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.
Under a new state law, if you visit an in-network facility - such as a hospital, lab or imaging center - you will be responsible only for your in-network share of the cost, even if you're seen by an out-of-network provider.
The law applies to non-emergency services received on or after July 1.
Here's a common scenario: A patient takes pains to ensure their hospital and surgeon are in network, only to get billed by the out-of-network anesthesiologist who appears at their bedside to put them under.
No one gets to pick their anesthesiologist, it depends on who is on duty, who is available. Surprise bills also often come from pathologists, radiologists and assistant surgeons - other providers that patients typically can't choose.
The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care (DMHC) and the state Department of Insurance, which includes roughly 70 percent of the state's private insurance market, according to the California Health Care Foundation.
Under a new state law, if you visit an in-network facility - such as a hospital, lab or imaging center - you will be responsible only for your in-network share of the cost
It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor.
The key point to remember is that you shouldn't pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services. So, if you receive what looks like a bill from a provider showing an out-of-network rate, don't panic.
First, read it carefully. It may not actually be a bill. Under the law, any communication to the patient from an out-of-network provider before that provider gets the consumer's in-network cost information must say - in bold, 12-point type - that it is "not a bill."
If it's an out-of-network doctor, they shouldn't be claiming that you owe anything right away, and don't pay anything until you receive an Explanation of Benefits from your insurer.
How does it work for Emergency Services in an emergency room? As of January 1st, 2017, you cannot be billed out-of-network charges for both emergency room and physician services.
In 2018 150 Million Medicare health insurance claim numbers (HICN) will begin to be changed to new Medicare beneficiary identifier number.
The Medicare Access and CHIP Reauthorization Act of 2015 requires CMS (Centers for Medicare and Medicaid Services) to remove Social Security Numbers (SSNs) from all Medicare cards.
Starting April 1st, 2018, CMS will be replacing all Social Security Number (SSN) based Health Insurance Claim Numbers (HICN) with Medicare Beneficiary Identifier (MBI) numbers. Over 150 million beneficiaries will be affected; including current Medicare beneficiaries, deceased beneficiaries, archived beneficiaries, and new beneficiaries.
By replacing the Social Security based HICN numbers with new unique 11 digit MBI numbers, CMS hopes to better protect private healthcare and financial information. The gender information and signature line will also be removed. This transition is scheduled to be completed by December 31st, 2019. By April 2019, all current Medicare beneficiaries are to have their new Medicare cards.
What is my opinion on this? It will be very chaotic for a while, but this is long overdue as we all know. Now, if they could only make these new cards with plastic vs. paper!!
The failure of the “Repeal and Replace” effort made media headlines for days.
For those of you that weren’t “glued to the news”, there were a few reasons that the bill failed according to most that have commented publically about the outcome in the media.
First of all, The Affordable Care Act, or Obamacare, had mandated that every insurance policy sold in the individual/family plan market to those without employer or government coverage had to include 10 essential benefits. Under the Republicans’ plan, that mandate – that all plans include things like prescription drug coverage, emergency room services, maternity care and mental health treatment – would have disappeared.
It also became more of a financial hardship on a demographic that is currently growing in the US: Older Americans. Older Americans would have had to pay more, sometimes thousands of dollars more to get health insurance. In 32 states, millions of Americans with incomes slightly above the poverty line who had gained coverage under their state’s Medicaid expansion program would have lost their coverage.
So, in the foreseeable future the Affordable Care Act will remain in place. My hope is that many that have not embraced this change that started several years ago will now realize that while it’s not perfect, it is the law for now and we should all get on board and support something that has more Americans insured in United States that ever before in our history.
As far as premiums are concerned, let me weigh in on something that I tell my clients because I too pay a lot of money for insurance (there are no discounts for insurance brokers) and my premiums go up every year as well.
As long as technology research continues to grow and expensive lifesaving treatments continue for all ages in our society, there will be a price tag that we all bear for this. If you pay $12,000 a year for insurance that is not much in addition to your annual out of pocket maximum of roughly $6500 if you get cancer and you need surgeries, chemotherapy and radiation to survive it. And if it comes back, that process may repeat itself. Or, what if you have a traumatic injury and then secondary infections and a long hospital stay in order to survive that? How much do you think all of this care cost to the private industry supplying it?
Not too long ago these examples weren’t that expensive for insurance companies to pay for because the mortality rate would come into play, and those afflicted by disease or suffering serious trauma wouldn’t survive long. Technology now keeps the mortality rate lower and the treatment for diseases and injuries longer lasting because people survive them. I feel that advancements in medicine can be a double-edged sword in many cases, medical advancements and their price tag certainly affect the premiums that we pay.
“Obamacare” has brought health insurance coverage to about 20 million previously uninsured Americans. About half those people gained coverage through an expansion of the Medicaid program for the poor.
There are actually 3 phases currently being debated; what’s to be repealed, what’s to remain and what the replacement provisions will be. (FYI: The cost of the proposed bill, dubbed The American Health Care Act, is still uncertain) I hesitated to give an update before the final “Yes” vote needed from 51 members of the Senate in order for these changes to pass, but this is the question I get asked about daily, so as of 5:30 a.m. March 7th, this is where things stand.
Currently, this is what stands to be Repealed:
Currently, this is what stands to Remain:
Currently, this stands to be offered as a Replacement:
These changes have four Committees to get through before heading for a vote in the Senate, projected to be around Mid-April. Stayed tuned next issue for an update.
When I get a phone call from someone that is preparing to go on Medicare, there are several questions that I ask to make sure they are set up properly before we meet.
You see my job is really about showing people their options for Medicare from private insurance companies (which is how I get paid and explains why my services are free). 8 times out of 10 I’m helping people what they need to do before we can proceed to review their options for a Medicare Advantage, Medicare Supplement or Medicare Prescription drug plan.
First off, if someone is still working covered under a large group insurance plan them self or through a spouse, they have an option of keeping that insurance or going onto Medicare. Variables to consider; what their household income is (if it’s higher than $170K for a married couple they’ll pay more for Part B and Part D in addition to any premiums from their Medicare privatized options), how good their insurance is that they currently have vs. options with Medicare, how much their premiums are.
If a large group insurance plan is an option for them, we also need to look their prescription drug use. On group plans there is no “doughnut hole” but on a Medicare drug plan there is. So, if someone is taking 3 or more name brand drugs a day, the likelihood of them going into the doughnut hole and consequently paying more for their prescriptions drugs is likely on a Medicare drug plan.
If someone has worked past 65 and stayed on a large group insurance plan but is now ready to retire, then there is a process with Social Security to get their Part B portion of Medicare activated (Part A typically happens automatically the month of your 65th birthday). Many times their retirement income will be much less than when they were working. There is a form that Social Security doesn’t broadcast but exists, that can filled out and turned in that shows a sudden decrease in income (Form SSA-44- Medicare Income Related Adjustment Amount-Life Changing Event and I have it electronically) so that they don’t have to pay more for their Medicare Part B or Medicare Part D, than necessary. The government bases what you pay for Medicare Part B & D on the tax return you filed two years earlier, so this can be a big savings.
Complicated? Yes...To me? No… Well, sometimes situations are unique and we learn together. Most of the time people tell me they don’t know how they could have ever gotten through the process without my help, and that’s rewarding.
There seems to be some confusion regarding the Medicare Part B premium. (This amount is taken out of someone’s Social Security check monthly, or if someone isn’t taking Social Security, it is billed quarterly). There have been more changes in the last 12 months to the Part B premium that I have seen historically in the last 7 years.
Starting January 1, most people with Medicare will see a small increase in their Part B premium, from $104.90 to an average of $109.00 per month. But about 30 percent of people covered by Medicare will see a minimum Part B premium of $134.00, a 10 percent increase from the minimum 2016 premium of $121.80.
This difference in premium amounts is due to a federal law which is commonly called the “hold harmless” provision. This provision prevents about 70 percent of beneficiaries from seeing major increases in Medicare Part B premiums when Social Security cost of living adjustments (COLAs) are nonexistent or very small.
The announced COLA for 2017 is very small, 0.3 percent, triggering the hold harmless provision.
Those who are held harmless will not see their Part B premium increase by an amount that is greater than the dollar amount of their COLA increase. Because the COLA is a percentage of a person’s Social Security benefits, the exact dollar amount of the increase, and the premium, will vary. For example, someone who has a premium of 104.90 deducted from their full Social Security benefits of $1,000 in 2016 will see a COLA of $3 and will have $107.90 deducted from their check for the Part B premium in 2017. Someone who gets 2,000 in Social Security benefits, will see a COLA of $6 and will have a Part B premium of $110.90.
Not everyone is protected by the hold harmless provision. Because the protection is tied to Social Security benefits, people with Medicare who do not receive Social Security or do not have premiums deducted from their Social Security checks are not covered. Those people who are new to the Medicare program in 2017, those who pay income-adjusted premiums, and those whose premiums are paid by their states are also not covered.
Many think that once December 7th is behind us (The Annual Enrollment period for Medicare) and December 15th (The cut-off for January 1st coverage to start for the Open Enrollment season in the Health Insurance Marketplace and Covered California), that opportunities for change are behind them.
As a broker with a schedule that for the last 3 months can be likened only to tax time for a CPA, I wish I could say that was the case, but it isn’t. Here are some other deadlines that you should know about.
Covered California and the Health Insurance Marketplace: You have until January 15th to enroll in a plan or make changes to your coverage effective for February 1st.
You have until January 31st to enroll in a plan or make changes to your coverage effective for March 1st.
Medicare “wanna be” beneficiaries: If you missed your initial enrollment period to activate the Part B portion of your Medicare when you turned 65 and you DO NOT have access to group health insurance from your employer or your spouse’s employer (COBRA Does NOT count, get off of that COBRA if you’re on it or otherwise face life long penalties) then you can take advantage of the Medicare General enrollment period from January 1st – March 31st. You would apply at your local social security office. Coverage wouldn’t start until July 1st however. You would still need to add a Medicare supplement and RX plan or enroll in a Medicare Advantage plan. That’s where I come in to help.
Medicare Advantage Disenrollment period: If you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. Your Original Medicare coverage will begin the first day of the following month. If you switch to Original Medicare during this period, you’ll have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your prescription drug coverage will begin the first day of the month after the plan gets your enrollment form.
Do you get your Medicare benefits from a private insurance company? If so, that means you’re on a Medicare Advantage plan. Typically these plans have a Medicare prescription drug plan included with the medical benefits offered to you that replace your Original Medicare and the need to carry that card with you or your spouse’s social security number on it, around in your wallet.
All Medicare Advantage HMO plans offered in Orange County have a zero premium. If you’re on a Medicare Advantage HMO plan in Orange County and you have a co-pay for doctor visits, lab tests, diagnostic imaging, out-patient surgery, and/or in-patient hospitalization, then you should stop reading this article and call me immediately to discuss your options before it’s too late for the 2017 benefit year. Open Enrollment (your time to change your Medicare Advantage plan coverage) ends December 7th.
If you’re on a Medicare Advantage PPO plan, you can do better 9 times out of 10.
On these plans (only 2 offered in Orange County) you pay premiums, deductibles, co-pays, co-insurance and out of pocket costs with not only a high “in-network” out of pocket maximum, but also a MUCH higher “out of network” out of pocket maximum. If you need the flexibility of no network restrictions, you would do much better financially by going back to Original Medicare during this open enrollment season and adding a Medicare supplemental plan and a prescription drug plan.
Don’t try to make these decisions by “self-educating” during Medicare Open Enrollment. Your time is valuable, and you can’t risk making the wrong decision that has you locked into your choice for a year. My services are free to you. I am compensated by the insurance companies that I contract with. Thousands of Medicare recipients have benefitted from my experience over the years, and now it’s your turn.
It’s no secret, the Medicare prescription drug plan “coverage gap” (fondly referred to as the donut-hole by many) is very complicated.
Many people will never need to understand it because they won’t ever enter the coverage gap, but for those that do the good news is that the complexity of the “donut hole” will slowly fade away.
Over the next several years, you’ll pay less in the coverage gap until it’s closed by 2020. By 2020, you’ll pay only 25% for covered brand-name and generic drugs while in the coverage gap—the same percentage you pay from the time you meet the deductible (if your plan has one) until you reach the out-of-pocket spending limit (up to $4850 in 2016).
In 2017 you’ll pay 40% for covered brand name (it was 45% in 2016) and 51% for covered generic drugs. (it was 58% in 2016). The reduction continues down in 2018 with you paying 35% for brand name/44% of generic; 2019 you’ll pay 30% of the brand name/ 37% of the generic.
So, what counts towards the coverage gap? Your yearly deductible (if your plan has one), your prescription drug co-pays and/or co-insurance, the discount you get on brand name drugs in the coverage gap and what you pay for drugs in the coverage gap.
What doesn’t count towards the coverage gap? Your drug plan premium, any pharmacy dispensing fees and what you pay for drugs that aren’t covered by your plan. (for example; compounded prescriptions and the ever popular Viagra).
Remember, drug plans change their formulary (the list of drugs they cover and what price you’ll pay for them) every year. They will notify you the end of September if any of their changes affect you. Early October is the time to contact me for a no-cost review and plan analysis.
No, the birthday rule I’m referring to isn’t the one that means your friends and family need to be extra nice to you on your special day, it’s the one that means the insurance companies can’t decline you for coverage in their Medicare Supplemental plan if you are coming from another existing Medicare Supplemental plan.
For starters, generally there are two times you are “guaranteed issue” for a Medicare Supplemental plan. First is the 6 month window following your enrollment into Medicare Part B or leaving an employer group health plan. Second, is during the 30 days following your birthday going from one Medicare Supplemental plan (also known as Medigap) to another. When utilizing the birthday rule, you must select an equal to or lesser plan than the one that you currently have.
Why bother? Well, money is really the main factor here. Medicare supplemental plans are standardized to be the same no matter the insurance carrier providing the insurance. So, Plan F is the same no matter where you buy, same with Plan N, etc.
Medicare supplemental premiums go up every year as a result of a few things; as you get older, as Medicare covers less each year and the Medicare supplemental insurance companies have to cover more and also as the cost of care increases. Some Medicare supplemental plans stop giving annual age premium increases at age 75, some continue up into the mid-eighties. So, if you’re 80’ish, you may have a good chance of saving a significant amount of money each month by shopping around near your birthday. Double that amount if you do the same for your spouse!
You can also choose not to wait for your birthday and apply with a new company at any time during the year and you aren’t restricted to selecting a “like” or “lesser” plan, you can “trade up”. In this situation you will be asked health questions on the application, and your approval is based on your current health status.
If you’re interested in comparing prices (remember, the benefits won’t change at all going from one like plan to another but with a different carrier) please contact me for a fast and easy quote!