How Medicare fits in if you’re still working

new vs old medicara cards 2018

Turning 65 and still working? What that means for your Medicare coverage.

Remember when 65 meant retirement? Well, the big birthday is here and you are still employed. But what does that mean for your healthcare coverage and Medicare?

Before we get into next steps, let’s review two important points:

  1.     If you have already filed for Social Security, you will be automatically enrolled in Medicare A and B when you turn 65. If you are covered by an employer plan (you or your spouse), you can potentially opt out of Part B coverage.
  2.     For almost everyone else, working or not, your Initial Enrollment Period (IEP) begins three months before you turn 65 and ends three months after you turn 65. Medicare will not notify you about this IEP so be proactive in reviewing your options. You may assume that your work plan will exempt you, but Medicare has several regulations and deadlines that affect that decision.

When you turn 65, you need to understand what your current plan covers and how it compares to Medicare’s coverage.

  • 1. Contact your benefits administrator or plan provider about your current insurance coverage. Acquire your coverage documentation, and ask questions that will allow you to directly compare your coverage with Medicare options, such as:

-How much does my current plan cost every month?

-How will my plan be affected if I enroll in Medicare?

-What have past employees in my position generally done?

  • 2. Familiarize yourself with what Medicare (Parts A, B, C, and D) covers and the costs associated with each (this page can help with that).
  • Third, if you’re married, note how the plans differ with spousal coverage. Understand that switching to Medicare could impact your spouse’s coverage.

 

So, what about the Parts of Medicare?

Medicare Part A: You have the option to enroll or delay enrollment in Part A, or “Hospital Insurance.” If you are thinking of enrolling, know that it is free for most people and it can pick up many services not covered by your current plan. By enrolling during your IEP, you could eliminate issues with future coverage. If you want to delay Part A coverage, you don’t need to do anything when you turn 65.

Regarding enrollment in Part A: If you have a Health Savings Account (HSA), your employer will likely stop contributing to the HSA plan once you are enrolled in Medicare. Be sure to be proactive and have the conversation with your benefits administrator or plan provider before you turn 65 so you do not run into any unnecessary complications.

Medicare Part B: The size of your employer will determine if you should consider enrolling in Part B, or “Medical Insurance.”

If your employer has 20 or more employees, your employer coverage will remain your primary insurer and you can delay Part B enrollment without penalty or gaps in coverage. If delaying enrollment, you don’t need to do anything when you turn 65. You have 8 months after leaving your employer to enroll in Part B through a Special Enrollment Period (SEP).

If your employer has fewer than 20 employees (19 or less), you should sign up for Part A and Part B when you’re first eligible because Medicare will be your primary insurer, no matter what. This means your employer coverage will become secondary, only picking up what Medicare cannot cover. If you do not enroll in Part B right when you’re eligible during your IEP, there will be a penalty and potential gap in coverage.

Regarding enrollment in Part B: There is a premium associated with enrollment whether it’s during your IEP or delayed enrollment. Your income will determine your premium and is outlined in this link: Part B Enrollment Premiums

 

What about Medicare Part C and D?

Medicare Part C (Medicare Advantage) – Part C, or Medicare Advantage, is an umbrella plan that includes all the services of Part A, B, and often prescription drugs. Key considerations to know with Medicare Part C if you’re still working include:

  • You might be better staying with your employer’s coverage to maintain the same physicians. With this plan, you will be required to choose care providers within restricted networks.
  • Medicare Advantage could cause you to automatically forfeit your employer’s plan. Due to this automatic forfeit, you’ll need to meet with your benefits administrator or plan provider prior to making any decisions.

Medicare Part D—Your employer may offer prescription drug coverage, but it must be deemed ‘creditable’ by Medicare. Creditable coverage can be defined as “as good as or better than the coverage provided by Medicare’s prescription drug benefit.” If this does not describe your coverage or your employer does not offer a plan, you will want to enroll as soon as you’re eligible. If you do not, there will be a late fee for enrollment. Note, you cannot buy both a Part C and Part D, however most Part C’s include Part D.

So what does all of this mean?

Overall, your current coverage, employer size, and Medicare premiums will help you choose the right plans. There are a lot of decisions to make when you turn 65 so if there’s anything you take away from this article, just know:

  • First, you need to contact your benefits administrator or plan provider and get educated on your current coverage. Understand how it will be affected by enrolling in the different parts of Medicare
  • To avoid penalties and coverage gaps, you’ll want to enroll in Medicare during your IEP. even while remaining on your employer’s plan. Medicare may not be your primary coverage, depending on the size of your employer and there are standard fees for Part B.
  • Lastly, don’t be afraid to ask questions. There are a lot of moving parts but asking questions and being knowledgeable about your choices ahead of time will help you find a plan that best fits your needs.

 

Need help navigating this process or customizing a plan? Griffin Insurance Solutions is an independent agency that offers plans from 15 different insurers. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.

 

7 Services you didn’t know Medicare covered

 

7 Services you didn’t know Medicare covered

We all are familiar with Medicare as covering hospital and medical bills, but it covers a variety of Medicare services and tests that are less widely known.

 

 

1. Sleep studies
Do you think you’re suffering from sleep apnea or at least would like to be tested? Medicare actually covers the four categories of sleep tests and devices. As long as you get tested in a sleep lab facility and your doctor orders the test, Part B will cover the standard 80% (with your Medigap Plan covering the rest). It will even cover a 3-month trial of CPAP therapy.

 

 

 

 

2. Mammograms

In 2016, a study presented at the Radiological Society of North America concluded that cancer frequency did not decrease among women older than 74, and there was not a recommended age cutoff for when women should stop annual mammograms. For those with Part B, Medicare covers one yearly preventive mammogram test for all women over 40. It also covers additional diagnostic mammograms when your doctor has deemed it  medically necessary. So neither age nor cost should prevent you from these valuable screenings.

 

 

 

 

3. Over the border care

As a guiding rule, Medicare doesn’t cover health care (see page 57 of Medicare and You 2018 Handbook) when you’re outside the U.S., but there are a few exceptions for those who live near the borders of the US. When a foreign hospital is closer to you than the U.S. hospital, Medicare will cover your care for both standard visits and emergencies. There is also an exception for those U.S. citizens directly en route to Alaska through Canada; if there is an emergency in that situation, Medicare will cover your care in Canada.

 

 

 

 

4. Depression Screenings

older-man-with-depression-black-and-whiteDepression can often accompany other health problems. But it should not be considered part of the aging process: it’s a treatable medical condition, and Medicare will cover your care if you decide to seek diagnosis and treatment. As long as your appointment takes place in a primary care doctor’s office that can provide both follow-up treatment and referrals, Medicare will completely cover one depression screening. If you are diagnosed,  Medicare will cover your therapy with your doctor’s referral to a psychiatrist or counselor for treatment. Your prescriptions, of course, will either be covered by your Prescription Drug Plan or your Medicare Advantage plan.

 

 

 

 

5. Physical Therapy

In 2018, Congress lifted the calendar year limit caps on what Medicare will pay for occupational, physical, and speech pathology therapy. Stipulations? As usual, this service coverage hinges on your therapists confirmation that these services are medically necessary and reasonable. Once you reach $2,010, Medicare asks your therapist to confirm and explain the need for therapy to continue. Once you have that confirmation, you can continue your therapy fully covered. To read about the additional financial benchmarks that Medicare examines, click here.

 

 

 

 

6. Obesity Screenings

overweight-waistline-measurementMany seniors who find activity more difficult as they age may start gaining weight and leave the doctor’s office with instructions to start taking action. But losing weight becomes more of a challenge as you get older and heavier, and Medicare offers help for those who have a diagnosed BMI of over 30 (30< is considered obese). Services also include behavioral counseling sessions and therapy. Like many items on this list, in order for Medicare to cover it, your primary care doctor must refer you for them.

 

 

 

 

7. Foot Care

Now, Medicare won’t cover your next pedicure, but if you are having a foot ailment that can be medically identified and treated, Medicare will cover it. Common treatable ailments include bunions, hammer toes (also called a rotated toe: when there is abnormal bend in the middle joint), deformities, and heel spurs. Many seniors don’t seek treatment because many of these issues seem “minor,” but if they are causing you pain and discomfort (and they don’t fall under routine care, like callus removal), we encourage our clients to seek treatment because it’s covered.

 

Medicare covers many of these medical services with Part B, so since that is only 80%, your Medigap plan will cover the 20% left of the costs. Unhappy with your Medigap Plan coverage?

Griffin Insurance Solutions is an independent agency that offers plans from 15 different insurers. We understand that each client is a unique individual, and we want to help you find the best plan and the right insurer. We ensure that your options remain flexible so you can use the providers and doctors of your choice. We’ll happily address your questions and concerns and help you find the best plan for you. Contact us today for in-person appointment by email or phone at 919-704-6147 or 800-774-1434.

 

Top Five Questions have about Skilled Nursing Facility Care (and how Medicare bills you!)

doctor and nurse visiting senior woman at hospital

Top five questions seniors have about Skilled Nursing Facility (SNF) care (like how Medicare bills you!)

You’ve heard about the term SNF, and maybe you thought nursing home, but there’s a lot more to it.

1. What defines SNF?

An easy way to think of SNF is as a specialized type of care that only skilled RNs or therapists can provide to treat, manage, observe, and evaluate a high level of medical care. Most commonly, SNF patients are recovering from an illness, injury, or surgery. Facilities must meet certain requirements to be certified as an SNF, and sometimes hospitals are also SNF facilities.

Most people do not receive SNF care for very long, with an average stay of 28 days. SNF care is only designed to treat a health concern for as long as it requires daily care. For example, if you broke your leg, you would go to an SNF after being released from the hospital. The initial care you receive would be considered SNF because it requires staff members specializing in surgery recovery. After you no longer need specialized follow-up care, you would then receive custodial (everyday) care, if you still needed assistance.

Here’s another example of SNF care: You’re hospitalized for a stroke, after which you receive occupational therapy at an SNF in order to relearn impacted basic daily tasks (eating, writing, etc.). If your doctor decides that the occupational therapy treatment isn’t working and that you instead need assistance with basic daily tasks, you are switched to custodial care, which is not covered by Medicare. Depending on the decision you and your doctor make together, you may next receive custodial care in the same facility, be sent home, or be transferred to a facility specializing in daily custodial care. This is because SNF facilities are not meant for maintenance of a health issue but rather for improvement.

2. Is SNF care the same thing as an assisted living?

No. The important difference between a skilled nursing facility and, say, an assisted living facility, is that you receive specialized services at an SNF. These terms are often interchanged mistakenly, so it is important to check your sources when gathering information. Remember Medicare rarely covers custodial care, which can be thought of as help with basic personal tasks. These other non-SNF facilities offer mostly custodial care. Custodial care facilities may have some medical equipment on the premises and may even have some medically trained staff, but the purpose of the facility is different. If your care is defined more by assistance than treatment, then, by most counts, it won’t count as SNF care. Custodial care may sometimes appear medical but is not considered specialized; custodial care can range from assistance with meals to using eye droppers or help bathing. Medicare doesn’t cover custodial care and thus does not cover assisted living facilities.

3. How do you get SNF care covered by Medicare?

Medicare has a number of requirements for your stay at an SNF to be covered, which are all outlined on medicare.gov. The most important one for seniors is the requirement of a qualifying inpatient hospital stay. This means an inpatient hospital stay of three consecutive days or more, starting with the day the hospital admits you as an inpatient, but not including the day you leave the hospital (see our previous blog post to learn about inpatient status). The second most important point is that you must enter the SNF within 30 days of leaving the hospital. Click here to read the full list of requirements.

4. How does a benefit period play in?

As Medicare.gov puts it, a benefit period is “the way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services.” A benefit period refers to the length of time that Medicare covers your care. As an SNF patient, your benefit period lasts 100 days, which means that on day 101, you will pay out of pocket for your SNF care.

You are also allowed up to 30 days after you leave SNF care to re-enter an SNF if needed, without needing a new qualifying inpatient hospital stay. But if it’s been more than 30 days since you had SNF care, Medicare does have some particular requirements:

  • Longer than 30, but less than 60: Your current benefit period continues, but you are required to have another three-day qualifying hospital stay.
  • Longer than 60: It’s like starting over. You’ll need a new 3-day hospital stay, and you’re eligible for a new 100-day benefit period.

There’s no limit to the number of benefit periods you can use. As long as 60 days have passed, you’re starting fresh. And with every new benefit period, there’s a new deductible.

It is important to note that breaks in SNF care can happen even without moving facilities. If at any time your care transitions from specialized to custodial, that is technically a break in SNF care, in which case the countdown to 30 days begins. We recommend that if you are expecting to need SNF care and you have days left on your benefit period, try to re-enter within 30 days so you can avoid the expense and hassle of another inpatient hospital stay.

5. What will I pay?

If you have a Medicare Supplement, or Medigap Plan, in most cases, you shouldn’t have to pay anything out-of-pocket. Medicare covers your qualifying hospital stay except for the deductible—which your Medigap covers—and 100% of your SNF care for the first 20 days.

Starting on day 21, SNF care Medicare requires a daily copay, currently $167.50. Medigap plans C, D, F, F-high deductible, G, M, and N all cover 100% of the copay until day 100, when your benefit period ends.

Your 100th day in an SNF is the last day of your benefit period, and thus your Medicare coverage. On day 101, you start paying full cost out-of-pocket.

Conclusions?

With SNF care, the high costs can add up quickly without meeting Medicare’s hospital and benefit period requirements, so it’s important to stay informed. When you are discharged from the hospital after your qualifying stay into SNF care, a hospital liaison should coach you through your financial transition with Medicare. If you are in the process of being discharged and you haven’t received that help, you can and should ask for it. If you can, ask a loved one to be with you and ask questions and to help you keep track of your days for both your inpatient hospital and SNF stays.

If you have questions about your coverage or your Medigap plan, we can help provide guidance. Our clients trust us and refer us because of availability and willingness to give help and advice throughout the year, not just when it’s time to renew. Please call us at 800-774-1434 or email with any questions you have while navigating this complex process. Call an agent to help shop around for a Medigap Plan to help cover this cost.

 

Inpatient Care vs Outpatient Care: Knowing the difference could save you thousands

Outpatient care word cloud

Outpatient vs Inpatient: The difference could save you thousands

So what exactly are these terms, outpatientinpatient, observational care, skilled nursing facility? And how do they affect you? If you have a Medicare Supplement Plan, then possibly by thousands of dollars.

No one wants to think about going to the hospital. But when you’re in the hospital, the last thing on your mind is how you will be billed. Understanding the subtleties ahead of time—of how they admit, treat, and bill Medicare patients—can potentially save you thousands of dollars, especially in long-term care costs. If you or a loved one does need to visit the hospital, you’ll be ready after reading our guide.

Outpatient vs Inpatient at-a-glance

An inpatient is a person who is formally admitted to a healthcare facility, like a hospital or skilled nursing facility. If you have not been formally admitted to the hospital by a doctor, you are not an inpatient. An outpatient is a patient who a doctor treats, who may receive ambulatory care at a hospital, and may even spend the night, but is not formally admitted to that facility. Outpatient and inpatient can look and feel very similar because they both take place in a hospital, but you can ask the doctor who is working with you if you are being formally admitted.

Remember: the key phrase for distinguishing between inpatient and outpatient care is ‘FORMALLY ADMITTED.’

How does observational care (aka hospital outpatient care) fit into this?

Observational services are the hospital outpatient services you get while your doctor decides whether to admit you as a patient or discharge you. That can happen in the emergency room or any other part of the hospital. Observational care can even be overnight and last up to 48 hours (although 24 is more typical, some cases have exceeded 48 hours). Due to medical and technological advances, many more health services are available without a formal hospital stay, and hospital observational services are increasing according to the CDC. For seniors, the distinction is even more pertinent, because observational services are most common among people 65 years and over. Please refer to this Medicare.gov publication, page 3 for a few specific examples of how different hospital situations would be covered between Parts A and B.

Will the hospital tell me if I am receiving observational care?

Yes, after 24 hours, as a Medicare patient, you have the right to what is known as a MOON, or Medicare Outpatient Observation Notice. A MOON is a written legal notice that explains if the patient is receiving observational care and the doctor’s reasons for that care. This notice is a written document that also requires an oral explanation by a hospital worker.

With a MOON, you have the right to be informed of the medical and coverage implications of the observational care. This is your chance to get as much clarity of your status from the hospital as you can. Medicare legally requires the hospital to obtain your signature saying that all details have been explained to you, so don’t hesitate to ask every question that you have.

Although you have a right to a MOON after 24 hours, the hospital is not legally bound to give it to you until after 36 hours of observational care has lapsed or upon your release, whichever comes sooner.

Our advice? If you realize that your or your loved one’s stay in the hospital may be a longer visit than expected, keep track of your time, and as your time nears 24 hours, start asking for your MOON to help expedite the progress of your notice. If you anticipate a longer stay, you can advocate to be formally admitted for better coverage. Learn more about MOON.

How does my patient status affect my Medicare charges?

The majority of your charges will be covered in some way with your Medigap plan. When you are an inpatient, Medicare Part A has a $1,340 deductible for all of your hospital and inpatient services for the first 60 days you’re in the hospital (that’s why Medicare refers to Part A as “hospital insurance”). An important distinction: Part B covers 80% of your doctor services, even while formally admitted.

These deductibles and leftover costs are why you have a Medicare Supplement Plan. All Medigap plans cover the Part A deductible, and after paying the Part B deductible, Plans like F and G will cover the other copays and deductibles from Part B. The other Medigap plans vary in how they cover the remaining Part B costs, so refer to your specific plan to understand your coverage. For a further breakdown of the Part A long-term costs, see Medicare and You 2018, page 31.

When you are an outpatient, Part B covers your hospital services and your doctor services after you have met your Part B deductible. Although, because of how Part B functions, you will likely have a copayment for each hospital service, and the amount you pay will vary on the type of Medicare Supplement Plan you have. For the full list of the Part B services and their costs, see pages 35-59 in Medicare and You 2018. You supplement plan will vary in how it covers Part B services, so refer to the specific coverage booklet for your plan.  If you have a Medicare Advantage Plan, your costs will be covered, but will vary with the amount of coinsurance you pay.

So how does Skilled Nursing Facility, or SNF, play in?

This is where the biggest drain on your wallet can come in. Sometimes hospitals transfer you to a skilled nursing facility, or SNF.  Medicare Part A covers 100 days of SNF care, but Part A will only cover it if you have been an inpatient for at least three days and check into a Medicare-approved SNF facility within 30 days. So, if you are expecting skilled nursing facility (SNF) care, you must be keep track of whether or not you are inpatient because three days as an inpatient in a hospital is required before SNF coverage kicks in. This can be confusing because you can spend three consecutive days in a hospital without being considered an inpatient for all three days. So, when you are transferred to a rehabilitation center, and you didn’t reach the three day mark prior to your discharge, you may pay completely out-of-pocket for those SNF costs. Keep an eye out for our upcoming post that gives a more detailed rundown on how Medicare works with skilled nursing facility (SNF) care.

What do I do while I am in the hospital?

Ask questions and look out for yourself. You have a right to have them answered, whether it regards the doctor’s treatment decisions, your status as an inpatient or outpatient, or if Medicare will cover your SNF stay. Remember the golden rule; you are not considered an inpatient nor receiving the financial benefits of an inpatient unless you areformally admitted by a doctor even if you have been in the hospital for a longer stay. If you are not being admitted, ask the hospital for documentation as to the reason. If you are admitted, ask the hospital for documentation on why and when you are formally admitted. Later on, if you feel their decision was in error, you can submit a claim for an appeal.

Finally, bring someone along as your advocate; don’t go to or remain at the hospital alone if you are in the middle of health crisis or treatment. Although you may have your head wrapped around the billing structure now, it can be near impossible to have the wherewithal to apply that knowledge while in the midst of experiencing it. Bring along a trusted family member or friend to be your advocate and handle the line of questioning. And share this article with them so that they are informed of your hospital Medicare needs.

We can help!

Here at Griffin Insurance Solutions, we know that your hospital experience is a unique and individual one that requires expert advice. Our clients trust us and refer us because of availability and willingness to give guidance and advice throughout the year, not just when it’s time to renew. Please call or email with any questions you have while navigating this complex process.

Plan F: Changes Coming in 2020

hand pointing to the year 2020Do you have a Medigap Plan F? What changes you need to know now.

You may have heard that changes are coming to Medicare Supplements in 2020. In 2015, Congress passed MACRA (Medicare Access and CHIP Reauthorization Act), a bipartisan law to provide physicians with incentives and higher pay to accept and treat more Medicare patients. MACRA added value and quality to Medicare plans, but in order to pass this, Congress needed to make changes to how Medicare patients used their supplement plans. MACRA specifically phases out Plan F and C because these plans don’t require patients to meet a deductible (essentially, it was rolled into your monthly premium), and this resulted in patients sometimes over-visiting the doctor for minor complaints.

So, who does this affect?

Most directly, MACRA affects those who will be eligible for Medicare in or after the year 2020. For all those enrollees, Plan F, High Deductible F, and the less popular C will no longer be offered. For those who are eligible before 2020, but are waiting to enroll because of employer coverage, you will still have the option to enroll in Plan F (although we don’t recommend it—keep reading to see why).

What if I currently have Plan F?

If you are currently enrolled in Plan F, you have the option to be grandfathered in and keep Plan F, but because fewer people will be on Plan F, your rates will continue to go up for the same coverage! A better option is to switch to a Plan G or N and not worry about the 2020 change. For those on the high deductible Plan F, our understanding is that a high deductible Plan G will be introduced (we’ll update this post with those details when we know them).  We strongly recommend that you switch from Plan F to a Plan G, because this won’t result in a significant change in coverage, and it’s quite likely that your rates will decrease.

How do I choose between Plan G and Plan N?

For those who are younger than the age of 70, we recommend Plan G, as it provides the same level of coverage as Plan F; the difference being a lower monthly premium with an annual deductible of $183. For those who are older than age 70, we generally recommend Plan G or N, although with Plan N, we advise a direct conversation with an independent agent who can carefully review that plan with you, as holds unique complexities. If you still feel reluctant to switch plans, you can review how the coverage compares here, and review how current sample rates compare in the chart below.*

65 70 75 80
  Male  Female   Male  Female   Male  Female   Male  Female
Plan F $130.12 $114.82 $133.15 $116.13 $153.67 $133.63  $192.15 $167.09
Plan G $103.87 $94.43 $111.55 $101.41 $134.19 $120.62 $155.11 $141.01
Plan N $87.71 $76.30 $98.21 $85.38 $116.12 $100.96 $136.28 $118.54

*(1) All rates are non-tobacco and non-discounted rates. Household discounts may be available on a case-by-case basis. And, tobacco user rates may be higher.

As you can see, Plan G and Plan N are already less costly than Plan F and the savings more than compensate for the $183 annual deductible that Plan G and N require; in our example, a 65-year-old non-smoking male on Plan G annually pays—with deductible included—a total of $1,429.44, while annually paying $1,561.44 with Plan F.

What should I do next?

Your next step should be to discuss the 2020 changes with an informed, reliable, and independent agent. An independent agent can advise you to implement the most valuable changes to your Medicare plan. At Griffin Insurance Solutions, we are successfully guiding our current clients through these changes, and we can help advise you as well. To learn more about the changes coming in 2020 or any other questions you may have about Medicare, please contact us for an in-person appointment, by email, or phone at 919-704-6147 or 800-774-1434.