way you have access to the nationwide network of doctors and hospitals participating in Original Medicare.

How does a High Deductible compare to Medicare Advantage plan?
      •  Medicare Advantage plans include a limit on out-of-pocket costs; ranging from $6,000 to $9,250 per year for in-network medical services. (Up to $13,900 for in and out of network)  Compare to a Medicare Supplement High Deductible plan with the annual maximum out-of-pocket cost capped at $2,950
      • Medicare Advantage plans manage your Medicare benefits through contracts with in-network providers and hospitals. As mentioned above, any provider accepting Original Medicare for your primary coverage will accept your supplement coverage – eliminating the “is my doctor in-network with my plan” questions.
      • Most Medicare Advantage plans, including those with a low monthly premium, include Part D prescription drug coverage. With Medicare Supplement, you will need to obtain separate creditable Part D drug coverage. during an Annual Enrollment, Open Enrollment or Special Enrollment  Period. VA drug benefits are considered creditable coverage.
      • Many Medicare Advantage plans include features like dental allowance, fitness membership, eyewear and hearing aid benefits not available with Original Medicare.

Globe Life of New York

 Download 3 separate documents↓↓↓
Globe Life application Form 1 sign page 3 (and 5 for EFT)
Globe Life application Form 2 sign page 1
Globe Life application Form 3 sign page 1
About Globe Life Insurance of NY

Our agents are authorized to represent the Globe Life Insurance Company and Humana Medicare Supplement High Deductible Plans. Please call us at (518) 346-2115 or send any agent a quick note with your questions:

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Categories
Medicare Medicare A & B Medicare supplement Part C Medicare Advantage Part D Prescription Drug

About the 2026 Medicare Annual Enrollment

Annual Enrollment Period

The Medicare Annual Enrollment Period, from October 15th through December 7th, is when Medicare beneficiaries can enroll in or change their Medicare Advantage (Part C) or Medicare Prescription Drug (Part D) plan to take effect January 1.

Some Important Tips to Consider if you are now enrolled in a Medicare Advantage (Part C) Plan:
  • You can leave your Medicare Advantage plan and enroll in another Medicare Advantage plan offered in your county. [We offer several]
  • Even if you decide to stay with your current Medicare Advantage plan, make sure your doctors and preferred hospitals are still in your network, especially if your plan is a HMO. 
  • You can leave Medicare Advantage and return to Original Medicare and purchase a Medicare Supplement (aka Medigap) policy. For New York State residents, acceptance is guaranteed and the continuous coverage transfer means no pre-existing condition limitations apply.
Some Important Tips to Consider if you HAVE ORIGINAL MEDICARE AND a Medicare SUPPLEMENT Plan:
  • The Annual Enrollment Period applies to your Part D drug plan only.
  • New York State residents can change their Medicare Supplement plan at any time of the year and without medical underwriting. An example could be changing from one company to another or changing from one plan (Plan F, Plan G, Plan N or High Deductible) to another. 
  • You can leave your Medicare Supplement (Medigap) plan and join a Medicare Advantage plan during the Annual Enrollment Period. There is no underwriting to move to a Medicare Advantage plan. You will be automatically accepted as long as your permanent address is within the coverage area.
  • Unless your prescription drugs are covered through the Veterans Administration, most individuals with Original Medicare and a Medicare Supplement plan also add a Medicare Part D prescription drug plan. We recommend updating your medication list and confirming – through your personal account at medicare.gov – which Part D drug plans will cover your prescriptions at the lowest annual out of pocket costs – that includes premium, deductible and prescription copay costs.

Our team of licensed, independent and certified agent advisors, from Long Island to the North Country, offer a no-obligation complimentary consultation to help you compare Medicare plans in your coverage area.

So, reach out to local agent by phone, an online note or book an appointment directly to his or her calendar and learn more about your Medicare plan options.

Categories
Webinar Reviews

Delaying Medicare Part B

Diane turned 65 in April 2023, however, declined the Medicare Part B coverage as she chose to remain working and insured through her employer’s group health plan.

In mid November, she decided her retirement date would be year-end and asked about Medicare Supplement plan to become effective in six weeks, January 1.

I advised that she would need to contact Social Security and activate Part B. And I also walked her through the form her employer would need to confirm she had been covered through the group plan since her 65th birthday. (That form prevents being assessed a Late Enrollment Penalty for going without coverage.)

Social Security expedited the Part B activation while I confirmed her primary care, specialist providers, and two medications were included in the Medicare Advantage PPO plan she chose.

On December 18th, her enrollment was all set for January 1, and I’m so appreciative of the kind words in her review posted a few days later.

Categories
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.

Categories
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.
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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