SSI Blog
Whether or not you take prescription drugs, you may want to consider your options carefully when it comes to joining Medicare Part D. Unless you have other, creditable coverage offered through work or a union, going without prescription drug benefits may end up costing you money. Do you have to join Medicare Part D to avoid extra fees? Part D coverage is optional, but without the right guidance, you could end up paying a higher premium from a late enrollment penalty. Hereâs some information on Part D coverage and what you should know if you are approaching your Initial Enrollment Period.Â
Avoid the Part D Penalty
Joining Medicare Part D, or prescription drug coverage is optional. However, joining late may trigger a penalty. How do you avoid the Part D penalty?
Join Part D when you are first eligible, during your Initial Enrollment period.
Maintain creditable coverage (other prescription drug coverage) through an employer, union, or other health insurance provider.
If you do not currently have prescription drug benefits through an employer or other source, the best time to join is when you are first eligible, during your Initial Enrollment period. Even if you do not need medications now, joining during Initial Enrollment ensures you avoid paying a late enrollment penalty.
Not everyone needs to join when they are first eligible, and many seniors delay enrollment without paying a penalty. Many employer-provided health insurance plans offer drug coverage that is considered âcreditableâ by Medicare.
If you do have drug benefits, as long as you are covered, you do not need to join Part D. However, if you lose coverage (employer benefits end or COBRA ends) you only have a certain amount of time to join Part D without penalty.
Your health insurance provider will let you know if your coverage is creditable. Be sure to keep this documentation safe as you will need to show it to Medicare when you are ready to join Part D. Without proof, you may end up paying a late enrollment penalty.
If You are Penalized, Hereâs How to Calculate Your PremiumÂ
If you go without a Part D or other creditable coverage for 63 days or more after your Initial Enrollment period ends, you may owe a late enrollment penalty. Penalties are calculated by multiplying the Part D premium amount by the number of full months you went without Part D or creditable drug coverage. Penalties are added to your monthly Part D premium for as long as you have coverage. For example, if you went 6 months without creditable coverage, your penalty would be .06 (for 6 months without coverage) times 35.63 (Part D premium) for a total of 2.13. Medicare rounds to the nearest .10, making your penalty $2.10 added to your Part D premium. Note: penalties are recalculated as annual premiums increase.
References:
Part D Penalty: Â https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html
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SSI Blog
As a Medicare-eligible policyholder, you have the right to know whether or not your current drug coverage meets the standard Medicare prescription drug coverage, and is considered âcreditableâ. If your current prescription drug benefits are provided through an employer, union, or another source, understanding what âcreditable coverageâ means and how it applies to you will help you make an informed decisionâpotentially saving you money. The good news? All companies offering prescription drug coverage are required by law to notify you about the status of benefits and whether or not your drug plan meets or exceeds the standard Medicare Part D Prescription Drug plan.
Creditable Coverage
For prescription drug coverage to be creditable, the plan must expect to pay (on average) as much as the standard Medicare prescription drug coverage. How is this determined?Â
Creditable coverage does the following:
Provides coverage for brand name and generic prescriptions.
Provides reasonable access to retail providers.
Pays an average of at least 60 percent of a participantâs drug expenses.
Satisfies at least one from below:
No annual benefit maximum.
An expectation is that the amount payable by the plan will be at least 2,000 annually.
For integrated coverage: No more than $250 deductible per year, no annual benefit maximum, and no less than a $1,000,000 lifetime combined benefit maximum.
Why It Matters
Of course, thereâs a good reason why it makes sense to maintain creditable prescription drug coverage. Medicare beneficiaries who decide not to sign up for Part D prescription drug coverage when they are first eligible, but enter the program late often have to pay more. People signing up late for Medicare Part D without creditable drug coverage may be subject to a 1 percent monthly premium penalty for late enrollment. However, if you have drug benefits through an employerâand itâs creditableâyou can stay with your current plan instead of enrolling in Medicare Part D and avoid paying higher prices when you do enroll. In other words, as long as your current drug benefits are as good as Medicare, or âcreditableâ, you can continue to use them and will not pay higher prices when you decide to enroll in Part D at a later date. Â
What You Should Know
As long as you maintain drug coverage through an employer or union, you should receive a notice by mail each September informing you whether or not your coverage is âcreditableâ. Be sure to keep this documentationâyou may need it should you decide to move to a Medicare drug plan later.Â
References:
https://www.cms.gov/medicare/prescription-drug-coverage/creditablecoverage/index.html
https://www.cms.gov/medicare/prescription-drug-coverage/creditablecoverage/downloads/whatiscreditablecoverage.pdf
https://www.medicare.gov/forms-help-and-resources/mail-about-medicare/notice-of-creditable-coverage.html
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SSI Blog
Medicare Advantage is a cost-saving option for many seniors to cover out-of-pocket expenses associated with Medicare. These plans include many additional benefits that Medicare does not. Putting together similar coverage using Part A and B would require adding a Part D plan to be comparable.
Insurance Companies
With Part C Plans, individuals receive Part A and B coverage from an insurance company, not Medicare. In exchange, the government makes payments to them to cover the cost. Insurance companies negotiate with local hospitals and doctors for reduced rates. Unlike Medicare, you will be required to use this specific network of providers with these plans.
Coverage
Individuals continue to receive Medicare Part A and B coverage, as well as additional benefits not provided by Medicare. Most plans include benefits for prescriptions, dental, vision, fitness programs, and even hearing. Plans use a network of providers, and as a member, you agree to use the hospitals, doctors, and pharmacies in the service area. You can use providers who are not, but it will cost you more. Itâs important to review your planâs network requirements, If you donât, you may be responsible for the total costs of services.
Cost of Plans
There are several different Medicare Advantage Plans to choose from, with varying premium amounts. Many companies offer $0 premium plans with additional benefits. Plans with no premium may be a cost-effective option, but they do have expenses like deductibles, and copays. The co-payment is in place of the 20 percent coinsurance you would pay under Medicare. Plans are required by law to put a maximum amount you will spend out-of-pocket for deductibles and copays each year.
Factors To Consider
Does the plan pay the Part B premium?
Does the plan provide extra benefits (prescription, vision, dental)?
What is the yearly deductible amount?
What is the cost for each doctor visit (copayment, coinsurance)?
What are the requirements and costs of network providers and out-of-network?
What is the out-of-pocket maximum?
Enrollment
You can enroll in Part C (Medicare Advantage plan) during specific times of the year. Enrollment periods were created to make it easy to get the coverage you need. However, outside of these dates, Medicare often requires that you stay with the plan you have until the following year. There are exceptions and in some cases, you may enroll outside of designated periods.
Initial Enrollment
The best time to enroll is during your Initial Enrollment period, or when you are first eligible to receive Medicare. Every senior in IL has an Initial Enrollment period that begins 3 months before you turn 65 and ends three months after. If you are disabled, your Initial Enrollment period begins 3 months before your 25th month of benefits and ends 3 months after your 25th month of benefits.
Annual Enrollment
Once you join Medicare, you can enroll in a Medicare Advantage plan during Annual Enrollment, October 15 through December 7 of each year. During this time, you can enroll, change, or drop a plan. If you miss the December 7 deadline, you may have to wait until the following year unless you qualify for a Special Enrollment.
Open Enrollment
If you are not satisfied with your plan, January 1st to March 31st is the time to make changes. You can change from Part C back to Medicare, or change a Part C plan to a different one. All changes take effect the following month.
Special Enrollment
Medicare realizes that some situations make it difficult to meet the enrollment periods. A Special enrollment was created to provide all seniors with the same opportunity.
References:
Medicare Advantage Stats: http://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/
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SSI Blog
Most seniors in Illinois choose Medicare Supplement Plan G, due to the low out-of-pocket costs, and coverage for foreign travel. All plans offer a basic level of protection, but there are many different costs and coverage levels between them.
Standardized
Companies are required by law to sell standardized plans. Plan G from one company must include the same coverage as Plan G from another. However, Insurance companies are not required to charge the same amount for plans.
Coverage
Offers 100% coverage for Part A deductible ($1632) as well as coverage for the remaining charge of days 61-90 in the hospital after Medicare pays. For days 91 and beyond, 100% of eligible expenses and 365 extra days of coverage after lifetime reserves are used. Provides coverage for the remainder of any Medicare-approved amount (after Part B deductible is paid in full), 100% of Part B excess charges.
Med-Select Option
Plan G is available in both standard and Med-Select Options. Both offer identical coverage but have different provider requirements. With the standard plan, you can use any provider that accepts Medicare. In the Med-Select option, you pay a reduced premium by using Hospitals in the network for all non-emergency care. It is important to check that your local hospitals are listed before selecting this option. You must live within 30 miles of a network hospital.
Resource:
https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.htmlÂ
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SSI Blog
Medicare does not provide coverage for medications. There are two ways to receive prescription coverage, enroll in a Part D plan or receive coverage through a Medicare Advantage Plan.
Cost
The average monthly premium for a Part D plan is $55.50Â in 2024. High-income Medicare beneficiaries can expect to pay an income-related monthly-adjusted amount, in addition to the premium. Most pay the standard amount. If you do not enroll when you are first eligible, you may be subject to a penalty. The Extra Help financial assistance program is available for qualified individuals.
Deductible
Most plans will have a yearly deductible and a maximum out-of-pocket cost. After that amount is met, Medicare will pay up to 75 percent of prescription costs. There are plans available that offer first-dollar coverage with no deductible and the coverage starts immediately.
Copayments
Most plans will have copayments or coinsurance. Medicare ensures that copayments are no more than 25 percent of the full cost of a prescription, and plans are required to pay no less than 75 percent.
Copayments Waived
Live in a long-term care nursing facility and are enrolled in both Medicare and Medicaid.
Plan waives the copayment for certain medications.
The pharmacy opts to waive the copayment for specific medications.
Once your plan reaches a maximum limit, then you enter the coverage gap when Medicare will stop paying. Leaving you responsible for 100 percent of your prescription cost.
Creditable Coverage
As a policyholder, you have the right to know whether or not your current plan meets the standard of creditable by Medicare. All companies offering policies are required by law to notify individuals about the status of benefits, and whether or not their plan meets the standard of Medicare. To be creditable, the policy must pay as much as Medicare.
Creditable Requirements
Provides coverage for brand name and generic.
Reasonable access to retail providers.
Pays an average of 60 percent of prescription cost.
No annual benefit maximum.
The amount payable will be at least $2,000 annually.
Integrated coverage, no more than a $250 deductible per year, no annual maximum, and no less than a $1,000,000 lifetime combined benefit maximum.
Differences
Most plans have different requirements. Some require prior authorization from your doctor before certain medications can be filled. Others impose limits on how much you can get at one time. Certain plans require you to try lower-cost drugs before a prescribed medication is covered. Each plan’s formulary is different, make sure the medications you currently take are covered, and your pharmacy is a participating provider.
Enrollment
The best time to enroll is when you are first eligible, during your Initial Enrollment period. If you don’t need coverage now, joining during this period ensures you avoid paying a penalty. Not everyone needs to enroll when they are first eligible, many seniors delay without paying a penalty. Many employer-provided insurance plans offer coverage that is considered creditable coverage by Medicare. If you do have prescription coverage you do not need to join. If you lose coverage (employer benefits end or COBRA ends) you only have a certain amount of time to enroll. The insurance provider will let you know if your coverage is creditable. Keep this documentation safe as you will need to show it to Medicare.
Penalty
If you go without coverage or another creditable plan for 63 days or more after your initial enrollment ends and then enroll later, you may owe a penalty. Amounts are calculated by multiplying the premium amount by the number of full months you went without creditable coverage. Penalties are added to your monthly premium for as long as you have coverage. If you went 6 months without coverage, your penalty would be .06 (for 6 months without coverage) times (Part D premium). Penalties are recalculated annually.
Resources:
https://www.medicare.gov/part-d/costs/part-d-costs.html
https://www.medicare.gov/part-d/coverage/rules/drug-plan-coverage-rules.html
https://www.medicare.gov/sign-up-change-plans/get-drug-coverage/get-drug-coverage.html
http://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/Â
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