There is a huge portfolio of products and Insurance Companies who:
- Cover what Medicare does not pay for.
- Complement what Medicare pays for.
- Receive payment from Medicare to manage your medical expenses.
- 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.
- 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.
- Some of our physicians' billers:
- Are not consistently billing Medicare.
- Are miscoding the service you received when they submit your claim to
- Are expecting you to pass on billing statements both to Medicare and your
- 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
- 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plans have been withdrawn from the market in rural communities.I believe the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
- Health Maintenance Organizations (HMO). In populated areas.
- HMO Point of Service. In populated areas.
- Preferred Provider Organizations (PPO).
- Private Fee for Service.
- Special Needs plans connected with Medi-Cal (Medicaid Welfare).
- Medical Savings Account.
- Provider Sponsored Organization (PSO).
- There are strict guidelines imposed by Government Industry regulation because of the
prevalence of fraud and
- 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
Anesthesiologists, technicians & other assistants become involved.
- Most Chiropractors do not accept Medicare Assignment. Also, Medicare pays for a
limited number of chiropractic
manipulations, but not always the exams.
- 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.
- 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
- 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
- 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
- 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.
- If you are traveling outside of the United States or in international waters,
Medicare pays nothing, but your
Medicare Supplement Insurer will:
- Only pay for EMERGENCY medical expenses.
- You are expected to pay for the expenses & wait for your Insurer to
- Your are subject to a deductible of $250.00.
- 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
- 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).
- Medicare "Select" Supplement plans do require that you stay inside their directory
of providers, except for
- If somebody has serious health problems, the eligibility to obtain a Medicare plan
is based upon these factors:
- 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.
- 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
- You are relocating to a new County or State and your prior plan does not
operate in your new location.
- 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.)
- 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.
- 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:
- 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
- Have almost no out-of-pocket expense for medical care.
- You purchase a separate prescription plan.
WHEREAS with Medicare Advantage plans:
- The Insurance Companies manages your health care.
- Exposes you to benefit maximums and copayments.
- Are lenient with health underwriting.
- Cost little or nothing for premium.
- Give you coverage for virtually every physical need including dental, eyeglasses,
hearing aids and often
REGARDING MEDICARE PART D PRESCRIPTION COVERAGE:
- 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
- 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:
- Relocating to a new County or State and already had a prescription plan at
- Losing coverage from an Insurance Company who is withdrawing their plan.
- Just now becoming eligible for Medicare.
- Retiring from a job that had benefits.
- 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:
- 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.
- 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.
- 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.
- 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 six 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
- If you reach the "donut hole" coverage gap period, you may get a 50% discount on
brand-name and 79% discount for
generic prescription drugs when you buy them! There will be additional savings in
the coverage gap each year
through 2020, when the donut hole is closed completely! A one time benefit
between January 1 - February
14, if you are in a Medicare Advantage Plan, you can leave your plan and switch to
Original Medicare and get a
Supplement plan. If you switch during this period, you have until February 14 to
also join a Prescription Drug
Plan. Your coverage will begin the first day of the month after the Insurer gets
your enrollment form. However,
during the period you cannot switch from Original Medicare to a Medicare Advantage
Plan, switch from one
Medicare Advantage plan to another, or switch from one Prescription Plan to another.
- 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).
- Most prescription plans on the market have four stages:
- The annual deductible which is either imposed or waived- depending on the
plan you purchase. The
deductible amount changes from year to year.
- Initial coverage which usually pays about 75% of your prescription cost
until your annual expense
- The coverage gap or donut hole. Between $3,700 and $4,660. During this time
you pay 51% on brand name
- Catastrophic coverage kicks in after your annual expense exceeds $7,400. 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.