What is the Donut Hole?

What is the Donut Hole?

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Medicare Donut Hole graphic

If you’re turning 65 or becoming Medicare eligible, one of your challenges is choosing a drug plan. Many are confused by the term “Donut Hole” (also called the Coverage Gap). Medicare Prescription Drug Plans have four parts or phases, Initial Deductible, Initial Coverage, Donut Hole and Catastrophic. To understand the Donut Hole it’s important to understand each of these parts. Read More

Applying for Health insurance in 2019

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Topics Covered and Questions Answered:

  • Explanation of the ACA (Affordable Care Act) provisions
  • Update on the plans available in Raleigh, Durham and Chapel Hill area
  • ACA Terminology
  • How to choose a plan?
  • Who is eligible for a government subsidy?
  • How to apply for a government subsidy and what questions to expect?
  • When you can apply for health insurance?
  • What alternatives are available to ACA compliant policies?
  • Who to call when you have health insurance complaints or to report fraud.

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Can you change from a Medicare Advantage to a Medicare Supplement?

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Unless someone turning 65 has lifetime health benefits from their or their spouse’s employment, they usually have two choices on how to receive their Medicare coverage. They can enroll in a Medicare Supplement and a separate prescription drug plan or in a Medicare Advantage Plan with drug coverage. If they have drug coverage from previous employment or military service, they also have the option to enroll in only a Medicare Supplement or a Medicare Advantage with no drug coverage.

Typically the premiums for a Medicare Advantage Plan are much lower than a Medicare Supplement. In the Research Triangle area (Raleigh, Durham and Chapel Hill) there are numerous Medicare Advantage Plans that have a zero premium. My experience is that the majority of seniors who sign up for these plans are very satisfied with the benefits and coverage. However, as we all know, life is unpredictable. When your health suddenly takes a turn for the worse having a plan that requires you stay in a network of medical providers or allows you to go out of network, but at a substantially higher cost, can create anxiety. This is why understanding the rules for change are important.

When you first turn 65 you have what is called a “trial right”. This term means you can try Medicare Advantage for one year. At any point during this 12 month period you can drop your Medicare Advantage Plan and return to Original Medicare. Once you drop your Medicare Advantage plan, you have 63 days to enroll in a Medicare Supplement without going through medical underwriting (answering health questions). If you wait longer the insurance companies that market Medicare Supplements will require medical underwriting and can decline you for coverage. You also have 63 days to enroll in a drug plan. If you don’t enroll during the 63 day period you will be required to wait until Annual Enrollment (October 15 through December 7th). The plan you enroll in during this period will not begin until January 1st of the following year. Unless you have a very low income, this will cause you to pay a penalty for going without creditable drug coverage for several months. This penalty will continue as long as you are enrolled in a prescription drug plan.

For folks that are already on a Medicare Supplement there is also a “trial right”. This allows them to drop their Medicare Supplement and try a Medicare Advantage for one year. However, their “trial right” is more restrictive. They can enroll in Medicare Supplement Plans A,B,C,F,K or L without medical underwriting, but the not the popular Plan G.

In 2019 during the Open Enrollment Period, which is from January 1 through March 31, one can change from a Medicare Advantage to a Medicare Supplement and a drug plan. However, unless they are in their first year of Medicare or are enrolled in a plan which is ending, they will be required to go through medical underwriting to obtain a Medicare Supplement.

Sometimes an insurance company will decide to terminate one of their Medicare Advantage plans. This is called a SAR (Service Area Reduction). When this happens they are required to send a letter to each person on this plan. In addition to explaining when the plan will end, the insurance company must provide details on the time period for obtaining new coverage and one’s options during this period. Instead of choosing another Medicare Advantage plan, the policy holders of the terminated plan can choose a Medicare Supplement. This letter is their proof that they are in a “guaranteed issue period”, which allows them to enroll in Medicare Supplement Plans A, B, C, F,K or L without going through medical underwriting.

There are also situations where CMS (Centers for Medicare & Medicaid Services) forces a Medicare Advantage Plan to terminate for not adhering to government rules. This type of termination gives the policy holders the same “guaranteed issue rights” described above.

 

 

 

 

Why enrolling in COBRA can be a costly Medicare mistake

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If you (or your spouse) lose or quit your job with health insurance when you are eligible for Medicare it is unlikely COBRA (Consolidated Omnibus Budget Reconciliation Act) will be your best choice for health insurance. Medicare does not recognize COBRA as creditable coverage as they do group health insurance.  Medicare eligible individuals have 8 months to sign up for Medicare Part B once they lose their group health insurance. However, if one chooses COBRA instead and stays on it 18 months, they will be required to enroll in Part B between January 1st and March 31st. To make matters worse their Part B coverage will not begin until July 1st. Since you are not allowed to buy a Medicare Supplement or Advantage Plan without Part B, it means they will go several months with only Part A (hospital) coverage. Read More

New to Raleigh and need a doctor?

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If you have recently moved to the Raleigh Durham area and need assistance finding a Duke primary care or specialist doctor, the Duke Consultation and Referral Center can help. They are opened  Monday through Friday from 8:00 AM until 6 PM. Call 1-888-ASK-Duke (275-3853) to request an appointment or visit them on-line at dukehealth.org.

 

Are you paying a penalty for not having health insurance?

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If  you have gone 3 months or longer without  ACA (Affordable Care Act) compliant health insurance in 2018 you may have to pay a penalty when you  file your 2018 taxes. No penalty for having health insurance does not kick in until 2019. The penalty is $695 per adult or 2.5% of household income, whichever is greater.

Save on Fertility Services if you have a BlueCross BlueShield of North Carolina policy

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BlueCross BlueShield of North Carolina (BCBSNC) now offers discounts on fertility services through a partnership with WINFertility. The highlights include 10% to 40% savings on fertility services which include intrauterine insemination, in vitro fertilization treatments and medications. Participants have access to a proven physician network, financing options and free consultations.

For more details members can go to www.bcbsnc.com/blue365. If you are a BCBSNC policyholder and have not joined Blue365 it’s easy to join and offers great deals to improve your health. From the www.bcbsnc.com website click on “Go to Blue365”.

This is important to know if you’re almost 65 & on a small group health plan

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Unlike large employer group plans,  employees on small group plans (fewer than 20) are required to enroll in Medicare Part B when they turn 65. Part B helps cover the cost of doctor visits, outpatient care, some preventative services, home health care and durable medical equipment. Once you enroll in Part B you have 6 months to purchase a Medicare Supplement without going through medical underwriting (being required to answer medical questions). If you have concerns about being declined or charged a higher premium due to your health status you should purchase your own plan before the end of this six month window.

Five More Fallacies of ObamaCare

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obamacare

As I pointed out in my ObamaCare video, we are constantly bombarded with misinformation about the Affordable Care Act(ACA) or ObamaCare. Here are five more examples of these fallacies:

fallacy #1:All health insurance must be purchased from the Marketplace. Read More

7 Tips for Finding the Best Health Insurance Deals

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As they say, “knowledge is power”. The information below will help you become a savvy health insurance shopper and find the best policy or policies for you and your family:

Explore your options with an agent who represents several health insurance companies and can help you make comparisons. There is no charge for this service and it can save you a lot of time and aggravation. Once you have educated your agent on your budget, expectations, doctors and preferred hospitals, he/she can advise you on the policies and insurance companies that would best fit your needs.  For quotes from several top insurance companies or additional information, Click Here.

Don’t wait until the last minute to apply for insurance. This is probably the best way to make sure you get the best possible deal. With the passage of the Affordable Care Act you may quality for government help paying for your health insurance policy.  Unless you have a qualifying life event (i.e. losing your health insurance due a job loss, moving to a new area, divorce or birth of a child) that gives you a 60 day period to purchase health insurance, you can only enroll in ACA compliant health insurance  during Open Enrollment (from November 1st until December 15th). If you apply during Open Enrollment your policy is effective January 1st.

Understand the following 4 insurance terms and use them to evaluate your choices:
Deductible – Dollar amount of medical expenses you pay before your insurance covers you.

Coinsurance – After the deductible this is the percentage the insurance company must pay.  For example, if your plan is an 80/20 this means the insurance company must pay 80% and you must pay 20%.  It is important to purchase a plan that has a limit on the dollar amount you are required to pay.

Co-payments – Fixed dollar amount you pay for a doctor visit, emergency room visit or a prescription drug.

Maximum out of pocket – This includes every dollar you pay for prescription drug, co-pays and deductibles using your insurance card. Once you reach your maximum your insurance company must cover all your medical expenses the rest of the year. The maximum out of pocket resets itself every January 1st.

Make sure you understand how your policy covers prescription drugs.  This means you must understand the deductibles, co-pays and yearly maximums.

If you have children who are 18 or younger and your income for the past year is low, your children may qualify for reduced or free government sponsored health insurance. For additional information contact the NC Division of Medical Assistance at 800-367-2229 or www.nchealthystart.org.

North Carolina State law requires university students to have health insurance. If your children are college students contact their Student Health Services and request information on their student health insurance plans.  Compare the cost of their university plans to your cost of adding them to your policy.

Consider purchasing an IRS-Qualified High Deductible Health Plan (HDHP).

Purchasing one of these policies can reduce your monthly premium by 50% or more.  This is a perfect solution for healthy people who rarely go to the doctor.  These HDHP’s can be paired with a Health Savings Account (HSA) that offers additional savings by reducing your taxable income. Unlike the traditional health insurance plans, the policy holder pays for all medical expenses until he reaches his deductible. Like traditional plans, HDHP’s have a wide range of deductibles, coinsurance options and benefits.  .