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.
My role in this process is really about showing people their options for Medicare from private insurance. However the majority of the time I’m helping people with what they need to do before we can proceed to review their options for a Medicare Advantage, Medicare Supplement and Medicare Prescription drug plan.
If someone is still working and covered under a large group insurance plan for themselves or through a spouse, they have an option of keeping that insurance or going onto Medicare. There are many variables to consider; what their household income is, how good is the insurance that they currently have vs. their options with a Medicare plan, and how much their group insurance 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 (Until 2020). 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 more 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. There is a form that Social Security doesn’t broadcast but exists that can be filled out and turned in that shows a sudden decrease in income so that they don’t have to pay more for their Medicare Part B and 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.
A prescription drug formulary is probably one of the most ignored portions of a person’s knowledge of their current insurance coverage.
Usually people don’t pay attention to it until they go to fill a new prescription from their doctor and get sticker shock from the price. It is your responsibility to know what medications are included and reasonably priced with your insurance, and you more than likely have never seen your formulary. So, you play “Russian Roulette” with your newly prescribed drugs, holding your breath when the pharmacist is ready to give you the total, or they call you to make sure you were aware of the cost of the medication before you arrive to the pharmacy (a much kinder approach). If a prescribed drug isn’t in your formulary, it can range in price between several hundreds to thousands of dollars. If it is included in your formulary, but is a Tier 4 or higher drug, you could pay up to several hundred dollars a month for just that medication.
What is the definition of a prescription drug formulary? The main function is to specify specific medications that are approved to be prescribed under a certain insurance policy. There are tiered levels with financial incentives for patients to select lower-cost drugs, which in turn saves both them and their insurance company money. The development of a formulary is based on evaluations of efficacy, safety and cost-effectiveness of drugs. Formularies cover at least one drug in each drug class and encourage generic substitutions.
Back to my “real world” experience. This is important stuff, and there is a lot of money at stake if you are complacent or ignorant about being informed. Many times this is the biggest monthly expense medically for my clients and the most important part of my “fact-finding” when I first meet with them. If you have an insurance broker, ask them for a current version of your plan formulary (it’s updated annually every January 1st).
If you don’t have an agent, call customer service for your current insurance and request one. Formularies are so large now, that most likely it will be sent to you in a PDF format, which is great because you can search “key words” in that electronic document. Lastly, if you’re computer savvy, then you should be able to go to the website of your insurance company and download the current formulary without entering anything more than the name of your plan. It’s information that the insurance companies want to be easily accessible and easy for you to find, unfortunately you just didn’t know that was the case, but now you do. So, get busy on your research before you forget, otherwise you may just be “throwing money away”.
Medicare generally does not coordinate with VA benefits. You can have both Medicare and VA benefits, and many people choose to use both benefits in order to have access to more providers and services.
However, with few exceptions, Medicare and VA benefits do not work together. Medicare generally does not pay for care that you receive at a VA facility.
In order for Medicare to cover your care, you usually will have to receive care at a Medicare Certified Facility that works with your Medicare coverage. In order for your VA coverage to cover your care, you must generally receive health care services at a VA facility. Exceptions can be made, such as
if you receive prior authorization from the VA to receive VA-covered services at a Medicare-approved facility. If an emergency occurs that requires you to receive such care, the VA may cover some of those costs until you can be moved to a VA facility for continued care.
If you are Medicare eligible, you may want to enroll in Medicare Part B ($134 monthly premium), even if you have VA coverage. Part B may cover services you receive from Medicare-certified providers and provide you with medical coverage outside the VA health system. Without Part B, you will not have Medicare coverage for physician, outpatient, and ambulance services. In addition, if you don’t enroll into Part B when you are first eligible to do so, but later decide to enroll in Part B, you will likely face a late enrollment penalty for Part B for each 12-month period you were without Medicare Part B coverage.
Drug coverage offered by the VA is considered, “credible”. This means that it is as good as or better than Medicare Part D prescription drug coverage, and as long as you remain enrolled in drug coverage through the VA, you can delay enrolling in Medicare Part D without a late enrollment penalty, or just keep your VA drug coverage indefinitely.
The recent wildfires in Orange county were tragic. But as the saying goes, “Every dark cloud has a silver lining.”
In this case, for those that didn’t change their current Medicare Advantage plan or Medicare Prescription Drug plan during the annual open enrollment window (October 15th -December 7th), they now have an opportunity to do so up until March 31st.
The Centers for Medicare & Medicaid Services (CMS) announced a special enrollment period (SEP) for those living in counties where FEMA (Federal Emergency Management Agency) has declared a weather-related state of emergency or major disaster such as the recent fires. This special enrollment period ends on March 31st, 2018.
In addition, the SEP is available to those individuals who don’t live in the affected areas but rely on friends or family members who live in the affected areas for making their healthcare decisions. You don’t need to live in the specific area where the fires happened, you just need to live in one for the following Southern CA counties: Orange, Los Angeles, Riverside and San Diego. There are other counties in Northern and Central CA as well.
This SEP (special enrollment period) is only available for Medicare beneficiaries who DID NOT enroll in a 2018 MAPD or PDP plan during the regular Annual Election Period (AEP). Individuals who made an election during the AEP cannot use this SEP to make a second AEP election. Residents have until March 31, 2018 to make changes to their Medicare health and prescription drug plans.
I’ve helped many people already benefit for this unexpected opportunity, if you have any questions about if you qualify, please don’t hesitate to call.
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, 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.
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 lost it for some reason. 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 that only happens if they started taking Social Security at age 62. (Enrollment in Part A still happens automatically at 65 and has no premium for the majority of our population) The second scenario; dropping Part B during the year, generally happens because someone forgets to pay their premium for Part B (if they’re not yet taking Social Security, they get billed for 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 the rest of you life (there are exemptions for some low-income cases) The LEP for Part B may go up to 10% more than the standard premium ($134 a month) for each full 12-month period that you could have had Part B, but didn’t sign up for it.
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.
For those already on Medicare, Open Enrollment is the time every year where you are allowed to change from one Medicare Advantage plan to another, change your Prescription drug plan, or go from a Medicare Advantage plan back to Original Medicare and a Prescription drug plan and a Medicare Supplement plan, or, go from Original Medicare with a prescription drug plan and a Medicare Supplement plan to a Medicare Advantage plan.
This last option is what I am seeing more and more of during the Open Enrollment season which starts October 1st (applications can’t be taken until October 15th however) and ends December 7th, with the changes taking effect on January 1st.
There is no underwriting for Medicare, Medicare Advantage and Prescription drug plans. Everyone is guaranteed issue because of the fact that Medicare is government sponsored not private insurance, and while Medicare Advantage and Prescription drug plans are offered by private insurance companies, they are subsidized by the Federal Government. There are also circumstances where Medicare Supplement plans can be guaranteed issue as well, they are NOT subsidized so this is more of a case to case scenario.
Medicare Advantage plan networks are growing. Many people have been paying a monthly premium for their Medicare Supplement plan and Prescription drug plan, not realizing that all of their doctors are in the same specific medical network that contracts with an insurance company offering Medicare Advantage plans that include prescription drug coverage at a zero monthly premium.
Your chosen doctors and prescriptions play a big part in making any changes during Open Enrollment. Using an experienced insurance broker with a focus on Medicare plans, such as myself, is the key to making changes without making painful or costly mistakes. I’m paid by the insurance companies I represent, so my services are always free.
If you’d like to review your options for 2018, it’s important to contact me to schedule your appointment before my schedule books up, and it does, every year during Medicare Open Enrollment.
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.