SSI Blog
There are financial resources available to help seniors with the costs of Medicare. Out-of-pocket costs, premiums, and copayments strain many financially to cover the costs.
Medicare Costs
The exact amount you pay for coverage is based on several factors, including your income. There are five different income tiers used to calculate costs, Part A is typically free for most people, and Part B carries a monthly premium. If you receive Social Security benefits, Railroad Retirement benefits, or Office of Personnel Management benefits, your Part B premium will be deducted each month from your benefit.
Financial Help
There are several programs available to help people with limited income get the coverage they need. Medicaid helps pay for medical costs for people with limited income and resources. In many cases, it offers additional benefits not provided by Medicare, such as nursing home care and prescription drug coverage. Eligibility rules differ by state. Be sure to call your state Medicaid program to see if you qualify.
State Medicare Savings
Created to help seniors pay for premiums and out-of-pocket costs like deductibles, coinsurance, copays, and even prescription drug coverage costs. Eligibility is based on income.
PACE Program
The PACE Program was created to help the elderly in need of nursing home-level care receive services at home or in a center rather than at a nursing home or elder care facility. To qualify, you must be at least 55 years old, live in the service area of a PACE organization, and need nursing home-level care. PACE often covers dental care, prescription drugs, meals, preventive care, emergency services, and more. If you qualify for Medicaid, you pay nothing for PACE coverage. If you do not qualify for Medicaid, you pay a monthly premium for prescription drugs along with a monthly premium to cover the costs of long-term care. However, there is no deductible or copayment.
Extra Help
The Extra Help Program helps pay for prescription coverage, available for those who meet certain income and resource limits. If you qualify, you may pay a reduced amount for your prescription drug plan premium and deductible. Seniors who have full Medicaid or get Supplemental Security Income (SSI) benefits, automatically qualify. Of course, using generic drugs over brand names, using mail-order services, and choosing the right plan can help keep drug costs low.
References:
Medicaid:
https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicaid/medicaid.html
Medicare Savings Program
https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html
PACE
https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html
Extra Help with Part D
https://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html
https://www.medicare.gov/your-medicare-costs/
https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html
https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-costs.html
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SSI Blog
Many seniors carry group insurance through an employer or a spouse’s employer. If you need medical services, which pays first? Different group plans are called payers. You will have a primary payer and a secondary one. Which pays first and which pays second depends on how many employees an employer has, retired or still working, and whether or not you are covered under a spouse’s plan.
20 or More Employees
For companies with over 20 employees, group coverage typically pays before Medicare. If you are over 65, have Medicare, and are enrolled in coverage through work, your group plan usually pays first. When employer benefits do not cover the entire cost of care, the balance is sent to Medicare. Your out-of-pocket costs will vary based on how much of the remaining balance Medicare pays.
20 or Fewer Employees
If you receive your benefits through an employer with less than 20 employees, Medicare typically pays first. However, there are instances where your group coverage might pay first if your employer joined with other employers to form a multi-employer plan, and at least one in the group has 20 or more employees, then group coverage pays first.
Former Employer
if you are retired and receiving coverage through a former employer, Medicare pays first and the group pays second. However, if you are retired, but your spouse is not retired and you are covered under that policy with 20 or more employees, the group pays first and Medicare pays second.
Primary vs Secondary
Receiving care outside an employer plan’s network can be tricky. In many cases, receiving care outside of the plan’s network can cause both group and Medicare not to pay. Be careful when considering out-of-network. Check with your employer to ensure they will still pay. If you do not take your employer’s coverage, coverage through a spouse will pay before Medicare. If you choose not to take employer coverage through work, Medicare will pay for approved services. If you have coverage through a spouse, or if your spouse’s employer has over 20 employees, Medicare will not pay first. If you are receiving COBRA, Medicare typically pays first. Even if you had benefits before being enrolled in Medicare. If you have Medicare and are 65 or older, and receive COBRA benefits after enrolling in Medicare, Medicare pays first. Even with a secondary payer, you may have out-of-pocket expenses. The primary payer (whether it’s Medicare or group coverage) doesn’t always pay the full balance owed from care. The secondary payer may not cover all of the remaining costs. If you chose to delay Part B, group coverage may not pay until you join Part B. The secondary payer only pays if there are costs the primary doesn’t cover. If you don’t have a primary because you chose to delay Part B, group coverage may not pay until you enroll.
References:
https://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/who-pays-first/which-insurance-pays.html
https://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/how-medicare-works-with-other-insurance.html
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SSI Blog
Whether you are already a Medicare beneficiary, or about to become one, you’re likely to run into some new terms. When it’s time to make informed decisions about your Medicare coverage, you’ll be in a better position to understand the coverage.
Coinsurance
The amount you pay for medical services after you pay your deductible. Coinsurance is typically a percentage. For example, you may have coinsurance equal to 20 percent.
Copayments
The amount you pay for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A co-payment is typically a set amount, not a percentage. For example, you might pay $10 or $20 for a doctor’s visit or a prescription drug.
Costs Sharing
The amount paid for medical services or supplies, like a doctor’s visit, hospital outpatient visit, or prescription drug. This can include copayments, coinsurance, and/or deductibles.
Excess Charges
If you have Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.
Extra Help
A program designed to help those with limited income pay for Medicare prescription drug costs, like premiums, deductibles, and coinsurance.
Formulary
The list of medications covered by a prescription plan.
Guaranteed Issue Rights
Rights you have when insurance companies are required by law to sell or offer you a Medicare Supplement Plan. With guaranteed issue rights, an insurance company cannot deny you a policy or charge you more for a policy because of a past or present health problem.
Guaranteed Renewable
An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All policies issued since 1992 are guaranteed renewable.
High-deductible Medicare Supplement
A type of plan that has a high deductible but a lower premium. You pay the deductible before the policy pays anything. The amount can change each year.
In-Network
Doctors, hospitals, pharmacies, and other healthcare providers have agreed to provide members of a certain insurance plan services and supplies at a discounted price. With some plans, you are only covered if you receive care from in-network doctors, hospitals, and pharmacies.
Medicare Part C
A plan offered by private companies that contract with Medicare to provide Part A and Part B benefits. Most Medicare Part C plans offer prescription drug coverage.
Medicare Part D
Part D adds prescription drug coverage to Medicare. Part C may also offer prescription coverage that follows the same rules as Medicare Prescription Plans.
Prescription Tiers
Groups of medications will have different costs for each group. Generally, medication in a lower tier will cost you less than one in a higher tier.
Medicare Supplement Open Enrollment
A one-time-only, 6-month period when federal law allows you to buy any policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.
Network Providers
The facilities, providers, and suppliers of your health insurer or plan that are contracted to provide health care services.
Out-of-pocket costs
Health or prescription drug costs that you must pay on your own because they are not covered by Medicare or other insurance.
Late Enrollment Penalty
An amount is added to your monthly premium for Part B or Part D if you don’t enroll when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.
Written Referral
A written order from your primary care doctor for you to see a specialist or to get certain medical services. In many HMOs, you need to get a referral before you can get medical care from anyone except your primary doctor. If you don’t get a referral first, the plan may not pay for the services.
References:
https://www.medicare.gov/glossary/c.html
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SSI Blog
If you are about to turn 65 in Illinois or already eligible for Medicare, but currently receiving health coverage through your spouse, you may be wondering if you need to enroll in Medicare.
Medicare or Group
The size of your employer decides whether or not you can delay enrollment in Part B without a penalty. In companies with fewer than 20 employees, Medicare becomes the primary insurer, with group secondary. If your current insurance will become secondary, then you should take Part A and Part B when you are first eligible. The reason is that the secondary only pays after the primary pays. If you choose to delay Medicare, you will not have a primary, and your out-of-pocket costs will be costly. If your employer has more than 20 employees and your group will remain the primary with Medicare second, then you may not need to enroll in Part B immediately as your current coverage will cover you.
Current Coverage
Group coverage in Illinois works differently once you become eligible for Medicare. After determining which one pays first, look at your coverage and find out how your current coverage changes once you or your spouse turn 65. Then you can decide if it’s worth having both coverages or delaying enrollment in Part B.
Special Enrollment
If you have group coverage and missed your Initial Enrollment, you can still enroll in Part B without paying a penalty. As long as you have coverage, you qualify for a Special Enrollment. And, you have an additional 8 months after losing coverage to enroll without paying a penalty. You’ll also get a guaranteed right to buy Medicare Supplement Insurance for six months after enrolling in Medicare Part B.
]References:
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/should-you-get-part-b/should-i-get-part-b.html#collapse-5783
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SSI Blog
The Annual Enrollment is one of the enrollment periods when you can make changes to an existing Medicare Advantage or Part D Plan. Begins on October 15th and ends on December 7th. If you make changes they will take effect on January 1st.
Annual Notice of Change
You will receive an Annual Notice of Change from your insurance provider before Annual Enrollment. This document provides information on changes in costs and benefits that will impact your current coverage in the upcoming year. If you no longer want to continue with a plan, Annual Enrollment is the time to make a change. If you leave a current Part C plan with prescription coverage and return to Medicare, you will need to purchase a Part D plan.
Review Coverage
You will receive your Annual Notice of Change, before Annual Enrollment. Part C plans often make changes to coverage and benefits. Double-check that the hospitals and providers you use will still be in the network. If the upcoming changes will not fit your needs, you can switch coverage during this time (October 15 – December 7). If your plan isn’t changing, or new changes will not matter, you don’t need to do anything, and you will continue to receive the coverage you have. Part D plans often change the formulary, which could affect the cost of prescription medications you currently take. Check the pharmacy you currently use is still listed in the network of providers.
Changes Allowed
Join, switch, or drop a Part C Plan or D during Annual Enrollment.
Join a new plan and be dis-enrolled from the old automatically when your new coverage starts.
Switch a Part C Plan back to Medicare
Enroll in a Part D plan. Coverage will be effective on January 1st.
References:
https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html#collapse-3190
https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/when-to-join-medicare-advantage-plan.html
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