Stephanie Frisch is the owner of Insurance 101 and is an independent insurance broker dedicated to helping others make “educated decisions” about their insurance choices when it comes to Medicare, Long-Term Care Planning, The Health Insurance Marketplace-Covered California and Life Insurance. For answers to your questions, or an in-home, no-fee consultation, call (949) 351-2443.
It’s a staggering number. According to the federal Government Accountability Office, Medicare paid almost $60 BILLION in fraudulent payments in just 2014 alone!!!! So, to get a full understanding of this sickening fact, let’s look at the “who, what, when, why and how”…
Who is responsible for the fraud? Providers of medical services are. Doctors, medical imaging companies, home health care group and individuals involved in elaborate schemes where they act as doctors to receive payment or individuals finding social security numbers and selling them to organized crime rings.
What constitutes the fraud? Billing Medicare for services never given to an individual, billing Medicare for unnecessary services, and Billing Medicare for services given to someone who doesn’t “exist”.
When will this end? The Affordable Care Act started the ball rolling. A lot of billing is now reviewed first prior to payments being made on claims. Site visits to high volume billing providers uncover false storefronts and payments are never made due to these findings. Insurance companies are sharing data with the government to help identify vulnerabilities and providers of concern.
Why is Medicare fraud hard to stop? 4.5 million claims a day come into Medicare and more than $1 billion in payments are made daily. That type of volume makes for extreme challenges especially in an open system like Medicare. Unlike Medicare Advantage plans that utilize networks which remove the risk of fraudulent billing, Original Medicare is required by law to allow providers that meet a base set of requirements to bill for services they give to Medicare beneficiaries.
How can you help? If you are on Original Medicare (Medicare Advantage members don’t need to worry about Medicare Fraud) inspect your Medicare explanation of benefits and bills. Make sure the services billed were received. If you suspect fraud, call Medicare’s hotline: 800-447-8477.
It’s been a long time since you mastered you’re ABC’s, but learning the ABC’s (and D too) of Medicare can make you feel like a frustrated school kid again.
Just like when you were young, repetition is key to learning and having the information sink in. You can’t just read about the different parts of Medicare once and expect yourself to remember each specific part. But many find Medicare extremely “boring” and don’t want to “deal with it”. If you’re that type of person I advise that you not to try to make sense of Medicare when the time comes without the help of a local professional. Or worse yet, do nothing at all by procrastinating. There are several costly mistakes that you can make, some that can affect you for the rest of your life.
Part A: Helps partially pay for inpatient hospitalization, skilled nursing facilities, home health services and hospice. Part A costs you nothing if you (or a spouse) paid Medicare payroll taxes for at least 40 quarters.
Part B: Helps partially pay for doctor’s services both in and out of the hospital and outpatient medical services such as physical therapy, diagnostic testing, chemotherapy, durable medical equipment and much more. You pay a premium for Part B. $121.80 is now the new standard premium for those making up to $85K a year that are single and up to $170K a year if they’re married. If you make more than that, you’ll pay more for Part B AND for your Part D coverage. If you have low income, you may qualify for help with your Part B premium and Part D drug costs.
Part C: Is offered by private insurance companies that the government goes into contract with. Part C gives you your Medicare benefits and more. It fills in a lot of the gaps of Original Medicare, and generally adds Part D coverage as well. You have to use networks to make Part C work favorably for you, and referrals are needed for the HMO plans. The upside to this is that there is a LOT of doctor and hospital participation here in Orange County and most Part C plans carry zero premiums. All you have to do is pay your Part B premium to the government.
Part D: Even if you don’t take prescriptions drugs, you must have a Part D plan in place or you’ll be subject to a late enrollment penalty. You can purchase a “stand alone” Part D plan or you can obtain it for zero cost if you enroll in a Part C plan that includes it. The most important thing about selecting your Part D plan is making sure you pick one that has all of your drugs covered at the lowest co-pays possible.
You won’t be automatically enrolled in Medicare Part B unless you took your Social Security at age 62. You are only enrolled in Part A when you turn 65 (and only enrolled in premium free Part A if you or your spouse paid into it for 40 quarters).
The reason this is the case now is because the age that someone gets fully vested into social security is increasing. It used to be age 65, so when someone applied for their Social Security benefits, Medicare would be notified that they were turning 65 and mail out a card with both Part A and B activated. If someone didn’t want Part B at that time (because of group coverage most likely) they’d sign the attachment refusing coverage.
What I find is happening now is that people expect their Medicare card to arrive with Part A & B activated automatically and both aren’t, their card arrives with only Part A activated. They may not look at it closely, they just tuck it away and when the time comes to enroll in a Medicare Advantage or Medicare Supplement plan, there is a “uh-oh” moment because they assumed they were all set to go and now they have to scramble to get to the Social Security office and get the Part B portion activated.
The protocol now for Part B to be activated is either going online to Medicare.gov to do that, or going in to the closest Social Security office. The earliest you can activate Part B is 3 months prior to your 65th birthday.
You must have both Part A and Part B active in order to enroll in a Medicare Advantage or Medicare Supplemental plan. Part A covers Hospitalization, Skilled Nursing and Hospice to some degree and Part B covers 80% of Outpatient and all Physician services. There is a lot of financial exposure having only Original Medicare and nothing else to fill in the gaps. Medicare doesn’t cover outpatient prescription drug coverage either, you have to enroll in a plan offered by a private insurance company. If you’re curious to learn more about your options when you turn 65, please call to schedule a consultation. My services are always free.
The networks that participate in Medicare Advantage plans are an association of physicians in private practice along with hospitals, labs and urgent care centers. These types of networks, even though they are referred to as an “HMO” are very different from the Kaiser/HMO structure.
Medicare Advantage plan networks deal with independent, private-practice physicians that are part of a coordinated network that works together to promote excellence in patient care. There are some really big networks here in Orange County. Most people that live in South Orange County would want to go to the Hoag, Mission, Saddleback, or UCI hospitals. All of these hospitals participate in Medicare Advantage plan networks. When I sit down with someone who is activating their Medicare Part B option for the first time (such as turning 65 or retiring) or looking to enroll in an Advantage plan during the annual enrollment period in the Fall, the first thing I ask is who their primary care physician and specialists are. The majority of the time their physicians are already participating in Medicare Advantage plan networks. (Such as Monarch, MemorialCare , Greater Newport Physicians, the most recently formed network; St. Joseph Hoag Health...just to name a few).
Some are concerned that their doctors will be upset if they go to a Medicare Advantage plan, as if they will be “cheating” their doctor out of something. That is simply not the case. To quote one of the doctors that I work with, “As it turns out, the Medicare HMO capitation is often better for the physician than the fee for service reimbursement”.....Capitation means the doctor gets paid MONTHLY when you enroll in a Medicare Advantage plan and have them listed as your primary care physician. They get paid whether they see you or not! If you use Original Medicare (with or without a Medicare Supplemental plan), they ONLY get paid when they see you! So for most doctors, a balanced “book of business (patients)” makes a lot of sense for them economically.
If you are turning 65 or retiring anytime in the near future, please call to schedule a no-fee consultation, it costs you NOTHING to enroll in your Medicare plan using my services. You’ll see why hundreds of people faced with the same decision as you feel relieved and happy that they took the time to meet with me.
During the first 12 months of activating their Medicare Part B, new Medicare beneficiaries should utilize their “Welcome to Medicare” preventative visit with their doctor.
This visit includes your doctor reviewing your medical and social history related to your health and includes certain screenings, shots, and referrals for other care, if needed. It includes height, weight, and your BMI calculation. Also included are blood pressure measurements, a simple vision test, and a depression screening. A recent addition to this visit is a consultation on creating an advanced directive. The doctor should then give you a written plan letting you know which screenings, shots, and other preventive services you need.
If you’ve had Part B for longer than 12 months, you can get an annual wellness visit.
Annual wellness visits are to develop or update a personalized prevention plan based on your current health and risk factors. This visit is covered once every 12 months.
IMPORTANT! This visit doesn’t include lab tests, or any DIAGNOSTIC testing. You may be responsible for payment for lab or diagnostic testing performed during your visit. It is important for you to visit www.Medicare.gov to see when certain screenings are covered by Medicare at zero cost to you otherwise you may be paying for many of these “routine” tests out of your own pocket. These common tests have a rotation varying from every 12 to 60 months. For example; Breast Cancer Screenings- 12 months; Cardiovascular Disease Testing- 60 months; Cervical and Vaginal Cancer Screening- 24 months; Prostate Cancer Screening Exams- 12 months.
With Open Enrollment behind us, many Medicare beneficiaries that are on a Medicare Advantage plan are unaware of the annual Medicare Advantage Disenrollment Period.
From January 1st to February 14th beneficiaries who wish to dis-enroll from their Medicare Advantage plan and go back to Original Medicare are allowed to. They can purchase a Medicare prescription drug plan and a Medicare supplemental plan to round out their Medicare coverage and fully protect themselves. Adding the Medicare prescription drug plan is a guaranteed right for them, but enrollment in a Medicare supplemental plan is not guaranteed unless certain criteria is met.If an individual does not meet the guaranteed issue criteria, then underwriting is involved. Sometimes someone doesn’t qualify right away for a Medicare Supplemental plan, and they may need to wait to add it until they do. Once someone is on Original Medicare, a supplemental plan can be added anytime in the year. Most people I meet with are unaware of this.
The second important enrollment period is the Medicare General Enrollment Period and it occurs annually between January 1st and March 31st, with coverage starting July 1st.
This is an important window of time for those that didn’t activate their Part B portion of Medicare during their Initial Enrollment Period, or had Part B activated but then dropped it. The first of the two scenarios is happening more frequently as the age requirement for receiving Social Security increases. Many people are still under the impression that they are automatically enrolled in Medicare Parts A and B when they turn 65. But now that most don’t qualify until after turning 65 for Social Security, they need to go online to Medicare.gov to enroll in Part B three months prior to their 65th birthday month. (Enrollment in Part A still happens automatically at 65 and for the majority of the population, and has no premium.) The second scenario; dropping Part B during the year generally happens because someone forgets to pay their premium (If you aren’t taking Social Security you get billed quarterly for Part B), or they fall on hard times and choose to not pay it.
In most cases, if you don’t sign up for Part B when you’re first eligible, you’ll have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it.
If you don’t have health insurance in 2016, you’ll pay the higher of these two amounts: 2.5% of your yearly household income (Only the amount of income above the tax filing threshold, about $10,150 for an individual in 2014, is used to calculate the penalty.)
The maximum penalty is the national average premium for a Bronze plan. Or, you’ll pay $695 per person ($347.50 per child under 18). The maximum penalty per family using this method is $2,085. Bottom line is it’s a lot of money and your risking even greater financial loss, and possibly ruin by going uninsured.
I know it can seem daunting, but for someone into their third year handling Covered California it’s really not. That’s why getting FREE help from me makes so much more sense than just putting your head in the sand and hoping it goes away, because it’s looking like the current process is here to stay.
Generally someone only applies for insurance through Covered California if their income is close to the guidelines below. You have to estimate your income for the upcoming year, so if you aren’t sure what it will be exactly, applying through Covered California will ensure that you DO get the Federal subsidy money that you deserve at tax filing time if you estimated making more money than you actually did.
If your income is under $47K as an individual, $63K as a married couple or $97K as a family of four (for example, not limited to) you have options with Covered California. You have until 1/31/16 to enroll in a plan for 2016 to avoid the penalty for 2016. If your income is higher, then we apply directly to the insurance plans for coverage. For coverage to start January 1st you need to apply by 12/15/15. If you’d like assistance understanding your choices, call to schedule a phone consultation with me, once again, my services are free.
Medicare beneficiaries, are your mailboxes and recycling bins ready? Yes, pretty soon literature from the various insurance companies will start the annual flow of information to you.
ctober 1st is the first day that the insurance companies and their representatives can begin telling you about what their Medicare Advantage and Medicare Prescription Drug plans will be offering for 2016. October 15 through December 7th is the timeframe that you have to enroll in one of these plans, or change the plan that you currently have.
First off, if you’re on a Medicare Supplemental plan (sometimes called Medigap), such as Plan F or Plan N, you can relax. These plans don’t change their benefits annually like Medicare Advantage and Medicare RX plans do. However, if you’re on one of these plans and you’d like to see what Medicare Advantage plans have to offer; learn about plans that have a zero premium and include RX coverage too, then this is your time to do research. If you do end up wanting to enroll in a Medicare Advantage with Prescription drug plan, you don’t need to worry about health conditions because enrollment is not subject to underwriting and guaranteed issue (unless you have end stage renal disease).
For those of you already on a Medicare Advantage plan, you need to be aware of a few important things. Keep an eye out for your, “Annual Notice of Change” otherwise known as “ANOC”. This will come from your current insurance carrier late September and it will show line by line any benefits from 2015 in comparison to 2016 that are changing.
The other really important information reported in your Annual Notice of Change is any drug plan changes. Sometimes carriers drop certain drugs from their formulary and if that drug is one you take, you need to know about that!! If this happens to you, it makes sense to shop for a new plan. Another change that happens with RX coverage is changes in drug tiers. Most Rx plans have tier 1 and tier 2 that are generic drug tiers, tier 1 is less expensive than 2. Sometimes the news is good in your ANOC and your tier 2 drugs are now tier 1. If the change is in reverse, your tier 1 drugs are now tier 2 and if you take a lot of generic medication, those small increases can add up. More financially substantial are the name brand tiers, generally tier 3, 4 and 5 (usually getting more expensive the higher the tier number). If your tier 3 drug becomes a tier 4 drug, this is a change could cost you double digits.
Bottom line: READ YOUR ANNUAL NOTICE OF CHANGE. If you don’t like how the changes in your plan affect you, then please contact me to schedule a personalized, no fee consultation in my office or at your home. I’m already booking appointments starting October 1st.
No! These benefits don’t count. You need to sign up for Medicare at age 65 in both of these situations.
Yes! But only is the employer has 20 or more employees. Once your employer insurance ends you have 8 months to enroll in Medicare without late enrollment penalties. I would suggest you compare the options open to you in Orange County’s Medicare market for deciding to stay on group insurance. Many times group benefits are more expensive and not as good as what’s available to you as a Medicare beneficiary.
The best option is to enroll in Medicare at age 65. Then, compare the Medicare options available to you in Orange County to round out your coverage vs. staying on your employer’s plan as the secondary insurance. Most times you’ll find your options are less expensive and richer in benefits that what you small group health plan offers.
Sorry, but you have to wait until the general enrollment period which runs January 1st to March 31st every year. Go to your local social security office to sign up during that timeframe. Unfortunately your coverage won’t start until July 1st and you’ll have late enrollment penalties for you Part B portion of Medicare and your RX coverage(Part D) (some exceptions for the RX late enrollment penalty exist)
I would say that it’s a waste of your money to do so if your employer plan is 20 or more workers. Reason being is that the employer plan in this situation is automatically your primary plan. Medicare Part B comes with a price-tag ($104.90 for the standard premium, it can be higher). So if your employer plan is decent, you would be paying for something that would never be utilized in most cases.