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Russell F. Porter Insurance Services

(530) 275-3800

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Health, Vision & Dental Insurance:

Medicare

There is a huge portfolio of products and Insurance Companies who:

  1. Cover what Medicare does not pay for.
  2. Complement what Medicare pays for.
  3. Receive payment from Medicare to manage your medical expenses.
  4. Participate with the Medicare Part D Prescription plan.

The decision of where to go and what planning to choose is daunting. I have twenty four years of experience in this field and am happy to assist.

I represent * Anthem Blue Cross * Blue Shield * Gerber * Mutual of Omaha * Secure Horizons * United Health Care .

There are numerous rules and time frames that we need to co-ordinate. This takes serious effort and concern.

INSURANCE TIPS

  1. If you have low income, you can contact Social Services to see if Medi-Cal (Medicaid) will cover you. That would take care of various things and percentages that Medicare does not cover and could eliminate the need to pay premium for plans purchased through an Insurance Company. Sometimes to qualify to receive Medi-Cal, you have to spend down. I can assist you to purchase a dental or vision plan so that you clear the requirements of the Welfare Department. You can also call Health Insurance Counseling and Advocacy Program (HICAP) at (530) 223-0999. Our tax dollars pays for the cost of their service; so you do not have to pay for their consultation.
  2. Some of our physicians' billers:
    1. Are not consistently billing Medicare.
    2. Are miscoding the service you received when they submit your claim to Medicare.
    3. Are expecting you to pass on billing statements both to Medicare and your Insurance Company.
    • While this should not happen, and is frustrating; somebody has to follow through with the paperwork. When a physician, hospital or medical provider does not get paid, they will in time turn you in to a collection agency. This can ruin your credit and cause providers to not want to serve you.
    • Both Medicare and your Insurance Company are usually prepared to pay claims promptly, but they must first be billed. Your Insurance Company cannot pay their share until Medicare first pays and sends out an "Explanation of Benefits" (EOB) statement..
    • NEVER ALLOW A CLAIM TO GO UNPAID BEYOND A YEAR, because Neither Medicare nor the Insurer are required to pay after that. (Appeals can be filed, but you may be dependent on their grace.)
  3. For several decades we had simple Medicare Supplement plans. Now we have Medicare Advantage plans. Some of these plans have been withdrawn from the market in rural communities.I believe the underlying cause is that Medical providers are unhappy with the amount of pay they receive from the plan structure. Nonetheless, in addition to Medicare Supplement plans, we still have a few other forms of coverage to choose from:
    1. Health Maintenance Organizations (HMO). In populated areas.
    2. HMO Point of Service. In populated areas.
    3. Preferred Provider Organizations (PPO).
    4. Private Fee for Service.
    5. Special Needs plans connected with Medi-Cal (Medicaid Welfare).
    6. Medical Savings Account.
    7. Provider Sponsored Organization (PSO).
  4. There are strict guidelines imposed by Government Industry regulation because of the prevalence of fraud and elder abuse.
  5. Your primary physician likely accepts Medicare and your Insurance Company plan. But once in a while other providers to whom you are referred might not accept Medicare Assignment. It is important to contact all providers to see where they stand. This is especially true if you are scheduled for an operation. Anesthesiologists, technicians & other assistants become involved.
  6. Most Chiropractors do not accept Medicare Assignment. Also, Medicare pays for a limited number of chiropractic manipulations, but not always the exams.
  7. Have your health provider's billing department take a copy of your current Medicare and Insurance Company ID cards. Have them compare your current cards against the information they have on you in their files. This will likely eliminate confusion and make your claims process go smoothly.
  8. Your Medicare plans are designed to cover MEDICAL EXPENSE. It is not intended for Long Term Care assisted living expenses. There can be short term provision for your cost for assisted living under certain circumstances, but you need a separate policy to cover you for Long Term Care, either at home or in a facility.
  9. Medicare and Medicare Supplement plans through Insurance Companies seldom pay for prescriptions, eye glasses, hearing aids and dental care. Exceptions may be made if you have a cataract or glaucoma operation.
  10. If you have a Medicare Supplement other than Plan A, you should almost never experience a deductible or co-payment. Between Medicare and your Insurance Company plan, you normally have 100 percent coverage, except for the things I mention in line 9. (Medicare Advantage plans may pay for those services, subject to co-payments and limitations.)
  11. If you are a military war veteran you may be entitled to prescription, eyeglass and other benefits through the Veterans Administration Health Clinic with a small copayment.
  12. If you are traveling outside of the United States or in international waters, Medicare pays nothing, but your Medicare Supplement Insurer will:
    1. Only pay for EMERGENCY medical expenses.
    2. You are expected to pay for the expenses & wait for your Insurer to reimburse you.
    3. Your are subject to a deductible of $250.00.
    4. It is wise to have your Travel Agent add a rider for accident and sickness before you leave USA.
  13. Those with diabetes are entitled to diabetic test strips under Medicare Part B coverage, whereas Medicare Part D handles prescriptions. Show your ID cards and physicians' prescription to your pharmacy. Part B also covers medication for Nebulization, Transplant, Oral Oncology & Nausea after Chemotherapy.
  14. The majority of Medicare Supplement plans are portable anywhere in the nation. You do not have to stay with certain providers, (except to be sure that they accept Medicare Assignment).
  15. Medicare "Select" Supplement plans do require that you stay inside their directory of providers, except for emergency care.
  16. If somebody has serious health problems, the eligibility to obtain a Medicare plan is based upon these factors:
    1. If you already have a Medicare Insurance plan, your birth month is approaching and you are applying for a plan of equal or lesser value.
    2. If you are within the "window" period or three months before or after age 65 and you already have Medicare parts A and B, you can choose any plan from any Insurance Company without answering health questions.
    3. You are relocating to a new County or State and your prior plan does not operate in your new location.
    4. You are losing coverage you had from your job, or you have decided to leave the coverage you had from your job. (Must be completed within time limits.)
    5. Medicare Advantage plans ask only one health question: If you have renal stage failure and are on a kidney dialysis machine. While these plans subject you to copayments and annual maximums, the health underwriting is very lenient.
    6. Anyone 65 or older who is healthy and hence is able to pass the health underwriting questions may choose any Medicare plan and any Insurance Company you desire.

In review, Medicare Insurance choices are diverse. Medicare Supplement plans:

  1. Usually require health underwriting after you have aged past the window period when you are first entitled to Medicare. (Three months before age 65, your , and three months after your birth month.)
  2. Have almost no out-of-pocket expense for medical care.
  3. You purchase a separate prescription plan.

WHEREAS with Medicare Advantage plans:

  1. The Insurance Companies manages your health care.
  2. Exposes you to benefit maximums and copayments.
  3. Are lenient with health underwriting.
  4. Cost little or nothing for premium.
  5. Give you coverage for virtually every physical need including dental, eyeglasses, hearing aids and often prescriptions.

REGARDING MEDICARE PART D PRESCRIPTION COVERAGE:

  1. If you were qualified to participate but failed to enroll at your qualified opportunity, you will likely have to pay a penalty of 1 % increase on the premium base per passing month at the next enrollment opportunity.
  2. While you may not presently use prescriptions to any large extent, your health can change your need for prescriptions. You almost certainly will not be able to apply for coverage outside of the annual coordinated election period; and the coverage would not commence until January 1. There can be exceptions if you are:
    1. Relocating to a new County or State and already had a prescription plan at prior address.
    2. Losing coverage from an Insurance Company who is withdrawing their plan.
    3. Just now becoming eligible for Medicare.
    4. Retiring from a job that had benefits.
  3. There are no health questions to answer and coverage is available regardless of income. You are guaranteed the privilege to purchase any plan choice from any Insurer during the:
    1. Initial Coverage Enrollment Period (ICEP) begins three months before you become eligible for Medicare parts A & B, (becomes effective on your 65th birth month), or earlier if there is a disability.
    2. Annual Election Period (AEP) from October 15 - December 7 if you have never enrolled or you want to switch to a new plan. coverage begins on January 1 the following year.
    3. A Special Election Period (SEP) can occur at certain times such as when you move in or out of a service area, an Insurance Company withdraws their plan from your area, you become newly eligible for low income subsidy Medi-Cal (Medicaid from Welfare), or you are losing coverage from an employer group where you or your spouse once worked.
  4. Having your premium deducted for your prescription plan from your Social Security payment IS NOT WORKING well at all. I recommend that you pay the premium yourself. It takes about three months before Social Security begins paying your Insurer when you sign up for your plan. Then, if you change your plan it takes many months for Social Security to stop paying your prior Insurer and begin paying your current Insurer.
  5. USE GENERIC DRUGS WHENEVER POSSIBLE. That will enhance your benefits and make your coverage last much longer. Also, you save a little if you get your prescriptions by mail or at your pharmacy for a 90 day supply. (If you are in a convalescent facility, you can save by using their supply).
  6. Prescription plans on the market have three stages:
    1. The annual deductible which is either imposed or waived- depending on the plan you purchase. The deductible amount changes from year to year.
    2. Initial coverage which usually pays about 75% of your prescription cost until your annual expense reaches $2000.
    3. Catastrophic coverage kicks in after your annual expense exceeds $2000. You then only pay about five percent of the cost & there is no limit I know about after that for the balance of the year. If you are low income, you can apply for help with your prescription plan premium. Ask Social Security about the extra help benefit.