Utah Medicare Advantage General Information
Serving all of Utah from Sunny St George |
Q. |
What is
Medicare? How does it work?
Call Licensed Insurance Agent Greg Davies
today
at
(435) 767-1415
in St George Area or
(435) 767-1415
in Salt Lake Area
Terms and
Abbreviations Discussed Below:
Medicare Part A - Hospital Coverage for
Medicare recipients / Medicare Part B -
Outpatient Medical Coverage for Medicare
Recipients / Medicare Part C - Medicare
Advantage Plans / MAPD - Medicare Part C
Medicare Advantage Prescription with
Prescription Drug Coverage / PDP - Medicare
Prescription Drug Plan / HMO - Health
Maintenance Organization / PPO - Preferred
Provider Organization / HMO-POS - HMO with a
Point of Service (out of network option) /
PFFS - Private Fee For Service Plan that is
an MA or MAPD with no network
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A. |
Medicare is a federal health
care program, managed by the Centers for
Medicare & Medicaid Services (CMS), which
provides health insurance to retired
individuals regardless of medical condition
and to certain people with disabilities.
Original Medicare is a fee-for-service plan
with two components, Medicare Part A and
Medicare Part B.
Medicare Part A provides coverage for
hospital bills (inpatient hospital care,
hospice care, and home health care). This is
financed by payroll taxes, with no premium
to beneficiaries who have at least 40
quarters of Medicare-covered employment.
The
beneficiary pays a Part A deductible (that
changes each year) for
hospital stays up to 60 days, with
additional copays required for each stay
longer than 60 days.
There is a Premium cost for Part B. For
example in 2012 the cost is $99.60/month.
The Part B cost for future years is
announced each year near the end of the year
and has not been announced for 2013 (as of
September 2012).
The beneficiary pays a Part B deductible for
treatment outside a hospital. they then pay
20% after the Part B deductible is met.
There is no cap or out of pocket maximums in
Medicare. For this reason many people choose
a Medicare Supplement or Medicare Advantage
Plan to help pay for what Medicare does not
pay.
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Q. |
What is a Medicare
Advantage Prescription Drug Plan (MA, or
MAPD)? |
A. |
Medicare Advantage is the
name for a few different types of plans that
contract with the federal government.
Medicare Advantage plans include Medicare
Managed Care Plan (HMO), Medicare Preferred
Provider Organization (PPO), Medicare
Private Fee-for-Service plan (PFFS) and
Medicare Cost and other specialty plans.
Essentially, these plans reduce
out-of-pocket expenses and provide greater
coverage than traditional Medicare alone,
providing all the benefits of Medicare Parts
A and B, plus additional benefits. The
beneficiary continues to pay the Medicare
Part B premium as well as any additional
premium charged by the Medicare Advantage
plan.
Many Medicare Advantage plans are offered at
no premium in addition to the Part B
premium. They can also include a Medicare
Part D Prescription Drug plan benefit at
little or no cost. They require copays for
using services much as a "pay as you go"
system.
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Q. |
Who is eligible
for a MA or MAPD Plan? |
A. |
Potential members need to be at least 65
years old or qualified as disabled by
Medicare if they are under age 65. They must have Medicare Parts A
and B, live within the plan's service area,
and not have end-stage renal disease [ESRD].
If they do not have Part B, they are only
eligible to purchase a Medicare Part D drug
plan.
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Q. |
What should you consider before purchasing a MedicareAdvantage Plan? |
A. |
Many Medicare Advantage (MedAdvantage MA or
MAPD) plans provide coverage at no
additional cost to the Part B premium. The
Zero cost plans require copays and
coinsurance but most have no deductibles.
There are three types of health care plans
that help protect you from unexpected costs.
Health Maintenance Organizations (HMOs) are
managed care plans that require the member
to use only contracted doctors and hospitals
and typically referrals are required to see
specialists.
Preferred Provider Organizations (PPOs) also
have a contracted network of providers, but
members can still see any provider that
accepts Medicare patients and receive
coverage. The plan pays more if you receive
your care and services in-network.
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HMOs and PPOs offer
increased benefits over Original
Medicare such as physicals and vision
care. HMOs and PPOs roll original
Medicare benefits and supplemental
benefits into one plan that usually also
includes a prescription drug plan (PDP).
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Q. |
What is a Medicare Supplement plan? |
A. |
Medicare Supplement plans are secondary
policies to Medicare. With only a few
exceptions, they do not have a network of
providers. Medicare Beneficiaries pay
a monthly premium and also need to purchase
a Medicare Part D Drug Card also.
Medicare Supplement (Medigap) plans help
reduce your out-of-pocket medical expenses
for unexpected medical costs associated with
Medicare deductibles and coinsurance. This
coverage can include the Part A and Part B
deductibles and coinsurance, the skilled
nursing facility coinsurance, as well as
other benefits.
-
There are twelve
standardized Medigap plans, labeled "A"
through "L" each with different sets of
benefits and premiums. Plan A has basic
supplemental benefits, Plan J the most
comprehensive. All plans include basic
benefits but not all insurance companies
offer all Supplement plans.
If you choose a
"Select" C or F plan available in many
markets, you would get a greatly
discounted premium for agreeing to go to
a certain network of Hospitals. Medicare
Beneficiaries are still able to go to
any doctor or provider that accepts
Medicare.
Some
companies have a "Select" C or F plan.
You can choose this Medicare Supplement
plan at a greatly discounted price and
only go to Hospitals in the Network they
specify. You are still free to see any
doctor that accepts Medicare as payment
for services.
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Q. |
What providers can I see
on a Medicare Advantage Part C Plan? |
A. |
With an HMO Medicare Advantage Plan members
usually must get their health care from
Network Doctors and Hospitals. In a PPO
Medicare Advantage Plan members are free to see any contracted provider
accepting Medicare patients but usually pay
more for services from non-network providers.
With a PFFSYour provider
network booklet will show you many qualified providers to
choose from. When a member chooses to see a
provider that is not in our network, the
member's share of the costs will be greater.
Members are encouraged to see in-network
providers to receive the best benefit from
the plan and lower out-of-pocket costs. The
opportunity for members to choose out of
network providers for their care is one of
the advantages of PPO or HMO/POS plan
as opposed to a strict HMO plan that does
not allow out of network coverage.
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Q. |
How do I choose between a Medicare
Supplement Plan vs a Medicare Advantage Plan? |
A. |
If you
want 100% coverage of everything that
Medicare doesn't pay, you might consider a
Plan F Medicare Supplement plan and a Part D
Drug plan. But the cost of such plans can be
into the thousands of dollars a year even if
you never see a doctor, go to a hospital or
fill a drug prescription. On the other
hand, a Medicare Supplemental plan gives the
peace of mind that there is no additional
cost in addition to the monthly premium.
You would still need to purchase an
additional Medicare Part D Drug plan (PDP).
If you want low cost or even Zero cost plan
and only pay small copays and/or coinsurance
as you receive treatment, a Medicare
Advantage (MA or MAPD) plan might be right
for you. And an MAPD plan usually
includes a Prescription Drug Plan (PDP) at no additional cost.
It is very important to discuss your options
with a qualified Licensed Insurance Agent.
Call us at (435) 767-1415
to learn more.
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Q. |
What do I need to look for in Medicare Part
D Prescription Drug Plan? |
A. |
Let us help you discover which Part D
Prescription Drug Plan will work for you.
We need to consider all of your current
medications to see what plan would result in
the lowest annual cost. You also need to see
what the Generic copay is vs the Name Brand
drug copays are on the plan. Some plans
classify drugs in different categories.
Other plans exclude some drugs altogether.
The only way to know if a certain plan is
right for you is to discuss it with a
qualified professional. We would love to
help!
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Q. |
What if I
don't get a Medicare Part D Prescription
Drug Plan when I am eligible? |
A. |
If you
choose not to purchase a Medicare Part D
Prescription Drug Plan when you become
eligible for Part A, then you would incur a
penalty if you ever purchase a Part D Drug
benefit in the future. The penalty is
apx 1% per month for each month you go
without a drug benefit. For example if you
waited 5 years (60 months) before getting a
plan, then you would pay approximately 60%
surcharge compared to someone that had a
drug plan in force without a gap in
coverage. So if the national average for a
Part D Drug plan is $35/month, then you
would pay $35 x 1.60 or $56/month. And this
additional surcharge NEVER GOES AWAY as long
as you have a drug plan. The only way to
stop paying the surcharge would be to drop
the Prescription Part D drug plan
altogether. But then the penalty continues
to accrue until you purchase a Part D plan
again. Let us help you decide if a
Prescription Drug Plan (PDP) is right for
your situation.
|
Q. |
When can
I change my Medicare Part D Prescription
Drug Plan
or Medicare Advantage (MA or MAPD) plan? |
A. |
Starting in 2011, the Annual Enrollment
Period (AEP) is October 15 to December 7th
each year. During that AEP period, you
can pick a new Part D Drug plan, or enroll
in a MAPD plan. The effective date for
the change would be the 1st of January
following the AEP period. If you want
to switch to a Medicare Supplement plan from
a MAPD plan, you would have to wait until
the AEP period.
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Q. |
What if I am on a MAPD plan and it cancels
or decides not to continue the following
year? |
A. |
This would result in a Special Enrollment
Period (SEP) that allows you to choose
another MAPD plan available in your area, or
switch to a guarantee issue Medicare
Supplemental plan. That means that even if
you have a serious health problem, and your
MAPD plan cancels, then you can go on the
Medicare Supplemental plan, or a Medicare
Advantage plan without going
through underwriting, or getting rated up
for any health problems. This can be a very
good situation for those that wish to switch
but can't due to health issues.
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Q. |
How long
do I have to sign up for a Medicare Part D
Drug plan when I turn 65? |
A. |
There is
generally a 7 month window for enrollment
without a Part D Drug penalty. Three
months before you turn 65, the month you
turn 65 and three months after the month you
turn 65. Example: You turn 65 on
April 12. Jan, Feb and Mar + April +
May Jun & July would be your 7 month Initial
Enrollment Period (IEP). If you miss
that IEP, you could start accruing a Part D
Penalty. You are usually given 6 months
after your birth date and still not receive
a penalty.
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Q. |
What
if I continue with my Employer Group
Insurance plan past age 65? |
A. |
Usually there
would be no penalty accrued for not
enrolling in a Part D drug plan after age 65
if it is done within the Medicare timeframe
after you drop or lose your Group Health
and/or Prescription Drug coverage. This is
only true though if
the Employer group plan was deemed
"Qualified" coverage in that it was at least as good
as the Part D plans as determined by
Medicare. As soon as you decide to drop your
group benefit or it is canceled, you would
have 60 days to choose an MAPD or Medicare
Part D Drug plan to avoid a Medicare Part D
Prescription penalty from
accruing. You would also be able to choose a
Medicare Supplemental Health plan during those 60
days and get approved even if you have
serious pre-existing health problems.
Missing that 60 day timeframe would require
you to qualify medically in an underwriting
process with the Medicare Supplemental Plan.
If you chose an MAPD, you can get covered
regardless of your health during the AEP
which is October 15 - December 7 each year.
But you may have a gap in coverage if you
miss your 60 day window after losing group
coverage.
|
Q. |
What
if I receive a Medicare Disability prior to
age 65? |
A. |
In Utah someone under the age of 65 that is
eligible for Medicare cannot choose a
Medicare Supplement plan. They can however choose a
Medicare Advantage plan if one is available
in their county. They have a 60 day
period following the month they are found
Medicare eligible to choose a Medicare
Advantage plan. They could also choose
to not have a Medicare health plan in
addition to Medicare benefits and only
choose a Part D Drug plan (PDP). This allows them
to avoid a penalty that would accrue for not
having a PDP in place when they became
eligible for Medicare.
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Q. |
What
if I am under 65 and eligible for both
Medicare AND Medicaid? |
A. |
This
would mean you are "Dual Eligible" or
eligible for a Special Needs Plan (SNP).
There are different levels of Medicaid. If
you eligible to pay nothing for your
Medicaid, then you can change your MAPD or
Part D plan as often as you like. If you do
a "spend down" when it comes to Medicaid -
or in other words you have to pay part of
your Medicaid premium - you can only make
changes to your MAPD or Part D drug plan
during the AEP Annual Enrollment Period of
October 15 to December 7 each year.
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Q. |
How do I
choose which plan is right for me? |
A. |
Contact
Greg Davies - a
qualified Licensed Utah Insurance Agent who
specializes in Medicare Advantage, Medicare
Supplement and Medicare Prescription Drug
Plans in the Utah market. Greg has
been in the Utah Insurance industry since 1997 and knows the
plans that work well for Medicare Eligible
Beneficiaries in Utah. Let Greg
help you with any questions you may have in
any of the above situations.
Greg Davies
Licensed Utah
Insurance Agent |
(435) 767-1415
40 N
300 E #203
St George UT
84770 |
OR |
(435) 767-1415
Wasatch Front
Sandy, UT
84020 |
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