CALIFORNIA MEDICARE SUPPLEMENTS

Heard something about, but definitely looking for more information on California Medicare Supplements?  

 

Look no further!

 

Turning 65... the big Medicare decisions arrive now which can have an impact for years to come.

 

As you turn age 65 you've likely seen mention of  Medicare Supplements, also called a 'Medi-Gap' policy but probably aren't sure what it is.

 

We know it's easy to be afraid of making a mistake on choosing the plan and there's nothing to worry about.  We are here to help. 

 

In this article we'll provide a general overview of various areas of Medicare Supplements, or Medi-Gap plans, and what you need to know.

 

 

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First off, what is a Medicare Supplement?

 

Under Original Medicare Parts A&B medical coverage is very strong, and most of your medical expenses are covered.  But, not all of it! 

 

Medicare Supplements are there to pick up and fill the gaps where Original Medicare A&B does not cover your medical expenses. 

 

Medicare Supplements cover medical expenses such as:

 

Co-Payments     

Flat dollar amounts in return for medical services.  For example, a $25 co-pay fee to pay for a doctors visit.

 

Co-Insurance       

Percentage or flat dollar amount of cost sharing between you and the insurance carrier for medical expenses after deductible is paid.  You'll see a coinsurance of 20% on Medicare Part B Physician's Services expense.

 

Deductible             

The amount you have to pay before the health insurance kicks in and helps paying the bills for you.

 

Here's some info which should help:  There are 10 Medicare Supplement policies in total which have standardized benefits titled by letters A-K.

 

This means the coverage is the same regardless of which insurance carrier you purchase the supplement from.  A "G" Supplement Plan is the same "G" Supplement Plan everywhere.

An insurance carrier who chooses to enter the Medicare Supplement market must at least offer Supplement Plan A.  They don't have to offer all the Supplements, but Supplement Plan A must be in the insurance carrier offering package.

2020 plan update!

Effective 1/1/20 Medicare no longer allows a supplement plan to pay for the Part B deductible.  This means the F and C Supplement plans are no longer available to new members.  Previously enrolled members on these plans will be grandfathered and can keep their coverage.

 

Fast Fact     

Confused on when your Medicare supplement steps up and pays?  No problem.  We will  make this really simple!

 

Your Medicare Supplement pays ONLY after Original Medicare A&B approves a bill and makes payment on a medical expense claim.  At that point the supplement kicks in and pays according to the schedule of benefits.

 

If Original Medicare A&B REJECTs a claim then the supplement will fall in line and REJECT the claim as well.

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There are 10 Medicare Supplement plans to choose from currently.

 

If an insurance carrier chooses to offer Medicare Supplements, they MUST offer the A plan at minimum, and can then choose toe offer any number of the others.

COVERAGE DETAIL

 

 

AVAILABLE SUPPLEMENT PLANS

 

 

 

 

 

 

AVAILABLE MEDICARE ELIGIBLE PRIOR TO 2020

 

 

A

B

D

G

K

L

M

N

 

C

F

Medicare Part A Coinsurance & Hospital Coverage + additional 365 days after Medicare exhausted

yes

yes

yes

yes

yes

yes

yes

yes

 

yes

yes

Medicare Part B Coinsurance + Co-Payment

yes

yes

yes

yes

50%

75%

yes

yes

 

yes

yes

Blood (3 pints)

yes

yes

 

 

50%

75%

 

 

 

 

 

Part A Hospice Care

yes

yes

 

 

50%

75%

 

 

 

 

 

Skilled Nursing Facility

 

 

yes

yes

50%

75%

yes

yes

 

yes

yes

Medicare Part A Deductible 

 

yes

yes

yes

50%

75%

50%

yes

 

yes

yes

Medicare Part B Deductible

 

 

 

yes

 

 

 

 

 

yes

yes

Medicare Part B Excess Charges

 

 

 

 

 

yes

 

 

 

 

yes

Foreign Travel Emergency

 

 

yes

yes

 

 

yes

yes

 

yes

yes

Out of Pocket Limit

 

 

 

 

$5,880

$2,940

 

 

 

 

 

*Note: this chart is not a complete list of Medicare Supplement benefits or exclusions.  We are happy to provide complete benefit & coverage document details.  Simply request via email help@plansforhealth.com or call us at 1-866-486-6551.

 

National Provider Network   

Original Medicare + Supplement utilizes a PPO style network nationally where you can visit any medical provider (doctors, hospitals, emergency rooms, urgent care, etc.)

 

This means you can go anywhere in the United States, visit a provider who accepts Medicare, and receive insurance coverage same as if you are 'in-state' and 'in-network.'

 

Want to see a heart surgeon at John Hopkins in MD?  No problem!

 

Interested in visiting the Cleveland Clinic for a cancer consultation?  Cleveland Clinic Medical Center is a contracted Medicare provider as well.

 

To check on Original Medicare provider lists click here.

 

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Pricing       

How are they priced?  You might see marketing out there describing the types of pricing models.  Some companies might even look to persuade you on one Medicare Supplement pricing model vs. another.

Let's review the pricing models Medicare Supplements can use and why it doesn't matter to you!

 

Community No-Age Rated

This pricing model charges the same premiums rate in a plan pool of members no matter the member age. 

 

Issue Age Rated

Issue Age prices and keeps the rates the same based on the applicant's age at the point of the intial application.

 

Attained Age Rated

Attained Age Rating uses pricing the member has attained.  It's just like Issue Age pricing in the first year, but increases every year thereafter with age unlike the Issue Age Rated model.

 

Here's the solution:  You won't likely be able to find a policy on the market with pricing based on anything other than Attained Age Rating.

 

Almost all insurance carriers  price their plans based on Attained Age & pricing changes every year with age increases.

 

So, the irony here is you don't really have the option of choosing the pricing model.  The insurance carriers are using only one!

 

What can you do about it?  Here are the options below.

 

First off, there's Great News! 

 

California uses what is called the 'Birthday Rule,' which allows individuals to switch Medicare Supplement plans and insurance carriers provided you transfer to the same Supplement letter plan or lesser coverage during the birthday month each year.

 

Can you apply for a new plan anytime?

 

This time there’s good news and potentially bad news in some cases.   

 

You can apply for a new Medicare Supplement in any month of the year, but your application can be declined based on medical history or condition.  

 

Let us know if you have a question on whether you should apply.  Call 1-866-486-6551 or email help@plansforhealth.com and we are happy to review your case.

 

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The application gives you a simple pre-screen which let's you know your chances up front.  To give you an idea of what they are looking for..

Sample application health questions may look like:

In the last 5 years have you been hospitalized or treated for any of the following conditions?  If so, please provide treatment type & date, results, and current condition.

  1. a) cancer or malignant tumors
  2. b) heart attack, heart surgery, or stroke
  3. c) respiratory diseases such as emphysema, copd, cystic fibrosis etc.
  4. d) taking any prescription medications?  If so, name, dosage, and underlying condition prescribed.
  5. e) hospitalized for any reason in the last 3 years?

**note it is legal for the insurance carrier to ask if you have HIV, AIDS, HRC etc.. but it is illegal for the insurance carrier to require a test

 

What does Original Medicare A&B NOT cover?   

 

Worried about getting stuck with an unexpected medical bill?  Here's the areas Original Medicare does not cover.

 

Vision care                                                                    

 

Original Medicare does not cover routine eye care such as exams, glasses, contacts, or frames.


Any exceptions?  Why yes.

 

If you have a health condition which effects your eyes or vision like cataract surgery or diabetes, Medicare will likely cover and treat the condition just like any other medically necessary health condition including eye exam & or glasses.

 

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Prescription Drugs   

 

Unlike the health coverage you have with your employer or individual & family coverage under age 65, Medicare does not cover prescription drugs.  

 

Medicare uses a different model.

 

Prescriptions are covered under "Part D" prescription programs you can purchase separately.

 

So, don't be alarmed if your prescriptions are not covered under Original Medicare A+B + Supplement.

 

We review prescription coverage in great detail in our article here.

 

Dental Care

 

 

Original Medicare A+B doesn't pay for routine dental care.  What is routine dental care?  

 

Just the kind you need.  :)  Routine dental care is annual exams/consultations, fillings, crowns, extractions etc..

 

If you have a separate medical issue which effects your teeth and the dental treatment is essential to the treatment you can inquire into coverage.

 

For example, if you had jaw cancer and a tooth extraction is required to treat the cancer.  Or, if jaw reconstruction is required, say, after a car accident.

 

Not great ways to get dental coverage, to say the least!

 

The insurance carriers offer standard HMO and PPO dental coverage you can purchase separately to your Medicare Supplement through Senior programs to cover routine dental care.

 

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Many Medicare Advantage plans (remember it's typically HMO or managed care plan model with these) have routine dental and vision offered in bonus packages which are inclusve of the medical insurance.

 

For questions on Senior Dental please don't hesitate call toll free at 1-866-486-6551 or contact us!

 

Hearing Aids   

 

Original Medicare A+B does not cover hearing aids or hearing exams.  

 

You might imagine we get this question a lot! 

 

Hearing Aid average prices have jumped to an average price of $2,000-$8,000 for a set of 2 in the United States.

 

Think of this as the same way health plans treat your teeth with dental coverage.

 

Is there any good news...?  Yes!  

 

If you have a medical condition which requires a hearing exam you can submit to Medicare and request coverage under Part B for the exam only.

 

The second piece of good news is that some Medicare Supplements (PPO Original Medicare A+B) and Medicare Part C Advantage plans now add some hearing exam and hearing aid coverage.  Read more about these plans here.

 

Long Term Care

 

If you need to live in a facility and receive nursing, assisted living, or also sometimes in the industry it's technical term is called "custodial care,"  you are not going to find Medicare very helpful.

 

The insurance coverage which helps with long term facility living is called "Long Term Care."

 

If you want some guidance or quotes Long Term Care insurance we would be happy to help!  Give us a call to talk it over at 1-866-486-6551 or email is help@plansforhealth.com.

 

Cosmetic Surgery

 

Medicare utilizes a medical necessity model for covering surgeries, just like health insurance plans under the age of 65.  So, for Cosmetic Surgery unfortunately you are on your own for the bill.  This includes botox and other injections, breast implants, facelifts, etc.

 

Acupuncture  

Medicare announced it will begin covering some limited acupuncture but only in certain cases.  If you have nonspecific chronic lower back pain Medicare will now cover up to 20 acupuncture visits per year.

 

This departure from the prior non covered stance is a reaction to getting safe treatment alternatives to opoid medications which have turned epidemic.

 

The approval is reliant on specific conditions though.  The pain must last longer than 12 weeks and have no identifiable cause.  You must also not have any of the following:

  • -pain tied to a specific condition
  • -pregnancy
  • -pain from surgery

 

How do you know what Medicare paid?

 

With Original Medicare + Supplement you will receive what's called a Medicare Summary Notice every quarter which describes all the claims submitted to Medicare and what Medicare paid the Provider (doctor, hospital, or other etc.)

 

Here's an example of what the Medicare Summary Notices look like:

 

You can download the entire sample pdf brochure document brochure on medicare.gov here.

 

Remaining amounts not covered are then submitted to your Medigap insurance carrier for claim review/payment.

 

These documents are the same you are likely very used to seeing with your insurance under age 65, either employer sponsored or individual but called EOB's or Explanation of Benefits documents.

 

 

 

EOB documents show the same type of claim data: 

  • -whether or not a claim was allowed
  • -amount the insurance carrier paid on a claim
  • -deductible and coinsurance applied
  • -claim type

 

Really the main different is that an EOB is generated on a per claim basis, not a quarterly summary report format.  

 

You can get your Medicare Summary Notices in electronic format via your Medicare.gov online account now to save time and paper!

 

If you have any questions regarding Medicare Supplement please don't hesitate to give us a call at 1-866-486-6551 or help@plansforhealth.com.

 

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