CDISNM Blog
Whether you are already a Medicare beneficiary, or about to become one, you’re likely to run into some new language concerning your healthcare coverage. Medicare has a name for everything—and that’s a good thing. But, the more familiar you are with the terminology.
Coinsurance The amount you pay for medical services after you pay your deductible. Coinsurance is typically a percentage. For example, you may have coinsurance equal to 20 percent.
Copayment The amount you pay for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A co-payment is typically a set amount, not a percentage. For example, you might pay $10 or $20 for a doctor’s visit or a prescription drug.
Costs sharing The amount paid for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or prescription drug. This amount can include copayments, coinsurance, and/or deductibles.
Excess charge If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.
Extra Help A program designed to help those with limited income pay for Medicare prescription drug costs, like premiums, deductibles, and coinsurance.
Formulary The list of prescription drugs covered by a prescription drug plan. Also called a drug list.
Guaranteed issue rights Rights you have when insurance companies are required by law to sell or offer you a Medigap policy. With guaranteed issue rights, an insurance company cannot deny you a policy or charge you more for a policy because of a past or present health problem.
Guaranteed renewable policy An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All policies issued since 1992 are guaranteed renewable.
High-deductible Medicare Supplement Plan A type of policy that has a high deductible but a lower premium. You pay the deductible before the policy pays anything. The deductible amount can change each year.
In-network Doctors, hospitals, pharmacies, and other healthcare providers have agreed to provide members of a certain insurance plan services and supplies at a discounted price. With some plans, you are only covered if you receive care from in-network doctors, hospitals, and pharmacies.
Medicare Advantage Plan (Part C) A Medicare health plan offered by private companies that contract with Medicare to provide Part A and Part B benefits. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare Advantage Prescription Drug (MA-PD) Plan A Medicare Advantage plan that offers Medicare prescription drug coverage (Part D), Part A, and Part B benefits in one plan.
Medicare Prescription Drug Plan (Part D) Part D adds prescription drug coverage to Original Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
Medicare Supplement Open Enrollment Period A one-time-only, 6-month period when federal law allows you to buy any policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.
Network The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
Out-of-pocket costs Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or other insurance.
Penalty An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.
Referral A written order from your primary care doctor for you to see a specialist or to get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.
Tiers are Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
References:
https://www.medicare.gov/glossary/c.html
MUC52-2017-BCBS
CDISNM Blog
You may have questions about some of the phrases used to explain your Part D benefits. Defining key terms will help you better understand how your prescription drug benefits work and what you can expect to pay for your medication.
Donut Hole (Coverage Gap)
Most Medicare Prescription Drug Plans have a coverage gap, also called the “donut hole”. This means there’s a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the donut hole—the gap begins after you (and your plan) spend a certain amount of money on drugs. While in the donut hole, you will need to pay for your prescriptions. However, most prescription drug plans offer savings on drugs once you reach the coverage gap. Expect to pay no more than 40 percent of your plan’s cost for brand-name prescription drugs. However, this does count toward your out-of-pocket spending amount. Medicare currently pays 49 percent of the total price for generic drugs during the donut hole; you pay the remaining 51 percent. The good news? This percentage will decrease each year until 2020 when it reaches 25 percent.
Formulary
The formulary is a list of drugs covered by a prescription drug plan. Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have different costs. Different Medicare drug plans have different formularies, and most change annually. Even if your drugs are included in your plan’s formulary, be prepared to look it over every year for changes.
Out-of-Pocket-Maximum
The out-of-pocket maximum, or limit, is the most you have to pay for covered services in one year. Typically, after you reach this amount in deductibles, copayments, and coinsurance, your plan pays 100 percent of any remaining costs of covered benefits.
Generic, Preferred, and Non-Preferred Brand Name Drugs
There are three tiers or levels of prescription drugs: generic, preferred brand name, and non-preferred brand name.
Generic drugs are typically the least expensive and are considered “equivalent alternatives” to more expensive brand-name drugs. A generic drug is identical to a brand-name drug in dosage, safety, strength, quality, and the way it works and should be used.
Preferred brand name drugs do not have an equivalent alternative or generic version available. However, they are widely used and accepted and can be obtained at a lower cost than non-preferred drugs.
Non-preferred brand-name drugs are the most expensive of the three. Usually, a less expensive alternative is available.
Extra Help For seniors with limited income and resources, financial help is available to help pay for medications. Eligibility for the Extra Help program is based on income but divided into levels offering full or partial benefits.
Resources:
Finding Your Level of Extra Help: https://www.medicare.gov/your-medicare-costs/help-paying-costs/extra-help/level-of-extra-help.html
Save on Drug Costs: https://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html
What Drug Plans Cover: https://www.medicare.gov/part-d/coverage/part-d-coverage.html
Generic Drugs: Questions and Answers: https://www.fda.gov/Drugs/ResourcesForYou/Consumers/QuestionsAnswers/ucm100100.htm
Costs in the Coverage Gap: https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html
MUC50-2017-BCBS
CDISNM Blog
While you are not required to join Medicare Part B, signing up at the wrong time may end up costing you money. If you don’t join when you are first eligible, you may have to pay a late enrollment penalty, which is added to your monthly premium for as long as you have Part B coverage. For each full 12-month period that you go without coverage, your premium may go up 10 percent. Understanding how the penalty works is important, and the key to avoiding paying more for benefits.
Penalty
When you first become eligible for Medicare, you are automatically enrolled in Part A (hospital coverage) and Part B (Medical insurance). If you choose to opt out of coverage for Part B, you can. However, the clock starts ticking on penalties for late enrollment the month after your 7-month Initial Enrollment Period (IEP) ends. In other words, if your birthday is in June, then your IEP extends from March through September. Your deadline to enroll in Part B expires at the end of September. However, even if your IEP expires, you will not be charged a penalty until a full 12 months have passed after your IEP ends. For example, let’s say your IEP expired at the end of March and you did not sign up for Part B. If you decide to join during General Enrollment the following January, you will not be charged a penalty as only 10 months passed after your IEP ended, not the full 12 required for the penalty. But, once your IEP ends, you can only join Part B during General Enrollment, January 1-March 31 each year. Your coverage will start on July 1st.
Joining after Initial Enrollment Ends
If you miss your first chance to join Part B (during your Initial Enrollment Period) but would still like to join, you must enroll during General Enrollment (January 1 through March 31). Remember, the Part B penalty doesn’t affect you until a full 12 months have passed after your IEP ends. That means you can miss your IEP, and still sign up without penalty during the General Enrollment. While you will not be charged a penalty until a full 12 months has passed, missing each March 31 deadline means another full 12 months and another 10 percent late penalty. For example, if you go without Part B coverage for 3 years (without having other acceptable coverage) and decide to sign up, you may incur a 30 percent penalty—10 percent for each full 12 months you could have had coverage but didn’t sign up.
Delay Signing Up Without Paying a Penalty
Not everyone decides to enroll in Part B coverage when they are first eligible. There are cases when it is okay to wait until after you turn 65. If you are still working, and covered through an employer’s group health insurance or your spouse is still working and you are covered under their employer’s group health insurance, you can wait. The good news is when you retire (or your spouse retires) you will have a full 8 months to sign up for Part B without paying a penalty. However, if you do not sign up during this Special Enrollment Period (SEP), then the penalty clock begins from the original date you lost coverage, not the date your SEP ended. Understanding the penalty can be complicated. Unless you have other coverage through an employer or a spouse, the easiest way to avoid penalties is to sign up for coverage when you are first eligible, during your Initial Enrollment period. If you miss your first opportunity to join, you may have to wait until the General Enrollment period to enroll.
References:
https://www.medicare.gov/your-medicare-costs/part-b-costs/penalty/part-b-late-enrollment-penalty.html
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CDISNM Blog
Many elderly need specialized long-term care – social and medical services that traditionally take place in nursing homes. Seniors who are over the age of 55 and in need of care may be eligible for Programs of All-inclusive Care for the Elderly, or PACE. A Medicare program designed to provide personalized, coordinated care for the disabled in a community setting, the goal of PACE is to help seniors preserve their independence and delay nursing home care as long as possible. Here is some information on the PACE program and how it works to help older adults in need of services.
Eligibility and Cost
Enrollment in the PACE program is involuntary, but to be eligible to receive benefits, seniors must meet a few conditions. Applicants must be at least 55 years old and certified by the state as requiring a nursing home level of care. Recipients must reside in the service area of the PACE organization and be capable of living safely in the PACE community. Seniors who are eligible for Medicare, Medicaid, or both can enroll in PACE. While PACE uses Medicare and Medicaid funds to pay for care and services, the cost of the program depends on each applicant’s financial situation. Medicaid recipients may pay nothing at all or a small fee for services. Medicare-only recipients who join PACE pay a monthly premium for long-term care and prescription drugs. In either case, there are no deductibles or coinsurance.
Benefits
PACE benefits include all Medicare and Medicaid-covered services in addition to some services not covered by Medicare. This includes doctor and nursing services through a primary care physician, care while in the hospital (including laboratory and x-ray services), emergency services, physical and occupational therapy, nursing home and home care, prescription drugs, dental, meals, and nutritional counseling, social services, and transportation. Seniors who enroll in PACE receive all of their Medicare benefits through the program.
Each applicant is assessed daily on an individual basis by a team of skilled healthcare professionals. The team consists of the following:
Primary care physician
Activity Coordinator
Nurse
Dietitian
Social Worker
Center supervisor
Physical therapist
Home care liaison
Occupational therapist
Driver
Is PACE the Right Choice for You?
For older adults suffering from a disability or chronic condition, having medical and supportive services available in a community setting offers peace of mind, promoting independence and delaying nursing home care. The mission of PACE is to help well-deserving seniors and their families accomplish this goal by offering comprehensive medical and social services provided by a team of interdisciplinary health professionals. Individual states elect to provide PACE benefits to Medicaid recipients.
References:
https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html
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CDISNM Blog
Seniors suffering from debilitating chronic health conditions may be eligible to join a Medicare-approved Special Needs Plan (SNP). An SNP provides additional benefits above and beyond Original Medicare, offering seniors with special care requirements the treatment and services they need.
Special Needs Plan
Treatment of certain chronic health conditions such as cancer or dementia may require additional services above and beyond that which Medicare provides. For many seniors, the extra cost associated with treatment is a burden and Special Needs Plans address these concerns. Most benefits provided by an SNP are paid in full for recipients who are enrolled in both Medicare and Medicaid. However, for seniors who do not qualify for Medicaid, participating in an SNP costs about the same as enrollment in a typical Medicare Advantage plan.
Eligibility
To be eligible to join a Medicare Special Needs Plan, you must be enrolled in Medicare Part A and Part B, reside in the plan’s service area, and meet specific medical requirements. Seniors with a disabling chronic condition or who live in a nursing home, require in-home care or currently receive both Medicare and Medicaid benefits may qualify. SNPs may not be available in all states as insurance companies providing benefits decide which counties will offer coverage.
What Qualifies as a Chronic Condition?
Many seniors face chronic health conditions with age. However, to qualify for a Special Needs Plan, seniors must have one or more of the following chronic conditions:
Alcohol or drug dependence
Hematologic disorder
Autoimmune disorder
HIV/Aids
Cancer
Chronic lung disorder
Cardiovascular disorder
Disabling mental health conditions
Chronic heart failure
Neurologic disorder
Dementia
Stroke
Diabetes
End-stage liver disease
References:
https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/special-needs-plans.html
https://www.medicare.gov/Pubs/pdf/11302.pdf
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